Pediatric periorificial dermatitis

Periorificial dermatitis (POD) has been documented in the pediatric population in patients as young as 3 months, with a slight predominance in girls compared to boys. Many patients have a personal or family history of atopic disorders. Periorificial dermatitis typically presents with erythematous to flesh-colored papules and rarely pustules near the eyes, nose, and mouth. Although the etiology is unknown, many patients have had recent exposure to a topical or less commonly an inhaled or systemic corticosteroid. Although steroids may initially control the skin lesions, disease often rebounds after discontinuing therapy. Diagnosis of POD is clinical. Laboratory tests are not helpful in making the diagnosis, and the histology of POD resembles rosacea. It is important to rule out other acneform diagnoses based on the age of the patient, clinical history, and presentation of the lesions. Topical metronidazole has been successful in the pediatric population. For pediatric patients with extrafacial skin lesions or more severe disease, oral antibiotics such as tetracycline, doxycycline, minocycline, azithromycin, and erythromycin can be used, depending on the age of the patient.

Tumor necrosis factor antagonist-induced psoriasis in a 3-year-old boy with Kawasaki disease

Tumor necrosis factor (TNF) antagonists have beenknown to trigger new-onset psoriasis in adult andpediatric patients. Here we report a case of TNFantagonist-induced psoriasis in a 3-year-old boytreated with infliximab for Kawasaki disease. Ourpatient is a 3-year-old boy with Kawasaki diseaseunresponsive to intravenous immunoglobulinwho was then treated with one dose of infliximab.A few days later he developed psoriatic plaqueson the face and extremities. The psoriatic plaqueswere treated with topical calcineurin inhibitors andtopical corticosteroids, with marked improvement.Prior reports of TNF antagonist-induced psoriasis inthe pediatric population have been in children withinflammatory bowel disease or juvenile idiopathicarthritis. To the best of our knowledge, this is thefirst case of TNF antagonist-induced psoriasis ina pediatric patient with Kawasaki disease, andthe youngest patient to date. Although we donot fully understand the mechanism behind thisphenomenon, in vitro studies have implicated theimportance of interferon-α, a pro-inflammatorycytokine, and plasmacytoid dendritic cells. Furtherresearch is necessary to understand who is at riskfor this condition and the molecular basis for thisparadoxical reaction.

Biosimilars in psoriasis: the future or not?

As patents for the biologic agents reach their expiration dates, dermatologists must prepare for the coming of biosimilars. These agents have been deemed "highly similar" to their reference products in a process outlined by the US Food and Drug Administration (FDA). In 2016, the FDA approved 3 biosimilars for various indications including plaque psoriasis and psoriatic arthritis. However, biosimilars are not the same as small-molecule generics because they have a complex manufacturing process that makes it impossible to produce identical products to their reference products. Therefore, should biosimilars be granted FDA approval for the same indications as their reference products? Furthermore, can biosimilars automatically be substituted for the branded drug at the pharmacy level? Putting aside these technical concerns, physicians must focus on the impact of biosimilars on patient care. These agents will have to be integrated into a complex health care system comprised of drug developers, employers, payers, and drug formularies.

Efficacy and safety of ustekinumab in adolescents

The biologic agent ustekinumab is a human monoclonal antibody that binds to the p40 subunit shared by interleukins (ILs) 12 and 23. The antibody is able to prevent binding of cytokines to the IL-12Rβ1 cell surface receptor and therefore may prevent IL-23 driven activation of the IL-23/Th 17 axis of inflammation. The anti-inflammatory activity has been beneficial in adult psoriasis. Ustekinumab has been approved in the United States for the treatment of adults with psoriasis and psoriatic arthritis. Approval in children and adolescents has not been granted by the US Food and Drug Administration. Subcutaneous injections of ustekinumab are administered at baseline, week 4 and every 12 weeks thereafter, a regimen that is particularly appealing to young patients who do not like more frequent injections at home. The product is attractive because, although it works through an immune system mechanism, the selective activity is such that the drug has not been associated with many of the side effects attributed to other immunosuppressive medications. Case reports of ustekinumab for pediatric psoriasis have shown promising results, and the recent Phase III CADMUS trial tested the agent in adolescents aged 12-17 years with psoriasis, using standard dose 0.75 mg/kg (≤60 kg), 45 mg (>60-≤100 kg), and 90 mg (>100 kg) or half-standard dosing 0.375 mg/kg (≤60 kg), 22.5 mg (>60-≤100 kg), and 45 mg (>100 kg) with a loading dosage at week 0 and week 4. Psoriasis area and severity index-75 was achieved in more than three-quarters of patients in full and half dosing by 12 weeks, and psoriasis area and severity index-90 in 54.1% and 61.1% of half and full dosage by 12 weeks, respectively. Ustekinumab was generally well tolerated in adolescents, with some patients developing antibodies, and nasopharyngitis being the major adverse event. Ustekinumab is a promising agent in adolescent psoriasis that appears to be well tolerated. The best monitoring plan and usage in younger patients still remain to be defined.

Pediatric rosacea

Because rosacea is uncommon in the pediatric population, care must be taken to exclude other papulopustular disorders. Children can present with vascular, papulopustular, and/or ocular findings. Importantly, ocular symptoms can appear before the cutaneous symptoms of rosacea, leading to misdiagnosis. Rosacea is a clinical diagnosis, but histopathologic examination typically reveals dilated vessels, perivascular lymphohistiocytic infiltrates in the upper dermis, elastosis, and disorganization of the upper dermal connective tissue. Treatment involves avoiding known triggers and utilizing topical and/or systemic therapies. Although treatment can control flares, pediatric rosacea often persists into adulthood.

Survival in patients treated for anaplastic meningioma

OBJECT

While most meningiomas are benign, 1%–3% display anaplastic features, with little current understanding regarding the molecular mechanisms underlying their formation. In a large single-center cohort, the authors tested the hypothesis that two distinct subtypes of anaplastic meningiomas, those that arise de novo and those that progress from lower grade tumors, exist and exhibit different clinical behavior.

METHODS

Pathology reports and clinical data of 37 patients treated between 1999 and 2012 for anaplastic meningioma at Memorial Sloan–Kettering Cancer Center (MSKCC) were retrospectively reviewed. Patients were divided into those whose tumors arose de novo and those whose tumors progressed from previously documented benign or atypical meningiomas.

RESULTS

Overall, the median age at diagnosis was 59 years and 57% of patients were female. Most patients (38%) underwent 2 craniotomies (range 1–5 surgeries) aimed at gross-total resection (GTR; 59%), which afforded better survival when compared with subtotal resection according to Kaplan-Meier estimates (median overall survival [OS] 3.2 vs 1.3 years, respectively; p = 0.04, log-rank test). Twenty-three patients (62%) presented with apparently de novo anaplastic meningiomas. Compared with patients whose tumors had progressed from a lower grade, those patients with de novo tumors were significantly more likely to be female (70% vs 36%, respectively; p = 0.04), experience better survival (median OS 3.0 vs 2.4 years, respectively; p = 0.03, log-rank test), and harbor cerebral hemispheric as opposed to skull base tumors (91% vs 43%, respectively; p = 0.002).

CONCLUSIONS

Based on this single-center experience at MSKCC, anaplastic meningiomas, similar to glial tumors, can arise de novo or progress from lower grade tumors. These tumor groups appear to have distinct clinical behavior. De novo tumors may well be molecularly distinct, which is under further investigation. Aggressive GTR appears to confer an OS advantage in patients with anaplastic meningioma, and this is likely independent of tumor progression status. Similarly, those patients with de novo tumors experience a survival advantage likely independent of extent of resection.