What's new in pediatric dermatology

Clinical and therapeutic approach to childhood acne: an update

There is a limited literature reporting on acne in childhood. Childhood acne can be classified in neonatal, infantile, mid-childhood, and prepubertal acne, depending on the age of onset. In this review we will present an update on the clinical approach and therapeutic options when facing prepubertal acne in a child. The use of tetracyclines is contraindicated in children younger than 8 years, and oral isotretinoin is not recommended in children younger than 12 years of age according to the FDA and the European Commission. Nevertheless, there are case reports of 10 patients successfully treated with oral isotretinoin for recalcitrant infantile acne with scarring. Further studies are needed to investigate whether isotretinoin may improve the long-term prognosis of infantile acne, which may be associated with more severe acne in adolescence.

Diagnosis and treatment of pustular disorders in the neonate

The diagnosis of a pustular dermatosis occurring during the first months of life is usually based on clinical findings. However, some cases may require simple investigations including microscopic examination of pustular content, cultures, and skin biopsies. The main benign transient neonatal types of pustulosis include erythema toxicum neonatorum, infantile acropustulosis, transient neonatal pustular melanosis, and neonatal acne. The most common causes of infectious pustular skin lesions include bacterial infections, which may be initially localized (Staphylococcus aureus) or septicemic (with Listeria monocytogenes as the leading causitive agent); viral infections (herpes simplex, varicella-zoster, and cytomegalovirus infections); fungal infections (candidiasis); or parasitic disorders (scabies). The main objective of this article is to propose a systematic approach to pustular eruptions in the neonate. The need for investigating every neonate with pustules for an infectious disease is emphasized. The Tzanck smear, the Gram's stain, and a potassium hydroxide preparation are the most important quick diagnostic tests. The Tzanck smear is a very easy, rapid, and sensitive test for detection of a herpetic infection (multinucleated giant cells) as well as noninfectious pustular eruptions (eosinophils, neutrophils). Therefore the Tzanck smear should be the first test performed. Moreover, a Gram's stain and potassium hydroxide preparation should be performed in cases of neonatal pustular disorders to detect bacterial and fungal infections. The goal of this diagnostic approach is to spare a healthy neonate with a benign transient condition an invasive evaluation for sepsis, potentially harmful antibiotic therapy, and prolonged hospitalization, with its own inherent morbidity.

Cutaneous granulomas in children with combined immunodeficiency

Noninfectious cutaneous granulomas, particularly in an acral distribution, may be an early sign of mixed cellular and humoral immunodeficiency. Special stains of skin biopsy sections and cultures for bacteria, acid-fast bacilli, and fungi are important in eliminating the possibility of underlying pathogens. In three children with combined immunodeficiency and cutaneous granulomas, the administration of moderate- to high-dose systemic corticosteroids was the most effective therapy. However, careful consideration should be given before administering systemic corticosteroids to an immunocompromised patient.