Scoring the proliferative activity of haemangioma of infancy: the Haemangioma Activity Score (HAS)

BACKGROUND

Haemangioma of infancy (HOI) is the most frequently occurring benign tumour of infancy. A good, reliable and objective scoring system for haemangioma activity is not yet available.

AIM

We have developed a simple system called the Haemangioma Activity Score (HAS) for scoring the (disease) proliferative activity of haemangiomas. The current study was undertaken to validate this system.

METHODS

We validated the HAS in a comparative study of photographs taken during consultations from 2000 until 2008 (n = 78). Agreement between three observers was assessed at two different time points (t(0) and t(1)) with a minimum interval of 6 months between them, using interclass correlation coefficients (ICC).

RESULTS

Agreement between observers was good. The average ICC of the HAS at t(0) and t(1) was 0.72 and 0.76, respectively. The average ICC of the HAS for the changes from baseline (HAS at t(0) minus HAS at t(1) ) was 0.69.

CONCLUSIONS

We conclude that the HAS is a good system for scoring the proliferative activity of haemangiomas, and believe it to be useful in future investigations. The number of studies comparing different therapies for treating haemangiomas is steadily increasing, and the HAS (before and after treatment) may provide a valuable scoring system for evaluating such therapies.

Delayed- and immediate-type reactions in the atopy patch test with food allergens in young children with atopic dermatitis

In recent years, the atopy patch test (APT) has been suggested as an addition in the allergological work-up of children with atopic dermatitis (AD) and suspected food allergy. We initiated a prospective clinical study in children with AD younger than 3 yr, to evaluate the additional clinical value of the APT next to our own standardized allergological work-up in case of a suspected food allergy. One hundred and thirty-five children were included in the study. They were tested using the skin application food test (SAFT), the APT and measurement of specific IgE. The allergens used in the skin tests were freshly prepared food stuffs and included commercially available cow's milk (CM), the egg white of a hard boiled hen's egg and mashed peanuts in a saline solution. Allergy was defined using a flowchart incorporating the results from the SAFT, oral challenges (OCs) and elimination and (re)introduction periods. To determine the additional value of the APT next to the SAFT, we analyzed the SAFT negative patients per allergen and used an exact binary logistic analysis to evaluate the simultaneous effects of the APT and measurement of specific IgE, calculating mutually adjusted odds ratios (ORs) for positive APTs and specific IgE levels above 0.70 U/l. We found clinically relevant food allergies in 23% (egg white) to 28% (CM and peanut) of our study population. Positive SAFT reactions were observed in 14% (peanut), 16% (egg white) and 21% (CM) of our patient population. Next to the SAFT, we did not observe a significant additional value of the APT for the diagnosis of CM or egg white allergy, but we did find a significant additional value for the diagnosis of peanut allergy (OR = 11.56; p < 0.005, 2-sided). In clinical practice this statistically significant value does not exclude the need for OC and controlled elimination and (re)introduction periods due to the presence of false-negative as well as false-positive results in the APT. In conclusion, we could not find enough support for the current addition of the APT to our standardized allergological work-up in young children below the age of 3 yr with AD and suspected food allergy. At the moment the additional value of the classical delayed-type APT next to the SAFT seems to be very limited at best in this study population and does not justify the time-consuming nature of the skin test.

Practical issues on interpretation of scoring atopic dermatitis: the SCORAD index, objective SCORAD and the three-item severity score

It is important to determine the severity of atopic dermatitis (AD) for evaluation of disease improvement after and during therapy. Scoring of the severity of AD is demanded in clinical trials. The European Task Force on Atopic Dermatitis (ETFAD) has developed the SCORAD (SCORing AD) index to create a consensus on assessment methods for AD, so that study results of different trials can be compared. However, modification of the SCORAD index has led on several occasions to wrong and incorrect use of the system. To measure the extent of AD, the rule of nines is applied on a front/back drawing of the patient's inflammatory lesions. The extent can be graded 0-100. The intensity part of the SCORAD index consists of six items: erythema, oedema/papulation, excoriations, lichenification, oozing/crusts and dryness. Each item can be graded on a scale 0-3. The subjective items include daily pruritus and sleeplessness. Both subjective items can be graded on a 10-cm visual analogue scale. The maximum subjective score is 20. All items should be filled out in the SCORAD evaluation form. The SCORAD index formula is: A/5 + 7B/2 + C. In this formula A is defined as the extent (0-100), B is defined as the intensity (0-18) and C is defined as the subjective symptoms (0-20). The maximum SCORAD score is 103. Based on training sessions by the ETFAD, the SCORAD index was modified by excluding the subjective symptoms (objective SCORAD). The objective SCORAD consists of just the extent and intensity items, the formula being A/5 + 7B/2. The maximum objective SCORAD score is 83 (plus an additional 10 bonus points). Bonus points are given for severe disfiguring eczema (on face and hands). The three-item severity (TIS) score involves the scoring of erythema (redness), oedema and excoriations (scratches) in one representative lesion, marked as R-O-S. The TIS score corresponds well with the more detailed objective SCORAD and can be used as a prescreening system or as a quick system in studies and is excellent for epidemiological studies.

Treatment of patients with atopic dermatitis using wet-wrap dressings with diluted steroids and/or emollients. An expert panel's opinion and review of the literature

BACKGROUND

The use of dampened bandages to reduce inflamed eczema (synonyme dermatitis) is an old remedy. In order to evaluate the current indications for so-called wet-wrap treatment (WWT) for atopic dermatitis (AD), and to compare the different currently recognized methods, a group of experts critically reviewed their own expertise on WWT in respect to the existing literature on the subject.

RESULTS

WWT is well tolerated in eczema due to the cooling effect on the skin and the rapid improvement in skin inflammation. It has been shown to be an extremely effective treatment for acute erythrodermic dermatitis, therapy-resistant AD and intolerable pruritus. Advantages of WWT include rapid response to therapy, reduction in itch and sleep disturbance, and potential for reduction in usage of topical corticosteroids (TCS). However, disadvantages include high cost, the necessity for special training in usage, potential for increased TCS absorption, increased cutaneous infections and folliculitis, and poor tolerability. Precautions to reduce the risks of long-term treatment should include education, monitoring of weight and height and, if necessary, serum cortisol levels. In adolescents the risk of striae from TCS absorption around puberty is high, and WWT with TCS in this age group should be used as a short-term therapy only and with extreme caution. To reduce risks, dilutions of steroids may be used ranging from 5 to 10%. In the maintenance phase this treatment can be rotated with the use of emollients only. Low potency TCS should be used on the face (with a mask).

CONCLUSION

WWT using diluted steroids is a relatively safe addition to the therapeutic treatment options for children and adults with severe and/or refractory AD. Explanation and education is extremely important in the treatment of AD and WWT should only be employed by practitioners trained in its use. Specialized nursing care is essential, especially when using WWT for prolonged periods.

A comparison of twice-daily calcipotriol ointment with once-daily short-contact dithranol cream therapy: a randomized controlled trial of supervised treatment of psoriasis vulgaris in a day-care setting

BACKGROUND

Calcipotriol has become a first-line treatment for psoriasis. Its efficacy and safety have been shown in many comparative clinical trials carried out in outpatients. In a comparative study in patients visiting the outpatient department once every 14 days, it was shown that calcipotriol was more effective and better tolerated compared with dithranol.

OBJECTIVES

To compare the clinical efficacy of calcipotriol ointment with that of dithranol cream in a supervised treatment regimen.

METHODS

In a multicentre randomized controlled trial in six centres in the Netherlands, 106 patients with chronic plaque psoriasis were included, 54 receiving calcipotriol ointment twice daily and 52 dithranol cream once daily. Patients were treated at the day-care centre, using the care instruction principle of daily visits during the first week and twice-weekly visits subsequently for up to 12 weeks.

RESULTS

This study failed to prove that calcipotriol is as efficacious as dithranol when used in a day-care setting (noninferiority test). The mean percentage reduction in Psoriasis Area and Severity Index from baseline to end of treatment was 57.0% in the calcipotriol group vs. 63.6% in the dithranol group. However, the two-sided test for superiority indicated no statistically significant difference between the treatment groups (P = 0.39). At the end of treatment, 15% of the patients treated with calcipotriol ointment and 25% of those treated with dithranol cream did not require any further treatment. Although calcipotriol ointment appeared to be more effective during the first 8 weeks, a difference was no longer apparent at 12 weeks. In comparison with the high number of drop-outs due to cutaneous side-effects in the calcipotriol group, the frequency of a tolerable degree of irritation appeared to be higher in patients treated with dithranol. However, concomitant corticosteroid treatment of dithranol irritation in seven patients may have contributed to this difference between both treatments. Moreover, patients receiving therapy with calcipotriol ointment experienced fewer application-related skin and subcutaneous tissue disorders than patients treated with dithranol cream: 21 of 53 (40%) and 37 of 52 (71%), respectively. This difference is statistically significant (P = 0.001).

CONCLUSIONS

The hypothesis that calcipotriol ointment might be at least as effective as dithranol cream in the day-care setting could not be proven in the present study. Whereas calcipotriol has become a mainstay in the routine outpatient treatment of psoriasis not requiring a day-care setting, dithranol treatment, being difficult as a routine outpatient therapy, has increased efficacy and improved tolerability if the treatment is carried out in a day-care setting.

Clobetasol propionate shampoo 0.05% and calcipotriol solution 0.005%: a randomized comparison of efficacy and safety in subjects with scalp psoriasis

BACKGROUND

Scalp involvement in psoriatic patients represents a common issue. Treatment of the hairy skin requires adequate pharmaceutical formulations; hence, a new specific shampoo formulation of clobetasol propionate 0.05% was developed by Galderma R&D, Inc.

METHODS

For this multicenter, randomized, investigator-masked, parallel group study, 151 subjects with moderate to severe scalp psoriasis were randomized to 4 weeks of treatment with clobetasol propionate shampoo or calcipotriol solution.

RESULTS

Clobetasol propionate demonstrated significantly superior efficacy to calcipotriol solution (total severity score: mean difference 0.51, 95% CI 0.05-0.97, p = 0.028; global severity score: mean difference 0.43, 95% CI 0.08-0.78, p = 0.016). Adverse events were more common in the calcipotriol group than in the clobetasol propionate shampoo group. Telangiectasia and skin atrophy did not differ significantly between treatments; however, a burning sensation was significantly more common in the calcipotriol solution group.

CONCLUSIONS

Short contact therapy of scalp psoriasis with this new shampoo formulation of clobetasol propionate was significantly more effective and better tolerated than calcipotriol solution for the treatment of scalp psoriasis.

Treatment of refractory atopic dermatitis using 'wet-wrap' dressings and diluted corticosteroids: results of standardized treatment in both children and adults

BACKGROUND

'Wet-wrap' dressings with diluted corticosteroids form an alternative treatment in patients with refractory atopic dermatitis (AD).

OBJECTIVE

To evaluate a standardized treatment, using wet-wrap dressings with diluted corticosteroids, in patients with refractory AD.

METHODS

Results of treatment, complications and possible side effects were retrospectively evaluated in 14 children and 12 adults.

RESULTS

Skin lesions improved dramatically during 1 week of inpatient treatment. A significant decrease in early-morning serum cortisol levels was measured. Levels below the normal range were only observed after 1 week in 2 adults and on day 4 in 3 children. Suppression of the hypothalamus-pituitary-adrenal-cortex axis in 1 adult and a new exacerbation of AD in 2 children and 3 adults complicated long-term treatment at home. Additional complications included folliculitis, a Pseudomonas aeruginosa infection, a secondary bacterial infection and refractory skin lesions between bandages.

CONCLUSION

Wet-wrap dressings and diluted corticosteroids form an effective treatment in patients with refractory AD.

Childhood discoid lupus erythematosus: report of five new cases and review of the literature

Discoid lupus erythematosus (DLE) is an uncommon disease in childhood. In this paper we present five new cases of childhood DLE. Two of them are identical twin brothers, who developed similar lesions during an interval of 5 years. This is in favour of the hypothesis that both genetic factors and somatic mutations, due to environmental factors, are implicated in the pathogenesis. A review of the English language literature is also presented. In order to have better epidemiological data on this disease, all cases of childhood DLE, including those published in non-English literature and those not yet published, should be placed together and analysed.

Treatment and pain relief of ulcerative hemangiomas with a polyurethane film

BACKGROUND

Hemangiomas are the most common tumors occurring in young children. The most common complication in the growing phase of hemangioma is ulceration.

AIM AND METHOD

We report healing, pain relief and evolutive effects of a polyurethane film in 8 cases with ulcerative hemangiomas.

RESULTS

In all 8 infants, prompt pain relief and healing within 1-2 months were observed. An increased regression was also noted within 2-4 months, when the hemangiomas were in the normal proliferative phase.

CONCLUSION

As far as the authors know, there is no explanation for the effectiveness of polyurethane film. Explanations could be the occlusive effects of the film inhibiting proliferation or the decrease in blood flow. As primary initial therapeutic approach in ulcerative hemangiomas, we advocate the application of a polyurethane film. This therapy is painless and suitable for children.

Cutis marmorata telangiectatica congenita: clinical features in 35 cases

OBJECTIVE

To evaluate the distribution of skin lesions, clinical features, and associated abnormalities in children with cutis marmorata telangiectatica congenita at onset and during follow-up.

DESIGN

Retrospective survey of the available medical data with an average follow-up of 1 year 5 months (range, 0-7 years).

SETTING

Pediatric Dermatology Unit (Department of Dermatovenereology) of the Sophia Children's Hospital in Rotterdam, the Netherlands.

PATIENTS

The diagnosis of cutis marmorata telangiectatica congenita was clinically established in 35 patients between July 1988 and February 1997. In 33 cases, the typical mottled, blue-violet pattern was present from birth and was readily visible at rest. In 2 cases, the skin lesions initially appeared less reticulated, mimicking a capillary malformation.

RESULTS

The skin lesions were almost generalized in 4 children (11%), whereas they were more localized in the other 31 children (89%). Associated anomalies, usually minor and sometimes questionable, were noted in 80% of the patients. Most patients showed a definite improvement of their mottled vascular skin lesions within 2 years. The lesions had totally disappeared, or only faded residual lesions remained.

CONCLUSIONS

We believe that cutis marmorata telangiectatica congenita is a relatively mild condition. The prognosis is usually good, with minor associated anomalies. Improvement of the mottled, vascular pattern is usually observed within 2 years. We recommend careful clinical examination of all patients to exclude any associated anomalies. Patients should be referred to a neurologist or an ophthalmologist only if symptoms are present or if vascular lesions are present around the eyes.

Diagnostic tests in children with atopic dermatitis and food allergy

BACKGROUND

Skin testing is a common diagnostic procedure in food allergy. The skin prick test is the test of first choice for investigating the immediate IgE-mediated reaction. The skin application food test (SAFT) has been developed on the basis of the mechanism of the contact urticaria syndrome (CUS).

METHODS

We studied the relevance of the SAFT in children younger than 4 years with atopic dermatitis and (suspected) food allergy as compared with the prick-prick test, the radioallergosorbent test (RAST), and the oral challenge. In the skin tests, we used fresh food, in the same state as it was consumed.

RESULTS

There was a good agreement between the SAFT and the prick-prick test. A moderate agreement was observed between the SAFT and the serologic test (RAST). Significantly more positive results in the RAST were observed than in the SAFT. There was very good agreement between the SAFT and the oral challenge (kappa = 0.86).

CONCLUSIONS

The SAFT is a reliable and child-friendly skin test for evaluating (suspected) food allergy in children younger than 4 years with atopic dermatitis. The very good correlation with the oral challenge indicates that one may probably consider the SAFT a "skin provocation" in children younger than 4 years.

Prilocaine/lidocaine patch as a local premedication for skin biopsy in children

BACKGROUND

Prilocaine-lidocaine emulsion (EMLA) has been used successfully as a local anesthetic in patients undergoing superficial procedures.

OBJECTIVE

The purpose of this study was to investigate the analgesic effect of the patch as a local anesthetic for children undergoing a skin biopsy procedure. The effect on both the pain at the injection site and the pain of the biopsy was investigated.

METHODS

The study was randomized, double blinded, and placebo controlled. Of the 63 children randomly recruited into the study, 60 children were evaluated; the remaining three were withdrawn from the study.

RESULTS

The anesthetic patch was significantly more effective than the placebo patch in decreasing pain at the injection site. No significant difference in pain scores of the biopsy procedure was found between the study groups. No serious side effects were observed.

CONCLUSION

The anesthetic patch reduced the pain experienced by children subjected to a skin biopsy procedure.

Topical calcipotriol in childhood psoriasis

BACKGROUND

The use of topical calcipotriol in adults with psoriasis is safe and effective.

OBJECTIVE

Our purpose was to study the efficacy and safety of calcipotriol in children.

METHODS

A multicenter, prospective, 8-week, double-blind, parallel group study was conducted in 77 children. Response to treatment was assessed by means of the Psoriasis Area and Severity Index (PASI) in that the intensity of redness, thickness, and scaliness as well as the area involved are scored. The children were 2 to 14 years of age and had stable psoriasis, involving less than 30% of the body surface. Forty-three children were assigned to receive calcipotriol ointment and 34 to receive placebo. Nine children dropped out of the study, six in the calcipotriol-treated group and three in the placebo-treated group.

RESULTS

Both treatment groups (calcipotriol and placebo) showed significant improvement in PASI from baseline to the end of treatment, and the difference was not statistically significant. No serious side effects, in particular including those relating to calcium and bone metabolism, were recorded.

CONCLUSION

Calcipotriol ointment was statistically significantly more effective than its vehicle in terms of the investigator's overall assessment and reduction in redness and scaliness but not in terms of PASI score.

Purpura caused by Emla is of toxic origin

Emla cream has been widely used as a local anaesthetic for superficial procedures. Blanching and redness are commonly observed side-effects. We observed purpura in 5 patients after application of Emla. Other authors have not reported this before. In 4 patients, purpura was observed after 30 min Emla application before the treatment of mollusca contagiosa. In 1 patient, Emla was used for 60 min before taking a lip biopsy. In these patients, patch tests were performed with the individual ingredients of Emla cream, Emla cream itself, placebo cream, and Tegaderm plaster. All tests were negative at an early reading after 30 min as well as after 2 and 3 days. We concluded that the purpuric reaction was not of an allergic nature. Possibly, it was caused by a toxic effect on the capillary endothelium.

Treatment of molluscum contagiosum using a lidocaine/prilocaine cream (EMLA) for analgesia

Eighty-three 4- to 12-year-old children, scheduled for curettage of at least five molluscum contagiosum lesions, participated in a double-blind study. The children were randomly allocated to receive lidocaine/prilocaine (EMLA) cream (n = 58) or placebo cream (n = 25), applied 15, 30, or 60 minutes before treatment. The pain was assessed by the children and the physician as none, slight, moderate, or severe. In addition, the children rated the pain on a visual analog scale. EMLA cream effectively prevented the pain after all three application times (p less than 0.01). No significant difference in pain was observed among the 15-, 30-, and 60-minute EMLA-treated groups, but the proportion of children reporting no pain on the verbal scale increased from 36% in the 15-minute group to 61% in the 60-minute group. In the placebo group, only one of 24 children (4%) reported no pain. Transient local redness was the only skin reaction noted. In conclusion, an application time of EMLA cream of less than 60 minutes is satisfactory for the curettage of molluscum contagiosum in children.