Bernard A Cohen, MD, is the section editor for Dermcase and professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Bernard A Cohen, MD

The parents of a 3-month-old girl seek medical advice regarding recent seizures and a facial birthmark. The dark pink lesion was noted to cover most of her face at birth. It grew in proportion to the child’s growth and became slightly darker. The infant had a seizure 1 month ago and has experienced 2 more since then.

Diagnosis: Sturge-Weber syndrome with a port-wine stain and seizures

Physical examination revealed a sharply demarcated dark pink blanching patch covering entire right side of face and left cheek. Eye examination revealed dilated blood vessels in right eye. There is no family history of neurocutaneous disorders or seizures.

Sturge-Weber syndrome (SWS), also known as encephalotrigeminal angiomatosis, is a sporadic congenital neurocutaneous disorder belonging in the phakomatoses group.

 It consists of hamartomatous vascular malformations that can affect the skin, eye, and central nervous system.

Typical manifestations include facial port-wine stains (PWS) which represent capillary vascular malformations, ocular-glaucoma, seizures, intellectual disability, and ipsilateral leptomeningeal angioma.

 Seizures are the most common neurological symptom and usually manifest in infancy.

 Glaucoma may be congenital or present later in life.

SWS is caused by a somatic activating mutation in the GNAQ gene located on chromosome 9.

 The gene product is a member of the Gαq family, a class of G protein alpha subunits that mediate signals between G-protein-coupled receptors and downstream effectors in different transmembrane signaling pathways.

 The activating GNAQ mutation in SWS increases signal transmission through RAS effector pathways.

 Capillary malformations (PWS) and leptomeningeal angiomatosis associated with SWS, start in the fetal stage and may be caused by the failure of the primitive cephalic venous plexus to regress.

The prevalence of SWS is around 1 in every 20,000 to 50,000.

 It affects both sexes equally and does not demonstrate a racial predisposition.

 PWS, a congenital capillary malformation, is the predominant dermatological feature and most frequent finding of the disease, and a child born with a PWS has a 6% chance of having SWS.

 The risk rises to 26% when the PWS is located in the ophthalmic branch of trigeminal nerve distribution.

 More recent data shows that embryologic patterns that involve the scalp, forehead, nose, and upper cheeks may be a better predictor of SWS symptoms than trigeminal nerve distribution alone.

SWS is classified into three types: type 1 with facial PWS and leptomeningeal angiomatosis, with or without glaucoma; type 2 with facial PWS and no leptomeningeal involvement, with or without glaucoma; and type 3 (least common) with only presence of leptomeningeal angiomatosis and absence of PWS and glaucoma.

The differential diagnosis for SWS includes Klippel-Trenaunay-Weber’s syndrome, Rendu-Osler-Weber’s Syndrome, Maffuci’s syndrome, and Beckwith-Wiedmann’s syndrome.

 Klippel-Trenaunay-Weber’s syndrome is characterized by a triad of PWS, varicose veins, and bony and soft tissue hypertrophy in extremities.

 Rendu-Osler-Weber’s syndrome, also known as hereditary hemorrhage telangiectasis, is characterized by vascular dysplasia in blood vessels.

 Maffuci’s syndrome presents with asymmetric enchondromas and hemangiomas that manifest as blue subcutaneous nodules.

 Beckwith-Wiedmann’s syndrome is an overgrowth syndrome, and capillary malformations in forehead and upper eyelid presents with a lesion similar to PWS.

Standard treatment for SWS includes laser treatment for port-wine stain, anticonvulsants, and medical treatment for glaucoma.

Surgical interventions like glaucoma surgery and procedures for neurological symptoms (e.g., lobectomy, vagal nerve stimulation) may be necessary with time.

 Topical sirolimus is an effective treatment for PWS, while oral sirolimus is a potential treatment for cognitive impairment and epilepsy associated with SWS.

 Counseling and physiotherapy is also helpful, while educational therapy is prescribed for children with intellectual disability or developmental delays.

The patient’s parents were informed that the child has SWS and that prognosis varies for SWS patients on an individual basis, depending on the degree of leptomeningeal involvement and severity of glaucoma. There is a greater likelihood of intellectual disability with treatment-resistant seizures. Life expectancy is normal. It is recommended that the patient undergoes routine monitoring to evaluate for glaucoma and other symptoms.

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Articles

The parents of a 3-month-old girl seek medical advice regarding recent seizures and a facial birthmark. What’s the diagnosis?

Facial birthmark and new-onset seizures in infant

A healthy 14-year old boy was evaluated for an intensely pruritic shin rash (Figure) that developed 2 weeks prior and had been treated with oral antibiotics for 10 days. On examination, the rash appeared more severe, with discrete, confluent, crusted, red papules and plaques on the shins, with relative sparing of the knees and ankles, progressing to the trunk and parts of the face and ears. He was upset because the rash interfered with his ability to play soccer.

Additional history taken from the patient’s father revealed that the boy was a goalkeeper on his school soccer team. The father explained that the inner lining of the boy’s protective shin guards was frayed. Owing to the initial location of the eruptions and lack of improvement on antibiotics, a diagnosis of allergic contact dermatitis due to a component of the shin guards was suspected. The dissemination of the rash was caused by autoeczematization. Patch testing to standard allergens and components of the patient’s soccer shin guards was planned.

Diagnosis: Shin guard allergic contact dermatitis to acetophenone azine now with generalized autoeczematization

Contact dermatitis is a common inflammatory skin condition characterized by erythematous, scaly, crusted, pruritic, and/or painful skin lesions after contact with a foreign substance. The condition can be irritant or allergic. Irritant contact dermatitis is caused by nonimmune-modulated chemical damage to the skin. Allergic contact dermatitis is a delayed hypersensitivity reaction (type 4) to contact antigens, and skin changes occur with reexposure.

Autoeczematization, or id reaction, is a disseminated eczematous reaction that occurs when the antigen is released after exposure to a stimulus at a primary site, with the reaction spreading to distant sites.

When determining the diagnosis, irritant contact dermatitis due to friction and sweat generally comes to mind first. However, the reaction is typical of allergic contact dermatitis, and this patient’s history favors the contact allergen acetophenone azine, a relatively new allergen, from his shin guards. The differential also includes atopic dermatitis, fungal infection, and psoriasis. The differences in the presentation of irritant and allergic contact dermatitis are summarized in the Table.

When must one suspect acetophenone azine contact dermatitis? The distribution of the primary rash and history of fraying shin guards should make this a high priority. Patch testing with a piece of the shin guard and the specific allergen, if available, should be considered and is recommended when avoiding the suspected allergen fails to bring improvement.

Avoidance of the allergen is the mainstay of prevention of recurrent allergic contact dermatitis. In this case, using shin guards and shoes made of other materials and/or placing barriers between the skin and the shin guards can help treat the patient and confirm the diagnosis. Acetophenone azine is presently unavailable as a commercial patch-test preparation.

Cool compresses and calamine lotion can soothe the acute symptoms. Localized lesions are often successfully treated with mid- or high-potency topical steroids, such as triamcinolone 0.1% or clobetasol 0.05% applied twice a day for 2 to 3 weeks.

If allergic contact dermatitis involves an extensive area of skin, the symptoms are extremely severe, or there is autoeczematization, systemic steroid therapy is often required and generally offers relief within 12 to 24 hours. If the allergen is removed and no effective therapy is instituted, it can take 2 to 3 weeks for the reaction to resolve, so an initial course of at least 5 to 7 days of prednisone, 0.5 to 1 mg/kg daily, is recommended. The dose may be tapered over the next 7 to 10 days.

With severe dermatitis, oral prednisone should be tapered over 2 to 3 weeks with emollients and cool compresses with high-potency topical steroids applied to the worst areas. Emollients, moisturizers, or barrier creams are secondary treatment to help avoid continued exposure.

A case report published in 2016 recognized the occurrence of severe, dramatic shin contact dermatitis in a young football player that progressed to generalized dermatitis.

 On further investigation and patch testing, acetophenone azine was found to be the culprit. High-performance liquid chromatography (HPLC) identified the chemical substance at concentrations of approximately 20 μg/g of shin pad samples. Patch tests gave strongly positive reactions to pieces of shin pads and to acetophenone azine down to dilutions of 0.001% in acetone.

It was later recognized the potent new allergen caused rash even on exposure to footwear containing ethylene vinyl acetate (EVA).

 Acetophenone azine is not a component that is directly added to EVA during the manufacture of shin guards, shoe insoles, flip-flops, and other athletic gear and footwear. Though the exact chemical reactions that lead to its formation are unknown, it is presumed that it is due to cross-reactions with other materials added during EVA synthesis.

 Acetophenone azine may arise from the degradation of dicumyl peroxide and hydrazine in the foaming agent azodicarbonamide.

On patch testing with materials including rubber, plastic, and shavings from the inner foam lining the shin guards, the only positive reaction was to the foam shavings that contained EVA. This material was sent to a laboratory, where HPLC revealed the allergen to be acetophenone azine.

The antibiotic was continued for 4 more days, and oral prednisone at 1 mg/kg/day was added. He improved dramatically over the next 48 to 72 hours, at which point the antibiotics were discontinued. The prednisone was tapered over the next 10 days.

1. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. 

2. Bertoli MJ, Schwartz RA, Janniger CK. Autoeczematization: a strange id reaction of the skin. 

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3. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. In: Usatine RP, Smith MA, Mayeaux EJ, Chumley H Jr, Tysinger J, eds. 

4. American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology. Contact dermatitis: a practice parameter

2006;97(3 suppl 2):S1-S38. Published correction appears in 

5. Raison-Peyron N, Bergendorff O, Bourrain JL, Bruze M. Acetophenone azine: a new allergen responsible for severe contact dermatitis from shin pads. 

 2016;75(2):106-110. doi:10.1111/cod.12579

6. Raison-Peyron N, Bergendorff O, Du-Thanh A, Bourrain JL, Bruze M. Two new cases of severe allergic contact dermatitis caused by acetophenone azine. 

 2017;76(6):380-381. doi:10.1111/cod.12777

7. De Fré C, Bergendorff O, Raison-Peyron N, et al. Acetophenone azine: a new shoe allergen causing severe foot dermatitis. 

 2017;77(6):416-417. doi:10.1111/cod.12843

8. Darrigade AS, Raison-Peyron N, Courouge-Dorcier D, et al. The chemical acetophenone azine: an important cause of shin and foot dermatitis in children. 

9. Acetophenone azine: The 2021 American Contact Dermatitis Society Allergen of the Year. 

 2021;107(5):238-240.doi:10.12788/cutis.0252

A healthy 14-year old boy was evaluated for an intensely pruritic shin rash that developed 2 weeks prior and had been treated with oral antibiotics for 10 days. 

A case of shin guard dermatitis?

Diaper dermatitis is a common presentation seen in dermatology. The differential diagnosis is broad and varies based on numerous risk factors, including patient age, gastrointestinal disorders, diaper hygiene practices, diaper breathability, and genetics. It is essential that pediatricians and dermatologists recognize the various forms of diaper dermatitis to effectively diagnose and treat it. The following 5 instructive cases of diaper dermatitis include the differential diagnosis (Table) and treatment options.

This 18-month-old boy with a family history of psoriasis presented for evaluation of an erythematous rash on the scrotum, suprapubic skin, and perineum, consistent with infantile psoriasis. Similar to adult psoriasis, infantile psoriasis presents as well-defined, often symmetrically dis- tributed erythematous papules and plaques. In contrast to psoriasis in adults, psoriatic plaques in childhood tend to be thinner, smaller, and less scaly and are more likely to develop on the face, trunk, and flexural areas, although they can develop on any skin area. In young children, infantile psoriasis is often diagnosed with a diaper rash that is unresponsive to irritant diaper dermatitis treatment.

 Psoriasis affects approximately 2% to 3% of the population worldwide, and it is estimated that up to half of cases begin before age 20 years. The incidence increases with age. Results of one study showed that the total rate of psoriasis in children under 18 years old was 0.71%, with rates increasing linearly from 0.12% at 1 year of age to 1.2% by 18 years.

 Findings of another study were similar, showing a prevalence of 0.55% in children aged 0 to 9 years compared with 1.37% in patients aged 10 to 19 years.

 Making a diagnosis of psoriasis is often more difficult in children because of atypical characteristics. Lesions in children may be thinner, softer, less scaly, and less well-defined than in adults.

 The differential diagnosis should include tinea corporis/cruris, atopic or nummular dermatitis, irritant contact dermatitis, seborrheic dermatitis, 

 dermatitis, and inverse pityriasis rosea.

Diagnosis of infantile psoriasis is often clinical and, in unclear cases, can be aided by biopsy; however, biopsy is often not necessary and should be avoided in uncomplicated cases. Histology is similar to that of adult psoriasis and would reveal neutrophils overlying parakeratosis, loss of the granular cell layer, variable spongiosis, and elongated rete ridges.

 First-line therapy for infantile psoriasis is topical corticosteroids. Medium- to high-potency topical steroids can be used up to 4 weeks during the initial flare and then up to 2 weeks for subsequent flares.

 Using topical corticosteroids in combination and rotation with nonsteroidal topicals such as topical calcineurin inhibitors, vitamin D analogues, tar, and keratolytics can optimize efficacy while reducing the risk of adverse effects. It is important to know the ages of approval for steroid-sparing agents. Calcipotriene is approved for children 4 years or older, and topical calcineurin inhibitors are approved for patients 2 years or older. Crisaborole (Eucrisa) can be considered in patients 3 months or older. Phototherapy can also be considered for extensive or refractory disease. For moderate to severe plaque psoriasis in children, systemic therapy should be considered. Etanercept (Enbrel) is approved for children 4 years or older; ustekinumab (Stelara), ixekizumab (Taltz), and secukinumab (Cosentyx) are all approved for children 6 years or older. Studies have shown significant improvements in quality of life and psoriasis area and severity index scores for children with moderate to severe plaque psoriasis on systemic immunomodulators.

 Pediatricians should monitor patients for comorbidities associated with psoriasis, including obesity, hypertension, hyperlipidemia, rheumatoid arthritis, and diabetes. The patient in the vignette responded well to topical steroids.

This 6-month-old girl presented with an erosive diaper rash following diarrhea with viral gastroenteritis. These findings were consistent with Jacquet erosive diaper dermatitis. Jacquet dermatitis is a rare, severe form of irritant diaper dermatitis characterized by ulcerated or eroded papules and nodules in the genital and perianal areas. It is typically associated with frequent loose stools, infrequent diaper changes, and poor hygiene. It is also more common in patients with chronic diarrhea or incontinence.

Milder forms of irritant diaper dermatitis often occur in infants with short episodes of loose stools associated with viral gastroenteritis and administration of oral antibiotics for otitis media and other infections. The differential diagnosis for severe erosive diaper dermatitis includes perianal pseudoverrucous papules and nodules, granuloma gluteale infantum, diaper dermatitis with superimposed bacterial and fungal infections, cutaneous Crohn disease, Langerhans cell histiocytosis, and acrodermatitis enteropathica.

 Secondary infection with Candida and bacteria is common in Jacquet dermatitis. Potassium hydroxide (KOH) preparation and bacterial culture can be performed to help guide antimicrobial therapy. If the patient fails to respond to therapy or has systemic findings, biopsy and additional laboratory tests may be indicated.

Jacquet dermatitis treatment is similar to that of uncomplicated irritant diaper dermatitis, with the goal to reduce contact of the skin to urine and feces. This is accomplished through frequent diaper changes, use of diapers lined with absorbent gel materials, and application of barrier ointments. Low-potency topical steroids can also be used to reduce inflammation. Topical antifungal/antibacterial agents may be required in the case of secondary infection. Severe cases may require oral antibiotics and/or oral corticosteroids.

This 7-month-old boy was brought to the clinic for pustules in the diaper area. These findings were consistent with staphylococcal pustulosis, a relatively uncommon manifestation of infection with 

. It can be difficult to diagnose because there is a wide differential for pustular eruption in infants, which includes both infectious and noninfectious etiologies. It is important to be able to distinguish benign causes from more serious causes that require additional management.

Noninfectious causes of pustules in an infant include erythema toxicum neonatorum, transient neonatal pustular melanosis, neonatal acne, and neonatal pustular psoriasis.

 In this case, some of those conditions could be ruled out based on timing. Erythema toxicum neonatorum typically affects full-term infants and presents within 1 to 2 days of birth. It is self-limited and usually resolves by 2 weeks of age. Neonatal pustular melanosis affects 0.2% to 4% of neonates, with a higher prevalence in Black babies. It usually occurs within a few days of birth and resolves spontaneously over a few weeks. Neonatal acne and pustular psoriasis have a wider range of age presentations. Neonatal acne presents as pustules as well as open and closed comedones that are usually limited to the face. It can occur within 3 to 16 months of age, although it usually appears within 3 to 6 months and resolves by 3 to 4 years. Neonatal pustular psoriasis is rare but can occur at any age and has a varied presentation. Pustules typically develop symmetrically and can occur on any area of the body, with a predilection for the diaper area and skinfolds.

Infectious causes include herpes simplex infection and candidiasis. Cutaneous manifestations of vertical herpes simplex virus (HSV) infection have been reported but are relatively rare and occur within a few days of life. Anogenital HSV infection in older babies and toddlers is also rare; it has additional implications and can be a sign of abuse. Candidiasis usually presents on a base of erythema with erythematous macular satellite lesions, neither of which is seen in this case.

To confirm the diagnosis, Gram stain and culture of the pustule fluid can be performed. Gram stain is often negative even in the setting of positive cultures and should not be used alone to rule out staphylococcal pustulosis. HSV polymerase chain reaction can be performed concomitantly if suspected.

 Biopsy typically does not play a role in the diagnosis of staphylococcal pustulosis. Although biopsy is often not performed for these lesions, histology would show subcorneal pustules with neutrophils and acantholysis.

 Limited skin disease can be treated with topical mupirocin ointment. The patient in the vignette responded well to this regimen. Patients with systemic symptoms or more widespread disease may require a course of oral antibiotics. Penicillinase-resistant antibiotics such as amoxicillin are usually sufficient. Methicillin-resistant 

 (MRSA) is relatively uncommon in children. However, coverage for MRSA with antibiotics such as clindamycin and trimethoprim/sulfamethoxazole should be considered in regions with high resistance rates.

This 3-month-old boy presented for evaluation of an erythematous rash in a diaper distribution; findings were consistent with seborrheic dermatitis. This benign, self-limited condition presents as salmon-colored plaques with greasy scales and typically occurs within the first 3 months of life. Unlike seborrheic dermatitis in adults, which takes on a chronic course, seborrheic dermatitis in children is self-limited and usually resolves without treatment within the first 9 to 12 months of life. Many parents are familiar with the term cradle cap, which is infantile seborrheic dermatitis of the scalp, but the condition can also present on the face, axillae, inguinal folds, and trunk. When it occurs on the face, it tends to involve the eyebrows, nasolabial folds, and hairline. Lesions on the trunk usually involve the lower abdomen and are more sharply demarcated than those seen elsewhere on other body.

 The differential diagnosis for symmetric, well- demarcated erythematous patches and plaques on a baby’s lower abdomen includes psoriasis, candidiasis, atopic dermatitis, contact dermatitis, and nutritional deficiency. Contact dermatitis is less likely when the skinfolds are affected. It is often difficult to distinguish atopic from seborrheic dermatitis in young children, and there can be overlap of the 2 conditions. However, seborrheic dermatitis is not usually pruritic, and atopic dermatitis typically spares the groin and axillae in young children.

 Diagnosis is usually made by history and physical exam alone. In cases where the diagnosis is not clear or the patient has an unusually prolonged course or lack of response to treatment, biopsy can be performed. Seborrheic dermatitis and psoriasis have similar histopathological findings, with a few key differences. Mounds of parakeratosis with neutrophils and clubbed and evenly elongated rete ridges are seen more often in psoriasis. Neutrophilic follicular scale/crust, shoulder parakeratosis, and lymphocytic exocytosis are seen more often in seborrheic dermatitis.

 A KOH preparation can be performed to rule out candidiasis. Patients with infantile seborrheic dermatitis are otherwise healthy and do not require additional laboratory monitoring.

 The mainstay of treatment for seborrheic dermatitis in infants consists of emollients that help loosen the scale, which can then be gently wiped away with a cloth. Because this is a self-limited disease that resolves without treatment, the risk to benefit ratio of additional therapies needs to be considered. Furthermore, treatments for seborrheic dermatitis in children have not been studied extensively for safety or efficacy, and it is unclear whether these interventions alter the course of the condition.

 Short courses of low-potency topical steroids also can be used. Calcineurin inhibitors and antifungal shampoos are not approved for use in children younger than age 2 years, so they should be avoided. The patient in the vignette responded well to emollients and topical steroids. He was able to discontinue therapy and did not have recurrence on follow-up a few months later.

Figure 5. Candidiasis with irritant dermatitis and candidiasis pustules

This girl between 5 and 6 months of age presented with a red rash in a diaper distribution. Findings showed erythematous papules coalescing into plaques, satellite lesions, and a few scattered pustules consistent with candidiasis, which usually presents as red erythematous papules, plaques, and peripheral satellite lesions in the groin with a predilection for skinfolds. Pustules, vesicles, and erosions can also be seen.

 The differential diagnosis for an erythematous rash with plaques, papules, and pustules in a diaper distribution includes psoriasis and contact dermatitis.

For this case, KOH preparation was performed and showed yeast and pseudohyphae. Although biopsy is often not required, histology would show neutrophils and vertically oriented pseudohyphae in the stratum corneum. Crusting and hyperkeratosis are also commonly seen.

Treatment with anticandidal antifungals such as nystatin and clotrimazole is required to achieve clearance. This patient responded well to topical antifungals and barrier cream therapy. Parents also can be educated to use breathable disposable diapers to reduce the rate of recurrence—the survival of 

 is reduced more than 50% in breathable vs nonbreathable diapers.

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Diaper dermatitis is common and the differential diagnosis is broad. Here are 5 cases that illustrate the various diagnoses that fall within this spectrum.

Looking at the spectrum of diaper dermatitis

Pediatric dermatology involves not only treating patients’ skin but also managing the psychosocial impact a disease has on children and their families, which can be significant. Many skin conditions have a quality-of-life (QOL) effect similar to that of systemic diseases such as renal disease, cystic fibrosis, and asthma.

 Skin diseases also can have emotional and social repercussions on the parents and caregivers of children with dermatology disorders.

 For pediatricians to provide optimal patient care, family support is essential.

The widely used Children’s Dermatology Life Quality Index (CDLQI), which was developed in 1995, gives the practitioner an understanding of QOL issues in children aged 4 to 16 years.

 The latest cartoon version is easier and faster for children to complete and was shown to have a score similar to the original scale.

 The questionnaire, which uses a recall period of 1 week, assesses various issues including feelings of sadness or self-consciousness, impact on friendships, bullying as a result of the disease, effects on going out or playing sports, interference with sleep, and response to treatment.

 Based on the scoring of the responses, the effect on QOL is stratified as none (0-1), small (2-6), moderate (7-12), very large (13-18), or extremely large (19-20).

 Findings from a 2016 meta-analysis of all studies using CDLQI, which included data from 7798 children with more than 20 conditions, concluded that most skin diseases have a major impact on QOL in a small proportion of children.

 However, further review of the literature demonstrates that skin disease has a significant impact for many children and their families.

Disease-specific scoring systems have also been developed, such as the Cardiff Acne Disability Index, the Psoriasis Area Severity Index (PASI) and Physician Global Assessment, the Infants’ Dermatology Quality of Life, the Childhood Atopic Dermatitis Impact Scale, the Quality of Life Index for Atopic Dermatitis, and the Dermatitis Family Impact questionnaire.

 These scoring systems not only help with assessing severity of disease but also give insight into QOL issues that are important for physicians to address.

This brief review discusses the QOL impact of a number of skin conditions compared with other chronic systemic diseases.

Psoriasis is a chronic inflammatory disease of autoimmune etiology that is not completely curable. Seen in an estimated 0.7% of children, psoriasis has a negative impact on QOL for not only children but also their parents and caregivers, even in the presence of mild disease.

 Results show that 36% of parents and caregivers of children with psoriasis have anxiety and depressive symptoms.

Compared with systemic diseases using the corresponding Children’s Life Quality Index (CLQI), psoriasis was found to have a greater impairment in QOL com- pared with enuresis, diabetes, and epilepsy.

 Psoriasis was also found to have a negative influence on physical activity, self-esteem, bullying, and stigmatization.

Investigators of another study concluded that improvement in CDLQI scores to imply no effect (0-1) was associated with a PASI score of > 90%, (a decrease in body surface area [BSA] involvement). As a consequence, this may be advised as a reasonable therapeutic goal. It was also noted that systemic therapy including biological and conventional drugs has a better outcome compared with topical agents.

Thus, physicians are advised to follow a combined approach including clinical therapy and QOL assessment to evaluate improvement or impairment, family counseling, and support.

With an estimated in- creasing global prevalence of 15.5% to 20.0% among children,

 atopic dermatitis (AD) is a chronic skin disease with relapses and remissions characterized by a wide array of clinical presentations that vary with age, environmental triggers, and genetic predisposition. The impact on QOL was found to be greater in children with AD compared with children with systemic diseases including renal disease, cystic fibrosis, asthma, and chronic urticaria.

 AD commonly arises in early childhood, with hallmark pruritic lesions that often worsen at night. Those with active AD alone had nearly 50% greater odds of reporting sleep-quality disturbances throughout childhood compared with 80% of children who also had asthma and/or allergic rhinitis. Consequently, early diagnosis and therapeutic interventions are needed to address QOL issues.

Recent findings also revealed a relative risk of 1.4 for learning disabilities among children with AD, an association independent of sociodemographic factors and other atopic and neurodevelopmental disorders.

 Significant positive association of atopic disease and childhood AD with memory impairment, developmental delay, and cognitive dysfunction has also been identified.

 and as one of the most common skin conditions among adolescents (findings reveal prevalence from 35% to close to 100%), acne vulgaris is rightly described this way by Sulzeberger and Zaidens: “There is probably no single disease which causes more psychic trauma, more maladjustment between parents and children, more general in- security and feeling of inferiority and greater sums of psychic suffering than does acne vulgaris.”

The point estimate from 5 studies using the CDLQI to assess QOL in children with acne is 5.37; that corresponds to a small impact, but research results reveal a significant impact in terms of self-esteem, relationships, and body image.

 Further, it is noted that children with truncal and facial acne were twice as likely to report the impact as “very large” or “extremely large” on the CDLQI questionnaire compared with children with only facial acne.

Acne profoundly affects self-perception, socialization, emotional health, and occupational opportunities as well as body dissatisfaction.

 It is also associated with depression and suicidal ideation.

 With these factors in mind, it is crucial for the primary care physician to provide not only dermatological care but also psychological support and counseling.

The most common cause of depigmentation worldwide, vitiligo is an acquired disorder of unknown origin and undoubtedly immunologically mediated. The disease is associated with widespread stigmatization and psychological impairment.25 Investigators who used the CDLQI questionnaire to assess QOL impairment reported a median score of 3.0.26 They also found that nearly 45.6% of children aged 0 to 6 years and 50% of participants aged 7 to 14 years were not bothered by the lesions, but 95.9% of adolescents aged 15 to 17 years were troubled. Involvement of the face and legs was most bothersome for parents. The authors concluded that self-consciousness, difficulty with friendships and schoolwork, and teasing and bullying were associated with lesions involving more than 25% BSA. Lesions on the face and arms were associated with teasing and bullying.26 Further, other investigators reported that 42% of caregivers of pediatric patients with vitiligo were reported to have anxiety symptoms, whereas 26% had depression.9

Thus, to improve QOL and create a safe environment for children with vitiligo, it is important to not only provide care for these patients and their parents but also play a larger role in educating and sensitizing the public and peer groups in schools and communities to destigmatize the condition.

A skin condition of viral etiology, molluscum contagiosum most commonly affects children. It is commonly asymptomatic but may present with erythema and pruritus. On some occasions, bacterial superinfections with pain and inflammation may be seen.27

In a British study the mean time to resolution was 13.3 months which confirms its chronic nature and the need to consider impact on QOL.28 Molluscum contagiosum had a small effect on quality of life for most participants, although for 33 (11%) of 301 participants it had a very severe effect (CDLQI score >13). A greater number of lesions and secondary infection was associated with a greater effect on quality of life (H=55.8, p<0.0001).

In conclusion, 1 in 10 children with molluscum contagiosum is likely to have a major issue with their QOL, and treatment should be considered for these children especially those with a large number of lesions at visible sites. It is also important to reassure parents about the course of their children’s disease.

The human papillomavirus causes warts, a benign, common skin disease that may appear on any part of the body. Per the CDLQI scoring, in children who had lesions greater than 6 months, it was seen that nearly a third had a small effect on QOL, whereas in 5% of the children, warts had an extremely large effect. It was also noted that the greatest negative effect was seen on the symptoms and feeling scores.29

The dermatology QOL indices clearly demonstrate the importance of early diagnosis and treatment of skin disease in children. As a result, practitioners should have a low threshold to refer patients early in their course for diagnosis and management of persistent dermatologic findings.

1.Beattie PE, Lewis-Jones MS. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. Br J Dermatol. 2006;155(1):145-151. doi:10.1111/j.1365-2133.2006.07185.x

2.Vivar KL, Kruse L. The impact of pediatric skin disease on self-esteem. Int J Womens Dermatol. 2017;4(1):27-31. doi:10.1016/j.ijwd.2017.11.002

3.Pustišek N, Vurnek Živković M, Šitum, M. Quality of life in families with children with atopic dermatitis. Pediatr Dermatol. 2016;33(1):28-32. doi:10.1111/pde.12698

4.Lewis-Jones MS, Finlay AY. The Children’s Dermatology Life Quality Index (CDLQI): initial validation and practical use. Br J Dermatol. 1995;132(6):942-949. doi:10.1111/j.1365-2133.1995.tb16953.x

5.Holme SA, Man I, Sharpe JL, Dykes PJ, Lewis-Jones MS, Finlay AY. The Children’s Dermatology Life Quality Index: validation of the cartoon version. Br J Dermatol. 2003;148(2):285-290. doi:10.1046/j.1365-2133.2003.05157.x

6.Waters A, Sandhu D, Beattie P, Ezughah F, Lewis-Jones S. Severity stratification of Children’s Dermatology Life Quality Index (CDLQI) scores. Br J Dermatol. 2010;163(suppl 1):121.

7.Olsen JR, Gallacher J, Finlay AY, Piguet V, Francis NA. Quality of life impact of childhood skin conditions measured using the Children’s Dermatology Life Quality Index (CDLQI): a meta-analysis. Br J Dermatol. 2016;174(4):853-861. doi:10.1111/bjd.14361

8.Augustin M, Langenbruch AK, Gutknecht M, Radtke MA, Blome C. Quality of life measures for dermatology: definition, evaluation, and interpretation. Curr Derm Rep. 2012(l):148-159. doi:10.1007/s13671-012-0020-z

9.Chernyshov PV. The evolution of quality of life assessment and use in dermatology. Dermatology. 2019;235(3):167-174. doi:10.1159/000496923

10. de Jager ME, van de Kerkhof PC, de Jong EM, Seyger MM. A cross-sectional study using the Children’s Dermatology Life Quality Index (CDLQI) in childhood psoriasis: negative effect on quality of life and moderate correlation of CDLQI with severity scores. Br J Dermatol. 2010;163(5):1099-1101. doi:10.1111/j.1365-2133.2010.09993.x

11. Salman A, Yucelten AD, Sarac E, Saricam MH, Perdahli-Fis N. Impact of psoriasis in the quality of life of children, adolescents and their families: a cross-sectional study. An Bras Dermatol. 2018;93(6):819-823. doi:10.1590/abd1806-4841.20186981

12. Manzoni AP, Weber MB, Nagatomi AR, Pereira RL, Townsend RZ, Cestari TF. Assessing depression and anxiety in the caregivers of pediatric patients with chronic skin disorders. An Bras Dermatol. 2013;88(6):894-899. doi:10.1590/abd1806-4841.20131915

13. Bruins FM, Bronckers IMGJ, Groenewoud HMM, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. Association between quality of life and improvement in psoriasis severity and extent in pediatric patients. JAMA Dermatol. 2020;156(1):72-78. doi:10.1001/jamadermatol.2019.3717

14. Gonzalez J, Cunningham K, Perlmutter J, Gottlieb A. Systematic review of health-related quality of life in adolescents with psoriasis. Dermatology. 2016;232:541-549. doi:10.1159/000450826

15. Gilaberte Y, Pérez-Gilaberte JB, Poblador-Plou B, Bliek-Bueno K, Gimeno-Miguel A, Prados-Torres A. Prevalence and comorbidity of atopic dermatitis in children: a large-scale population study based on real-world data. J Clin Med. 2020;9(6):1632. doi:10.3390/jcm9061632

16. Nutten S. Atopic dermatitis: global epidemiology and risk factors. Ann Nutr Metab. 2015;66(suppl 1):8-16. doi:10.1159/000370220

17. Ramirez FD, Chen S, Langan SM, et al. Association of atopic dermatitis with sleep quality in children. JAMA Pediatr. 2019;173(5):e190025. doi:10.1001/jamapediatrics.2019.0025

18.Wan J, Shin DB, Gelfand JM. Association between atopic dermatitis and learning disability in children. J Allergy Clin Immunol Pract. 2020;8(8):2808-2810. doi:10.1016/j.jaip.2020.04.032

Acne, molluscum, atopic dermatitis, and other dermatological disorders can be detrimental to quality of life for children and their families.

Bernard A Cohen, MD

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