Publications by authors named "Dean S Morrell"

128 Publications

Current Perspectives on the Systemic Management of Atopic Dermatitis.

J Asthma Allergy 2021 1;14:595-607. Epub 2021 Jun 1.

Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.

Atopic dermatitis (AD) is a common disease of childhood, and some patients experience a prolonged clinical course into adolescence and adulthood. Systemic management is required when AD is not adequately controlled with topical medications. Our aim is to provide a comprehensive review of commonly used systemic immunomodulating agents in childhood and adult AD, including cyclosporine A (CsA), azathioprine (AZA), methotrexate (MTX) and mycophenolate mofetil (MMF), which are prescribed off-label in the United States, as well as dupilumab, an FDA-approved biologic. We will also provide a brief overview of emerging systemic therapies currently under investigation.
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http://dx.doi.org/10.2147/JAA.S287638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8179820PMC
June 2021

Demographic characteristics, clinical features, and optimal management of hospitalized patients with staphylococcal scalded skin syndrome.

Pediatr Dermatol 2021 May 18. Epub 2021 May 18.

Department of Dermatology, University of North Carolina, Chapel Hill, NC, USA.

Background/objectives: Optimal management of staphylococcal scalded skin syndrome (SSSS) has not been established. Clindamycin may benefit patients via inhibition of ribosomal toxin production, but resistance patterns suggest penicillinase-resistant penicillins or cephalosporins should be the first line. Our goal was to describe demographic and clinical characteristics of SSSS patients at our institution, delineate bacterial resistance patterns, and examine outcomes of varying therapeutic strategies in SSSS.

Methods: We performed a retrospective review of patients under the age of 18 with confirmed clinical SSSS diagnosis by the dermatology consult team at the University of North Carolina (UNC) Hospitals from January 2008 to April 2017. Median hospital and ICU length of stay (LOS) were compared using a Wilcoxon Rank Sum Test.

Results: We found 59 SSSS patients. Coverage with clindamycin and vancomycin versus absence of that combination was associated with shorter ICU LOS. Although trending toward reduced hospital LOS, this was not significantly altered with the use of vancomycin and clindamycin after adjustment for multiple comparisons. Individual use of either clindamycin or vancomycin did not significantly alter overall hospital or ICU LOS. Among 24 patients with a pathogen identified on culture, 18 (75.0%) revealed resistance to clindamycin, and 2 (8.3%) revealed MRSA.

Conclusions: Clindamycin resistance is more prevalent in hospitalized SSSS patients compared to our pediatric outpatient population. The combination of vancomycin and clindamycin results in shorter ICU LOS. Individual use of clindamycin or vancomycin does not significantly reduce hospital or ICU LOS after adjustment for multiple comparisons.
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http://dx.doi.org/10.1111/pde.14629DOI Listing
May 2021

Pediatric Vulvar Lichen Sclerosus: A Survey of Disease Course.

J Pediatr Adolesc Gynecol 2021 May 11. Epub 2021 May 11.

Department of Dermatology, University of North Carolina at Chapel Hill. Electronic address:

Study Objective: To assess long-term outcomes of Lichen Sclerosus (LS) in the female pediatric population, specifically in relation to patient age, treatment type and duration, and remission.

Design: Retrospective chart review was conducted to identify female pediatric patients (0-18 years of age) who were diagnosed with LS between 1/1/2015 and 1/1/2020 at the University of North Carolina Dermatology and/or OB/GYN Departments. Patients were contacted via telephone for follow-up interviews consisting of a series of questions regarding patient age, symptom onset, time of diagnosis, treatment, and current symptoms.

Results: Out of the 128 patients identified, 61 patients consented and participated in follow-up interviews. At the time of study follow-up, 90% of participants reported their symptoms were improved. Patients reported using a variety of treatments, with medium- to high-potency topical steroids being the most common. At the time of follow-up, 87% of patients reported being asymptomatic, 70% of which were not using any form of maintenance therapy. Those who achieved symptom resolution did so at an average of 8.4 years of age. There was no significant difference in ages between asymptomatic patients on maintenance therapy and off maintenance therapy. There was a positive correlation found between the duration of LS treatment and time in remission (p<0.001). Increased patient age at time of follow-up also correlated positively with time in remission (p<0.001).

Conclusion: In our cohort, the need for continued maintenance therapy was not correlated with age or, by proxy, pubertal status. Thus, LS remission may be determined more by early and successful pharmacological interventions.
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http://dx.doi.org/10.1016/j.jpag.2021.04.010DOI Listing
May 2021

Anterior chest mass with cutaneous sinus tract in an 11-month-old girl.

Pediatr Dermatol 2021 Jan;38(1):272-273

Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1111/pde.14407DOI Listing
January 2021

Atrophic lesion on the abdomen.

Cutis 2020 Dec;106(6):E17-E19

Department of Dermatology, University of North Carolina at Chapel Hill, USA.

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http://dx.doi.org/10.12788/cutis.0159DOI Listing
December 2020

Lentinan Dermatitis: Time to Rename Shiitake Dermatitis.

Dermatitis 2021 Jan-Feb 01;32(1):e16-e18

Department of Dermatology, University of North Carolina at Chapel Hill.

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http://dx.doi.org/10.1097/DER.0000000000000647DOI Listing
January 2021

A 15-month-old boy with white plaques on the oral mucosa.

Pediatr Dermatol 2020 Nov;37(6):e87-e88

Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

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http://dx.doi.org/10.1111/pde.14358DOI Listing
November 2020

Current Perspectives on the Management of Infantile Atopic Dermatitis.

J Asthma Allergy 2020 5;13:563-573. Epub 2020 Nov 5.

Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.

Atopic dermatitis (AD) is a common disease of childhood, and infantile AD may manifest from birth to 2 years. Guidelines for the management of infantile AD are lacking, and our aim is to provide a comprehensive review of best practices and possible interventions. We will focus on topical therapy, since the use of systemic immunomodulating agents in infantile AD is rarely advised. Topical agents include emollients, topical corticosteroids (TCS), topical calcineurin inhibitors (TCIs), and phosphodiesterase 4 (PDE-4) inhibitors. We will also provide a brief overview of promising emerging therapies currently under investigation in the pediatric population.
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http://dx.doi.org/10.2147/JAA.S246175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652565PMC
November 2020

Value of personal statements to dermatology programs: a survey-based critical review.

Dermatol Online J 2020 Oct 15;26(10). Epub 2020 Oct 15.

Department of Dermatology, University of North Carolina School of Medicine, NC.

The personal statement is a required component of the residency application, offering applicants the opportunity to showcase their personality as well as unique thoughts and experiences not explicitly stated elsewhere in their application. Although the applicant-generated nature of personal statements can gauge an applicant's professionalism, creativity, sound judgement, and tact, specific criteria for evaluating personal statements and comparing them to one another is lacking. Research on the value of personal statements in the application process is also lacking. The purpose of this research project is to quantify the perceived value of the personal statement to program directors and faculty members of U.S. dermatology programs involved in residency application review. Analysis of our survey responses determined that although the majority of participants consider the personal statement to be a necessary element of an application, it was rated least important compared to other components of the application. An applicant's Medical Student Performance Evaluation, clerkship grades, research projects and publications, board scores, and letters of recommendation were consistently rated as more important than the personal statement. These findings suggest the personal statement lacks the standardization needed for decision makers to confidently choose the best new dermatology residents for their program.
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October 2020

Angioedema: A potential complication of dupilumab in atopic dermatitis.

Pediatr Dermatol 2021 Jan 25;38(1):237-238. Epub 2020 Oct 25.

Department of Dermatology, University of North Carolina, Chapel Hill, NC, USA.

Dupilumab is a relatively new and quite effective medication for recalcitrant atopic dermatitis in patients over 6 years of age. Here, we present a 12-year-old girl with progressively worsening episodic facial swelling and erythema while treated with dupilumab. This case highlights the possibility of angioedema as an adverse effect of dupilumab treatment.
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http://dx.doi.org/10.1111/pde.14434DOI Listing
January 2021

Alopecia universalis after drug reaction with eosinophilia and systemic symptoms (Dress).

Pediatr Dermatol 2020 Sep 11;37(5):947-949. Epub 2020 Jun 11.

Department of Dermatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse reaction characterized by a morbilliform cutaneous eruption, fever, lymphadenopathy, and multiorgan involvement. Alopecia universalis is a variant of alopecia areata characterized by complete loss of hair on the entire body. Herein, we report a case of alopecia universalis that presented after DRESS.
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http://dx.doi.org/10.1111/pde.14217DOI Listing
September 2020

Dermatology residency applications: correlation of applicant personal statement content with match result.

Cutis 2020 Feb;105(2):83-85

Department of Dermatology, University of North Carolina at Chapel Hill, USA.

The personal statement is a narrative written by an applicant to residency programs to discuss his/her interests and express his/her personality, but it is unclear how the personal statement impacts the dermatology residency application process. The aim of this study was to analyze personal statements from applicants to a dermatology program at a major academic institution to identify common themes and determine if certain themes were associated with successful matching. All personal statements submitted to the dermatology residency program at UNC School of Medicine (Chapel Hill, North Carolina) during the 2012 application cycle (N=422) were analyzed to identify 9 common themes of content. Certain themes differed in prevalence between matched and unmatched applicants. Further investigation is needed to elucidate the impact of personal statement themes and other application content on the residency selection process.
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February 2020

Structural racism and its influence on the severity of atopic dermatitis in African American children.

Pediatr Dermatol 2020 Jan 18;37(1):142-146. Epub 2019 Dec 18.

Department of Dermatology, University of North Carolina, Chapel Hill, NC.

Background/objectives: Atopic dermatitis (AD) is the most common skin disease of childhood and is often more severe in African American than white children. The reason for this disparity is unknown, but recent research indicates that it may be due to a combination of environmental and genetic factors. The objective of this article was to explore the relationship between measures of structural racism and residential segregation within pediatric AD.

Methods: An in-office, online survey consisting of 58 questions spanning 5 domains (demographics, in-home crowding, community crowding, air quality, and litter) was administered to a convenience sample of 201 pediatric AD patients (age 0-18 years). Survey data were geocoded and linked to a measure of structural racism (ie, residential segregation).

Results: African American children were more likely to live in rented homes, be in lower income families, have caregivers with lower educational attainment, and be exposed to tobacco smoke. The same factors that were associated with worse AD severity in this study were also found in published literature, emphasizing the role of social determinants of health and racial differences in AD severity. Additionally, this study found that living in highly segregated communities was more likely to be associated with severe AD in African American children.

Conclusions: Consistent with reported literature, socioeconomic status, race, and the physical environment appear to affect AD severity. This investigation adds structural racism as an important community characteristic that likely has significant effects on AD severity for African American Children.
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http://dx.doi.org/10.1111/pde.14058DOI Listing
January 2020

Painful subcutaneous nodules in a patient with shortened digits.

Pediatr Dermatol 2019 Nov;36(6):944-945

UNC School of Medicine, Chapel Hill, North Carolina.

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http://dx.doi.org/10.1111/pde.13951DOI Listing
November 2019

Curvilinear Alopecia in an Infant.

Clin Pediatr (Phila) 2019 06 21;58(6):704-706. Epub 2019 Feb 21.

1 University of North Carolina, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1177/0009922819832033DOI Listing
June 2019

Childhood pemphigus foliaceus presenting as a polycyclic eruption: Case report and review of the literature.

Pediatr Dermatol 2019 Mar 14;36(2):236-241. Epub 2019 Feb 14.

Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.

Pemphigus foliaceus (PF) is an autoimmune bullous disorder that has occasionally been reported to present as a polycyclic or arcuate eruption in children. We present a case of childhood PF presenting as an annular and polycyclic eruption, which initially led to a diagnostic conundrum and a delay in diagnosis but which ultimately responded well to therapy with systemic steroids and rituximab infusions. We briefly review the literature on polycyclic presentations of PF in childhood as well as the use of rituximab for pediatric pemphigus.
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http://dx.doi.org/10.1111/pde.13750DOI Listing
March 2019

Erythematous Crusted Papules on Face Arising in an Immunocompromised Child With Chemotherapy-Induced Acral Erythema.

Clin Pediatr (Phila) 2019 04 23;58(4):478-481. Epub 2019 Jan 23.

1 University of North Carolina, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1177/0009922818825148DOI Listing
April 2019

Firm, Indurated Plaques After Therapeutic Hypothermia.

Clin Pediatr (Phila) 2018 10 9;57(12):1468-1471. Epub 2018 Jul 9.

2 Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1177/0009922818785992DOI Listing
October 2018

Do looks matter? The role of the Electronic Residency Application Service photograph in dermatology residency selection.

Dermatol Online J 2018 Apr 15;24(4). Epub 2018 Apr 15.

University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.

Background: There is a lack of research on the impact of the Electronic Residency Application Service (ERAS) photograph on the residency selection process.

Objective: We sought to elucidate the role of the ERAS photograph in the dermatology residency selection outcome and to determine if photographs submitted by matched applicants differ from those of unmatched applicants.

Methods: We analyzed ERAS photographs submitted by dermatology residency applicants based on photograph characteristics related to composition, attire, facial expression, hairstyle, and accessories.

Results: Candidates who smiled, wore glasses, and wore jackets in their photographs were more likely to match. There was no difference in the rate of matching among applicants depending on whether their photograph was of professional quality or whether they wore formal attire in their pictures. Gender specific characteristics were not found to be influential in the match outcome for male applicants. Among female applicants, having hair to the shoulders or longer was associated with a positive match outcome.

Conclusion: Certain characteristics of the ERAS photographs were found to be associated with a more favorable match outcome. Further biases inferred from these photographs might be present in the dermatology selection process. We suggest blinding the selection committees to ERAS application photographs prior to granting residency interviews.
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April 2018

Pyoderma gangrenosum in an infant: A case report and review of the literature.

Pediatr Dermatol 2018 Sep 15;35(5):e257-e261. Epub 2018 Apr 15.

University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Pyoderma gangrenosum is a neutrophilic dermatosis that is rare in infancy, with only 20 cases reported in the literature. We present a case of infantile pyoderma gangrenosum refractory to topical steroids, tacrolimus, and dapsone as well as systemic steroids and infliximab that is currently well controlled with the addition of oral tacrolimus. To our knowledge, this is the first report of the effective, safe use of oral tacrolimus in combination with infliximab for infantile pyoderma gangrenosum. We review all current cases of infantile pyoderma gangrenosum, as well as tacrolimus and its role in the treatment of this condition.
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http://dx.doi.org/10.1111/pde.13471DOI Listing
September 2018

A newborn with significant white hyperkeratotic plaques.

Pediatr Dermatol 2018 Jan;35(1):143-144

Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1111/pde.13356DOI Listing
January 2018

Persistent Perianal Rash in a Young Boy.

Clin Pediatr (Phila) 2018 09 28;57(10):1243-1245. Epub 2017 Nov 28.

1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1177/0009922817744609DOI Listing
September 2018

What Is the Cause of the Chronic Erythematous Scaling Plaques on This 22-Month-Old Girl and Her Family?

Clin Pediatr (Phila) 2018 06 30;57(7):874-878. Epub 2017 Oct 30.

1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1177/0009922817738347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5985158PMC
June 2018

Hemophagocytic Lymphohistiocytosis in a Newborn Presenting as "Blueberry Muffin Baby".

Pediatr Dermatol 2017 May;34(3):e150-e151

Department of Dermatology, School of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome characterized by uncontrolled activation and proliferation of proinflammatory cytokines. Initial presentation commonly includes fever, hepatosplenomegaly, and pancytopenia; 6 to 65% of cases also have a concurrent cutaneous eruption. We present the case of a 6-day-old premature infant boy with congenital severe thrombocytopenia, anemia, and hepatosplenomegaly who presented with several cutaneous violaceous papules and nodules and was found to have HLH.
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http://dx.doi.org/10.1111/pde.13128DOI Listing
May 2017

The Internet for patient education on atopic dermatitis: Friend or foe?

J Am Acad Dermatol 2017 Jun;76(6):1197-1198

Department of Dermatology, University of North Carolina, Chapel Hill, North Carolina.

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http://dx.doi.org/10.1016/j.jaad.2017.01.054DOI Listing
June 2017

Verrucae Planae Within Previous Xenograft Sites of Burn Wounds.

Pediatr Dermatol 2017 May 27;34(3):e130-e131. Epub 2017 Feb 27.

Department of Dermatology, University of North Carolina, Chapel Hill, North Carolina.

Burn injuries are known to compromise host immune defenses through disruption of mucocutaneous barriers and suppression of cell-mediated immune responses, which may render patients with burn injuries susceptible to viral infections in the days to years after an initial insult. We report a case of verrucae planae developing as a secondary condition confined to former xenograft sites in a child, appearing more than 3.5 years after initial second-degree burn injuries. Only a few reports have previously described the development of verrucae in former burn sites, with most reporting latency to onset of verrucae appearance of months rather than years. Current hypotheses suggest that the postburn immune response shifts from an early proinflammatory to a late antiinflammatory response characterized by altered cytokine profiles and diminished cellular cytotoxicity mediated by cytotoxic T-lymphocytes, natural killer cells, and epidermal antigen-presenting cells, which together likely contribute to an enduring postburn regional immunosuppression that allows for the seeding and proliferation of viral agents.
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http://dx.doi.org/10.1111/pde.13109DOI Listing
May 2017

Common Skin Conditions in Children: Congenital Melanocytic Nevi and Infantile Hemangiomas.

FP Essent 2017 Feb;453:33-37

University of North Carolina Chapel Hill School of Medicine Dermatology Residency Program, 410 Market St. Suite 400 CB#7715, Chapel Hill, NC 27516.

Congenital melanocytic nevi (CMN) are hamartomas present at birth that are composed of nevomelanocytes and thought to originate from faulty migration of precursor melanocytes in the neural crest. Classification is based on projected adult size of the lesion. CMN size correlates positively with risk of melanoma and neurocutaneous melanocytosis. Management requires a patient-centered approach that weighs the risks and benefits of and alternatives to complete removal. All children with large and giant CMN, regardless of surgical status, should be monitored closely and undergo periodic skin examination. Infantile hemangiomas (IHs) are vascular neoplasms arising from endothelial cell hyperplasia that go through proliferative (growth) and involutional phases. Large, segmental IHs carry a higher risk of bleeding, and patients with these IHs may benefit from imaging. Small, focal IHs in noncritical areas do not require treatment. In contrast, early referral and treatment should be considered for patients with large, extensive, deep, segmental, or syndromic IHs. Systemic and topical beta blockers have the strongest efficacy data and have replaced systemic and intralesional corticosteroids as first-line treatment for IHs in the United States. Surgical therapies are second-line modalities, with laser treatment being used most widely.
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February 2017

Common Skin Conditions in Children: Skin Infections.

FP Essent 2017 Feb;453:26-32

University of North Carolina Chapel Hill School of Medicine Dermatology Residency Program, 410 Market St. Suite 400 CB#7715, Chapel Hill, NC 27516.

Skin infections account for a significant subset of dermatologic conditions of childhood. Common cutaneous viral infections in children include warts, molluscum contagiosum, hand-foot-and-mouth disease, and herpes simplex. Although viral infections are self-limited and often only mildly symptomatic, they can cause anxiety, embarrassment, and health care use. Recognition of their common and atypical presentations is necessary to differentiate them from other skin conditions of similar morphology. Impetigo, cellulitis, and abscess comprise the majority of childhood bacterial skin infections and are treated with topical or systemic antibiotics that cover group A Streptococcus and Staphylococcus aureus. Common fungal dermatologic infections in children are oral and genital candidiasis, tinea capitis, and tinea corporis. Management consists of topical and systemic antifungals, including nystatin, triazoles, terbinafine, griseofulvin, and imidazoles. Scabies is the most common parasitic skin infection among children and is managed with topical permethrin. Although serious illness is not common among children returning from international travel, patients presenting with fever and rash, especially petechial or hemorrhagic lesions, require thorough evaluation. Of the numerous reportable conditions that present with childhood rash, tick-borne illnesses, measles, rubella, and varicella are the most common.
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February 2017

Common Skin Conditions in Children: Noninfectious Rashes.

FP Essent 2017 Feb;453:18-25

University of North Carolina Chapel Hill School of Medicine Dermatology Residency Program, 410 Market St. Suite 400 CB#7715, Chapel Hill, NC 27516.

Cutaneous adverse drug reactions are among the most common noninfectious rashes of childhood. Cutaneous adverse drug reactions are classified as morbilliform, urticarial, bullous, pustular, or psoriasiform. Atopic dermatitis is one of the most common inflammatory cutaneous eruptions, and is characterized by pruritus and flexural distribution. Emollients and topical corticosteroids are first-line therapies. Topical calcineurin inhibitors are second-line, steroid-sparing drugs for certain conditions, such as face and eyelid eczema. Systemic and immunologic conditions have mucocutaneous features, such as malar rash, discoid lupus, and photosensitivity in systemic lupus erythematosus; lip, oral, and extremity changes as well as polymorphous rash in Kawasaki disease; erythematous, scaly plaques in psoriasis; and xerosis and face, hand, and leg skin changes in type 1 diabetes. Genetic conditions that manifest as changes in skin pigmentation are important to recognize because of the thorough diagnostic evaluation they warrant, the often challenging interventions they necessitate, and the permanent disability that frequently accompanies them. These conditions include neurofibromatosis, LEOPARD syndrome, incontinentia pigmenti, congenital hemidysplasia with ichthyosiform erythroderma and limb defects syndrome, hypomelanosis of Ito, and acanthosis nigricans. Childhood dermatologic emergencies often are associated with infection and drugs and require early recognition and intervention.
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February 2017

Common Skin Conditions in Children: Neonatal Skin Lesions.

FP Essent 2017 Feb;453:11-17

University of North Carolina Chapel Hill School of Medicine Dermatology Residency Program, 410 Market St. Suite 400 CB#7715, Chapel Hill, NC 27516.

Skin findings during the initial month of life are ubiquitous. One study estimated that more than 95% of newborns have cutaneous findings, which often are distressing to parents but frequently are benign and self-limited. Among them are milia, cutis marmorata, congenital dermal melanocytosis, and the benign neonatal pustular eruptions (eg, benign cephalic pustulosis, erythema toxicum neonatorum, transient neonatal pustular melanosis). Clinicians need to recognize these benign skin conditions and differentiate them from more serious conditions, such as infectious pustular eruptions from bacterial, viral, and fungal causes, and inflammatory conditions, such as Langerhans cell histiocytosis. Notable bacterial pustular eruptions are bullous impetigo and congenital syphilis. Viral pustular dermatoses include neonatal herpes simplex virus infection and varicella zoster virus infection, which consists of congenital varicella syndrome, perinatal varicella, and infantile zoster. Fungal pustular eruptions include congenital and neonatal candidiasis. Seborrheic dermatitis is a self-limited condition that occurs with varying severity; symptomatic treatment is reserved for the more severe forms. Diaper dermatitis encompasses a broad clinical diagnosis, including allergic and irritant contact dermatitis, atopic dermatitis, infections, psoriasis, and other dermatologic conditions. Critical components of newborn skin care are immersion bathing, umbilical cord care, and use of emollients to augment skin barrier function.
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February 2017