Rosacea Core Domain Set for Clinical Trials and Practice: A Consensus Statement

Importance

Inconsistent reporting of outcomes in clinical trials of rosacea is impeding and likely preventing accurate data pooling and meta-analyses. There is a need for standardization of outcomes assessed during intervention trials of rosacea.

Objective

To develop a rosacea core outcome set (COS) based on key domains that are globally relevant and applicable to all demographic groups to be used as a minimum list of outcomes for reporting by rosacea clinical trials, and when appropriate, in clinical practice.

Evidence Review

A systematic literature review of rosacea clinical trials was conducted. Discrete outcomes were extracted and augmented through discussions and focus groups with key stakeholders. The initial list of 192 outcomes was refined to identify 50 unique outcomes that were rated through the Delphi process Round 1 by 88 panelists (63 physicians from 17 countries and 25 patients with rosacea in the US) on 9-point Likert scale. Based on feedback, an additional 11 outcomes were added in Round 2. Outcomes deemed to be critical for inclusion (rated 7-9 by ≥70% of both groups) were discussed in consensus meetings. The outcomes deemed to be most important for inclusion by at least 85% of the participants were incorporated into the final core domain set.

Findings

The Delphi process and consensus-building meetings identified a final core set of 8 domains for rosacea clinical trials: ocular signs and symptoms; skin signs of disease; skin symptoms; overall severity; patient satisfaction; quality of life; degree of improvement; and presence and severity of treatment-related adverse events. Recommendations were also made for application in the clinical setting.

Conclusions and Relevance

This core domain set for rosacea research is now available; its adoption by researchers may improve the usefulness of future trials of rosacea therapies by enabling meta-analyses and other comparisons across studies. This core domain set may also be useful in clinical practice.

Idiopathic calcinosis cutis in an infant: The importance of a wait-and-see approach

A healthy 2-year-old girl presented with multiple asymptomatic subcutaneous nodules on both legs. Histologically demonstrated calcium deposition within the dermis and subcutaneous tissue consistent with calcinosis cutis. Laboratory abnormalities, underlying genetic conditions, and potential triggering factors were ruled out. The lesions resolved over an 18-month period without treatment, emphasizing the importance of the wait-and-see approach in idiopathic cases of calcinosis cutis.

Conradi-Hünermann-Happle syndrome with minimal signs

A 4-year-old girl presented with congenital patches of scalp alopecia, which on physical examination, was consistent with blaschkolinear alopecic patches with mild epidermal atrophy. Similar atrophic hypopigmented patches were seen on the trunk and proximal extremities. With the clinical suspicion of Conradi-Hünermann-Happle syndrome, genetic testing was performed and revealed a mutation in the EBP gene. Despite characteristic cutaneous findings, no skeletal, ocular, or other anomalies were found on further evaluation.

Suspected COVID-19-related reticulated purpura of the soles in an infant

A growing number of skin lesions during the COVID-19 pandemic are being recognized. Acral ischemic lesions identical to chilblains are most typical in children and young adults. We report an infant girl, aged 1 month and 29 days, with a peculiar reticulated purpuric eruption on her soles, with positive immunohistochemistry for SARS-CoV-2 in the endothelia of dermal blood vessels. The patient had an excellent outcome without specific therapy.

Childhood rosacea and related disorders

Rosacea is a chronic inflammatory condition that affects the skin and the eyes. The pathogenesis of rosacea is complex and includes the interaction between genetic and environmental factors, dysregulation of the innate immune system, neurovascular modifications and the interaction with skin commensals. Clinical manifestations in children include the telangiectatic form, papulopustular rosacea, ocular rosacea, periorificial dermatitis, granulomatous rosacea and idiopathic facial aseptic granuloma. Management is aimed at identifying and avoiding triggers. Topical therapy is used for mild cases with topical antibiotics and anti-inflammatory agents. Oral agents are indicated, in combination with topical therapy, for moderate to severe cases. Prolonged therapy may be required.

SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases

Background

Chilblains (‘COVID toes’) are being seen with increasing frequency in children and young adults during the COVID‐19 pandemic. Detailed histopathological descriptions of COVID‐19 chilblains have not been reported, and causality of SARS‐CoV‐2 has not yet been established.

Objectives

To describe the histopathological features of COVID‐19 chilblains and to explore the presence of SARS‐CoV‐2 in the tissue.

Methods

We examined skin biopsies from seven paediatric patients presenting with chilblains during the COVID‐19 pandemic. Immunohistochemistry for SARS‐CoV‐2 was performed in all cases and electron microscopy in one.

Results

Histopathology showed variable degrees of lymphocytic vasculitis ranging from endothelial swelling and endotheliitis to fibrinoid necrosis and thrombosis. Purpura, superficial and deep perivascular lymphocytic inflammation with perieccrine accentuation, oedema, and mild vacuolar interface damage were also seen. SARS‐CoV‐2 immunohistochemistry was positive in endothelial cells and epithelial cells of eccrine glands. Coronavirus particles were found in the cytoplasm of endothelial cells on electron microscopy.

Conclusions

Although the clinical and histopathological features were similar to other forms of chilblains, the presence of viral particles in the endothelium and the histological evidence of vascular damage support a causal relation of the lesions with SARS‐CoV‐2. Endothelial damage induced by the virus could be the key mechanism in the pathogenesis of COVID‐19 chilblains and perhaps also in a group of patients severely affected by COVID‐19 presenting with features of microangiopathic damage.

What is already known about this topic?

Despite the high number of cases of chilblains seen during the COVID‐19 pandemic, a definite causative role for SARS‐CoV‐2 has not yet been proven.

Different pathogenetic hypotheses have been proposed, including coagulation anomalies, interferon release and external factors.

What does this study add?

The demonstration of SARS‐CoV‐2 in endothelial cells of skin biopsies by immunohistochemistry and electron microscopy confirms that these lesions are part of the spectrum of COVID‐19.

Virus‐induced vascular damage and secondary ischaemia could explain the pathophysiology of COVID‐19 chilblains.

Our findings support the hypothesis that widespread endothelial infection by SARS‐CoV‐2 could have a pathogenetic role in the severe forms of COVID‐19.

Linked Comment:  Wetter. Br J Dermatol 2020; 183:611.

Erythema multiforme-like lesions in children and COVID-19

During examination of cases of chilblains in children and adolescents, we identified four patients who also showed skin lesions similar to erythema multiforme (EM). They had no other known triggers for EM. One of them had a positive PCR for SARS-CoV-2, while the other three were negative. Skin biopsies from two patients showed features not typical of EM, such as deep perivascular and perieccrine infiltrate and absence of necrosis of keratinocytes. Immunohistochemistry for SARS-CoV/SARS-CoV-2 spike protein showed granular positivity in endothelial cells and epithelial cells of eccrine glands in both biopsies. All patients had an excellent outcome, and had minimal or no systemic symptoms. The coincidence of EM, a condition commonly related to viruses, and chilblains in the setting of COVID-19, and the positivity for SARS-CoV/SARS-CoV-2 spike protein by immunohistochemistry strongly suggest a link between EM-like lesions and SARS-CoV-2.

Chilblains in children in the setting of COVID-19 pandemic

BACKGROUND

Different skin manifestations of COVID-19 are being reported. Acral lesions on the hands and feet, closely resembling chilblains, have been recognized during the peak incidence of the COVID-19 pandemic.

MATERIAL AND METHODS

A retrospective review of 22 children and adolescents with chilblain-like lesions seen over a short period of time in the Emergency Department of a children's hospital during the peak incidence of COVID-19 in Madrid, Spain.

RESULTS

All patients had lesions clinically consistent with chilblains of the toes or feet, with three also having lesions of the fingers. Pruritus and mild pain were the only skin symptoms elicited, and only 10 had mild respiratory and/or GI symptoms. None had fever. Coagulation tests, hemogram, serum chemistry, and lupus anticoagulant were normal in all patients tested. One out of 16 tested cases had elevated D-dimer results, but without systemic symptoms or other laboratory anomalies. SARS-CoV-2 PCR tested in 19 cases was positive in just one case. Skin biopsies obtained in six patients were consistent with chilblains. On follow-up, all cases showed spontaneous marked improvement or complete healing.

CONCLUSION

Acute chilblains were observed during COVID-19 pandemic in children and teenagers. It is a mildly symptomatic condition with an excellent prognosis, usually requiring no therapy. Etiopathogenesis remains unknown.

A case of mid-face toddler excoriation syndrome (MiTES)

The term mid-face toddler excoriation syndrome (MiTES) has been proposed to describe a rare condition that arises in infancy as is characterized by self-inflicted excoriations. It is considered to be a milder variant of hereditary sensory-autonomic neuropathy (HSAN) type VIII. We present an 8-year-old boy with lesions on the mid-face that were admittedly self-induced and associated with an abnormally high pain threshold. The diagnosis and management of MiTES is reviewed.

Papillary hemangioma in a child and sonographic characterization

Papillary hemangioma (PH) is a rare, benign, vascular tumor that usually appears on the scalp and face and is reported most frequently in adults. We present a pediatric case of PH and provide sonographic features that may assist in establishing the diagnosis.

Spitz Nevus and Other Spitzoid Tumors in Children. Part 2: Cytogenetic and Molecular Features. Prognosis and Treatment

Melanocytic neoplasms with spitzoid morphology (Spitz nevi, atypical Spitz tumors, and spitzoid melanomas) may be benign or malignant. Because the malignant potential of atypical Spitz tumors is uncertain, the proper therapeutic approach has been much debated over the years. Promising new techniques for molecular analysis have enabled better predictions of the biological behavior of these tumors. We review their cytogenetic features and prognosis and also provide an update of the most recent recommendations for management.

Use of topical rapamycin in the treatment of superficial lymphatic malformations

BACKGROUND

The superficial lymphatic component of vascular malformations poses a significant treatment challenge. It is responsible for the majority of symptoms presented, and to date, there is no consensus regarding treatment.

OBJECTIVE

To evaluate the effectiveness of topical rapamycin in treating superficial lymphatic malformations (LM).

METHODS

A case series study was performed of patients with superficial LM, treated with topical rapamycin. The clinical characteristics of patients and the concentration and application mode of the drug were recorded. The changes in the signs and symptoms observed and associated adverse effects were noted and analyzed.

RESULTS

The study population consisted of 11 patients of an average age of 10.5 years. All were treated with topical rapamycin: 6 patients with a 1% concentration, 1 with a 0.8% concentration, and 4 with a 0.4% concentration. Changes in the clinical appearance of the lesions were observed in all patients. The associated symptoms, present in 9 of 11 patients, improved in every case. The mean follow-up time was 16.1 months.

LIMITATIONS

This study is retrospective, with a small sample size and considerable heterogeneity of lesions and treatment approaches.

CONCLUSION

Treatment with topical rapamycin modifies the clinical appearance and alleviates symptoms of superficial LM.

Viral exanthems in children: A great imitator

Viral exanthems are frequent in children and are mostly self-limited. Early recognition and differentiation from other childhood illnesses are important to direct further investigations and treatment initiation. The clinical presentation of viral exanthems in children includes a polymorphic spectrum of skin eruptions ranging from classic viral exanthems to "atypical" presentations that can mimic nonviral diseases; thus, viral exanthems of childhood can be readily diagnosed on clinical grounds, but not rarely do they represent a diagnostic challenge. In this review, we focus on viral diseases in children that may be difficult to diagnose due to their clinical similarities with nonviral diseases, and we offer clues for the differential diagnosis and proper diagnostic testing in such cases.

Superimposed linear atopic dermatitis

Superimposed linear atopic dermatitis is rarely manifested in polygenic disease as a counterpart to type 2 segmental mosaicism of monogenic skin diseases. Linear arrangement following Blaschko lines represents more severe disease on a generalized background of atopic dermatitis, perhaps reflecting clonal loss of heterozygosity. Only three cases of superimposed linear atopic dermatitis have been reported; we describe three additional cases.

Chronic urticaria in infants as the first manifestation of autoinflammatory disease

We report two unrelated infants in whom chronic urticaria was the first clinical manifestation of cryopyrin-associated periodic syndrome, which should be suspected in infants with early-onset chronic urticaria, especially if there is a neutrophil-rich infiltrate in the skin biopsy. Early diagnosis of cryopyrin-associated periodic syndrome may lead to early and successful treatment with anti-interleukin-1 medications.

A Retrospective Study of Systemic Treatment of Severe Atopic Dermatitis With Azathioprine: Effectiveness and Tolerance in 11 Pediatric Patients

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that typically affects children. Severe forms may have a profound effect on patients' quality of life. Some forms are resistant to conventional treatment and require the use of systemic immunosuppressants such as azathioprine (AZA) to adequately manage the disease.

OBJECTIVE

To evaluate the effectiveness and tolerance of AZA in children with severe AD.

PATIENTS AND METHODS

We performed a retrospective study of children with severe AD treated with AZA between January 2007 and May 2017.

RESULTS

We reviewed the cases of 11 patients (6 boys and 5 girls) with a mean age of 13 years (range, 8-18 years). The mean (SD) age at start of treatment was 10.9 (2.2) years (95% CI 8.6-13.1). The mean initial dosage of AZA was 1.8 (0.2) mg/kg/d. We evaluated treatment response after 4 weeks, 12 to 16 weeks, and 6 months. Mean treatment duration was 10.8 (5.7) months. Treatment had to be suspended in 2 patients because of adverse effects. Seven of the 9 remaining patients presented complete or almost complete clearance of the AD after 6 months of treatment.

CONCLUSION

In our experience, AZA is well tolerated and may be considered as a treatment option in children with severe AD resistant to conventional treatment.

Methotrexate for severe nummular eczema in children: Efficacy and tolerability in a retrospective study of 28 patients

BACKGROUND/OBJECTIVES

Nummular eczema in children is a chronic condition characterized by pruritic coin-shaped eczematous lesions that affect any part of the body and often become exudative. Mid- to high-potency topical corticosteroids are considered the mainstay treatment, but there are limited data on the use of systemic therapy for nummular eczema in children. The objective of the current study was to evaluate the efficacy and safety of methotrexate in children with severe nummular eczema.

METHODS

A retrospective review was undertaken of children with nummular eczema treated with methotrexate between January 2007 and May 2017.

RESULTS

The records of 28 patients (24 male, 4 female) with a mean age at the beginning of treatment of 7.8 ± 1.6 years (95% confidence interval (CI) = 6.1-9.4 years) were reviewed. The median duration of treatment was 12.6 ± 3.3 months (95% CI = 9.2-16 months), and 14 patients were still undergoing methotrexate therapy at the time of last review. Ten patients (35.7%) had complete or almost complete clearance of eczema (> 90% improvement), 13 (46.4%) had marked improvement (50%-89%), four had mild improvement (< 50%), and one failed methotrexate therapy. Gastrointestinal intolerance (21.4%) and a nonsignificant increase in liver enzymes (17.9%) were the most frequent side effects. No serious adverse events were noted.

CONCLUSION

Methotrexate is an effective, well-tolerated treatment in children with moderate to severe nummular eczema that has failed to respond to conventional topical therapy.

Omeprazole-induced hypertrichosis in two children

Omeprazole significantly increases duodenal prostaglandin E₂ synthesis. Prostaglandins are involved in hair growth regulation: prostaglandin E₂ and prostaglandin F₂ alpha stimulate hair growth, and prostaglandin D₂ has an inhibitory effect. The use of omeprazole can cause acquired generalized hypertrichosis by increasing prostaglandin E₂ levels.

Ultrasound findings in idiopathic facial aseptic granuloma: Case series and literature review

Idiopathic facial aseptic granuloma is an inflammatory nodule commonly located on the cheeks and eyelids in young children. Despite its prolonged course, it tends toward spontaneous resolution, so invasive diagnostic procedures should be avoided. Cutaneous ultrasound is a noninvasive modality that has been found to improve the diagnostic accuracy of nodular skin lesions. We report five children with idiopathic facial aseptic granuloma in whom high-resolution ultrasound examination provided distinctive findings.

Identical COL71A1 heterozygous mutations resulting in different dystrophic epidermolysis bullosa phenotypes

Dystrophic epidermolysis bullosa is a rare blistering condition caused by mutations in the COL7A1 gene. Different clinical variants have been described, with dominant and recessive inheritance, but no consistent findings have been elucidated to establish a genotype-phenotype correlation. We present three unrelated patients with two identical pathogenic compound heterozygous mutations in the COL7A1 gene that developed different clinical forms of dystrophic epidermolysis bullosa-epidermolysis bullosa pruriginosa and mild recessive non-Hallopeau-Siemens-raising the possibility of other genetic or environmental modifying factors responsible for the phenotype of the disease.

Cutaneous and Systemic Findings in Mosaic Neurofibromatosis Type 1

BACKGROUND/OBJECTIVES

Mosaic neurofibromatosis type 1 (MNF1) is a variant of neurofibromatosis type 1 (NF1) in which clinical manifestations are limited to one or several body segments. The objective was to characterize the cutaneous features and associated systemic findings in a cohort of children with MNF1.

METHODS

We performed a retrospective study of 40 children diagnosed with MNF1 at the Department of Dermatology, Hospital Infantil Niño Jesús, Madrid, Spain, from January 1, 1986, to October 31, 2015.

RESULTS

All patients had pigmentary changes, alone (n = 39) or in combination with neurofibromas (n = 1). Twenty-four cases fulfilling the definition of MNF1 had six or more café au lait spots with or without freckling within the affected segment. They all lacked any other National Institutes of Health criteria of NF1. No patient had juvenile xanthogranuloma (JXG) or nevus anemicus (NA). Two children with MNF1 had epilepsy and two others developed malignancy (Hodgkin's lymphoma and ganglioneuroblastoma).

CONCLUSIONS

Pigmentary changes are the most frequent presentation of MNF1 in children. MNF1 must be considered with segmentary distribution of freckling and café au lait spots. Other frequent cutaneous findings in NF1, such as JXG or NA, seem to be exceptional in MNF1. Although the possibility of systemic complications and cancer risk seem to be low, patients must be followed up.

Autoinflammatory Diseases in Pediatric Dermatology-Part 2: Histiocytic, Macrophage Activation, and Vasculitis Syndromes

The discovery of new autoinflammatory syndromes and novel mutations has advanced at breakneck speed in recent years. Part 2 of this review focuses on vasculitis syndromes and the group of histiocytic and macrophage activation syndromes. We also include a table showing the mutations associated with these autoinflammatory syndromes and treatment alternatives.

A Case with Juvenile Xanthogranuloma and Progressive Nodular Histiocytosis Overlap

A patient with overlap between juvenile xanthogranuloma and progressive nodular histiocytosis is presented. He had progressive, superficial, small, yellow-reddish papules and large dermal nodules, consistent with progressive nodular histiocytosis. Histopathology showed distinctive features of juvenile xanthogranuloma. Our patient reinforces the view that progressive nodular histiocytosis is not a distinct clinical entity, but an evolutionary form of juvenile xanthogranuloma.

Two cases of overlap severe cutaneous adverse reactions to benznidazole treatment for asymptomatic Chagas disease in a nonendemic country

Chagas disease is a parasitosis endemic to South America. It is normally treated with benznidazole as first choice, which has been associated with numerous cutaneous reactions. However, very few benznidazole-associated severe cutaneous adverse reactions have been reported to date. The rise of Chagas disease in nonendemic countries represents a growing public health challenge. We report two patients who met the criteria for drug reaction with eosinophilia and systemic symptoms syndrome and Stevens-Johnson syndrome/toxic epidermal necrolysis according to the RegiSCAR scoring systems. They were thus deemed overlapping cases, with a lymphocyte transformation test positive for benznidazole. Both required intensive care unit admission and both survived. Considering the rising application of this drug for trypanosomiasis in immigrant populations, clinicians should be aware of this newly reported, potentially life-threatening risk.

Two small yellowish papules in a 1 year-old boy: cutaneous leishmaniasis

Cutaneous leishma iasis (CL) is zoonosis with a spectrum of cutaneous manifestations caused by protozoan parasites of thegenus Leishmania.Manifestation varies according to the parasite virulence and the host immune response. Pentavalent antimonials (sodium stibogluconate and meglumine antimoniate) have been used as a first-line therapy for the last 70 years around the world.We report a case of a 1-year-old boy with two small yellowish papules mimicking juvenile xantogranuloma diagnosed with cutaneous leishmaniasis after a biopsy. Patient underwent treatment with 2 sessions of intralesional (IL) meglumine antimoniate (Glucantime®) with complete clearance of both lesions.

CONCLUSION

Cutaneous leishmaniasis treatment is difficult to standardize; treatment options in children include wound careand watchful waiting,  intralesional pentavalent antimonials, topical paramomycin, or oral miltefosine.

Two Cases of Autosomal Recessive Congenital Ichthyosis due to CYP4F22 Mutations: Expanding the Genotype of Self-Healing Collodion Baby

Collodion babies are born with a tight, shiny cast that sheds in a few weeks. After shedding, most patients will display features of autosomal recessive congenital ichthyosis (ARCI) later in life but in up to 10% of cases, the skin eventually becomes normal or only minimally involved, a phenotype called self-healing collodion baby (SHCB), which is considered as ARCI subtype in the 2010 consensus classification of congenital ichthyosis. The term self-improving collodion ichthyosis (SICI) has been proposed for these patients. SHCB/SICI was initially associated with mutations in the gene TGM1. However, some cases showing ALOX12B and ALOXE3 gene mutations have also been reported. We report two cases of SHCB/SICI showing homozygous mutations in the gene CYP4F22.