Dermatology

The family physician diagnosed a nevus sebaceous (NS) in this patient.

There are 3 stages of evolution paralleling the histologic differentiation of normal sebaceous glands:

1. Infancy and young children. The lesion is smooth to slightly papillated, waxy, and hairless. (See Photo Rounds Friday, 6/15/18.)
2. Puberty.  Epidermal hyperplasia results in verrucous irregularity of the surface and coverage with numerous closely aggregated yellow-to-brown papules (this case).
3. Development of secondary appendageal tumors. This occurs in 20% to 30% of patients. Most lesions are benign, but single (most commonly basal cell carcinoma) or multiple malignant tumors of both epidermal and adnexal origins may be seen. These malignancies are rarely seen in childhood.

In this case, a biopsy was not needed because the clinical picture was clear and no operative intervention was planned. When needed, a shave biopsy should provide adequate tissue for diagnosis because the pathology is epidermal and in the upper dermis. The NS need not be removed to prevent malignant transformation.

The FP explained that hair usually doesn’t grow where an NS is, and it was okay to proceed with observation only. He advised the patient’s father that if any changes were to occur, he would be happy to refer the child for surgical removal. The boy was not worried about the appearance of the NS and did not want to have surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The family physician diagnosed a nevus sebaceous (NS) in this patient.

There are 3 stages of evolution paralleling the histologic differentiation of normal sebaceous glands:

1. Infancy and young children. The lesion is smooth to slightly papillated, waxy, and hairless. (See Photo Rounds Friday, 6/15/18.)
2. Puberty.  Epidermal hyperplasia results in verrucous irregularity of the surface and coverage with numerous closely aggregated yellow-to-brown papules (this case).
3. Development of secondary appendageal tumors. This occurs in 20% to 30% of patients. Most lesions are benign, but single (most commonly basal cell carcinoma) or multiple malignant tumors of both epidermal and adnexal origins may be seen. These malignancies are rarely seen in childhood.

In this case, a biopsy was not needed because the clinical picture was clear and no operative intervention was planned. When needed, a shave biopsy should provide adequate tissue for diagnosis because the pathology is epidermal and in the upper dermis. The NS need not be removed to prevent malignant transformation.

The FP explained that hair usually doesn’t grow where an NS is, and it was okay to proceed with observation only. He advised the patient’s father that if any changes were to occur, he would be happy to refer the child for surgical removal. The boy was not worried about the appearance of the NS and did not want to have surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The family physician diagnosed a nevus sebaceous (NS) in this patient.

There are 3 stages of evolution paralleling the histologic differentiation of normal sebaceous glands:

1. Infancy and young children. The lesion is smooth to slightly papillated, waxy, and hairless. (See Photo Rounds Friday, 6/15/18.)
2. Puberty.  Epidermal hyperplasia results in verrucous irregularity of the surface and coverage with numerous closely aggregated yellow-to-brown papules (this case).
3. Development of secondary appendageal tumors. This occurs in 20% to 30% of patients. Most lesions are benign, but single (most commonly basal cell carcinoma) or multiple malignant tumors of both epidermal and adnexal origins may be seen. These malignancies are rarely seen in childhood.

In this case, a biopsy was not needed because the clinical picture was clear and no operative intervention was planned. When needed, a shave biopsy should provide adequate tissue for diagnosis because the pathology is epidermal and in the upper dermis. The NS need not be removed to prevent malignant transformation.

The FP explained that hair usually doesn’t grow where an NS is, and it was okay to proceed with observation only. He advised the patient’s father that if any changes were to occur, he would be happy to refer the child for surgical removal. The boy was not worried about the appearance of the NS and did not want to have surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Nails should not be overlooked in treating common scabies, cautioned Marie Chinazzo, MD, of Centre Hospitalier Régional et Universitaire Tours, France, and her associates.

Nails can harbor mites, representing a potential source for relapse, not only in children, but also in adults.

wikimedia commons

Few studies have addressed scabies on the nails, which is typically observed in immunocompromised adults with crusted scabies, but also rarely in healthy adults and children.

In an observational, multicenter, prospective study conducted between June 2015 and January 2017, 47 pediatric patients with common scabies, including 3 children under 2 years of age, presented with mites on the first toenail/thumbnail; two of them had already completed treatment and were experiencing relapse. All children with dermatologic diagnosis that was confirmed by visual inspection of “the delta sign” (presence of the mite seen as a triangle representing the head) using dermoscopy or by microscopic identification of Sarcoptes scabiei were included in the study. Dermatologists were required to complete a standardized questionnaire for each participant. Full body inspections and nail samplings also were done.

Clinical nail damage, consisting of hyperkeratosis, onycholysis, onychoschizia, and pachyonychia, appeared in 5 of the 47 patients (11%). No other cause of nail damage was determined in four of the cases, for which mites were not directly visualized, the researchers noted. The report was published in the Journal of Pediatrics.

Of the 47 confirmed cases, 26 were female; 23 were under 2 years of age; 20 were 2-12 years; and 4 were older than 12. Ten cases presented with significant medical history; none were classified as immunocompromised.

Fully 42 of the 47 children (89%) reported pruritus, and of these, 64% also had pruritus present in the family home; 60% of siblings and 45% of parents were affected.

None were diagnosed with crusted scabies. The mean delay from disease onset to diagnosis was 55 days. In 38% of cases, previous treatment for scabies had been rendered.

Treatments varied based on presentation. Ivermectin, esdepallethrin, and 40% urea were repeated after 10 days in at least one case. In another case, an entire family was treated once with topical 5% permethrin; once the child experienced relapse, oral ivermectin was employed. In the case of an 18-month-old girl with pruritus and skin lesions, topical corticosteroid was used for 10 days until such time that dermatoscopy revealed the “delta sign” and 5% topical permethrin was added.

The authors observed that nail scabies in the medical literature is more commonly seen in immunocompromised patients with crusted scabies and higher concentrations of parasites. They were able to locate only three other reports, all in adults, of nail scabies occurring with common scabies.

“Treatment of nail scabies is difficult and is not highly evidence based,” cautioned Dr. Chinazzo and her associates. The primary study limitations were the small patient population and that nail sampling was taken only from the first fingers and toes, which could mean that the number of mites present is actually underestimated, they added.

The authors had no relevant financial disclosures.

SOURCE: Chinazzo M et al. J Pediatr. 2018. doi: 10.1016/j.jpeds.2018.01.038.

Nails should not be overlooked in treating common scabies, cautioned Marie Chinazzo, MD, of Centre Hospitalier Régional et Universitaire Tours, France, and her associates.

Nails can harbor mites, representing a potential source for relapse, not only in children, but also in adults.

wikimedia commons

Few studies have addressed scabies on the nails, which is typically observed in immunocompromised adults with crusted scabies, but also rarely in healthy adults and children.

In an observational, multicenter, prospective study conducted between June 2015 and January 2017, 47 pediatric patients with common scabies, including 3 children under 2 years of age, presented with mites on the first toenail/thumbnail; two of them had already completed treatment and were experiencing relapse. All children with dermatologic diagnosis that was confirmed by visual inspection of “the delta sign” (presence of the mite seen as a triangle representing the head) using dermoscopy or by microscopic identification of Sarcoptes scabiei were included in the study. Dermatologists were required to complete a standardized questionnaire for each participant. Full body inspections and nail samplings also were done.

Clinical nail damage, consisting of hyperkeratosis, onycholysis, onychoschizia, and pachyonychia, appeared in 5 of the 47 patients (11%). No other cause of nail damage was determined in four of the cases, for which mites were not directly visualized, the researchers noted. The report was published in the Journal of Pediatrics.

Of the 47 confirmed cases, 26 were female; 23 were under 2 years of age; 20 were 2-12 years; and 4 were older than 12. Ten cases presented with significant medical history; none were classified as immunocompromised.

Fully 42 of the 47 children (89%) reported pruritus, and of these, 64% also had pruritus present in the family home; 60% of siblings and 45% of parents were affected.

None were diagnosed with crusted scabies. The mean delay from disease onset to diagnosis was 55 days. In 38% of cases, previous treatment for scabies had been rendered.

Treatments varied based on presentation. Ivermectin, esdepallethrin, and 40% urea were repeated after 10 days in at least one case. In another case, an entire family was treated once with topical 5% permethrin; once the child experienced relapse, oral ivermectin was employed. In the case of an 18-month-old girl with pruritus and skin lesions, topical corticosteroid was used for 10 days until such time that dermatoscopy revealed the “delta sign” and 5% topical permethrin was added.

The authors observed that nail scabies in the medical literature is more commonly seen in immunocompromised patients with crusted scabies and higher concentrations of parasites. They were able to locate only three other reports, all in adults, of nail scabies occurring with common scabies.

“Treatment of nail scabies is difficult and is not highly evidence based,” cautioned Dr. Chinazzo and her associates. The primary study limitations were the small patient population and that nail sampling was taken only from the first fingers and toes, which could mean that the number of mites present is actually underestimated, they added.

The authors had no relevant financial disclosures.

SOURCE: Chinazzo M et al. J Pediatr. 2018. doi: 10.1016/j.jpeds.2018.01.038.

Nails should not be overlooked in treating common scabies, cautioned Marie Chinazzo, MD, of Centre Hospitalier Régional et Universitaire Tours, France, and her associates.

Nails can harbor mites, representing a potential source for relapse, not only in children, but also in adults.

wikimedia commons

Few studies have addressed scabies on the nails, which is typically observed in immunocompromised adults with crusted scabies, but also rarely in healthy adults and children.

In an observational, multicenter, prospective study conducted between June 2015 and January 2017, 47 pediatric patients with common scabies, including 3 children under 2 years of age, presented with mites on the first toenail/thumbnail; two of them had already completed treatment and were experiencing relapse. All children with dermatologic diagnosis that was confirmed by visual inspection of “the delta sign” (presence of the mite seen as a triangle representing the head) using dermoscopy or by microscopic identification of Sarcoptes scabiei were included in the study. Dermatologists were required to complete a standardized questionnaire for each participant. Full body inspections and nail samplings also were done.

Clinical nail damage, consisting of hyperkeratosis, onycholysis, onychoschizia, and pachyonychia, appeared in 5 of the 47 patients (11%). No other cause of nail damage was determined in four of the cases, for which mites were not directly visualized, the researchers noted. The report was published in the Journal of Pediatrics.

Of the 47 confirmed cases, 26 were female; 23 were under 2 years of age; 20 were 2-12 years; and 4 were older than 12. Ten cases presented with significant medical history; none were classified as immunocompromised.

Fully 42 of the 47 children (89%) reported pruritus, and of these, 64% also had pruritus present in the family home; 60% of siblings and 45% of parents were affected.

None were diagnosed with crusted scabies. The mean delay from disease onset to diagnosis was 55 days. In 38% of cases, previous treatment for scabies had been rendered.

Treatments varied based on presentation. Ivermectin, esdepallethrin, and 40% urea were repeated after 10 days in at least one case. In another case, an entire family was treated once with topical 5% permethrin; once the child experienced relapse, oral ivermectin was employed. In the case of an 18-month-old girl with pruritus and skin lesions, topical corticosteroid was used for 10 days until such time that dermatoscopy revealed the “delta sign” and 5% topical permethrin was added.

The authors observed that nail scabies in the medical literature is more commonly seen in immunocompromised patients with crusted scabies and higher concentrations of parasites. They were able to locate only three other reports, all in adults, of nail scabies occurring with common scabies.

“Treatment of nail scabies is difficult and is not highly evidence based,” cautioned Dr. Chinazzo and her associates. The primary study limitations were the small patient population and that nail sampling was taken only from the first fingers and toes, which could mean that the number of mites present is actually underestimated, they added.

The authors had no relevant financial disclosures.

SOURCE: Chinazzo M et al. J Pediatr. 2018. doi: 10.1016/j.jpeds.2018.01.038.

A case of inflammatory myopathy in an immunosuppressed patient who received a tattoo highlights a possible risk of tattooing in people with a compromised immune system.

Writing in the June 18 online edition of BMJ Case Reports, clinicians described a 31-year-old woman who was on long-term immunosuppressive therapy after bilateral lung transplants for cystic fibrosis.

The woman received a large, colored tattoo on her upper leg, with no immediate complications beyond the usual mild skin irritation. However, 9 days later, she developed pain in her left thigh and knee that was severe enough to require analgesic treatment that included tramadol and paracetamol.

The pain settled over the following few months, but the woman continued to experience a sense of fullness from her hip to knee along the medial side of her thigh. She presented to a rheumatology clinic 10 months after she was tattooed, with pain that was still constant and disturbing her sleep, but with no apparent aggravating factors and, otherwise, she was in good health.

Work-up included an MRI that showed focal inflammation of the vastus medialis muscle, particularly in the distal third, but a biopsy found no bacterial growth, nor was there any bacterial or fungal infection found in fluid drawn from the knee. However, histopathology revealed scattered internal nuclei, atrophic fibers, a mild perivascular inflammatory infiltrate, and upregulation of human leukocyte antigen.

In the report, William T. Wilson, MD, and his colleagues from the department of trauma and orthopedics, NHS Greater Glasgow and Clyde, Glasgow, said that these findings gave the impression of an inflammatory myopathy in which the pathologic response may have been influenced by the immunosuppression.

“To our knowledge, there have been no previously reported cases of tattoo-associated reactions causing an inflammatory myopathy,” they wrote. “This could be a rare occurrence or represent an underdiagnosis for patients presenting with similar symptoms having had tattoos.”

The authors suggested there was a chance that the myopathy may have been stimulated by a toxin or pathogen introduced during tattoo procedure. However, they pointed out that they could not identify a causative pathogen, although the timing of onset and location of symptoms correlated with the tattoo application.

“This case serves as a reminder to consider tattoo-related complications as part of the differential diagnosis when patients, especially the immune-suppressed, present with unusual atraumatic musculoskeletal symptoms,” they wrote.

After the biopsy, the woman received physiotherapy in the form of basic quadriceps-strengthening exercises. Her condition did not start to improve until about 1 year after the onset of symptoms, and by 3 years, she had no more pain and had resumed normal activities.

No funding or conflicts of interest were declared.

SOURCE: Wilson W et al. BMJ Case Rep. 2018. Jun 18. doi: 10.1136/bcr-2018-224968.

A case of inflammatory myopathy in an immunosuppressed patient who received a tattoo highlights a possible risk of tattooing in people with a compromised immune system.

Writing in the June 18 online edition of BMJ Case Reports, clinicians described a 31-year-old woman who was on long-term immunosuppressive therapy after bilateral lung transplants for cystic fibrosis.

The woman received a large, colored tattoo on her upper leg, with no immediate complications beyond the usual mild skin irritation. However, 9 days later, she developed pain in her left thigh and knee that was severe enough to require analgesic treatment that included tramadol and paracetamol.

The pain settled over the following few months, but the woman continued to experience a sense of fullness from her hip to knee along the medial side of her thigh. She presented to a rheumatology clinic 10 months after she was tattooed, with pain that was still constant and disturbing her sleep, but with no apparent aggravating factors and, otherwise, she was in good health.

Work-up included an MRI that showed focal inflammation of the vastus medialis muscle, particularly in the distal third, but a biopsy found no bacterial growth, nor was there any bacterial or fungal infection found in fluid drawn from the knee. However, histopathology revealed scattered internal nuclei, atrophic fibers, a mild perivascular inflammatory infiltrate, and upregulation of human leukocyte antigen.

In the report, William T. Wilson, MD, and his colleagues from the department of trauma and orthopedics, NHS Greater Glasgow and Clyde, Glasgow, said that these findings gave the impression of an inflammatory myopathy in which the pathologic response may have been influenced by the immunosuppression.

“To our knowledge, there have been no previously reported cases of tattoo-associated reactions causing an inflammatory myopathy,” they wrote. “This could be a rare occurrence or represent an underdiagnosis for patients presenting with similar symptoms having had tattoos.”

The authors suggested there was a chance that the myopathy may have been stimulated by a toxin or pathogen introduced during tattoo procedure. However, they pointed out that they could not identify a causative pathogen, although the timing of onset and location of symptoms correlated with the tattoo application.

“This case serves as a reminder to consider tattoo-related complications as part of the differential diagnosis when patients, especially the immune-suppressed, present with unusual atraumatic musculoskeletal symptoms,” they wrote.

After the biopsy, the woman received physiotherapy in the form of basic quadriceps-strengthening exercises. Her condition did not start to improve until about 1 year after the onset of symptoms, and by 3 years, she had no more pain and had resumed normal activities.

No funding or conflicts of interest were declared.

SOURCE: Wilson W et al. BMJ Case Rep. 2018. Jun 18. doi: 10.1136/bcr-2018-224968.

A case of inflammatory myopathy in an immunosuppressed patient who received a tattoo highlights a possible risk of tattooing in people with a compromised immune system.

Writing in the June 18 online edition of BMJ Case Reports, clinicians described a 31-year-old woman who was on long-term immunosuppressive therapy after bilateral lung transplants for cystic fibrosis.

The woman received a large, colored tattoo on her upper leg, with no immediate complications beyond the usual mild skin irritation. However, 9 days later, she developed pain in her left thigh and knee that was severe enough to require analgesic treatment that included tramadol and paracetamol.

The pain settled over the following few months, but the woman continued to experience a sense of fullness from her hip to knee along the medial side of her thigh. She presented to a rheumatology clinic 10 months after she was tattooed, with pain that was still constant and disturbing her sleep, but with no apparent aggravating factors and, otherwise, she was in good health.

Work-up included an MRI that showed focal inflammation of the vastus medialis muscle, particularly in the distal third, but a biopsy found no bacterial growth, nor was there any bacterial or fungal infection found in fluid drawn from the knee. However, histopathology revealed scattered internal nuclei, atrophic fibers, a mild perivascular inflammatory infiltrate, and upregulation of human leukocyte antigen.

In the report, William T. Wilson, MD, and his colleagues from the department of trauma and orthopedics, NHS Greater Glasgow and Clyde, Glasgow, said that these findings gave the impression of an inflammatory myopathy in which the pathologic response may have been influenced by the immunosuppression.

“To our knowledge, there have been no previously reported cases of tattoo-associated reactions causing an inflammatory myopathy,” they wrote. “This could be a rare occurrence or represent an underdiagnosis for patients presenting with similar symptoms having had tattoos.”

The authors suggested there was a chance that the myopathy may have been stimulated by a toxin or pathogen introduced during tattoo procedure. However, they pointed out that they could not identify a causative pathogen, although the timing of onset and location of symptoms correlated with the tattoo application.

“This case serves as a reminder to consider tattoo-related complications as part of the differential diagnosis when patients, especially the immune-suppressed, present with unusual atraumatic musculoskeletal symptoms,” they wrote.

After the biopsy, the woman received physiotherapy in the form of basic quadriceps-strengthening exercises. Her condition did not start to improve until about 1 year after the onset of symptoms, and by 3 years, she had no more pain and had resumed normal activities.

No funding or conflicts of interest were declared.

SOURCE: Wilson W et al. BMJ Case Rep. 2018. Jun 18. doi: 10.1136/bcr-2018-224968.

MALMO, SWEDEN – The unique 20-year U.S. experience with pediatric universal varicella vaccination hasn’t resulted in the anticipated increase in herpes zoster predicted by the exogenous boosting hypothesis, Lara J. Wolfson, PhD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

In fact, the opposite has occurred. And this finding – based upon hard data – should be of considerable interest to European health officials who have been considering introducing universal varicella vaccination into their national health care systems but have refrained because of theoretical concerns raised by the venerable exogenous boosting hypothesis, noted Dr. Wolfson, director of outcomes research at the Merck Center for Observational and Real-World Evidence, Kenilworth, N.J.

Bruce Jancin/MDedge News

The exogenous boosting hypothesis, which dates back to the mid-1960s, holds that reexposure to wild circulating varicella virus prevents development of herpes zoster later in life. Conversely, by vaccinating children against varicella, opportunities are diminished for reexposure to wild type virus among adults who weren’t vaccinated against varicella, so the hypothesis would predict an increase in the incidence of herpes zoster that should peak 15-35 years after introduction of universal varicella vaccination.

“The same virus that causes varicella in children later reactivates after going dormant in the dorsal root ganglia, and it reactivates as herpes zoster, which is 10 times more severe than chicken pox and leads to 10 times the health care costs. So if in fact implementing a universal varicella vaccine program would lead to an increased incidence of herpes zoster, this would be a bad thing,” the researcher explained.

However, the predictive models based upon the exogenous boosting hypothesis are built upon scanty data. And the models have great difficulty in adjusting for the changes in population dynamics that have occurred in the United States and Western Europe during the past quarter century: namely, declining birth rates coupled with survival to an older age.

Dr. Wolfson presented a retrospective study of deidentified administrative claims data from the MarketScan database covering roughly one-fifth of the U.S. population during 1991-2016. Her analysis broke down the annual incidence of varicella and herpes zoster in three eras: 1991-1995, which was the pre–varicella vaccination period; 1996-2006, when single-dose universal varicella vaccination of children was recommended; and 2007-2016, when two-dose vaccination became standard.

The first key study finding was that herpes zoster rates in the United States already were climbing across all age groups back in 1991-1995; that is, before introduction of universal varicella vaccination. Why? Probably because of those changes in population dynamics, although that’s speculative. The second key finding was that contrary to the exogenous boosting hypothesis prediction that the annual incidence of herpes zoster would accelerate after introduction of universal varicella vaccination, the rate of increase slowed, then plateaued during 2013-2016, most prominently in individuals aged 65 or older.

“In comparing the pre–universal varicella vaccination period to the one- or two-dose period or the total 20 years of vaccination, what we saw consistently across every age group is that herpes zoster is decelerating. There is actually less increase in the rate of herpes zoster than before varicella vaccination,” Dr. Wolfson said.

Uptake of the herpes zoster vaccine, introduced in the United States in 2008, was too low during the study years to account for this trend, she added.

Most dramatically, the incidence of herpes zoster among youths under age 18 years plummeted by 61.4%, from 88 per 100,000 person-years in 1991-1995 to 34 per 100,000 in 2016.

And of course, varicella disease has sharply declined in all age groups following the introduction of universal pediatric varicella vaccination, Dr. Wolfson observed.

Her study was supported by her employer, Merck.

bjancin@mdedge.com

MALMO, SWEDEN – The unique 20-year U.S. experience with pediatric universal varicella vaccination hasn’t resulted in the anticipated increase in herpes zoster predicted by the exogenous boosting hypothesis, Lara J. Wolfson, PhD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

In fact, the opposite has occurred. And this finding – based upon hard data – should be of considerable interest to European health officials who have been considering introducing universal varicella vaccination into their national health care systems but have refrained because of theoretical concerns raised by the venerable exogenous boosting hypothesis, noted Dr. Wolfson, director of outcomes research at the Merck Center for Observational and Real-World Evidence, Kenilworth, N.J.

Bruce Jancin/MDedge News

The exogenous boosting hypothesis, which dates back to the mid-1960s, holds that reexposure to wild circulating varicella virus prevents development of herpes zoster later in life. Conversely, by vaccinating children against varicella, opportunities are diminished for reexposure to wild type virus among adults who weren’t vaccinated against varicella, so the hypothesis would predict an increase in the incidence of herpes zoster that should peak 15-35 years after introduction of universal varicella vaccination.

“The same virus that causes varicella in children later reactivates after going dormant in the dorsal root ganglia, and it reactivates as herpes zoster, which is 10 times more severe than chicken pox and leads to 10 times the health care costs. So if in fact implementing a universal varicella vaccine program would lead to an increased incidence of herpes zoster, this would be a bad thing,” the researcher explained.

However, the predictive models based upon the exogenous boosting hypothesis are built upon scanty data. And the models have great difficulty in adjusting for the changes in population dynamics that have occurred in the United States and Western Europe during the past quarter century: namely, declining birth rates coupled with survival to an older age.

Dr. Wolfson presented a retrospective study of deidentified administrative claims data from the MarketScan database covering roughly one-fifth of the U.S. population during 1991-2016. Her analysis broke down the annual incidence of varicella and herpes zoster in three eras: 1991-1995, which was the pre–varicella vaccination period; 1996-2006, when single-dose universal varicella vaccination of children was recommended; and 2007-2016, when two-dose vaccination became standard.

The first key study finding was that herpes zoster rates in the United States already were climbing across all age groups back in 1991-1995; that is, before introduction of universal varicella vaccination. Why? Probably because of those changes in population dynamics, although that’s speculative. The second key finding was that contrary to the exogenous boosting hypothesis prediction that the annual incidence of herpes zoster would accelerate after introduction of universal varicella vaccination, the rate of increase slowed, then plateaued during 2013-2016, most prominently in individuals aged 65 or older.

“In comparing the pre–universal varicella vaccination period to the one- or two-dose period or the total 20 years of vaccination, what we saw consistently across every age group is that herpes zoster is decelerating. There is actually less increase in the rate of herpes zoster than before varicella vaccination,” Dr. Wolfson said.

Uptake of the herpes zoster vaccine, introduced in the United States in 2008, was too low during the study years to account for this trend, she added.

Most dramatically, the incidence of herpes zoster among youths under age 18 years plummeted by 61.4%, from 88 per 100,000 person-years in 1991-1995 to 34 per 100,000 in 2016.

And of course, varicella disease has sharply declined in all age groups following the introduction of universal pediatric varicella vaccination, Dr. Wolfson observed.

Her study was supported by her employer, Merck.

bjancin@mdedge.com

MALMO, SWEDEN – The unique 20-year U.S. experience with pediatric universal varicella vaccination hasn’t resulted in the anticipated increase in herpes zoster predicted by the exogenous boosting hypothesis, Lara J. Wolfson, PhD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

In fact, the opposite has occurred. And this finding – based upon hard data – should be of considerable interest to European health officials who have been considering introducing universal varicella vaccination into their national health care systems but have refrained because of theoretical concerns raised by the venerable exogenous boosting hypothesis, noted Dr. Wolfson, director of outcomes research at the Merck Center for Observational and Real-World Evidence, Kenilworth, N.J.

Bruce Jancin/MDedge News

The exogenous boosting hypothesis, which dates back to the mid-1960s, holds that reexposure to wild circulating varicella virus prevents development of herpes zoster later in life. Conversely, by vaccinating children against varicella, opportunities are diminished for reexposure to wild type virus among adults who weren’t vaccinated against varicella, so the hypothesis would predict an increase in the incidence of herpes zoster that should peak 15-35 years after introduction of universal varicella vaccination.

“The same virus that causes varicella in children later reactivates after going dormant in the dorsal root ganglia, and it reactivates as herpes zoster, which is 10 times more severe than chicken pox and leads to 10 times the health care costs. So if in fact implementing a universal varicella vaccine program would lead to an increased incidence of herpes zoster, this would be a bad thing,” the researcher explained.

However, the predictive models based upon the exogenous boosting hypothesis are built upon scanty data. And the models have great difficulty in adjusting for the changes in population dynamics that have occurred in the United States and Western Europe during the past quarter century: namely, declining birth rates coupled with survival to an older age.

Dr. Wolfson presented a retrospective study of deidentified administrative claims data from the MarketScan database covering roughly one-fifth of the U.S. population during 1991-2016. Her analysis broke down the annual incidence of varicella and herpes zoster in three eras: 1991-1995, which was the pre–varicella vaccination period; 1996-2006, when single-dose universal varicella vaccination of children was recommended; and 2007-2016, when two-dose vaccination became standard.

The first key study finding was that herpes zoster rates in the United States already were climbing across all age groups back in 1991-1995; that is, before introduction of universal varicella vaccination. Why? Probably because of those changes in population dynamics, although that’s speculative. The second key finding was that contrary to the exogenous boosting hypothesis prediction that the annual incidence of herpes zoster would accelerate after introduction of universal varicella vaccination, the rate of increase slowed, then plateaued during 2013-2016, most prominently in individuals aged 65 or older.

“In comparing the pre–universal varicella vaccination period to the one- or two-dose period or the total 20 years of vaccination, what we saw consistently across every age group is that herpes zoster is decelerating. There is actually less increase in the rate of herpes zoster than before varicella vaccination,” Dr. Wolfson said.

Uptake of the herpes zoster vaccine, introduced in the United States in 2008, was too low during the study years to account for this trend, she added.

Most dramatically, the incidence of herpes zoster among youths under age 18 years plummeted by 61.4%, from 88 per 100,000 person-years in 1991-1995 to 34 per 100,000 in 2016.

And of course, varicella disease has sharply declined in all age groups following the introduction of universal pediatric varicella vaccination, Dr. Wolfson observed.

Her study was supported by her employer, Merck.

bjancin@mdedge.com

The FP recognized the growth as an early nevus sebaceous (NS).

NS may be present at birth or noted in early childhood and occurs in males and females equally. In early stages of development, it appears skin-colored and waxy. Because of the potential for malignant transformation, particularly following puberty, many authors have recommended early complete plastic surgical excision. However, in a retrospective analysis of 757 cases of NS from 1996 to 2002 in children <16 years, investigators found no malignancies and questioned the need for prophylactic surgical removal.

The FP emphasized that this condition was benign and would likely get darker and more raised over time. He said that he would keep an eye on it during future visits and that the boy could choose to have it removed when he became an adult. The FP explained that reasons for removal include cosmetic issues and the prevention of malignant changes.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized the growth as an early nevus sebaceous (NS).

NS may be present at birth or noted in early childhood and occurs in males and females equally. In early stages of development, it appears skin-colored and waxy. Because of the potential for malignant transformation, particularly following puberty, many authors have recommended early complete plastic surgical excision. However, in a retrospective analysis of 757 cases of NS from 1996 to 2002 in children <16 years, investigators found no malignancies and questioned the need for prophylactic surgical removal.

The FP emphasized that this condition was benign and would likely get darker and more raised over time. He said that he would keep an eye on it during future visits and that the boy could choose to have it removed when he became an adult. The FP explained that reasons for removal include cosmetic issues and the prevention of malignant changes.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized the growth as an early nevus sebaceous (NS).

NS may be present at birth or noted in early childhood and occurs in males and females equally. In early stages of development, it appears skin-colored and waxy. Because of the potential for malignant transformation, particularly following puberty, many authors have recommended early complete plastic surgical excision. However, in a retrospective analysis of 757 cases of NS from 1996 to 2002 in children <16 years, investigators found no malignancies and questioned the need for prophylactic surgical removal.

The FP emphasized that this condition was benign and would likely get darker and more raised over time. He said that he would keep an eye on it during future visits and that the boy could choose to have it removed when he became an adult. The FP explained that reasons for removal include cosmetic issues and the prevention of malignant changes.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.

Courtesy RegionalDerm.com

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.
 

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.
 

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

Of all the techniques addressed, microscopy was found to be the fastest, but not always the most accurate, means of diagnosing tinea capitis. Dr. Gupta and his associates advised that diagnosis confirmation and precise species identification is best obtained with cultured scrapings, but this process can take 3 weeks or longer.

While fomites and hair care practices play a key role in tinea capitis infection, large family size, crowded living conditions, and low socioeconomic status are predisposing factors. Those who come in contact with infected patients should be considered possible asymptomatic carriers and be evaluated accordingly for treatment and to prevent spread of infection, the authors advised. Furthermore, recent studies recognized the impracticality of isolating children recently treated with oral therapy from classrooms since shedding of spores can continue for months.

The researchers had no relevant financial disclosures to report.

SOURCE: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.

The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.

Courtesy RegionalDerm.com

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.
 

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.
 

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

Of all the techniques addressed, microscopy was found to be the fastest, but not always the most accurate, means of diagnosing tinea capitis. Dr. Gupta and his associates advised that diagnosis confirmation and precise species identification is best obtained with cultured scrapings, but this process can take 3 weeks or longer.

While fomites and hair care practices play a key role in tinea capitis infection, large family size, crowded living conditions, and low socioeconomic status are predisposing factors. Those who come in contact with infected patients should be considered possible asymptomatic carriers and be evaluated accordingly for treatment and to prevent spread of infection, the authors advised. Furthermore, recent studies recognized the impracticality of isolating children recently treated with oral therapy from classrooms since shedding of spores can continue for months.

The researchers had no relevant financial disclosures to report.

SOURCE: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.

The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.

Courtesy RegionalDerm.com

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.
 

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.
 

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

Of all the techniques addressed, microscopy was found to be the fastest, but not always the most accurate, means of diagnosing tinea capitis. Dr. Gupta and his associates advised that diagnosis confirmation and precise species identification is best obtained with cultured scrapings, but this process can take 3 weeks or longer.

While fomites and hair care practices play a key role in tinea capitis infection, large family size, crowded living conditions, and low socioeconomic status are predisposing factors. Those who come in contact with infected patients should be considered possible asymptomatic carriers and be evaluated accordingly for treatment and to prevent spread of infection, the authors advised. Furthermore, recent studies recognized the impracticality of isolating children recently treated with oral therapy from classrooms since shedding of spores can continue for months.

The researchers had no relevant financial disclosures to report.

SOURCE: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.

ORLANDO – The more nevi a person has, the greater the risk of basal cell carcinoma, according to a review of over 200,000 subjects in decades-long health professional cohorts.

It’s well known that nevi increase the risk of melanoma, and the study confirmed that fact. The basal cell carcinoma finding, however, is novel. “The relationship between nevi and non-melanoma skin cancer has not [previously] been clearly demonstrated in large population cohorts,” said lead investigator Erin X. Wei, MD, a dermatologist at Brigham and Women’s Hospital, Boston.

“Nevus count serves as a convenient maker to identify patients at risk for both melanoma and basal cell carcinoma. Providers should be aware of these increased risks in patients with any nevi on the extremity, particularly 15 or more,” she said at the International Investigative Dermatology meeting.

There was no association, meanwhile, between nevus counts and squamous cell carcinoma (SCC).

The team reviewed 176,317 women in the Nurses’ Health Study 1 and 2, as well as 32,383 men in the Health Professionals Follow-up Study. Subjects were enrolled in the 1980s and followed through 2012. They reported nevus counts on their arms or legs at baseline, and filled out questionnaires on a regular basis that, among many other things, asked about new skin cancer diagnoses.

Overall, there were 30,457 incident basal cell carcinomas (BCCs), 1,704 incident melanomas, and 2,296 incident SCCs. Melanomas and SCCs – as well as a portion of BCCs – were confirmed by histology.

The team correlated the skin cancer incidence with how many moles subjects reported at baseline: zero, 1-5, 6-14, or 15 or more.

aotto@frontlinemedcom.com

SOURCE: Wei EX et al. 2018 International Investigative Dermatology meeting abstract 233

ORLANDO – The more nevi a person has, the greater the risk of basal cell carcinoma, according to a review of over 200,000 subjects in decades-long health professional cohorts.

It’s well known that nevi increase the risk of melanoma, and the study confirmed that fact. The basal cell carcinoma finding, however, is novel. “The relationship between nevi and non-melanoma skin cancer has not [previously] been clearly demonstrated in large population cohorts,” said lead investigator Erin X. Wei, MD, a dermatologist at Brigham and Women’s Hospital, Boston.

“Nevus count serves as a convenient maker to identify patients at risk for both melanoma and basal cell carcinoma. Providers should be aware of these increased risks in patients with any nevi on the extremity, particularly 15 or more,” she said at the International Investigative Dermatology meeting.

There was no association, meanwhile, between nevus counts and squamous cell carcinoma (SCC).

The team reviewed 176,317 women in the Nurses’ Health Study 1 and 2, as well as 32,383 men in the Health Professionals Follow-up Study. Subjects were enrolled in the 1980s and followed through 2012. They reported nevus counts on their arms or legs at baseline, and filled out questionnaires on a regular basis that, among many other things, asked about new skin cancer diagnoses.

Overall, there were 30,457 incident basal cell carcinomas (BCCs), 1,704 incident melanomas, and 2,296 incident SCCs. Melanomas and SCCs – as well as a portion of BCCs – were confirmed by histology.

The team correlated the skin cancer incidence with how many moles subjects reported at baseline: zero, 1-5, 6-14, or 15 or more.

aotto@frontlinemedcom.com

SOURCE: Wei EX et al. 2018 International Investigative Dermatology meeting abstract 233

ORLANDO – The more nevi a person has, the greater the risk of basal cell carcinoma, according to a review of over 200,000 subjects in decades-long health professional cohorts.

It’s well known that nevi increase the risk of melanoma, and the study confirmed that fact. The basal cell carcinoma finding, however, is novel. “The relationship between nevi and non-melanoma skin cancer has not [previously] been clearly demonstrated in large population cohorts,” said lead investigator Erin X. Wei, MD, a dermatologist at Brigham and Women’s Hospital, Boston.

“Nevus count serves as a convenient maker to identify patients at risk for both melanoma and basal cell carcinoma. Providers should be aware of these increased risks in patients with any nevi on the extremity, particularly 15 or more,” she said at the International Investigative Dermatology meeting.

There was no association, meanwhile, between nevus counts and squamous cell carcinoma (SCC).

The team reviewed 176,317 women in the Nurses’ Health Study 1 and 2, as well as 32,383 men in the Health Professionals Follow-up Study. Subjects were enrolled in the 1980s and followed through 2012. They reported nevus counts on their arms or legs at baseline, and filled out questionnaires on a regular basis that, among many other things, asked about new skin cancer diagnoses.

Overall, there were 30,457 incident basal cell carcinomas (BCCs), 1,704 incident melanomas, and 2,296 incident SCCs. Melanomas and SCCs – as well as a portion of BCCs – were confirmed by histology.

The team correlated the skin cancer incidence with how many moles subjects reported at baseline: zero, 1-5, 6-14, or 15 or more.

aotto@frontlinemedcom.com

SOURCE: Wei EX et al. 2018 International Investigative Dermatology meeting abstract 233

The prevalence of food, respiratory, and skin allergy is greater in U.S. children with autism spectrum disorder (ASD) than in U.S. children without the disorder, according to findings published June 8 in JAMA Network Open.

An analysis of data from the National Health Interview Survey found that the weighted prevalence of food, respiratory, and skin allergies was 11.25%, 18.73%, and 16.81%, respectively, in children with ASD, compared with 4.25%, 12.08%, and 9.84%, respectively, in children without ASD (P less than .001).

Survey data were collected between 1997 and 2016, and included patients aged 3-17 years. Allergic conditions were defined by the respondent, usually a parent, answering in the affirmative that the child had any kind of food, digestive, respiratory, or skin allergy in the past 12 months. ASD was defined based on an affirmative response to a question asking whether the child received an ASD diagnosis from a health professional. The question was asked as part of a 10-condition checklist from 1997 to 2013, and as a standalone item from 2014 onward, with revised wording to distinguish autism, Asperger’s disorder, pervasive developmental disorder, and ASD, wrote Guifeng Xu, MD, of the department of epidemiology at the University of Iowa, Iowa City, and her coauthors.

Of the 199,520 children included in the study, 8,734 had food allergy, 24,555 had respiratory allergy, and 19,399 had skin allergy. An ASD diagnosis was reported in 1,868 children. The weighted prevalence was 4.31% for food allergy (95% confidence interval, 4.20%-4.43%), 12.15% for respiratory allergy (95% CI, 11.92%-12.38%), and 9.91% for skin allergy (95% CI, 9.72%-10.10%), the authors said.

Children with ASD were more likely than were children without ASD to have food allergy, respiratory allergy, and skin allergy (P less than .001). After adjustment for factors including age, sex, ethnicity, and family education level, the odds ratio of ASD was more than double among children with food allergy, compared with those without food allergy (odds ratio, 2.72; 95% CI, 2.26-3.28; P less than .001).

Respiratory allergy and skin allergy also were significantly associated with ASD, but to a lesser degree, with an OR of 1.53 (95% CI, 1.32-1.78; P less than .001) for respiratory allergy and 1.80 (95% CI, 1.55-2.09; P less than .001) for skin allergy, Dr. Xu and her colleagues reported.

The findings suggest a “possible presence of shared mechanisms (e.g., immunologic dysfunction) among these allergic conditions in relation to ASD,” though the underlying mechanisms still need to be identified, the authors wrote.

SOURCE: Guifeng X et al. JAMA Network Open. 2018 Jun 8. doi: 10.1001/jamanetworkopen.2018.0279.

The prevalence of food, respiratory, and skin allergy is greater in U.S. children with autism spectrum disorder (ASD) than in U.S. children without the disorder, according to findings published June 8 in JAMA Network Open.

An analysis of data from the National Health Interview Survey found that the weighted prevalence of food, respiratory, and skin allergies was 11.25%, 18.73%, and 16.81%, respectively, in children with ASD, compared with 4.25%, 12.08%, and 9.84%, respectively, in children without ASD (P less than .001).

Survey data were collected between 1997 and 2016, and included patients aged 3-17 years. Allergic conditions were defined by the respondent, usually a parent, answering in the affirmative that the child had any kind of food, digestive, respiratory, or skin allergy in the past 12 months. ASD was defined based on an affirmative response to a question asking whether the child received an ASD diagnosis from a health professional. The question was asked as part of a 10-condition checklist from 1997 to 2013, and as a standalone item from 2014 onward, with revised wording to distinguish autism, Asperger’s disorder, pervasive developmental disorder, and ASD, wrote Guifeng Xu, MD, of the department of epidemiology at the University of Iowa, Iowa City, and her coauthors.

Of the 199,520 children included in the study, 8,734 had food allergy, 24,555 had respiratory allergy, and 19,399 had skin allergy. An ASD diagnosis was reported in 1,868 children. The weighted prevalence was 4.31% for food allergy (95% confidence interval, 4.20%-4.43%), 12.15% for respiratory allergy (95% CI, 11.92%-12.38%), and 9.91% for skin allergy (95% CI, 9.72%-10.10%), the authors said.

Children with ASD were more likely than were children without ASD to have food allergy, respiratory allergy, and skin allergy (P less than .001). After adjustment for factors including age, sex, ethnicity, and family education level, the odds ratio of ASD was more than double among children with food allergy, compared with those without food allergy (odds ratio, 2.72; 95% CI, 2.26-3.28; P less than .001).

Respiratory allergy and skin allergy also were significantly associated with ASD, but to a lesser degree, with an OR of 1.53 (95% CI, 1.32-1.78; P less than .001) for respiratory allergy and 1.80 (95% CI, 1.55-2.09; P less than .001) for skin allergy, Dr. Xu and her colleagues reported.

The findings suggest a “possible presence of shared mechanisms (e.g., immunologic dysfunction) among these allergic conditions in relation to ASD,” though the underlying mechanisms still need to be identified, the authors wrote.

SOURCE: Guifeng X et al. JAMA Network Open. 2018 Jun 8. doi: 10.1001/jamanetworkopen.2018.0279.

The prevalence of food, respiratory, and skin allergy is greater in U.S. children with autism spectrum disorder (ASD) than in U.S. children without the disorder, according to findings published June 8 in JAMA Network Open.

An analysis of data from the National Health Interview Survey found that the weighted prevalence of food, respiratory, and skin allergies was 11.25%, 18.73%, and 16.81%, respectively, in children with ASD, compared with 4.25%, 12.08%, and 9.84%, respectively, in children without ASD (P less than .001).

Survey data were collected between 1997 and 2016, and included patients aged 3-17 years. Allergic conditions were defined by the respondent, usually a parent, answering in the affirmative that the child had any kind of food, digestive, respiratory, or skin allergy in the past 12 months. ASD was defined based on an affirmative response to a question asking whether the child received an ASD diagnosis from a health professional. The question was asked as part of a 10-condition checklist from 1997 to 2013, and as a standalone item from 2014 onward, with revised wording to distinguish autism, Asperger’s disorder, pervasive developmental disorder, and ASD, wrote Guifeng Xu, MD, of the department of epidemiology at the University of Iowa, Iowa City, and her coauthors.

Of the 199,520 children included in the study, 8,734 had food allergy, 24,555 had respiratory allergy, and 19,399 had skin allergy. An ASD diagnosis was reported in 1,868 children. The weighted prevalence was 4.31% for food allergy (95% confidence interval, 4.20%-4.43%), 12.15% for respiratory allergy (95% CI, 11.92%-12.38%), and 9.91% for skin allergy (95% CI, 9.72%-10.10%), the authors said.

Children with ASD were more likely than were children without ASD to have food allergy, respiratory allergy, and skin allergy (P less than .001). After adjustment for factors including age, sex, ethnicity, and family education level, the odds ratio of ASD was more than double among children with food allergy, compared with those without food allergy (odds ratio, 2.72; 95% CI, 2.26-3.28; P less than .001).

Respiratory allergy and skin allergy also were significantly associated with ASD, but to a lesser degree, with an OR of 1.53 (95% CI, 1.32-1.78; P less than .001) for respiratory allergy and 1.80 (95% CI, 1.55-2.09; P less than .001) for skin allergy, Dr. Xu and her colleagues reported.

The findings suggest a “possible presence of shared mechanisms (e.g., immunologic dysfunction) among these allergic conditions in relation to ASD,” though the underlying mechanisms still need to be identified, the authors wrote.

SOURCE: Guifeng X et al. JAMA Network Open. 2018 Jun 8. doi: 10.1001/jamanetworkopen.2018.0279.

ORLANDO – Rituximab (Rituxan) is under priority review by the Food and Drug Administration for pemphigus vulgaris, and could be approved for the indication soon.

With approval pending, “rituximab is quickly emerging as frontline therapy” for pemphigus, so “we should begin to prepare to answer our patients’ questions. It’s likely they will be interested in its use,” said Carolyn Kushner, a medical student and dermatology research fellow at the University of Pennsylvania, Philadelphia. Rituximab manufacturer Genentech announced the priority review for this indication in a Feb. 2018 press release.

M. Alexander Otto/MDedge News

aotto@MDedge.com

SOURCE: Kushner CJ et al. IID 2018, Abstract 552.

ORLANDO – Rituximab (Rituxan) is under priority review by the Food and Drug Administration for pemphigus vulgaris, and could be approved for the indication soon.

With approval pending, “rituximab is quickly emerging as frontline therapy” for pemphigus, so “we should begin to prepare to answer our patients’ questions. It’s likely they will be interested in its use,” said Carolyn Kushner, a medical student and dermatology research fellow at the University of Pennsylvania, Philadelphia. Rituximab manufacturer Genentech announced the priority review for this indication in a Feb. 2018 press release.

M. Alexander Otto/MDedge News

aotto@MDedge.com

SOURCE: Kushner CJ et al. IID 2018, Abstract 552.

ORLANDO – Rituximab (Rituxan) is under priority review by the Food and Drug Administration for pemphigus vulgaris, and could be approved for the indication soon.

With approval pending, “rituximab is quickly emerging as frontline therapy” for pemphigus, so “we should begin to prepare to answer our patients’ questions. It’s likely they will be interested in its use,” said Carolyn Kushner, a medical student and dermatology research fellow at the University of Pennsylvania, Philadelphia. Rituximab manufacturer Genentech announced the priority review for this indication in a Feb. 2018 press release.

M. Alexander Otto/MDedge News

aotto@MDedge.com

SOURCE: Kushner CJ et al. IID 2018, Abstract 552.

About six months ago, the parents of this 1-year-old boy first noticed the lesion on his shoulder. It started as a pinpoint papule but has grown to its current size—at which point, it caught their full attention. Although there are no associated symptoms, the parents request referral to dermatology to clear up the matter.

The child is reportedly healthy in all other respects, maintaining weight as expected, and normally active and reactive to verbal and visual stimuli.

EXAMINATION

A distinctive orangish brown, ovoid, 8 x 4–mm nodule is located on the child’s right superior shoulder. The lesion has a smooth, soft surface, and there is no tenderness on palpation. No additional lesions are seen elsewhere.

Eye examination reveals normal and symmetrical red reflexes.

What is the diagnosis?

Juvenile xanthogranuloma (JXG) is a rare, benign variant of non-Langerhans cell histiocytosis. This patient’s lesion is typical, but JXG can vary in appearance; some patients present with darker or larger lesions—or multiple lesions.

JXGs are essentially granulomatous tumors that, on histologic examination, display multinucleated giant cells called Touton giant cells. These macrophage-derived foam cells are seen in lesions with high lipid content.

JXG tends to favor the neck, face, and trunk but can appear around or (rarely) inside the eye, typically unilaterally in the iris. Benign in all other respects, ocular JXG lesions can cause spontaneous hyphema, glaucoma, or blindness; they must therefore be dealt with by a specialist. Fortunately, only about 10% of patients display ocular involvement.

JXGs can be confused with compound nevi, warts, or Spitz tumors. Therefore, biopsy is often necessary to establish the diagnosis.

TAKE-HOME LEARNING POINTS

• Juvenile xanthogranuloma (JXG) is a rare non-Langerhans cell tumor usually seen on the neck, face, or trunk of children younger than 2.
• The orangish brown, soft appearance of this patient’s papule was typical.
• Although atypical JXG lesions may require shave biopsy to confirm the diagnosis, they typically resolve on their own without treatment.
• When JXG lesions appear in the eye (most commonly in the iris), there is potential for serious complications, including heterochromia, glaucoma, spontaneous hyphema, or even blindness.

About six months ago, the parents of this 1-year-old boy first noticed the lesion on his shoulder. It started as a pinpoint papule but has grown to its current size—at which point, it caught their full attention. Although there are no associated symptoms, the parents request referral to dermatology to clear up the matter.

The child is reportedly healthy in all other respects, maintaining weight as expected, and normally active and reactive to verbal and visual stimuli.

EXAMINATION

A distinctive orangish brown, ovoid, 8 x 4–mm nodule is located on the child’s right superior shoulder. The lesion has a smooth, soft surface, and there is no tenderness on palpation. No additional lesions are seen elsewhere.

Eye examination reveals normal and symmetrical red reflexes.

What is the diagnosis?

Juvenile xanthogranuloma (JXG) is a rare, benign variant of non-Langerhans cell histiocytosis. This patient’s lesion is typical, but JXG can vary in appearance; some patients present with darker or larger lesions—or multiple lesions.

JXGs are essentially granulomatous tumors that, on histologic examination, display multinucleated giant cells called Touton giant cells. These macrophage-derived foam cells are seen in lesions with high lipid content.

JXG tends to favor the neck, face, and trunk but can appear around or (rarely) inside the eye, typically unilaterally in the iris. Benign in all other respects, ocular JXG lesions can cause spontaneous hyphema, glaucoma, or blindness; they must therefore be dealt with by a specialist. Fortunately, only about 10% of patients display ocular involvement.

JXGs can be confused with compound nevi, warts, or Spitz tumors. Therefore, biopsy is often necessary to establish the diagnosis.

TAKE-HOME LEARNING POINTS

• Juvenile xanthogranuloma (JXG) is a rare non-Langerhans cell tumor usually seen on the neck, face, or trunk of children younger than 2.
• The orangish brown, soft appearance of this patient’s papule was typical.
• Although atypical JXG lesions may require shave biopsy to confirm the diagnosis, they typically resolve on their own without treatment.
• When JXG lesions appear in the eye (most commonly in the iris), there is potential for serious complications, including heterochromia, glaucoma, spontaneous hyphema, or even blindness.

About six months ago, the parents of this 1-year-old boy first noticed the lesion on his shoulder. It started as a pinpoint papule but has grown to its current size—at which point, it caught their full attention. Although there are no associated symptoms, the parents request referral to dermatology to clear up the matter.

The child is reportedly healthy in all other respects, maintaining weight as expected, and normally active and reactive to verbal and visual stimuli.

EXAMINATION

A distinctive orangish brown, ovoid, 8 x 4–mm nodule is located on the child’s right superior shoulder. The lesion has a smooth, soft surface, and there is no tenderness on palpation. No additional lesions are seen elsewhere.

Eye examination reveals normal and symmetrical red reflexes.

What is the diagnosis?

Juvenile xanthogranuloma (JXG) is a rare, benign variant of non-Langerhans cell histiocytosis. This patient’s lesion is typical, but JXG can vary in appearance; some patients present with darker or larger lesions—or multiple lesions.

JXGs are essentially granulomatous tumors that, on histologic examination, display multinucleated giant cells called Touton giant cells. These macrophage-derived foam cells are seen in lesions with high lipid content.

JXG tends to favor the neck, face, and trunk but can appear around or (rarely) inside the eye, typically unilaterally in the iris. Benign in all other respects, ocular JXG lesions can cause spontaneous hyphema, glaucoma, or blindness; they must therefore be dealt with by a specialist. Fortunately, only about 10% of patients display ocular involvement.

JXGs can be confused with compound nevi, warts, or Spitz tumors. Therefore, biopsy is often necessary to establish the diagnosis.

TAKE-HOME LEARNING POINTS

• Juvenile xanthogranuloma (JXG) is a rare non-Langerhans cell tumor usually seen on the neck, face, or trunk of children younger than 2.
• The orangish brown, soft appearance of this patient’s papule was typical.
• Although atypical JXG lesions may require shave biopsy to confirm the diagnosis, they typically resolve on their own without treatment.
• When JXG lesions appear in the eye (most commonly in the iris), there is potential for serious complications, including heterochromia, glaucoma, spontaneous hyphema, or even blindness.