Pediatrics

Recognizing the ongoing value of benzoyl peroxide, educating patients about the role of antibiotics, and embracing spironolactone are among the acne treatment pearls provided by Hilary Baldwin, MD, during a virtual presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.

Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license

Benzoyl peroxide celebrates its 60th birthday and is still going strong as an acne treatment, said Dr. Baldwin, of the department of dermatology, Rutgers Robert Wood Johnston Medical Center, New Brunswick, N.J. Benzoyl peroxide can be used as a stand-alone and has the added benefit of not being associated with antimicrobial resistance. In addition, “benzoyl peroxide is the heavy lifter in combinations,” she said. In fact, benzoyl peroxide can prevent the development of resistance to topical and oral antibiotics such as clindamycin, and can reverse resistance that has occurred, she noted.

However, patient compliance can be an issue. Benzoyl peroxide often is underused because of its tendency to bleach fabric, noted Dr. Baldwin, who is also medical director of The Acne Treatment and Research Center in New York. To help combat this problem and improve compliance, she advises patients to establish a dosing schedule for benzoyl peroxide, such as using it first thing in the morning, or applying in the afternoon and using a paper towel first, or a white towel, to wash their faces at bedtime, she said. When dealing with teenagers, “it sounds like a lot of work, but it makes the mothers much happier not to have their towels bleached.”

Although clinicians want to reduce unnecessary antibiotic use in acne, there is a place for antibiotics, but not as monotherapy, Dr. Baldwin said. Instead, initiate topical therapy, such as a retinoid or benzoyl peroxide, simultaneously with antibiotics and evaluate the response in 6-8 weeks, she advised. At that point, the antibiotics can be stopped, even if 100% clearing has not been achieved, and “the topicals can carry you on for months and months,” she noted.

Also, in female patients, consider oral contraceptive pills or spironolactone at the same time as oral antibiotics, then discontinue the antibiotics and continue with the hormonal therapy, she added. “Plan your exit strategy early,” she said. Explain to patients that you will stop the oral antibiotics after 2 months, so they must continue with the topicals.

“Embrace spironolactone if you haven’t already,” said Dr. Baldwin, who noted that spironolactone has been underused in recent years. Spironolactone use for acne has not been well studied, “but consensus groups and expert opinions certainly favor its use,” she added.

Recognizing the ongoing value of benzoyl peroxide, educating patients about the role of antibiotics, and embracing spironolactone are among the acne treatment pearls provided by Hilary Baldwin, MD, during a virtual presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.

Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license

Benzoyl peroxide celebrates its 60th birthday and is still going strong as an acne treatment, said Dr. Baldwin, of the department of dermatology, Rutgers Robert Wood Johnston Medical Center, New Brunswick, N.J. Benzoyl peroxide can be used as a stand-alone and has the added benefit of not being associated with antimicrobial resistance. In addition, “benzoyl peroxide is the heavy lifter in combinations,” she said. In fact, benzoyl peroxide can prevent the development of resistance to topical and oral antibiotics such as clindamycin, and can reverse resistance that has occurred, she noted.

However, patient compliance can be an issue. Benzoyl peroxide often is underused because of its tendency to bleach fabric, noted Dr. Baldwin, who is also medical director of The Acne Treatment and Research Center in New York. To help combat this problem and improve compliance, she advises patients to establish a dosing schedule for benzoyl peroxide, such as using it first thing in the morning, or applying in the afternoon and using a paper towel first, or a white towel, to wash their faces at bedtime, she said. When dealing with teenagers, “it sounds like a lot of work, but it makes the mothers much happier not to have their towels bleached.”

Although clinicians want to reduce unnecessary antibiotic use in acne, there is a place for antibiotics, but not as monotherapy, Dr. Baldwin said. Instead, initiate topical therapy, such as a retinoid or benzoyl peroxide, simultaneously with antibiotics and evaluate the response in 6-8 weeks, she advised. At that point, the antibiotics can be stopped, even if 100% clearing has not been achieved, and “the topicals can carry you on for months and months,” she noted.

Also, in female patients, consider oral contraceptive pills or spironolactone at the same time as oral antibiotics, then discontinue the antibiotics and continue with the hormonal therapy, she added. “Plan your exit strategy early,” she said. Explain to patients that you will stop the oral antibiotics after 2 months, so they must continue with the topicals.

“Embrace spironolactone if you haven’t already,” said Dr. Baldwin, who noted that spironolactone has been underused in recent years. Spironolactone use for acne has not been well studied, “but consensus groups and expert opinions certainly favor its use,” she added.

Recognizing the ongoing value of benzoyl peroxide, educating patients about the role of antibiotics, and embracing spironolactone are among the acne treatment pearls provided by Hilary Baldwin, MD, during a virtual presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.

Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license

Benzoyl peroxide celebrates its 60th birthday and is still going strong as an acne treatment, said Dr. Baldwin, of the department of dermatology, Rutgers Robert Wood Johnston Medical Center, New Brunswick, N.J. Benzoyl peroxide can be used as a stand-alone and has the added benefit of not being associated with antimicrobial resistance. In addition, “benzoyl peroxide is the heavy lifter in combinations,” she said. In fact, benzoyl peroxide can prevent the development of resistance to topical and oral antibiotics such as clindamycin, and can reverse resistance that has occurred, she noted.

However, patient compliance can be an issue. Benzoyl peroxide often is underused because of its tendency to bleach fabric, noted Dr. Baldwin, who is also medical director of The Acne Treatment and Research Center in New York. To help combat this problem and improve compliance, she advises patients to establish a dosing schedule for benzoyl peroxide, such as using it first thing in the morning, or applying in the afternoon and using a paper towel first, or a white towel, to wash their faces at bedtime, she said. When dealing with teenagers, “it sounds like a lot of work, but it makes the mothers much happier not to have their towels bleached.”

Although clinicians want to reduce unnecessary antibiotic use in acne, there is a place for antibiotics, but not as monotherapy, Dr. Baldwin said. Instead, initiate topical therapy, such as a retinoid or benzoyl peroxide, simultaneously with antibiotics and evaluate the response in 6-8 weeks, she advised. At that point, the antibiotics can be stopped, even if 100% clearing has not been achieved, and “the topicals can carry you on for months and months,” she noted.

Also, in female patients, consider oral contraceptive pills or spironolactone at the same time as oral antibiotics, then discontinue the antibiotics and continue with the hormonal therapy, she added. “Plan your exit strategy early,” she said. Explain to patients that you will stop the oral antibiotics after 2 months, so they must continue with the topicals.

“Embrace spironolactone if you haven’t already,” said Dr. Baldwin, who noted that spironolactone has been underused in recent years. Spironolactone use for acne has not been well studied, “but consensus groups and expert opinions certainly favor its use,” she added.

A commonly used newborn hearing test shows promise in the early detection of autism spectrum disorder (ASD), new research shows.  

Results from one of the largest studies of its kind show the auditory brainstem response (ABR) test, which is carried out on most newborns, represents “a huge untapped potential” to detect autism, lead author Oren Miron, research associate, department of biomedical informatics, Harvard Medical School, Boston, and a PhD candidate at Ben Gurion University in Beersheba, Israel, said in an interview.

“The findings further reinforce our understanding that autism, in many cases, has a sensorial and auditory aspect to it,” said Mr. Miron, adding that an adverse response to sound is one of the earliest behavioral signs of autism.

The research was published online Oct. 31 in Autism Research.
 

Early intervention critical

Autism spectrum disorder (ASD), which involves problems in social communication and interaction, affects an estimated 1 in 59 children. Early identification and intervention are critical for improving outcomes and decreasing the economic burden associated with ASD.

The ABR test, which is used for Universal Newborn Hearing Screening (UNHS), uses surface electrodes to measure auditory nerve and brainstem responses to sound.

Previous studies identified abnormal ABR amplitude in children with ASD. However, it’s unclear whether healthy newborns who later develop autism also show ABR differences vs those who don’t develop the disorder.

Researchers used UNHS data, which allowed them to examine a larger, younger, and healthier sample compared with previous studies. The study included 321 newborns later diagnosed with ASD and 138,844 controls without a subsequent ASD diagnosis.

The mean ABR testing age was 1.76 days for newborns later diagnosed with ASD and 1.86 for those in the non-ASD group.

The ASD group was 77% male and the non-ASD group was 51% male. The rate of neonatal intensive care unit admission was 8% in the ASD group and 10% in the non-ASD group.

The hearing test involves placing an earpiece in the baby’s ear and delivering a click sound at 35 dB above normal hearing level (nHL) at a rate of 77 clicks per second in the right ear and 79 clicks per second in the left ear.
 

Brainstem abnormalities?

The clicks create electrical activity, which is recorded by a surface electrode and used to extract the ABR waveform. When a sound reaches the brain stem, it creates five consecutive waveforms – waves I, II, III, IV, and V.

Previous studies focused on wave V, which is easiest to detect. The current study used low intensity sound that resulted in a weaker signal.

To overcome this low intensity issue, researchers focused on the negative drop (latency) after the wave V (Vn), which is easier to detect, and on the ABR phase, or entire waveform. They illustrated the differences between the ASD and non-ASD groups in a series of graphs.

Results showed that the ABR phase in the right ear was significantly prolonged in the ASD vs non-ASD group (P < .001). ABR phase in the left ear was also significantly prolonged in the ASD group (P = .021)

Vn latency in the right ear was significantly prolonged in the ASD group compared with the non-ASD group (P = .048); however, this was not the case in the left ear.

The prolongation could mean that the V-negative wave might appear after 8 ms in normally developing children compared with 8.5 or 9 ms in children with autism, said Mr. Miron.

The new study is the first to show V-negative and phase abnormalities are associated with ASD, the authors note. The brainstem prolongation could be due to anatomical abnormalities in the brainstem in individuals with ASD, the researchers added.
 

Present before birth?

The presence of ABR biomarkers of ASD in the first weeks after birth suggests the disorder is likely present before birth in a large group of these individuals, the researchers note.

It’s possible the ABR test could be modified to use lower intensities not only to detect hearing impairment but autism risk, said Mr. Miron. “The test has been optimized to detect hearing impairment, and it does so brilliantly and helps thousands of children. We want to do the same kind of optimization for autism.”

This could lead to earlier behavioral diagnoses, which, in turn, could lead to earlier treatment and better outcomes for children with ASD, said Mr. Miron.

At this time, the level of prolongation to detect ASD is unclear. “I would think a lot of people would want to make it one standard deviation, but it depends on a lot of factors, including for example, whether a baby is preterm,” said Mr. Miron.

More research and better accuracy and specificity are needed before the newborn hearing test is clinically useful.

He noted that the hearing test is only one marker of autism and that it could potentially be combined with other behavioral signs and genetic markers to facilitate earlier diagnosis and treatment and improve outcomes for patients with ASD.

Future research by his group will investigate whether the degree of auditory prolongation relates to autism severity. They also plan to research ASD subgroups including children with comorbid epilepsy.
 

Terrific, clever research

Jeremy Veenstra-VanderWeele, MD, professor, child and adolescent psychiatry, Columbia University, New York, said in an interview that the study is “terrific” and a “clever use” of an existing dataset.

“They showed a difference between a large group of kids with autism and a large group of kids without.”

However, he added, more research is needed before the test can be used as an autism screening tool.

“In order for this to be a screening test that could be broadly applied you would need to identify a cutoff where you’d think a child was at risk for autism, and if you look at the graphs in the article, there are no clear cutoffs,” said Dr. Veenstra-VanderWeele.

To turn this into a useful test, “you would have to establish sensitivity and specificity, you would have to look not just at the comparison of kids with autism and kids without but apply it in a predictive way in a second population.”

The study authors and Dr. Veenstra-VanderWeele have reported no relevant financial relationships. Veenstra-VanderWeele is an associate editor at Autism Research, which published the article, but he did not handle or view it before being interviewed.

A version of this article originally appeared on Medscape.com.

A commonly used newborn hearing test shows promise in the early detection of autism spectrum disorder (ASD), new research shows.  

Results from one of the largest studies of its kind show the auditory brainstem response (ABR) test, which is carried out on most newborns, represents “a huge untapped potential” to detect autism, lead author Oren Miron, research associate, department of biomedical informatics, Harvard Medical School, Boston, and a PhD candidate at Ben Gurion University in Beersheba, Israel, said in an interview.

“The findings further reinforce our understanding that autism, in many cases, has a sensorial and auditory aspect to it,” said Mr. Miron, adding that an adverse response to sound is one of the earliest behavioral signs of autism.

The research was published online Oct. 31 in Autism Research.
 

Early intervention critical

Autism spectrum disorder (ASD), which involves problems in social communication and interaction, affects an estimated 1 in 59 children. Early identification and intervention are critical for improving outcomes and decreasing the economic burden associated with ASD.

The ABR test, which is used for Universal Newborn Hearing Screening (UNHS), uses surface electrodes to measure auditory nerve and brainstem responses to sound.

Previous studies identified abnormal ABR amplitude in children with ASD. However, it’s unclear whether healthy newborns who later develop autism also show ABR differences vs those who don’t develop the disorder.

Researchers used UNHS data, which allowed them to examine a larger, younger, and healthier sample compared with previous studies. The study included 321 newborns later diagnosed with ASD and 138,844 controls without a subsequent ASD diagnosis.

The mean ABR testing age was 1.76 days for newborns later diagnosed with ASD and 1.86 for those in the non-ASD group.

The ASD group was 77% male and the non-ASD group was 51% male. The rate of neonatal intensive care unit admission was 8% in the ASD group and 10% in the non-ASD group.

The hearing test involves placing an earpiece in the baby’s ear and delivering a click sound at 35 dB above normal hearing level (nHL) at a rate of 77 clicks per second in the right ear and 79 clicks per second in the left ear.
 

Brainstem abnormalities?

The clicks create electrical activity, which is recorded by a surface electrode and used to extract the ABR waveform. When a sound reaches the brain stem, it creates five consecutive waveforms – waves I, II, III, IV, and V.

Previous studies focused on wave V, which is easiest to detect. The current study used low intensity sound that resulted in a weaker signal.

To overcome this low intensity issue, researchers focused on the negative drop (latency) after the wave V (Vn), which is easier to detect, and on the ABR phase, or entire waveform. They illustrated the differences between the ASD and non-ASD groups in a series of graphs.

Results showed that the ABR phase in the right ear was significantly prolonged in the ASD vs non-ASD group (P < .001). ABR phase in the left ear was also significantly prolonged in the ASD group (P = .021)

Vn latency in the right ear was significantly prolonged in the ASD group compared with the non-ASD group (P = .048); however, this was not the case in the left ear.

The prolongation could mean that the V-negative wave might appear after 8 ms in normally developing children compared with 8.5 or 9 ms in children with autism, said Mr. Miron.

The new study is the first to show V-negative and phase abnormalities are associated with ASD, the authors note. The brainstem prolongation could be due to anatomical abnormalities in the brainstem in individuals with ASD, the researchers added.
 

Present before birth?

The presence of ABR biomarkers of ASD in the first weeks after birth suggests the disorder is likely present before birth in a large group of these individuals, the researchers note.

It’s possible the ABR test could be modified to use lower intensities not only to detect hearing impairment but autism risk, said Mr. Miron. “The test has been optimized to detect hearing impairment, and it does so brilliantly and helps thousands of children. We want to do the same kind of optimization for autism.”

This could lead to earlier behavioral diagnoses, which, in turn, could lead to earlier treatment and better outcomes for children with ASD, said Mr. Miron.

At this time, the level of prolongation to detect ASD is unclear. “I would think a lot of people would want to make it one standard deviation, but it depends on a lot of factors, including for example, whether a baby is preterm,” said Mr. Miron.

More research and better accuracy and specificity are needed before the newborn hearing test is clinically useful.

He noted that the hearing test is only one marker of autism and that it could potentially be combined with other behavioral signs and genetic markers to facilitate earlier diagnosis and treatment and improve outcomes for patients with ASD.

Future research by his group will investigate whether the degree of auditory prolongation relates to autism severity. They also plan to research ASD subgroups including children with comorbid epilepsy.
 

Terrific, clever research

Jeremy Veenstra-VanderWeele, MD, professor, child and adolescent psychiatry, Columbia University, New York, said in an interview that the study is “terrific” and a “clever use” of an existing dataset.

“They showed a difference between a large group of kids with autism and a large group of kids without.”

However, he added, more research is needed before the test can be used as an autism screening tool.

“In order for this to be a screening test that could be broadly applied you would need to identify a cutoff where you’d think a child was at risk for autism, and if you look at the graphs in the article, there are no clear cutoffs,” said Dr. Veenstra-VanderWeele.

To turn this into a useful test, “you would have to establish sensitivity and specificity, you would have to look not just at the comparison of kids with autism and kids without but apply it in a predictive way in a second population.”

The study authors and Dr. Veenstra-VanderWeele have reported no relevant financial relationships. Veenstra-VanderWeele is an associate editor at Autism Research, which published the article, but he did not handle or view it before being interviewed.

A version of this article originally appeared on Medscape.com.

A commonly used newborn hearing test shows promise in the early detection of autism spectrum disorder (ASD), new research shows.  

Results from one of the largest studies of its kind show the auditory brainstem response (ABR) test, which is carried out on most newborns, represents “a huge untapped potential” to detect autism, lead author Oren Miron, research associate, department of biomedical informatics, Harvard Medical School, Boston, and a PhD candidate at Ben Gurion University in Beersheba, Israel, said in an interview.

“The findings further reinforce our understanding that autism, in many cases, has a sensorial and auditory aspect to it,” said Mr. Miron, adding that an adverse response to sound is one of the earliest behavioral signs of autism.

The research was published online Oct. 31 in Autism Research.
 

Early intervention critical

Autism spectrum disorder (ASD), which involves problems in social communication and interaction, affects an estimated 1 in 59 children. Early identification and intervention are critical for improving outcomes and decreasing the economic burden associated with ASD.

The ABR test, which is used for Universal Newborn Hearing Screening (UNHS), uses surface electrodes to measure auditory nerve and brainstem responses to sound.

Previous studies identified abnormal ABR amplitude in children with ASD. However, it’s unclear whether healthy newborns who later develop autism also show ABR differences vs those who don’t develop the disorder.

Researchers used UNHS data, which allowed them to examine a larger, younger, and healthier sample compared with previous studies. The study included 321 newborns later diagnosed with ASD and 138,844 controls without a subsequent ASD diagnosis.

The mean ABR testing age was 1.76 days for newborns later diagnosed with ASD and 1.86 for those in the non-ASD group.

The ASD group was 77% male and the non-ASD group was 51% male. The rate of neonatal intensive care unit admission was 8% in the ASD group and 10% in the non-ASD group.

The hearing test involves placing an earpiece in the baby’s ear and delivering a click sound at 35 dB above normal hearing level (nHL) at a rate of 77 clicks per second in the right ear and 79 clicks per second in the left ear.
 

Brainstem abnormalities?

The clicks create electrical activity, which is recorded by a surface electrode and used to extract the ABR waveform. When a sound reaches the brain stem, it creates five consecutive waveforms – waves I, II, III, IV, and V.

Previous studies focused on wave V, which is easiest to detect. The current study used low intensity sound that resulted in a weaker signal.

To overcome this low intensity issue, researchers focused on the negative drop (latency) after the wave V (Vn), which is easier to detect, and on the ABR phase, or entire waveform. They illustrated the differences between the ASD and non-ASD groups in a series of graphs.

Results showed that the ABR phase in the right ear was significantly prolonged in the ASD vs non-ASD group (P < .001). ABR phase in the left ear was also significantly prolonged in the ASD group (P = .021)

Vn latency in the right ear was significantly prolonged in the ASD group compared with the non-ASD group (P = .048); however, this was not the case in the left ear.

The prolongation could mean that the V-negative wave might appear after 8 ms in normally developing children compared with 8.5 or 9 ms in children with autism, said Mr. Miron.

The new study is the first to show V-negative and phase abnormalities are associated with ASD, the authors note. The brainstem prolongation could be due to anatomical abnormalities in the brainstem in individuals with ASD, the researchers added.
 

Present before birth?

The presence of ABR biomarkers of ASD in the first weeks after birth suggests the disorder is likely present before birth in a large group of these individuals, the researchers note.

It’s possible the ABR test could be modified to use lower intensities not only to detect hearing impairment but autism risk, said Mr. Miron. “The test has been optimized to detect hearing impairment, and it does so brilliantly and helps thousands of children. We want to do the same kind of optimization for autism.”

This could lead to earlier behavioral diagnoses, which, in turn, could lead to earlier treatment and better outcomes for children with ASD, said Mr. Miron.

At this time, the level of prolongation to detect ASD is unclear. “I would think a lot of people would want to make it one standard deviation, but it depends on a lot of factors, including for example, whether a baby is preterm,” said Mr. Miron.

More research and better accuracy and specificity are needed before the newborn hearing test is clinically useful.

He noted that the hearing test is only one marker of autism and that it could potentially be combined with other behavioral signs and genetic markers to facilitate earlier diagnosis and treatment and improve outcomes for patients with ASD.

Future research by his group will investigate whether the degree of auditory prolongation relates to autism severity. They also plan to research ASD subgroups including children with comorbid epilepsy.
 

Terrific, clever research

Jeremy Veenstra-VanderWeele, MD, professor, child and adolescent psychiatry, Columbia University, New York, said in an interview that the study is “terrific” and a “clever use” of an existing dataset.

“They showed a difference between a large group of kids with autism and a large group of kids without.”

However, he added, more research is needed before the test can be used as an autism screening tool.

“In order for this to be a screening test that could be broadly applied you would need to identify a cutoff where you’d think a child was at risk for autism, and if you look at the graphs in the article, there are no clear cutoffs,” said Dr. Veenstra-VanderWeele.

To turn this into a useful test, “you would have to establish sensitivity and specificity, you would have to look not just at the comparison of kids with autism and kids without but apply it in a predictive way in a second population.”

The study authors and Dr. Veenstra-VanderWeele have reported no relevant financial relationships. Veenstra-VanderWeele is an associate editor at Autism Research, which published the article, but he did not handle or view it before being interviewed.

A version of this article originally appeared on Medscape.com.

Current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents, the U.S. Preventive Services Task Force reported in JAMA.

©Vishnu Kumar/Thinkstock

However, two experts in this area suggested there is evidence if you know where to look, and pediatric BP testing is crucial now.

In this update to the 2013 statement, the USPSTF’s systematic review focused on evidence surrounding the benefits of screening, test accuracy, treatment effectiveness and harms, and links between hypertension and cardiovascular disease (CVD) markers in childhood and adulthood.

Limited information was available on the accuracy of screening tests. No studies were found that directly evaluated screening for pediatric high BP or reported effectiveness in delayed onset or risk reduction for cardiovascular outcomes related to hypertension. Additionally, no studies were found that addressed screening for secondary hypertension in asymptomatic pediatric patients. No studies were found that evaluated the treatment of primary childhood hypertension and BP reduction or other outcomes in adulthood. The panel also was unable to identify any studies that reported on harms of screening and treatment.

When the adult framework for cardiovascular risk reduction is extended in pediatric patients, there are methodological challenges that make it harder to determine how much of the potential burden can actually be prevented, the panel said. The clinical and epidemiologic significance of percentile thresholds that are used to determine their ties to adult CVD has limited supporting evidence. Inconsistent performance characteristics of current diagnostic methods, of which there are few, tend to yield unfavorable high false-positive rates. Such false positives are potentially harmful, because they lead to “unnecessary secondary evaluations or treatments.” Because pharmacologic management of pediatric hypertension is continued for a much longer period, it is the increased likelihood of adverse events that should be cause for concern.
 

Should the focus for screening be shifted to significant risk factors?

In an accompanying editorial, Joseph T. Flynn, MD, MS, of Seattle Children’s Hospital, said that the outcome of the latest statement is expected, “given how the key questions were framed and the analysis performed.” To begin, he suggested restating the question: “What is the best approach to assess whether childhood BP measurement is associated with adult CVD or whether treatment of high BP in childhood is associated with reducing the burden of adult CVD?” The answer is to tackle these questions with randomized clinical trials that compare screening to no screening and treatment to no treatment. But such studies are likely infeasible, partly because of the required length of follow-up of 5-6 decades.

Perhaps a better question would be: “Does BP measurement in childhood identify children and adolescents who already have markers of CVD or who are at risk of developing them as adults?” Were these youth to be identified, they would become candidates for approaches that seek to prevent disease progression. Reframing the question in this manner better positions physicians to focus on prevention and sidestep “the requirement that the only acceptable outcome is prevention of CVD events in adulthood,” he explained.

The next step would be to identify data already available to address the reframed question. Cross-sectional studies could be used to make the association between BP levels and cardiovascular risk markers already present. For example, several publications from the multicenter Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth (SHIP-AHOY), which enrolled roughly 400 youth, provided data that reinforce prior single-center studies that essentially proved there are adverse consequences for youth with high BP, and they “set the stage for the institution of measures designed to reverse target-organ damage and reduce cardiovascular risk in youth,” said Dr. Flynn.

More specifically, results from SHIP-AHOY “have demonstrated that increased left ventricular mass can be demonstrated at BP levels currently classified as normotensive and that abnormal left ventricular function can be seen at similar BP levels,” Dr. Flynn noted. In addition, “they have established a substantial association between an abnormal metabolic phenotype and several forms of target-organ damage associated with high BP.”
 

One approach is to analyze longitudinal cohort studies

Because there is a paucity of prospective clinical trials, Dr. Flynn suggested that analyzing longitudinal cohort studies would be the most effective approach for evaluating the potential link between current BP levels and future CVD. Such studies already have “data that address an important point raised in the USPSTF statement, namely whether the pediatric percentile-based BP cut points, such as those in the 2017 AAP [American Academy of Pediatrics] guideline, are associated with adult hypertension and CVD,” noted Dr. Flynn. “In the International Childhood Cardiovascular Cohort Consortium study, the specific childhood BP levels that were associated with increased adult carotid intima-medial thickness were remarkably similar to the BP percentile cut points in the AAP guideline for children of similar ages.”

Analysis of data from the Bogalusa Heart Study found looking at children classified as having high BP by the 2017 AAP guideline had “increased relative risks of having hypertension, left ventricular hypertrophy, or metabolic syndrome as adults 36 years later.”

“The conclusions of the USPSTF statement underscore the need for additional research on childhood high BP and its association with adult CVD. The starting points for such research can be deduced from currently available cross-sectional and longitudinal data, which demonstrate the detrimental outcomes associated with high BP in youth. Using these data to reframe and answer the questions raised by the USPSTF should point the way toward effective prevention of adult CVD,” concluded Dr. Flynn.

In a separate interview, Kristen Sexson Tejtel, MD, PhD, MPH, medical director of the preventive cardiology clinic at Texas Children’s Hospital and Baylor College of Medicine, both in Houston, noted that in spite of USPSTF’s findings, there is actually an association between children with high blood pressure and intermediate outcomes in adults.

“Dr. Flynn suggests reframing the question. In fact, evidence exists that children with high blood pressure are at higher risk of left ventricular hypertrophy, increased arterial stiffness, and changes in retinal arteries,” noted Dr. Sexson Tejtel.
 

Evidence of pediatric heart damage has been documented in autopsies

“It is imperative that children have blood pressure evaluation,” she urged. “There is evidence that there are changes similar to those seen in adults with cardiovascular compromise. It has been shown that children dying of other causes [accidents] who have these problems also have more plaque on autopsy, indicating that those with high blood pressure are more likely to have markers of CVD already present in childhood.

“One of the keys of pediatric medicine is prevention and the counseling for prevention of adult diseases. The duration of study necessary to objectively determine whether treatment of hypertension in childhood reduces the risk of adult cardiac problems is extensive. If nothing is done now, we are putting more future generations in danger. We must provide appropriate counseling for children and their families regarding lifestyle improvements, to have a chance to improve cardiovascular risk factors in adults, including hypertension, hyperlipidemia and/or obesity,” urged Dr. Sexson Tejtel.

All members of the USPSTF received travel reimbursement and honoraria. Dr. Barry received grants and personal fees from Healthwise. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF. Dr. Flynn reported receiving grants from the National Institutes of Health and royalties from UpToDate and Springer outside the submitted work. Dr. Sexson Tejtel said she had no relevant financial disclosures or conflicts of interest.

SOURCE: USPSTF. JAMA. 2020 Nov 10. doi: 10.1001/jama.2020.20122.

Current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents, the U.S. Preventive Services Task Force reported in JAMA.

©Vishnu Kumar/Thinkstock

However, two experts in this area suggested there is evidence if you know where to look, and pediatric BP testing is crucial now.

In this update to the 2013 statement, the USPSTF’s systematic review focused on evidence surrounding the benefits of screening, test accuracy, treatment effectiveness and harms, and links between hypertension and cardiovascular disease (CVD) markers in childhood and adulthood.

Limited information was available on the accuracy of screening tests. No studies were found that directly evaluated screening for pediatric high BP or reported effectiveness in delayed onset or risk reduction for cardiovascular outcomes related to hypertension. Additionally, no studies were found that addressed screening for secondary hypertension in asymptomatic pediatric patients. No studies were found that evaluated the treatment of primary childhood hypertension and BP reduction or other outcomes in adulthood. The panel also was unable to identify any studies that reported on harms of screening and treatment.

When the adult framework for cardiovascular risk reduction is extended in pediatric patients, there are methodological challenges that make it harder to determine how much of the potential burden can actually be prevented, the panel said. The clinical and epidemiologic significance of percentile thresholds that are used to determine their ties to adult CVD has limited supporting evidence. Inconsistent performance characteristics of current diagnostic methods, of which there are few, tend to yield unfavorable high false-positive rates. Such false positives are potentially harmful, because they lead to “unnecessary secondary evaluations or treatments.” Because pharmacologic management of pediatric hypertension is continued for a much longer period, it is the increased likelihood of adverse events that should be cause for concern.
 

Should the focus for screening be shifted to significant risk factors?

In an accompanying editorial, Joseph T. Flynn, MD, MS, of Seattle Children’s Hospital, said that the outcome of the latest statement is expected, “given how the key questions were framed and the analysis performed.” To begin, he suggested restating the question: “What is the best approach to assess whether childhood BP measurement is associated with adult CVD or whether treatment of high BP in childhood is associated with reducing the burden of adult CVD?” The answer is to tackle these questions with randomized clinical trials that compare screening to no screening and treatment to no treatment. But such studies are likely infeasible, partly because of the required length of follow-up of 5-6 decades.

Perhaps a better question would be: “Does BP measurement in childhood identify children and adolescents who already have markers of CVD or who are at risk of developing them as adults?” Were these youth to be identified, they would become candidates for approaches that seek to prevent disease progression. Reframing the question in this manner better positions physicians to focus on prevention and sidestep “the requirement that the only acceptable outcome is prevention of CVD events in adulthood,” he explained.

The next step would be to identify data already available to address the reframed question. Cross-sectional studies could be used to make the association between BP levels and cardiovascular risk markers already present. For example, several publications from the multicenter Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth (SHIP-AHOY), which enrolled roughly 400 youth, provided data that reinforce prior single-center studies that essentially proved there are adverse consequences for youth with high BP, and they “set the stage for the institution of measures designed to reverse target-organ damage and reduce cardiovascular risk in youth,” said Dr. Flynn.

More specifically, results from SHIP-AHOY “have demonstrated that increased left ventricular mass can be demonstrated at BP levels currently classified as normotensive and that abnormal left ventricular function can be seen at similar BP levels,” Dr. Flynn noted. In addition, “they have established a substantial association between an abnormal metabolic phenotype and several forms of target-organ damage associated with high BP.”
 

One approach is to analyze longitudinal cohort studies

Because there is a paucity of prospective clinical trials, Dr. Flynn suggested that analyzing longitudinal cohort studies would be the most effective approach for evaluating the potential link between current BP levels and future CVD. Such studies already have “data that address an important point raised in the USPSTF statement, namely whether the pediatric percentile-based BP cut points, such as those in the 2017 AAP [American Academy of Pediatrics] guideline, are associated with adult hypertension and CVD,” noted Dr. Flynn. “In the International Childhood Cardiovascular Cohort Consortium study, the specific childhood BP levels that were associated with increased adult carotid intima-medial thickness were remarkably similar to the BP percentile cut points in the AAP guideline for children of similar ages.”

Analysis of data from the Bogalusa Heart Study found looking at children classified as having high BP by the 2017 AAP guideline had “increased relative risks of having hypertension, left ventricular hypertrophy, or metabolic syndrome as adults 36 years later.”

“The conclusions of the USPSTF statement underscore the need for additional research on childhood high BP and its association with adult CVD. The starting points for such research can be deduced from currently available cross-sectional and longitudinal data, which demonstrate the detrimental outcomes associated with high BP in youth. Using these data to reframe and answer the questions raised by the USPSTF should point the way toward effective prevention of adult CVD,” concluded Dr. Flynn.

In a separate interview, Kristen Sexson Tejtel, MD, PhD, MPH, medical director of the preventive cardiology clinic at Texas Children’s Hospital and Baylor College of Medicine, both in Houston, noted that in spite of USPSTF’s findings, there is actually an association between children with high blood pressure and intermediate outcomes in adults.

“Dr. Flynn suggests reframing the question. In fact, evidence exists that children with high blood pressure are at higher risk of left ventricular hypertrophy, increased arterial stiffness, and changes in retinal arteries,” noted Dr. Sexson Tejtel.
 

Evidence of pediatric heart damage has been documented in autopsies

“It is imperative that children have blood pressure evaluation,” she urged. “There is evidence that there are changes similar to those seen in adults with cardiovascular compromise. It has been shown that children dying of other causes [accidents] who have these problems also have more plaque on autopsy, indicating that those with high blood pressure are more likely to have markers of CVD already present in childhood.

“One of the keys of pediatric medicine is prevention and the counseling for prevention of adult diseases. The duration of study necessary to objectively determine whether treatment of hypertension in childhood reduces the risk of adult cardiac problems is extensive. If nothing is done now, we are putting more future generations in danger. We must provide appropriate counseling for children and their families regarding lifestyle improvements, to have a chance to improve cardiovascular risk factors in adults, including hypertension, hyperlipidemia and/or obesity,” urged Dr. Sexson Tejtel.

All members of the USPSTF received travel reimbursement and honoraria. Dr. Barry received grants and personal fees from Healthwise. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF. Dr. Flynn reported receiving grants from the National Institutes of Health and royalties from UpToDate and Springer outside the submitted work. Dr. Sexson Tejtel said she had no relevant financial disclosures or conflicts of interest.

SOURCE: USPSTF. JAMA. 2020 Nov 10. doi: 10.1001/jama.2020.20122.

Current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents, the U.S. Preventive Services Task Force reported in JAMA.

©Vishnu Kumar/Thinkstock

However, two experts in this area suggested there is evidence if you know where to look, and pediatric BP testing is crucial now.

In this update to the 2013 statement, the USPSTF’s systematic review focused on evidence surrounding the benefits of screening, test accuracy, treatment effectiveness and harms, and links between hypertension and cardiovascular disease (CVD) markers in childhood and adulthood.

Limited information was available on the accuracy of screening tests. No studies were found that directly evaluated screening for pediatric high BP or reported effectiveness in delayed onset or risk reduction for cardiovascular outcomes related to hypertension. Additionally, no studies were found that addressed screening for secondary hypertension in asymptomatic pediatric patients. No studies were found that evaluated the treatment of primary childhood hypertension and BP reduction or other outcomes in adulthood. The panel also was unable to identify any studies that reported on harms of screening and treatment.

When the adult framework for cardiovascular risk reduction is extended in pediatric patients, there are methodological challenges that make it harder to determine how much of the potential burden can actually be prevented, the panel said. The clinical and epidemiologic significance of percentile thresholds that are used to determine their ties to adult CVD has limited supporting evidence. Inconsistent performance characteristics of current diagnostic methods, of which there are few, tend to yield unfavorable high false-positive rates. Such false positives are potentially harmful, because they lead to “unnecessary secondary evaluations or treatments.” Because pharmacologic management of pediatric hypertension is continued for a much longer period, it is the increased likelihood of adverse events that should be cause for concern.
 

Should the focus for screening be shifted to significant risk factors?

In an accompanying editorial, Joseph T. Flynn, MD, MS, of Seattle Children’s Hospital, said that the outcome of the latest statement is expected, “given how the key questions were framed and the analysis performed.” To begin, he suggested restating the question: “What is the best approach to assess whether childhood BP measurement is associated with adult CVD or whether treatment of high BP in childhood is associated with reducing the burden of adult CVD?” The answer is to tackle these questions with randomized clinical trials that compare screening to no screening and treatment to no treatment. But such studies are likely infeasible, partly because of the required length of follow-up of 5-6 decades.

Perhaps a better question would be: “Does BP measurement in childhood identify children and adolescents who already have markers of CVD or who are at risk of developing them as adults?” Were these youth to be identified, they would become candidates for approaches that seek to prevent disease progression. Reframing the question in this manner better positions physicians to focus on prevention and sidestep “the requirement that the only acceptable outcome is prevention of CVD events in adulthood,” he explained.

The next step would be to identify data already available to address the reframed question. Cross-sectional studies could be used to make the association between BP levels and cardiovascular risk markers already present. For example, several publications from the multicenter Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth (SHIP-AHOY), which enrolled roughly 400 youth, provided data that reinforce prior single-center studies that essentially proved there are adverse consequences for youth with high BP, and they “set the stage for the institution of measures designed to reverse target-organ damage and reduce cardiovascular risk in youth,” said Dr. Flynn.

More specifically, results from SHIP-AHOY “have demonstrated that increased left ventricular mass can be demonstrated at BP levels currently classified as normotensive and that abnormal left ventricular function can be seen at similar BP levels,” Dr. Flynn noted. In addition, “they have established a substantial association between an abnormal metabolic phenotype and several forms of target-organ damage associated with high BP.”
 

One approach is to analyze longitudinal cohort studies

Because there is a paucity of prospective clinical trials, Dr. Flynn suggested that analyzing longitudinal cohort studies would be the most effective approach for evaluating the potential link between current BP levels and future CVD. Such studies already have “data that address an important point raised in the USPSTF statement, namely whether the pediatric percentile-based BP cut points, such as those in the 2017 AAP [American Academy of Pediatrics] guideline, are associated with adult hypertension and CVD,” noted Dr. Flynn. “In the International Childhood Cardiovascular Cohort Consortium study, the specific childhood BP levels that were associated with increased adult carotid intima-medial thickness were remarkably similar to the BP percentile cut points in the AAP guideline for children of similar ages.”

Analysis of data from the Bogalusa Heart Study found looking at children classified as having high BP by the 2017 AAP guideline had “increased relative risks of having hypertension, left ventricular hypertrophy, or metabolic syndrome as adults 36 years later.”

“The conclusions of the USPSTF statement underscore the need for additional research on childhood high BP and its association with adult CVD. The starting points for such research can be deduced from currently available cross-sectional and longitudinal data, which demonstrate the detrimental outcomes associated with high BP in youth. Using these data to reframe and answer the questions raised by the USPSTF should point the way toward effective prevention of adult CVD,” concluded Dr. Flynn.

In a separate interview, Kristen Sexson Tejtel, MD, PhD, MPH, medical director of the preventive cardiology clinic at Texas Children’s Hospital and Baylor College of Medicine, both in Houston, noted that in spite of USPSTF’s findings, there is actually an association between children with high blood pressure and intermediate outcomes in adults.

“Dr. Flynn suggests reframing the question. In fact, evidence exists that children with high blood pressure are at higher risk of left ventricular hypertrophy, increased arterial stiffness, and changes in retinal arteries,” noted Dr. Sexson Tejtel.
 

Evidence of pediatric heart damage has been documented in autopsies

“It is imperative that children have blood pressure evaluation,” she urged. “There is evidence that there are changes similar to those seen in adults with cardiovascular compromise. It has been shown that children dying of other causes [accidents] who have these problems also have more plaque on autopsy, indicating that those with high blood pressure are more likely to have markers of CVD already present in childhood.

“One of the keys of pediatric medicine is prevention and the counseling for prevention of adult diseases. The duration of study necessary to objectively determine whether treatment of hypertension in childhood reduces the risk of adult cardiac problems is extensive. If nothing is done now, we are putting more future generations in danger. We must provide appropriate counseling for children and their families regarding lifestyle improvements, to have a chance to improve cardiovascular risk factors in adults, including hypertension, hyperlipidemia and/or obesity,” urged Dr. Sexson Tejtel.

All members of the USPSTF received travel reimbursement and honoraria. Dr. Barry received grants and personal fees from Healthwise. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF. Dr. Flynn reported receiving grants from the National Institutes of Health and royalties from UpToDate and Springer outside the submitted work. Dr. Sexson Tejtel said she had no relevant financial disclosures or conflicts of interest.

SOURCE: USPSTF. JAMA. 2020 Nov 10. doi: 10.1001/jama.2020.20122.

As part of the 50th anniversary of Dermatology News, it is intriguing to think about where a time machine journey 5 decades back would find the field of pediatric dermatology, and to assess the changes in the specialty during the time that Dermatology News (operating then as “Skin & Allergy News”) has been reporting on innovations and changes in the practice of dermatology.

Society for Pediatric Dermatology

So, starting in 1970, we would find that pediatric dermatology did not exist as an organized specialty. It was not until 3 years later, in October 1973 in Mexico City, that the first international symposium on Pediatric Dermatology was held, and the International Society for Pediatric Dermatology was founded. I reached out to Andrew Margileth, MD, 100 years old this past July, and still active voluntary faculty in pediatric dermatology at the University of Miami, to help me “reach back” to those days. Dr. Margileth commented on how the first symposium was “brilliantly orchestrated by Ramon Ruiz-Maldonado,” from the National Institute of Paediatrics in Mexico, and that it was his “Aha moment for future practice!” That meeting spurred discussions on the development of the Society for Pediatric Dermatology the next year, with Alvin Jacobs, MD; Samuel Weinberg, MD; Nancy Esterly, MD; Sidney Hurwitz, MD; William Weston, MD; and Coleman Jacobson, MD, as some of the initial “founding mothers and fathers,” and the society was officially established in 1975.

The field of pediatric dermatology was fairly “infantile” 50 years ago, with few practitioners. But the early leaders in the field recognized that up to 30% of pediatric primary care visits included skin problems, and that there was limited training for dermatologists, as well as pediatricians, about skin diseases in children. There were clearly clinical and educational needs to establish a subspecialty of pediatric dermatology, and over the next 1-2 decades, the field expanded. The journal Pediatric Dermatology was established (in 1982), the Section on Dermatology was established by the American Academy of Pediatrics (in 1986), and fellowship programs were launched at select academic centers. And it was 30 years into our timeline before the formal subspecialty of pediatric dermatology was established through the American Board of Dermatology (2000).

The field of pediatric dermatology has evolved and matured rapidly. Standard reference textbooks have been developed in the United States and around the world (and of course, online). Pediatric dermatology is an essential part of the core curriculum for dermatologist trainees. Organizations promoting pediatric research have developed to influence basic, translational, and clinical research in conditions in neonates through adolescents, such as the Pediatric Dermatology Research Alliance (PeDRA). And meetings throughout the world now feature pediatric dermatology sessions and help to spread the advances in the diagnosis and management of pediatric skin disorders.

The practice of pediatric dermatology: How has it changed?

It is beyond the scope of this article to try to comprehensively review all of the changes in pediatric dermatology practice. But review of the evolution of a few disease states (choices influenced by my discussions with my 100-year old history guide, Dr. Margileth) displays examples of where we have been, and where we are going in our next 5, 10, or 50 years.

Hemangiomas and vascular malformations

Some of the first natural history studies on hemangiomas were done in the early 1960s, establishing that standard cutaneous hemangiomas had a typical clinical course of fairly rapid growth, plateau, and involution over time. Of interest, the hallmark article’s first author was Dr. Margileth, published in 1965 in JAMA!.This was still at a time when the identification of hemangiomas of infancy (or “HOI” as we say in the trade) was confused with vascular malformations, and no one had recognized the distinct variant tumors such as rapidly involuting and noninvoluting congenital hemangiomas (RICHs or NICHs), tufted angiomas, or hemangioendotheliomas. PHACE syndrome was not yet described (that was done in 1996 by Ilona Frieden, MD, and colleagues). And for a time, hemangiomas were treated with x-rays, before the negative impact of such radiation was acknowledged. It seems that, as a consequence of the use of x-ray therapy and as a backlash from the radiation therapy side effects and potential toxicities, even deforming and functionally significant lesions were “followed clinically” for natural involution, with a sensibility that doing nothing might be better than doing the wrong thing.

Over the next 15 years, the recognition of functionally significant hemangiomas, deformation associated with their proliferation, and the recognition of PHACE syndrome made hemangiomas of infancy an area of concern, with systemic steroids and occasionally chemotherapeutic agents (such as vincristine) being used for problematic lesions.

It has now been 12 years since the work of Christine Léauté-Labrèze, MD, et al., from the University of Bordeaux (France), led to the breakthrough of propranolol for hemangioma treatment, profoundly changing hemangioma management to an incredibly effective medical therapy extensively studied, tested in formal clinical trials, and approved by regulatory authorities. And how intriguing that this was pursued after the chance (but skilled) observation that a child who developed hypertension as a side effect of systemic steroids for nasal hemangioma treatment was prescribed propranolol for the hypertension and had his nasal hemangioma rapidly shrink, with a response superior and much quicker than that to corticosteroids.

Courtesy of Rady Children&#039;s Hospital

Inflammatory skin disorders: Acne, psoriasis, and atopic dermatitis

The care of pediatric inflammatory skin disorders has evolved, but more slowly for some diseases than others. Acne vulgaris is now recognized as much more common under age 12 than previously, presumably reflecting earlier pubertal changes in our preteens. Over the past 30 years, therapy has evolved with the use of topical retinoids (still underused by pediatricians, considered a “practice gap”), hormonal therapy with combined oral contraceptives, and oral isotretinoin, a powerful but highly effective systemic agent for severe and refractory acne. Specific pediatric guidelines came much later, with expert recommendations formulated by the American Acne and Rosacea Society and endorsed by the American Academy of Pediatrics in 2013. Over the past few years, there has been a push by experts for more judicious use of antibiotics for acne (oral and topical) to minimize the emergence of bacterial resistance. There are unanswered questions as we evolve our care: How will the new topical antiandrogens be used? Will spironolactone become part of hormonal therapy under age 18? Will the insights on certain strains of Cutibacterium acnes being associated with worse acne translate to microbiome or vaccine-based strategies?

Pediatric psoriasis has suffered, being “behind in the revolution” of biologic agents because of delayed approval of any biologic agent for treatment of pediatric psoriasis in the United States until just a few years ago, and lags behind Europe and elsewhere in the world by almost a decade. Only this year have we expanded beyond one biologic agent approved for under age 12 and two for ages 12 and older, with other approvals expected including interleukin (IL)-17 and IL-23 agents. Adult psoriasis has been recognized to be associated with a broad set of comorbidities, including obesity and early heart disease, and there is now research on how children are at risk as well, with new recommendations on how to screen children with psoriasis, supplied first by PeDRA and then in the new American Academy of Dermatology-National Psoriasis Foundation pediatric psoriasis guidelines .

Pediatric atopic dermatitis (AD) is in its early years of revolution. In the 50-year period of our thought experiment, AD has increased in prevalence from 5% or less of the pediatric population to 10%-15%. Treatment of most individuals has remained the same over the decades: Good skin care, frequent moisturizers, topical corticosteroids for flares, and management of infection if noted. The topical calcineurin inhibitors (TCIs) broadened the therapeutic approach when introduced in 2000 and 2001, but the boxed warning resulted in some practitioners minimizing their use of these useful agents. But newer studies are markedly reassuring about their safe use in children.

Steroid phobia, as well as concerns about potential side effects of the TCIs, has resulted in undertreatment of childhood AD. It is quite common to see multiple children during pediatric dermatology office hours with poorly controlled eczema, high body-surface areas of eczema, compromised sleep, secondary infections, and anxiety and depression, especially in our moderate to severe adolescents. The field is “hot” with new topical and systemic agents, including our few years’ experience with topical crisaborole, a phosphodiesterase (PDE)-4 inhibitor; and dupilumab, an IL-4-alpha blocker – the first biologic agent approved for AD and the first systemic agent (other than oral corticosteroids), just extended from 12 years to 6 years of age! As dupilumab gets studied for younger children, other biologics (including IL-13 and IL-31 blockers) are undertaking pediatric and/or adolescent trials, oral and topical JAK inhibitors are including adolescents in core clinical trials, and other novel topical agents are under study, including an aryl-hydrocarbon receptor–modulating agent and other PDE-4 inhibitors.

Procedural pediatric dermatology: From liquid nitrogen to laser, surgery, and multimodal skin care

The first generation of pediatric dermatologists were considered medical dermatologist specialists. The care of the conditions discussed above, as well as genodermatoses, diagnostic dilemmas, and management of dermatologic manifestations of systemic disease and other conditions, was the “bread and butter” of pediatric dermatology care. When I was in training, my mentor Paul Honig, MD, at the Children’s Hospital of Philadelphia had a procedure half-day each week, where he would care for a few patients who needed liquid nitrogen therapy for warts, or who needed biopsies. It was uncommon to have a large procedural/surgical part of pediatric dermatology practice. But this is now a routine part of many specialists in the field. How did this change occur?

The fundamental shift began to occur with the introduction of the pulsed dye laser for treatment of port-wine birthmarks in children with minimal scarring, and a seminal article published in the New England Journal of Medicine in 1989. Vascular lesions including port-wine stains were common, and pediatric dermatologists managed these patients for both diagnosis and medical management. Also, dermatology residencies at this time offered training in cutaneous surgery, excisions (including Mohs surgery) and repairs, and trainees in pediatric dermatology were “trained up” to high levels of expertise. As lasers were incorporated into dermatology residency work and practices, pediatric dermatologists developed the exposure and skill to do this work. An added advantage was having the knowledge of how to handle children and adolescents in an age-appropriate manner, with consideration of methods to minimize the pain and anxiety of procedures. Within a few years, pediatric dermatologists were at the forefront of the use of topical anesthetics (EMLA and liposomal lidocaine) and had general anesthesia privileges for laser and excisional surgery.

So while pediatric dermatologists still do “small procedures” every hour in most practices (cryotherapy for warts, cantharidin for molluscum, shave and punch biopsies), a subset now have extensive procedural practices, which in recent years has extended to pigment lesion lasers (to treat nevus of Ota, for example), hair laser, and combinations of lasers, including fractionated CO₂ technology, to treat hypertrophic, constrictive and/or deforming scars.
 

The future

What will pediatric dermatology be like in 10, 20, or 50 years?

I have not yet discussed some of the most challenging diseases in our field, including epidermolysis bullosa, ichthyosis, and neurocutaneous disorders and other genetic skin disorders that have an incredible impact on the lives of affected children and their families, with incredible morbidity and with many conditions that shorten lifespans. But these are the conditions where “the future is happening now,” and we are looking forward to our new gene therapy techniques helping to transform our care.

And other aspects of practice? Will we be doing a large percentage of practice over the phone (or whatever devices we have then – remember, the first iPhone was only released 13 years ago)?

Will our patients be using their own imaging systems to evaluate their nevi and skin growths, and perhaps to diagnose and manage their rashes?

Will we have prevented our inflammatory skin disorders, or “turned them off” in early life with aggressive therapy in infantile life?

I project only that all of us in dermatology will still be a resource to our pediatric patients, from neonate through young adult, through our work of preventing, caring, healing and minimizing disease impact, and hopefully enjoying the pleasures of seeing our patients healthfully develop and evolve! As will our field.
 

Dr. Eichenfield is professor of dermatology and pediatrics and vice-chair of the department of dermatology at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. Dr. Eichenfield reports financial relationships with 20 pharmaceutical companies that manufacture dermatologic products, including products for the diseases discussed here.

As part of the 50th anniversary of Dermatology News, it is intriguing to think about where a time machine journey 5 decades back would find the field of pediatric dermatology, and to assess the changes in the specialty during the time that Dermatology News (operating then as “Skin & Allergy News”) has been reporting on innovations and changes in the practice of dermatology.

Society for Pediatric Dermatology

So, starting in 1970, we would find that pediatric dermatology did not exist as an organized specialty. It was not until 3 years later, in October 1973 in Mexico City, that the first international symposium on Pediatric Dermatology was held, and the International Society for Pediatric Dermatology was founded. I reached out to Andrew Margileth, MD, 100 years old this past July, and still active voluntary faculty in pediatric dermatology at the University of Miami, to help me “reach back” to those days. Dr. Margileth commented on how the first symposium was “brilliantly orchestrated by Ramon Ruiz-Maldonado,” from the National Institute of Paediatrics in Mexico, and that it was his “Aha moment for future practice!” That meeting spurred discussions on the development of the Society for Pediatric Dermatology the next year, with Alvin Jacobs, MD; Samuel Weinberg, MD; Nancy Esterly, MD; Sidney Hurwitz, MD; William Weston, MD; and Coleman Jacobson, MD, as some of the initial “founding mothers and fathers,” and the society was officially established in 1975.

The field of pediatric dermatology was fairly “infantile” 50 years ago, with few practitioners. But the early leaders in the field recognized that up to 30% of pediatric primary care visits included skin problems, and that there was limited training for dermatologists, as well as pediatricians, about skin diseases in children. There were clearly clinical and educational needs to establish a subspecialty of pediatric dermatology, and over the next 1-2 decades, the field expanded. The journal Pediatric Dermatology was established (in 1982), the Section on Dermatology was established by the American Academy of Pediatrics (in 1986), and fellowship programs were launched at select academic centers. And it was 30 years into our timeline before the formal subspecialty of pediatric dermatology was established through the American Board of Dermatology (2000).

The field of pediatric dermatology has evolved and matured rapidly. Standard reference textbooks have been developed in the United States and around the world (and of course, online). Pediatric dermatology is an essential part of the core curriculum for dermatologist trainees. Organizations promoting pediatric research have developed to influence basic, translational, and clinical research in conditions in neonates through adolescents, such as the Pediatric Dermatology Research Alliance (PeDRA). And meetings throughout the world now feature pediatric dermatology sessions and help to spread the advances in the diagnosis and management of pediatric skin disorders.

The practice of pediatric dermatology: How has it changed?

It is beyond the scope of this article to try to comprehensively review all of the changes in pediatric dermatology practice. But review of the evolution of a few disease states (choices influenced by my discussions with my 100-year old history guide, Dr. Margileth) displays examples of where we have been, and where we are going in our next 5, 10, or 50 years.

Hemangiomas and vascular malformations

Some of the first natural history studies on hemangiomas were done in the early 1960s, establishing that standard cutaneous hemangiomas had a typical clinical course of fairly rapid growth, plateau, and involution over time. Of interest, the hallmark article’s first author was Dr. Margileth, published in 1965 in JAMA!.This was still at a time when the identification of hemangiomas of infancy (or “HOI” as we say in the trade) was confused with vascular malformations, and no one had recognized the distinct variant tumors such as rapidly involuting and noninvoluting congenital hemangiomas (RICHs or NICHs), tufted angiomas, or hemangioendotheliomas. PHACE syndrome was not yet described (that was done in 1996 by Ilona Frieden, MD, and colleagues). And for a time, hemangiomas were treated with x-rays, before the negative impact of such radiation was acknowledged. It seems that, as a consequence of the use of x-ray therapy and as a backlash from the radiation therapy side effects and potential toxicities, even deforming and functionally significant lesions were “followed clinically” for natural involution, with a sensibility that doing nothing might be better than doing the wrong thing.

Over the next 15 years, the recognition of functionally significant hemangiomas, deformation associated with their proliferation, and the recognition of PHACE syndrome made hemangiomas of infancy an area of concern, with systemic steroids and occasionally chemotherapeutic agents (such as vincristine) being used for problematic lesions.

It has now been 12 years since the work of Christine Léauté-Labrèze, MD, et al., from the University of Bordeaux (France), led to the breakthrough of propranolol for hemangioma treatment, profoundly changing hemangioma management to an incredibly effective medical therapy extensively studied, tested in formal clinical trials, and approved by regulatory authorities. And how intriguing that this was pursued after the chance (but skilled) observation that a child who developed hypertension as a side effect of systemic steroids for nasal hemangioma treatment was prescribed propranolol for the hypertension and had his nasal hemangioma rapidly shrink, with a response superior and much quicker than that to corticosteroids.

Courtesy of Rady Children&#039;s Hospital

Inflammatory skin disorders: Acne, psoriasis, and atopic dermatitis

The care of pediatric inflammatory skin disorders has evolved, but more slowly for some diseases than others. Acne vulgaris is now recognized as much more common under age 12 than previously, presumably reflecting earlier pubertal changes in our preteens. Over the past 30 years, therapy has evolved with the use of topical retinoids (still underused by pediatricians, considered a “practice gap”), hormonal therapy with combined oral contraceptives, and oral isotretinoin, a powerful but highly effective systemic agent for severe and refractory acne. Specific pediatric guidelines came much later, with expert recommendations formulated by the American Acne and Rosacea Society and endorsed by the American Academy of Pediatrics in 2013. Over the past few years, there has been a push by experts for more judicious use of antibiotics for acne (oral and topical) to minimize the emergence of bacterial resistance. There are unanswered questions as we evolve our care: How will the new topical antiandrogens be used? Will spironolactone become part of hormonal therapy under age 18? Will the insights on certain strains of Cutibacterium acnes being associated with worse acne translate to microbiome or vaccine-based strategies?

Pediatric psoriasis has suffered, being “behind in the revolution” of biologic agents because of delayed approval of any biologic agent for treatment of pediatric psoriasis in the United States until just a few years ago, and lags behind Europe and elsewhere in the world by almost a decade. Only this year have we expanded beyond one biologic agent approved for under age 12 and two for ages 12 and older, with other approvals expected including interleukin (IL)-17 and IL-23 agents. Adult psoriasis has been recognized to be associated with a broad set of comorbidities, including obesity and early heart disease, and there is now research on how children are at risk as well, with new recommendations on how to screen children with psoriasis, supplied first by PeDRA and then in the new American Academy of Dermatology-National Psoriasis Foundation pediatric psoriasis guidelines .

Pediatric atopic dermatitis (AD) is in its early years of revolution. In the 50-year period of our thought experiment, AD has increased in prevalence from 5% or less of the pediatric population to 10%-15%. Treatment of most individuals has remained the same over the decades: Good skin care, frequent moisturizers, topical corticosteroids for flares, and management of infection if noted. The topical calcineurin inhibitors (TCIs) broadened the therapeutic approach when introduced in 2000 and 2001, but the boxed warning resulted in some practitioners minimizing their use of these useful agents. But newer studies are markedly reassuring about their safe use in children.

Steroid phobia, as well as concerns about potential side effects of the TCIs, has resulted in undertreatment of childhood AD. It is quite common to see multiple children during pediatric dermatology office hours with poorly controlled eczema, high body-surface areas of eczema, compromised sleep, secondary infections, and anxiety and depression, especially in our moderate to severe adolescents. The field is “hot” with new topical and systemic agents, including our few years’ experience with topical crisaborole, a phosphodiesterase (PDE)-4 inhibitor; and dupilumab, an IL-4-alpha blocker – the first biologic agent approved for AD and the first systemic agent (other than oral corticosteroids), just extended from 12 years to 6 years of age! As dupilumab gets studied for younger children, other biologics (including IL-13 and IL-31 blockers) are undertaking pediatric and/or adolescent trials, oral and topical JAK inhibitors are including adolescents in core clinical trials, and other novel topical agents are under study, including an aryl-hydrocarbon receptor–modulating agent and other PDE-4 inhibitors.

Procedural pediatric dermatology: From liquid nitrogen to laser, surgery, and multimodal skin care

The first generation of pediatric dermatologists were considered medical dermatologist specialists. The care of the conditions discussed above, as well as genodermatoses, diagnostic dilemmas, and management of dermatologic manifestations of systemic disease and other conditions, was the “bread and butter” of pediatric dermatology care. When I was in training, my mentor Paul Honig, MD, at the Children’s Hospital of Philadelphia had a procedure half-day each week, where he would care for a few patients who needed liquid nitrogen therapy for warts, or who needed biopsies. It was uncommon to have a large procedural/surgical part of pediatric dermatology practice. But this is now a routine part of many specialists in the field. How did this change occur?

The fundamental shift began to occur with the introduction of the pulsed dye laser for treatment of port-wine birthmarks in children with minimal scarring, and a seminal article published in the New England Journal of Medicine in 1989. Vascular lesions including port-wine stains were common, and pediatric dermatologists managed these patients for both diagnosis and medical management. Also, dermatology residencies at this time offered training in cutaneous surgery, excisions (including Mohs surgery) and repairs, and trainees in pediatric dermatology were “trained up” to high levels of expertise. As lasers were incorporated into dermatology residency work and practices, pediatric dermatologists developed the exposure and skill to do this work. An added advantage was having the knowledge of how to handle children and adolescents in an age-appropriate manner, with consideration of methods to minimize the pain and anxiety of procedures. Within a few years, pediatric dermatologists were at the forefront of the use of topical anesthetics (EMLA and liposomal lidocaine) and had general anesthesia privileges for laser and excisional surgery.

So while pediatric dermatologists still do “small procedures” every hour in most practices (cryotherapy for warts, cantharidin for molluscum, shave and punch biopsies), a subset now have extensive procedural practices, which in recent years has extended to pigment lesion lasers (to treat nevus of Ota, for example), hair laser, and combinations of lasers, including fractionated CO₂ technology, to treat hypertrophic, constrictive and/or deforming scars.
 

The future

What will pediatric dermatology be like in 10, 20, or 50 years?

I have not yet discussed some of the most challenging diseases in our field, including epidermolysis bullosa, ichthyosis, and neurocutaneous disorders and other genetic skin disorders that have an incredible impact on the lives of affected children and their families, with incredible morbidity and with many conditions that shorten lifespans. But these are the conditions where “the future is happening now,” and we are looking forward to our new gene therapy techniques helping to transform our care.

And other aspects of practice? Will we be doing a large percentage of practice over the phone (or whatever devices we have then – remember, the first iPhone was only released 13 years ago)?

Will our patients be using their own imaging systems to evaluate their nevi and skin growths, and perhaps to diagnose and manage their rashes?

Will we have prevented our inflammatory skin disorders, or “turned them off” in early life with aggressive therapy in infantile life?

I project only that all of us in dermatology will still be a resource to our pediatric patients, from neonate through young adult, through our work of preventing, caring, healing and minimizing disease impact, and hopefully enjoying the pleasures of seeing our patients healthfully develop and evolve! As will our field.
 

Dr. Eichenfield is professor of dermatology and pediatrics and vice-chair of the department of dermatology at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. Dr. Eichenfield reports financial relationships with 20 pharmaceutical companies that manufacture dermatologic products, including products for the diseases discussed here.

As part of the 50th anniversary of Dermatology News, it is intriguing to think about where a time machine journey 5 decades back would find the field of pediatric dermatology, and to assess the changes in the specialty during the time that Dermatology News (operating then as “Skin & Allergy News”) has been reporting on innovations and changes in the practice of dermatology.

Society for Pediatric Dermatology

So, starting in 1970, we would find that pediatric dermatology did not exist as an organized specialty. It was not until 3 years later, in October 1973 in Mexico City, that the first international symposium on Pediatric Dermatology was held, and the International Society for Pediatric Dermatology was founded. I reached out to Andrew Margileth, MD, 100 years old this past July, and still active voluntary faculty in pediatric dermatology at the University of Miami, to help me “reach back” to those days. Dr. Margileth commented on how the first symposium was “brilliantly orchestrated by Ramon Ruiz-Maldonado,” from the National Institute of Paediatrics in Mexico, and that it was his “Aha moment for future practice!” That meeting spurred discussions on the development of the Society for Pediatric Dermatology the next year, with Alvin Jacobs, MD; Samuel Weinberg, MD; Nancy Esterly, MD; Sidney Hurwitz, MD; William Weston, MD; and Coleman Jacobson, MD, as some of the initial “founding mothers and fathers,” and the society was officially established in 1975.

The field of pediatric dermatology was fairly “infantile” 50 years ago, with few practitioners. But the early leaders in the field recognized that up to 30% of pediatric primary care visits included skin problems, and that there was limited training for dermatologists, as well as pediatricians, about skin diseases in children. There were clearly clinical and educational needs to establish a subspecialty of pediatric dermatology, and over the next 1-2 decades, the field expanded. The journal Pediatric Dermatology was established (in 1982), the Section on Dermatology was established by the American Academy of Pediatrics (in 1986), and fellowship programs were launched at select academic centers. And it was 30 years into our timeline before the formal subspecialty of pediatric dermatology was established through the American Board of Dermatology (2000).

The field of pediatric dermatology has evolved and matured rapidly. Standard reference textbooks have been developed in the United States and around the world (and of course, online). Pediatric dermatology is an essential part of the core curriculum for dermatologist trainees. Organizations promoting pediatric research have developed to influence basic, translational, and clinical research in conditions in neonates through adolescents, such as the Pediatric Dermatology Research Alliance (PeDRA). And meetings throughout the world now feature pediatric dermatology sessions and help to spread the advances in the diagnosis and management of pediatric skin disorders.

The practice of pediatric dermatology: How has it changed?

It is beyond the scope of this article to try to comprehensively review all of the changes in pediatric dermatology practice. But review of the evolution of a few disease states (choices influenced by my discussions with my 100-year old history guide, Dr. Margileth) displays examples of where we have been, and where we are going in our next 5, 10, or 50 years.

Hemangiomas and vascular malformations

Some of the first natural history studies on hemangiomas were done in the early 1960s, establishing that standard cutaneous hemangiomas had a typical clinical course of fairly rapid growth, plateau, and involution over time. Of interest, the hallmark article’s first author was Dr. Margileth, published in 1965 in JAMA!.This was still at a time when the identification of hemangiomas of infancy (or “HOI” as we say in the trade) was confused with vascular malformations, and no one had recognized the distinct variant tumors such as rapidly involuting and noninvoluting congenital hemangiomas (RICHs or NICHs), tufted angiomas, or hemangioendotheliomas. PHACE syndrome was not yet described (that was done in 1996 by Ilona Frieden, MD, and colleagues). And for a time, hemangiomas were treated with x-rays, before the negative impact of such radiation was acknowledged. It seems that, as a consequence of the use of x-ray therapy and as a backlash from the radiation therapy side effects and potential toxicities, even deforming and functionally significant lesions were “followed clinically” for natural involution, with a sensibility that doing nothing might be better than doing the wrong thing.

Over the next 15 years, the recognition of functionally significant hemangiomas, deformation associated with their proliferation, and the recognition of PHACE syndrome made hemangiomas of infancy an area of concern, with systemic steroids and occasionally chemotherapeutic agents (such as vincristine) being used for problematic lesions.

It has now been 12 years since the work of Christine Léauté-Labrèze, MD, et al., from the University of Bordeaux (France), led to the breakthrough of propranolol for hemangioma treatment, profoundly changing hemangioma management to an incredibly effective medical therapy extensively studied, tested in formal clinical trials, and approved by regulatory authorities. And how intriguing that this was pursued after the chance (but skilled) observation that a child who developed hypertension as a side effect of systemic steroids for nasal hemangioma treatment was prescribed propranolol for the hypertension and had his nasal hemangioma rapidly shrink, with a response superior and much quicker than that to corticosteroids.

Courtesy of Rady Children&#039;s Hospital

Inflammatory skin disorders: Acne, psoriasis, and atopic dermatitis

The care of pediatric inflammatory skin disorders has evolved, but more slowly for some diseases than others. Acne vulgaris is now recognized as much more common under age 12 than previously, presumably reflecting earlier pubertal changes in our preteens. Over the past 30 years, therapy has evolved with the use of topical retinoids (still underused by pediatricians, considered a “practice gap”), hormonal therapy with combined oral contraceptives, and oral isotretinoin, a powerful but highly effective systemic agent for severe and refractory acne. Specific pediatric guidelines came much later, with expert recommendations formulated by the American Acne and Rosacea Society and endorsed by the American Academy of Pediatrics in 2013. Over the past few years, there has been a push by experts for more judicious use of antibiotics for acne (oral and topical) to minimize the emergence of bacterial resistance. There are unanswered questions as we evolve our care: How will the new topical antiandrogens be used? Will spironolactone become part of hormonal therapy under age 18? Will the insights on certain strains of Cutibacterium acnes being associated with worse acne translate to microbiome or vaccine-based strategies?

Pediatric psoriasis has suffered, being “behind in the revolution” of biologic agents because of delayed approval of any biologic agent for treatment of pediatric psoriasis in the United States until just a few years ago, and lags behind Europe and elsewhere in the world by almost a decade. Only this year have we expanded beyond one biologic agent approved for under age 12 and two for ages 12 and older, with other approvals expected including interleukin (IL)-17 and IL-23 agents. Adult psoriasis has been recognized to be associated with a broad set of comorbidities, including obesity and early heart disease, and there is now research on how children are at risk as well, with new recommendations on how to screen children with psoriasis, supplied first by PeDRA and then in the new American Academy of Dermatology-National Psoriasis Foundation pediatric psoriasis guidelines .

Pediatric atopic dermatitis (AD) is in its early years of revolution. In the 50-year period of our thought experiment, AD has increased in prevalence from 5% or less of the pediatric population to 10%-15%. Treatment of most individuals has remained the same over the decades: Good skin care, frequent moisturizers, topical corticosteroids for flares, and management of infection if noted. The topical calcineurin inhibitors (TCIs) broadened the therapeutic approach when introduced in 2000 and 2001, but the boxed warning resulted in some practitioners minimizing their use of these useful agents. But newer studies are markedly reassuring about their safe use in children.

Steroid phobia, as well as concerns about potential side effects of the TCIs, has resulted in undertreatment of childhood AD. It is quite common to see multiple children during pediatric dermatology office hours with poorly controlled eczema, high body-surface areas of eczema, compromised sleep, secondary infections, and anxiety and depression, especially in our moderate to severe adolescents. The field is “hot” with new topical and systemic agents, including our few years’ experience with topical crisaborole, a phosphodiesterase (PDE)-4 inhibitor; and dupilumab, an IL-4-alpha blocker – the first biologic agent approved for AD and the first systemic agent (other than oral corticosteroids), just extended from 12 years to 6 years of age! As dupilumab gets studied for younger children, other biologics (including IL-13 and IL-31 blockers) are undertaking pediatric and/or adolescent trials, oral and topical JAK inhibitors are including adolescents in core clinical trials, and other novel topical agents are under study, including an aryl-hydrocarbon receptor–modulating agent and other PDE-4 inhibitors.

Procedural pediatric dermatology: From liquid nitrogen to laser, surgery, and multimodal skin care

The first generation of pediatric dermatologists were considered medical dermatologist specialists. The care of the conditions discussed above, as well as genodermatoses, diagnostic dilemmas, and management of dermatologic manifestations of systemic disease and other conditions, was the “bread and butter” of pediatric dermatology care. When I was in training, my mentor Paul Honig, MD, at the Children’s Hospital of Philadelphia had a procedure half-day each week, where he would care for a few patients who needed liquid nitrogen therapy for warts, or who needed biopsies. It was uncommon to have a large procedural/surgical part of pediatric dermatology practice. But this is now a routine part of many specialists in the field. How did this change occur?

The fundamental shift began to occur with the introduction of the pulsed dye laser for treatment of port-wine birthmarks in children with minimal scarring, and a seminal article published in the New England Journal of Medicine in 1989. Vascular lesions including port-wine stains were common, and pediatric dermatologists managed these patients for both diagnosis and medical management. Also, dermatology residencies at this time offered training in cutaneous surgery, excisions (including Mohs surgery) and repairs, and trainees in pediatric dermatology were “trained up” to high levels of expertise. As lasers were incorporated into dermatology residency work and practices, pediatric dermatologists developed the exposure and skill to do this work. An added advantage was having the knowledge of how to handle children and adolescents in an age-appropriate manner, with consideration of methods to minimize the pain and anxiety of procedures. Within a few years, pediatric dermatologists were at the forefront of the use of topical anesthetics (EMLA and liposomal lidocaine) and had general anesthesia privileges for laser and excisional surgery.

So while pediatric dermatologists still do “small procedures” every hour in most practices (cryotherapy for warts, cantharidin for molluscum, shave and punch biopsies), a subset now have extensive procedural practices, which in recent years has extended to pigment lesion lasers (to treat nevus of Ota, for example), hair laser, and combinations of lasers, including fractionated CO₂ technology, to treat hypertrophic, constrictive and/or deforming scars.
 

The future

What will pediatric dermatology be like in 10, 20, or 50 years?

I have not yet discussed some of the most challenging diseases in our field, including epidermolysis bullosa, ichthyosis, and neurocutaneous disorders and other genetic skin disorders that have an incredible impact on the lives of affected children and their families, with incredible morbidity and with many conditions that shorten lifespans. But these are the conditions where “the future is happening now,” and we are looking forward to our new gene therapy techniques helping to transform our care.

And other aspects of practice? Will we be doing a large percentage of practice over the phone (or whatever devices we have then – remember, the first iPhone was only released 13 years ago)?

Will our patients be using their own imaging systems to evaluate their nevi and skin growths, and perhaps to diagnose and manage their rashes?

Will we have prevented our inflammatory skin disorders, or “turned them off” in early life with aggressive therapy in infantile life?

I project only that all of us in dermatology will still be a resource to our pediatric patients, from neonate through young adult, through our work of preventing, caring, healing and minimizing disease impact, and hopefully enjoying the pleasures of seeing our patients healthfully develop and evolve! As will our field.
 

Dr. Eichenfield is professor of dermatology and pediatrics and vice-chair of the department of dermatology at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. Dr. Eichenfield reports financial relationships with 20 pharmaceutical companies that manufacture dermatologic products, including products for the diseases discussed here.

The all-consuming news about SARS-CoV-2 and COVID-19 has overshadowed other viral pathogens that are the cause of severe or fatal lower respiratory infections (LRI) including human metapneumovirus (HMPV).

“MPV is really a leading cause of LRI not just in children but in adults, with high mortality rates in the frail elderly, long-term care facilities, and cancer patients with pneumonia, “ said John Williams, MD, from the department of pediatric infectious diseases at the University of Pittsburgh Medical Center.

“Right now we have no effective antivirals. There are monoclonal antibodies in development that my group and others have discovered. In fact, some of these treat MPV and RSV [respiratory syncytial virus], so we may have good options,” he said in an online presentation during an annual scientific meeting on infectious diseases.

The virus preys, wolf-like, on the most vulnerable patients, including children and frail elderly adults, as well as other adults with predisposing conditions, he said.

HMPV causes acute respiratory illnesses in approximately 2%-11% of hospitalized adults, 3%-25% of organ transplant recipients or cancer patients, 4%-12% of chronic obstructive pulmonary disease exacerbations, 5%-20% of asthma exacerbations, and it has been identified in multiple outbreaks at long-term care facilities.


 

Relative newcomer

Metapneumovirus was isolated and discovered from children with respiratory tract disease in the early 2000s. Once included in the family of paramyxoviruses (including measles, mumps, Nipah virus, and parainfluenza virus 1-4), HMPV and RSV are now classified as pneumoviruses, based on gene order and other characteristics, Dr. Williams explained.

Various studies have consistently placed the prevalence of HMPV ranging from 5%-14% in young children with LRI, children hospitalized for wheezing, adults with cancer and LRI, adults with asthma admissions, children with upper respiratory infections, and children hospitalized in the United States and Jordan for LRI, as well as children hospitalized in the United States and Peru with acute respiratory infections.

A study tracking respiratory infections in a Rochester, N.Y., cohort from 1999 through 2003 showed that healthy elderly patients had and annual incidence of HMPV infections of 5.9%, compared with 9.1% for high-risk patients, 13.1% for young patients, and 8.5% among hospitalized adult patients.

“These percentages are virtually identical to what has been seen in the same cohort for respiratory syncytial virus, so in this multiyear prospective cohort, metapneumovirus was as common as RSV,” Dr. Williams said.

Although the incidences of both HMPV and RSV were lower among hospitalized adults “clinically, we can’t tell these respiratory viruses apart. If we know it’s circulating we can make a guess, but we really can’t discriminate them,” he added.

In the Rochester cohort the frequency of clinical symptoms – including congestion, sore throat, cough, sputum production, dyspnea, and fever – were similar among patients infected with HMPV, RSV, or influenza A, with the exception of a slightly higher incidence of wheezing (80%) with HMPV, compared with influenza.

“I can tell you as a pediatrician, this is absolutely true in children, that metapneumovirus is indistinguishable from other respiratory viruses in kids,” he said.
 

Fatalities among older adults

As noted before, HMPV can cause severe and fatal illness in adults. For example, during an outbreak in North Dakota in 2016, 3 of 27 hospitalized adults with HMPV (median age, 69 years) died, and 10 required mechanical or noninvasive ventilation.

In a study from Korea comparing outcomes of severe HMPV-associated community-acquired pneumonia (CAP) with those of severe influenza-associated CAP, the investigators found that 30- and 60-day mortality rates were similar between the groups, at 24% of patients with HMPV-associated CAP and 32.1% for influenza-associated CAP, and 32% versus 38.5%, respectively.

Patients at high risk for severe disease or death from HMPV infection include those over 65 years, especially frail elderly, patients with chronic obstructive pulmonary disease, immunocompromised patients, and those with cardiopulmonary diseases such as congestive heart failure.
 

Supportive care only

“Do we have anything for treatment? The short answer is, No,” Dr. Williams.

Supportive care is currently the only effective approach for patients with severe HMPV infection.

Ribavirin, used to treat patients with acute RSV infection, has poor in vitro activity against HMPV and poor oral bioavailability and hemolysis, and there are no randomized controlled trials to support its use in this situation.

“It really can’t be recommended, and I don’t recommend it,” he said.
 

Virology may still help

Mark J. Siedner, MD, an infectious diseases physician at Mass General and associate professor of medicine at Harvard Medical School, both in Boston, who was not involved in the study, said that, despite the inability to clinically distinguish HMPV from RSV or influenza A, there is still clinical value to identifying HMPV infections.

“We spend millions of dollar each year treating people for upper respiratory tract infections, often with antibacterials, sometimes with antivirals, but those have costs to the health care system, and they also have costs in terms of drug resistance,” he said in an interview seeking objective commentary.

“Diagnostic tests that determine the actual source or the cause of these upper respiratory tract infections and encourage both patients and physicians not to be using antibiotics have value,” he said.

Identifying the pathogen can also help clinicians take appropriate infection-control precautions to prevent patient-to-clinician or patient-to-patient transmission of viral infections, he added.

Dr. Williams’ research is supported by the National Institutes of Health, Henry L. Hillman Foundation, and Asher Krop Memorial Fund of Children’s Hospital of Pittsburgh. Dr. Williams and Dr. Siedner reported no relevant conflict of interest disclosures.

The all-consuming news about SARS-CoV-2 and COVID-19 has overshadowed other viral pathogens that are the cause of severe or fatal lower respiratory infections (LRI) including human metapneumovirus (HMPV).

“MPV is really a leading cause of LRI not just in children but in adults, with high mortality rates in the frail elderly, long-term care facilities, and cancer patients with pneumonia, “ said John Williams, MD, from the department of pediatric infectious diseases at the University of Pittsburgh Medical Center.

“Right now we have no effective antivirals. There are monoclonal antibodies in development that my group and others have discovered. In fact, some of these treat MPV and RSV [respiratory syncytial virus], so we may have good options,” he said in an online presentation during an annual scientific meeting on infectious diseases.

The virus preys, wolf-like, on the most vulnerable patients, including children and frail elderly adults, as well as other adults with predisposing conditions, he said.

HMPV causes acute respiratory illnesses in approximately 2%-11% of hospitalized adults, 3%-25% of organ transplant recipients or cancer patients, 4%-12% of chronic obstructive pulmonary disease exacerbations, 5%-20% of asthma exacerbations, and it has been identified in multiple outbreaks at long-term care facilities.


 

Relative newcomer

Metapneumovirus was isolated and discovered from children with respiratory tract disease in the early 2000s. Once included in the family of paramyxoviruses (including measles, mumps, Nipah virus, and parainfluenza virus 1-4), HMPV and RSV are now classified as pneumoviruses, based on gene order and other characteristics, Dr. Williams explained.

Various studies have consistently placed the prevalence of HMPV ranging from 5%-14% in young children with LRI, children hospitalized for wheezing, adults with cancer and LRI, adults with asthma admissions, children with upper respiratory infections, and children hospitalized in the United States and Jordan for LRI, as well as children hospitalized in the United States and Peru with acute respiratory infections.

A study tracking respiratory infections in a Rochester, N.Y., cohort from 1999 through 2003 showed that healthy elderly patients had and annual incidence of HMPV infections of 5.9%, compared with 9.1% for high-risk patients, 13.1% for young patients, and 8.5% among hospitalized adult patients.

“These percentages are virtually identical to what has been seen in the same cohort for respiratory syncytial virus, so in this multiyear prospective cohort, metapneumovirus was as common as RSV,” Dr. Williams said.

Although the incidences of both HMPV and RSV were lower among hospitalized adults “clinically, we can’t tell these respiratory viruses apart. If we know it’s circulating we can make a guess, but we really can’t discriminate them,” he added.

In the Rochester cohort the frequency of clinical symptoms – including congestion, sore throat, cough, sputum production, dyspnea, and fever – were similar among patients infected with HMPV, RSV, or influenza A, with the exception of a slightly higher incidence of wheezing (80%) with HMPV, compared with influenza.

“I can tell you as a pediatrician, this is absolutely true in children, that metapneumovirus is indistinguishable from other respiratory viruses in kids,” he said.
 

Fatalities among older adults

As noted before, HMPV can cause severe and fatal illness in adults. For example, during an outbreak in North Dakota in 2016, 3 of 27 hospitalized adults with HMPV (median age, 69 years) died, and 10 required mechanical or noninvasive ventilation.

In a study from Korea comparing outcomes of severe HMPV-associated community-acquired pneumonia (CAP) with those of severe influenza-associated CAP, the investigators found that 30- and 60-day mortality rates were similar between the groups, at 24% of patients with HMPV-associated CAP and 32.1% for influenza-associated CAP, and 32% versus 38.5%, respectively.

Patients at high risk for severe disease or death from HMPV infection include those over 65 years, especially frail elderly, patients with chronic obstructive pulmonary disease, immunocompromised patients, and those with cardiopulmonary diseases such as congestive heart failure.
 

Supportive care only

“Do we have anything for treatment? The short answer is, No,” Dr. Williams.

Supportive care is currently the only effective approach for patients with severe HMPV infection.

Ribavirin, used to treat patients with acute RSV infection, has poor in vitro activity against HMPV and poor oral bioavailability and hemolysis, and there are no randomized controlled trials to support its use in this situation.

“It really can’t be recommended, and I don’t recommend it,” he said.
 

Virology may still help

Mark J. Siedner, MD, an infectious diseases physician at Mass General and associate professor of medicine at Harvard Medical School, both in Boston, who was not involved in the study, said that, despite the inability to clinically distinguish HMPV from RSV or influenza A, there is still clinical value to identifying HMPV infections.

“We spend millions of dollar each year treating people for upper respiratory tract infections, often with antibacterials, sometimes with antivirals, but those have costs to the health care system, and they also have costs in terms of drug resistance,” he said in an interview seeking objective commentary.

“Diagnostic tests that determine the actual source or the cause of these upper respiratory tract infections and encourage both patients and physicians not to be using antibiotics have value,” he said.

Identifying the pathogen can also help clinicians take appropriate infection-control precautions to prevent patient-to-clinician or patient-to-patient transmission of viral infections, he added.

Dr. Williams’ research is supported by the National Institutes of Health, Henry L. Hillman Foundation, and Asher Krop Memorial Fund of Children’s Hospital of Pittsburgh. Dr. Williams and Dr. Siedner reported no relevant conflict of interest disclosures.

The all-consuming news about SARS-CoV-2 and COVID-19 has overshadowed other viral pathogens that are the cause of severe or fatal lower respiratory infections (LRI) including human metapneumovirus (HMPV).

“MPV is really a leading cause of LRI not just in children but in adults, with high mortality rates in the frail elderly, long-term care facilities, and cancer patients with pneumonia, “ said John Williams, MD, from the department of pediatric infectious diseases at the University of Pittsburgh Medical Center.

“Right now we have no effective antivirals. There are monoclonal antibodies in development that my group and others have discovered. In fact, some of these treat MPV and RSV [respiratory syncytial virus], so we may have good options,” he said in an online presentation during an annual scientific meeting on infectious diseases.

The virus preys, wolf-like, on the most vulnerable patients, including children and frail elderly adults, as well as other adults with predisposing conditions, he said.

HMPV causes acute respiratory illnesses in approximately 2%-11% of hospitalized adults, 3%-25% of organ transplant recipients or cancer patients, 4%-12% of chronic obstructive pulmonary disease exacerbations, 5%-20% of asthma exacerbations, and it has been identified in multiple outbreaks at long-term care facilities.


 

Relative newcomer

Metapneumovirus was isolated and discovered from children with respiratory tract disease in the early 2000s. Once included in the family of paramyxoviruses (including measles, mumps, Nipah virus, and parainfluenza virus 1-4), HMPV and RSV are now classified as pneumoviruses, based on gene order and other characteristics, Dr. Williams explained.

Various studies have consistently placed the prevalence of HMPV ranging from 5%-14% in young children with LRI, children hospitalized for wheezing, adults with cancer and LRI, adults with asthma admissions, children with upper respiratory infections, and children hospitalized in the United States and Jordan for LRI, as well as children hospitalized in the United States and Peru with acute respiratory infections.

A study tracking respiratory infections in a Rochester, N.Y., cohort from 1999 through 2003 showed that healthy elderly patients had and annual incidence of HMPV infections of 5.9%, compared with 9.1% for high-risk patients, 13.1% for young patients, and 8.5% among hospitalized adult patients.

“These percentages are virtually identical to what has been seen in the same cohort for respiratory syncytial virus, so in this multiyear prospective cohort, metapneumovirus was as common as RSV,” Dr. Williams said.

Although the incidences of both HMPV and RSV were lower among hospitalized adults “clinically, we can’t tell these respiratory viruses apart. If we know it’s circulating we can make a guess, but we really can’t discriminate them,” he added.

In the Rochester cohort the frequency of clinical symptoms – including congestion, sore throat, cough, sputum production, dyspnea, and fever – were similar among patients infected with HMPV, RSV, or influenza A, with the exception of a slightly higher incidence of wheezing (80%) with HMPV, compared with influenza.

“I can tell you as a pediatrician, this is absolutely true in children, that metapneumovirus is indistinguishable from other respiratory viruses in kids,” he said.
 

Fatalities among older adults

As noted before, HMPV can cause severe and fatal illness in adults. For example, during an outbreak in North Dakota in 2016, 3 of 27 hospitalized adults with HMPV (median age, 69 years) died, and 10 required mechanical or noninvasive ventilation.

In a study from Korea comparing outcomes of severe HMPV-associated community-acquired pneumonia (CAP) with those of severe influenza-associated CAP, the investigators found that 30- and 60-day mortality rates were similar between the groups, at 24% of patients with HMPV-associated CAP and 32.1% for influenza-associated CAP, and 32% versus 38.5%, respectively.

Patients at high risk for severe disease or death from HMPV infection include those over 65 years, especially frail elderly, patients with chronic obstructive pulmonary disease, immunocompromised patients, and those with cardiopulmonary diseases such as congestive heart failure.
 

Supportive care only

“Do we have anything for treatment? The short answer is, No,” Dr. Williams.

Supportive care is currently the only effective approach for patients with severe HMPV infection.

Ribavirin, used to treat patients with acute RSV infection, has poor in vitro activity against HMPV and poor oral bioavailability and hemolysis, and there are no randomized controlled trials to support its use in this situation.

“It really can’t be recommended, and I don’t recommend it,” he said.
 

Virology may still help

Mark J. Siedner, MD, an infectious diseases physician at Mass General and associate professor of medicine at Harvard Medical School, both in Boston, who was not involved in the study, said that, despite the inability to clinically distinguish HMPV from RSV or influenza A, there is still clinical value to identifying HMPV infections.

“We spend millions of dollar each year treating people for upper respiratory tract infections, often with antibacterials, sometimes with antivirals, but those have costs to the health care system, and they also have costs in terms of drug resistance,” he said in an interview seeking objective commentary.

“Diagnostic tests that determine the actual source or the cause of these upper respiratory tract infections and encourage both patients and physicians not to be using antibiotics have value,” he said.

Identifying the pathogen can also help clinicians take appropriate infection-control precautions to prevent patient-to-clinician or patient-to-patient transmission of viral infections, he added.

Dr. Williams’ research is supported by the National Institutes of Health, Henry L. Hillman Foundation, and Asher Krop Memorial Fund of Children’s Hospital of Pittsburgh. Dr. Williams and Dr. Siedner reported no relevant conflict of interest disclosures.

The number of new cases soared in the past week as the United States exceeded 1 million children infected with the coronavirus, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

For the first time, the number of cases in children for the week ending Nov. 12 passed 100,000, and it didn’t stop until it reached 111,946, bringing the total for the pandemic to 1,039,464 reported cases in 49 states (New York is not reporting ages), the District of Columbia, New York City, and Guam, the AAP and the CHA said in their weekly COVID-19 update.

“As a pediatrician who has practiced medicine for over 3 decades, I find this number staggering and tragic. We haven’t seen a virus flash through our communities in this way since before we had vaccines for measles and polio,” AAP President Sally Goza, MD, said in a written statement.

The previous 1-week high of almost 74,000 cases came just last week, and that number had surpassed the previous week’s new high of 61,000. The number of cumulative child cases, meanwhile, has doubled since Sept. 3, when it was just over 513,000. Children now represent 11.5% of all COVID-19 cases since the start of the pandemic in the jurisdictions reporting age distribution, the AAP and CHA said.

For the week ending Nov. 12, COVID-19 cases children made up 14% of cases nationally, rising from 13% the week before and reversing a decline that started in mid-October, the AAP/CHA data show.

The two groups continue to note the rarity of severe illness in children, but the number of deaths nationally had its biggest 1-week increase since late July, as the total rose from 123 to 133 in the 42 states reporting such data by age, as well as New York City. The cumulative hospitalization rate for children decreased slightly in the past week and is now down to 1.6% in the 23 states (and NYC) with available data, the AAP and CHA said.

The AAP called on elected leaders to enact a national strategy to combat the spread of the virus and urged health authorities to do more to collect data on longer-term impacts on children.

“Most natural disasters have an end, but this pandemic has gone on for over 8 months, and is likely to continue to disrupt our lives for many more. We’re very concerned about how this will impact all children, including toddlers who are missing key educational opportunities, as well as adolescents who may be at higher risk for anxiety and depression,” Dr. Goza said.

rfranki@mdedge.com

The number of new cases soared in the past week as the United States exceeded 1 million children infected with the coronavirus, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

For the first time, the number of cases in children for the week ending Nov. 12 passed 100,000, and it didn’t stop until it reached 111,946, bringing the total for the pandemic to 1,039,464 reported cases in 49 states (New York is not reporting ages), the District of Columbia, New York City, and Guam, the AAP and the CHA said in their weekly COVID-19 update.

“As a pediatrician who has practiced medicine for over 3 decades, I find this number staggering and tragic. We haven’t seen a virus flash through our communities in this way since before we had vaccines for measles and polio,” AAP President Sally Goza, MD, said in a written statement.

The previous 1-week high of almost 74,000 cases came just last week, and that number had surpassed the previous week’s new high of 61,000. The number of cumulative child cases, meanwhile, has doubled since Sept. 3, when it was just over 513,000. Children now represent 11.5% of all COVID-19 cases since the start of the pandemic in the jurisdictions reporting age distribution, the AAP and CHA said.

For the week ending Nov. 12, COVID-19 cases children made up 14% of cases nationally, rising from 13% the week before and reversing a decline that started in mid-October, the AAP/CHA data show.

The two groups continue to note the rarity of severe illness in children, but the number of deaths nationally had its biggest 1-week increase since late July, as the total rose from 123 to 133 in the 42 states reporting such data by age, as well as New York City. The cumulative hospitalization rate for children decreased slightly in the past week and is now down to 1.6% in the 23 states (and NYC) with available data, the AAP and CHA said.

The AAP called on elected leaders to enact a national strategy to combat the spread of the virus and urged health authorities to do more to collect data on longer-term impacts on children.

“Most natural disasters have an end, but this pandemic has gone on for over 8 months, and is likely to continue to disrupt our lives for many more. We’re very concerned about how this will impact all children, including toddlers who are missing key educational opportunities, as well as adolescents who may be at higher risk for anxiety and depression,” Dr. Goza said.

rfranki@mdedge.com

The number of new cases soared in the past week as the United States exceeded 1 million children infected with the coronavirus, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

For the first time, the number of cases in children for the week ending Nov. 12 passed 100,000, and it didn’t stop until it reached 111,946, bringing the total for the pandemic to 1,039,464 reported cases in 49 states (New York is not reporting ages), the District of Columbia, New York City, and Guam, the AAP and the CHA said in their weekly COVID-19 update.

“As a pediatrician who has practiced medicine for over 3 decades, I find this number staggering and tragic. We haven’t seen a virus flash through our communities in this way since before we had vaccines for measles and polio,” AAP President Sally Goza, MD, said in a written statement.

The previous 1-week high of almost 74,000 cases came just last week, and that number had surpassed the previous week’s new high of 61,000. The number of cumulative child cases, meanwhile, has doubled since Sept. 3, when it was just over 513,000. Children now represent 11.5% of all COVID-19 cases since the start of the pandemic in the jurisdictions reporting age distribution, the AAP and CHA said.

For the week ending Nov. 12, COVID-19 cases children made up 14% of cases nationally, rising from 13% the week before and reversing a decline that started in mid-October, the AAP/CHA data show.

The two groups continue to note the rarity of severe illness in children, but the number of deaths nationally had its biggest 1-week increase since late July, as the total rose from 123 to 133 in the 42 states reporting such data by age, as well as New York City. The cumulative hospitalization rate for children decreased slightly in the past week and is now down to 1.6% in the 23 states (and NYC) with available data, the AAP and CHA said.

The AAP called on elected leaders to enact a national strategy to combat the spread of the virus and urged health authorities to do more to collect data on longer-term impacts on children.

“Most natural disasters have an end, but this pandemic has gone on for over 8 months, and is likely to continue to disrupt our lives for many more. We’re very concerned about how this will impact all children, including toddlers who are missing key educational opportunities, as well as adolescents who may be at higher risk for anxiety and depression,” Dr. Goza said.

rfranki@mdedge.com

Peanut allergy immunotherapy now comes with approval from the US Food and Drug Administration (FDA), but it also comes with protocols, standards, and paperwork. Whether it will be widely adopted has yet to be determined.

A few dozen allergists around the world have been offering food allergy immunotherapy for many years, having developed their own measuring techniques using store-bought food.

But the vast majority of allergists are not interested in developing home-grown treatments, not only because it involves research and development, but also because it comes with legal risks.

“Finally we have another treatment option,” said Edwin Kim, MD, from the UNC Allergy and Immunology Clinic in Chapel Hill, N.C. “This is what we were waiting for. It’s not cowboy stuff; this works.”

In January, the FDA approved peanut allergen powder (Palforzia) for patients 4-17 years of age, as reported by Medscape Medical News.

The pill contains measured doses of peanut flour and comes with a protocol that will allow allergists to bring patients to a peanut tolerance of 300 mg (about one peanut) and a black-box warning about anaphylaxis risk.

And before allergists can prescribe it, they must take a Risk Evaluation and Mitigation Strategy course to learn about dosing and the allergic reaction protocol.

“That may scare some away,” said Dr. Kim, who discussed the FDA-approved option during his presentation at the American College of Allergy, Asthma & Immunology 2020 Annual Scientific Meeting.

Allergic reaction, including the potential for anaphylaxis, has always been an issue with immunotherapy.

“People make the argument that there is a difference” between an expected allergic reaction – such as one that occurs after the administration of immunotherapy – and an unexpected reaction, he said. Because an expected reaction can be treated quickly, “some feel these expected reactions don’t matter so much.”

“Others say a reaction is a reaction” and argue that if, a treatment causes reaction, then it doesn’t make sense, he explained.

It comes down to patients – they must be willing to take a risk to develop tolerance and improve their quality of life – and the allergists willing to treat them.

The peanut powder involves paperwork, preauthorization forms, denials of care, a higher price tag, regimented procedures, and a prerequisite number of visits with patients. “Not everyone will want to do this,” said Dr. Kim.

The regimen involves three phases. During initial dose escalation, five doses are administered in the office on day 1. Then, over the next 6 months, updoses are administered during 11 in-office sessions and a 300-mg tolerance is achieved. Finally, to maintain tolerance to one peanut, daily doses are administered at home.

The drug cost alone is about $4,200 a year, according to Institute for Clinical and Economic Review. Peanut flour from the grocery store is cheaper, but comes with the risk of bacteria or other contamination.

“This product offers some reassurance, and that matters,” Dr. Kim said.

It’s good to have more options for food allergy treatment. “We need a more proactive way to treat food allergy; avoidance is not good enough,” he explained. “And presumably, at some point, the patient will be able to eat a grocery-store peanut instead of buying the pills.”
 

The art of medicine

But not all allergists will be able to make the protocol work. And it’s not clear whether there is room to alter treatment and offer patients with a higher tolerance a higher starting dose. What we do know, though, is that “the product leaves little room for ‘the art of medicine,’ ” Kim said.

That art is practiced by Arnon Elizur, MD, from the Shamir Medical Center in Tzrifin, Israel, but it’s backed by a rigid home-grown protocol.

Since 2010, he has treated 1,800 patients for peanut allergy, updosing slowly to a tolerance of 3,000 mg of peanut, the equivalent of 10 peanuts. He keeps the maintenance dose at four peanuts (1,200 mg). His center takes a personalized approach, starting patients on the highest dose they can tolerate and working up, with daily patient check-ins from home and a staff available around the clock to answer questions and deal with reactions.

“We aim for full sensitization,” Dr. Elizur said in an interview.

The peanut pill is “a big step forward” for immunotherapy, he said. It is “a standardized product, checked for bacteria and allergen content, which is available to a wide community of physicians.”

But, he pointed out, “it’s expensive.” And it’s only for peanut. “There are millions of food-allergic patients around the world dying from adverse reactions to many different kinds of food. We don’t want to wait for years for a product for all of them. We can use the actual food.”

He questions the lifelong maintenance protocol with a daily 300-mg pill. “If you can’t eat a peanut, why would you buy a drug that’s a peanut?” he asked.

He also said he’s disappointed that the product is not indicated for adults.

At the Shamir clinic, reactions are closely monitored. “Some are mild, others we treat with autoinjectors, epinephrine,” he reported. “Those are the most undesirable.”

Data from his center show that reactions occur in about 15% of patients. But his treatment success rates are good. In an average of 8 months, he is able to get 80% of his adult patients to full sensitization.

But it’s not for all patients or for all clinics, he acknowledged. “We continue to look at this balance in quality of life throughout the process. Our goal is to improve the quality of life threshold.”

Treatment that involves “native food” is “a lot of work” and requires “a lot of investment,” Dr. Elizur said. His center uses a web reporting system to maintain a 24/7 dialogue with patients, “and we look at the reports every day.” They also have a physician on call at all times. “Not everyone can commit to providing care throughout the day and night.”

His center charges the equivalent of $US3,000 per food allergy treated. “That’s whether it takes 6 months or 2 years,” he said.

There are more than 1,000 people on his 3-year waiting list.

“This is the first year that the American College of Allergy, Asthma, and Immunology is not hosting a pro–con debate on oral immunotherapy,” Dr. Kim pointed out. “We have a therapy now.”

However, the pandemic has slowed treatment uptake. “Immunotherapy is not easy to do, whether it’s FDA approved or not,” he explained. With at least 11 doctor visits in the first 6 months – each visit is between 30 minutes and 2-3 hours long – it hasn’t been possible to set up this year. “It’s not ideal.”

It will be interesting to see “how this will roll out and how it will be adopted,” Dr. Kim said. “From a food allergy point of view, the next 12 months are going to be very interesting.”

Dr. Kim reports receiving consulting honorarium from Aimmune, the maker of Palforzia; being on the clinical medical advisory board for DBV Technologies; and consulting for Aimmune, Allakos, Allergenis, DBV, Duke Clinical Research Institute, Ukko Incorporated, Vibrant America, and Kenota Health. Dr. Elizur has disclosed no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

Peanut allergy immunotherapy now comes with approval from the US Food and Drug Administration (FDA), but it also comes with protocols, standards, and paperwork. Whether it will be widely adopted has yet to be determined.

A few dozen allergists around the world have been offering food allergy immunotherapy for many years, having developed their own measuring techniques using store-bought food.

But the vast majority of allergists are not interested in developing home-grown treatments, not only because it involves research and development, but also because it comes with legal risks.

“Finally we have another treatment option,” said Edwin Kim, MD, from the UNC Allergy and Immunology Clinic in Chapel Hill, N.C. “This is what we were waiting for. It’s not cowboy stuff; this works.”

In January, the FDA approved peanut allergen powder (Palforzia) for patients 4-17 years of age, as reported by Medscape Medical News.

The pill contains measured doses of peanut flour and comes with a protocol that will allow allergists to bring patients to a peanut tolerance of 300 mg (about one peanut) and a black-box warning about anaphylaxis risk.

And before allergists can prescribe it, they must take a Risk Evaluation and Mitigation Strategy course to learn about dosing and the allergic reaction protocol.

“That may scare some away,” said Dr. Kim, who discussed the FDA-approved option during his presentation at the American College of Allergy, Asthma & Immunology 2020 Annual Scientific Meeting.

Allergic reaction, including the potential for anaphylaxis, has always been an issue with immunotherapy.

“People make the argument that there is a difference” between an expected allergic reaction – such as one that occurs after the administration of immunotherapy – and an unexpected reaction, he said. Because an expected reaction can be treated quickly, “some feel these expected reactions don’t matter so much.”

“Others say a reaction is a reaction” and argue that if, a treatment causes reaction, then it doesn’t make sense, he explained.

It comes down to patients – they must be willing to take a risk to develop tolerance and improve their quality of life – and the allergists willing to treat them.

The peanut powder involves paperwork, preauthorization forms, denials of care, a higher price tag, regimented procedures, and a prerequisite number of visits with patients. “Not everyone will want to do this,” said Dr. Kim.

The regimen involves three phases. During initial dose escalation, five doses are administered in the office on day 1. Then, over the next 6 months, updoses are administered during 11 in-office sessions and a 300-mg tolerance is achieved. Finally, to maintain tolerance to one peanut, daily doses are administered at home.

The drug cost alone is about $4,200 a year, according to Institute for Clinical and Economic Review. Peanut flour from the grocery store is cheaper, but comes with the risk of bacteria or other contamination.

“This product offers some reassurance, and that matters,” Dr. Kim said.

It’s good to have more options for food allergy treatment. “We need a more proactive way to treat food allergy; avoidance is not good enough,” he explained. “And presumably, at some point, the patient will be able to eat a grocery-store peanut instead of buying the pills.”
 

The art of medicine

But not all allergists will be able to make the protocol work. And it’s not clear whether there is room to alter treatment and offer patients with a higher tolerance a higher starting dose. What we do know, though, is that “the product leaves little room for ‘the art of medicine,’ ” Kim said.

That art is practiced by Arnon Elizur, MD, from the Shamir Medical Center in Tzrifin, Israel, but it’s backed by a rigid home-grown protocol.

Since 2010, he has treated 1,800 patients for peanut allergy, updosing slowly to a tolerance of 3,000 mg of peanut, the equivalent of 10 peanuts. He keeps the maintenance dose at four peanuts (1,200 mg). His center takes a personalized approach, starting patients on the highest dose they can tolerate and working up, with daily patient check-ins from home and a staff available around the clock to answer questions and deal with reactions.

“We aim for full sensitization,” Dr. Elizur said in an interview.

The peanut pill is “a big step forward” for immunotherapy, he said. It is “a standardized product, checked for bacteria and allergen content, which is available to a wide community of physicians.”

But, he pointed out, “it’s expensive.” And it’s only for peanut. “There are millions of food-allergic patients around the world dying from adverse reactions to many different kinds of food. We don’t want to wait for years for a product for all of them. We can use the actual food.”

He questions the lifelong maintenance protocol with a daily 300-mg pill. “If you can’t eat a peanut, why would you buy a drug that’s a peanut?” he asked.

He also said he’s disappointed that the product is not indicated for adults.

At the Shamir clinic, reactions are closely monitored. “Some are mild, others we treat with autoinjectors, epinephrine,” he reported. “Those are the most undesirable.”

Data from his center show that reactions occur in about 15% of patients. But his treatment success rates are good. In an average of 8 months, he is able to get 80% of his adult patients to full sensitization.

But it’s not for all patients or for all clinics, he acknowledged. “We continue to look at this balance in quality of life throughout the process. Our goal is to improve the quality of life threshold.”

Treatment that involves “native food” is “a lot of work” and requires “a lot of investment,” Dr. Elizur said. His center uses a web reporting system to maintain a 24/7 dialogue with patients, “and we look at the reports every day.” They also have a physician on call at all times. “Not everyone can commit to providing care throughout the day and night.”

His center charges the equivalent of $US3,000 per food allergy treated. “That’s whether it takes 6 months or 2 years,” he said.

There are more than 1,000 people on his 3-year waiting list.

“This is the first year that the American College of Allergy, Asthma, and Immunology is not hosting a pro–con debate on oral immunotherapy,” Dr. Kim pointed out. “We have a therapy now.”

However, the pandemic has slowed treatment uptake. “Immunotherapy is not easy to do, whether it’s FDA approved or not,” he explained. With at least 11 doctor visits in the first 6 months – each visit is between 30 minutes and 2-3 hours long – it hasn’t been possible to set up this year. “It’s not ideal.”

It will be interesting to see “how this will roll out and how it will be adopted,” Dr. Kim said. “From a food allergy point of view, the next 12 months are going to be very interesting.”

Dr. Kim reports receiving consulting honorarium from Aimmune, the maker of Palforzia; being on the clinical medical advisory board for DBV Technologies; and consulting for Aimmune, Allakos, Allergenis, DBV, Duke Clinical Research Institute, Ukko Incorporated, Vibrant America, and Kenota Health. Dr. Elizur has disclosed no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

Peanut allergy immunotherapy now comes with approval from the US Food and Drug Administration (FDA), but it also comes with protocols, standards, and paperwork. Whether it will be widely adopted has yet to be determined.

A few dozen allergists around the world have been offering food allergy immunotherapy for many years, having developed their own measuring techniques using store-bought food.

But the vast majority of allergists are not interested in developing home-grown treatments, not only because it involves research and development, but also because it comes with legal risks.

“Finally we have another treatment option,” said Edwin Kim, MD, from the UNC Allergy and Immunology Clinic in Chapel Hill, N.C. “This is what we were waiting for. It’s not cowboy stuff; this works.”

In January, the FDA approved peanut allergen powder (Palforzia) for patients 4-17 years of age, as reported by Medscape Medical News.

The pill contains measured doses of peanut flour and comes with a protocol that will allow allergists to bring patients to a peanut tolerance of 300 mg (about one peanut) and a black-box warning about anaphylaxis risk.

And before allergists can prescribe it, they must take a Risk Evaluation and Mitigation Strategy course to learn about dosing and the allergic reaction protocol.

“That may scare some away,” said Dr. Kim, who discussed the FDA-approved option during his presentation at the American College of Allergy, Asthma & Immunology 2020 Annual Scientific Meeting.

Allergic reaction, including the potential for anaphylaxis, has always been an issue with immunotherapy.

“People make the argument that there is a difference” between an expected allergic reaction – such as one that occurs after the administration of immunotherapy – and an unexpected reaction, he said. Because an expected reaction can be treated quickly, “some feel these expected reactions don’t matter so much.”

“Others say a reaction is a reaction” and argue that if, a treatment causes reaction, then it doesn’t make sense, he explained.

It comes down to patients – they must be willing to take a risk to develop tolerance and improve their quality of life – and the allergists willing to treat them.

The peanut powder involves paperwork, preauthorization forms, denials of care, a higher price tag, regimented procedures, and a prerequisite number of visits with patients. “Not everyone will want to do this,” said Dr. Kim.

The regimen involves three phases. During initial dose escalation, five doses are administered in the office on day 1. Then, over the next 6 months, updoses are administered during 11 in-office sessions and a 300-mg tolerance is achieved. Finally, to maintain tolerance to one peanut, daily doses are administered at home.

The drug cost alone is about $4,200 a year, according to Institute for Clinical and Economic Review. Peanut flour from the grocery store is cheaper, but comes with the risk of bacteria or other contamination.

“This product offers some reassurance, and that matters,” Dr. Kim said.

It’s good to have more options for food allergy treatment. “We need a more proactive way to treat food allergy; avoidance is not good enough,” he explained. “And presumably, at some point, the patient will be able to eat a grocery-store peanut instead of buying the pills.”
 

The art of medicine

But not all allergists will be able to make the protocol work. And it’s not clear whether there is room to alter treatment and offer patients with a higher tolerance a higher starting dose. What we do know, though, is that “the product leaves little room for ‘the art of medicine,’ ” Kim said.

That art is practiced by Arnon Elizur, MD, from the Shamir Medical Center in Tzrifin, Israel, but it’s backed by a rigid home-grown protocol.

Since 2010, he has treated 1,800 patients for peanut allergy, updosing slowly to a tolerance of 3,000 mg of peanut, the equivalent of 10 peanuts. He keeps the maintenance dose at four peanuts (1,200 mg). His center takes a personalized approach, starting patients on the highest dose they can tolerate and working up, with daily patient check-ins from home and a staff available around the clock to answer questions and deal with reactions.

“We aim for full sensitization,” Dr. Elizur said in an interview.

The peanut pill is “a big step forward” for immunotherapy, he said. It is “a standardized product, checked for bacteria and allergen content, which is available to a wide community of physicians.”

But, he pointed out, “it’s expensive.” And it’s only for peanut. “There are millions of food-allergic patients around the world dying from adverse reactions to many different kinds of food. We don’t want to wait for years for a product for all of them. We can use the actual food.”

He questions the lifelong maintenance protocol with a daily 300-mg pill. “If you can’t eat a peanut, why would you buy a drug that’s a peanut?” he asked.

He also said he’s disappointed that the product is not indicated for adults.

At the Shamir clinic, reactions are closely monitored. “Some are mild, others we treat with autoinjectors, epinephrine,” he reported. “Those are the most undesirable.”

Data from his center show that reactions occur in about 15% of patients. But his treatment success rates are good. In an average of 8 months, he is able to get 80% of his adult patients to full sensitization.

But it’s not for all patients or for all clinics, he acknowledged. “We continue to look at this balance in quality of life throughout the process. Our goal is to improve the quality of life threshold.”

Treatment that involves “native food” is “a lot of work” and requires “a lot of investment,” Dr. Elizur said. His center uses a web reporting system to maintain a 24/7 dialogue with patients, “and we look at the reports every day.” They also have a physician on call at all times. “Not everyone can commit to providing care throughout the day and night.”

His center charges the equivalent of $US3,000 per food allergy treated. “That’s whether it takes 6 months or 2 years,” he said.

There are more than 1,000 people on his 3-year waiting list.

“This is the first year that the American College of Allergy, Asthma, and Immunology is not hosting a pro–con debate on oral immunotherapy,” Dr. Kim pointed out. “We have a therapy now.”

However, the pandemic has slowed treatment uptake. “Immunotherapy is not easy to do, whether it’s FDA approved or not,” he explained. With at least 11 doctor visits in the first 6 months – each visit is between 30 minutes and 2-3 hours long – it hasn’t been possible to set up this year. “It’s not ideal.”

It will be interesting to see “how this will roll out and how it will be adopted,” Dr. Kim said. “From a food allergy point of view, the next 12 months are going to be very interesting.”

Dr. Kim reports receiving consulting honorarium from Aimmune, the maker of Palforzia; being on the clinical medical advisory board for DBV Technologies; and consulting for Aimmune, Allakos, Allergenis, DBV, Duke Clinical Research Institute, Ukko Incorporated, Vibrant America, and Kenota Health. Dr. Elizur has disclosed no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

Given the longstanding scarring alopecia, with negative fungal cultures and with perifollicular erythema and scaling, this diagnosis is most consistent with lichen planopilaris.

Lichen planopilaris (LPP) is considered one of the primary scarring alopecias, a group of diseases characterized by inflammation and subsequent irreversible hair loss.¹ LPP specifically is believed to be caused by dysfunction of cell-mediated immunity, resulting in T lymphocytes attacking follicular hair stem cells.² It typically presents with hair loss, pruritus, scaling, burning pain, and tenderness of the scalp when active,^1,3 with exam showing perifollicular scale and erythema on the borders of the patches of alopecia.^4,5 Over time, scarring of the scalp develops with loss of follicular ostia.¹ Definitive diagnosis typically requires punch biopsy of the affected scalp, as such can determine the presence or absence of inflammation in affected areas of the scalp.¹

What’s the treatment plan?

Given that LPP is an autoimmune inflammatory disease process, the goal of treatment is to calm down the inflammation of the scalp to prevent further progression of a patient’s hair loss. This is typically achieved with superpotent topical corticosteroids, such as clobetasol applied directly to the scalp, and/or intralesional corticosteroids, such as triamcinolone acetonide suspension injected directly to the affected scalp.^3,6,7 Other treatment options include systemic agents, such as hydroxychloroquine, methotrexate, mycophenolate mofetil, pioglitazone, and doxycycline.^3,6 Hair loss is not reversible as loss of follicular ostia and hair stem cells results in permanent scarring.¹ Management often requires a referral to dermatology for aggressive treatment to prevent further hair loss.

What’s the differential diagnosis?

The differential diagnosis of lichen planopilaris includes other scarring alopecias, including central centrifugal cicatricial alopecia, discoid lupus erythematosus, folliculitis decalvans. While nonscarring, alopecia areata, trichotillomania, and telogen effluvium are discussed below as well.

Central centrifugal cicatricial alopecia is very rare in pediatrics, and is a type of asymptomatic scarring alopecia that begins at the vertex of the scalp, spreading centrifugally and resulting in shiny plaque development. Treatment involves reduction of hair grooming as well as topical and intralesional steroids.

Discoid lupus erythematosus presents as scaling erythematous plaques on the face and scalp that result in skin pigment changes and atrophy over time. Scalp involvement results in scarring alopecia. Treatment includes the use of high-potency topical corticosteroids, topical calcineurin inhibitors, and hydroxychloroquine.

Folliculitis decalvans is another form of scarring alopecia believed to be caused by an inflammatory response to Staphylococcus aureus in the scalp, resulting in the formation of scarring of the scalp and perifollicular pustules. Treatment is topical antibiotics and intralesional steroids.

Alopecia areata is a form of nonscarring alopecia resulting in small round patches of partially reversible hair loss characterized by the pathognomonic finding of so-called exclamation point hairs that are broader distally and taper toward the scalp on physical exam. Considered an autoimmune disorder, it varies greatly in extent and course. While focal hair loss is the hallmark of this disease, usually hair follicles are present.

Trichotillosis, also known as trichotillomania (hair pulling), results in alopecia with irregular borders and broken hairs of different lengths secondary to the urge to remove or pull one’s own hair, resulting in nonscarring alopecia. It may be associated with stress or anxiety, obsessive-compulsive disorders, or other repetitive body-altering behaviors. Treatments include reassurance and education as it can be self-limited in some, behavior modification, or systemic therapy including tricyclic antidepressants or SSRIs.

Our patient underwent scalp punch biopsy to confirm the diagnosis and was started on potent topical corticosteroids with good disease control.

Dr. Haft is a pediatric dermatology research associate in the division of pediatric and adolescent dermatology, University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is the vice chair of the department of dermatology and a professor of dermatology and pediatrics at the university, and he is chief of pediatric and adolescent dermatology at the hospital. Neither of the doctors had any relevant financial disclosures. Email them at pdnews@mdedge.com.
 

References

1. J Am Acad Dermatol. 2005 Jul. doi: 10.1016/j.jaad.2004.06.015.

2. J Pathol. 2013 Oct. doi: 10.1002/path.4233.

3. Pediatr Dermatol. 2015 Sep-Oct. doi: 10.1111/pde.12624.

4. J Am Acad Dermatol. 2004 Jan. doi: 10.1016/j.jaad.2003.04.001.

5. J Am Acad Dermatol. 1992 Dec. doi: 10.1016/0190-9622(92)70290-v.

6. Clin Cosmet Investig Dermatol. 2018 Feb 27. doi: 10.2147/CCID.S137870.

7. Semin Cutan Med Surg. 2009 Mar. doi: 10.1016/j.sder.2008.12.006.

Given the longstanding scarring alopecia, with negative fungal cultures and with perifollicular erythema and scaling, this diagnosis is most consistent with lichen planopilaris.

Lichen planopilaris (LPP) is considered one of the primary scarring alopecias, a group of diseases characterized by inflammation and subsequent irreversible hair loss.¹ LPP specifically is believed to be caused by dysfunction of cell-mediated immunity, resulting in T lymphocytes attacking follicular hair stem cells.² It typically presents with hair loss, pruritus, scaling, burning pain, and tenderness of the scalp when active,^1,3 with exam showing perifollicular scale and erythema on the borders of the patches of alopecia.^4,5 Over time, scarring of the scalp develops with loss of follicular ostia.¹ Definitive diagnosis typically requires punch biopsy of the affected scalp, as such can determine the presence or absence of inflammation in affected areas of the scalp.¹

What’s the treatment plan?

Given that LPP is an autoimmune inflammatory disease process, the goal of treatment is to calm down the inflammation of the scalp to prevent further progression of a patient’s hair loss. This is typically achieved with superpotent topical corticosteroids, such as clobetasol applied directly to the scalp, and/or intralesional corticosteroids, such as triamcinolone acetonide suspension injected directly to the affected scalp.^3,6,7 Other treatment options include systemic agents, such as hydroxychloroquine, methotrexate, mycophenolate mofetil, pioglitazone, and doxycycline.^3,6 Hair loss is not reversible as loss of follicular ostia and hair stem cells results in permanent scarring.¹ Management often requires a referral to dermatology for aggressive treatment to prevent further hair loss.

What’s the differential diagnosis?

The differential diagnosis of lichen planopilaris includes other scarring alopecias, including central centrifugal cicatricial alopecia, discoid lupus erythematosus, folliculitis decalvans. While nonscarring, alopecia areata, trichotillomania, and telogen effluvium are discussed below as well.

Central centrifugal cicatricial alopecia is very rare in pediatrics, and is a type of asymptomatic scarring alopecia that begins at the vertex of the scalp, spreading centrifugally and resulting in shiny plaque development. Treatment involves reduction of hair grooming as well as topical and intralesional steroids.

Discoid lupus erythematosus presents as scaling erythematous plaques on the face and scalp that result in skin pigment changes and atrophy over time. Scalp involvement results in scarring alopecia. Treatment includes the use of high-potency topical corticosteroids, topical calcineurin inhibitors, and hydroxychloroquine.

Folliculitis decalvans is another form of scarring alopecia believed to be caused by an inflammatory response to Staphylococcus aureus in the scalp, resulting in the formation of scarring of the scalp and perifollicular pustules. Treatment is topical antibiotics and intralesional steroids.

Alopecia areata is a form of nonscarring alopecia resulting in small round patches of partially reversible hair loss characterized by the pathognomonic finding of so-called exclamation point hairs that are broader distally and taper toward the scalp on physical exam. Considered an autoimmune disorder, it varies greatly in extent and course. While focal hair loss is the hallmark of this disease, usually hair follicles are present.

Trichotillosis, also known as trichotillomania (hair pulling), results in alopecia with irregular borders and broken hairs of different lengths secondary to the urge to remove or pull one’s own hair, resulting in nonscarring alopecia. It may be associated with stress or anxiety, obsessive-compulsive disorders, or other repetitive body-altering behaviors. Treatments include reassurance and education as it can be self-limited in some, behavior modification, or systemic therapy including tricyclic antidepressants or SSRIs.

Our patient underwent scalp punch biopsy to confirm the diagnosis and was started on potent topical corticosteroids with good disease control.

Dr. Haft is a pediatric dermatology research associate in the division of pediatric and adolescent dermatology, University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is the vice chair of the department of dermatology and a professor of dermatology and pediatrics at the university, and he is chief of pediatric and adolescent dermatology at the hospital. Neither of the doctors had any relevant financial disclosures. Email them at pdnews@mdedge.com.
 

References

1. J Am Acad Dermatol. 2005 Jul. doi: 10.1016/j.jaad.2004.06.015.

2. J Pathol. 2013 Oct. doi: 10.1002/path.4233.

3. Pediatr Dermatol. 2015 Sep-Oct. doi: 10.1111/pde.12624.

4. J Am Acad Dermatol. 2004 Jan. doi: 10.1016/j.jaad.2003.04.001.

5. J Am Acad Dermatol. 1992 Dec. doi: 10.1016/0190-9622(92)70290-v.

6. Clin Cosmet Investig Dermatol. 2018 Feb 27. doi: 10.2147/CCID.S137870.

7. Semin Cutan Med Surg. 2009 Mar. doi: 10.1016/j.sder.2008.12.006.

Given the longstanding scarring alopecia, with negative fungal cultures and with perifollicular erythema and scaling, this diagnosis is most consistent with lichen planopilaris.

Lichen planopilaris (LPP) is considered one of the primary scarring alopecias, a group of diseases characterized by inflammation and subsequent irreversible hair loss.¹ LPP specifically is believed to be caused by dysfunction of cell-mediated immunity, resulting in T lymphocytes attacking follicular hair stem cells.² It typically presents with hair loss, pruritus, scaling, burning pain, and tenderness of the scalp when active,^1,3 with exam showing perifollicular scale and erythema on the borders of the patches of alopecia.^4,5 Over time, scarring of the scalp develops with loss of follicular ostia.¹ Definitive diagnosis typically requires punch biopsy of the affected scalp, as such can determine the presence or absence of inflammation in affected areas of the scalp.¹

What’s the treatment plan?

Given that LPP is an autoimmune inflammatory disease process, the goal of treatment is to calm down the inflammation of the scalp to prevent further progression of a patient’s hair loss. This is typically achieved with superpotent topical corticosteroids, such as clobetasol applied directly to the scalp, and/or intralesional corticosteroids, such as triamcinolone acetonide suspension injected directly to the affected scalp.^3,6,7 Other treatment options include systemic agents, such as hydroxychloroquine, methotrexate, mycophenolate mofetil, pioglitazone, and doxycycline.^3,6 Hair loss is not reversible as loss of follicular ostia and hair stem cells results in permanent scarring.¹ Management often requires a referral to dermatology for aggressive treatment to prevent further hair loss.

What’s the differential diagnosis?

The differential diagnosis of lichen planopilaris includes other scarring alopecias, including central centrifugal cicatricial alopecia, discoid lupus erythematosus, folliculitis decalvans. While nonscarring, alopecia areata, trichotillomania, and telogen effluvium are discussed below as well.

Central centrifugal cicatricial alopecia is very rare in pediatrics, and is a type of asymptomatic scarring alopecia that begins at the vertex of the scalp, spreading centrifugally and resulting in shiny plaque development. Treatment involves reduction of hair grooming as well as topical and intralesional steroids.

Discoid lupus erythematosus presents as scaling erythematous plaques on the face and scalp that result in skin pigment changes and atrophy over time. Scalp involvement results in scarring alopecia. Treatment includes the use of high-potency topical corticosteroids, topical calcineurin inhibitors, and hydroxychloroquine.

Folliculitis decalvans is another form of scarring alopecia believed to be caused by an inflammatory response to Staphylococcus aureus in the scalp, resulting in the formation of scarring of the scalp and perifollicular pustules. Treatment is topical antibiotics and intralesional steroids.

Alopecia areata is a form of nonscarring alopecia resulting in small round patches of partially reversible hair loss characterized by the pathognomonic finding of so-called exclamation point hairs that are broader distally and taper toward the scalp on physical exam. Considered an autoimmune disorder, it varies greatly in extent and course. While focal hair loss is the hallmark of this disease, usually hair follicles are present.

Trichotillosis, also known as trichotillomania (hair pulling), results in alopecia with irregular borders and broken hairs of different lengths secondary to the urge to remove or pull one’s own hair, resulting in nonscarring alopecia. It may be associated with stress or anxiety, obsessive-compulsive disorders, or other repetitive body-altering behaviors. Treatments include reassurance and education as it can be self-limited in some, behavior modification, or systemic therapy including tricyclic antidepressants or SSRIs.

Our patient underwent scalp punch biopsy to confirm the diagnosis and was started on potent topical corticosteroids with good disease control.

Dr. Haft is a pediatric dermatology research associate in the division of pediatric and adolescent dermatology, University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is the vice chair of the department of dermatology and a professor of dermatology and pediatrics at the university, and he is chief of pediatric and adolescent dermatology at the hospital. Neither of the doctors had any relevant financial disclosures. Email them at pdnews@mdedge.com.
 

References

1. J Am Acad Dermatol. 2005 Jul. doi: 10.1016/j.jaad.2004.06.015.

2. J Pathol. 2013 Oct. doi: 10.1002/path.4233.

3. Pediatr Dermatol. 2015 Sep-Oct. doi: 10.1111/pde.12624.

4. J Am Acad Dermatol. 2004 Jan. doi: 10.1016/j.jaad.2003.04.001.

5. J Am Acad Dermatol. 1992 Dec. doi: 10.1016/0190-9622(92)70290-v.

6. Clin Cosmet Investig Dermatol. 2018 Feb 27. doi: 10.2147/CCID.S137870.

7. Semin Cutan Med Surg. 2009 Mar. doi: 10.1016/j.sder.2008.12.006.

The U.S. Department of Agriculture and the Department of Health & Human Services aim to release new dietary guidelines by the end of 2020. For the first time, the guidelines are mandated to include dietary recommendations from birth to 24 months and for women who are pregnant or lactating.

Bonnie Becker/MDedge News

An advisory committee submitted to the agencies a scientific report that examines relationships between diet and health at various life stages. Four chapters focus on dietary considerations for infants and toddlers, and two chapters focus on diet during pregnancy and lactation.

The report may inform the development of the new guidelines. The advisory committee’s recommendations include introducing infants to foods that are rich in zinc and iron at about age 6 months and having women who are lactating eat sources of omega-3 and omega-6 fatty acids, such as fish, to improve the fatty acid status of infants.

Ahead of the release of the 2020-2025 Dietary Guidelines for Americans, Joan Younger Meek, MD, discussed parts of the scientific report at the annual meeting of the American Academy of Pediatrics, held virtually this year.

While the 2015-2020 guidelines use ChooseMyPlate to help people implement the recommendations, it is not known how the new guidelines will be presented to the public, she said. “Many of you will remember the pyramids earlier and different food groups before that.”
 

Promote healthy dietary patterns

The advisory committee’s report notes that diet in the first years of life contributes to long-term health and shapes taste preferences, said Dr. Meek, professor of clinical sciences at Florida State University, Orlando. Human milk or infant formula are primary sources of nutrition until approximately 6 months, when families may introduce complementary foods and beverages. Between 6 months and 24 months, children transition to the typical family diet.

Dr. Meek highlighted some of the advisory committee’s findings and recommendations.

• Infants who are ever breastfed have a reduced risk of overweight or obesity, type 1 diabetes, and asthma. Likewise, longer duration of breastfeeding is associated with lower risk of type 1 diabetes and asthma, and exclusive breastfeeding is associated with lower risk of type 1 diabetes.
• Complementary foods and beverages should not be introduced before age 4 months. Limited evidence indicates that their introduction before 4 months may be associated with increased odds of overweight or obesity. Introducing complementary foods or beverages at 4 or 5 months, compared with 6 months, is not associated with long-term advantages or disadvantages.
• Introducing peanut and egg after age 4 months may reduce the risk of food allergies.
• From age 12 months to 24 months, children should consume a variety of nutrient-rich protein sources from animals – including meat, poultry, seafood, eggs, and dairy – plus nuts, seeds, fruits, vegetables, and grains.
• The report prioritizes oils over solid fats, and whole grains over refined grains. It also discourages added sugars, particularly from sugar-sweetened beverages. Other sources of added sugars include sweets, baked goods, and sweetened dairy products.

The report acknowledges that dietary guidelines should accommodate cultural preferences and cost considerations.
 

Recommendations during pregnancy

Healthy dietary patterns before or during pregnancy may modestly reduce the odds of gestational diabetes, hypertensive disorders of pregnancy, and preterm birth, according to the report.

The report recommends that during pregnancy women consume 8-12 ounces per week of seafood with high levels of omega-3 fatty acids and low levels of methylmercury, consistent with existing recommendations.

Egg and milk consumption during pregnancy does not influence the risk of food allergy, asthma, or atopic disease in the child, according to the report.

The advisory committee recommended universal folic acid supplementation during pregnancy.
 

Addressing a gap

The Agricultural Act of 2014 required that infants and toddlers and women who are pregnant or lactating be included in the 2020-2025 guidelines. Covering these populations in the scientific report was a substantial undertaking, said Kathryn Dewey, PhD, of the Institute for Global Nutrition at the University of California, Davis. Dr. Dewey chaired the subcommittee on birth to 24 months for the 2020 Dietary Guidelines Advisory Committee.

“Given that this age group had not been covered before, we could not rely on previous dietary guidelines’ reports,” Dr. Dewey said in an interview.

Outlining food patterns for infants and toddlers proved challenging. The committee explored models that considered various scenarios including children who consumed human milk, children who consumed formula, and those with vegetarian diets. Future research should clarify dietary reference intakes for these age groups, Dr. Dewey said.

Dr. Dewey sees the committee’s report on dietary guidance for birth to 24 months as a starting point and not necessarily an exhaustive look at the subject.

For one, the committee focused more on what to feed infants and toddlers rather than on how to feed them. Information about how to feed children is considered more in depth in a 2020 report from the National Academies of Sciences, Engineering, and Medicine. That report summarizes existing guidance from various organizations on feeding infants and children from birth to 24 months. Dr. Dewey chaired the committee that created the National Academies report.

Sharing the new USDA and HHS guidelines after they are released could be the next important step. “The public does not necessarily know about the guidelines or they do not necessarily seek them out unless there is a very well-constructed strategy for dissemination and implementation,” Dr. Dewey said.

To that end, health care providers can play a role, Dr. Meek said. “Be aware of changes in guidance, adopt those new recommendations, and then advocate those with our patients as well as with the public at large.”

Dr. Meek and Dr. Dewey had no relevant financial disclosures.

jremaly@mdedge.com

The U.S. Department of Agriculture and the Department of Health & Human Services aim to release new dietary guidelines by the end of 2020. For the first time, the guidelines are mandated to include dietary recommendations from birth to 24 months and for women who are pregnant or lactating.

Bonnie Becker/MDedge News

An advisory committee submitted to the agencies a scientific report that examines relationships between diet and health at various life stages. Four chapters focus on dietary considerations for infants and toddlers, and two chapters focus on diet during pregnancy and lactation.

The report may inform the development of the new guidelines. The advisory committee’s recommendations include introducing infants to foods that are rich in zinc and iron at about age 6 months and having women who are lactating eat sources of omega-3 and omega-6 fatty acids, such as fish, to improve the fatty acid status of infants.

Ahead of the release of the 2020-2025 Dietary Guidelines for Americans, Joan Younger Meek, MD, discussed parts of the scientific report at the annual meeting of the American Academy of Pediatrics, held virtually this year.

While the 2015-2020 guidelines use ChooseMyPlate to help people implement the recommendations, it is not known how the new guidelines will be presented to the public, she said. “Many of you will remember the pyramids earlier and different food groups before that.”
 

Promote healthy dietary patterns

The advisory committee’s report notes that diet in the first years of life contributes to long-term health and shapes taste preferences, said Dr. Meek, professor of clinical sciences at Florida State University, Orlando. Human milk or infant formula are primary sources of nutrition until approximately 6 months, when families may introduce complementary foods and beverages. Between 6 months and 24 months, children transition to the typical family diet.

Dr. Meek highlighted some of the advisory committee’s findings and recommendations.

• Infants who are ever breastfed have a reduced risk of overweight or obesity, type 1 diabetes, and asthma. Likewise, longer duration of breastfeeding is associated with lower risk of type 1 diabetes and asthma, and exclusive breastfeeding is associated with lower risk of type 1 diabetes.
• Complementary foods and beverages should not be introduced before age 4 months. Limited evidence indicates that their introduction before 4 months may be associated with increased odds of overweight or obesity. Introducing complementary foods or beverages at 4 or 5 months, compared with 6 months, is not associated with long-term advantages or disadvantages.
• Introducing peanut and egg after age 4 months may reduce the risk of food allergies.
• From age 12 months to 24 months, children should consume a variety of nutrient-rich protein sources from animals – including meat, poultry, seafood, eggs, and dairy – plus nuts, seeds, fruits, vegetables, and grains.
• The report prioritizes oils over solid fats, and whole grains over refined grains. It also discourages added sugars, particularly from sugar-sweetened beverages. Other sources of added sugars include sweets, baked goods, and sweetened dairy products.

The report acknowledges that dietary guidelines should accommodate cultural preferences and cost considerations.
 

Recommendations during pregnancy

Healthy dietary patterns before or during pregnancy may modestly reduce the odds of gestational diabetes, hypertensive disorders of pregnancy, and preterm birth, according to the report.

The report recommends that during pregnancy women consume 8-12 ounces per week of seafood with high levels of omega-3 fatty acids and low levels of methylmercury, consistent with existing recommendations.

Egg and milk consumption during pregnancy does not influence the risk of food allergy, asthma, or atopic disease in the child, according to the report.

The advisory committee recommended universal folic acid supplementation during pregnancy.
 

Addressing a gap

The Agricultural Act of 2014 required that infants and toddlers and women who are pregnant or lactating be included in the 2020-2025 guidelines. Covering these populations in the scientific report was a substantial undertaking, said Kathryn Dewey, PhD, of the Institute for Global Nutrition at the University of California, Davis. Dr. Dewey chaired the subcommittee on birth to 24 months for the 2020 Dietary Guidelines Advisory Committee.

“Given that this age group had not been covered before, we could not rely on previous dietary guidelines’ reports,” Dr. Dewey said in an interview.

Outlining food patterns for infants and toddlers proved challenging. The committee explored models that considered various scenarios including children who consumed human milk, children who consumed formula, and those with vegetarian diets. Future research should clarify dietary reference intakes for these age groups, Dr. Dewey said.

Dr. Dewey sees the committee’s report on dietary guidance for birth to 24 months as a starting point and not necessarily an exhaustive look at the subject.

For one, the committee focused more on what to feed infants and toddlers rather than on how to feed them. Information about how to feed children is considered more in depth in a 2020 report from the National Academies of Sciences, Engineering, and Medicine. That report summarizes existing guidance from various organizations on feeding infants and children from birth to 24 months. Dr. Dewey chaired the committee that created the National Academies report.

Sharing the new USDA and HHS guidelines after they are released could be the next important step. “The public does not necessarily know about the guidelines or they do not necessarily seek them out unless there is a very well-constructed strategy for dissemination and implementation,” Dr. Dewey said.

To that end, health care providers can play a role, Dr. Meek said. “Be aware of changes in guidance, adopt those new recommendations, and then advocate those with our patients as well as with the public at large.”

Dr. Meek and Dr. Dewey had no relevant financial disclosures.

jremaly@mdedge.com

The U.S. Department of Agriculture and the Department of Health & Human Services aim to release new dietary guidelines by the end of 2020. For the first time, the guidelines are mandated to include dietary recommendations from birth to 24 months and for women who are pregnant or lactating.

Bonnie Becker/MDedge News

An advisory committee submitted to the agencies a scientific report that examines relationships between diet and health at various life stages. Four chapters focus on dietary considerations for infants and toddlers, and two chapters focus on diet during pregnancy and lactation.

The report may inform the development of the new guidelines. The advisory committee’s recommendations include introducing infants to foods that are rich in zinc and iron at about age 6 months and having women who are lactating eat sources of omega-3 and omega-6 fatty acids, such as fish, to improve the fatty acid status of infants.

Ahead of the release of the 2020-2025 Dietary Guidelines for Americans, Joan Younger Meek, MD, discussed parts of the scientific report at the annual meeting of the American Academy of Pediatrics, held virtually this year.

While the 2015-2020 guidelines use ChooseMyPlate to help people implement the recommendations, it is not known how the new guidelines will be presented to the public, she said. “Many of you will remember the pyramids earlier and different food groups before that.”
 

Promote healthy dietary patterns

The advisory committee’s report notes that diet in the first years of life contributes to long-term health and shapes taste preferences, said Dr. Meek, professor of clinical sciences at Florida State University, Orlando. Human milk or infant formula are primary sources of nutrition until approximately 6 months, when families may introduce complementary foods and beverages. Between 6 months and 24 months, children transition to the typical family diet.

Dr. Meek highlighted some of the advisory committee’s findings and recommendations.

• Infants who are ever breastfed have a reduced risk of overweight or obesity, type 1 diabetes, and asthma. Likewise, longer duration of breastfeeding is associated with lower risk of type 1 diabetes and asthma, and exclusive breastfeeding is associated with lower risk of type 1 diabetes.
• Complementary foods and beverages should not be introduced before age 4 months. Limited evidence indicates that their introduction before 4 months may be associated with increased odds of overweight or obesity. Introducing complementary foods or beverages at 4 or 5 months, compared with 6 months, is not associated with long-term advantages or disadvantages.
• Introducing peanut and egg after age 4 months may reduce the risk of food allergies.
• From age 12 months to 24 months, children should consume a variety of nutrient-rich protein sources from animals – including meat, poultry, seafood, eggs, and dairy – plus nuts, seeds, fruits, vegetables, and grains.
• The report prioritizes oils over solid fats, and whole grains over refined grains. It also discourages added sugars, particularly from sugar-sweetened beverages. Other sources of added sugars include sweets, baked goods, and sweetened dairy products.

The report acknowledges that dietary guidelines should accommodate cultural preferences and cost considerations.
 

Recommendations during pregnancy

Healthy dietary patterns before or during pregnancy may modestly reduce the odds of gestational diabetes, hypertensive disorders of pregnancy, and preterm birth, according to the report.

The report recommends that during pregnancy women consume 8-12 ounces per week of seafood with high levels of omega-3 fatty acids and low levels of methylmercury, consistent with existing recommendations.

Egg and milk consumption during pregnancy does not influence the risk of food allergy, asthma, or atopic disease in the child, according to the report.

The advisory committee recommended universal folic acid supplementation during pregnancy.
 

Addressing a gap

The Agricultural Act of 2014 required that infants and toddlers and women who are pregnant or lactating be included in the 2020-2025 guidelines. Covering these populations in the scientific report was a substantial undertaking, said Kathryn Dewey, PhD, of the Institute for Global Nutrition at the University of California, Davis. Dr. Dewey chaired the subcommittee on birth to 24 months for the 2020 Dietary Guidelines Advisory Committee.

“Given that this age group had not been covered before, we could not rely on previous dietary guidelines’ reports,” Dr. Dewey said in an interview.

Outlining food patterns for infants and toddlers proved challenging. The committee explored models that considered various scenarios including children who consumed human milk, children who consumed formula, and those with vegetarian diets. Future research should clarify dietary reference intakes for these age groups, Dr. Dewey said.

Dr. Dewey sees the committee’s report on dietary guidance for birth to 24 months as a starting point and not necessarily an exhaustive look at the subject.

For one, the committee focused more on what to feed infants and toddlers rather than on how to feed them. Information about how to feed children is considered more in depth in a 2020 report from the National Academies of Sciences, Engineering, and Medicine. That report summarizes existing guidance from various organizations on feeding infants and children from birth to 24 months. Dr. Dewey chaired the committee that created the National Academies report.

Sharing the new USDA and HHS guidelines after they are released could be the next important step. “The public does not necessarily know about the guidelines or they do not necessarily seek them out unless there is a very well-constructed strategy for dissemination and implementation,” Dr. Dewey said.

To that end, health care providers can play a role, Dr. Meek said. “Be aware of changes in guidance, adopt those new recommendations, and then advocate those with our patients as well as with the public at large.”

Dr. Meek and Dr. Dewey had no relevant financial disclosures.

jremaly@mdedge.com

As an East Coast transplant residing in Texas, I look forward to the annual sojourn home to celebrate the holidays with family and friends – as do many of our patients and their families. But this is 2020. SARS-CoV-2, the causative agent of COVID-19, is still circulating. To make matters worse, cases are rising in 45 states and internationally. The day of this writing 102,831 new cases were reported in the United States. As we prepare for the holidays, it is time to rethink how safe it is to travel and/or gather with people who do not live in our household.

Social distancing, wearing masks, and hand washing have been strategies recommended to help mitigate the spread of the virus. We know adherence is not always 100%. The reality is that several families will consider traveling and gathering with others over the holidays. Their actions may lead to increased infections, hospitalizations, and even deaths. It behooves us to at least remind them of the potential consequences of the activity, and if travel and/or holiday gatherings are inevitable, to provide some guidance to help them look at both the risks and benefits and offer strategies to minimize infection and spread.
 

What should be considered prior to travel?

Here is a list of points to ponder:

• Is your patient is in a high-risk group for developing severe disease or visiting someone who is in a high-risk group?
• What is their mode of transportation?
• What is their destination?
• How prevalent is the disease at their destination, compared with their community?
• What will be their accommodations?
• How will attendees prepare for the gathering, if at all?
• Will multiple families congregate after quarantining for 2 weeks or simply arrive?
• At the destination, will people wear masks and socially distance?
• Is an outdoor venue an option?

All of these questions should be considered by patients.
 

Review high-risk groups

In terms of high-risk groups, we usually focus on underlying medical conditions or extremes of age, but Black and LatinX children and their families have been diagnosed with COVID-19 and hospitalized more frequently than other racial/ ethnic groups in the United States. Of 277,285 school-aged children infected between March 1 and Sept. 19, 2020, 42% were LatinX, 32% White, and 17% Black, yet they comprise 18%, 60%, and 11% of the U.S. population, respectively. Of those hospitalized, 45% were LatinX, 22% White, and 24% Black. LatinX and Black children also have disproportionately higher mortality rates.

Think about transmission and how to mitigate it

Many patients erroneously think combining multiple households for small group gatherings is inconsequential. These types of gatherings serve as a continued source of SARS-CoV-2 spread. For example, a person in Illinois with mild upper respiratory infection symptoms attended a funeral; he reported embracing the family members after the funeral. He dined with two people the evening prior to the funeral, sharing the meal using common serving dishes. Four days later, he attended a birthday party with nine family members. Some of the family members with symptoms subsequently attended church, infecting another church attendee. A cluster of 16 cases of COVID-19 was subsequently identified, including three deaths likely resulting from this one introduction of COVID-19 at these two family gatherings.

In Tennessee and Wisconsin, household transmission of SARS-CoV-2 was studied prospectively. A total of 101 index cases and 191 asymptomatic household contacts were enrolled between April and Sept. 2020; 102 of 191 (53%) had SARS-CoV-2 detected during the 14-day follow-up. Most infections (75%) were identified within 5 days and occurred whether the index case was an adult or child.

Lastly, one adolescent was identified as the source for an outbreak at a family gathering where 15 persons from five households and four states shared a house between 8 and 25 days in July 2020. Six additional members visited the house. The index case had an exposure to COVID-19 and had a negative antigen test 4 days after exposure. She was asymptomatic when tested. She developed nasal congestion 2 days later, the same day she and her family departed for the gathering. A total of 11 household contacts developed confirmed, suspected, or probable COVID-19, and the teen developed symptoms. This report illustrates how easily SARS-CoV-2 is transmitted, and how when implemented, mitigation strategies work because none of the six who only visited the house was infected. It also serves as a reminder that antigen testing is indicated only for use within the first 5-12 days of onset of symptoms. In this case, the adolescent was asymptomatic when tested and had a false-negative test result.
 

Ponder modes of transportation

How will your patient arrive to their holiday destination? Nonstop travel by car with household members is probably the safest way. However, for many families, buses and trains are the only options, and social distancing may be challenging. Air travel is a must for others. Acquisition of COVID-19 during air travel appears to be low, but not absent based on how air enters and leaves the cabin. The challenge is socially distancing throughout the check in and boarding processes, as well as minimizing contact with common surfaces. There also is loss of social distancing once on board. Ideally, masks should be worn during the flight. Additionally, for those with international destinations, most countries now require a negative polymerase chain reaction COVID-19 test within a specified time frame for entry.

Essentially the safest place for your patients during the holidays is celebrating at home with their household contacts. The risk for disease acquisition increases with travel. You will not have the opportunity to discuss holiday plans with most parents. However, you can encourage them to consider the pros and cons of travel with reminders via telephone, e-mail, and /or social messaging directly from your practices similar to those sent for other medically necessary interventions. As for me, I will be celebrating virtually this year. There is a first time for everything.

For additional information that also is patient friendly, the Centers for Disease Control and Prevention offers information about travel within the United States and international travel.
 

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

As an East Coast transplant residing in Texas, I look forward to the annual sojourn home to celebrate the holidays with family and friends – as do many of our patients and their families. But this is 2020. SARS-CoV-2, the causative agent of COVID-19, is still circulating. To make matters worse, cases are rising in 45 states and internationally. The day of this writing 102,831 new cases were reported in the United States. As we prepare for the holidays, it is time to rethink how safe it is to travel and/or gather with people who do not live in our household.

Social distancing, wearing masks, and hand washing have been strategies recommended to help mitigate the spread of the virus. We know adherence is not always 100%. The reality is that several families will consider traveling and gathering with others over the holidays. Their actions may lead to increased infections, hospitalizations, and even deaths. It behooves us to at least remind them of the potential consequences of the activity, and if travel and/or holiday gatherings are inevitable, to provide some guidance to help them look at both the risks and benefits and offer strategies to minimize infection and spread.
 

What should be considered prior to travel?

Here is a list of points to ponder:

• Is your patient is in a high-risk group for developing severe disease or visiting someone who is in a high-risk group?
• What is their mode of transportation?
• What is their destination?
• How prevalent is the disease at their destination, compared with their community?
• What will be their accommodations?
• How will attendees prepare for the gathering, if at all?
• Will multiple families congregate after quarantining for 2 weeks or simply arrive?
• At the destination, will people wear masks and socially distance?
• Is an outdoor venue an option?

All of these questions should be considered by patients.
 

Review high-risk groups

In terms of high-risk groups, we usually focus on underlying medical conditions or extremes of age, but Black and LatinX children and their families have been diagnosed with COVID-19 and hospitalized more frequently than other racial/ ethnic groups in the United States. Of 277,285 school-aged children infected between March 1 and Sept. 19, 2020, 42% were LatinX, 32% White, and 17% Black, yet they comprise 18%, 60%, and 11% of the U.S. population, respectively. Of those hospitalized, 45% were LatinX, 22% White, and 24% Black. LatinX and Black children also have disproportionately higher mortality rates.

Think about transmission and how to mitigate it

Many patients erroneously think combining multiple households for small group gatherings is inconsequential. These types of gatherings serve as a continued source of SARS-CoV-2 spread. For example, a person in Illinois with mild upper respiratory infection symptoms attended a funeral; he reported embracing the family members after the funeral. He dined with two people the evening prior to the funeral, sharing the meal using common serving dishes. Four days later, he attended a birthday party with nine family members. Some of the family members with symptoms subsequently attended church, infecting another church attendee. A cluster of 16 cases of COVID-19 was subsequently identified, including three deaths likely resulting from this one introduction of COVID-19 at these two family gatherings.

In Tennessee and Wisconsin, household transmission of SARS-CoV-2 was studied prospectively. A total of 101 index cases and 191 asymptomatic household contacts were enrolled between April and Sept. 2020; 102 of 191 (53%) had SARS-CoV-2 detected during the 14-day follow-up. Most infections (75%) were identified within 5 days and occurred whether the index case was an adult or child.

Lastly, one adolescent was identified as the source for an outbreak at a family gathering where 15 persons from five households and four states shared a house between 8 and 25 days in July 2020. Six additional members visited the house. The index case had an exposure to COVID-19 and had a negative antigen test 4 days after exposure. She was asymptomatic when tested. She developed nasal congestion 2 days later, the same day she and her family departed for the gathering. A total of 11 household contacts developed confirmed, suspected, or probable COVID-19, and the teen developed symptoms. This report illustrates how easily SARS-CoV-2 is transmitted, and how when implemented, mitigation strategies work because none of the six who only visited the house was infected. It also serves as a reminder that antigen testing is indicated only for use within the first 5-12 days of onset of symptoms. In this case, the adolescent was asymptomatic when tested and had a false-negative test result.
 

Ponder modes of transportation

How will your patient arrive to their holiday destination? Nonstop travel by car with household members is probably the safest way. However, for many families, buses and trains are the only options, and social distancing may be challenging. Air travel is a must for others. Acquisition of COVID-19 during air travel appears to be low, but not absent based on how air enters and leaves the cabin. The challenge is socially distancing throughout the check in and boarding processes, as well as minimizing contact with common surfaces. There also is loss of social distancing once on board. Ideally, masks should be worn during the flight. Additionally, for those with international destinations, most countries now require a negative polymerase chain reaction COVID-19 test within a specified time frame for entry.

Essentially the safest place for your patients during the holidays is celebrating at home with their household contacts. The risk for disease acquisition increases with travel. You will not have the opportunity to discuss holiday plans with most parents. However, you can encourage them to consider the pros and cons of travel with reminders via telephone, e-mail, and /or social messaging directly from your practices similar to those sent for other medically necessary interventions. As for me, I will be celebrating virtually this year. There is a first time for everything.

For additional information that also is patient friendly, the Centers for Disease Control and Prevention offers information about travel within the United States and international travel.
 

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

As an East Coast transplant residing in Texas, I look forward to the annual sojourn home to celebrate the holidays with family and friends – as do many of our patients and their families. But this is 2020. SARS-CoV-2, the causative agent of COVID-19, is still circulating. To make matters worse, cases are rising in 45 states and internationally. The day of this writing 102,831 new cases were reported in the United States. As we prepare for the holidays, it is time to rethink how safe it is to travel and/or gather with people who do not live in our household.

Social distancing, wearing masks, and hand washing have been strategies recommended to help mitigate the spread of the virus. We know adherence is not always 100%. The reality is that several families will consider traveling and gathering with others over the holidays. Their actions may lead to increased infections, hospitalizations, and even deaths. It behooves us to at least remind them of the potential consequences of the activity, and if travel and/or holiday gatherings are inevitable, to provide some guidance to help them look at both the risks and benefits and offer strategies to minimize infection and spread.
 

What should be considered prior to travel?

Here is a list of points to ponder:

• Is your patient is in a high-risk group for developing severe disease or visiting someone who is in a high-risk group?
• What is their mode of transportation?
• What is their destination?
• How prevalent is the disease at their destination, compared with their community?
• What will be their accommodations?
• How will attendees prepare for the gathering, if at all?
• Will multiple families congregate after quarantining for 2 weeks or simply arrive?
• At the destination, will people wear masks and socially distance?
• Is an outdoor venue an option?

All of these questions should be considered by patients.
 

Review high-risk groups

In terms of high-risk groups, we usually focus on underlying medical conditions or extremes of age, but Black and LatinX children and their families have been diagnosed with COVID-19 and hospitalized more frequently than other racial/ ethnic groups in the United States. Of 277,285 school-aged children infected between March 1 and Sept. 19, 2020, 42% were LatinX, 32% White, and 17% Black, yet they comprise 18%, 60%, and 11% of the U.S. population, respectively. Of those hospitalized, 45% were LatinX, 22% White, and 24% Black. LatinX and Black children also have disproportionately higher mortality rates.

Think about transmission and how to mitigate it

Many patients erroneously think combining multiple households for small group gatherings is inconsequential. These types of gatherings serve as a continued source of SARS-CoV-2 spread. For example, a person in Illinois with mild upper respiratory infection symptoms attended a funeral; he reported embracing the family members after the funeral. He dined with two people the evening prior to the funeral, sharing the meal using common serving dishes. Four days later, he attended a birthday party with nine family members. Some of the family members with symptoms subsequently attended church, infecting another church attendee. A cluster of 16 cases of COVID-19 was subsequently identified, including three deaths likely resulting from this one introduction of COVID-19 at these two family gatherings.

In Tennessee and Wisconsin, household transmission of SARS-CoV-2 was studied prospectively. A total of 101 index cases and 191 asymptomatic household contacts were enrolled between April and Sept. 2020; 102 of 191 (53%) had SARS-CoV-2 detected during the 14-day follow-up. Most infections (75%) were identified within 5 days and occurred whether the index case was an adult or child.

Lastly, one adolescent was identified as the source for an outbreak at a family gathering where 15 persons from five households and four states shared a house between 8 and 25 days in July 2020. Six additional members visited the house. The index case had an exposure to COVID-19 and had a negative antigen test 4 days after exposure. She was asymptomatic when tested. She developed nasal congestion 2 days later, the same day she and her family departed for the gathering. A total of 11 household contacts developed confirmed, suspected, or probable COVID-19, and the teen developed symptoms. This report illustrates how easily SARS-CoV-2 is transmitted, and how when implemented, mitigation strategies work because none of the six who only visited the house was infected. It also serves as a reminder that antigen testing is indicated only for use within the first 5-12 days of onset of symptoms. In this case, the adolescent was asymptomatic when tested and had a false-negative test result.
 

Ponder modes of transportation

How will your patient arrive to their holiday destination? Nonstop travel by car with household members is probably the safest way. However, for many families, buses and trains are the only options, and social distancing may be challenging. Air travel is a must for others. Acquisition of COVID-19 during air travel appears to be low, but not absent based on how air enters and leaves the cabin. The challenge is socially distancing throughout the check in and boarding processes, as well as minimizing contact with common surfaces. There also is loss of social distancing once on board. Ideally, masks should be worn during the flight. Additionally, for those with international destinations, most countries now require a negative polymerase chain reaction COVID-19 test within a specified time frame for entry.

Essentially the safest place for your patients during the holidays is celebrating at home with their household contacts. The risk for disease acquisition increases with travel. You will not have the opportunity to discuss holiday plans with most parents. However, you can encourage them to consider the pros and cons of travel with reminders via telephone, e-mail, and /or social messaging directly from your practices similar to those sent for other medically necessary interventions. As for me, I will be celebrating virtually this year. There is a first time for everything.

For additional information that also is patient friendly, the Centers for Disease Control and Prevention offers information about travel within the United States and international travel.
 

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.