Dermatological manifestations in Costello syndrome: A prospective multicentric study of 31 HRAS-positive variant patients

BACKGROUND

Data on dermatological manifestations of Costello syndrome (CS) remain heterogeneous and lack in validated description.

OBJECTIVES

To describe the dermatological manifestations of CS; compare them with the literature findings; assess those discriminating CS from other RASopathies, including cardiofaciocutaneous syndrome (CFCS) and the main types of Noonan syndrome (NS); and test for dermatological phenotype-genotype correlations.

METHODS

We performed a 10-year, large, prospective, multicentric, collaborative dermatological and genetic study.

RESULTS

Thirty-one patients were enrolled. Hair abnormalities were ubiquitous, including wavy or curly hair and excessive eyebrows, respectively in 68% and 56%. Acral excessive skin (AES), papillomas and keratotic papules (PKP), acanthosis nigricans (AN), palmoplantar hyperkeratosis (PPHK) and 'cobblestone' papillomatous papules of the upper lip (CPPUL), were noted respectively in 84%, 61%, 65%, 55% and 32%. Excessive eyebrows, PKP, AN, CCPUL and AES best differentiated CS from CFCS and NS. Multiple melanocytic naevi (>50) may constitute a new marker of attenuated CS associated with intragenic duplication in HRAS. Oral acitretin may be highly beneficial for therapeutic management of PPHK. No significant dermatological phenotype-genotype correlation was determined between patients with and without HRAS c.34G>A (p.G12S).

CONCLUSIONS AND RELEVANCE

This validated phenotypic characterization of a large number of patients with CS will allow future researchers to make a positive diagnosis, and to differentiate CS from CFCS and NS.

The Patient-Oriented Scoring of Atopic Dermatitis and SCORAD in young children: New data on interpretability and clinical usefulness

BACKGROUND

There is limited data about the clinical meaningfulness of the Scoring of Atopic Dermatitis (SCORAD) and Patient-Oriented SCORAD (PO-SCORAD), particularly in children with mild-to-moderate AD. Regular use of patient-reported outcomes, may deliver more accurate information about the overall health status of AD patients than routine but sparse physician assessments.

OBJECTIVE

To confirm the correlation between SCORAD, PO-SCORAD, Patient-Oriented Eczema Measure (POEM) and Investigator's Global Assessment (IGA). To evaluate the interpretability and clinical usefulness of the SCORAD and PO-SCORAD scores in children.

METHODS

Data were drawn from a 12-week randomized controlled trial in 335 children, aged 2-6 years, with mainly mild-to-moderate AD. Investigators captured SCORAD and IGA at each study visit. Parents used PO-SCORAD twice-weekly, and POEM once-weekly.

RESULTS

There were strong correlations between PO-SCORAD and SCORAD (r = 0.874), PO-SCORAD and POEM (0.734) and PO-SCORAD and IGA (0.613). The best fit ('k' statistic: 0.68) between SCORAD and IGA classes was noted for the following SCORAD categories: <12 (clear/almost clear); 12-25 (mild); and ≥25 (moderate/severe). PO-SCORAD area under the curve over 8 weeks was significantly greater than that of SCORAD (p = 0.0002), giving a better estimate of disease severity between visits. Patients with a flare within the next 7 days had significantly higher PO-SCORAD scores 7 days before the flare (p < 0.0001). Moderate erythema was the most significant flare predictor (p < 0.0001).

CONCLUSION

PO-SCORAD is robust and reliable and appears to warrant far greater utility in routine clinical practice than other scores. PO-SCORAD, used twice-weekly, may improve the management of patients with AD.

cLFM‐Qol : a specific quality of life measurement tool for children from 11 to 15 years with low‐flow malformations

BACKGROUND

Low-flow malformations (LFMs) are rare diseases with a significant impact on health-related quality of life (HRQoL), especially in children. No disease-specific questionnaire is available for children with LFMs.

OBJECTIVE

To develop and validate a specific HRQoL questionnaire for children from 11 to 15 years old suffering from LFMs.

METHODS

A preliminary questionnaire based on a verbatim from focus groups was created and sent to children from 11 to 15 years old suffering from LFMs, together with a dermatology specific and a generic HRQoL questionnaire (cDLQI and EQ-5D-Y).

RESULTS

A total of 75 from 201 included children responded to the questionnaires. The final version of the questionnaire (cLFM-QoL) included 15 questions and was not divisible into subscales. It demonstrated excellent internal consistency (cronbach 0.89), convergent validity and readability (SMOG 6.04). cLFM-QoL mean score (+ SD) was 12.9/45 (8.03) for all grades of severity, for mild 8.22/45 (7.5), moderate 14.03/45 (8.35), severe 12.35/45 (6.59) or very severe patients 20.7/45 (3.39) (p 0.006).

CONCLUSION

cLFM-QoL is a validated short and easy to use specific questionnaire with excellent psychometric capacities. It will be suitable for any children 11 to 15 with LFMs, in daily practice or clinical trials.

IL-4/IL-13 Inhibitors for Atopic Dermatitis Induce Psoriatic Rash Transcriptionally Close to Pustular Psoriasis

Dupilumab is a therapeutic antibody targeting IL-4 and IL-13 receptor subunit alpha used for the treatment of patients with atopic dermatitis (AD). Cases of psoriasis-like reactions induced under dupilumab treatment (dupilumab-induced psoriatic eruption [DI-Pso]) for AD were recently reported. To understand the pathogenesis of DI-Pso, we performed gene expression profiling studies on skin biopsies of DI-Pso (n = 7) compared with those of plaque psoriasis, AD, and healthy controls (n = 4 each). Differential gene expression was performed using enrichment and Gene Ontology analysis. Gene expression was validated by qPCR, and protein levels were assessed by immunohistochemistry. Transcriptomic and protein analysis of DI-Pso compared with that of healthy controls, plaque psoriasis, and AD skins revealed activation of T helper 17/IL-23 pathways associated with a significant expression of IL-36, surrogate marker of pustular psoriasis. By contrast, T helper 2 representative genes' expression was strongly decreased in DI-Pso across comparison. Matching analysis with public data of pustular psoriasis skin corroborated that DI-Pso and pustular psoriasis upstream regulators overlap, greater than the overlap with plaque psoriasis. Furthermore, DI-Pso showed strongly decreased expression of many barrier skin genes compared with healthy controls, plaque psoriasis, and AD. Our data indicate that the pathogenesis of DI-Pso relied on a shift of skin immune responses from a T helper 2 to an IL-36 and T helper 17 polarization and on intensified skin barrier alterations.

Risk of melanoma in congenital melanocytic nevi of all sizes: A systematic review

Congenital melanocytic nevi (CMN) are commonly encountered benign skin lesions in newborns. Larger CMN is associated with a higher lifetime risk of developing melanoma. However, the level of risk is unclear when CMN are small or medium-sized. Our objective was to assess melanoma risk in patients with CMN of all size categories. A literature review with meta-analysis was performed. Prevalence and incidence densities of melanoma at onset were calculated in the entire study population and according to CMN size, type of treatment and location of the CMN. A total of 91 melanomas were reported in 7915 patients (1.15%, 95% CI, 0.93-1.41). The overall incidence density was 0.057% person-years (95% CI_, 0.044-0.071). The risk ratio of melanoma incidence densities was 21.9 (95% CI, 8.55-56.3) in large to giant CMN compared with small to medium CMN at 15 years of age. The incidence density was higher in CMN located on the trunk and as well as in those which were untreated or partially treated versus complete excision. Our review suggests patients with CMN of medium, large and giant size are at risk of melanoma, whereas the risk remains unknown for small CMN.

Effectiveness and safety of dupilumab in the treatment of atopic dermatitis in children (6-11 years): data from a French multicenter retrospective cohort in daily practice

BACKGROUND

Dupilumab is the first biotherapy available for the treatment of moderate-to-severe childhood atopic dermatitis (AD).

OBJECTIVE

The aim of this study was to evaluate the effectiveness and safety of dupilumab in daily practice.

METHODS

Patients aged 6 to 11, who had received a first dose of dupilumab were included in this multicenter retrospective cohort study. The primary endpoint was change in SCORAD after 3 months of treatment. Secondary endpoints were change in IGA score at 3 months, proportion of patients with SCORAD50 and SCORAD75, description of adverse events and proportion of children in our cohort who would be excluded from pivotal phase 3 clinical trial.

RESULTS

80 patients were included. After 3 months of treatment, there was a significant decrease in SCORAD (mean: 21.8 ± 13.8 vs 53.9 ± 18.5; p<0.0001) and IGA (1.3 ± 0.8 vs 3.5 ± 0.7; p<0.0001). Conjunctivitis was observed in 11.3%(n=9/80); 3 patients experienced dupilumab facial redness (DFR); 17.5% (n=14/80) reported injection site reactions; 6.3% (n=5/80) discontinued treatment. 61.2 % (n=49/80) children were ineligible in the phase 3 trial.

LIMITATIONS

There is no control group. Because it was a real life study based on information from patient medical records in a French multicenter cohort, we cannot rule out the presence of reporting bias generated by the use of patient reported characteristics and missing information.

CONCLUSION

These real-life data confirm the efficacy and safety of dupilumab in children with moderate to severe AD extended to dyshidrosis and atopic prurigo but it also revealed a lower frequency of DFR and conjunctivitis. However, administration in injectable form may be a barrier in this age group.

Effectiveness and Safety of Adalimumab, Etanercept and Ustekinumab for Severe Psoriasis in Children Under 12 Years of Age: A French-Italian Daily Practice Cohort (BiPe Jr)

INTRODUCTION

Biological therapies are valuable treatments for severe psoriasis. Children aged under 12 years are underrepresented in therapeutic trials for these drugs. The objective of the 'BiPe Jr' cohort study was to evaluate the drug survival, effectiveness, tolerance and switching patterns of biological therapies in children under 12 years of age with psoriasis.

METHODS

We conducted a multicentre retrospective study of children with psoriasis who received at least one injection of a biological agent, even off-licence, before the age of 12 years in France and Italy, collecting the data between April and August 2021. The data collected were from March 2012 up to August 2021.

RESULTS

In total, 82 children (mean age: 9.1 years; females: 61.0%) received 106 treatments. The drugs administered were adalimumab (n = 49), etanercept (n = 37), ustekinumab (n = 15), anakinra (n = 2), infliximab (n = 2) and secukinumab (n = 1). The most common form of psoriasis was plaque psoriasis (62.9%). The Physician Global Assessment and the Psoriasis Area Severity Index (PASI) scores decreased significantly from baseline to 3 months after treatment initiation for the three main biological drugs; PASI went from 14.1 ± 9.4 to 4.1 ± 11.3 for adalimumab (p = 0.001), 14.9 ± 9.3 to 5.1 ± 4.0 for etanercept (p = 0.002) and 11.6 ± 8.3 to 2.6 ± 2.2 for ustekinumab (p = 0.007). A trend towards higher 2-year maintenance rates was observed for ustekinumab and adalimumab, compared with etanercept (p = 0.06). 52 children discontinued their biological therapy, most frequently due to inefficacy (n = 28) and remission (n = 14). Seven serious adverse events (SAEs) were reported, including four severe infections.

DISCUSSION

Our analyses of drug survival and treatment patterns, combined with those of previous studies conducted in older children, indicate that there is a trend towards higher 2-year survival rates of ustekinumab and adalimumab. The SAEs identified were rare, but highlight the need for increased vigilance concerning infections. Overall, the biological therapies showed good effectiveness and safety profiles when used in daily practice for the treatment of young children with psoriasis.

Treatment of two infants with PIK3CA-related overgrowth spectrum by alpelisib

PIK3CA-related overgrowth spectrum (PROS) includes rare genetic conditions due to gain-of-function mutations in the PIK3CA gene. There is no approved medical therapy for patients with PROS, and alpelisib, an approved PIK3CA inhibitor in oncology, showed promising results in preclinical models and in patients. Here, we report for the first time the outcome of two infants with PROS having life-threatening conditions treated with alpelisib (25 mg) and monitored with pharmacokinetics. Patient 1 was an 8-mo-old girl with voluminous vascular malformation. Patient 2 was a 9-mo-old boy presenting with asymmetrical body overgrowth and right hemimegalencephaly with West syndrome. After 12 mo of follow-up, alpelisib treatment was associated with improvement in signs and symptoms, morphological lesions and vascular anomalies in the two patients. No adverse events were reported during the study. In this case series, pharmacological inhibition of PIK3CA with low-dose alpelisib was feasible and associated with clinical improvements, including a smaller size of associated complex tissue malformations and good tolerability.

Les engelures apparues pendant le confinement sont associées à une exposition au SARS-CoV-2

Introduction

De nombreux cas d’engelures ont été rapportés depuis le début de la pandémie de Covid-19. Cependant, la RT-PCR et la sérologie ne mettaient pas en évidence d’infection à SARS-CoV-2 chez la majorité des patients. L’hypothèse d’une réponse interféron-médiée au SARS-CoV-2, permettant une clairance rapide du virus qui ne pourrait alors pas activer l’immunité humorale, a été soulevée et pourrait expliquer la séronégativité. Notre objectif était de rechercher une association entre les engelures survenues pendant le premier confinement en France et l’exposition au SARS-CoV-2 au sein des foyers.

Matériel et méthodes

Dans cette étude cas-témoins multicentrique, les cas étaient les 102 individus adressés entre mars et mai 2020 aux CHU de Rennes, Nantes, Angers, Tours, et Brest pour des engelures. Les témoins étaient recrutés à partir des fichiers de volontaires sains tenus par ces hôpitaux. Tous les membres de ces foyers étaient inclus, constituant ainsi 77 foyers cas (262 individus) et 74 foyers témoins (230 individus). L’exposition des foyers au SARS-CoV-2 lors du premier confinement était catégorisée en 3 niveaux : faible, intermédiaire ou élevé, à partir d’un algorithme prenant en compte les symptômes, les contacts à risque et les activités hors du foyer des individus de chaque foyer. Une sérologie SARS-CoV-2 était proposée à tous les individus.

Résultats

Après ajustement sur l’âge, l’association entre engelures et exposition au SARS-CoV-2 au sein des foyers de confinement était estimée à 3,3, intervalle de confiance à 95 % (1,4–7,3), pour un niveau d’exposition intermédiaire, et à 6,9 (2,5–19,5) pour un niveau d’exposition élevé au SARS-CoV-2. Parmi les 57 foyers cas ayant eu une sérologie, 6 (11 %) avaient développé des anticorps anti- SARS-CoV-2, alors que tous les foyers témoins testés étaient séronégatifs (n = 50).

Discussion

Cette étude cas-témoin démontre l’association entre engelures et exposition des foyers au SARS-CoV-2 durant le premier confinement. Notre critère de jugement étant déclaratif, un biais de mémorisation était possible. Cependant, même si 20 % des patients étaient classés exposés au SARS-CoV-2 par erreur, la mesure d’association resterait significative.

Reasons for Discontinuation of dupilumab in Adult Atopic Dermatitis in Clinical Practice

Dupilumab, an anti-IL-4ɑ monoclonal antibody, has shown a positive benefit-risk ratio when treating moderate to severe atopic dermatitis (AD) in clinical studies (1). High persistence on dupilumab has recently been reported in clinical-practice setting with 77% of patients remaining in treatment for 12 months in a retrospective study including 1,963 patients with AD but reasons for discontinuation were not investigated (2).

Treatment of Eosinophilic Annular Erythema: Retrospective multicenter study and literature review

BACKGROUND

Eosinophilic annular erythema (EAE) is a rare eosinophil-related skin disease which typically manifests with annular erythematous plaques and severe pruritus. Besides the diagnosis, the treatment of EAE is challenging since relevant published data are sparse.

METHODS

The aim of this study was to assess the underlying diseases, treatments and outcomes of patients with EAE. To this end, we conducted a retrospective multicenter study and a systematic review of the MEDLINE database.

RESULTS

We included 18 patients with EAE followed in 8 centers. The MEDLINE database search yielded 37 relevant publications reporting 55 cases of EAE with 106 treatment sequences. The most common and efficient treatments included topical or systemic corticosteroids, hydroxychloroquine and dapsone. In refractory patients, a combination of systemic corticosteroids with hydroxychloroquine was associated with 88% of complete clinical response.

DISCUSSION

To improve the management of EAE patients, we discuss the following treatment strategy: in topical steroid-resistant patients, hydroxychloroquine can be given as first-line systemic treatment. Dapsone, hydroxychloroquine or systemic corticosteroids are second-line options to consider. Last, monoclonal antibodies or JAK inhibitors targeting type 2 inflammation could represent promising last-resort options in refractory patients.

Long-term Outcome of Chilblains Associated with SARS-CoV-2

Numerous cases of chilblains have been observed in the course if the COVID-19 pandemic. The aims of this study were to provide comprehensive follow-up data for patients reporting chilblains, and to determine the risk factors for incomplete recovery. Patients referred to 5 hospitals in France between March and May 2020 for chilblains were surveyed on December 2020. A teleconsultation was offered. Among 82 patients reporting chilblains, 27 (33%) reported complete recovery, 33 (40%) had recurrences of chilblains after their hands and feet had returned to normal, and 22 (27%) developed persistent acral manifestations, mostly acrocyanosis, with or without further recurrences of chilblains. Most recurrences of chilblains occurred during the following autumn and winter. A past history of chilblains was not associated with recurrences or persistent acral manifestations. Women had a significantly higher risk of developing recurrences or persistent acral manifestations (odds ratio 1.30; 95% confidence interval 1.06–1.59). In conclusion, two-thirds of patients reporting chilblains at the start of the COVID-19 pandemic experienced persistent or recurrent acral manifestations after a 10-month follow-up.

Position statement on the role of nurses in therapeutic patient education in atopic dermatitis

In chronic skin diseases such as atopic dermatitis (AD), therapeutic failure due to poor patient adherence to treatment is commonly reported. Therapeutic patient education (TPE) is an approach to improve self-management and adherence. Several studies demonstrated that TPE programmes have positive effects on disease management resulting in decreased disease severity and improved quality of life in AD patients. Various healthcare professionals (dermatologists, nurses, psychologists, dieticians) have been involved. TPE performed by trained dermatology nurses are highly efficient and improve various health-related outcomes. The aim of this position paper is to analyse the aims, modalities and efficacy of TPE in AD, to identify specific roles of dermatology nurses, to assess qualification requirements, and to propose practical recommendations. Potential activities of nurses in ongoing and future TPE programmes for AD patients will be discussed.

Transient abdominal telangiectasia of the newborn

We report 20 newborns who developed, at a median age of 7 days, large abdominal patches of radially arranged purplish telangiectasia in a bilateral and symmetrical pattern in relation to the midline, creating a "butterfly wing" pattern. Clinical examination was normal in 13 newborns, six newborns had abdominal distention, and one newborn had poor weight gain due to inadequate breastfeeding. Most lesions spontaneously resolved within 3 months and did not reoccur for 19 newborns. Transient abdominal telangiectasia of the newborn (TATN) appears to be a distinctive entity that has not been previously described.

Acute acral eruptions in children during the COVID-19 pandemic: Characteristics of 103 children and their family clusters

Background

A marked increase in frequency of acute acral eruptions (AAE) was observed in children during the COVID-19 pandemic in the spring period.

Objectives

In this observational multicenter study, based on children with AAE, we aimed to assess the proportion of household members possibly infected by SARS-CoV-2.

Methods

We collected data from all children observed with AAE, prospectively from April 7, 2020 to June 22, 2020, and retrospectively since February 28, 2020. The primary outcome was the household infection rate, defined as the proportion of family clusters having at least one member with COVID-19 infection other than the child with AAE (“index child”). The definition of a case was based on characteristic clinical signs and a positive PCR or serology.

Results

The study included 103 children in 10 French departments and in Quebec. The median age was 13 years and the interquartile range [8–15], with a female-to-male ratio of 1/1.15. In children with AAE, all PCR tests were negative (n = 18), and serology was positive in 2/14 (14.3%) cases. We found no significant anomalies in the lab results. A total of 66 of the 103 families (64.1%) of included children had at least one other infected member apart from the index child. The total number of household members was 292, of whom 119 (40.8%) were considered possibly infected by SARS-CoV-2. No index children or households exhibited severe COVID-19.

Discussion

Among the 103 households included, 64.1% had at least one infected member. Neither children with AAE nor their households showed severe COVID-19.

Management of Congenital Melanocytic Naevi in Children: A French National Survey Using Clinical Vignettes

Management of congenital melanocytic naevi in childhood may vary depending on the habits and experience of the treating clinician. The aim of this study was to assess current practice and determinants of surgical excision decision-making among French physicians. A national survey was conducted among dermatologists, paediatricians and surgeons, using clinical vignettes illustrating 29 scenarios. The primary outcome was the decision to perform surgical excision in each vignette. Of the 11,310 decisions made by the 390 participants (257 dermatologists, 35 surgeons, and 98 paediatricians) surgical excision was chosen in 33% of cases. The stated motivations for performing surgical excision were: melanoma risk, aesthetic/psychosocial risk, or both, in 39%, 34% and 27% of cases, respectively. Physicians with a higher level of experience in oncodermatology were more likely to opt for surgical excision. The age of the child, the size of the congenital melanocytic naevi, and the visibility of the lesion had no influence on the decision to perform surgical excision.

Factors influencing quality of life in children with low-flow vascular malformations: a qualitative study using focus groups

BACKGROUND

Very few studies have evaluated the quality of life (QoL) of children suffering from low-flow vascular malformations. This is the first study investigating the influencing factors.

OBJECTIVES

To identify the factors influencing QoL in children with low-flow vascular malformations.

METHODS

We conducted a qualitative study employing focus group interviews (Clinical Trials Number: NCT03440827). The study was a prospective, interventional, non-comparative, multicentre study performed in four expert centres for vascular anomalies. Qualitative data about personal experiences, feelings, difficulties, needs and various factors influencing behaviours were collected. Theme-based content analysis (manual and specialist textural software guided) were used to analyse the verbatim transcripts of all focus group sessions. Manual qualitative discourse analysis was performed to identify the different themes and categories. Informatics' analyses were subsequently performed for each individual category.

RESULTS

Ten focus groups (26 individuals including 10 children aged 11 to 15 years) were conducted until saturation. Influencing factors were related to 4 categories: medical care, self-image, social impact on daily activities and challenging social relationships. These factors were responsible for intrafamily upheavals and may lead to future identity-building problems.

CONCLUSIONS

This study provides an essential framework from which physicians can develop strategies to improve patient care and quality of life. These data may also be useful to develop specific age-sensitive QoL questionnaires.

Rheumatic involvement and bone scan features in Schnitzler syndrome: initial and follow-up data from a single-center cohort of 25 patients

Objective

To report on the characteristics and long-term course of rheumatic manifestations in Schnitzler syndrome (SchS).

Methods

A retrospective cohort study of patients with SchS followed between 2000 and 2020. Inclusion criteria included a diagnosis of SchS (Strasbourg criteria). All available bone scans were reviewed and scored according to the intensity and number of pathological sites. The scintigraphic score was compared with the clinical activity score, CRP level, and treatments.

Results

Twenty-five patients were included. Median age at diagnosis was 68 years. Eighty patients (72%) had SchS-related rheumatic pain. Most patients had a long-standing isolated rash before constitutional and/or rheumatic symptoms appeared. The monoclonal component level was usually very low (IgMκ in 22/25). Rheumatic pain predominated around the knees. Bone scans revealed abnormal tracer uptake in 15/18 (85%). The scintigraphic score correlated with clinical activity (r = 0.4, p < 0.02) and CRP level (r = 0.47, p < 0.01). The scintigraphic score was lower in patients receiving corticosteroids or IL1Ra (interleukin 1 receptor antagonist) than in untreated patients (median scores:2, 0, and 13, respectively; p < 0.05). Two patients developed Waldenström macroglobulinemia. Of the 22 surviving patients, median age at follow-up was 76 years. IL1Ra was used in 13 patients, with dramatic efficacy on both symptoms and bone scan features.

Conclusions

Rheumatic manifestations are very prevalent in SchS. However, bone pain can be misleading and contribute to misdiagnosis. Bone scan abnormalities are very prevalent and correlate with disease activity and treatments. IL1-Ra has a dramatic and durable efficacy but may not be required in every patient early on.

Incontinentia pigmenti in boys: Causes and consequences

INTRODUCTION

Incontinentia pigmenti (IP) is an X-linked genodermatosis caused by mutation of the NEMO/IKBKG gene. While lethal in male foetuses, heterozygous females survive because of X-inactivation mosaicism. Herein we discuss 9 male patients with IP.

MATERIALS AND METHODS

This is an observational, descriptive, retrospective, multicentre, French study carried out with the help of the SFDP research group. Statistical analysis was performed both on our own patients and on those reported in the literature.

RESULTS

Nine boys with no family history of IP but with typical neonatal skin reactions were included. Genetic analysis of blood (n=8) and skin biopsy (n=3) confirmed the diagnosis of IP by identification of common deletion of the IKBKG/NEMO gene (exons 4 to 10) in the state of somatic mosaic in 6 and 2 cases respectively. Where analysed, the karyotype was normal (n=6). Over a median follow-up period of 48 months (3 months to 10 years), 3 patients had neurological abnormalities, 2 had severe ophthalmologic abnormalities, and 1 had dental abnormalities. Extensive skin involvement is a systemic risk factor, unlike cutaneous scarring.

CONCLUSION

IP in boys is often due to a mosaic mutation that should be sought in blood and skin. Long-term neurological and ophthalmological monitoring is essential, especially in cases of extensive skin involvement.

Physiopathologie de la dermatite atopique

Atopic dermatitis is a multifactorial disease due to a combination of genetic and environmental factors. The pathophysiological mechanisms involved in AD are multiple: innate functional abnormality in the skin barrier partly linked to mutations of the filaggrin, a major structural protein of the skin; and genes involved in innate and adaptive immunity; Finally, the model of the hygiene theory has been clarified in recent years: environmental factors alter the diversity of skin and digestive microbiomes, and this diversity seems to play a major role in the development of atopy.

Clinical Profile of Methotrexate-resistant Juvenile Localised Scleroderma

Methotrexate has demonstrated its efficiency for the treatment of juvenile localized scleroderma but some patients may be resistant. The aim of our study was to define the profile of such patients. We performed an observational retrospective multicenter study between 2007 and 2016 and included all children seen in the French Paediatric Dermatology and Rheumatology departments with active localized scleroderma treated by methotrexate for a minimum of 4 months. Metho-trexate efficacy was assessed clinically and/or by imaging between the fourth to twelfth months of treatment. A total of 57 patients were included. Metho-trexate dosage ranged from 7 to 15 mg/m2/week. Only 4 patients were resistant. No common features could be identified between these 4 patients. Children with localized scleroderma are rarely resistant to metho-trexate and we did not identify a clinical profile for those resistant patients.

Effectiveness of an antenatal maternal supplementation with prebiotics for preventing atopic dermatitis in high-risk children (the PREGRALL study): protocol for a randomised controlled trial

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory disease affecting 10%-15% of children in Europe. There is a need for new primary preventive therapeutic strategies in at-risk populations. Recent research has indicated that atopic diseases are associated with a disrupted gut microbial 'balance' in early life raising the possibility that interventions which yield optimal patterns of microflora could improve host's health. Prebiotics, sugars with immunomodulatory properties that stimulate the diversity of the digestive microbiota, are ideal candidates for such research. So far, most clinical trials have focused on improving infant gut colonisation postnatally. However, prenatal life is a crucial period during which different tolerance mechanisms are put in place. We aim to determine whether antenatal prebiotics supplementation prevents AD in high-risk children.

METHODS AND ANALYSIS

This is a randomised, multicentre, double-blind, trial to evaluate the effectiveness of antenatal prebiotic maternal supplementation (galacto-oligosaccharide/inulin) in pregnant women versus placebo on the occurrence of AD at 1 year of age in at-risk children (defined as having a maternal history of atopic disease). Participating women will be randomised to daily ingestion of a prebiotics or placebo (maltodextrin) from 20 weeks' gestation until delivery. The primary outcome is the prevalence of AD at 1 year of age, using the version of the UK Working Party Diagnostic Criteria optimised for preventive studies. Key secondary endpoints are AD severity, quality of life and prebiotics tolerance. The target sample size is 376 women (188 patients per group) which will provide 80% power to detect a 33% reduction of the risk of AD in the verum group (α=0.05). The primary analysis will be based on the intention-to-treat principle.

ETHICS AND DISSEMINATION

Results will be presented in peer-reviewed journals and at international conferences. Ethics approval for the study was obtained from the institutional ethical review board of 'Comité de Protection des Personnes Sud Ouest-Outre-Mer III' of the University Hospital Centre of Bordeaux (2017/13).

TRIAL REGISTRATION NUMBER

NCT03183440; Pre-results.