Andrew C. Krakowski

For most children and adolescents who have developed symptomatic scars, cosmetic concerns are only a portion of the motivation that drives them and their caregivers to obtain treatment. In addition to the potential for cosmetic disfigurement, scars may be associated with a number of physical comorbidities including hypertrichosis, dyshidrosis, tenderness/pain, pruritus, dysesthesias, and functional impairments such as contractures, all of which may be compounded by psychosocial factors. Although a plethora of options for treating scars exists, specific management guidelines for the pediatric and adolescent populations do not, and evidence must be extrapolated from adult studies. New modalities such as the scar team approach, autologous fat transfer, and ablative fractional laser resurfacing suggest a promising future for children who suffer symptomatically from their scars. In this state-of-the-art review, we summarize cutting-edge scar treatment strategies as they relate to the pediatric and adolescent populations.

Oral doxycycline is an antibiotic commonly used for the treatment of inflammatory acne in adolescents. Dose-dependent phototoxicity, unrelated to dose duration, is a well-known complication of its use. We present three adolescents who developed bilateral phototoxic rashes on the dorsal thenar spaces of their hands while taking doxycycline for their acne. Identification of the "heart sign" rash as a specific doxycycline-related phototoxic reaction should alert clinicians to the need for prompt intervention, including sun protection counseling and a possible change in antibiotics, in the uniquely vulnerable adolescent population. Early recognition may allow patients to avoid future, more widespread phototoxic drug reactions.

Complementary and alternative medicine therapies are gaining popularity among patients, aided by modern media outlets that facilitate easy and rapid dissemination of information. "Urine therapy" is one such complementary and alternative medicine and is described by its proponents as a wonder therapy for inflammatory conditions, such as acne vulgaris. As with other complementary and alternative medicines, healthcare providers should be mindful of the use of urine therapy and its potential implications for patients who may utilize it.

Background and Objective: Leishmaniasis is a vector borne disease that can cause disease manifestations that range from localized skin ulceration to lethal visceral disease. With increased global travel, cutaneous leishmaniasis (CL) is becoming more common in developed nations. However, current treatment options are limited.Study Design: We report a 16‐year‐old female who presented with several non‐tender, non‐healing CL wounds on her bilateral upper and lower extremities. Ablative fractional laser resurfacing (AFR) was used in conjunction with topical paromomycin via laser‐assisted delivery to treat the largest non‐healing CL wound on the patient's distal lower extremity.Results: Upon follow‐up after two treatments with AFR, the patient's wound healed completely without evidence of infection and with minimal scarring.Conclusion: AFR with laser‐assisted delivery of topical paromomycin represents a novel treatment option for resistant, non‐healing CL wounds. The technique may prove additionally useful for concurrent mitigation of scarring related to CL. Lasers Surg. Med. 47:788–791, 2015.

"Errors of transcription" are rarely reported, but may cause significant adverse effects in patients. Here, the authors report the case of a 15-year-old Burmese girl presenting with telogen effluvium after being dispensed the wrong medication due to a pharmacy auto-complete error.

"Natural home remedies" for nevi removal found on the Internet can be ineffective, or worse, dangerous. Children and teens, in particular, may be more likely to attempt self-treatment in order to avoid discussing their concerns with their parents. Here, the authors report a case of an adolescent who presented with a chemical burn after following an Internet-based protocol for nevi removal using apple cider vinegar.

Since the advent of the varicella vaccine, occurrence of herpes zoster in children has been rare. However, a subset of patients may develop herpes zoster after receiving the vaccine. Herein the authors report a case of a two-year-old boy who developed herpes zoster in the V1 distribution and meningitis following a single dose of varicella vaccine.

Case Challenge Christine R. Totri, MAS; Lucia Diaz, MD; Catalina Matiz, MD; Andrew C. Krakowski, MD Each month, this department features a discussion of an unusual diagnosis. A description and images are presented, followed by the diagnosis and an explanation of how the diagnosis was determined. As always, your comments are welcome via email at pedann@Healio.com. A 15-year-old healthy Somali girl who had been living in the United States with her parents for the past 2 years presented to our emergency department with a 3-week history of a progressively painful body rash. The patient initially denied the use of any prescription medications, complementary/herbal therapies, or over-the-counter products. She denied the use of tampons, weight loss, recent cough or fevers, and any difficulty or pain with urination or defecation. She had no history of sexual activity. Physical examination revealed a young woman in severe distress, although she was afebrile and hemodynamically stable. Cutaneous inspection revealed tender, red-brown plaques coalescing into near-confluent desquamation on her neck, torso, buttocks, and extremities (Figure 1). Flaccid bullae on her back and forearms and striae on her shoulders and torso were also noted. She had no oral or genital lesions. Her conjunctivae were normal. There was no lymphadenopathy or hepatosplenomegaly seen on examination. Finally, there were no signs of other systemic illness or abuse. Figure 1. (A–C) Tender, red-brown papules and plaques with erosions and bullae coalescing into near-confluent desquamation on the patient’s chest, arms, and lower back; striae are evident on the patient’s shoulders and chest. (D) Interdigital spaces demonstrating intense erythema, suggesting a “pooling effect” ⁷ from a local contact irritant. The differential diagnosis included chemical/thermal burns, atypical toxic epidermal necrolysis, pemphigus vulgaris, toxin-mediated erythroderma, and bullous lupus. A complete blood count with differential and comprehensive metabolic panel were normal. Bacterial swabs of her eyes, nose, mouth, skin, and genital and rectal areas revealed no organisms on Gram stain and cultures remained negative. A skin biopsy of the thigh revealed epidermal necrosis and thinning with a small number of dyskeratotic cells, consistent with toxic epidermal necrolysis or a chemical burn. A second biopsy from the thigh was also performed and sent for traditional hematoxylin and eosin stain that ultimately confirmed these findings (Figure 2). Figure 2. Hematoxylin and eosin stain of skin biopsy taken from the patient’s thigh shows a noninflammatory subepidermal blister with dyskeratotic cells. The histopathologic differential diagnosis includes toxic epidermal necrolysis and chemical burn. Clinically, the lack of facial involvement, the patient’s stable vital signs, and predominant interdigital fold involvement point to an “outside job,” suggestive of a chemical burn. Superficial and Partial-Thickness Chemical Burns Secondary to Skin Bleaching Shortly after admission to our children’s hospital, the patient disclosed her attempts of trying to lighten her skin color by applying betamethasone 0.05% ointment, hydrogen peroxide 12%, and potassium persulfate to her skin twice a day for 3 weeks. Her friend had recommended these products, which were purchased by the patient via the Internet. For 3 weeks she continued to apply the products despite increasing amounts of pain and irritation. The patient’s parents denied specific knowledge that their daughter was self-bleaching, but did confirm the high prevalence of the practice among Somali women. Evaluation of the girl by the hospital’s psychiatry department determined that further psychiatric assessment was unnecessary, as the practice of skin bleaching is a cultural norm in the Somali community and the patient did not intend to harm herself. The patient was treated with local wound care, patient-controlled analgesia, and the next day was transferred to the burn unit for debridement of superficial and partial thickness burns covering 20% of her body. Skin lightening (ie, bleaching) is the topical application of a chemical to lighten the complexion of one’s skin.¹ The practice is especially common in Africa, Asia, and the Middle East. In sub-Saharan Africa, it is estimated that between 25% and 67% of the adult female population practice skin lightening daily.² With immigration and globalization being commonplace in today’s world, demand for these products now includes consumers in the United States. There is a paucity of literature on skin bleaching in America;^3,4 therefore, the majority of American health care providers are unlikely to have experience treating patients who practice it. The aim of this case report is to describe the motives, practice, and medical complications of skin lightening. The production and sale of skin lightening products is a multibillion dollar industry.⁵ In India, the skin lightening cosmetic market is worth approximately $250 million and makes up 61% of the total dermatology market in the country.⁶ Governments around the world have sought to instill legislative restrictions on the skin bleaching market due to the dangerous side effects of these products.⁷ Manufacturers, however, have been able to skirt these restrictions by...

The iPLEDGE protocol for isotretinoin treatment requires multiple steps to be completed within strict timing windows, resulting in many interruptions or discontinuations of treatment. The US Food and Drug Administration has indicated that approximately 40% of isotretinoin prescriptions written over the course of one year of the iPLEDGE program were denied due to failure to comply with iPLEDGE. Insurance restrictions add to the likelihood of prescriptions not being filled. Here, we describe a novel program implemented specifically to assist patients and providers with improving isotretinoin therapy adherence. This innovative isotretinoin support program provides assistance with insurance questions and hurdles, an uninterrupted treatment supply, educational support, reminder communications, and an indigent patient assistance program. Proof-of-concept analysis shows that 17 months after implementation of the program, 93% of prescriptions received have been filled. Utilization of the program appears to improve adherence to an isotretinoin treatment regimen, with fewer interruptions due directly to unfilled prescriptions.