Risk factors and outcomes of melanoma in children and adolescents: A retrospective multicenter study

BACKGROUND

Pediatric melanoma presents with distinct clinical features compared to adult disease.

OBJECTIVE

Characterize risk factors and negative outcomes in pediatric melanoma.

METHODS

Multicenter retrospective study of patients under 20 years diagnosed with melanoma between January 1, 1995 and June 30, 2015 from 11 academic medical centers.

RESULTS

Melanoma was diagnosed in 317 patients, 73% of whom were diagnosed in adolescence (age ≥11). Spitzoid (31%) and superficial spreading (26%) subtypes were most common and 11% of cases arose from congenital nevi. Sentinel lymph node biopsy was performed in 68% of cases and positive in 46%. Fatality was observed in 7% of cases. Adolescent patients with melanoma were more likely to have family history of melanoma (P = .046) compared to controls.

LIMITATIONS

Retrospective nature, cohort size, control selection, and potential referral bias.

CONCLUSION

Pediatric melanoma has diverse clinical presentations. Better understanding of these cases and outcomes may facilitate improved risk stratification of pediatric melanoma.

Melanoma-like features in pediatric longitudinal melanonychia: A systematic review and meta-analysis

BACKGROUND

Pediatric longitudinal melanonychia (LM) can exhibit atypical features that mimic red-flag signs for subungual melanoma in adults and lead to diagnostic uncertainty. Nail biopsy may be unnecessary if clinical inspection and dermoscopy suggest a benign nature.

METHODS

We searched PubMed and Embase from inception to February 2023 for studies of any design reporting either the number or proportion of clinical and dermoscopic features in at least five children (≤18 years) with LM. Non-English articles, reviews, and abstracts were excluded. We performed a systematic review and meta-analysis to collate all existing data.

RESULTS

A total of 1218 articles were screened and 24 studies with 1391 pediatric patients were included. Nevus was the most common diagnosis (86.3%). The most prevalent sites were fingernails (76.2%) and first digits (45.4%). Pooled proportions of common features were: dark-color bands (69.8%), multi-colored bands (47.6%), broad bandwidth (41.1%), pseudo-Hutchinson sign (41.0%), irregular patterns (38.1%), Hutchinson sign (23.7%), dots and globules (22.5%), nail dystrophy (18.2%), and triangular sign (10.9%). Outcomes included progression (widening or darkening, 29.9%), stability (23.3%), and spontaneous regression (narrowing or fading, 19.9%). Only eight cases of subungual melanoma in situ were reported, and no invasive melanomas were identified.

CONCLUSION

Although atypical characteristics are common in pediatric LM, the probability of malignant transformation is exceedingly low. Appropriate evaluation and management of pediatric LM includes careful clinical and dermoscopic inspection with attention to benign features followed by long-term interval follow-up.

Features, management, and outcomes of pediatric scalp melanomas

Pediatric melanoma of the scalp has the highest mortality of any anatomic location. We describe five pediatric patients with a diagnosis of scalp melanoma receiving care at Massachusetts General Hospital and/or Boston Children's Hospital from 2018 through 2022. Melanoma presented in diverse contexts: cellular blue nevus-associated, compound nevus-associated, spitzoid, nodular, and superficial spreading subtypes. This study describes a range of melanoma presentations and emphasizes the need for additional compilation of data on pediatric scalp melanomas to promote their recognition and improve patient care.

Updates in the Management of Congenital Melanocytic Nevi

Congenital melanocytic nevi (CMN) carry an increased risk of melanoma and may be disfiguring, and consensus regarding treatment recommendations is lacking. While clinical monitoring is the standard of care, many caregivers are interested in its removal to prevent psychosocial burden or to decrease risk. Although melanoma can occur regardless of CMN removal, there are a variety of treatments that may offer improved cosmesis or local symptom control, including surgical excision, laser therapy, and other superficially destructive techniques. Regardless of the selected management, these patients are monitored for ongoing melanoma risk. An extensive discussion with families regarding the risks and benefits of observation versus active intervention is essential. To facilitate these discussions, we herein summarize current CMN management strategies and considerations.

Early Detection and Prognostic Assessment of Cutaneous Melanoma: Consensus on Optimal Practice and the Role of Gene Expression Profile Testing

Importance

Therapy for advanced melanoma has transformed during the past decade, but early detection and prognostic assessment of cutaneous melanoma (CM) remain paramount goals. Best practices for screening and use of pigmented lesion evaluation tools and gene expression profile (GEP) testing in CM remain to be defined.

Objective

To provide consensus recommendations on optimal screening practices and prebiopsy diagnostic, postbiopsy diagnostic, and prognostic assessment of CM.

Evidence Review

Case scenarios were interrogated using a modified Delphi consensus method. Melanoma panelists (n = 60) were invited to vote on hypothetical scenarios via an emailed survey (n = 42), which was followed by a consensus conference (n = 51) that reviewed the literature and the rationale for survey answers. Panelists participated in a follow-up survey for final recommendations on the scenarios (n = 45).

Findings

The panelists reached consensus (≥70% agreement) in supporting a risk-stratified approach to melanoma screening in clinical settings and public screening events, screening personnel recommendations (self/partner, primary care provider, general dermatologist, and pigmented lesion expert), screening intervals, and acceptable appointment wait times. Participants also reached consensus that visual and dermoscopic examination are sufficient for evaluation and follow-up of melanocytic skin lesions deemed innocuous. The panelists reached consensus on interpreting reflectance confocal microscopy and some but not all results from epidermal tape stripping, but they did not reach consensus on use of certain pigmented lesion evaluation tools, such as electrical impedance spectroscopy. Regarding GEP scores, the panelists reached consensus that a low-risk prognostic GEP score should not outweigh concerning histologic features when selecting patients to undergo sentinel lymph node biopsy but did not reach consensus on imaging recommendations in the setting of a high-risk prognostic GEP score and low-risk histology and/or negative nodal status.

Conclusions and Relevance

For this consensus statement, panelists reached consensus on aspects of a risk-stratified approach to melanoma screening and follow-up as well as use of visual examination and dermoscopy. These findings support a practical approach to diagnosing and evaluating CM. Panelists did not reach consensus on a clearly defined role for GEP testing in clinical decision-making, citing the need for additional studies to establish the clinical use of existing GEP assays.

Dynamic evolution of a scalp congenital melanocytic nevus with poliosis and cutis verticis gyrata

Cutis verticis gyrata (CVG), characterized by cerebriform overgrowth of the scalp, is rarely observed in congenital melanocytic nevi (CMN). We describe a 13-year-old male with autism and a large CMN of the scalp with numerous satellite nevi whose scalp nevus exhibited evolution with poliosis and CVG. Given the potential association of CVG (independent of CMN) with seizures, neuropsychiatric, and ophthalmologic disorders, and nevus-associated CVG (cerebriform intradermal nevus) with melanoma, multidisciplinary evaluation of CMN patients with CVG is important to guide management and treatment.

Tumor necrosis factor-alpha inhibitors and acne fulminans: Friend or foe?

Acne fulminans (AF) is an uncommon variant of inflammatory acne with abrupt eruption of painful nodules, pustules, and hemorrhagic ulcerations, often associated with systemic symptoms. Paradoxical adverse reactions to tumor necrosis (TNF)-alpha inhibitors have been reported, and rare cutaneous complications include pyoderma gangrenosum, Sweet syndrome-like hypersensitivity eruptions, and pustular folliculitis. We report an unusual case of AF in a patient with Crohn disease that worsened with doses of adalimumab, which is considered a second-line treatment for AF. This case highlights that acneiform eruptions may be an underreported paradoxical adverse reaction to anti-TNF alpha therapy.

Central nervous system magnetic resonance imaging abnormalities and neurologic outcomes in pediatric patients with congenital nevi: A 10-year multi-institutional retrospective study

BACKGROUND

High-risk congenital melanocytic nevi (CMN) are associated with abnormalities of the central nervous system (CNS), prompting magnetic resonance imaging (MRI) screening guidelines.

OBJECTIVE

Describe MRI brain and spine abnormalities in children with CMN and report trends between nevus features, MRI findings, and neurologic outcomes.

METHODS

Retrospective review of individuals aged ≤18 years with an MRI of the brain and/or spine and at least 1 dermatologist-diagnosed CMN.

RESULTS

Three hundred fifty-two patients were identified. Forty-six children had CMN that prompted an MRI of the brain and/or spine (50% male, average age at first image, 354.8 days). In these children, 8 (17%) had melanin detected in the CNS, of whom all had >4 CMN. One developed brain melanoma (fatal). In patients without CNS melanin, 4 had concerning imaging. Concerning MRI patients had more neurodevelopmental problems, seizures, neurosurgery, and death than individuals with unremarkable imaging. Three hundred six patients received MRIs for other reasons; none detected melanin. No children with only multiple small CMN (n = 15) had concerning imaging.

LIMITATIONS

Lack of a control group, cohort size, and retrospective methods.

CONCLUSION

MRI of the brain and spine is useful for detecting intervenable abnormalities in high-risk children. Healthy infants with few small CMN may not require screening MRI.

Patient and caregiver perspectives on delayed childhood Gorlin syndrome diagnoses

The diagnostic trends of Gorlin syndrome (GS) in the pediatric population are not well understood. In an international survey conducted by the Gorlin Syndrome Alliance, 118 individuals who were diagnosed with GS when aged 18 years and under provided information about their diagnosis. Oral surgeons and dermatologists were the most commonly reported physicians involved in diagnosis for 48.3% and 28% of cases, respectively. For 50% of children, the diagnosis was made within a year from presenting sign(s), while 27% report over 4 years to receive GS diagnosis. Of individuals who reported >4 years between presenting signs and diagnosis, 81.3% attributed the delay to insufficient medical team knowledge and 65.6% attributed to lack of personal awareness that presenting signs were related to GS, emphasizing the need for patient and physician education of GS for prompt diagnosis.

Pediatric Lichen Myxedematosus: A Diagnostic and Management Challenge

Localized lichen myxedematosus (LM) is a rare, idiopathic mucinosis characterized by dermal mucin deposition and variable fibroblast proliferation. Nodular lichen myxedematosus, a clinicopathologic subtype of localized LM, is exceedingly rare in pediatric patients with only three prior cases reported. Understanding of LM in pediatric patients is limited by the rarity of the disease, and diagnosis is complicated by overlapping clinical and histopathologic features. There is no standardized treatment for localized LM and treatment is largely dictated by a patient’s desire to minimize cosmetic disfigurement. This case series reports two additional patients with juvenile nodular lichen myxedematosus, highlights the limitations of existing diagnostic criteria, and describes successful treatment of one patient with intralesional triamcinolone.

Topical therapy for regression and melanoma prevention of congenital giant nevi

Giant congenital melanocytic nevi are NRAS-driven proliferations that may cover up to 80% of the body surface. Their most dangerous consequence is progression to melanoma. This risk often triggers preemptive extensive surgical excisions in childhood, producing severe lifelong challenges. We have presented preclinical models, including multiple genetically engineered mice and xenografted human lesions, which enabled testing locally applied pharmacologic agents to avoid surgery. The murine models permitted the identification of proliferative versus senescent nevus phases and treatments targeting both. These nevi recapitulated the histologic and molecular features of human giant congenital nevi, including the risk of melanoma transformation. Cutaneously delivered MEK, PI3K, and c-KIT inhibitors or proinflammatory squaric acid dibutylester (SADBE) achieved major regressions. SADBE triggered innate immunity that ablated detectable nevocytes, fully prevented melanoma, and regressed human giant nevus xenografts. These findings reveal nevus mechanistic vulnerabilities and suggest opportunities for topical interventions that may alter the therapeutic options for children with congenital giant nevi.

Genomic comparison of malignant melanoma and atypical Spitz tumor in the pediatric population

BACKGROUND/OBJECTIVES

The diagnostic distinction between atypical Spitz tumor (AST) and malignant melanoma (MM) in pediatric tumors is challenging. Molecular tests are increasingly used to characterize these neoplasms; however, limited studies are available in pediatric patients. This study aimed to provide a genomic comparison of pediatric MM and AST in the context of comprehensive clinical annotation.

METHODS

Pediatric patients diagnosed with MM (n=11) and AST (n=12) were compared to a cohort of 693 adult melanoma patients. DNA next-generation sequencing assessed kinase gene fusions, tumor mutational burden, sequence variants, copy number alterations, structural variants, microsatellite instability, and mutational signatures.

RESULTS

Seven AST cases and eight MM cases were successfully sequenced. Kinase gene fusions were identified in both the MM and AST cohorts (NTRK1, ROS1, and MET). MM cases had TERT, BRAF, and CDKN2A alterations, which were not identified in the AST cohort. Tumor mutational burden (TMB) analysis showed pediatric ASTs had an average of 2.82 mutations/Mb, pediatric MM had an average of 5.7 mutations/Mb, and adult MM cases averaged 18.8 mut/Mb. One pediatric MM case had an elevated TMB of 15 mutations/Mb and a UV mutational signature.

CONCLUSIONS

These data expand our understanding of pediatric malignant melanoma. The differences between the molecular signatures for AST and MM are not statistically significant, and histopathology remains the gold standard for the diagnosis of pediatric AST and MM at this time. With more data, molecular studies may provide additional support for diagnosis and targeted therapeutics.

Care of Congenital Melanocytic Nevi in Newborns and Infants: Review and Management Recommendations

A pediatric dermatology expert working group performed a narrative review to describe care related to congenital melanocytic nevi (CMN) in neonates and infants. There are no published guidelines for most aspects of care, including routine skin care and visit intervals. Few guidelines exist for surgical management; newer recommendations favor conservative practice. Emerging evidence contributes to recommendations for screening MRI to evaluate for neural melanosis and related central nervous system complications, however, more research is needed. Risk for melanoma is generally low, but those with large, giant, or multiple CMN have a higher risk. Multidisciplinary care, with a focus on family and patient preferences, is of paramount importance. Without standardized screening and management guidelines, questions abound regarding appropriate physical examination intervals, potential treatment including full or partial excision, timing and frequency of imaging, melanoma risk, and assessment for neural melanosis. This review highlights the current state of knowledge concerning care of patients with CMN, reveals gaps in the literature surrounding skin care, and provides management recommendations. We additionally discuss cutaneous complications of CMN, such as pruritus, hypertrichosis, and wound healing. Resources and references for families and providers can help patients navigate this sometimes challenging diagnosis. Finally, we contribute expert care recommendations to the current body of literature as a foundation for the development of future, more comprehensive care guidelines.

Pigmented Lesions in Children: Update on Clinical, Histopathologic and Ancillary Testing

Patients are commonly referred to pediatric dermatology for the evaluation of pigmented lesions. For families, pediatricians, and dermatologists alike, malignancy is the main fear. In the past few decades, there has been evolving literature to inform diagnosis and management. This article provides an update on the clinical, histopathologic, and ancillary testing for 3 categories of particularly challenging pigmented lesions: congenital melanocytic nevi, spitzoid neoplasms, and pediatric melanoma.

Language-centered approach to care improvement in a pediatric dermatology clinic

Language-congruent care can improve clinical outcomes. As a quality improvement initiative supported by the Department of Dermatology at Massachusetts General Hospital, the American Academy of Dermatology, and the Society for Pediatric Dermatology, our group established monthly pediatric dermatology "Spanish clinics" that scheduled Spanish-speaking patients on the same day and utilized a dedicated, live interpreter who stayed with the clinical team throughout the clinic. Patients reported high satisfaction scores, averaging 9.8 out of 10, and 90.5% of patients preferred this model to traditional appointments. Our participating physician found "Spanish clinics" allowed for more efficient care not only in the monthly pilot clinics, but in all clinics occurring during the time period.

Topical corticosteroids for noninvasive treatment of pyogenic granulomas

Pyogenic granulomas are benign vascular proliferations of the skin and mucous membranes that tend to bleed easily. They typically require procedural treatments that can be difficult for patients with intellectual disabilities or behavioral concerns to tolerate. In our practice, we have found the use of topical clobetasol to be effective to induce regression of cutaneous pyogenic granulomas. We present here a case of an adolescent patient with autism and two bleeding pyogenic granulomas who poorly tolerated a biopsy of the first lesion and could not tolerate subsequent procedures. Topical therapy with clobetasol effectively managed the second pyogenic granuloma, an approach representative of a noninvasive practice utilized in our clinic.

Evaluation of electronic consults for outpatient pediatric patients with dermatologic complaints

BACKGROUND

Although dermatologic complaints are frequently encountered by pediatricians, access to pediatric dermatologists remains limited. Teledermatology has been proposed to expand access to dermatologic care for children. We report our experience with a physician-to-physician store-and-forward teledermatology service (eConsults), focusing on patient and consult characteristics and their relationship with teledermatologist confidence and follow-up recommendations as well as clinical outcomes.

METHODS

We reviewed electronic health records of all pediatric patients referred through eConsults at the Massachusetts General Hospital from 1/13/2020 to 7/17/2020. We assessed pediatrician and parental receptiveness with a confidential survey.

RESULTS

A total of 302 referrals (median patient age 4.6 years (IQR 0.6-12); 54% female) and 310 cases were completed in 1.8 days on average (SD = 1.2). Teledermatologists rated their confidence as definite and moderate in 51.3% and 39.4% cases, respectively. Teledermatologists felt comfortable managing rashes remotely, but patients with alopecia, pigmented and vascular lesions, and warts frequently required formal dermatology evaluation. Among patients seen subsequently, full concordance was seen for 70.1% of diagnoses and 74.4% of management recommendations. All responding pediatricians were satisfied with the service, and 97.5% felt that the parents were receptive to it.

CONCLUSIONS

Our study supports the growing evidence that store-and-forward teledermatology can quickly and effectively provide the access to pediatric dermatologic care and is well received by pediatricians and parents. To maximize cost-effectiveness of store-and-forward teledermatology, dermatologists should work with referring providers to improve the quality of submitted photographs and patient history as well as advise in-person referrals for cases likely to require further follow-up.

Solitary congenital lip pit in an infant

Lower lip pits are infrequent, affecting fewer than 1 in 75 000 individuals. While more frequently associated with inherited syndromes, isolated lower lip pits may present sporadically as a solitary congenital anomaly. We describe an otherwise healthy 9-day-old infant who presented with a congenital lower lip lesion with unremarkable family history and testing. The appropriate workup for a solitary congenital lip nodule, differential diagnosis, and management of lip pits is described.

Disparities in telemedicine access for Spanish-speaking patients during the COVID-19 crisis

The rapid rise of telemedicine during the COVID-19 pandemic raised the prospect of worsening health care disparities for vulnerable populations. We retrospectively compared pediatric teledermatology visits scheduled during the pandemic (03/17/2020-07/31/2020) with in-person appointments scheduled during the same period in 2019 and found that Spanish-speaking patients had significantly fewer scheduled appointments in 2020 (9% vs 5%, P < .001). Among the telemedicine cohort, Spanish-speaking patients were less likely to have an email address documented within the electronic medical record and less likely to have activated an online patient portal account prior to their visit during the pandemic (45% vs 62%, P = .017, and 23% vs 66%, P < .001, respectively). Our findings suggest that email connectedness may represent a bottleneck in telemedicine access for Spanish-speaking pediatric dermatology patients.

Fatal GNAQ-mutated CNS melanoma in an adolescent with nevus of Ota

Nevus of Ota is an uncommon benign mesodermal melanosis that involves the first and second divisions of the trigeminal nerve. Primary non-cutaneous melanoma often involves distinct genetic mutations compared to cutaneous melanoma. In primary central nervous system (CNS) melanomas associated with nevus of Ota, somatic mutations most commonly occur at the Q209 and R183 residues of GNAQ and likely induce tumorigenesis through upregulation of the MAP kinase pathway. This case underscores the importance of elucidating neurologic symptoms early in patients with nevus of Ota, as a delayed presentation of CNS melanoma could portend a devastating outcome.

An Innovative Model for Providing Dermatology Services Within Primary Care

OBJECTIVE

Dermatologic complaints are common in outpatient pediatrics. However, pediatric dermatology specialty care can be difficult to access. We aimed to test the feasibility of co-locating dermatology services within primary care and increase the proportion of patients treated for basic skin complaints within the medical home while decreasing wait times.

METHODS

The Rapid Assessment of Skin Health (RASH) clinic was created within a hospital-based primary care clinic in 11/2013. The clinic was staffed by 2 pediatricians trained in the dermatology department and supported with specialist advice as needed. Referral volume and wait times to dermatology and RASH clinic were tracked for visits between 11/1/12 and 10/31/18. A chart review was also conducted on a subset of RASH clinic visits. Primary care providers (PCPs) were surveyed about their experiences.

RESULTS

Fifty-eight percent of patients referred for a dermatologic complaint were scheduled in RASH clinic. Wait times for new patient appointments in RASH clinic were significantly shorter than for new dermatology appointments in the previous 12 months (mean 36 days vs 65 days, P < .001). The monthly number of referrals to dermatology also decreased significantly after the RASH clinic opened (24/month vs 12/month, P < .001). Ten percent of RASH patients were referred on to dermatology. In a survey of PCPs (N = 67), 76% said the RASH clinic was "extremely/very helpful."

CONCLUSIONS

Providing dermatologic care to low or moderate complexity patients within the medical home is feasible and leads to better access to care. This innovative model could be spread to other clinics and subspecialties.

Pediatric dermatology eConsults: Reduced wait times and dermatology office visits

BACKGROUND/OBJECTIVES

Store-and-forward teledermatology provides pediatricians with specialist guidance in managing skin disease. This study evaluates wait times and face-to-face (FTF) dermatology visit avoidance associated with a pediatric dermatology eConsult program at an urban academic medical center.

METHODS

In this retrospective cohort study, electronic medical records were reviewed for patients under age 18 for whom a dermatology eConsult was completed between November 1, 2014, and December 31, 2017. Wait times for eConsult completion and initial FTF dermatology appointments were calculated and compared to average wait times for new patient dermatology office appointments from 2016 to 2017. Recommendations for FTF dermatology visits were assessed, along with FTF visit attendance and potential cost savings.

RESULTS

One hundred eighty pediatric patients with 188 unrelated skin conditions ("cases") were referred to the program. Of 188 cases, FTF dermatology visits were recommended for 60 (31.9%). Actual FTF dermatology visit avoidance was 53.7% of total cases (n = 101 for whom FTF visit was not recommended and no dermatology visit occurred within 90 days after eConsult submission). The program generated potential savings of $24 059 ($9840 out-of-pocket) in 2016 dollars. Average turnaround for eConsult completion was 1.8 calendar days (median: 1 calendar day, target: 2 business days). Average wait time to initial FTF dermatology evaluation was 37.3 calendar days (versus 54.1 days for pediatric patients referred directly to dermatology clinic between 2016 and 2017).

CONCLUSION

Pediatric dermatology eConsults reduce wait times for specialist care, triage cases for in-office evaluation, reduce need for FTF dermatology visits, and offer potential cost savings for payers and patients.

Trends in pediatric skin cancer

PURPOSE OF REVIEW

To inform pediatric providers of the clinical characteristics, underlying genetic drivers, and therapeutic options for skin cancer arising in childhood and adolescence.

RECENT FINDINGS

The incidence of melanoma in pediatric patients has been declining in the past decades. Pediatric-specific diagnostic criteria should be utilized when assessing lesions concerning for melanoma to better account for the different presentations seen in pediatric disease compared with adults, such as an increased prevalence of amelanotic melanoma or frequent mimic of benign pediatric lesions. Pediatric melanoma often presents with a higher histopathologic stage and a higher Breslow depth as compared with adult melanoma. Pediatric nonmelanoma skin cancer including basal cell carcinoma and squamous cell carcinoma are associated with genetic conditions and immunosuppression, both iatrogenic and inherited.

SUMMARY

Melanoma in pediatric patients often presents differently from conventional adult melanoma, including Spitz melanoma and melanoma associated with congenital melanocytic nevi. Pediatric patients with nonmelanoma skin cancers should be evaluated for predisposing risk factors. More research on therapeutic options for pediatric skin cancer is vital to understanding the tolerance and response of our pediatric patients to therapies that are more frequently utilized in adult disease.

A pediatric approach to management of skin growths in basal cell nevus syndrome

Little guidance on management of basal cell nevus syndrome in children exists. We report a case series of four patients diagnosed with BCNS in early childhood, in whom several highly suspicious lesions were biopsied, but several smaller and questionably concerning lesions were treated with therapies that are more tolerable for children, including topical imiquimod, 5-fluorouracil, cryotherapy, or touch electrodessication following topical anesthetic cream. These therapies were well tolerated, and all residual or persistent lesions were subsequently biopsied and found to be benign. This approach is often preferable for pediatric BCNS patients, in whom concerning lesions can be identified clinically and managed compassionately. However, any lesion that exhibits growth, bleeding, or symptoms should be biopsied for definitive diagnosis.

Sun exposure and protection practices in children after allogeneic hematopoietic stem cell transplantation: A Survey-Based Cross-Sectional Cohort Study

BACKGROUND/OBJECTIVE

Pediatric hematopoietic stem cell transplantation (HSCT) patients are at an increased risk for skin cancers. Sun exposure is a significant modifiable environmental risk factor. While patient education on sun protection and avoidance behaviors with regular dermatology evaluations are crucial for pediatric HSCT patients, the real-life practice of these sun-protection recommendations in this patient population compared to their peers is unknown.

METHODS

A survey-based cross-sectional cohort study was performed in pediatric HSCT patients seen at the Dana-Farber Cancer Institute and Boston Children's Hospital over a 1.5-year period compared with age/sex/Fitzpatrick skin phototype-matched healthy controls. Study participants were surveyed using the validated Glanz survey for pediatric sun protection behavioral research.

RESULTS

Eighty-five pediatric HSCT patients and 85 controls completed the study. Pediatric HSCT patients more frequently used sunscreen, hats, umbrellas, and sunglasses and obtained full-body skin exams compared to controls. No difference was observed in sun exposure during hours of peak sun intensity, frequency of purposeful tanning, tanning bed use, and the number of painful sunburns received between pediatric HSCT patients and controls.

CONCLUSIONS

Although pediatric HSCT patients practice more sun protection behaviors, they experienced harmful sunburns and intentional tanning behaviors at the same rate as their peers. Patient-directed counseling and strategies to improve patient adherence to optimal sun protection behaviors could have a significant impact on the dermatology quality of life in pediatric HSCT patients.

Risk Factors and Outcomes of Nonmelanoma Skin Cancer in Children and Young Adults

OBJECTIVE

To identify risk factors associated with nonmelanoma skin cancer (NMSC) occurrence and survival in children.

STUDY DESIGN

This was a multicenter, retrospective, case-control study of patients <20 years of age diagnosed with NMSC between 1995 and 2015 from 11 academic medical centers. The primary outcome measure was frequency of cases and controls with predisposing genetic conditions and/or iatrogenic exposures, including chemotherapy, radiation, systemic immunosuppression, and voriconazole.

RESULTS

Of the 124 children with NMSC (40 with basal cell carcinoma, 90 with squamous cell carcinoma), 70% had at least 1 identifiable risk factor. Forty-four percent of the cases had a predisposing genetic condition or skin lesion, and 29% had 1 or more iatrogenic exposures of prolonged immunosuppression, radiation therapy, chemotherapy, and/or voriconazole use. Prolonged immunosuppression and voriconazole use were associated with squamous cell carcinoma occurrence (cases vs controls; 30% vs 0%, P = .0002, and 15% vs 0%, P = .03, respectively), and radiation therapy and chemotherapy were associated with basal cell carcinoma occurrence (both 20% vs 1%, P < .0001). Forty-eight percent of initial skin cancers had been present for >12 months prior to diagnosis and 49% of patients were diagnosed with ≥2 skin cancers. At last follow-up, 5% (6 of 124) of patients with NMSC died. Voriconazole exposure was noted in 7 cases and associated with worse 3-year overall survival (P = .001).

CONCLUSIONS

NMSC in children and young adults is often associated with a predisposing condition or iatrogenic exposure. High-risk patients should be identified early to provide appropriate counseling and management.

Correction to: Medical Options for the Adjuvant Treatment and Management of Pediatric Melanoma

Study NCT01519323 (A study of vemurafenib in pediatric patients with stage IIIC or stage IV melanoma harbouring BRAFV600 mutations) was included in a table listing ongoing clinical trials of adjuvant therapies for pediatric melanoma (Table 1) in error. The study was in fact closed early due to low enrollment as correctly noted in section 4 of the article.

Clinical features and outcomes of spitzoid proliferations in children and adolescents

BACKGROUND

Spitzoid proliferations range from Spitz naevi to melanomas. There are few studies describing clinical features and outcomes in the paediatric population.

OBJECTIVES

To determine the clinical features and outcomes of a large paediatric cohort with histopathologically confirmed Spitz tumours.

METHODS

This was a retrospective cohort study of patients seen at Boston Children's Hospital who were aged < 20 years and had a histopathological diagnosis of spitzoid proliferation from 1 January 1994 to 23 October 2012.

RESULTS

In total 595 patients with 622 spitzoid proliferations were identified (median age 7·4 years, interquartile range 4·6-11·7). Overall 512 proliferations (82·3%) were typical, 107 (17·2.%) were atypical and three (0·5%) were melanomas. The median ages at biopsy were 7·4, 7·2 and 17·2 years, respectively, and there was a significant difference in age at biopsy for patients with typical or atypical proliferations vs. melanoma (P < 0·01). Among samples with positive margins (n = 153), 55% (54 of 98) of typical proliferations, 77% (41 of 53) of atypical proliferations and 100% (two of two) of melanomas were re-excised. Six patients had sentinel lymph node biopsy performed, with three patients demonstrating nodes positive for melanocytic cells. Within a median follow-up of 4·1 years for the full cohort there were no related deaths.

CONCLUSIONS

Spitz tumours have strikingly benign outcomes in the paediatric population, although this study is limited by the low number of melanomas and restriction to a single paediatric institution. Aggressive management recommendations should be reconsidered for children and adolescents with banal-appearing Spitz naevi, based on the clinically indolent behaviour in this cohort.

Associations of Eczema Severity and Parent Knowledge With Child Quality of Life in a Pediatric Primary Care Population

We investigated factors associated with quality of life (QOL) in children with eczema. We conducted a cross-sectional analysis of survey data from 224 parents of children with eczema attending a large, hospital-based pediatric clinic. Parents completed a validated eczema severity scale (Patient-Oriented Eczema Measure), a QOL scale (Infants' Dermatitis QOL Index or Children's Dermatology Life Quality Index), and a knowledge and understanding questionnaire. In adjusted multivariate analyses, worse eczema severity was associated with worse overall QOL (β = 0.5; 95% confidence interval [CI] = [0.5, 0.6]), while a higher knowledge score was associated with better QOL (β = -3.4; 95% CI = [-6.6, -0.2]). Similarly, even after adjustment for eczema severity, greater understanding of a child's individual treatment plan was associated with better QOL (β = -0.7; 95% CI = [-1.4, -0.08]), while increased frequency of worrying about a child's eczema was associated with worse QOL (β = 0.7; 95% CI = [0.03, 1.1]). These results suggest primary care providers may be able to influence QOL through optimal eczema management and family education.