Research highlights and trends in treating pediatric dermatology conditions.
TRENDS IN PEDIATRIC S. AUREUS HEAD AND NECK INFECTIONS
Seeking to evaluate the epidemiologic manifestations of pediatric Staphylococcus aureus head and neck infections nationwide and to identify possible trends in the antibiotic drug susceptibility of S. aureus during a 6-year period, researchers conducted a retrospective review of microbiologic data from a peer-reviewed national database. The researchers, Iman Naseri, MD, Robert C. Jerris, PhD, and Steven E. Sobol, MD, MSc, reviewed data on all pediatric patients with head and neck infections that involved S. aureus in more than 300 hospitals across the country. Anatomic sites were divided into oropharynx/neck, sinonasal and otologic infection categories. Demographic and antimicrobial drug susceptibility patterns were reviewed. Results: The results, which were published in the January 2009 issue of Archives of Otolaryngology – Head & Neck Surgery, were based on database findings gathered on 21,009 pediatric head and neck S. aureus infections that occurred between January 2001 and December 31, 2006. Predominance was observed in the oropharyngeal/neck category (60.3%). For all sites, the mean patient age was 6.7 years (range, 0 to 18 years), with a 51.7% male predominance. There was a high occurrence in the North East Central region of the United States. Overall, methicillin-resistant S. aureus (MRSA) was seen in 21.6% of all patient isolates (n = 4534), with rates of 11.8%, 12.5%, 18.1%, 27.2%, 25.5%, and 28.1% for 2001 through 2006, respectively. This represents a 16.3% increase in MRSA during these 6 years for all pediatric head and neck S. aureus infections. The researchers concluded that there is an alarming nationwide increase in the prevalence of pediatric MRSA head and neck infections. The disparities in the treatment of various head and neck infections nationwide may contribute to the regional differences in the prevalence of such infections. Judicious use of antibiotic agents and increased effectiveness in diagnosis and treatment are warranted to reduce further antimicrobial drug resistance in pediatric head and neck infections, according to the study authors. Source: Iman Naseri, MD; Robert C. Jerris, PhD; Steven E. Sobol, MD, MS, Arch Otolaryngol Head Neck Surg. 2009;135(1):14-16. __________________________
ELEMENTARY SCHOOL STUDENTS: SUN EXPOSURE AND SKIN CANCER RISK
To assess baseline knowledge of skin cancer, sun protection practices and perceptions of tanning among third through fifth grade elementary students in Florida, researchers surveyed 4,002 students in 19 elementary schools in Palm Beach County, FL, using the SunSmart America curriculum pretest responses for the main outcome measures. Results: The survey found that students’ overall knowledge scores, based on their mean knowledge scale scores of skin cancer and sun protection, were low (<40% of questions answered correctly) and were found to increase with grade level (p < 0.01). Boys more frequently reported spending more than 2 hours in the sun when compared with girls (p < 0.01). Girls, however, were more likely to try to get a tan most of the time or always when compared with boys (p = 0.02). Non-Hispanic White students (51.3%) more frequently reported use of SPF 15 or greater sunscreen “most of the time or always” compared with Hispanic (35.3%) and non-Hispanic Black (13.4%) students (p < 0.01). The researchers, Panta Rouhani, PhD, MPH, Yisrael Parmet, PhD, Ann G. Bessell, PhD, Tamika Peay, BA, Alina Weiss, BA, and Robert S. Kirsner, MD, PhD, concluded that elementary school-aged students in south Florida have limited knowledge about sun safety, despite spending a considerable amount of time in the sun. The results also showed that sun-safe behavior is associated with gender and ethnicity. Based on their findings, the researchers found that results of this survey provided empirical support for the need for a school-based educational intervention. Source: Rouhani P, Parmet Y, Bessell AG, Peay T, Weiss A, Kirsner RS. Knowledge, attitudes, and behaviors of elementary school students regarding sun exposure and skin cancer. Pediatr Dermatol. Published online May 2009. __________________________
Risk for Allergies to Atopic Dermatitis Treatments
To determine risk factors associated with skin sensitization — about which little is currently known — a group of researchers assessed the frequency of sensitization to several topical treatments prescribed for atopic dermatitis (AD) in children. For this study, 641 children with AD were systematically patch tested with these seven common topical treatment agents: chlorhexidine, hexamidine, budesonide, tixocortol pivalate, bufexamac, sodium fusidate and with the current emollient used by the child. The following variables were recorded: age, sex, age at onset of AD, associated asthma, severity of AD and history of previous exposure to topical agents used in the treatment of AD. Skin prick tests to inhalant and food allergens were used to explore the IgE-mediated sensitization. Results: There were 41 positive patch tests found in 40 patients (6.2%). Allergens were emollients (47.5%), chlorhexidine (42.5%), hexamidine (7.5%), tixocortol pivalate and bufexamac (2.5% each). Risk factors associated with sensitization to AD treatment were AD severity (OR: 3.3; 95% confidence interval [CI]):1.5-7.1 for moderate to severe AD), AD onset before the age of 6 months (OR: 2.7; 95% CI: 1.2-6.1), and IgE-mediated sensitization (OR: 2.5; 95% CI: 1.1-5.9). The researchers, who published their findings in the May 2009 issue of Allergy, concluded that topical treatment of AD is associated with cutaneous sensitization. Antiseptics and emollients represent the most frequent sensitizers and may be included in the standard series in AD children when contact dermatitis is suspected. Risk factors associated with sensitization to AD topical treatments are AD severity, early AD onset and IgE-mediated sensitization, according to the study authors. Source: Mailhol C, Lauwers-Cances V, Rancé F, Paul C, Giordano-Labadie F. Prevalence and risk factors for allergic contact dermatitis to topical treatment in atopic dermatitis: a study in 641 children. Allergy. 2009 May;64(5):801-6. __________________________
Video Offers Sun Safety Tips for Children
Pediatric dermatologist-researcher Alfred Lane, MD, a pediatrician and researcher at Packard Children’s Hospital and professor of dermatology and of pediatrics at the Stanford University School of Medicine, created a YouTube video to offer sunscreen safety tips. In the video, available at www.youtube.com/watch?v=6acZo-UPcx8, Dr. Lane provides guidance to parents to ensure their children are well-protected when outdoors. Highlights of the tips include the following. Sunscreen for infants and children. Though your sunscreen may say “not for use for those under 6 months of age,” Dr. Lane says it’s OK, but perhaps unnecessary. He suggests you use sunscreen on their hands, faces and other exposed areas, but that protection can be provided by dressing them in a hat, long sleeves and long pants. Dr. Lane also suggests placing them in the shade, especially since children less than 6 months usually stay in place and don’t move around much. “But once a child is older and becomes mobile, they have more exposure to the sun’s ultraviolet light, and that’s when you should definitely use a sunscreen,” he adds. SPF (sun protection factor) clothing. Dr. Lane explores the question of whether SPF clothing really works. “High SPF clothing is absolutely helpful,” says Dr. Lane, who recommends combining this type of cover-up with an application of sunscreen on any exposed areas. Sticks, lotions or sprays? “Whether it’s a stick, lotion, or spray, all are fine,” says Dr. Lane, “but it’s important not to use the sprays and lotions around the eyes. Instead, use a sunscreen stick around the eyes and maybe even around the lips.” Older children and young adults. “Younger children will keep high SPF sunscreen on, but older children and young adults often say it’s too greasy,” says Dr. Lane. “They seek a sunscreen that’s more comfortable, but regardless, they need to be certain to use lotion with at least a 30 SPF. The higher the SPF, the better the protection from ultraviolet damage and skin cancer. Be certain the sunscreen is also waterproof.” __________________________
The Role of Imiquimod in Treating Infantile Hemangiomas
APhase II, open-label, noncomparative study of imiquimod applied during 16 weeks, with post-therapy follow-up 16 weeks later (8 months total) was performed to explore the efficacy and safety of imiquimod 5% cream as a treatment for infantile hemangioma. The study of healthy infants up to 8.8 months of age with previously untreated, nonulcerated, proliferative superficial or mixed infantile hemangioma — excluding periorbital or perineal localization — > or =100 cm2 in size was performed at the outpatient pediatric tertiary care referral center in Quebec, Canada. Topical imiquimod was applied three to seven times per week for 16 weeks to infantile hemangioma. The main outcome measures included lesion area, volume, depth (Doppler ultrasound), and color (erythema), serum drug and interferon-alpha levels. Results: Sixteen infants (11 girls, 5 boys) with a mean age at entry of 4.1 months and mean lesion area of 32.89 cm2 and volume of 39.98 cm3 were enrolled. Two participants discontinued treatment early, one for an adverse event (crying upon application), the other due to lack of compliance. Local skin reactions were consistent with those reported in adults. Two cases had a decrease and three had an increase in lesion parameters; otherwise, no meaningful changes in lesion area, volume or depth were observed. At the 4-month post-treatment visit, 11 of 14 subjects had improvement in erythema (marginal homogeneity test = 2.668, p = 0.008). Measured serum drug and interferon-alpha levels were low or undetectable. The results, which were published in the March-April 2009 issue of Pediatric Dermatology, led the study authors to conclude that treatment of infants with infantile hemangioma with imiquimod up to seven times per week for 16 weeks was generally well tolerated with low systemic exposure. Improvement was observed in hemangioma coloration, but not lesion size, suggesting effects were limited to the superficial component. Source: McCuaig CC, Dubois J, Powell J, Belleville C, David M, Rousseau E, Gendron R, Jafarian F, Auger I. A phase II, open-label study of the efficacy and safety of imiquimod in the treatment of superficial and mixed infantile hemangioma. Pediatr Dermatol. 2009 Mar-Apr;26(2):203-12. __________________________
The Effectiveness of Combining Bathing and Moisturizing Regimens on Skin Hydration in Atopic Dermatitis
Skin hydration and use of moisturizers are important in standard care regimens for atopic dermatitis. However, there is little objective data to guide recommendations regarding the optimal practice methods of bathing and emollient application, so researchers conducted a study to quantify cutaneous hydration status after various combination bathing and moisturizing regimens. Four bathing/moisturizer regimens were evaluated in 10 patients, five pediatric patients with atopic dermatitis and five patients with healthy skin. The regimens consisted of bathing alone without emollient application, bathing followed by immediate emollient application, bathing and delayed application, and emollient application alone. Each regimen was evaluated in all patients, utilizing a crossover design. Skin hydration was assessed with standard capacitance measurements. Results: In atopic dermatitis patients, emollient alone yielded a significantly (p < 0.05) greater mean hydration over 90 minutes (206.2% baseline hydration) than bathing with immediate emollient (141.6%), bathing and delayed emollient (141%), and bathing alone (91.4%). The combination bathing and emollient application regimens demonstrated hydration values at 90 minutes, which was not significantly greater than baseline. Atopic dermatitis patients had a decreased mean hydration benefit compared with normal skin subjects. Researchers concluded that bathing without moisturizer may compromise skin hydration. Bathing followed by moisturizer application provides modest hydration benefits, though less than that of simply applying moisturizer alone. Source: Chiang C, and Eichenfield LF. Quantitative assessment of combination bathing and moisturizing regimens on skin hydration in atopic dermatitis. Pediatr Dermatol. Published online May 2009. __________________________
Promoting Epidermolysis Bullosa Research
Debra of America is a non-profit organization dedicated to research and direct services for epidermolysis bullosa (EB). The organization provides a Family Advocate Program to provide a support system for newborns and families learning to care for a child with EB. According to Debra, education is crucial to learning how to live with this disease. The organization also offers a Patient Care Conference every other year and provides a Nurse Educator to serve as a point of contact to assist new parents and patients, as well as to help healthcare professionals manage the care of EB patients. This program provides general information on EB and referrals to related professionals. Service is available via phone or email Monday through Friday, 9 a.m. to 5 p.m. Eastern Time. Visit www.debra.org for contact information. Along with the educational and emotional support services, Debra tries to help ease the financial burdens of treating EB by offering financial aid for unreimbursed costs of medical supplies, other comforting aids, or procedures for EB patients. For information on ways to help the organization, visit the Web site at www.debra.org. __________________________
New Study finds Formaldehyde and 1,4-dioxane in many Children’s Bath Products
Arecent study by the Campaign for Safe Cosmetics found that despite marketing claims like “gentle” and “pure,” dozens of top-selling children’s bath products are contaminated with the cancer-causing chemicals formaldehyde and 1,4-dioxane. These findings were based on product test results released by the Campaign for Safe Cosmetics. The chemicals were not disclosed on product labels because contaminants are exempt from labeling laws. This study is the first to document the widespread presence of both formaldehyde and 1,4-dioxane in bath products for children. Formaldehyde and 1,4-dioxane are known to cause cancer in animals and are listed as probable human carcinogens by the Environmental Protection Agency. Formaldehyde can also trigger skin rashes in some children. For the study, the Campaign for Safe Cosmetics commissioned an independent laboratory to test 48 top-selling children’s products for 1,4-dioxane; 28 of those products were also tested for formaldehyde. The lab found that: • 17 out of 28 products tested (61%) contained both formaldehyde and 1,4-dioxane, including Johnson’s Baby Shampoo, Sesame Street Bubble Bath, Grins & Giggles Milk & Honey Baby Wash and Huggies Naturally Refreshing Cucumber & Green Tea Baby Wash. • 23 out of 28 products (82%) contained formaldehyde at levels ranging from 54 to 610 parts per million (ppm). Baby Magic Baby Lotion had the highest levels of formaldehyde. • 32 out of 48 products (67%) contained 1,4-dioxane at levels ranging from 0.27 to 35 ppm. American Girl shower products had the highest levels of 1,4-dioxane. The full results of the study can be found in the report, “No More Toxic Tub” at https://www.safecosmetics.org/toxictub. For more on this study and other contact allergens in children, don’t miss the Pediatric Contact Dermatitis feature in next month’s issue of Skin & Aging.
Research highlights and trends in treating pediatric dermatology conditions.
TRENDS IN PEDIATRIC S. AUREUS HEAD AND NECK INFECTIONS
Seeking to evaluate the epidemiologic manifestations of pediatric Staphylococcus aureus head and neck infections nationwide and to identify possible trends in the antibiotic drug susceptibility of S. aureus during a 6-year period, researchers conducted a retrospective review of microbiologic data from a peer-reviewed national database. The researchers, Iman Naseri, MD, Robert C. Jerris, PhD, and Steven E. Sobol, MD, MSc, reviewed data on all pediatric patients with head and neck infections that involved S. aureus in more than 300 hospitals across the country. Anatomic sites were divided into oropharynx/neck, sinonasal and otologic infection categories. Demographic and antimicrobial drug susceptibility patterns were reviewed. Results: The results, which were published in the January 2009 issue of Archives of Otolaryngology – Head & Neck Surgery, were based on database findings gathered on 21,009 pediatric head and neck S. aureus infections that occurred between January 2001 and December 31, 2006. Predominance was observed in the oropharyngeal/neck category (60.3%). For all sites, the mean patient age was 6.7 years (range, 0 to 18 years), with a 51.7% male predominance. There was a high occurrence in the North East Central region of the United States. Overall, methicillin-resistant S. aureus (MRSA) was seen in 21.6% of all patient isolates (n = 4534), with rates of 11.8%, 12.5%, 18.1%, 27.2%, 25.5%, and 28.1% for 2001 through 2006, respectively. This represents a 16.3% increase in MRSA during these 6 years for all pediatric head and neck S. aureus infections. The researchers concluded that there is an alarming nationwide increase in the prevalence of pediatric MRSA head and neck infections. The disparities in the treatment of various head and neck infections nationwide may contribute to the regional differences in the prevalence of such infections. Judicious use of antibiotic agents and increased effectiveness in diagnosis and treatment are warranted to reduce further antimicrobial drug resistance in pediatric head and neck infections, according to the study authors. Source: Iman Naseri, MD; Robert C. Jerris, PhD; Steven E. Sobol, MD, MS, Arch Otolaryngol Head Neck Surg. 2009;135(1):14-16. __________________________
ELEMENTARY SCHOOL STUDENTS: SUN EXPOSURE AND SKIN CANCER RISK
To assess baseline knowledge of skin cancer, sun protection practices and perceptions of tanning among third through fifth grade elementary students in Florida, researchers surveyed 4,002 students in 19 elementary schools in Palm Beach County, FL, using the SunSmart America curriculum pretest responses for the main outcome measures. Results: The survey found that students’ overall knowledge scores, based on their mean knowledge scale scores of skin cancer and sun protection, were low (<40% of questions answered correctly) and were found to increase with grade level (p < 0.01). Boys more frequently reported spending more than 2 hours in the sun when compared with girls (p < 0.01). Girls, however, were more likely to try to get a tan most of the time or always when compared with boys (p = 0.02). Non-Hispanic White students (51.3%) more frequently reported use of SPF 15 or greater sunscreen “most of the time or always” compared with Hispanic (35.3%) and non-Hispanic Black (13.4%) students (p < 0.01). The researchers, Panta Rouhani, PhD, MPH, Yisrael Parmet, PhD, Ann G. Bessell, PhD, Tamika Peay, BA, Alina Weiss, BA, and Robert S. Kirsner, MD, PhD, concluded that elementary school-aged students in south Florida have limited knowledge about sun safety, despite spending a considerable amount of time in the sun. The results also showed that sun-safe behavior is associated with gender and ethnicity. Based on their findings, the researchers found that results of this survey provided empirical support for the need for a school-based educational intervention. Source: Rouhani P, Parmet Y, Bessell AG, Peay T, Weiss A, Kirsner RS. Knowledge, attitudes, and behaviors of elementary school students regarding sun exposure and skin cancer. Pediatr Dermatol. Published online May 2009. __________________________
Risk for Allergies to Atopic Dermatitis Treatments
To determine risk factors associated with skin sensitization — about which little is currently known — a group of researchers assessed the frequency of sensitization to several topical treatments prescribed for atopic dermatitis (AD) in children. For this study, 641 children with AD were systematically patch tested with these seven common topical treatment agents: chlorhexidine, hexamidine, budesonide, tixocortol pivalate, bufexamac, sodium fusidate and with the current emollient used by the child. The following variables were recorded: age, sex, age at onset of AD, associated asthma, severity of AD and history of previous exposure to topical agents used in the treatment of AD. Skin prick tests to inhalant and food allergens were used to explore the IgE-mediated sensitization. Results: There were 41 positive patch tests found in 40 patients (6.2%). Allergens were emollients (47.5%), chlorhexidine (42.5%), hexamidine (7.5%), tixocortol pivalate and bufexamac (2.5% each). Risk factors associated with sensitization to AD treatment were AD severity (OR: 3.3; 95% confidence interval [CI]):1.5-7.1 for moderate to severe AD), AD onset before the age of 6 months (OR: 2.7; 95% CI: 1.2-6.1), and IgE-mediated sensitization (OR: 2.5; 95% CI: 1.1-5.9). The researchers, who published their findings in the May 2009 issue of Allergy, concluded that topical treatment of AD is associated with cutaneous sensitization. Antiseptics and emollients represent the most frequent sensitizers and may be included in the standard series in AD children when contact dermatitis is suspected. Risk factors associated with sensitization to AD topical treatments are AD severity, early AD onset and IgE-mediated sensitization, according to the study authors. Source: Mailhol C, Lauwers-Cances V, Rancé F, Paul C, Giordano-Labadie F. Prevalence and risk factors for allergic contact dermatitis to topical treatment in atopic dermatitis: a study in 641 children. Allergy. 2009 May;64(5):801-6. __________________________
Video Offers Sun Safety Tips for Children
Pediatric dermatologist-researcher Alfred Lane, MD, a pediatrician and researcher at Packard Children’s Hospital and professor of dermatology and of pediatrics at the Stanford University School of Medicine, created a YouTube video to offer sunscreen safety tips. In the video, available at www.youtube.com/watch?v=6acZo-UPcx8, Dr. Lane provides guidance to parents to ensure their children are well-protected when outdoors. Highlights of the tips include the following. Sunscreen for infants and children. Though your sunscreen may say “not for use for those under 6 months of age,” Dr. Lane says it’s OK, but perhaps unnecessary. He suggests you use sunscreen on their hands, faces and other exposed areas, but that protection can be provided by dressing them in a hat, long sleeves and long pants. Dr. Lane also suggests placing them in the shade, especially since children less than 6 months usually stay in place and don’t move around much. “But once a child is older and becomes mobile, they have more exposure to the sun’s ultraviolet light, and that’s when you should definitely use a sunscreen,” he adds. SPF (sun protection factor) clothing. Dr. Lane explores the question of whether SPF clothing really works. “High SPF clothing is absolutely helpful,” says Dr. Lane, who recommends combining this type of cover-up with an application of sunscreen on any exposed areas. Sticks, lotions or sprays? “Whether it’s a stick, lotion, or spray, all are fine,” says Dr. Lane, “but it’s important not to use the sprays and lotions around the eyes. Instead, use a sunscreen stick around the eyes and maybe even around the lips.” Older children and young adults. “Younger children will keep high SPF sunscreen on, but older children and young adults often say it’s too greasy,” says Dr. Lane. “They seek a sunscreen that’s more comfortable, but regardless, they need to be certain to use lotion with at least a 30 SPF. The higher the SPF, the better the protection from ultraviolet damage and skin cancer. Be certain the sunscreen is also waterproof.” __________________________
The Role of Imiquimod in Treating Infantile Hemangiomas
APhase II, open-label, noncomparative study of imiquimod applied during 16 weeks, with post-therapy follow-up 16 weeks later (8 months total) was performed to explore the efficacy and safety of imiquimod 5% cream as a treatment for infantile hemangioma. The study of healthy infants up to 8.8 months of age with previously untreated, nonulcerated, proliferative superficial or mixed infantile hemangioma — excluding periorbital or perineal localization — > or =100 cm2 in size was performed at the outpatient pediatric tertiary care referral center in Quebec, Canada. Topical imiquimod was applied three to seven times per week for 16 weeks to infantile hemangioma. The main outcome measures included lesion area, volume, depth (Doppler ultrasound), and color (erythema), serum drug and interferon-alpha levels. Results: Sixteen infants (11 girls, 5 boys) with a mean age at entry of 4.1 months and mean lesion area of 32.89 cm2 and volume of 39.98 cm3 were enrolled. Two participants discontinued treatment early, one for an adverse event (crying upon application), the other due to lack of compliance. Local skin reactions were consistent with those reported in adults. Two cases had a decrease and three had an increase in lesion parameters; otherwise, no meaningful changes in lesion area, volume or depth were observed. At the 4-month post-treatment visit, 11 of 14 subjects had improvement in erythema (marginal homogeneity test = 2.668, p = 0.008). Measured serum drug and interferon-alpha levels were low or undetectable. The results, which were published in the March-April 2009 issue of Pediatric Dermatology, led the study authors to conclude that treatment of infants with infantile hemangioma with imiquimod up to seven times per week for 16 weeks was generally well tolerated with low systemic exposure. Improvement was observed in hemangioma coloration, but not lesion size, suggesting effects were limited to the superficial component. Source: McCuaig CC, Dubois J, Powell J, Belleville C, David M, Rousseau E, Gendron R, Jafarian F, Auger I. A phase II, open-label study of the efficacy and safety of imiquimod in the treatment of superficial and mixed infantile hemangioma. Pediatr Dermatol. 2009 Mar-Apr;26(2):203-12. __________________________
The Effectiveness of Combining Bathing and Moisturizing Regimens on Skin Hydration in Atopic Dermatitis
Skin hydration and use of moisturizers are important in standard care regimens for atopic dermatitis. However, there is little objective data to guide recommendations regarding the optimal practice methods of bathing and emollient application, so researchers conducted a study to quantify cutaneous hydration status after various combination bathing and moisturizing regimens. Four bathing/moisturizer regimens were evaluated in 10 patients, five pediatric patients with atopic dermatitis and five patients with healthy skin. The regimens consisted of bathing alone without emollient application, bathing followed by immediate emollient application, bathing and delayed application, and emollient application alone. Each regimen was evaluated in all patients, utilizing a crossover design. Skin hydration was assessed with standard capacitance measurements. Results: In atopic dermatitis patients, emollient alone yielded a significantly (p < 0.05) greater mean hydration over 90 minutes (206.2% baseline hydration) than bathing with immediate emollient (141.6%), bathing and delayed emollient (141%), and bathing alone (91.4%). The combination bathing and emollient application regimens demonstrated hydration values at 90 minutes, which was not significantly greater than baseline. Atopic dermatitis patients had a decreased mean hydration benefit compared with normal skin subjects. Researchers concluded that bathing without moisturizer may compromise skin hydration. Bathing followed by moisturizer application provides modest hydration benefits, though less than that of simply applying moisturizer alone. Source: Chiang C, and Eichenfield LF. Quantitative assessment of combination bathing and moisturizing regimens on skin hydration in atopic dermatitis. Pediatr Dermatol. Published online May 2009. __________________________
Promoting Epidermolysis Bullosa Research
Debra of America is a non-profit organization dedicated to research and direct services for epidermolysis bullosa (EB). The organization provides a Family Advocate Program to provide a support system for newborns and families learning to care for a child with EB. According to Debra, education is crucial to learning how to live with this disease. The organization also offers a Patient Care Conference every other year and provides a Nurse Educator to serve as a point of contact to assist new parents and patients, as well as to help healthcare professionals manage the care of EB patients. This program provides general information on EB and referrals to related professionals. Service is available via phone or email Monday through Friday, 9 a.m. to 5 p.m. Eastern Time. Visit www.debra.org for contact information. Along with the educational and emotional support services, Debra tries to help ease the financial burdens of treating EB by offering financial aid for unreimbursed costs of medical supplies, other comforting aids, or procedures for EB patients. For information on ways to help the organization, visit the Web site at www.debra.org. __________________________
New Study finds Formaldehyde and 1,4-dioxane in many Children’s Bath Products
Arecent study by the Campaign for Safe Cosmetics found that despite marketing claims like “gentle” and “pure,” dozens of top-selling children’s bath products are contaminated with the cancer-causing chemicals formaldehyde and 1,4-dioxane. These findings were based on product test results released by the Campaign for Safe Cosmetics. The chemicals were not disclosed on product labels because contaminants are exempt from labeling laws. This study is the first to document the widespread presence of both formaldehyde and 1,4-dioxane in bath products for children. Formaldehyde and 1,4-dioxane are known to cause cancer in animals and are listed as probable human carcinogens by the Environmental Protection Agency. Formaldehyde can also trigger skin rashes in some children. For the study, the Campaign for Safe Cosmetics commissioned an independent laboratory to test 48 top-selling children’s products for 1,4-dioxane; 28 of those products were also tested for formaldehyde. The lab found that: • 17 out of 28 products tested (61%) contained both formaldehyde and 1,4-dioxane, including Johnson’s Baby Shampoo, Sesame Street Bubble Bath, Grins & Giggles Milk & Honey Baby Wash and Huggies Naturally Refreshing Cucumber & Green Tea Baby Wash. • 23 out of 28 products (82%) contained formaldehyde at levels ranging from 54 to 610 parts per million (ppm). Baby Magic Baby Lotion had the highest levels of formaldehyde. • 32 out of 48 products (67%) contained 1,4-dioxane at levels ranging from 0.27 to 35 ppm. American Girl shower products had the highest levels of 1,4-dioxane. The full results of the study can be found in the report, “No More Toxic Tub” at https://www.safecosmetics.org/toxictub. For more on this study and other contact allergens in children, don’t miss the Pediatric Contact Dermatitis feature in next month’s issue of Skin & Aging.
Research highlights and trends in treating pediatric dermatology conditions.
TRENDS IN PEDIATRIC S. AUREUS HEAD AND NECK INFECTIONS
Seeking to evaluate the epidemiologic manifestations of pediatric Staphylococcus aureus head and neck infections nationwide and to identify possible trends in the antibiotic drug susceptibility of S. aureus during a 6-year period, researchers conducted a retrospective review of microbiologic data from a peer-reviewed national database. The researchers, Iman Naseri, MD, Robert C. Jerris, PhD, and Steven E. Sobol, MD, MSc, reviewed data on all pediatric patients with head and neck infections that involved S. aureus in more than 300 hospitals across the country. Anatomic sites were divided into oropharynx/neck, sinonasal and otologic infection categories. Demographic and antimicrobial drug susceptibility patterns were reviewed. Results: The results, which were published in the January 2009 issue of Archives of Otolaryngology – Head & Neck Surgery, were based on database findings gathered on 21,009 pediatric head and neck S. aureus infections that occurred between January 2001 and December 31, 2006. Predominance was observed in the oropharyngeal/neck category (60.3%). For all sites, the mean patient age was 6.7 years (range, 0 to 18 years), with a 51.7% male predominance. There was a high occurrence in the North East Central region of the United States. Overall, methicillin-resistant S. aureus (MRSA) was seen in 21.6% of all patient isolates (n = 4534), with rates of 11.8%, 12.5%, 18.1%, 27.2%, 25.5%, and 28.1% for 2001 through 2006, respectively. This represents a 16.3% increase in MRSA during these 6 years for all pediatric head and neck S. aureus infections. The researchers concluded that there is an alarming nationwide increase in the prevalence of pediatric MRSA head and neck infections. The disparities in the treatment of various head and neck infections nationwide may contribute to the regional differences in the prevalence of such infections. Judicious use of antibiotic agents and increased effectiveness in diagnosis and treatment are warranted to reduce further antimicrobial drug resistance in pediatric head and neck infections, according to the study authors. Source: Iman Naseri, MD; Robert C. Jerris, PhD; Steven E. Sobol, MD, MS, Arch Otolaryngol Head Neck Surg. 2009;135(1):14-16. __________________________
ELEMENTARY SCHOOL STUDENTS: SUN EXPOSURE AND SKIN CANCER RISK
To assess baseline knowledge of skin cancer, sun protection practices and perceptions of tanning among third through fifth grade elementary students in Florida, researchers surveyed 4,002 students in 19 elementary schools in Palm Beach County, FL, using the SunSmart America curriculum pretest responses for the main outcome measures. Results: The survey found that students’ overall knowledge scores, based on their mean knowledge scale scores of skin cancer and sun protection, were low (<40% of questions answered correctly) and were found to increase with grade level (p < 0.01). Boys more frequently reported spending more than 2 hours in the sun when compared with girls (p < 0.01). Girls, however, were more likely to try to get a tan most of the time or always when compared with boys (p = 0.02). Non-Hispanic White students (51.3%) more frequently reported use of SPF 15 or greater sunscreen “most of the time or always” compared with Hispanic (35.3%) and non-Hispanic Black (13.4%) students (p < 0.01). The researchers, Panta Rouhani, PhD, MPH, Yisrael Parmet, PhD, Ann G. Bessell, PhD, Tamika Peay, BA, Alina Weiss, BA, and Robert S. Kirsner, MD, PhD, concluded that elementary school-aged students in south Florida have limited knowledge about sun safety, despite spending a considerable amount of time in the sun. The results also showed that sun-safe behavior is associated with gender and ethnicity. Based on their findings, the researchers found that results of this survey provided empirical support for the need for a school-based educational intervention. Source: Rouhani P, Parmet Y, Bessell AG, Peay T, Weiss A, Kirsner RS. Knowledge, attitudes, and behaviors of elementary school students regarding sun exposure and skin cancer. Pediatr Dermatol. Published online May 2009. __________________________
Risk for Allergies to Atopic Dermatitis Treatments
To determine risk factors associated with skin sensitization — about which little is currently known — a group of researchers assessed the frequency of sensitization to several topical treatments prescribed for atopic dermatitis (AD) in children. For this study, 641 children with AD were systematically patch tested with these seven common topical treatment agents: chlorhexidine, hexamidine, budesonide, tixocortol pivalate, bufexamac, sodium fusidate and with the current emollient used by the child. The following variables were recorded: age, sex, age at onset of AD, associated asthma, severity of AD and history of previous exposure to topical agents used in the treatment of AD. Skin prick tests to inhalant and food allergens were used to explore the IgE-mediated sensitization. Results: There were 41 positive patch tests found in 40 patients (6.2%). Allergens were emollients (47.5%), chlorhexidine (42.5%), hexamidine (7.5%), tixocortol pivalate and bufexamac (2.5% each). Risk factors associated with sensitization to AD treatment were AD severity (OR: 3.3; 95% confidence interval [CI]):1.5-7.1 for moderate to severe AD), AD onset before the age of 6 months (OR: 2.7; 95% CI: 1.2-6.1), and IgE-mediated sensitization (OR: 2.5; 95% CI: 1.1-5.9). The researchers, who published their findings in the May 2009 issue of Allergy, concluded that topical treatment of AD is associated with cutaneous sensitization. Antiseptics and emollients represent the most frequent sensitizers and may be included in the standard series in AD children when contact dermatitis is suspected. Risk factors associated with sensitization to AD topical treatments are AD severity, early AD onset and IgE-mediated sensitization, according to the study authors. Source: Mailhol C, Lauwers-Cances V, Rancé F, Paul C, Giordano-Labadie F. Prevalence and risk factors for allergic contact dermatitis to topical treatment in atopic dermatitis: a study in 641 children. Allergy. 2009 May;64(5):801-6. __________________________
Video Offers Sun Safety Tips for Children
Pediatric dermatologist-researcher Alfred Lane, MD, a pediatrician and researcher at Packard Children’s Hospital and professor of dermatology and of pediatrics at the Stanford University School of Medicine, created a YouTube video to offer sunscreen safety tips. In the video, available at www.youtube.com/watch?v=6acZo-UPcx8, Dr. Lane provides guidance to parents to ensure their children are well-protected when outdoors. Highlights of the tips include the following. Sunscreen for infants and children. Though your sunscreen may say “not for use for those under 6 months of age,” Dr. Lane says it’s OK, but perhaps unnecessary. He suggests you use sunscreen on their hands, faces and other exposed areas, but that protection can be provided by dressing them in a hat, long sleeves and long pants. Dr. Lane also suggests placing them in the shade, especially since children less than 6 months usually stay in place and don’t move around much. “But once a child is older and becomes mobile, they have more exposure to the sun’s ultraviolet light, and that’s when you should definitely use a sunscreen,” he adds. SPF (sun protection factor) clothing. Dr. Lane explores the question of whether SPF clothing really works. “High SPF clothing is absolutely helpful,” says Dr. Lane, who recommends combining this type of cover-up with an application of sunscreen on any exposed areas. Sticks, lotions or sprays? “Whether it’s a stick, lotion, or spray, all are fine,” says Dr. Lane, “but it’s important not to use the sprays and lotions around the eyes. Instead, use a sunscreen stick around the eyes and maybe even around the lips.” Older children and young adults. “Younger children will keep high SPF sunscreen on, but older children and young adults often say it’s too greasy,” says Dr. Lane. “They seek a sunscreen that’s more comfortable, but regardless, they need to be certain to use lotion with at least a 30 SPF. The higher the SPF, the better the protection from ultraviolet damage and skin cancer. Be certain the sunscreen is also waterproof.” __________________________
The Role of Imiquimod in Treating Infantile Hemangiomas
APhase II, open-label, noncomparative study of imiquimod applied during 16 weeks, with post-therapy follow-up 16 weeks later (8 months total) was performed to explore the efficacy and safety of imiquimod 5% cream as a treatment for infantile hemangioma. The study of healthy infants up to 8.8 months of age with previously untreated, nonulcerated, proliferative superficial or mixed infantile hemangioma — excluding periorbital or perineal localization — > or =100 cm2 in size was performed at the outpatient pediatric tertiary care referral center in Quebec, Canada. Topical imiquimod was applied three to seven times per week for 16 weeks to infantile hemangioma. The main outcome measures included lesion area, volume, depth (Doppler ultrasound), and color (erythema), serum drug and interferon-alpha levels. Results: Sixteen infants (11 girls, 5 boys) with a mean age at entry of 4.1 months and mean lesion area of 32.89 cm2 and volume of 39.98 cm3 were enrolled. Two participants discontinued treatment early, one for an adverse event (crying upon application), the other due to lack of compliance. Local skin reactions were consistent with those reported in adults. Two cases had a decrease and three had an increase in lesion parameters; otherwise, no meaningful changes in lesion area, volume or depth were observed. At the 4-month post-treatment visit, 11 of 14 subjects had improvement in erythema (marginal homogeneity test = 2.668, p = 0.008). Measured serum drug and interferon-alpha levels were low or undetectable. The results, which were published in the March-April 2009 issue of Pediatric Dermatology, led the study authors to conclude that treatment of infants with infantile hemangioma with imiquimod up to seven times per week for 16 weeks was generally well tolerated with low systemic exposure. Improvement was observed in hemangioma coloration, but not lesion size, suggesting effects were limited to the superficial component. Source: McCuaig CC, Dubois J, Powell J, Belleville C, David M, Rousseau E, Gendron R, Jafarian F, Auger I. A phase II, open-label study of the efficacy and safety of imiquimod in the treatment of superficial and mixed infantile hemangioma. Pediatr Dermatol. 2009 Mar-Apr;26(2):203-12. __________________________
The Effectiveness of Combining Bathing and Moisturizing Regimens on Skin Hydration in Atopic Dermatitis
Skin hydration and use of moisturizers are important in standard care regimens for atopic dermatitis. However, there is little objective data to guide recommendations regarding the optimal practice methods of bathing and emollient application, so researchers conducted a study to quantify cutaneous hydration status after various combination bathing and moisturizing regimens. Four bathing/moisturizer regimens were evaluated in 10 patients, five pediatric patients with atopic dermatitis and five patients with healthy skin. The regimens consisted of bathing alone without emollient application, bathing followed by immediate emollient application, bathing and delayed application, and emollient application alone. Each regimen was evaluated in all patients, utilizing a crossover design. Skin hydration was assessed with standard capacitance measurements. Results: In atopic dermatitis patients, emollient alone yielded a significantly (p < 0.05) greater mean hydration over 90 minutes (206.2% baseline hydration) than bathing with immediate emollient (141.6%), bathing and delayed emollient (141%), and bathing alone (91.4%). The combination bathing and emollient application regimens demonstrated hydration values at 90 minutes, which was not significantly greater than baseline. Atopic dermatitis patients had a decreased mean hydration benefit compared with normal skin subjects. Researchers concluded that bathing without moisturizer may compromise skin hydration. Bathing followed by moisturizer application provides modest hydration benefits, though less than that of simply applying moisturizer alone. Source: Chiang C, and Eichenfield LF. Quantitative assessment of combination bathing and moisturizing regimens on skin hydration in atopic dermatitis. Pediatr Dermatol. Published online May 2009. __________________________
Promoting Epidermolysis Bullosa Research
Debra of America is a non-profit organization dedicated to research and direct services for epidermolysis bullosa (EB). The organization provides a Family Advocate Program to provide a support system for newborns and families learning to care for a child with EB. According to Debra, education is crucial to learning how to live with this disease. The organization also offers a Patient Care Conference every other year and provides a Nurse Educator to serve as a point of contact to assist new parents and patients, as well as to help healthcare professionals manage the care of EB patients. This program provides general information on EB and referrals to related professionals. Service is available via phone or email Monday through Friday, 9 a.m. to 5 p.m. Eastern Time. Visit www.debra.org for contact information. Along with the educational and emotional support services, Debra tries to help ease the financial burdens of treating EB by offering financial aid for unreimbursed costs of medical supplies, other comforting aids, or procedures for EB patients. For information on ways to help the organization, visit the Web site at www.debra.org. __________________________
New Study finds Formaldehyde and 1,4-dioxane in many Children’s Bath Products
Arecent study by the Campaign for Safe Cosmetics found that despite marketing claims like “gentle” and “pure,” dozens of top-selling children’s bath products are contaminated with the cancer-causing chemicals formaldehyde and 1,4-dioxane. These findings were based on product test results released by the Campaign for Safe Cosmetics. The chemicals were not disclosed on product labels because contaminants are exempt from labeling laws. This study is the first to document the widespread presence of both formaldehyde and 1,4-dioxane in bath products for children. Formaldehyde and 1,4-dioxane are known to cause cancer in animals and are listed as probable human carcinogens by the Environmental Protection Agency. Formaldehyde can also trigger skin rashes in some children. For the study, the Campaign for Safe Cosmetics commissioned an independent laboratory to test 48 top-selling children’s products for 1,4-dioxane; 28 of those products were also tested for formaldehyde. The lab found that: • 17 out of 28 products tested (61%) contained both formaldehyde and 1,4-dioxane, including Johnson’s Baby Shampoo, Sesame Street Bubble Bath, Grins & Giggles Milk & Honey Baby Wash and Huggies Naturally Refreshing Cucumber & Green Tea Baby Wash. • 23 out of 28 products (82%) contained formaldehyde at levels ranging from 54 to 610 parts per million (ppm). Baby Magic Baby Lotion had the highest levels of formaldehyde. • 32 out of 48 products (67%) contained 1,4-dioxane at levels ranging from 0.27 to 35 ppm. American Girl shower products had the highest levels of 1,4-dioxane. The full results of the study can be found in the report, “No More Toxic Tub” at https://www.safecosmetics.org/toxictub. For more on this study and other contact allergens in children, don’t miss the Pediatric Contact Dermatitis feature in next month’s issue of Skin & Aging.
