Heidi Splete

More than 25% of children and adolescents with obsessive-compulsive disorder had comorbid attention-deficit hyperactivity disorder in a consecutive study of 94 patients, reported Dr. Gabriele Masi and her associates at the Scientific Institute of Child Neurology and Psychiatry in Calambrone, Pisa (Italy).

Overall, 88% of the 24 comorbid patients were male, and the average age of onset of obsessive-compulsive disorder (OCD) was slightly higher among patients with comorbid attention-deficit hyperactivity disorder (ADHD). Several disruptive behavior disorders—oppositional defiant disorder, bipolar disorder, and tic disorder—were significantly more common among comorbid patients.

The 3-year study included 65 males and 29 females aged 8–18 years. All of the patients were undergoing treatment for OCD with selective serotonin reuptake inhibitors, such as fluoxetine and sertraline (Zoloft), but none was being treated for ADHD with psychostimulants (Compr. Psychiatry 2006;47:42–7).

In patients with comorbid ADHD, functional baseline impairment was higher, and improvement in symptoms after 6 months of follow-up was lower. Patients with co-occurring OCD-ADHD were more frequently male (88% vs. 62%). In addition, patients with OCD and ADHD had higher rates of comorbid disorders, such as various anxiety disorders.

There were no significant differences between patients with and without comorbid ADHD with regard to OCD behaviors involving ordering, aggression, contamination, and hoarding.

The study results suggest a need for ADHD screening in all children and adolescents with OCD, the investigators wrote.

More than 25% of children and adolescents with obsessive-compulsive disorder had comorbid attention-deficit hyperactivity disorder in a consecutive study of 94 patients, reported Dr. Gabriele Masi and her associates at the Scientific Institute of Child Neurology and Psychiatry in Calambrone, Pisa (Italy).

Overall, 88% of the 24 comorbid patients were male, and the average age of onset of obsessive-compulsive disorder (OCD) was slightly higher among patients with comorbid attention-deficit hyperactivity disorder (ADHD). Several disruptive behavior disorders—oppositional defiant disorder, bipolar disorder, and tic disorder—were significantly more common among comorbid patients.

The 3-year study included 65 males and 29 females aged 8–18 years. All of the patients were undergoing treatment for OCD with selective serotonin reuptake inhibitors, such as fluoxetine and sertraline (Zoloft), but none was being treated for ADHD with psychostimulants (Compr. Psychiatry 2006;47:42–7).

In patients with comorbid ADHD, functional baseline impairment was higher, and improvement in symptoms after 6 months of follow-up was lower. Patients with co-occurring OCD-ADHD were more frequently male (88% vs. 62%). In addition, patients with OCD and ADHD had higher rates of comorbid disorders, such as various anxiety disorders.

There were no significant differences between patients with and without comorbid ADHD with regard to OCD behaviors involving ordering, aggression, contamination, and hoarding.

The study results suggest a need for ADHD screening in all children and adolescents with OCD, the investigators wrote.

More than 25% of children and adolescents with obsessive-compulsive disorder had comorbid attention-deficit hyperactivity disorder in a consecutive study of 94 patients, reported Dr. Gabriele Masi and her associates at the Scientific Institute of Child Neurology and Psychiatry in Calambrone, Pisa (Italy).

Overall, 88% of the 24 comorbid patients were male, and the average age of onset of obsessive-compulsive disorder (OCD) was slightly higher among patients with comorbid attention-deficit hyperactivity disorder (ADHD). Several disruptive behavior disorders—oppositional defiant disorder, bipolar disorder, and tic disorder—were significantly more common among comorbid patients.

The 3-year study included 65 males and 29 females aged 8–18 years. All of the patients were undergoing treatment for OCD with selective serotonin reuptake inhibitors, such as fluoxetine and sertraline (Zoloft), but none was being treated for ADHD with psychostimulants (Compr. Psychiatry 2006;47:42–7).

In patients with comorbid ADHD, functional baseline impairment was higher, and improvement in symptoms after 6 months of follow-up was lower. Patients with co-occurring OCD-ADHD were more frequently male (88% vs. 62%). In addition, patients with OCD and ADHD had higher rates of comorbid disorders, such as various anxiety disorders.

There were no significant differences between patients with and without comorbid ADHD with regard to OCD behaviors involving ordering, aggression, contamination, and hoarding.

The study results suggest a need for ADHD screening in all children and adolescents with OCD, the investigators wrote.

The adult formula of the tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) can be given to children and adolescents starting at 18 months after a children's formula tetanus and diphtheria vaccine, said Dr. Scott A. Halperin of Dalhousie University, Halifax, Nova Scotia, and his colleagues.

Prior recommendations for a 10-year waiting period between doses of the tetanus and diphtheria toxoid-containing vaccine for infants and young children (TD) or the vaccine for older children and adults (Td) had been based on effectiveness rather than a lack of safety information, the investigators noted.

Concerns about the timing of vaccinations and adverse events prompted an open-label clinical trial including 7,156 children in grades 3–12 who received Tdap at time intervals ranging from 18 months to 9 years after their previous vaccinations with TD, Td, or diphtheria-tetanus-acellular pertussis (DTaP).

Tdap was generally well tolerated regardless of the time elapsed since the previous vaccination. Data on fever, injection site erythema, swelling, and pain were solicited for 14 days after immunization, and unsolicited adverse events were recorded for 28 days (Pediatr. Infect. Dis. J. 2006;25:195–200).

Overall, more than 80% of the children in each time interval reported injection site pain, but this was not significantly different from pain reports in children who were vaccinated 10 years after a previous immunization. Injection site erythema was slightly increased among children whose previous vaccine had been DTaP, but not among those whose previous vaccine had been Td. The four reported serious adverse events included one case each of asthma, bronchospasm, syncope, and juvenile onset diabetes mellitus, but none of these were attributed to Tdap.

The adult formula of the tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) can be given to children and adolescents starting at 18 months after a children's formula tetanus and diphtheria vaccine, said Dr. Scott A. Halperin of Dalhousie University, Halifax, Nova Scotia, and his colleagues.

Prior recommendations for a 10-year waiting period between doses of the tetanus and diphtheria toxoid-containing vaccine for infants and young children (TD) or the vaccine for older children and adults (Td) had been based on effectiveness rather than a lack of safety information, the investigators noted.

Concerns about the timing of vaccinations and adverse events prompted an open-label clinical trial including 7,156 children in grades 3–12 who received Tdap at time intervals ranging from 18 months to 9 years after their previous vaccinations with TD, Td, or diphtheria-tetanus-acellular pertussis (DTaP).

Tdap was generally well tolerated regardless of the time elapsed since the previous vaccination. Data on fever, injection site erythema, swelling, and pain were solicited for 14 days after immunization, and unsolicited adverse events were recorded for 28 days (Pediatr. Infect. Dis. J. 2006;25:195–200).

Overall, more than 80% of the children in each time interval reported injection site pain, but this was not significantly different from pain reports in children who were vaccinated 10 years after a previous immunization. Injection site erythema was slightly increased among children whose previous vaccine had been DTaP, but not among those whose previous vaccine had been Td. The four reported serious adverse events included one case each of asthma, bronchospasm, syncope, and juvenile onset diabetes mellitus, but none of these were attributed to Tdap.

The adult formula of the tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) can be given to children and adolescents starting at 18 months after a children's formula tetanus and diphtheria vaccine, said Dr. Scott A. Halperin of Dalhousie University, Halifax, Nova Scotia, and his colleagues.

Prior recommendations for a 10-year waiting period between doses of the tetanus and diphtheria toxoid-containing vaccine for infants and young children (TD) or the vaccine for older children and adults (Td) had been based on effectiveness rather than a lack of safety information, the investigators noted.

Concerns about the timing of vaccinations and adverse events prompted an open-label clinical trial including 7,156 children in grades 3–12 who received Tdap at time intervals ranging from 18 months to 9 years after their previous vaccinations with TD, Td, or diphtheria-tetanus-acellular pertussis (DTaP).

Tdap was generally well tolerated regardless of the time elapsed since the previous vaccination. Data on fever, injection site erythema, swelling, and pain were solicited for 14 days after immunization, and unsolicited adverse events were recorded for 28 days (Pediatr. Infect. Dis. J. 2006;25:195–200).

Overall, more than 80% of the children in each time interval reported injection site pain, but this was not significantly different from pain reports in children who were vaccinated 10 years after a previous immunization. Injection site erythema was slightly increased among children whose previous vaccine had been DTaP, but not among those whose previous vaccine had been Td. The four reported serious adverse events included one case each of asthma, bronchospasm, syncope, and juvenile onset diabetes mellitus, but none of these were attributed to Tdap.

DENVER — Increased risk of coronary heart disease is significantly associated with stronger symptoms of depression in diabetic adults, Susan M. Barry-Bianchi, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Dr. Barry-Bianchi, of the Behavioural Cardiology Research Unit at the University Health Network in Toronto, and her colleagues recruited 353 patients for the study from an ongoing investigation, the Community Outreach and Health Risk Reduction Trial. The average patient age was 56 years.

The average score on the Beck Depression Inventory (BDI) was 11.1 among the 184 patients at high risk for coronary heart disease (CHD), compared with 8.8 among the 169 patients at low risk for CHD, Dr. Barry-Bianchi wrote. The 10-year absolute risk for CHD was nearly 22% for high-risk patients and 9% for the low-risk patients. CHD risk for each patient was determined using the Framingham index.

Given the significant difference in the depression levels based on the risk for developing heart disease, depression and CHD risk should be evaluated jointly, when investigating morbidity and mortality in diabetic patients, the investigators suggested. Additionally, treatment of CHD risk factors in diabetic patients may correspond with a reduction in depressive symptoms and improved overall health.

In addition, the results supported previous findings of increased depression among women and patients with low levels of emotional support. Women demonstrated a significantly higher average BDI score, compared with men (11.4 vs. 8.4). Patients with low reported levels of emotional support demonstrated a significantly higher average BDI score, compared with those who reported more support (12 vs. 8).

DENVER — Increased risk of coronary heart disease is significantly associated with stronger symptoms of depression in diabetic adults, Susan M. Barry-Bianchi, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Dr. Barry-Bianchi, of the Behavioural Cardiology Research Unit at the University Health Network in Toronto, and her colleagues recruited 353 patients for the study from an ongoing investigation, the Community Outreach and Health Risk Reduction Trial. The average patient age was 56 years.

The average score on the Beck Depression Inventory (BDI) was 11.1 among the 184 patients at high risk for coronary heart disease (CHD), compared with 8.8 among the 169 patients at low risk for CHD, Dr. Barry-Bianchi wrote. The 10-year absolute risk for CHD was nearly 22% for high-risk patients and 9% for the low-risk patients. CHD risk for each patient was determined using the Framingham index.

Given the significant difference in the depression levels based on the risk for developing heart disease, depression and CHD risk should be evaluated jointly, when investigating morbidity and mortality in diabetic patients, the investigators suggested. Additionally, treatment of CHD risk factors in diabetic patients may correspond with a reduction in depressive symptoms and improved overall health.

In addition, the results supported previous findings of increased depression among women and patients with low levels of emotional support. Women demonstrated a significantly higher average BDI score, compared with men (11.4 vs. 8.4). Patients with low reported levels of emotional support demonstrated a significantly higher average BDI score, compared with those who reported more support (12 vs. 8).

DENVER — Increased risk of coronary heart disease is significantly associated with stronger symptoms of depression in diabetic adults, Susan M. Barry-Bianchi, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Dr. Barry-Bianchi, of the Behavioural Cardiology Research Unit at the University Health Network in Toronto, and her colleagues recruited 353 patients for the study from an ongoing investigation, the Community Outreach and Health Risk Reduction Trial. The average patient age was 56 years.

The average score on the Beck Depression Inventory (BDI) was 11.1 among the 184 patients at high risk for coronary heart disease (CHD), compared with 8.8 among the 169 patients at low risk for CHD, Dr. Barry-Bianchi wrote. The 10-year absolute risk for CHD was nearly 22% for high-risk patients and 9% for the low-risk patients. CHD risk for each patient was determined using the Framingham index.

Given the significant difference in the depression levels based on the risk for developing heart disease, depression and CHD risk should be evaluated jointly, when investigating morbidity and mortality in diabetic patients, the investigators suggested. Additionally, treatment of CHD risk factors in diabetic patients may correspond with a reduction in depressive symptoms and improved overall health.

In addition, the results supported previous findings of increased depression among women and patients with low levels of emotional support. Women demonstrated a significantly higher average BDI score, compared with men (11.4 vs. 8.4). Patients with low reported levels of emotional support demonstrated a significantly higher average BDI score, compared with those who reported more support (12 vs. 8).

DENVER — End-stage liver disease was associated with significant deficits in memory, abstract thought, sustained attention, and executive function in a study of 104 adult patients, Tina Meyer, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

“We want to enlighten the surgeons and primary care doctors that cognitive decline can indicate serious liver problems,” Dr. Meyer said in an interview.

She and her colleagues in the Transplant Institute at the Henry Ford Health System in Detroit enrolled liver disease patients who met medical and psychosocial criteria for a transplant. About half (51%) were male, 74% were white, and the average age was 54 years. The patients' average score on the mean model for end-stage liver disease (MELD) was 11.3.

The participants completed a cognitive assessment including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), which estimates brain function in five different domains: immediate memory, delayed memory, visuospatial abilities, language, and attention.

Overall, scores on the RBANS were below average on the subtests of immediate memory, visuospatial abilities, and attention. After the investigators controlled for education levels, higher MELD scores were significantly associated with lower scores on the immediate memory and delayed memory subtests of RBANS, as well as with lower scores on the Mini-Mental State Exam, the Shipley Institute of Living Scale, and the Trail-Making Test, parts A and B.

DENVER — End-stage liver disease was associated with significant deficits in memory, abstract thought, sustained attention, and executive function in a study of 104 adult patients, Tina Meyer, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

“We want to enlighten the surgeons and primary care doctors that cognitive decline can indicate serious liver problems,” Dr. Meyer said in an interview.

She and her colleagues in the Transplant Institute at the Henry Ford Health System in Detroit enrolled liver disease patients who met medical and psychosocial criteria for a transplant. About half (51%) were male, 74% were white, and the average age was 54 years. The patients' average score on the mean model for end-stage liver disease (MELD) was 11.3.

The participants completed a cognitive assessment including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), which estimates brain function in five different domains: immediate memory, delayed memory, visuospatial abilities, language, and attention.

Overall, scores on the RBANS were below average on the subtests of immediate memory, visuospatial abilities, and attention. After the investigators controlled for education levels, higher MELD scores were significantly associated with lower scores on the immediate memory and delayed memory subtests of RBANS, as well as with lower scores on the Mini-Mental State Exam, the Shipley Institute of Living Scale, and the Trail-Making Test, parts A and B.

DENVER — End-stage liver disease was associated with significant deficits in memory, abstract thought, sustained attention, and executive function in a study of 104 adult patients, Tina Meyer, Ph.D., reported in a poster presented at the annual meeting of the American Psychosomatic Society.

“We want to enlighten the surgeons and primary care doctors that cognitive decline can indicate serious liver problems,” Dr. Meyer said in an interview.

She and her colleagues in the Transplant Institute at the Henry Ford Health System in Detroit enrolled liver disease patients who met medical and psychosocial criteria for a transplant. About half (51%) were male, 74% were white, and the average age was 54 years. The patients' average score on the mean model for end-stage liver disease (MELD) was 11.3.

The participants completed a cognitive assessment including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), which estimates brain function in five different domains: immediate memory, delayed memory, visuospatial abilities, language, and attention.

Overall, scores on the RBANS were below average on the subtests of immediate memory, visuospatial abilities, and attention. After the investigators controlled for education levels, higher MELD scores were significantly associated with lower scores on the immediate memory and delayed memory subtests of RBANS, as well as with lower scores on the Mini-Mental State Exam, the Shipley Institute of Living Scale, and the Trail-Making Test, parts A and B.

DENVER — Age and low hostility are independent predictors of poor blood pressure in women over a 10-year period, suggesting a link between certain personality traits and disease development, Jocelyne Leclerc reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Ms. Leclerc and her colleagues at the University of British Columbia, Vancouver, compared the results of ambulatory blood pressure monitoring and personality questionnaires of 112 healthy adults at baseline and after 10 years. The study group included 54 men and 63 women; the average age was 40 years at baseline. Average blood pressure monitoring was done on predetermined days when the patients did not expect significant stressful events. Overall, blood pressure and personality traits were stable over the 10 years. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly correlated with depression at baseline. Baseline hostility predicted increased DBP 10 years later; baseline SBP predicted hostility later.

Gender and family history may moderate the impact of personality on blood pressure, they said (Pers. Individ. Diff. 2006;40:1313–21). Increased age and low hostility significantly predicted SBP in women, while high levels of self-deception were the only significant predictors of SBP and DBP over time in men. The observation of low hostility in women predicting high BP suggests a need to consider “possibly differential adaptiveness of the same personality features of women and men.” In those with a family history of high blood pressure, age and high levels of self-deception were significant SBP predictors, and self-deception was the lone significant DBP predictor. In those without a family history of high blood pressure, only age was a significant SBP predictor. No variables were significant DBP predictors.

DENVER — Age and low hostility are independent predictors of poor blood pressure in women over a 10-year period, suggesting a link between certain personality traits and disease development, Jocelyne Leclerc reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Ms. Leclerc and her colleagues at the University of British Columbia, Vancouver, compared the results of ambulatory blood pressure monitoring and personality questionnaires of 112 healthy adults at baseline and after 10 years. The study group included 54 men and 63 women; the average age was 40 years at baseline. Average blood pressure monitoring was done on predetermined days when the patients did not expect significant stressful events. Overall, blood pressure and personality traits were stable over the 10 years. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly correlated with depression at baseline. Baseline hostility predicted increased DBP 10 years later; baseline SBP predicted hostility later.

Gender and family history may moderate the impact of personality on blood pressure, they said (Pers. Individ. Diff. 2006;40:1313–21). Increased age and low hostility significantly predicted SBP in women, while high levels of self-deception were the only significant predictors of SBP and DBP over time in men. The observation of low hostility in women predicting high BP suggests a need to consider “possibly differential adaptiveness of the same personality features of women and men.” In those with a family history of high blood pressure, age and high levels of self-deception were significant SBP predictors, and self-deception was the lone significant DBP predictor. In those without a family history of high blood pressure, only age was a significant SBP predictor. No variables were significant DBP predictors.

DENVER — Age and low hostility are independent predictors of poor blood pressure in women over a 10-year period, suggesting a link between certain personality traits and disease development, Jocelyne Leclerc reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Ms. Leclerc and her colleagues at the University of British Columbia, Vancouver, compared the results of ambulatory blood pressure monitoring and personality questionnaires of 112 healthy adults at baseline and after 10 years. The study group included 54 men and 63 women; the average age was 40 years at baseline. Average blood pressure monitoring was done on predetermined days when the patients did not expect significant stressful events. Overall, blood pressure and personality traits were stable over the 10 years. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly correlated with depression at baseline. Baseline hostility predicted increased DBP 10 years later; baseline SBP predicted hostility later.

Gender and family history may moderate the impact of personality on blood pressure, they said (Pers. Individ. Diff. 2006;40:1313–21). Increased age and low hostility significantly predicted SBP in women, while high levels of self-deception were the only significant predictors of SBP and DBP over time in men. The observation of low hostility in women predicting high BP suggests a need to consider “possibly differential adaptiveness of the same personality features of women and men.” In those with a family history of high blood pressure, age and high levels of self-deception were significant SBP predictors, and self-deception was the lone significant DBP predictor. In those without a family history of high blood pressure, only age was a significant SBP predictor. No variables were significant DBP predictors.

Vesicoureteral Reflux and UTIs

Mild to moderate vesicoureteral reflux did not increase the incidence of urinary tract infections, recurrent pyelonephritis, or renal scarring in children with acute pyelonephritis, reported Dr. Eduardo H. Garin of the University of South Florida, Tampa, and his colleagues.

In addition, urinary antibiotic prophylaxis showed no effect on the prevention of either the recurrence of infection or the development of renal scars (Pediatrics 2006;117:626–32).

A total of 218 children aged 3 months to 18 years were monitored for 1 year. Children who were randomized to antibiotics received a once-daily dose of either 1–2 mg/kg of trimethoprim or 5–10 mg/kg sulfamethoxazole or 1.5 mg/kg nitrofurantoin. The overall incidence of urinary tract infections (UTIs) after pyelonephritis was 20.1%. Among children who did not receive antibiotic prophylaxis, the incidence of UTIs was not significantly different between those with and without vesicoureteral reflux (VUR; 22.4% vs. 23.3%). Similarly, among children who did receive antibiotic prophylaxis, the incidence of UTIs was not significantly different between children with and without VUR (23.6% vs. 8.8%).

Only 12 of the 218 patients (5.5%) had recurrence of pyelonephritis. Although more recurrences occurred in patients with VUR than without it (8 vs. 4), there was no significant evidence that reflux increased the odds of recurrence.

In addition, only 13 patients developed renal scars during the follow-up period—7 with VUR and 6 without VUR—there was no significant evidence that VUR increased the risk for scarring. The rates of scarring were similar in the prophylaxis and control groups.

Adult Tdap Called Safe for Children

The adult formula of the tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) can be given to children and adolescents starting at 18 months after a children's formula tetanus and diphtheria vaccine, said Dr. Scott A. Halperin of Dalhousie University, Halifax, Nova Scotia, and his colleagues.

Prior recommendations for a 10-year waiting period between doses of the tetanus and diphtheria toxoid-containing vaccine for infants and young children (TD) or the vaccine for older children and adults (Td) had been based on effectiveness rather than a lack of safety information, the investigators noted.

Concerns about the relationship between the timing of vaccinations and adverse events prompted an open-label clinical trial including 7,156 children in grades 3–12 who received Tdap at time intervals ranging from 18 months to 9 years after their previous vaccinations with TD, Td, or diphtheria-tetanus-acellular pertussis (DTaP).

Tdap was generally well tolerated regardless of the time elapsed since the previous vaccination. Data on fever, injection site erythema, swelling, and pain were solicited for 14 days after immunization, and unsolicited adverse events were recorded for 28 days (Pediatr. Infect. Dis. J. 2006;25:195–200). Overall, more than 80% of the children in each time interval reported injection site pain, but this was not significantly different from pain reports in children who were vaccinated 10 years after a previous immunization. Injection site erythema was slightly increased among children whose previous vaccine had been DTaP, but not among those whose previous vaccine had been Td.

DTaP Reactions Defeat OTC Drugs

Neither acetaminophen nor ibuprofen had a significant preventive effect against localized reactions to the fifth dose of the diphtheria-tetanus -acellular pertussis vaccine based on data from 372 children aged 4–6 years.

Dr. Lisa A. Jackson of the University of Washington, Seattle, and her colleagues conducted a randomized, blinded controlled trial within a larger safety study of the Tripedia DTaP vaccine. Dr. Jackson has served on the speakers' bureau for Sanofi Pasteur, which manufactures the vaccine and provided a research grant for the study (Pediatrics 2006;117:620–5).

The children were assigned to receive their first dose of 15 mg/kg of acetaminophen, with a maximum dose of 450 mg; 10 mg/kg of ibuprofen, with a maximum dose of 300 mg; or a placebo 2 hours before their scheduled vaccinations. The second and third doses were given at 6-hour intervals after vaccination, although an interval of up to 12 hours between consecutive doses was allowed. Overall, 90% of parents reported giving their child all three doses, and 70% reported giving all doses on schedule.

Overall, local reactions with an area of redness at least 2.5 cm in size occurred in 43% of the children. In addition, 49% reported some pain in the vaccinated limb and 23% reported some itching in the vaccinated limb during the 2 days after vaccination.

Vesicoureteral Reflux and UTIs

Mild to moderate vesicoureteral reflux did not increase the incidence of urinary tract infections, recurrent pyelonephritis, or renal scarring in children with acute pyelonephritis, reported Dr. Eduardo H. Garin of the University of South Florida, Tampa, and his colleagues.

In addition, urinary antibiotic prophylaxis showed no effect on the prevention of either the recurrence of infection or the development of renal scars (Pediatrics 2006;117:626–32).

A total of 218 children aged 3 months to 18 years were monitored for 1 year. Children who were randomized to antibiotics received a once-daily dose of either 1–2 mg/kg of trimethoprim or 5–10 mg/kg sulfamethoxazole or 1.5 mg/kg nitrofurantoin. The overall incidence of urinary tract infections (UTIs) after pyelonephritis was 20.1%. Among children who did not receive antibiotic prophylaxis, the incidence of UTIs was not significantly different between those with and without vesicoureteral reflux (VUR; 22.4% vs. 23.3%). Similarly, among children who did receive antibiotic prophylaxis, the incidence of UTIs was not significantly different between children with and without VUR (23.6% vs. 8.8%).

Only 12 of the 218 patients (5.5%) had recurrence of pyelonephritis. Although more recurrences occurred in patients with VUR than without it (8 vs. 4), there was no significant evidence that reflux increased the odds of recurrence.

In addition, only 13 patients developed renal scars during the follow-up period—7 with VUR and 6 without VUR—there was no significant evidence that VUR increased the risk for scarring. The rates of scarring were similar in the prophylaxis and control groups.

Adult Tdap Called Safe for Children

The adult formula of the tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) can be given to children and adolescents starting at 18 months after a children's formula tetanus and diphtheria vaccine, said Dr. Scott A. Halperin of Dalhousie University, Halifax, Nova Scotia, and his colleagues.

Prior recommendations for a 10-year waiting period between doses of the tetanus and diphtheria toxoid-containing vaccine for infants and young children (TD) or the vaccine for older children and adults (Td) had been based on effectiveness rather than a lack of safety information, the investigators noted.

Concerns about the relationship between the timing of vaccinations and adverse events prompted an open-label clinical trial including 7,156 children in grades 3–12 who received Tdap at time intervals ranging from 18 months to 9 years after their previous vaccinations with TD, Td, or diphtheria-tetanus-acellular pertussis (DTaP).

Tdap was generally well tolerated regardless of the time elapsed since the previous vaccination. Data on fever, injection site erythema, swelling, and pain were solicited for 14 days after immunization, and unsolicited adverse events were recorded for 28 days (Pediatr. Infect. Dis. J. 2006;25:195–200). Overall, more than 80% of the children in each time interval reported injection site pain, but this was not significantly different from pain reports in children who were vaccinated 10 years after a previous immunization. Injection site erythema was slightly increased among children whose previous vaccine had been DTaP, but not among those whose previous vaccine had been Td.

DTaP Reactions Defeat OTC Drugs

Neither acetaminophen nor ibuprofen had a significant preventive effect against localized reactions to the fifth dose of the diphtheria-tetanus -acellular pertussis vaccine based on data from 372 children aged 4–6 years.

Dr. Lisa A. Jackson of the University of Washington, Seattle, and her colleagues conducted a randomized, blinded controlled trial within a larger safety study of the Tripedia DTaP vaccine. Dr. Jackson has served on the speakers' bureau for Sanofi Pasteur, which manufactures the vaccine and provided a research grant for the study (Pediatrics 2006;117:620–5).

The children were assigned to receive their first dose of 15 mg/kg of acetaminophen, with a maximum dose of 450 mg; 10 mg/kg of ibuprofen, with a maximum dose of 300 mg; or a placebo 2 hours before their scheduled vaccinations. The second and third doses were given at 6-hour intervals after vaccination, although an interval of up to 12 hours between consecutive doses was allowed. Overall, 90% of parents reported giving their child all three doses, and 70% reported giving all doses on schedule.

Overall, local reactions with an area of redness at least 2.5 cm in size occurred in 43% of the children. In addition, 49% reported some pain in the vaccinated limb and 23% reported some itching in the vaccinated limb during the 2 days after vaccination.

Vesicoureteral Reflux and UTIs

Mild to moderate vesicoureteral reflux did not increase the incidence of urinary tract infections, recurrent pyelonephritis, or renal scarring in children with acute pyelonephritis, reported Dr. Eduardo H. Garin of the University of South Florida, Tampa, and his colleagues.

In addition, urinary antibiotic prophylaxis showed no effect on the prevention of either the recurrence of infection or the development of renal scars (Pediatrics 2006;117:626–32).

A total of 218 children aged 3 months to 18 years were monitored for 1 year. Children who were randomized to antibiotics received a once-daily dose of either 1–2 mg/kg of trimethoprim or 5–10 mg/kg sulfamethoxazole or 1.5 mg/kg nitrofurantoin. The overall incidence of urinary tract infections (UTIs) after pyelonephritis was 20.1%. Among children who did not receive antibiotic prophylaxis, the incidence of UTIs was not significantly different between those with and without vesicoureteral reflux (VUR; 22.4% vs. 23.3%). Similarly, among children who did receive antibiotic prophylaxis, the incidence of UTIs was not significantly different between children with and without VUR (23.6% vs. 8.8%).

Only 12 of the 218 patients (5.5%) had recurrence of pyelonephritis. Although more recurrences occurred in patients with VUR than without it (8 vs. 4), there was no significant evidence that reflux increased the odds of recurrence.

In addition, only 13 patients developed renal scars during the follow-up period—7 with VUR and 6 without VUR—there was no significant evidence that VUR increased the risk for scarring. The rates of scarring were similar in the prophylaxis and control groups.

Adult Tdap Called Safe for Children

The adult formula of the tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) can be given to children and adolescents starting at 18 months after a children's formula tetanus and diphtheria vaccine, said Dr. Scott A. Halperin of Dalhousie University, Halifax, Nova Scotia, and his colleagues.

Prior recommendations for a 10-year waiting period between doses of the tetanus and diphtheria toxoid-containing vaccine for infants and young children (TD) or the vaccine for older children and adults (Td) had been based on effectiveness rather than a lack of safety information, the investigators noted.

Concerns about the relationship between the timing of vaccinations and adverse events prompted an open-label clinical trial including 7,156 children in grades 3–12 who received Tdap at time intervals ranging from 18 months to 9 years after their previous vaccinations with TD, Td, or diphtheria-tetanus-acellular pertussis (DTaP).

Tdap was generally well tolerated regardless of the time elapsed since the previous vaccination. Data on fever, injection site erythema, swelling, and pain were solicited for 14 days after immunization, and unsolicited adverse events were recorded for 28 days (Pediatr. Infect. Dis. J. 2006;25:195–200). Overall, more than 80% of the children in each time interval reported injection site pain, but this was not significantly different from pain reports in children who were vaccinated 10 years after a previous immunization. Injection site erythema was slightly increased among children whose previous vaccine had been DTaP, but not among those whose previous vaccine had been Td.

DTaP Reactions Defeat OTC Drugs

Neither acetaminophen nor ibuprofen had a significant preventive effect against localized reactions to the fifth dose of the diphtheria-tetanus -acellular pertussis vaccine based on data from 372 children aged 4–6 years.

Dr. Lisa A. Jackson of the University of Washington, Seattle, and her colleagues conducted a randomized, blinded controlled trial within a larger safety study of the Tripedia DTaP vaccine. Dr. Jackson has served on the speakers' bureau for Sanofi Pasteur, which manufactures the vaccine and provided a research grant for the study (Pediatrics 2006;117:620–5).

The children were assigned to receive their first dose of 15 mg/kg of acetaminophen, with a maximum dose of 450 mg; 10 mg/kg of ibuprofen, with a maximum dose of 300 mg; or a placebo 2 hours before their scheduled vaccinations. The second and third doses were given at 6-hour intervals after vaccination, although an interval of up to 12 hours between consecutive doses was allowed. Overall, 90% of parents reported giving their child all three doses, and 70% reported giving all doses on schedule.

Overall, local reactions with an area of redness at least 2.5 cm in size occurred in 43% of the children. In addition, 49% reported some pain in the vaccinated limb and 23% reported some itching in the vaccinated limb during the 2 days after vaccination.

BAL HARBOUR, FLA. — Although there is no single classification for neonatal rashes, subdividing these conditions into infectious versus noninfectious conditions, and further separating them by lesion type, provides a framework for diagnosing infants with skin disease, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

For example, infectious lesions in newborns may be characterized as either vesiculopustular or those that present with bullae, erosions, or ulcers, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

Vesiculopustular conditions include staphylococcal pustulosis. This condition occurs most often in the diaper area, and patients present with relatively few lesions. Rarely, the lesions are accompanied by bacteremia, cellulitis, meningitis, or pneumonia. Although Staphylococcus aureus is the most common cause of pustulosis, group A or B streptococcus, Listeria, and Pseudomonas also can cause pustulosis.

Another infectious vesiculopustular condition is congenital candidiasis, which usually occurs within the first 6 days of life, and can be associated with maternal vulvovaginitis. The infant with congenital candidiasis presents with erythematous papules and pustules on the soles and palms, usually caused by an ascending in utero infection. Risk factors for serious disease include low birth weight and a history of delivery room instrumentation, maternal intrauterine device, or cerclage. Also, these infants may have yellow discoloration, thickening, and ridging of their nails, sometimes with paronychial inflammation, Dr. Mancini noted.

A newborn with neonatal herpes—usually acquired from the mother during passage through the birth canal—usually presents with the characteristic vesicles on an erythematous base, often with clustering around the eyes. Neonatal herpes can affect the skin, eyes, and mucous membranes, as well as the central nervous system and other organs, and a significant number of benign cases may progress into a more serious disseminated form of herpes if they are not treated early, Dr. Mancini noted.

Infections in newborns that may present as bullae, erosions, or ulcers include bullous impetigo and staphylococcal scalded skin syndrome. A toxin secreted by S. aureus causes both of these conditions; bullous impetigo is the localized form, while scalded skin syndrome is a disseminated process based on hematogenous spread of the toxin.

Superficial peeling is a characteristic feature, but in severe cases the extensive skin peeling can require intensive care.

Other bullous or ulcerative infectious conditions in neonates include ecthyma gangrenosum, in which disk-shaped purple papules can evolve into bullae, erosions, and necrotic ulcers with eschar. This condition is most likely to occur in immunocompromised children, and indicates the presence of Pseudomonas aeruginosa bacteremia.

In the noninfectious category, conditions presenting as vesiculopustular lesions include erythema toxicum neonatorum, which presents as papules, pustules, and blotchy erythema.

This condition occurs in up to 50% of full-term neonates, but it is rare in premature infants with birth weights of less than 2,500 g, Dr. Mancini said. The condition arises within the first 2 days of life, and usually resolves over the next week or two.

Transient neonatal pustular melanosis is more common in darker skin, compared with lighter skin; as many as 5% of African American newborns have this condition, Dr. Mancini said. Prominent pustules, especially on the palms and soles, characterize the condition, as does a lack of erythema. After rupture, peripheral collarettes of scale are seen, and hyperpigmentation develops, which may last for several months.

Neonatal acne, also known as neonatal cephalic pustulosis, usually presents within the first 2–3 weeks of life, and resolves within a few weeks or a few months. The papulopustules tend to appear on the cheeks, but not on the trunk, and may be treated with a mild (2.5%) benzoyl peroxide or 2% erythromycin gel, if necessary. Topical antifungal cream also may be considered, given the occasional association of this condition with Malassezia species, but the lesions of neonatal acne usually resolve on their own with time.

Miliaria, or prickly heat, can be so extensive that it is misdiagnosed as atopic dermatitis and treated as such, with extensive application of emollients, which makes the condition worse, Dr. Mancini said. Prickly heat occurs in the summer due to humidity, but it can occur in the winter due to overbundling babies in cold weather. Parents can make the condition worse by overapplying an emollient, especially a greasy product. Miliaria presents as tiny, red papules and papulopustules, compared with the scaly plaques of eczema.

Finally, consider histiocytosis when faced with noninfectious, vesiculopustular lesions in infants. Histiocytosis is more common than congenital herpes, which is among the most common misdiagnoses in affected neonates, Dr. Mancini noted, and the lesions may become hemorrhagic.

Diagnostic pearls for neonatal histiocytosis include refractory or purpuric seborrheic dermatitis, eroded papules or nodules in areas of skin flexion, and crusted papules on the palms and soles.

Noninfectious bullous disorders include sucking blisters, a common and benign disorder caused by vigorous sucking of the affected body part by the fetus in utero.

Epidermolysis bullosa (EB) is an inherited mechanobullous disease and another source of noninfectious bullae. Infants with this condition present with blistering and open erosions, Dr. Mancini said. In addition, they may have large areas of aplasia cutis and mucosal involvement. The subtype of EB that the patient has determines the clinical presentation.

Mastocytosis is caused by an increase in cutaneous mast cells, and it can manifest as bullous lesions in infants. It presents with tan macules and papules that may have a “peau d'orange” (orange peel) appearance. Flushing, irritability, diarrhea, and respiratory distress are other potential features of this condition.

Finally, another category of noninfectious diagnoses are those that refer to a “red, scaly baby,” a neonate or infant who presents with widespread erythema and scaling. Diagnoses of this presentation include seborrheic dermatitis, atopic dermatitis, and psoriasis, Dr. Mancini said.

However, other conditions to consider include nutritional or metabolic disorders, immunodeficiency, ichthyoses, or ectodermal dysplasia.

“Cradle cap” is a characteristic presentation of seborrheic dermatitis in infants, which also may involve the groin, the umbilicus, and areas of skin flexion. By contrast, atopic dermatitis tends to spare the diaper area, and often involves the extremities.

Cradle cap can often be associated with a S. aureus colonization or infection. Psoriasis has some clinical overlap with seborrhea; it often occurs in the diaper area and scalp, and it can be triggered by infection with group A streptococcus.

Consider immunodeficiency in any baby with eczema or seborrheic dermatitis that resists treatment, Dr. Mancini said.

Another cause of red, scaly lesions in the infant is neonatal lupus, a diagnosis which should not be missed. It presents as scaly, erythematous patches and plaques that are sometimes diffuse, but most often occur in the periorbital area, which creates a “raccoon eye” presentation. Atrophy or telangiectasia also may be present. The mothers of children with neonatal lupus likely have anti-Ro, anti-La, or anti-U1 ribonucleoprotein antibodies, he noted, and the condition can be associated with congenital heart block.

BAL HARBOUR, FLA. — Although there is no single classification for neonatal rashes, subdividing these conditions into infectious versus noninfectious conditions, and further separating them by lesion type, provides a framework for diagnosing infants with skin disease, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

For example, infectious lesions in newborns may be characterized as either vesiculopustular or those that present with bullae, erosions, or ulcers, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

Vesiculopustular conditions include staphylococcal pustulosis. This condition occurs most often in the diaper area, and patients present with relatively few lesions. Rarely, the lesions are accompanied by bacteremia, cellulitis, meningitis, or pneumonia. Although Staphylococcus aureus is the most common cause of pustulosis, group A or B streptococcus, Listeria, and Pseudomonas also can cause pustulosis.

Another infectious vesiculopustular condition is congenital candidiasis, which usually occurs within the first 6 days of life, and can be associated with maternal vulvovaginitis. The infant with congenital candidiasis presents with erythematous papules and pustules on the soles and palms, usually caused by an ascending in utero infection. Risk factors for serious disease include low birth weight and a history of delivery room instrumentation, maternal intrauterine device, or cerclage. Also, these infants may have yellow discoloration, thickening, and ridging of their nails, sometimes with paronychial inflammation, Dr. Mancini noted.

A newborn with neonatal herpes—usually acquired from the mother during passage through the birth canal—usually presents with the characteristic vesicles on an erythematous base, often with clustering around the eyes. Neonatal herpes can affect the skin, eyes, and mucous membranes, as well as the central nervous system and other organs, and a significant number of benign cases may progress into a more serious disseminated form of herpes if they are not treated early, Dr. Mancini noted.

Infections in newborns that may present as bullae, erosions, or ulcers include bullous impetigo and staphylococcal scalded skin syndrome. A toxin secreted by S. aureus causes both of these conditions; bullous impetigo is the localized form, while scalded skin syndrome is a disseminated process based on hematogenous spread of the toxin.

Superficial peeling is a characteristic feature, but in severe cases the extensive skin peeling can require intensive care.

Other bullous or ulcerative infectious conditions in neonates include ecthyma gangrenosum, in which disk-shaped purple papules can evolve into bullae, erosions, and necrotic ulcers with eschar. This condition is most likely to occur in immunocompromised children, and indicates the presence of Pseudomonas aeruginosa bacteremia.

In the noninfectious category, conditions presenting as vesiculopustular lesions include erythema toxicum neonatorum, which presents as papules, pustules, and blotchy erythema.

This condition occurs in up to 50% of full-term neonates, but it is rare in premature infants with birth weights of less than 2,500 g, Dr. Mancini said. The condition arises within the first 2 days of life, and usually resolves over the next week or two.

Transient neonatal pustular melanosis is more common in darker skin, compared with lighter skin; as many as 5% of African American newborns have this condition, Dr. Mancini said. Prominent pustules, especially on the palms and soles, characterize the condition, as does a lack of erythema. After rupture, peripheral collarettes of scale are seen, and hyperpigmentation develops, which may last for several months.

Neonatal acne, also known as neonatal cephalic pustulosis, usually presents within the first 2–3 weeks of life, and resolves within a few weeks or a few months. The papulopustules tend to appear on the cheeks, but not on the trunk, and may be treated with a mild (2.5%) benzoyl peroxide or 2% erythromycin gel, if necessary. Topical antifungal cream also may be considered, given the occasional association of this condition with Malassezia species, but the lesions of neonatal acne usually resolve on their own with time.

Miliaria, or prickly heat, can be so extensive that it is misdiagnosed as atopic dermatitis and treated as such, with extensive application of emollients, which makes the condition worse, Dr. Mancini said. Prickly heat occurs in the summer due to humidity, but it can occur in the winter due to overbundling babies in cold weather. Parents can make the condition worse by overapplying an emollient, especially a greasy product. Miliaria presents as tiny, red papules and papulopustules, compared with the scaly plaques of eczema.

Finally, consider histiocytosis when faced with noninfectious, vesiculopustular lesions in infants. Histiocytosis is more common than congenital herpes, which is among the most common misdiagnoses in affected neonates, Dr. Mancini noted, and the lesions may become hemorrhagic.

Diagnostic pearls for neonatal histiocytosis include refractory or purpuric seborrheic dermatitis, eroded papules or nodules in areas of skin flexion, and crusted papules on the palms and soles.

Noninfectious bullous disorders include sucking blisters, a common and benign disorder caused by vigorous sucking of the affected body part by the fetus in utero.

Epidermolysis bullosa (EB) is an inherited mechanobullous disease and another source of noninfectious bullae. Infants with this condition present with blistering and open erosions, Dr. Mancini said. In addition, they may have large areas of aplasia cutis and mucosal involvement. The subtype of EB that the patient has determines the clinical presentation.

Mastocytosis is caused by an increase in cutaneous mast cells, and it can manifest as bullous lesions in infants. It presents with tan macules and papules that may have a “peau d'orange” (orange peel) appearance. Flushing, irritability, diarrhea, and respiratory distress are other potential features of this condition.

Finally, another category of noninfectious diagnoses are those that refer to a “red, scaly baby,” a neonate or infant who presents with widespread erythema and scaling. Diagnoses of this presentation include seborrheic dermatitis, atopic dermatitis, and psoriasis, Dr. Mancini said.

However, other conditions to consider include nutritional or metabolic disorders, immunodeficiency, ichthyoses, or ectodermal dysplasia.

“Cradle cap” is a characteristic presentation of seborrheic dermatitis in infants, which also may involve the groin, the umbilicus, and areas of skin flexion. By contrast, atopic dermatitis tends to spare the diaper area, and often involves the extremities.

Cradle cap can often be associated with a S. aureus colonization or infection. Psoriasis has some clinical overlap with seborrhea; it often occurs in the diaper area and scalp, and it can be triggered by infection with group A streptococcus.

Consider immunodeficiency in any baby with eczema or seborrheic dermatitis that resists treatment, Dr. Mancini said.

Another cause of red, scaly lesions in the infant is neonatal lupus, a diagnosis which should not be missed. It presents as scaly, erythematous patches and plaques that are sometimes diffuse, but most often occur in the periorbital area, which creates a “raccoon eye” presentation. Atrophy or telangiectasia also may be present. The mothers of children with neonatal lupus likely have anti-Ro, anti-La, or anti-U1 ribonucleoprotein antibodies, he noted, and the condition can be associated with congenital heart block.

BAL HARBOUR, FLA. — Although there is no single classification for neonatal rashes, subdividing these conditions into infectious versus noninfectious conditions, and further separating them by lesion type, provides a framework for diagnosing infants with skin disease, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

For example, infectious lesions in newborns may be characterized as either vesiculopustular or those that present with bullae, erosions, or ulcers, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

Vesiculopustular conditions include staphylococcal pustulosis. This condition occurs most often in the diaper area, and patients present with relatively few lesions. Rarely, the lesions are accompanied by bacteremia, cellulitis, meningitis, or pneumonia. Although Staphylococcus aureus is the most common cause of pustulosis, group A or B streptococcus, Listeria, and Pseudomonas also can cause pustulosis.

Another infectious vesiculopustular condition is congenital candidiasis, which usually occurs within the first 6 days of life, and can be associated with maternal vulvovaginitis. The infant with congenital candidiasis presents with erythematous papules and pustules on the soles and palms, usually caused by an ascending in utero infection. Risk factors for serious disease include low birth weight and a history of delivery room instrumentation, maternal intrauterine device, or cerclage. Also, these infants may have yellow discoloration, thickening, and ridging of their nails, sometimes with paronychial inflammation, Dr. Mancini noted.

A newborn with neonatal herpes—usually acquired from the mother during passage through the birth canal—usually presents with the characteristic vesicles on an erythematous base, often with clustering around the eyes. Neonatal herpes can affect the skin, eyes, and mucous membranes, as well as the central nervous system and other organs, and a significant number of benign cases may progress into a more serious disseminated form of herpes if they are not treated early, Dr. Mancini noted.

Infections in newborns that may present as bullae, erosions, or ulcers include bullous impetigo and staphylococcal scalded skin syndrome. A toxin secreted by S. aureus causes both of these conditions; bullous impetigo is the localized form, while scalded skin syndrome is a disseminated process based on hematogenous spread of the toxin.

Superficial peeling is a characteristic feature, but in severe cases the extensive skin peeling can require intensive care.

Other bullous or ulcerative infectious conditions in neonates include ecthyma gangrenosum, in which disk-shaped purple papules can evolve into bullae, erosions, and necrotic ulcers with eschar. This condition is most likely to occur in immunocompromised children, and indicates the presence of Pseudomonas aeruginosa bacteremia.

In the noninfectious category, conditions presenting as vesiculopustular lesions include erythema toxicum neonatorum, which presents as papules, pustules, and blotchy erythema.

This condition occurs in up to 50% of full-term neonates, but it is rare in premature infants with birth weights of less than 2,500 g, Dr. Mancini said. The condition arises within the first 2 days of life, and usually resolves over the next week or two.

Transient neonatal pustular melanosis is more common in darker skin, compared with lighter skin; as many as 5% of African American newborns have this condition, Dr. Mancini said. Prominent pustules, especially on the palms and soles, characterize the condition, as does a lack of erythema. After rupture, peripheral collarettes of scale are seen, and hyperpigmentation develops, which may last for several months.

Neonatal acne, also known as neonatal cephalic pustulosis, usually presents within the first 2–3 weeks of life, and resolves within a few weeks or a few months. The papulopustules tend to appear on the cheeks, but not on the trunk, and may be treated with a mild (2.5%) benzoyl peroxide or 2% erythromycin gel, if necessary. Topical antifungal cream also may be considered, given the occasional association of this condition with Malassezia species, but the lesions of neonatal acne usually resolve on their own with time.

Miliaria, or prickly heat, can be so extensive that it is misdiagnosed as atopic dermatitis and treated as such, with extensive application of emollients, which makes the condition worse, Dr. Mancini said. Prickly heat occurs in the summer due to humidity, but it can occur in the winter due to overbundling babies in cold weather. Parents can make the condition worse by overapplying an emollient, especially a greasy product. Miliaria presents as tiny, red papules and papulopustules, compared with the scaly plaques of eczema.

Finally, consider histiocytosis when faced with noninfectious, vesiculopustular lesions in infants. Histiocytosis is more common than congenital herpes, which is among the most common misdiagnoses in affected neonates, Dr. Mancini noted, and the lesions may become hemorrhagic.

Diagnostic pearls for neonatal histiocytosis include refractory or purpuric seborrheic dermatitis, eroded papules or nodules in areas of skin flexion, and crusted papules on the palms and soles.

Noninfectious bullous disorders include sucking blisters, a common and benign disorder caused by vigorous sucking of the affected body part by the fetus in utero.

Epidermolysis bullosa (EB) is an inherited mechanobullous disease and another source of noninfectious bullae. Infants with this condition present with blistering and open erosions, Dr. Mancini said. In addition, they may have large areas of aplasia cutis and mucosal involvement. The subtype of EB that the patient has determines the clinical presentation.

Mastocytosis is caused by an increase in cutaneous mast cells, and it can manifest as bullous lesions in infants. It presents with tan macules and papules that may have a “peau d'orange” (orange peel) appearance. Flushing, irritability, diarrhea, and respiratory distress are other potential features of this condition.

Finally, another category of noninfectious diagnoses are those that refer to a “red, scaly baby,” a neonate or infant who presents with widespread erythema and scaling. Diagnoses of this presentation include seborrheic dermatitis, atopic dermatitis, and psoriasis, Dr. Mancini said.

However, other conditions to consider include nutritional or metabolic disorders, immunodeficiency, ichthyoses, or ectodermal dysplasia.

“Cradle cap” is a characteristic presentation of seborrheic dermatitis in infants, which also may involve the groin, the umbilicus, and areas of skin flexion. By contrast, atopic dermatitis tends to spare the diaper area, and often involves the extremities.

Cradle cap can often be associated with a S. aureus colonization or infection. Psoriasis has some clinical overlap with seborrhea; it often occurs in the diaper area and scalp, and it can be triggered by infection with group A streptococcus.

Consider immunodeficiency in any baby with eczema or seborrheic dermatitis that resists treatment, Dr. Mancini said.

Another cause of red, scaly lesions in the infant is neonatal lupus, a diagnosis which should not be missed. It presents as scaly, erythematous patches and plaques that are sometimes diffuse, but most often occur in the periorbital area, which creates a “raccoon eye” presentation. Atrophy or telangiectasia also may be present. The mothers of children with neonatal lupus likely have anti-Ro, anti-La, or anti-U1 ribonucleoprotein antibodies, he noted, and the condition can be associated with congenital heart block.

WASHINGTON — A total of 1.8 million U.S. youth aged 12–17 years—including about 17% of eighth graders—reported that they had initiated inhalant use within the year during the years 2002–2004.

This was according to data from the report by the National Survey on Drug Use and Health, “Characteristics of Recent Adolescent Inhalant Initiates.”

“Kids don't view inhalants as dangerous,” Dr. Nora D. Volkow, director of the National Institute on Drug Abuse said at a press conference.

They have it wrong—a single episode of “huffing” from seemingly innocuous products such as shoe polish, spray paint, or compressed air, computer keyboard cleaner can be deadly.

About 35% of the youth who had started using inhalants during the past year said they had used them for 1 day; 23% had used inhalants on 2–3 days, 14% on 6–12 days, and 19% on at least 13 days, according to the report, which was published by the Substance Abuse and Mental Health Services Administration.

The most commonly reported types of inhalants were glue, toluene (a solvent used in paint thinners), and shoe polish (30%); gasoline or lighter fluid (25%); whipped cream cartridges (whippets) or nitrous oxide (25%); and spray paints (23%).

Overall, these recent inhalant initiates were significantly more likely to be white, compared with the general population (70% vs. 62%), and significantly more likely to be 14–15 years old, compared with the general population (39% vs. 34%).

The chemicals in products that serve as inhalants cross the blood-brain barrier and produce a high, said Dr. Volkow.

However, the chemicals have catastrophic consequences on other parts of the body. Sudden cardiac death and suffocation or asphyxiation are the most common causes of death as a result of inhalant use.

The toxicity of the inhaled compounds can cause neurologic symptoms, as well. (See box.)

Products that are used as inhalants are widely available and unregulated, and they can become addictive. Inhalants are difficult to detect; these products don't show up on drug tests, and many children do not think of inhalants as drugs, Dr. Volkow said.

Education is the best way to prevent inhalant abuse, and education campaigns in the medical profession, as well as in the community, are the keys to addressing this problem, she emphasized.

Physicians can have an extraordinary impact on preventing inhalant abuse, because they are in a position to ask questions and educate their patients. “If the physician doesn't ask the question, he or she will never get an answer,” Dr. Volkow said in an interview.

Be vigilant about inhalant abuse, Dr. Volkow said, because studies have shown that children who have used inhalants are more likely to exhibit behavior problems and anger and to develop conduct disorder.

Inhalants also may serve as a starter. The survey data showed that 23% of recent inhalant initiates had not used cigarettes, alcohol, or marijuana prior to their first use of inhalants.

For a copy of the National Survey on Drug Use and Health report, visit www.samhsa.govwww.inhalants.orgwww.inhalantprevention.org

KATHRYN DALES, ILLUSTRATION

Telltale Signs and Symptoms of Abuse

Someone who is abusing inhalants may exhibit one or all of the following symptoms:

▸ Burning sensation on the tongue.

▸ Dazed, dizzy, or drunken-seeming appearance.

▸ Nausea and/or loss of appetite.

▸ Neurologic problems including peripheral neuropathy, loss of vision, severe cognitive impairment, and seizures.

▸ Red or runny eyes and/or nose.

▸ Signs of paint, correction fluid, or other chemical products in unusual places, such as the face or fingers.

▸ Slurred or disoriented speech.

▸ Unusual behaviors such as anxiety, irritability, anger, excitability, or restlessness with no discernable cause.

▸ Unusual odor on the breath or chemical odor on clothing.

Sources: U.S. Consumer Product Safety Commission and the National Inhalant Prevention Coalition

WASHINGTON — A total of 1.8 million U.S. youth aged 12–17 years—including about 17% of eighth graders—reported that they had initiated inhalant use within the year during the years 2002–2004.

This was according to data from the report by the National Survey on Drug Use and Health, “Characteristics of Recent Adolescent Inhalant Initiates.”

“Kids don't view inhalants as dangerous,” Dr. Nora D. Volkow, director of the National Institute on Drug Abuse said at a press conference.

They have it wrong—a single episode of “huffing” from seemingly innocuous products such as shoe polish, spray paint, or compressed air, computer keyboard cleaner can be deadly.

About 35% of the youth who had started using inhalants during the past year said they had used them for 1 day; 23% had used inhalants on 2–3 days, 14% on 6–12 days, and 19% on at least 13 days, according to the report, which was published by the Substance Abuse and Mental Health Services Administration.

The most commonly reported types of inhalants were glue, toluene (a solvent used in paint thinners), and shoe polish (30%); gasoline or lighter fluid (25%); whipped cream cartridges (whippets) or nitrous oxide (25%); and spray paints (23%).

Overall, these recent inhalant initiates were significantly more likely to be white, compared with the general population (70% vs. 62%), and significantly more likely to be 14–15 years old, compared with the general population (39% vs. 34%).

The chemicals in products that serve as inhalants cross the blood-brain barrier and produce a high, said Dr. Volkow.

However, the chemicals have catastrophic consequences on other parts of the body. Sudden cardiac death and suffocation or asphyxiation are the most common causes of death as a result of inhalant use.

The toxicity of the inhaled compounds can cause neurologic symptoms, as well. (See box.)

Products that are used as inhalants are widely available and unregulated, and they can become addictive. Inhalants are difficult to detect; these products don't show up on drug tests, and many children do not think of inhalants as drugs, Dr. Volkow said.

Education is the best way to prevent inhalant abuse, and education campaigns in the medical profession, as well as in the community, are the keys to addressing this problem, she emphasized.

Physicians can have an extraordinary impact on preventing inhalant abuse, because they are in a position to ask questions and educate their patients. “If the physician doesn't ask the question, he or she will never get an answer,” Dr. Volkow said in an interview.

Be vigilant about inhalant abuse, Dr. Volkow said, because studies have shown that children who have used inhalants are more likely to exhibit behavior problems and anger and to develop conduct disorder.

Inhalants also may serve as a starter. The survey data showed that 23% of recent inhalant initiates had not used cigarettes, alcohol, or marijuana prior to their first use of inhalants.

For a copy of the National Survey on Drug Use and Health report, visit www.samhsa.govwww.inhalants.orgwww.inhalantprevention.org

KATHRYN DALES, ILLUSTRATION

Telltale Signs and Symptoms of Abuse

Someone who is abusing inhalants may exhibit one or all of the following symptoms:

▸ Burning sensation on the tongue.

▸ Dazed, dizzy, or drunken-seeming appearance.

▸ Nausea and/or loss of appetite.

▸ Neurologic problems including peripheral neuropathy, loss of vision, severe cognitive impairment, and seizures.

▸ Red or runny eyes and/or nose.

▸ Signs of paint, correction fluid, or other chemical products in unusual places, such as the face or fingers.

▸ Slurred or disoriented speech.

▸ Unusual behaviors such as anxiety, irritability, anger, excitability, or restlessness with no discernable cause.

▸ Unusual odor on the breath or chemical odor on clothing.

Sources: U.S. Consumer Product Safety Commission and the National Inhalant Prevention Coalition

WASHINGTON — A total of 1.8 million U.S. youth aged 12–17 years—including about 17% of eighth graders—reported that they had initiated inhalant use within the year during the years 2002–2004.

This was according to data from the report by the National Survey on Drug Use and Health, “Characteristics of Recent Adolescent Inhalant Initiates.”

“Kids don't view inhalants as dangerous,” Dr. Nora D. Volkow, director of the National Institute on Drug Abuse said at a press conference.

They have it wrong—a single episode of “huffing” from seemingly innocuous products such as shoe polish, spray paint, or compressed air, computer keyboard cleaner can be deadly.

About 35% of the youth who had started using inhalants during the past year said they had used them for 1 day; 23% had used inhalants on 2–3 days, 14% on 6–12 days, and 19% on at least 13 days, according to the report, which was published by the Substance Abuse and Mental Health Services Administration.

The most commonly reported types of inhalants were glue, toluene (a solvent used in paint thinners), and shoe polish (30%); gasoline or lighter fluid (25%); whipped cream cartridges (whippets) or nitrous oxide (25%); and spray paints (23%).

Overall, these recent inhalant initiates were significantly more likely to be white, compared with the general population (70% vs. 62%), and significantly more likely to be 14–15 years old, compared with the general population (39% vs. 34%).

The chemicals in products that serve as inhalants cross the blood-brain barrier and produce a high, said Dr. Volkow.

However, the chemicals have catastrophic consequences on other parts of the body. Sudden cardiac death and suffocation or asphyxiation are the most common causes of death as a result of inhalant use.

The toxicity of the inhaled compounds can cause neurologic symptoms, as well. (See box.)

Products that are used as inhalants are widely available and unregulated, and they can become addictive. Inhalants are difficult to detect; these products don't show up on drug tests, and many children do not think of inhalants as drugs, Dr. Volkow said.

Education is the best way to prevent inhalant abuse, and education campaigns in the medical profession, as well as in the community, are the keys to addressing this problem, she emphasized.

Physicians can have an extraordinary impact on preventing inhalant abuse, because they are in a position to ask questions and educate their patients. “If the physician doesn't ask the question, he or she will never get an answer,” Dr. Volkow said in an interview.

Be vigilant about inhalant abuse, Dr. Volkow said, because studies have shown that children who have used inhalants are more likely to exhibit behavior problems and anger and to develop conduct disorder.

Inhalants also may serve as a starter. The survey data showed that 23% of recent inhalant initiates had not used cigarettes, alcohol, or marijuana prior to their first use of inhalants.

For a copy of the National Survey on Drug Use and Health report, visit www.samhsa.govwww.inhalants.orgwww.inhalantprevention.org

KATHRYN DALES, ILLUSTRATION

Telltale Signs and Symptoms of Abuse

Someone who is abusing inhalants may exhibit one or all of the following symptoms:

▸ Burning sensation on the tongue.

▸ Dazed, dizzy, or drunken-seeming appearance.

▸ Nausea and/or loss of appetite.

▸ Neurologic problems including peripheral neuropathy, loss of vision, severe cognitive impairment, and seizures.

▸ Red or runny eyes and/or nose.

▸ Signs of paint, correction fluid, or other chemical products in unusual places, such as the face or fingers.

▸ Slurred or disoriented speech.

▸ Unusual behaviors such as anxiety, irritability, anger, excitability, or restlessness with no discernable cause.

▸ Unusual odor on the breath or chemical odor on clothing.

Sources: U.S. Consumer Product Safety Commission and the National Inhalant Prevention Coalition

BAL HARBOUR, FLA. — Warts and molluscum in children are often more troubling to their parents, and it is acceptable to wait for them to resolve on their own, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

However, warts and molluscum are cosmetically unpleasant and can create social stigma. Some families insist on treatment, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

When treating warts and molluscum, use the specific reimbursement codes, he said. Use code 17000 for treatment of 1 wart, 17003 for each wart when there are 2–14 warts, and 17004 for more than 15 warts. When treating molluscum, use 17110 for treatment of fewer than 15 lesions, and 17111 for 15 or more lesions.

Warts

Warts occur in nearly 10% of children, Dr. Mancini said.

Skin-to-skin contact from other individuals with warts, or skin contact with public surfaces with moisture (such as locker room floors and showers), are among the most common sources of warts in children. In addition, autoinoculation (spreading the wart virus on one's own skin by scratching, or skin-to-skin contact) is a common way that warts spread.

There are two schools of thought regarding warts. Some doctors say treat them, while others suggest leaving them alone, he said. Much depends on the desires of the patient or, more commonly, the parents.

Arguments for leaving warts alone include the fact that they are generally benign, rarely symptomatic, and usually resolve spontaneously. Also, the most effective treatments can be traumatic for young children.

Arguments for treating warts include the social stigma, especially if the wart is on the face or another obvious location, and the contagious nature of warts, which may cause concern with regard to the child's socializing and playing with friends.

Categories of wart treatment include chemovesicants, cryotherapy, immunotherapy, intralesional injections, laser or ablative therapy, and even hypnosis, as well as homeopathic remedies. “Homeopathic remedies may have as much effect as anything that we can offer medically,” Dr. Mancini noted.

Chemovesicants include podophyllin and trichloroacetic acid, which are often tried for anogenital warts. “Salicylic acid is probably one of the most effective treatments for warts,” Dr. Mancini said. “But we need to teach parents that they may have to treat the wart for weeks or months.” Most over-the-counter (OTC) salicylic acid liquids are the same, and contain about 17% salicylic acid.

Some parents may ask about the use of duct tape for warts. “I think that duct tape is a useful adjunct,” Dr. Mancini said.

His strategy is to use duct tape in conjunction with salicylic acid. “I have parents apply the salicylic acid to the wart, let it dry for 30 seconds or so, then occlude with a piece of duct tape overnight and remove it in the morning,” he said. This method probably works via a debridement effect, but only if duct tape is used. “Scotch tape and masking tape aren't strong enough.” Some researchers have suggested that occlusion with duct tape alone is useful, possibly via an immune mechanism.

Cryotherapy is very effective against warts, but it can be quite painful. “We spray the skin and create a large, hemorrhagic blister, with the hope that when the blister falls off, the wart falls off with it,” Dr. Mancini said. “If the patient doesn't develop a blister, the treatment is usually not effective.”

Overzealous treatment of warts can result in significant wounds, he cautioned. Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area.

OTC cryotherapy has been available since 2003, and these products can be effective for small warts, but they are not nearly as effective as liquid nitrogen, he said. These over-the-counter methods utilize dimethyl ether/propane, the same ingredient found in Histofreeze, but the OTC methods don't reach the same temperature, and thus they are significantly less effective.

Liquid nitrogen is a good choice for older children, such as a 10-year-old with one or two warts who says, “I want these gone.”

However, Dr. Mancini has a “no hold” policy regarding cryotherapy. “If we would have to hold the child down to do it, I generally recommend against it.”

Patients who do not want cryotherapy may consider oral or topical immunotherapy or injection therapy.

Cimetidine is the most common oral therapy used for warts. “The bottom line is that it is worth a try,” Dr. Mancini said. “It does work in some patients; the success rate is probably near 30%.” He generally prescribes a relatively high dose, 30–40 mg/kg per day, divided and given twice daily.

Squaric acid, a topical immunotherapy, is a fairly painless wart treatment, and the recurrence rate is fairly low among patients who respond, Dr. Mancini said. Allergic contact dermatitis can occur with this treatment, but it is not usually limiting.

Imiquimod is approved for genital warts with a recommended application frequency of 3 times per week, but it can be effective as an off-label treatment for common warts in children when applied once or twice daily, Dr. Mancini said.

Chemotherapy, in the form of 5% 5-fluorouracil (5-FU), also can be used off-label for warts in children, and is particularly useful for flat warts. Dr. Mancini recommends an application of 5-FU to the wart 3 nights each week, with the caveat that this treatment can result in severe dermatitis.

The injection of fungal antigens into the warts has been shown to be effective in some patients, possibly by inducing a host immune response directed at the human papillomavirus-infected tissue. Candida antigen injections have demonstrated some effectiveness, and are injected into 1–3 warts at each of two or three visits. As with other forms of topical or injection immunotherapy, untreated lesions often resolve on a parallel time frame to the involution of treated lesions.

Finally, laser therapy can be used to treat warts. Laser therapy, which is usually done with a pulsed dye laser, probably works by targeting the blood supply to the wart.

Dr. Mancini generally reserves this mode of therapy as a last resort, and it often requires several treatment sessions.

Molluscum Contagiosum

Mollusca have become more common than warts in many practices, Dr. Mancini noted. The condition is spread by skin-to-skin contact and possibly via fomites. Public swimming pools frequently are cited as a potential source of infection transmission.

Mollusca present as dome-shaped waxy papules, and often occur in conjunction with an associated dermatitis (“molluscum dermatitis”). The spontaneous resolution rate is nearly 100%, he said, although it may take 12–18 months, or longer. Remind parents that when the molluscum lesions suddenly and synchronously turn red, it is a good sign; it usually signals that the host immune response has kicked in, Dr. Mancini noted.

Despite a physician's efforts at reassurance of their self-limiting nature, many families want to treat mollusca. Treatment options have some overlap with those used for warts, and include chemovesicants, curettage, cryotherapy, imiquimod, cidofovir, tretinoin cream (especially for the face), and laser treatments.

Cantharidin, made from the extract of the Chinese blister beetle (Cantharis vesicatoris) is clearly the most effective treatment for mollusca in children. When used correctly, it has been demonstrated as safe and effective in the treatment of mollusca.

Dr. Mancini cited a study from his practice in which 90% of 300 molluscum patients cleared after cantharidin treatment, and another 8% improved. “It was very well-tolerated, and about 95% of parents said that they would choose this therapy again for their child.”

Cantharidin is not approved by the Food and Drug Administration, but was nominated for inclusion on a list of bulk drug substances that may be used in compounding and applied by the physician in the professional office setting.

Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area. DR. MANCINI

Common warts are shown prior to treatment by Candida antigen injection therapy.

The warts have resolved following two injections into the lesions.

A host immune response (erythema, edema) is shown in two molluscum contagiosum lesions. Photos courtesy Dr. Anthony J. Mancini

BAL HARBOUR, FLA. — Warts and molluscum in children are often more troubling to their parents, and it is acceptable to wait for them to resolve on their own, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

However, warts and molluscum are cosmetically unpleasant and can create social stigma. Some families insist on treatment, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

When treating warts and molluscum, use the specific reimbursement codes, he said. Use code 17000 for treatment of 1 wart, 17003 for each wart when there are 2–14 warts, and 17004 for more than 15 warts. When treating molluscum, use 17110 for treatment of fewer than 15 lesions, and 17111 for 15 or more lesions.

Warts

Warts occur in nearly 10% of children, Dr. Mancini said.

Skin-to-skin contact from other individuals with warts, or skin contact with public surfaces with moisture (such as locker room floors and showers), are among the most common sources of warts in children. In addition, autoinoculation (spreading the wart virus on one's own skin by scratching, or skin-to-skin contact) is a common way that warts spread.

There are two schools of thought regarding warts. Some doctors say treat them, while others suggest leaving them alone, he said. Much depends on the desires of the patient or, more commonly, the parents.

Arguments for leaving warts alone include the fact that they are generally benign, rarely symptomatic, and usually resolve spontaneously. Also, the most effective treatments can be traumatic for young children.

Arguments for treating warts include the social stigma, especially if the wart is on the face or another obvious location, and the contagious nature of warts, which may cause concern with regard to the child's socializing and playing with friends.

Categories of wart treatment include chemovesicants, cryotherapy, immunotherapy, intralesional injections, laser or ablative therapy, and even hypnosis, as well as homeopathic remedies. “Homeopathic remedies may have as much effect as anything that we can offer medically,” Dr. Mancini noted.

Chemovesicants include podophyllin and trichloroacetic acid, which are often tried for anogenital warts. “Salicylic acid is probably one of the most effective treatments for warts,” Dr. Mancini said. “But we need to teach parents that they may have to treat the wart for weeks or months.” Most over-the-counter (OTC) salicylic acid liquids are the same, and contain about 17% salicylic acid.

Some parents may ask about the use of duct tape for warts. “I think that duct tape is a useful adjunct,” Dr. Mancini said.

His strategy is to use duct tape in conjunction with salicylic acid. “I have parents apply the salicylic acid to the wart, let it dry for 30 seconds or so, then occlude with a piece of duct tape overnight and remove it in the morning,” he said. This method probably works via a debridement effect, but only if duct tape is used. “Scotch tape and masking tape aren't strong enough.” Some researchers have suggested that occlusion with duct tape alone is useful, possibly via an immune mechanism.

Cryotherapy is very effective against warts, but it can be quite painful. “We spray the skin and create a large, hemorrhagic blister, with the hope that when the blister falls off, the wart falls off with it,” Dr. Mancini said. “If the patient doesn't develop a blister, the treatment is usually not effective.”

Overzealous treatment of warts can result in significant wounds, he cautioned. Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area.

OTC cryotherapy has been available since 2003, and these products can be effective for small warts, but they are not nearly as effective as liquid nitrogen, he said. These over-the-counter methods utilize dimethyl ether/propane, the same ingredient found in Histofreeze, but the OTC methods don't reach the same temperature, and thus they are significantly less effective.

Liquid nitrogen is a good choice for older children, such as a 10-year-old with one or two warts who says, “I want these gone.”

However, Dr. Mancini has a “no hold” policy regarding cryotherapy. “If we would have to hold the child down to do it, I generally recommend against it.”

Patients who do not want cryotherapy may consider oral or topical immunotherapy or injection therapy.

Cimetidine is the most common oral therapy used for warts. “The bottom line is that it is worth a try,” Dr. Mancini said. “It does work in some patients; the success rate is probably near 30%.” He generally prescribes a relatively high dose, 30–40 mg/kg per day, divided and given twice daily.

Squaric acid, a topical immunotherapy, is a fairly painless wart treatment, and the recurrence rate is fairly low among patients who respond, Dr. Mancini said. Allergic contact dermatitis can occur with this treatment, but it is not usually limiting.

Imiquimod is approved for genital warts with a recommended application frequency of 3 times per week, but it can be effective as an off-label treatment for common warts in children when applied once or twice daily, Dr. Mancini said.

Chemotherapy, in the form of 5% 5-fluorouracil (5-FU), also can be used off-label for warts in children, and is particularly useful for flat warts. Dr. Mancini recommends an application of 5-FU to the wart 3 nights each week, with the caveat that this treatment can result in severe dermatitis.

The injection of fungal antigens into the warts has been shown to be effective in some patients, possibly by inducing a host immune response directed at the human papillomavirus-infected tissue. Candida antigen injections have demonstrated some effectiveness, and are injected into 1–3 warts at each of two or three visits. As with other forms of topical or injection immunotherapy, untreated lesions often resolve on a parallel time frame to the involution of treated lesions.

Finally, laser therapy can be used to treat warts. Laser therapy, which is usually done with a pulsed dye laser, probably works by targeting the blood supply to the wart.

Dr. Mancini generally reserves this mode of therapy as a last resort, and it often requires several treatment sessions.

Molluscum Contagiosum

Mollusca have become more common than warts in many practices, Dr. Mancini noted. The condition is spread by skin-to-skin contact and possibly via fomites. Public swimming pools frequently are cited as a potential source of infection transmission.

Mollusca present as dome-shaped waxy papules, and often occur in conjunction with an associated dermatitis (“molluscum dermatitis”). The spontaneous resolution rate is nearly 100%, he said, although it may take 12–18 months, or longer. Remind parents that when the molluscum lesions suddenly and synchronously turn red, it is a good sign; it usually signals that the host immune response has kicked in, Dr. Mancini noted.

Despite a physician's efforts at reassurance of their self-limiting nature, many families want to treat mollusca. Treatment options have some overlap with those used for warts, and include chemovesicants, curettage, cryotherapy, imiquimod, cidofovir, tretinoin cream (especially for the face), and laser treatments.

Cantharidin, made from the extract of the Chinese blister beetle (Cantharis vesicatoris) is clearly the most effective treatment for mollusca in children. When used correctly, it has been demonstrated as safe and effective in the treatment of mollusca.

Dr. Mancini cited a study from his practice in which 90% of 300 molluscum patients cleared after cantharidin treatment, and another 8% improved. “It was very well-tolerated, and about 95% of parents said that they would choose this therapy again for their child.”

Cantharidin is not approved by the Food and Drug Administration, but was nominated for inclusion on a list of bulk drug substances that may be used in compounding and applied by the physician in the professional office setting.

Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area. DR. MANCINI

Common warts are shown prior to treatment by Candida antigen injection therapy.

The warts have resolved following two injections into the lesions.

A host immune response (erythema, edema) is shown in two molluscum contagiosum lesions. Photos courtesy Dr. Anthony J. Mancini

BAL HARBOUR, FLA. — Warts and molluscum in children are often more troubling to their parents, and it is acceptable to wait for them to resolve on their own, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

However, warts and molluscum are cosmetically unpleasant and can create social stigma. Some families insist on treatment, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

When treating warts and molluscum, use the specific reimbursement codes, he said. Use code 17000 for treatment of 1 wart, 17003 for each wart when there are 2–14 warts, and 17004 for more than 15 warts. When treating molluscum, use 17110 for treatment of fewer than 15 lesions, and 17111 for 15 or more lesions.

Warts

Warts occur in nearly 10% of children, Dr. Mancini said.

Skin-to-skin contact from other individuals with warts, or skin contact with public surfaces with moisture (such as locker room floors and showers), are among the most common sources of warts in children. In addition, autoinoculation (spreading the wart virus on one's own skin by scratching, or skin-to-skin contact) is a common way that warts spread.

There are two schools of thought regarding warts. Some doctors say treat them, while others suggest leaving them alone, he said. Much depends on the desires of the patient or, more commonly, the parents.

Arguments for leaving warts alone include the fact that they are generally benign, rarely symptomatic, and usually resolve spontaneously. Also, the most effective treatments can be traumatic for young children.

Arguments for treating warts include the social stigma, especially if the wart is on the face or another obvious location, and the contagious nature of warts, which may cause concern with regard to the child's socializing and playing with friends.

Categories of wart treatment include chemovesicants, cryotherapy, immunotherapy, intralesional injections, laser or ablative therapy, and even hypnosis, as well as homeopathic remedies. “Homeopathic remedies may have as much effect as anything that we can offer medically,” Dr. Mancini noted.

Chemovesicants include podophyllin and trichloroacetic acid, which are often tried for anogenital warts. “Salicylic acid is probably one of the most effective treatments for warts,” Dr. Mancini said. “But we need to teach parents that they may have to treat the wart for weeks or months.” Most over-the-counter (OTC) salicylic acid liquids are the same, and contain about 17% salicylic acid.

Some parents may ask about the use of duct tape for warts. “I think that duct tape is a useful adjunct,” Dr. Mancini said.

His strategy is to use duct tape in conjunction with salicylic acid. “I have parents apply the salicylic acid to the wart, let it dry for 30 seconds or so, then occlude with a piece of duct tape overnight and remove it in the morning,” he said. This method probably works via a debridement effect, but only if duct tape is used. “Scotch tape and masking tape aren't strong enough.” Some researchers have suggested that occlusion with duct tape alone is useful, possibly via an immune mechanism.

Cryotherapy is very effective against warts, but it can be quite painful. “We spray the skin and create a large, hemorrhagic blister, with the hope that when the blister falls off, the wart falls off with it,” Dr. Mancini said. “If the patient doesn't develop a blister, the treatment is usually not effective.”

Overzealous treatment of warts can result in significant wounds, he cautioned. Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area.

OTC cryotherapy has been available since 2003, and these products can be effective for small warts, but they are not nearly as effective as liquid nitrogen, he said. These over-the-counter methods utilize dimethyl ether/propane, the same ingredient found in Histofreeze, but the OTC methods don't reach the same temperature, and thus they are significantly less effective.

Liquid nitrogen is a good choice for older children, such as a 10-year-old with one or two warts who says, “I want these gone.”

However, Dr. Mancini has a “no hold” policy regarding cryotherapy. “If we would have to hold the child down to do it, I generally recommend against it.”

Patients who do not want cryotherapy may consider oral or topical immunotherapy or injection therapy.

Cimetidine is the most common oral therapy used for warts. “The bottom line is that it is worth a try,” Dr. Mancini said. “It does work in some patients; the success rate is probably near 30%.” He generally prescribes a relatively high dose, 30–40 mg/kg per day, divided and given twice daily.

Squaric acid, a topical immunotherapy, is a fairly painless wart treatment, and the recurrence rate is fairly low among patients who respond, Dr. Mancini said. Allergic contact dermatitis can occur with this treatment, but it is not usually limiting.

Imiquimod is approved for genital warts with a recommended application frequency of 3 times per week, but it can be effective as an off-label treatment for common warts in children when applied once or twice daily, Dr. Mancini said.

Chemotherapy, in the form of 5% 5-fluorouracil (5-FU), also can be used off-label for warts in children, and is particularly useful for flat warts. Dr. Mancini recommends an application of 5-FU to the wart 3 nights each week, with the caveat that this treatment can result in severe dermatitis.

The injection of fungal antigens into the warts has been shown to be effective in some patients, possibly by inducing a host immune response directed at the human papillomavirus-infected tissue. Candida antigen injections have demonstrated some effectiveness, and are injected into 1–3 warts at each of two or three visits. As with other forms of topical or injection immunotherapy, untreated lesions often resolve on a parallel time frame to the involution of treated lesions.

Finally, laser therapy can be used to treat warts. Laser therapy, which is usually done with a pulsed dye laser, probably works by targeting the blood supply to the wart.

Dr. Mancini generally reserves this mode of therapy as a last resort, and it often requires several treatment sessions.

Molluscum Contagiosum

Mollusca have become more common than warts in many practices, Dr. Mancini noted. The condition is spread by skin-to-skin contact and possibly via fomites. Public swimming pools frequently are cited as a potential source of infection transmission.

Mollusca present as dome-shaped waxy papules, and often occur in conjunction with an associated dermatitis (“molluscum dermatitis”). The spontaneous resolution rate is nearly 100%, he said, although it may take 12–18 months, or longer. Remind parents that when the molluscum lesions suddenly and synchronously turn red, it is a good sign; it usually signals that the host immune response has kicked in, Dr. Mancini noted.

Despite a physician's efforts at reassurance of their self-limiting nature, many families want to treat mollusca. Treatment options have some overlap with those used for warts, and include chemovesicants, curettage, cryotherapy, imiquimod, cidofovir, tretinoin cream (especially for the face), and laser treatments.

Cantharidin, made from the extract of the Chinese blister beetle (Cantharis vesicatoris) is clearly the most effective treatment for mollusca in children. When used correctly, it has been demonstrated as safe and effective in the treatment of mollusca.

Dr. Mancini cited a study from his practice in which 90% of 300 molluscum patients cleared after cantharidin treatment, and another 8% improved. “It was very well-tolerated, and about 95% of parents said that they would choose this therapy again for their child.”

Cantharidin is not approved by the Food and Drug Administration, but was nominated for inclusion on a list of bulk drug substances that may be used in compounding and applied by the physician in the professional office setting.

Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area. DR. MANCINI

Common warts are shown prior to treatment by Candida antigen injection therapy.

The warts have resolved following two injections into the lesions.

A host immune response (erythema, edema) is shown in two molluscum contagiosum lesions. Photos courtesy Dr. Anthony J. Mancini

DENVER – Age and low hostility are independent predictors of high blood pressure in women over a 10-year period, suggesting a link between certain personality traits and disease development, Jocelyne Leclerc reported in a poster presentation at the annual meeting of the American Psychosomatic Society.

Ms. Leclerc and her colleagues at the University of British Columbia, Vancouver, compared the results of ambulatory blood pressure monitoring and personality questionnaires of 112 healthy adults at baseline and again after 10 years. The study group included 54 men and 63 women; the average age was 40 years at baseline. Average blood pressure monitoring was conducted on predetermined days when the patients did not expect significant stressful events.

Overall, blood pressure and personality traits remained stable over the 10 years. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly correlated with depression at baseline. Baseline hostility predicted increased DBP 10 years later, and baseline SBP predicted hostility 10 years later.

Gender and family history may moderate the impact of personality on blood pressure, the investigators noted in the recently published study (Pers. Individ. Diff. 2006;40:1313–21).

Increased age and low hostility significantly predicted SBP among women, while high levels of self-deception were the only significant predictors of SBP and DBP over time among men.

“The observation of low hostility in women predicting high BP appears quite surprising,” the investigators noted. This finding suggests a need to consider “possibly differential adaptiveness of the same personality features of women and men.”

Among individuals with a family history of high blood pressure, age and high levels of self-deception were significant predictors of SBP, while self-deception was the lone significant predictor of DBP. Among those without a family history of high blood pressure, only age was a significant predictor of SBP, and no variables were significant predictors of DBP.

DENVER – Age and low hostility are independent predictors of high blood pressure in women over a 10-year period, suggesting a link between certain personality traits and disease development, Jocelyne Leclerc reported in a poster presentation at the annual meeting of the American Psychosomatic Society.

Ms. Leclerc and her colleagues at the University of British Columbia, Vancouver, compared the results of ambulatory blood pressure monitoring and personality questionnaires of 112 healthy adults at baseline and again after 10 years. The study group included 54 men and 63 women; the average age was 40 years at baseline. Average blood pressure monitoring was conducted on predetermined days when the patients did not expect significant stressful events.

Overall, blood pressure and personality traits remained stable over the 10 years. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly correlated with depression at baseline. Baseline hostility predicted increased DBP 10 years later, and baseline SBP predicted hostility 10 years later.

Gender and family history may moderate the impact of personality on blood pressure, the investigators noted in the recently published study (Pers. Individ. Diff. 2006;40:1313–21).

Increased age and low hostility significantly predicted SBP among women, while high levels of self-deception were the only significant predictors of SBP and DBP over time among men.

“The observation of low hostility in women predicting high BP appears quite surprising,” the investigators noted. This finding suggests a need to consider “possibly differential adaptiveness of the same personality features of women and men.”

Among individuals with a family history of high blood pressure, age and high levels of self-deception were significant predictors of SBP, while self-deception was the lone significant predictor of DBP. Among those without a family history of high blood pressure, only age was a significant predictor of SBP, and no variables were significant predictors of DBP.

DENVER – Age and low hostility are independent predictors of high blood pressure in women over a 10-year period, suggesting a link between certain personality traits and disease development, Jocelyne Leclerc reported in a poster presentation at the annual meeting of the American Psychosomatic Society.

Ms. Leclerc and her colleagues at the University of British Columbia, Vancouver, compared the results of ambulatory blood pressure monitoring and personality questionnaires of 112 healthy adults at baseline and again after 10 years. The study group included 54 men and 63 women; the average age was 40 years at baseline. Average blood pressure monitoring was conducted on predetermined days when the patients did not expect significant stressful events.

Overall, blood pressure and personality traits remained stable over the 10 years. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly correlated with depression at baseline. Baseline hostility predicted increased DBP 10 years later, and baseline SBP predicted hostility 10 years later.

Gender and family history may moderate the impact of personality on blood pressure, the investigators noted in the recently published study (Pers. Individ. Diff. 2006;40:1313–21).

Increased age and low hostility significantly predicted SBP among women, while high levels of self-deception were the only significant predictors of SBP and DBP over time among men.

“The observation of low hostility in women predicting high BP appears quite surprising,” the investigators noted. This finding suggests a need to consider “possibly differential adaptiveness of the same personality features of women and men.”

Among individuals with a family history of high blood pressure, age and high levels of self-deception were significant predictors of SBP, while self-deception was the lone significant predictor of DBP. Among those without a family history of high blood pressure, only age was a significant predictor of SBP, and no variables were significant predictors of DBP.