Literature updates in pediatric dermatology

Key pediatric publications over the last year highlighted topics including food allergies, atopic dermatitis (AD) and acne, according to an expert at the 75th annual American Academy of Dermatology meeting, Orlando, Fla.

"The Learning Early about Peanut Allergy (LEAP) study brought to the forefront the concept that you could reduce peanut allergy by introducing peanuts at a younger age. That left many of us intrigued, but still wondering what to do. Now, two years later, we have better recommendations," says Howard B. Pride, M.D., director of dermatology, Geisinger Health System.

A recent study addressing high-risk children (those with severe egg allergy or eczema) suggests checking IgE antibodies to peanuts. If below 0.35 kU/L, he says, "Then peanut can be introduced presumably safely. If it's above 0.35 kU/L, authors recommend a specialist consultation and/or prick testing."¹ The publication also recommends a commercial product, or a recipe for peanut purée, suitable for infants.

For patients with mild-to-moderate eczema (or no eczema or allergies), investigators recommend introducing peanuts at 4 to 6 months of age, without allergy testing. "While the LEAP study did not specifically address this, study authors say that introducing peanuts is anticipated to be safe, and to contribute modestly to an overall reduction in the prevalence of peanut allergy," he says.

In another study, a similar approach resulted in significantly fewer food allergies among children introduced early to a variety of foods.²

In AD, melatonin may do more than improve sleep.

"All of us in pediatric dermatology tend to use sedating antihistamines for children who don't sleep well as a result of their itching. But none of us feel spectacular about loading children up with antihistamines," Dr. Pride says.

A randomized, double-blind, placebo-controlled crossover study of 38 children with AD showed that after four weeks, 3 mg of melatonin at bedtime reduced Scoring Atopic Dermatitis (SCORAD) scores by 9.1, and sleep latency by 24 minutes.³

"There was no correlation between decrease in sleep latency and decrease in SCORAD. That suggests that there may be an immunomodulatory effect of melatonin over and above helping children sleep better,"  Dr. Pride says.

Regarding infantile hemangioma, he says, "Ever since we've been using propranolol, there's been a bit of a debate regarding how much evaluation must be done before starting propranolol."

The most cautious dermatologists believe that evaluation should include routine electrocardiography (ECG), he explains, while other physicians believe that a physical examination and directed history suffice. A retrospective study showed that outside of children with risk factors such as arrhythmia, abnormally low heart rate, a family history of congenital heart disease or maternal history of connective tissue disease, routine ECG is unnecessary.⁴

Additionally, "A vexing problem for all of us who take care of adolescents is prescribing isotretinoin. There's some evidence that it's linked to causing inflammatory bowel disease (IBD)." However, he says, a large meta-analysis showed definitively that there is no association between the development of IBD in those exposed to isotretinoin versus those who have not been exposed."⁵

Another publication addressed the baseline incidence of major depression among adolescents. Dr. Pride says, "I would not begin to minimize that isotretinoin can be linked with worsening depression or withdrawn behavior in adolescents. But knowing the baseline incidence of depression in adolescents is very helpful in putting into perspective the effect of another pharmacologic agent" often used with antidepressants in teens.

A large survey showed that baseline incidence of major depressive episodes in adolescents is staggering, and growing, he said – from 8.7% of adolescents in 2005 to 11.3 % in 2014. For girls specifically, the rate rose from 13.1% to 17.3%.

"These figures tell me that basically, at least one in six girls that I treat with isotretinoin is going to be at risk of having a major depressive episode" completely independent of isotretinoin, he cautions.

Disclosures: Dr. Pride reports no relevant financial interests.

References

1. Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. J Allergy Clin Immunol. 2017;139:29-44

2. Perkin MR, Logan K, Tseng A, et al. Randomized trial of introduction of allergenic foods in breast-fed infants.N Engl J Med. 2016;374(18):1733-43.

3.   Chang YS, Lin MH, Lee JH, et al. Melatonin supplementation for children with atopic dermatitis and sleep disturbance: a randomized clinical trial.JAMA Pediatr. 2016;170(1):35-42.

4. Yarbrough KB, Tollefson MM, Krol AL, Leitenberger SL, Mann JA, MacArthur CJ. Is routine electrocardiography necessary before initiation of propranolol for treatment of infantile hemangiomas? Pediatr Dermatol. 2016;33(6):615-620.

5. Lee SY, Jamal MM, Nguyen ET, Bechtold ML, Nguyen DL. Does exposure to isotretinoin increase the risk for the development of inflammatory bowel disease? A meta-analysis. Eur J Gastroenterol Hepatol. 2016;28:210-16

6. Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics. 2016;138:e20161878.