Oral propranolol in the treatment of proliferating infantile haemangiomas: British Society for Paediatric Dermatology consensus guidelines

BACKGROUND

Infantile haemangiomas (IH) are the most common vascular tumours of infancy. Despite their frequency and potential complications, there are currently no unified U.K. guidelines for the treatment of IH with propranolol. There are still uncertainties and diverse opinions regarding indications, pretreatment investigations, its use in PHACES (posterior fossa malformations-haemangiomas-arterial anomalies-cardiac defects-eye abnormalities-sternal cleft and supraumbilical raphe) syndrome and cessation of treatment.

OBJECTIVES

To provide unified guidelines for the treatment of IH with propranolol.

METHODS

This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face-to-face multidisciplinary panel meeting and anonymous voting.

RESULTS

The expert panel achieved consensus on 47 statements in eight categories, including indications and contraindications for starting propranolol, pretreatment investigations, starting and target dose, monitoring of adverse effects, the use of propranolol in PHACES syndrome and how to stop treatment.

CONCLUSIONS

These consensus guidelines will help to standardize and simplify the treatment of IH with oral propranolol across the U.K. and assist in clinical decision-making.

Future research into the treatment of vitiligo: where should our priorities lie? Results of the vitiligo priority setting partnership

BACKGROUND

Vitiligo is the most frequent depigmentation disorder of the skin and is cosmetically and psychologically devastating. A recently updated Cochrane systematic review 'Interventions for vitiligo' showed that the research evidence for treatment of vitiligo is poor, making it difficult to make firm recommendations for clinical practice.

OBJECTIVES

To stimulate and steer future research in the field of vitiligo treatment, by identifying the 10 most important research areas for patients and clinicians.

METHODS

A vitiligo priority setting partnership was established including patients, healthcare professionals and researchers with an interest in vitiligo. Vitiligo treatment uncertainties were gathered from patients and clinicians, and then prioritized in a transparent process, using a methodology advocated by the James Lind Alliance.

RESULTS

In total, 660 treatment uncertainties were submitted by 461 participants. These were reduced to a list of the 23 most popular topics through an online/paper voting process. The 23 were then prioritized at a face-to-face workshop in London. The final list of the top 10 treatment uncertainties included interventions such as systemic immunosuppressants, topical treatments, light therapy, melanocyte-stimulating hormone analogues, gene therapy, and the impact of psychological interventions on the quality of life of patients with vitiligo.

CONCLUSIONS

The top 10 research areas for the treatment of vitiligo provide guidance for researchers and funding bodies, to ensure that future research answers questions that are important both to clinicians and to patients.

Systemic allergic contact dermatitis to 8-methoxypsoralen (8-MOP)

Photochemotherapy with psoralens and UVA (PUVA) is widely used in the treatment of psoriasis and many other skin conditions. Cutaneous adverse reactions to 8-methoxypsoralen (8-MOP) appear to be rare and may be difficult to distinguish from phototoxicity or UV-induced polymorphic light eruption. We describe a patient who had a systemic allergic contact dermatitis to 8-MOP develop during her second course of PUVA treatment for psoriasis.

Extension of life-span with superoxide dismutase/catalase mimetics

We tested the theory that reactive oxygen species cause aging. We augmented the natural antioxidant systems of Caenorhabditis elegans with small synthetic superoxide dismutase/catalase mimetics. Treatment of wild-type worms increased their mean life-span by a mean of 44 percent, and treatment of prematurely aging worms resulted in normalization of their life-span (a 67 percent increase). It appears that oxidative stress is a major determinant of life-span and that it can be counteracted by pharmacological intervention.

Trichophyton tonsurans tinea capitis and tinea corporis: treatment and follow-up of four affected family members

We report a Caucasian family of two veterinary practitioners and their two children, ages 2 years and 6 months, simultaneously infected with the dermatophyte Trichophyton tonsurans, causing tinea capitis and tinea corporis in the children and tinea corporis in the parents. The parents and older child were successfully treated with oral terbinafine. The infant clinically responded to treatment with topical terbinafine and ketoconazole shampoo but presented with recurrent tinea capitis 12 months later, from which T. tonsurans was cultured. At this time, scalpbrush samples from the other family members failed to culture any fungi, and neither were fungi isolated from the family hairbrushes. The infant then received oral terbinafine, resulting in clinical and mycologic cure. After a further 12 months follow-up, there has been no mycologic evidence of recurrence in any family member.

Does oral isotretinoin prevent Propionibacterium acnes resistance?

Oral and topical antibiotics play a major role in acne therapy. Physicians base treatment choices on personal perceptions of efficacy, cost-effectiveness or risk-benefit ratios and rarely take bacterial resistance into account. Propionibacterium acnes isolates resistant to one or more anti-acne antibiotics have been reported in Europe, the USA, Japan and New Zealand. Therapeutic failure on some but not all antibiotic regimens is an increasing management problem. In Leeds, UK, resistant strains are found in 60% of acne patients and 50% of close contacts. Recommendations for the use of antibiotics in acne therapy to help prevent the emergence of resistance in P. acnes include the implementation of antibiotic usage policies and the encouragement of improved prescribing habits. Strategies to reduce the resistant P. acnes population are necessary. This paper reports preliminary data demonstrating that oral isotretinoin (Roaccutane/Accutane) significantly reduces total numbers of resistant P. acnes on the skin of all patients.

Social support and adverse pregnancy outcome in a high-risk population

Low birth weight is a significant health problem in the United States, particularly among poor women. By combining traditional predictors of birth weight with social support indicators, we were able to substantially improve the discrimination between the highest birth weight quartile from the lowest among high-risk gravidae receiving first time prenatal care at the Albany, New York, County Department of Health. The impact of traditional predictors and social support indicators varied considerably between African-American and white women. Providers of care to poor women can utilize this information to maximize the likelihood of a good birth outcome.