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SheandaThambyrajah, MD, Resident, Loyola University

Articles

The patient described the headache as “pressure-like,” episodes that occurred for 1 to 2 hours with high severity.

A headache with a red flag in a 10-year-old girl

. He joined the brand in March of 2023 as an editor before being promoted to senior editor in January 2024. Fitch graduated from Youngstown State University in Youngstown, Ohio in 2020 with a degree in telecommunications and journalism. He started his career as a news and sports videographer before becoming an on-air sports anchor at the NBC-affiliated news station in Youngstown. Fitch briefly worked as a national content writer for a Chicago-based national television station before joining the 

team. He can be reached at: jfitch@mjhlifesciences.com.

 and joined the MJH Life Sciences team in December 2019. She graduated from Youngstown State University in 2019 with a bachelor's degree in journalism and a minor in political science. Prior to graduating, Morgan worked as the editor-in-chief of her college newspaper. She went on to work as an assignment editor at a broadcast news station in Youngstown, Ohio before joining 

 You can reach her at mpetronelli@mjhlifesciences.com.

Lenacapavir is the first twice-yearly option available in the US for those who need or want PrEP, according to Gilead Sciences. 

FDA approves twice-yearly lenacapavir as PrEP for HIV in adolescents, adults 

Currently, omaveloxolone (Skyclarys) is approved to treat adults and adolescents aged 16 years and older impacted by FA.

Phase 3 trial of omaveloxolone to treat Friedreich ataxia in children aged 2 to <16 begins

The American Academy of Pediatrics urges clinicians to offer confidential, adolescent-centered contraceptive care using evidence-based, equity-informed approaches.

AAP updates guidance on contraception for adolescents

Contemporary Pediatrics connects pediatricians with peer-reviewed articles, guideline updates, and practice strategies for real-world clinical application.

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**Editor's Note** Please note that starting January 1, 2025, we will be switching to an online-exclusive publication process. This will allow us to publish case submissions quicker without having to deal with the variables that come along with print publication. All cases will still be eligible for print publication consideration, but publication in our print magazine is not guaranteed and will be up to the editor's discretion. 

Do you have a puzzling pediatric case that you’d like to share with the readers of 

We are looking for intriguing diagnoses that have stumped the experts—a diagnostic “Puzzler”—to help our physicians enhance their day-to-day practices. If you have such a story to tell, tell us.

Here’s what to do: Before you begin, we suggest that first you review the Puzzler 

https://www.contemporarypediatrics.com/case-studies

. Please note the specific style required for writing Puzzler manuscripts.

Next, prepare a draft of your case, including a summary of the presenting symptoms, a case overview, a 

table of the differential diagnosis (MANDATORY)

, and the special aspects of your case that qualify it as a Puzzler, and send it to us. Please note that the differential diagnosis table should also be discussed in the body text. We’ll review your draft and let you know what you need to add or revise before we send the manuscript to peer review for evaluation.

Puzzlers vary in length, and we suggest a minimum of 1,200 words up to a maximum of 2,000 words, but that is because of the complexity of some cases and whether some patients returned for many assessments before their diagnoses were determined. Also, some authors describe the pathophysiology of the differentials in great detail. Please also note no more than 3 authors are allowed per article.

What's most important is to show us the process that you used to analyze the case, including:

Why you decided to order certain tests and why you did not order others.

Peer consultations or why you elected to contact other specialists.

Lab values including vital signs or blood tests.

Labs and values if your patient was attended to in the emergency department or other hospital departments such as radiology or neurology.

Discussion related to the possible diagnoses.

Final diagnosis, treatment, prognosis, and follow-up.

Remember to indicate numbered citations within the body of the text and include a complete list of corresponding literature/references at the end of the manuscript. (Do not use any citation management programs or unlink them.) 

Limit references to 25. No references (unless it is a seminal study) can be older than 10 years.

We prefer primary research as references, but some cases are so obscure that authors will need to pull from a variety of sources. However, 

. Be advised that peer reviewers are adamant that the disease/disorder you describe was actually diagnosed and not determined by index of suspicion on the basis of ruling out various differentials. We use AMA11 as our publication style, which uses superscript citation numbers and a corresponding numbered reference list. Please create your citations and references in this style.  Check this recent article posted online at 

https://www.contemporarypediatrics.com/view/the-rx-of-adhd

 for examples of reference style. IMPORTANT NOTE WITH AMA 11TH EDITION: PLEASE PUT DOI OR WEBSITES/URLS AT THE END OF THE REFERENCE LINE.

When you send your draft manuscript, also 

. These image files must be high-resolution jpg or tiff files (minimum of 300 dpi) and as large in size as possible. We suggest a minimum of 7 horizontal inches. The images must be original photos with clear permissions to use, not images from copyrighted sources. Send as separate attachments with your e-mail submission; do not embed images into your manuscript document.

After we receive your manuscript, our editors and peer reviewers will review your draft and let you know if we accept your submission for publication. 

Puzzler is one of the departments for which we receive the most submissions, so it may be several months after submission before you receive feedback from us.

If we do accept your submission for publication, we will contact you with further instructions.

Send your submissions in Microsoft Word format to 

, via e-mail to mpetronelli@mjhlifesciences.com

Guidelines for PUZZLER, Contemporary Pediatrics

 poll. Take a look at the following case below. After reading through the description, choose a multiple choice answer and try to guess the correct patient diagnosis. 

 on Monday, March 24, 2025 at 12:00 PM ET or later for the full case presentation, differential diagnoses, and the correct patient diagnosis. 

This case was provided by Muhammad Aamir Anees and Bernard A. Cohen, MD

Want more puzzler and dermatology cases? 

A healthy 9-year-old girl developed an asymptomatic eruption of discrete and confluent, 2 to 3 mm, hypopigmented papules in a linear pattern along the lines of Blaschko on the back of her left thigh and leg over the past 3 weeks. The lesions cleared without treatment 4 to 5 months later. 

Inflammatory linear verrucous epidermal nevus

on Monday, March 24, 2025 at 12:00 PM ET or later for the full case presentation, differential diagnosis, and correct patient diagnosis.

Take your best guess and try to diagnose this 9-year-old girl's linear eruption on the back of her left thigh and leg. Stay tuned for the full case presentation and correct diagnosis! 

News

Case Studies

Poll: What's the diagnosis of this linear eruption on the leg of a 9-year-old girl?

John Browning, MD, FAAD, FAAP discusses the FDA approval of tapinarof cream, 1% to treat atopic dermatitis

FDA approves tapinarof cream, 1% for atopic dermatitis patients 2 years and up

Organon's tapinarof cream, 1% (VTAMA), an aryl hydrocarbon receptor agonist, once-daily, steroid-free topical cream, has been approved by the FDA to treat atopic dermatitis in patients aged 2 years and up, according to a press release from Organon.

"It's rare to first of all, have a steroid free option, but also to have something that's going to work in a completely different mechanism," John Browning, MD, FAAD, FAAP, in the above interview with 

Browning is a board-certified pediatric and adult dermatologist in San Antonio, Texas, and is an assistant professor at the Baylor College of Medicine, as well as the chief of Dermatology at the Children's Hospital of San Antonio. 

"Instead of just blocking inflammation, with tapinarof we're actually seeing the epidermal barrier, so your skin integrity improves with it," said Browning. "The other thing that's unique is the ability to go through these disease free intervals, [basically] a time when the skin clears up. It's very exciting to have a steroid free option for treating atopic dermatitis aged 2 and up." 

The supplemental New Drug Application and subsequent approval by the federal agency was based on data from the 

ADORING 1 (NCT05014568) and ADORING 2 (NCT05032859)

 phase 3 trials. The trials are identical, double-blind, randomized, and vehicle-controlled, with a primary endpoint being a Validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD) score of clear (0) or almost clear (1) with at least a 2-grade improvement from baseline at week 8.

In ADORING 1, adult and pediatric participants aged 2 years and up with moderate to severe AD were randomized (2 to 1) to receive once-daily tapinarof or vehicle cream. By week 8, 45.4% of participants that received tapinarof achieved the primary endpoint of a vIGA-AD score of 0 or 1 with at least a 2-grade improvement from baseline. In the trial, 55.8% of tapinarof users achieved the key secondary endpoint of the proportion of participants with a 75% or greater improvement in the Eczema Area and Severity Index (EASI75) from baseline at week 8 (

A significant improvement in itch was observed in study participants 12 years and older that received tapinarof. Of these participants with a Peak Pruritus Numeric Rating Scale (PP-NRS) score of 4 or greater at baseline, 61.1% achieved a 4-point or greater reduction in the PP-NRS at week 8 (

 = 0.0366), another key secondary endpoint of the study.

“VTAMA cream approval in AD is important because it can be prescribed for children as young as 2 years old. VTAMA cream has the potential to bring much needed relief to a significant number of children suffering from this disease,” said Adelaide A. Hebert, MD, Professor and Chief of Pediatric Dermatology at McGovern Medical School at UTHealth Houston and Children’s Memorial Hermann Hospital and lead investigator for the ADORING program, in a press release.

"Moreover, because the prevalence of itch makes this condition extremely burdensome to patients and their families, the itch data from the ADORING program demonstrates reduction of one of the condition’s most prevalent symptoms with use of VTAMA cream," said Hebert.

In January of 2024, Organon announced data

 from an interim analysis of the ADORING 3 open-label, long-term extension study to evaluate the safety and efficacy of tapinarof cream 1% in AD patients for up to 48 weeks, as well as an integrated analysis of data that included 711 patients from the ADORING 1 and 2 trials.

In the integrated analysis, 73% (519/711) of patients achieved a vIGA-AD™ score of 0 (clear) or 1 (almost clear) with at least a 2-grade improvement from baseline.

Interim analysis for ADORING 3 revealed that 51.2% achieved complete disease clearance (vIGA-AD score: 0).

In October 2023, Dermavant released new pruritus data for tapinarof cream, 1% that revealed a greater reduction in itch as early as 24 hours after first application in children as young as 2 years of age with AD.

"Overall, these results show a rapid reduction in itch as early as 24 hours after first application of tapinarof, with a consistent improvement in itch through week 8," Eric Simpson, MD, MCR, professor, Frances J. Storrs Medical Dermatology, director, CLEAR Eczema Center, Oregon Health & Science University, told 

"Itch remains the most burdensome and prevalent symptoms of atopic dermatitis, and these results highlight the potential of tapinarof as a clinically meaningful therapy with the ability to reduce itch for adults and children living with atopic dermatitis," said Simpson.

Click here for full 24-hour application results and full commentary from Simpson.

"I've had patients that looked like they really needed a systemic agent, one of the injectable biologics, and they were able to go into the study, and it was incredible to see the results at the end of the study in terms of having clear skin, itch reduction, and just having happy patients," said Browning.

"I really hope that this can become a first line agent that people are comfortable prescribing, whether they're dermatology, pediatric dermatology, or primary care, and that's because of the great safety profile and efficacy that it provides," concluded Browning.

Tapinarof cream, 1% was approved by the FDA to treat plaque psoriasis in adults in May of 2022.

The most common adverse reactions occurring in ≥1% of patients in the pivotal trials were: upper respiratory tract infection; red raised bumps around the hair pores (folliculitis); lower respiratory tract infection; headache; asthma; vomiting; ear infection; pain in extremity; and stomach-area (abdominal) pain.

1. FDA Approves VTAMA® (tapinarof) cream, 1% for the Treatment of Atopic Dermatitis in Adults and Children 2 Years of Age and Older. Organan. Press release. December 16, 2024. Accessed December 16, 2024. https://www.organon.com/news/fda-approves-vtama-tapinarof-cream-1-for-the-treatment-of-atopic-dermatitis-in-adults-and-children-2-years-of-age-and-older/

2. Fitch, J. FDA accepts sNDA for tapinarof cream, 1% to treat AD in children 2 years and up. 

. April 29, 2024. https://www.contemporarypediatrics.com/view/fda-accepts-snda-for-tapinarof-cream-1-to-treat-ad-in-children-2-years-and-up

3. Fitch, J. Tapinarof cream 1% demonstrates positive topline results for treating pediatric AD.  

. May 16, 2023. https://www.contemporarypediatrics.com/view/tapinarof-cream-1-demonstrates-positive-topline-results-for-treating-pediatric-ad

4. Fitch, J. New topline phase 3 data for tapinarof cream 1% to treat AD in children. 

. January 11, 2024. https://www.contemporarypediatrics.com/view/new-topline-phase-3-data-for-tapinarof-cram-1-to-treat-ad-in-children

"I really hope this becomes a first-line agent that people are comfortable prescribing whether they are in dermatology, pediatric dermatology, or primary care."

Michael O. Daines, MD, outlines key diagnostic criteria and treatment challenges for pediatric acute-onset neuropsychiatric syndrome (PANS), emphasizing the need for multidisciplinary care and improved treatment access.

  Michael Daines, MD, discusses pediatric acute-onset neuropsychiatric syndrome

Primary care providers may be the first line of defense for children with pediatric acute-onset neuropsychiatric syndrome (PANS), but diagnosing and managing the condition can present significant challenges, according to Michael O. Daines, MD, division chief of Pediatric Allergy and Immunology at the University of Arizona College of Medicine.

“I think there are 3 main hurdles that people in primary care hit with this disease,” Daines said. “The first is recognition,and if you can't find it, you can't treat it.”

PANS is a clinical diagnosis characterized by a sudden onset of obsessive-compulsive disorder (OCD) or severe food restriction, accompanied by at least 2 additional neuropsychiatric symptoms, according to Daines. These can include anxiety, mood changes, regression of skills, sleep disturbances, urinary symptoms, and movement or sensory issues.

“All of these things can be normal or caused by other things in children,” Daines explained. “So it is also essentially a diagnosis of exclusion, where you have to rule out other medical conditions before you go forward. The second threshold you really hit is trying to find a treatment team that is willing to take care of these kids,” he said. “They have a bio-behavioral background, so there are very few doctors that are good at treating both the immunology and the behavioral components.”

Successful management of PANS typically requires a multidisciplinary approach that incorporates both medical and behavioral therapies. In Daines’ clinic, this includes outreach to community pediatricians to help guide treatment for milder cases.

“A lot of the milder cases can be treated with other anti-inflammatories—things like naproxen—and treatment of infections that may be triggering the illness,” he said.

Ultimately, Daines encouraged general pediatricians to remain alert to sudden behavioral or psychiatric shifts in patients and to feel confident initiating a workup. 

Beverly P Giordano, RN, MS, CPNP, PPCMHS

Articles

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