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REVIEW OF CURRENT LITERATURE
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 81-85

Hot topics in pediatric dermatology


Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication14-Dec-2018

Correspondence Address:
Dr. Rahul Mahajan
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_143_18

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How to cite this article:
Bhattacharjee R, Mahajan R. Hot topics in pediatric dermatology. Indian J Paediatr Dermatol 2019;20:81-5

How to cite this URL:
Bhattacharjee R, Mahajan R. Hot topics in pediatric dermatology. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Dec 7];20:81-5. Available from: http://www.ijpd.in/text.asp?2019/20/1/81/247546




  Therapeutic Options of Tinea Capitis in Children Top


We discuss this recent systematic review of the different treatment options of tinea capitis in children by Gupta et al.[1] It was aimed to evaluate the differences between different antifungal medications for the treatment of tinea capitis in pediatric population (children aged below 18 years) in terms of various parameters including clinical, mycological, and complete cure rates; to determine if there are any significant adverse effects associated; and to define the usefulness of sample collection methods. Primary outcome measures analyzed were efficacy rates among eligible studies and included mycological cure, clinical cure, and complete cure. Mycological cure was defined as negative mycological testing (e.g., negative culture, negative potassium hydroxide, and periodic acid–Schiff stain). Clinical cure was defined as the absence of signs and symptoms of tinea capitis (could be Total Signs and Symptoms [TSSS] score of 0 or a clinical parameter score of 0). Complete cure was defined as both mycological and clinical cure. Across all studies, five oral antifungals (terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole) were examined in 3998 children. Some studies evaluating the efficacy and safety of combinations of oral and topical therapies were also included and evaluated. Wood's light examination/light microscopic examination of the hair sample was the most frequently employed method for the diagnosis.

Among the different antifungal therapies (oral and combination thereof), continuous itraconazole and terbinafine were found to have the highest mycological cure rates (79% and 81%, respectively); griseofulvin and terbinafine had the highest clinical cure rates (46% and 58%, respectively); and griseofulvin and terbinafine had the highest complete cure rate (72% and 92%, respectively). Griseofulvin was found to be more effective for Microsporum infections, while terbinafine and itraconazole more effectively cured Trichophyton infections. Hairbrush collection method was found to be the most efficient method of sample collection. In addition, using a hairbrush, toothbrush, or cotton swab to identify the infecting organism(s) was the least invasive and most efficient method of tinea capitis sample collection in children.

Comments

This study deals with a much-desired topic in today's scenario where fungal infections, particularly dermatophytosis, have risen in incidence to alarming proportions, including in children.[2],[3],[4] The study methodology was excellent, and the literature search was extensive and adhered to much of the PRISMA guidelines for reporting systematic reviews. The review reported cure rates of three different drugs for tinea capitis – terbinafine, griseofulvin, and itraconazole. To objectively define complete cure, the authors used TSSS score. Another highlight of this review is that the efficacy of each of these antifungal drugs for different dermatophyte species was also assessed, emphasizing the importance of species identification, especially for treatment-refractory and chronic cases. Methods of sample collection were analyzed, and so was the predominant species in various regions. The total number of children included is large, giving strength to the findings.

However, on the flipside, much of the information on drug efficacy provided in the manuscript was well detailed in the updated Cochrane review on systemic antifungal therapy for tinea capitis in children in 2016.[5] Despite having done all the hard work of data collection, the authors chose not to go ahead with the meta-analysis. Details on the homogeneity or heterogeneity (I) of data, assessment of publication bias with funnel plots, and details on the drug efficacy with Forest plots would have provided more information to the readers.

Treatment of tinea capitis in children is often a dilemma for clinicians regarding prescribing the most efficacious drug. Based on the findings of this review, a proper evaluation including Wood's lamp examination, appropriate sample collection for species identification, and careful monitoring of all pediatric patients with tinea capitis should be carried out, giving way to well-designed comparison studies among the different drugs. In addition, more studies are the need of the hour to analyze changes in the incidence, clinical features, causative organisms, and evaluation of treatment regimens, in the Indian setting, considering the current upsurge of superficial fungal infections.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. Gupta AK, Mays RR, Versteeg SG, Piraccini BM, Shear NH, Piguet V, et al. Tinea capitis in children: A systematic review of management. J Eur Acad Dermatol Venereol 2018;32:2264-74.
  2. Sangameshwara G, Venkatesh U. Clinical study of cutaneous infection in children: Changing trends. Indian J Paediatr Dermatol 2015;16:136-8.
  3. Dash M, Panda M, Patro N, Mohapatra M. Sociodemographic profile and pattern of superficial dermatophytic infections among pediatric population in a tertiary care teaching hospital in Odisha. Indian J Paediatr Dermatol 2017;18:191-5.
  4. Mishra N, Rastogi MK, Gahalaut P, Yadav S, Srivastava N, Aggarwal A. Clinicomycological study of dermatophytoses in children: Presenting at a tertiary care center. Indian J Paediatr Dermatol 2018;19:326-30.
  5. Chen X, Jiang X, Yang M, González U, Lin X, Hua X, et al. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev 2016;13:CD004685.



  Impact of Facial Morphea in Children Top


We analyze this interesting study by Stasiulis et al.,[1] where the authors explore the qualitative aspects of the impact of facial morphea on the lives of children living with it and their parents and their ways of dealing with the same. They used a qualitative methodological approach guided by social constructionism, involving semi-structured interviews individually as well as in focus groups in addition to drawing activities. The study included ten children of both genders with facial morphea between 8 and 17 years of age and 13 parents, of which all but one were mothers. Interpretive thematic analysis was utilized to examine the data. The findings were presented in two main themes alongside corresponding subthemes: (1) The impact of living with facial morphea and (2) Managing the impact of living with facial morphea. It was found that stress was a major part of living with facial morphea and a large part of it was because of lack of knowledge about the disease, its treatment, and the implications of both, which in turn resulted in them not being able to answer questions about the same (which often are intrusive, and may amount to bullying), thereby propagating the anxiety further. This anxiety and stress were exacerbated during times of transition to less familiar and newer surroundings such as on achieving puberty. Some parents reported to be more affected than their children who seemed better at dealing with the disease.

Comments

The idea of assessing the psychosocial impact of facial morphea on the lives of children and parents by using a qualitative and thematic approach is both noble and praiseworthy. The concept of social constructionism in illness is still developing as it is distinct from the medical notion of disease. For the latter, disease is an unchanging biological condition, in contrast to the former which defines illnesses in relation to their social meaning and effect on individual's identity.[2] Psychosocial aspects have a wide spectrum of responses and issues which often cannot be adequately judged by means of structured questionnaire tools, which is also highlighted by the widely variant responses obtained from children and parents alike in this study. The authors have studied not only the impact of the disease and the diagnosis on the children's minds and social relationships, but also the impact of treatment decisions, including those of adverse effects of medications. This suggests that the effects of treatment must also be taken into consideration when developing treatment plans. This is extremely important to ensure compliance not just on the part of the children but also on their parents. The results of this study also suggest that perhaps such patients could derive comfort and confidence by talking and confiding to others suffering from the same diagnosis; hence, a support group or group counseling sessions could be highly beneficial in this regard.

The limitations of this study include the small sample size of 13 families and the lack of participation from fathers. Mothers often are more susceptible to heightened emotional responses to their children's sufferings, which is why perhaps a mix of either parent would have strengthened the findings. Furthermore, the qualitative nature of the approach acts as a double-edged sword as it lacks an objective assessment of the psychosocial impact of facial morphea. Most children recruited in this study had received their diagnosis at least 7 years prior and had surpassed the active phase of the disease. Inclusion of children with active facial morphea would perhaps have modified the findings further. A blinded approach could have served better as the researchers observed that children who agreed to participate had less visible lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. Stasiulis E, Gladstone B, Boydell K, O'Brien C, Pope E, Laxer RM, et al. Children with facial morphea managing everyday life: A qualitative study. Br J Dermatol 2018;179:353-61.
  2. Conrad P, Barker KK. The social construction of illness: Key insights and policy implications. J Health Soc Behav 2010;51 Suppl 4:S67-79.



  Epidermal barrier and epidermal biomarkers in Atopic Dermatitis Top


We discuss a recent study by Hulshof et al.[1] which investigated the epidermal barrier and immune response biomarkers in stratum corneum (SC) tape strips from atopic dermatitis (AD) children with different skin types. The aim was to study a multitude of SC biomarkers including immunomodulatory mediators, natural moisturizing factor (NMF), and Dermal Texture Index (DTI) in 53 AD children compared to 50 children with healthy skin using the SC tape-stripping method. The differences in these biomarkers were also studied with respect to the skin color and presence or absence of FLG mutations. The biomarkers IL1β, IL18, CXCL8, CCL22, CCL17, CXCL10, and CCL2 were found to be significantly higher in lesional AD skin versus nonlesional AD skin, while IL-1α showed the opposite trend. CXCL8, CCL2, and CCL17 showed association with Objective Scoring Atopic Dermatitis (oSCORAD) index. NMF levels showed a gradual decrease from healthy skin to nonlesional and lesional AD skin, a pattern more marked in Type II skin in comparison to skin Type VI, which showed higher NMF levels in both nonlesional and lesional AD skin. Corneocyte morphology was seen to be significantly different in lesional AD skin versus nonlesional AD and healthy skin.

Comments

This study explores a minimally invasive tape-stripping technique to study biomarkers that could aid in assessing the disease severity of AD. The use of this method in analyzing differences in cytokine and chemokine biomarkers between two different Fitzpatrick skin types is less invasive compared to skin biopsy and provokes interest. The analysis of three different types of skin samples, that is, healthy skin, nonlesional AD skin, and lesional AD skin, as well as assessment of NMF and the DTI, is also interesting and offers fresh and deeper insights. In another study by Koppes et al.,[2] the authors also assessed the effect of 6 weeks of topical treatment with ceramide- and magnesium-based emollients on the local levels of biomarkers in skin samples obtained by tape stripping. The authors had studied 24 mediators quantitatively and found IL-4, IL-13, CCL2, CCL22, and CCL17 as well as IL-1β, IL-2, IL-8 (CXCL8), IL-10, acute-phase protein serum amyloid A, C-reactive protein, and vascular adhesion molecule-1 to be significantly decreased after therapy. The decrease of CCL17 and IL-8 correlated with the decrease in oSCORAD in moderate AD. The effect of treatment on biomarker levels is another useful territory that can be explored in future studies. In skin Type VI, both DTI and NMF levels did not show any significantly differences between healthy skin and either nonlesional or lesional AD skin, in contrast to the lighter skin Type II. This may imply that there are additional local factors in darker skin types that determine susceptibility as well as severity of AD. This is another aspect that should be dealt with in future studies.

Though interesting, the concept of tape stripping to study biomarkers in AD is not entirely novel and has been attempted in several studies before. The methodology and inclusion criteria do not explicitly mention the subgroups of AD that were studied, though the results mention that patients recruited had mild-to-moderate disease with a mean oSCORAD of 17.6 (±standard deviation 9.7). Children with severe or treatment refractory AD were not included, and these are the subgroups of AD that probably demand and would benefit from such biomarker analysis, especially if flares or treatment refractoriness can be explained or predicted by levels of these biomarkers. Though the study of biomarkers in darker skin Type (Type VI) is interesting and requires further exploration, the skin types studied in this study[1] belong to two extreme ends of the spectrum and probably may not adequately represent data that could be extrapolated for our (Indian) population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. Hulshof L, Hack DP, Hasnoe QCJ, Dontje B, Jakasa I, Riethmüller C, et al. A minimally invasive tool to study immune response and skin barrier in children with atopic dermatitis. Br J Dermatol 2018. doi: 10.1111/bjd.16994. [Epub ahead of print].
  2. Koppes SA, Brans R, Ljubojevic Hadzavdic S, Frings-Dresen MH, Rustemeyer T, Kezic S, et al. Stratum corneum tape stripping: Monitoring of inflammatory mediators in atopic dermatitis patients using topical therapy. Int Arch Allergy Immunol 2016;170:187-93.



  Association between terra firma-forme dermatosis (TFFD) and Atopic Dermatitis Top


This study from Italy by Neri et al.[1] proposes that there is a significant association between terra firma-forme dermatosis (TFFD) and atopic dermatitis (AD) in children. The authors analyzed 137 consecutive patients of AD aged up to 14 years for the presence of TFFD over a period of 1 month. The diagnosis of AD was made using Hanifin and Rajka criteria and the revised criteria of Eichenfield and that of TFFD by dermoscopy and a positive isopropyl alcohol-wipe test. Patients were divided into the following four groups: patients with TFFD without AD, patients with TFFD and AD, patients without TFFD but with AD, and patients without both TFFD and AD. The authors found a significant association between TFFD and AD; 44.1% of patients affected by AD were found to suffer from TFFD, while in contrast, only 27.5% of patients not affected by AD presented with TFFD (odds ratio [OR] = 2.08). A peculiar finding was that the umbilicus was the most frequent site involved in TFFD in patients with and without AD. However, in all cases, the patients were not aware or did not consider the presence of TFFD as significant.

Comments

The idea of exploring the presence of TFFD in patients with AD is novel and interesting. In this study, the authors set out to find any association between AD and TFFD. The comparison for TFFD among the four groups has also contributed in consolidating the findings of this study, making them more strength. However, it would have been more appropriate to recruit study population of an ideal sample size with respect to the outcome. The study is also limited by the small sample size, the recruitment of patients over a period of only 1 month, that too in the winter season when the prevalence of AD increases, and patients are prone to less frequent bathing. Since the study population were all patients, it would have been worthwhile to mention the primary diagnosis and to adjust the OR for any confounders. Of 137 consecutive patients, 49 cases of TFFD (38.5%) were diagnosed, which is a high prevalence in any patient cohort. This may suggest that TFFD is either much more common than is usually considered or is perhaps misdiagnosed or underreported by clinicians. However, the authors also found a very high percentage of patients affected by AD in their study, 68/137 (49.6%), which could have skewed their interpretation.

The authors speculate that the link between TFFD and AD could possibly be the result of alteration of keratinization, considering that AD is characterized by epidermal barrier defects and many authors believe that TFFD is caused by delayed keratinocyte maturation, and AD patients probably bath less frequently than the general population and use less skin sponges, both factors that can possibly contribute to the formation of TFFD. One more factor that can contribute is the failure to rinse off oil-based soaps or liquid cleansers during shower that are routinely prescribed as a part of treatment of AD. Remnant soaps, cleansers, emollients, and pathological scaling admixed with sweat and sebum in diseased skin may impart the skin adhesive or keratoplastic properties that prevent normal keratinocyte shedding and accumulating scales, dirt, and sebum, leading to higher frequency of this presentation in patients with AD.[2]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. Neri I, Savoia F, Tengattini V, Sechi A, Rucci P, Patrizi A, et al. Terra firma-forme dermatosis is underestimated in children and is associated with atopic dermatitis. J Eur Acad Dermatol Venereol 2018;32:e421-2.
  2. Erkek E, Sahin S, Çetin ED, Sezer E. Terra firma-forme dermatosis. Indian J Dermatol Venereol Leprol 2012;78:358-60.



  IgG antibody levels against Staphylococcus aureus in Atopic Dermatitis Top


We discuss this cross-sectional study where Totte et al.[1] aimed to investigate children with atopic dermatitis (AD) from two interventional study cohorts, the Shared Medical Appointment (SMA) cohort and DAVOS cohort, for the presence of IgG antibody levels against 55 Staphylococcus aureus antigens (four main biological groups of antigens – immunomodulators [superantigens and nonsuperantigens], household enzymes, cell membrane-damaging molecules, and microbial surface components-recognizing adhesive matrix molecules) quantified simultaneously. AD severity was assessed using the Self-Administered Eczema Area and Severity Index (SA-EASI) and serum levels of thymus and activation-regulated chemokine (TARC). The authors analyzed the associations between 55 IgG levels, and SA-EASI and TARC, and the results were assessed by linear regression analysis having adjusted for age, sex, and S. aureus colonization. Among the 136 and 76 children studied from the SMA and DAVOS cohorts with median ages of 2 years and 13 years, respectively, AD disease severity was found to be associated with IgG responses directed against antigens with mainly immunomodulatory functions. Comparing the results between the two study cohorts, it was observed that the medians of the absolute antibody levels were higher and showed less variation in the DAVOS cohort than in the SMA study cohort, and the median TARC values were higher in the latter cohort. The IgG antibody responses did not significantly differ between the four groups of antigens. Spearman's correlation test showed correlations among the IgG levels of the staphylococcal superantigen-like proteins 3, 5, 9, and 10; leukotoxin (Luk) LukE, LukD, and LukS; extracellular fibrinogen-binding protein; and alanine transaminase. The authors also found significant associations between IgG levels and AD severity in the SMA cohort. Sixteen antigens were associated with SA-EASI and 12 with TARC. Ten of the 12 antigens associated with TARC were also associated with SAEASI. The associated IgG antibodies targeted mainly secreted proteins with immunomodulatory functions (e.g., LukD and LukE). The described associations between antigen levels and AD severity were independent of age, sex, and colonization of the skin and/or nose with S. aureus. In the DAVOS study, IgG levels against only four and one S. aureus antigen(s) were associated with SAEASI and TARC, respectively, and there was no overlap.

Comments

This study analyzed IgG responses against 55 S. aureus antigens simultaneously, covering a wide spectrum of biologically different antigens, which is the strength of the study, and adds to its novelty. It is the first of its kind to evaluate antibody responses against a wide array of S. aureus antigens and sheds light on the role of IgG-mediated immune response to S. aureus in AD. It also emphasizes on the significance of other S. aureus antigens apart from the superantigens (cytolytic α- and δ-toxins) in eliciting immune responses in AD. The authors found AD severity to be associated with IgG antibodies directed against S. aureus antigens with mainly immunomodulatory functions. Two cohorts were analyzed separately as they used different inclusion criteria regarding AD severity and age. The study results also reinforce the role of S. aureus in AD pathogenesis as there is diminution of skin microbiome diversity with predominance of S. aureus in AD. The findings of this study can be extrapolated to fuel further researches to confirm these findings and associations. The results may be relevant with respect to the therapeutic aspects too as newer treatment which specifically lyses S. aureus may be an important target.

This idea has been partly implemented previously by Sohn et al. who studied the staphylococcal IgG response to staphylococcal enterotoxin B and found no correlation with AD severity.[2] Other minor limitations of this study include its small sample size, the lack of a control group without AD, and its cross-sectional nature.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. Totté JE, Pardo LM, Fieten KB, de Wit J, de Boer DV, van Wamel WJ, et al. IgG response against Staphylococcus aureus is associated with severe atopic dermatitis in children. Br J Dermatol 2018;179:118-26.
  2. Sohn MH, Kim CH, Kim WK, Jang GC, Kim KE. Effect of staphylococcal enterotoxin B on specific antibody production in children with atopic dermatitis. Allergy Asthma Proc 2003;24:67-71.







 

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