IMPORTANCE Advances in smartphone photography (both quality and image transmission) may improve access to care via direct parent-to-clinician telemedicine. However, the accuracy of diagnoses that are reliant on parent-provided photographs has not been formally compared with diagnoses made in person.OBJECTIVE To assess whether smartphone photographs of pediatric skin conditions taken by parents are of sufficient quality to permit accurate diagnosis. DESIGN, SETTING, AND PARTICIPANTSA prospective study was conducted among 40 patient-parent dyads at a pediatric dermatology clinic at the Children's Hospital of Philadelphia from March 1 to September 30, 2016, to assess concordance between diagnoses made by an independent pediatric dermatologist based on in-person examination and those based on parental photographs. Half of the patient-parent dyads were randomized for a secondary analysis to receive instructions on how best to take photographs with smartphones. Clinicians were blinded to whether parents had received photography instructions.EXPOSURES Half of the patient-parent dyads received a simple, 3-step instruction sheet on how best to take photographs using a smartphone (intervention group); the other half did not (control group). MAIN OUTCOMES AND MEASURES Concordance between photograph-based vs in-persondiagnosis in the intervention vs control groups, as quantified using Cohen κ, a measure of interrater agreement that takes into account the possibility of agreement occurring by chance.RESULTS Among the 40 patient-parent dyads (22 female children and 18 male children; mean [SD] age, 6.96 [5.23] years), overall concordance between photograph-based vs in-person diagnosis was 83% (95% CI, 71%-94%; κ = 0.81). Diagnostic concordance was 89% (95% CI, 75%-97%; κ = 0.88) in a subgroup of 37 participants with photographs considered of high enough quality to make a diagnosis. No statistically significant effect of photography instructions on concordance was detected (group that received instructions, 85%; group that did not receive instructions, 80%; P = .68). In cases of diagnostic disagreement, appropriate follow-up was suggested.CONCLUSIONS AND RELEVANCE Parent-operated smartphone photography can accurately be used as a method to provide pediatric dermatologic care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT03246945

Although anti-tumor necrosis factor alpha (TNF-α) agents are commonly used to treat psoriasis and other inflammatory diseases in adults and children, numerous reports have documented new-onset or flaring psoriasis in adults treated for the other conditions. Individual case reports have documented similar observations in three children. We report a series of anti-TNF-α-induced psoriasis in children with juvenile idiopathic arthritis or inflammatory bowel disease treated at a large children's hospital. All five patients presented with severe scalp involvement. One child was treated with adalimumab for juvenile idiopathic arthritis, and four received infliximab for inflammatory bowel disease. The five patients developed psoriasis 2 to 10 months after initiating anti-TNF-α therapy. They presented with erythematous, scaly, crusted scalp lesions. Three of the five patients were initially treated with griseofulvin for presumed tinea capitis. The anti-TNF-α agent was discontinued at the time of diagnosis in two cases. Topical steroids were the mainstay of psoriasis therapy, with improvement in four of five patients. Anti-TNF-α agents have been associated with the onset or worsening of psoriasis in adults, but this has rarely been reported in children. We describe five pediatric cases of anti-TNF-α-induced psoriasis presenting with severe scalp involvement and review their subsequent management. We hope that clinicians caring for patients receiving anti-TNF-α agents will consider psoriasis from the onset of cutaneous symptoms and institute appropriate therapy or referral.

Background HHV6-positivity in context of drug hypersensitivity syndrome (DHS) may influence disease severity. Systemic corticosteroid treatment of those with DHS, testing positive for HHV6, has been speculated to prolong the duration of disease. Objectives This study's objectives are to: (1) Evaluate whether DHS patients with HHV6-positivity develop a more severe illness compared to DHS patients without presumed reactivation in the pediatric population, and (2) Evaluate the response to systemic corticosteroid treatment. Methods Retrospective case series of 29 pediatric inpatients treated for DHS and tested for HHV6. HHV6-positive and -negative patients were identified and stratified to groups treated with and without systemic corticosteroids to examine their disease severity on the basis of hospital length-of-stay (LOS), total number of febrile days (Tfeb), and days until cessation of progression (CTP). Results HHV6-positive patients had similar demographic characteristics as HHV6-negative patients, but had significantly longer hospital LOS (11.5 days v 5 days, p=0.0386), Tfeb (12.5 days v 3 days, p=0.0325), and CTP (4 days v 2 days, p=0.0141). All HHV6-positive patients and most (80%) of the HHV6-negative patients received systemic corticosteroids. Among the HHV6-negative patients, those who received corticosteroids showed significantly shorter CTP than those who did not receive corticosteroids (3 days v 2 days, p=0.043). Additionally, there was a trend towards shorter hospital LOS and Tfeb among HHV6-negative patients who received corticosteroids when compared with those who did not, though these differences were not statistically significant. The most common inciting drugs included trimethoprim-sulfamethoxazole (33%), phenytoin (10%), and amoxicillin (10%). Conclusions HHV6-positivity with DHS is associated with a more severe disease course. Treatment with systemic corticosteroids was associated with a non-statistical trend toward reduced hospital LOS and febrile days, and a statistically reduced number of days until cessation of progression.

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Objective To estimate the incidence rate (IR) of psoriasis in children with inflammatory bowel disease (IBD), juvenile idiopathic arthritis (JIA), and chronic noninfectious osteomyelitis (CNO) with tumor necrosis factor inhibitor (TNFi) exposure as compared to children without TNFi exposure and to the general pediatric population. Methods This was a single‐center retrospective cohort study of children with IBD, JIA, or CNO from 2008 to 2018. TNFi exposure was defined as a prescription for adalimumab, etanercept, infliximab, certolizumab, or golimumab, and the primary outcome was incident psoriasis. IRs and standardized incidence ratios (SIRs) were calculated. Cox proportional hazards models were used to assess the association of psoriasis with TNFi exposure and other risk factors. Results Of the 4,111 children who met inclusion criteria, 1,614 (39%) had TNFi exposure and 2,497 (61%) did not, with 4,705 and 6,604 person‐years of follow‐up, respectively. There were 58 cases (IR 12.3 per 1,000 person‐years) and 25 cases (IR 3.8 per 1,000 person‐years) of psoriasis in children with and without TNFi exposure, respectively. The SIR was 18 (95% confidence interval [95% CI] 15–22) overall, 30 (95% CI 23–39) for children with TNFi exposure, and 9.3 (95% CI 6.3–14) for children without TNFi exposure. The hazard ratio of psoriasis comparing TNFi exposure to no TNFi exposure was 3.84 (95% CI 2.28–6.47; P < 0.001). Conclusion Children with IBD, JIA, and CNO had an increased rate of psoriasis compared to the general pediatric population, with the highest rate in those with TNFi exposure.

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Background: The proliferative phase of infantile hemangiomas (IHs) is usually complete by 9 months of life. Late growth beyond age 3 years is rarely reported.Objective: To describe the demographic and clinic characteristics of a cohort of patients with late growth of IH, defined as growth in a patient [3 years of age.Methods: A multicenter, retrospective cohort study.Results: In total, 59 patients, 85% of which were female, met the inclusion criteria. The mean first episode of late growth was 4.3 (range 3-8.5) years. Head and neck location (55/59; 93%) and presence of deep hemangioma (52/59; 88%) were common characteristics. Posterior fossa malformations, hemangiomas, arterial anomalies, cardiac defects, eye abnormalities (PHACE) syndrome was noted in 20 of 38 (53%) children with segmental facial IH. Systemic therapy (corticosteroid or b-blocker) was given during infancy in 58 of 59 (98%) and 24 of 59 (41%) received systemic therapy (b-blockers) for late IH growth. Limitations:The retrospective nature and ascertainment by investigator recall are limitations of the study. Conclusion:Late IH growth can occur in children after 3 years of age. Risk factors include head and neck location, segmental morphology, and involvement of deep dermal/subcutaneous tissues.

Background/Objectives The development of psoriasis while on tumor necrosis factor inhibitors (TNFi) is a paradoxical effect of agents that treat psoriasis. There is a paucity of data available on this entity in juvenile idiopathic arthritis (JIA). Our objectives were to determine the prevalence of TNFi‐induced psoriasis in patients with JIA at two pediatric centers, and psoriasis response to therapeutic modifications. Methods We performed retrospective chart review on patients with JIA treated with TNFi (adalimumab, etanercept, infliximab) who developed psoriasis. TNFi‐induced psoriasis was defined as an incident diagnosis of psoriasis after starting a TNFi. Patients with personal histories of psoriasis prior to TNFi therapy were excluded. Following diagnosis, responses to medication changes were defined based on physician assessments. Results Nine of 166 (5.4%) patients on TNFi for JIA were diagnosed with TNFi‐induced psoriasis. All cases were female. One had a family history of psoriasis. The median age was 10 (range 2‐16) years. Five (55%) patients experienced scalp psoriasis, including four (44%) with alopecia. Two (22%) patients achieved significant improvement after switching to different classes of biologic agents, while three (33%) patients had significant improvement following discontinuation of biologic therapy. One of five patients who switched to a different TNFi had complete resolution, while four had worsening symptoms or partial improvement. Conclusions Our findings demonstrate the prevalence of TNFi‐induced psoriasis in JIA at two centers. Though larger studies are needed, our data suggest discontinuation of TNFi or biologic class switching should be considered as treatment strategies in select patients.