Howard Fischer, MD

In the course of studying azithromycin as a treatment for pityriasis rosea (PR),

 which we found does not work, we collected much data on the distribution, morphology, and course of the lesions.

 We also amassed many photos, some of which appear in this Photo Essay. These photos highlight the various presentations of PR in African American children, which we discovered are often different from the standard “textbook” descriptions.

Figure 1 – The herald patch on the neck and classic lesions on the back of this patient are characteristic of pityriasis rosea.

We followed the natural history of PR in 50 African American children in the United States.

 The data included the presence and location of a herald patch, duration of lesions, number of lesions, types and distribution of lesions, and presence of pruritus. The PR lesions involved the trunk in all patients, neck in 44%, face in 30%, arms and forearms in 60%, thighs and legs in 54%, pelvis or groin in 12%, and scalp in 8%. Almost all (90%) of our patients had pruritus. See 

 for the clear-cut differences between our results and what pediatricians read in textbooks about PR. It is worth keeping in mind that the usual description of PR applies mainly to white patients.


1. Amer A, Fischer H. Azithromycin does not cure pityriasis rosea. 

. 2006;117:1702-1705.
2. Amer A, Fischer H, Li X. The natural history of pityriasis rosea in black American children: how correct is the “classic” description? 

Articles

In the course of studying azithromycin as a treatment for pityriasis rosea (PR) which we found does not work, we collected much data on the distribution, morphology, and course of the lesions.

Pityriasis Rosea in Dark-Skinned Children

“If You Open Your Mind Too Much, Your Brain Will Fall Out”

Warning: this is a column about political correctness. If you find it impossible to be judgmental in any situation, or are incapable of offering decisive opinions about anything, you are advised to go no further-your feelings will be hurt.

The way in which some people currently assess blame is a path containing at least 3 steps. These steps range from the useful to the ridiculous-from an approach to improving care that takes human tendencies and weaknesses into consideration (Step 1) to the dangerous denial of reality that leads to persistent pernicious pollyannaism (Step 3). Following this path will ultimately lead to our brains falling out.

Don't blame people: things are poorly designed


Human factors engineering is the intersection of engineering, psychology, and medicine. It seeks to improve care and reduce errors by simplifying and standardizing systems (eg, having all the items in all the crash carts in an institution standardized in dose, size, and location in the drawer), reducing noise, improving lighting, and providing backup and needed redundancy (eg, having an auditory alarm on a monitor backed up by flashing lights, even multicolored lights). Human factors engineering is valuable and logical. It can save lives.

Don't blame anyone: the system is at fault


Now we are on shakier ground. This philosophy may sometimes be seen in action at hospital morbidity and mortality (M & M) conferences. These conferences discuss errors of commission or omission which led-or might have led-to patient illness or death. The purpose of these conferences is to prevent recurrences of errors by educating the providers of medical care. Thus, it is patient safety that is the concern here. Blame is often cast upon “the system” (eg, the computer system, the system of signing out patients to the next shift, or the system of training physicians). However, what if there are persons who deserve some blame? If you ask this question at an M & M conference, you are considered, at best, a dinosaur and a victim of outdated thinking. At worst, you are-gasp!-politically incorrect.

No one is to blame, and there is nothing to blame


Before elaborating on this category, I would like to offer a prejudice of mine. Many people who go into medicine are peculiar, and those who go into academic medicine are the most peculiar of all. At a recent faculty meeting at a medical school pediatric department, it was noted that some attending physicians were responding neither appropriately nor politely to resident phone calls. This was a problem. The leader of the meeting clarified, before the discussion could start, that “there are no bad guys.” Huh? Who can pretend that in a room full of division chiefs, for example, there is not one smiling back-stabber, one individual with the massive ego of a 3-year-old, and several prima donnas? As H. L. Mencken said, “It is a sin to believe evil of others, but it is seldom a mistake.” If, in fact, there are no bad guys, why did Moses (if you believe this) have to bring down the Ten Commandments from Mount Sinai? Why did the Catholic Church (if you believe this) need to establish a hierarchy of sins? Why did we need trials at Nuremberg? And which non-bad guys authorized the continuation of the Tuskegee syphilis study into the 1970s?

It is nice to look at the world as free of human error; however, we must acknowledge that sometimes we do make mistakes and deserve some blame. To say otherwise is careless communication. Sloppy speech is a reflection of sloppy thinking. Pollyannas need to read George Orwell’s 

 (1946). Orwell wrote, “If you simplify your English, you are freed from the worst follies of orthodoxy…and when you make a stupid remark its stupidity will be obvious, even to yourself. Political language-and with variations this is true of all political parties, from Conservatives to Anarchists-is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind. One cannot change all this in a moment, but one can at least change one’s own habits.”

Down with political correctness, in medicine and elsewhere.

Assigning Blame in Medicine: Where Are We Headed?

An 11-day-old African American boy was brought in for a well-baby visit. Pregnancy, labor, and delivery had been uncomplicated. He had bilateral ulnar supernumerary digits, which had been suture-ligated on day 2 of life. The digits had autoamputated, but necrotic stumps remained. His mother stated that he was irritable and cried whenever these remnants were touched. The necrotic stumps were removed in the office, under local anesthesia, with a scalpel.

Polydactyly-the presence of an extra finger or toe-is a common minor malformation. The frequency of polydactyly in African Americans is 13.9 per 1000 births; this is 9 times the frequency seen in US whites.

 Postaxial polydactyly (also called ulnar polydactyly) is the most common type and refers to duplication of the little finger. In type A postaxial polydactyly, the extra digit is fully developed. In type B postaxial polydactyly, the extra digit is rudimentary and pedunculated (

The usual method of treating type B postaxial polydactyly in the newborn is suture ligation at the base of the pedicle, which produces necrosis and autoamputation. The most recent editions of 2 standard pediatric textbooks advise this approach.

However, several treatment options are available for a neonate in whom type B postaxial polydactyly is discovered. These include:
•cNo treatment (which is not really an option).
• Suture ligation.
• The use of local anesthesia and simple excision with scalpel or scissors.
• Surgical division of the pedicle with attentive transection of the accessory digital nerve branches, followed by skin closure.

Although suture ligation is simple to perform, it does have the potential for complications. Frieden and colleagues5 describe an infected ligated supernumerary digit, and one report mentions a necrosed digit that remained attached a month after ligation.

 A residual bump at the site of ligation was found in 43% of patients examined at an average of 20 months of age.

Another possible complication of suture ligation is the development of an amputation neuroma at the ligation site.

 Leber and Gosain6 describe the operative and histological findings of neuroma in 3 children who had had 5 supernumerary digits ligated. Two of the patients presented with pain at the neuroma site. When the authors examined the parents and grandparents of children referred for treatment of supernumerary digits, they found at least 8 adults with sequelae of digit ligation. These adults, and an additional adult in another report,

 had at least 1 of the following in the vestigial remnant: 
"discomfort on pressing or hitting the remnant, . . . tingling, . . . and intermittent bleeding or ulceration." Leber and Gosain

 thus conclude that the true incidence of neuroma formation following suture ligation of pedunculated supernumerary digits in infancy may be much higher than previously thought." Amputation neuromas arise, according to Leber and Gosain,

 because ligation does not properly treat the digital nerve that is always present in the supernumerary digit. The authors explain why ligation predisposes to neuroma formation: "When nerve tissue is cut the Schwann cell-endoneural barrier is disrupted, allowing the axons to regenerate in a disorganized fashion. The regenerating axons are often surrounded by connective tissue, further disorganizing the regenerate. If a nerve lies too near the end of the stump . . . it is subject to repeated trauma from pressure, [and] friction. . . . This leads to increased edema and fibrosis of the nerve, leading to increased sensitivity." Thus, to prevent the development of amputation neuromas, one must avoid cutting or ligating a nerve at skin level.


Leber and Gosain6 prefer the last of the above options: they recommend dissecting the nerve free from the surrounding tissue before transection and then placing traction on the nerve while transection is performed. They note that this method allows the nerve to retract into a bed of healthy soft tissue away from the surface of the amputated stump. In fact, they consider simple excision to have as much potential for complication as does ligation.

Growing Support for Surgical Excision Opinions


on the question of ligation versus surgical excision do appear to be shifting. A survey of 149 pediatricians and neonatologists in the United Kingdom revealed that 79% would refer a child with type B postaxial polydactyly to a hand surgeon, 15% would ligate, and 5% would use excision.

 We found 3 articles recommending primary surgical excision,

 as well as a similar statement in the recent (2009) American Academy of Pediatrics' textbook, 

Another article advises caution in using ligation because of a "high rate of complications" (even though the complications referred to were most likely cosmetic).

 advise using local anesthetic and iris scissors. Still, the only prospective study on the subject recommends suture ligation.


We consider necrosis a poorly controllable surgical instrument. We cannot prove the superiority of local anesthetic and scalpel excision, but while we wait for a trial comparing treatment techniques, we suggest that clinicians use the latter approach. This obviates the need to perform the procedure in the operating room while eliminating the risk of infection that is always associated with tissue necrosis.

Genetic Variation and Disorders in Peoples of African Origin

. Baltimore: Johns Hopkins University Press; 1990:270-271.
 2. Watson BT, Hennrikus WL. Postaxial type-B poly- dactyly. Prevalence and treatment. J Bone Joint Surg  Am. 1997;79:65-68.
 3. Cornwall R. Upper limb. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia: Saunders; 2007:2826-2827.
 4. Mehlman CT. Upper extremity problems. In: Rudolph CD, Rudolph AM, Hostetter MK, et al, eds. RudolphÃs Pediatrics. 21st ed. New York: McGraw-Hill; 2003:2449.
 5. Frieden IJ, Chang MW, Lee I. Suture ligation  of supernumerary digits and ÃtagsÃ: an outmoded practice? Arch Pediatr Adolesc Med. 1995;149:1284.
 6. Leber GE, Gosain AK. Surgical excision of  pedunculated supernumerary digits prevents traumatic amputation neuromas. Pediatr Dermatol. 2003;20:108-112. 
7. Heras L, Barco J, Cohen A. Unusual complication of ligation of a rudimentary ulnar digit. J Hand Surg Br. 1999;6:750-751.
 8. Hartzell TL, Taylor H. Traumatic amputation of a supernumerary digit: a 16-year-old boyÃs perspective of suture ligation. Pediatr Dermatol. 2009;26:100-102.
 9. Dodd JK, Jones PM, Chinn DJ, et al. Neonatal  accessory digits: a survey of practice amongst  paediatricians and hand surgeons in the United Kingdom. Acta Paediatr. 2004;93:200-204.
 10. Trevino JJ, Bakos MA, Janik MP. Neonatal skin. In: McInerny TK, Adam HM, Campbell D, et al, eds. Pediatric Primary Care. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:783. 11. Rayan GM, Frey B. Ulnar polydactyly. Plast  Reconstr Surg. 2001;107:1449-1454.

An 11-day-old African American boy was brought in for a well-baby visit. Pregnancy, labor, and delivery had been uncomplicated.

To Tie or Not to Tie: The Dilemma of the Supernumerary Digit

When I was growing up in Brooklyn in the 1950s, kids started their preparations for Halloween after dinner on October 31. We would find an old mask, or make one out of a paper bag; wealthier kids might buy one. I would grab a pillowcase to hold my "loot" and take off. Neighbors would give us store-bought candy or homemade cookies or cupcakes. It didn't occur to anyone that an unwrapped, unsealed item could be dangerous. Older kids were the real danger: they would steal our goodies and often beat us up.

 Fast-forward 50 years. The average American, according to 

Most of this money is spent on costumes, including costumes for pets. The holiday of Halloween, an ancient pagan festival that later was made to coincide with the eve of All Saints' Day ("All Hallow Even"), seems to induce a decorating and partying mania in adults. Other than the abundance of tombstones, dismembered limbs, and skeletons on people's lawns, are there some substantial reasons to dislike Halloween?

Candies that contain foreign bodies (eg, pins, razor blades) may be what parents first think of, but incidents of candy-tampering are extremely rare. The x-raying of Halloween candy has a very low yield. Moreover, it is an expensive process (costing, on average, more than $3 to scan a single child's bag of candy), produces unnecessary crowds in radiology departments, and may even disrupt hospital functioning.

However, Halloween does pose several very real dangers to children. Eye injuries, some serious, have been seen in the United States and the United Kingdom as a result of eggs thrown on Halloween. Sorbitol-sweetened candies, when eaten in excess, may produce diarrhea. More college students who wear costumes to Halloween parties drink alcohol than do students who don't come in costume.

What is most worrisome is that children are 4 times more likely to be hit and injured by a car on Halloween than they are on any other night. There is also a 4-fold increase in deaths of child pedestrians on Halloween, compared with other nights.

I know Halloween is not going to go away. I know that children love trick-or-treating. I'd just like to see adults supervise their children better to prevent serious injuries that night. Would it be too much to also ask them to take some of that ugly stuff off their lawns?

Kramer L. Where the jack-o'-lanterns are only the beginning. 

Miller KA, Jasper CR, Hill DR. Dressing in costume and the use of alcohol, marijuana, and other drugs by college students. 

Centers for Disease Control and Prevention (CDC). Childhood pedestrian deaths during Halloween-United States, 1975-1996. 

Howard Fischer, MD

Articles

Pityriasis Rosea in Dark-Skinned Children

Assigning Blame in Medicine: Where Are We Headed?

To Tie or Not to Tie: The Dilemma of the Supernumerary Digit

Halloweenmania