Adolescent Medicine: State of the Art Reviews is the official Journal of the AAP Section on Adolescent Health Care. This issue is a compendium of topics that affect the skin of adolescents. During medical visits, adolescents may or may not ask questions about their skin concerns; however, their self-esteem and well-being may be significantly interconnected to those very concerns. Acne, for example, has documented effects on self-esteem in adolescents. The authors have compiled reviews of a variety of dermatologic topics for this issue. We hope to provide the readers with a source for diagnostic pearls andupdates on therapy for these topics.
About the Author
Author: American Academy of Pediatrics Section on Adolescent Health The American Academy of Pediatrics Section on Adolescent Health (SOAH), founded in 1978, brings together both general pediatricians interested in adolescent health issues as well as adolescent medicine specialists. It provides an educational and networking forum with the goal of improving and enhancing the care of the adolescent population. The SOAH executive committee leadership works closely with the AAP Committee on Adolescence (COA) to bring policy and education together, both for providers and for the families/adolescents they serve.
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Adolescent Medicine: State Of The Art Reviews Adolescent Dermatology April 2011 ? Volume 22 ? Number 1
By Patricia A. Treadwell
American Academy of PediatricsCopyright © 2011 American Academy of Pediatrics
All rights reserved.
Dermatoses in Adolescents of Color
Daneeque Woolfolk, BS, Patricia A. Treadwell, MD
Patients from ethnic backgrounds are presenting with cutaneous disorders common to the population at an increasing frequency. The epidemiology of skin disorders in African-Americans, Hispanic, Asian, and Native American populations has not been widely studied. However, a few retrospective studies have demonstrated that disorders commonly occurring in this demographic include eczematous dermatitis, acne vulgaris, postinflammatory hyperpigmentation, melasma, tinea capitis, pityriasis rosea, acne keloidalis nuchae, scalp and facial folliculitis, traction alopecia, keloidal scarring, and infection (bacterial, viral, or fungal). These dermatoses pose certain challenges for the clinician because patients with them may have unique presentations, may have adverse reactions to treatment modalities, and may exhibit distinctive pigmentary changes as a result of the skin disease and or treatment.
A review of skin histology by La Ruche and Cesarini revealed that there is no variation in structure between skin of color and that of Caucasian skin. The differences noted in African-American skin were (1) increased lipid content of the epidermis; (2) more compact stratum corneum; and (3) higher electrical resistance. These differences are thought to account for decreased permeability of African-American skin to chemicals and less hydration than Caucasian skin.
ACNE KELOIDALIS NUCHAE
Acne keloidalis nuchae (AKN) is an eruptive disorder of the occipital scalp and nape of the neck, presenting primarily in individuals of African descent. It is seen less often in those of Hispanic and Asian descent and rarely in Caucasians. Khumalo et al found the prevalence of AKN to be 1.3% to 13.7% in 3 studies of people of African ancestry. Most cases occur in individuals aged 14 to 25, with males being affected more often than females in a ratio of 20:1. This disorder can be psychologically devastating for patients due to the cosmetic disfigurement that can occur.
Acne keloidalis nuchae is thought to be initiated by close shaving of the neck, constant irritation from clothing, or trauma from other sources such as picking, rubbing, or scratching. Firm, follicular based papules and pustules 2 to 4 mm in size develop first. They may be associated with burning, pain, and bleeding when disturbed. Untreated papules and pustules may later coalesce into plaques that are keloid-like and may be as large as 10 cm in diameter. A scarring alopecia may develop at the site of plaque formation (Fig 1).
Herzberg et al proposed a series of events that occur in the pathophysiology of AKN. An acute perifollicular inflammation occurs due to external irritation, resulting in a weakening of the follicular wall. The naked hair shaft present in the dermis acts as a foreign body to cause acute and chronic granulomatous inflammation leading to the papules and pustules. Persistent inflammation results in deposition of collagen and occlusion of the follicle, thus causing retention of the hair shaft in inferior part of the follicle, perpetuating granulomatous inflammation and scarring.
Initial treatment of AKN involves patient education about how to avoid friction, including discouraging close shaving of hair. Topical corticosteroids, topical antibiotics, and the use of retinoids are first-line treatments of papules and pustules. Callender et al in an open-label study of 20 patients demonstrated that topical clobetasol propionate foam, utilized in a pulsed-dose regimen, was effective in improving total papule and pustule count and symptoms of pruritus and burning in AKN. In addition, steroid shampoos such as fluocinolone acetonide may be helpful. Other treatment modalities include cryotherapy and intrale- sional steroids.
Surgical excision is the treatment of choice for extensive AKN lesions. Studies have shown that secondary intention healing, as compared with primary closure, produces more cosmetically acceptable results and less recurrence. Glosterdemonstrated good to excellent cosmetic results in 25 patients using primary closure after excision. However, 15 patients had recurrence of tiny pustules and papules in the first 4 months, with 5 patients developing hypertrophic scars. Bajaj et al used closure by secondary intention healing and demonstrated in a case series the achievement of good cosmesis and no recurrence at 14 and 18 months postoperatively. Other modalities used include hair epilation treatments. Shah demonstrated a 90% to 95% clearance of papules in 2 cases of AKN treated with 4-monthly laser hair epilation treatments along with the daily use of topical tretinoin and nightly use of betamethasone cream.
Kawasaki disease (KD) is an acute vasculitis affecting medium-sized muscular arteries. It is recognized as the most common cause of acquired heart disease in children in the United Kingdom and United States. The etiology of the condition has not been determined. It is thought that superantigens may play a role in the pathogenesis of KD, although this is still controversial. The highest incidence of KD is seen in Japanese and Korean children; intermediate incidence in African-American, Hispanic, Chinese, Filipino, and Polynesian children; and lowest incidence in Caucasian children.
Diagnosis and Complications
Kawasaki disease is most common in young children, although it may present in adolescents. Diagnosis is based on clinical findings. Criteria for the diagnosis of KD include 1 mandatory criterion: fever persisting 5 days or more, and at least 4 of the remaining criteria: polymorphous exanthema, conjunctival injection, erythema of the lips and oral pharynx, strawberry tongue, lymphadenopathy, and erythema and swelling of the palms and soles with later desquamation. Cardiac complications of KD, presenting as coronary artery aneurysms, are a significant source of morbidity and mortality. Risk factors associated with cardiac complications include age less than 1 year or between 9 and 17 years, male gender, and Hispanic, Asian, or Pacific Islander ethnicity.
A retrospective study of 85 patients with KD in a high-prevalence African-American population found that coronary artery complications occurred less frequently compared with Caucasians. Another case series by Porcalla et al identified 2 independent variables predictive of development of coronary artery aneurysms: duration of fever prior to diagnosis and African-American ethnicity. It is thought that African-American ethnicity may play a protective role regarding cardiac complications.
Therapy should be initiated early in the course of KD. The foundation of therapy consists of aspirin and intravenous immunoglobulin. High-dose aspirin is begun initially at 30 to 100 mg/kg/day for its antiinflammatory properties, and then transitioned to a lower antiplatelet dose of 3 to 8 mg/kg/day upon the abatement of fever. Aspirin therapy has no impact on the development of cardiac complications. Intravenous immunoglobulin (IVIG), in a single infusion of 2 g/kg should be administered in the first 10 days of illness, although the patient may need an additional infusion if treated prior to day 5 of the disease. The total IVIG dose has the greatest impact on the development of coronary artery aneurysms. The use of corticosteroids may be considered in the treatment of KD resistant to IVIG therapy; however, this subject remains controversial.
Lichen striatus (LS) is a relatively frequent, self-limited skin condition with an unknown etiology. It presents along Blaschko lines as flat-topped, grouped erythematous papules arranged in a linear or whorled pattern. They may be scaly or associated with vesicles. The most common presentation of LS is on the extremities, with more than half of such occurrences appearing on the legs. Lesions also may appear in other locations. Patients with skin of color may present primarily with hypopigmented papules. Lichen striatus usually resolves within 6 to 24 months. There may be transitory postinflammatory hypopigmentation in darker-skinned patients.
Lichen striatus affects children between the ages of 5 and 15. Some studies have shown predilection for occurrence in females, while others show equal prevalence among males and females. A retrospective study by Taniguchi et al demonstrated a female to male ratio of 3:1.
A proposed association between LS and atopy has been controversial. It is thought that a history positive for atopy may suggest development of the disease and increased frequency of pruritic disease. One study demonstrated that only 20% of patients with LS had a personal history of atopy, an incidence rate of atopy similar to the general population. This same study demonstrated that 34% of subjects suffered with pruritus, while only 26% of those without atopy reported pruritus. Other studies have demonstrated a positive correlation, with 50% to 80% of patients reporting a personal history of atopy.
Several dermatoses may mimic LS clinically, but may be differentiated by histologic appearance. Inflammatory linear verrucous epidermal nevus (ILVEN) also follows Blaschko lines. In comparison, ILVEN is almost always pruritic and does not undergo spontaneous regression. Inflammatory linear verrucous epidermal nevus lesions also present from birth, although they could be more subtle and less evident at that time. Other conditions to consider in the differential diagnosis include linear epidermal nevus, linear lichen planus, linear psoriasis, and linear verruca plana.
Treatment of LS is generally observational due to the relatively self-limited and asymptomatic nature of the condition. For symptomatic patients, topical corticosteroids used with oral antihistamines may relieve pruritus. One case report has demonstrated the effectiveness of topical tacrolimus ointment in treating persistent forms of LS.
Pityriasis rosea (PR) is a papulosquamous dermatosis presenting with a primary eruption of a 2- to 5-cm herald patch, followed several days later by a secondary eruption of classically salmon-pink, oval lesions with overlying collarettes of scale, in a "fir tree" distribution (Fig 2). This benign dermatosis is generally selflimited and is most prevalent among adolescents aged 13 to 36 years.
A prospective study of African-American children and adolescents with PR found a female predilection; 90% of the population had pruritus and 88% a herald patch. This study also characterized the lesions as presenting largely as papulosquamous lesions (66%), with 34% of the lesions predominantly papular. Distribution included the face (30%), arms and forearms (60%), thighs and legs (50%), pelvis and groin (12%), and the scalp (8%). Roughly one third of the patients had between 200 to 300 lesions over the entire body. After an average resolution of disease activity within 2 weeks, most patients had postinflammatory pigmentary changes. Hyperpigmentation occurred in 48% of the patients, with hypopigmentation occurring in 14%.
A viral origin for PR has been suggested and explored, particularly the association between human herpes virus (HHV) 6 and 7 and PR. Drago et al in a critical review reasoned that PR may be due to reactive response to HHV 6 and 7 replication. Another study implicated HHV 8 as a possible causative agent of PR, after 20% of skin samples from patients with acute PR were positive for the HHV 8 genome.
Therapeutic interventions in PR are targeted at symptomatic relief. A Cochrane review of randomized controlled trials evaluating therapeutics in the treatment of PR proposed a few potentially efficacious options. In 1 study, the oral antihistamine dexchlorpheniramine versus oral betamethasone, versus a combination dexchlorpheniramine and betamethasone was evaluated. After 2 weeks of therapy, pruritus was not relieved by either of the options; however, the use of either dexchlorpheniramine or betamethasone alone seemed to be most effective in clearing the lesions. The results of one trial demonstrated efficacy of oral erythromycin compared with placebo in terms of rash resolution at 2 weeks. Oral acyclovir has been proposed to be efficacious in clearing PR if treatment is initiated within the first week of eruption, with 2 studies reporting 79% of patients with full resolution as compared to 4% of placebo at 2 weeks. Ultraviolet B phototherapy is reported to reduce the severity of the eruption, but has no effect on duration or symptoms.
POSTINFLAMMATORY HYPERPIGMENTATION AND DYSPIGMENTATION
Patients with skin of color develop postinflammatory hyperpigmentation (PIH) and dyspigmentation at a disproportionately higher rate compared to patients with a lighter skin complexion (Fig 3). In African-American adolescents with a medium to dark complexion, PIH can present as irregularly shaped, darkly pigmented spots that occur in areas that have been inflamed due to acne, folliculitis, eczema, and multiple other inflammatory disorders. There may be resulting cosmetic disfigurement resulting from nonresolving or slowly resolving dark spots. PIH is thought to be a pathophysiologic response to local inflammation resulting in stimulation of the melanocytes with an increase in quantity of melanocytes or an increase in the quantity of melanin. The increased melanin may be taken up into the keratinocytes, resulting in epidermal hyperpigmentation (ie, as seen in acne), or settle in the dermis via a disrupted basement membrane through which melanin is displaced and is stored in melanophages in dermal hyperpigmentation.
ATOPIC AND CONTACT DERMATITIS
Atopic dermatitis (AD) is a chronic, inflammatory skin condition common in pediatric patients and may be particularly difficult to treat in various ethnic populations. The diagnosis of AD is based on clinical findings. Patients usually present with the basic feature of pruritus and, additionally, a family or personal history of asthma, allergic rhinitis, or AD. Clinical features in patients of color include hyperlinear palms, Morgan-Dennie folds, white dermatographism, infra-auricular fissures, and xerosis. One study highlighted the fact that erythema is not a reliable indicator of severity of AD in African-American children. Variations in skin pigmentation may complicate erythema assessment, leading to inappropriate evaluation and treatment. Associated conditions or variants of AD include keratosis pilaris, nummular eczema, ichthyosis vulgaris, and pityriasis alba.
Contact dermatitis (CD) is an inflammatory dermatosis that develops in an area exposed to allergens. The most common irritants among children and adolescents are nickel, cobalt, neomycin, fragrance mix, gold, and quaternium. Clinically, the affected area presents with edema and erythema and accompanying vesicobullous lesions and pruritus.
Patient and parent education is the cornerstone of treating AD and CD. Patients should be instructed in proper bathing practices, including short, warm baths and the use of mild soaps. Nails should be maintained well trimmed. Hypoallergenic detergent should be used for laundering the clothes of patients with AD and CD, and fabric-softener or other types of dryer sheets should not be used. Therapeutic interventions in the treatment of AD and CD include topical corticosteroids applied via ointment, cream, or lotion. Additionally, antihistamines may be prescribed for pruritus; antibiotics for staphylococcal colonization and infection; and topical immunomodulators as an alternative antiinflammatory agent.
Melasma occurs more frequently among Latino and Hispanic patients. Melasma presents as brownish macules with irregular borders that may coalesce into a reticular pattern in sun-exposed areas of the face. There are 3 major patterns of distribution of the lesions: centrofacial (63%), malar (21%), and mandibular (16%). Melasma may be seen in postpubertal females, and although the pathogenesis is not clearly understood, UV light exposure, genetic factors, and hormonal factors are known to play a role. Birth control pills, ovarian tumors, mild thyroid and ovarian dysfunction, nutrition, cosmetics, epilepsy medications, and photoallergic or phototoxic medications all are known to cause melasma. Facial dyspigmentation has been demonstrated to be a source of distress to Latino patients, with a negative impact on quality of life (QOL) scores. Women are more affected than men. A study noted QOL scores as ascertained by the Dermatology Life Quality Index (DLQI) in 115 patients before treatment for melasma correlated directly with melasma severity. Posttreatment scores improved dramatically.
Excerpted from Adolescent Medicine: State Of The Art Reviews Adolescent Dermatology April 2011 ? Volume 22 ? Number 1 by Patricia A. Treadwell. Copyright © 2011 American Academy of Pediatrics. Excerpted by permission of American Academy of Pediatrics.
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Table of Contents
Dermatoses in Adolescents of Color
Alopecia in Adolescents
Cutaneous Manifestations of Connective Tissue Disease
Cutaneous Malignancy in Adolescents
Acne Therapy in Primary Care: Comprehensive Review of Current Evidence-Based Interventions and Treatments
Body Art in Adolescents: Paint, Piercings, and Perils
Dermatologic Findings in the Evaluation of Adolescents with Suspected Eating Disorders
Cutaneous Infestations and Infections
Skin Findings Associated with Obesity
Papulosquamous Disorders: Atopic Dermatitis, Psoriasis, Seborrheic Dermatitis, and Nickel Contact Dermatitis