▸ What can be done about melanoma in children? The incidence of melanoma in children is low but rising. In children, the disease can present as nodular lesions and amelanotic lesions, and it can be mistaken for pyogenic granuloma. Risk factors include a family history of melanoma, large numbers of moles, atypical moles, fair skin, freckling, red hair, sun exposure, and BRAF and NRAS activating gene mutations in tissue (Oncogene 2003;22:305362; Am. J. Hum. Genet. 2003;73:30113).
The most effective treatment is high-dose interferon alpha-2b. Some data suggest that the younger the patient, the greater the likelihood of event-free survival (Cancer 2005;103:7807).
▸ How can children be protected from the sun? "I always emphasize physical protection," Dr. Friedlander said. "Get the cap out, get the clothing out, and reserve the sunscreen for areas you can't cover." Sunscreens should provide UVA protection as well as UVB. Good options include Helioplex (Neutrogena), which contains a new stabilizer at strengths of SPF 30 and 45, and Anthelios (La Roche Posay), which contains mexoryl, SPF 15, she said.
Although it's been found that a little sun exposure is good for getting vitamin D, consider food alternatives, including milk, Dr. Friedlander said.
▸ Hemangiomas: Which ones may lead to a complication? The problem hemangiomas are those that are large, segmental, located on the face, and/or that obstruct a vital function. The number of hemangiomas may increase risk, particularly if there are more than six or seven, she said.
Therapy includes "watchful waiting" and the use of systemic prednisolone (23 mg/kg per day).
Orapred 15 mg/5 mL tastes better. It should be given in the morning for 48 weeks and then tapered as much as possible. This is effective in 84% of patients with hemangioma of infancy, Dr. Friedlander said.
Other options include the use of topical class 1 steroids (clobetasol) and intralesional corticosteroidsbut beware that the latter can cause thromboses of the eye.
Another option is laser therapy, but not as first-line treatment. Difficult cases may be treated with vincristine, but it is phlebitic, she said.
Large facial hemangiomas require a careful physical exam, eye exam, and cardiac exam with echocardiography. Consider cranial magnetic resonance angiography and be aware of long-term vasculo-occlusive risks.
Hemangiomas that present in a "beard distribution" may mark underlying airway hemangiomas that compromise the airway.
For these, short courses of oral steroids may improve for a while but also may delay diagnosis. Pay attention also to midline and sacral lesions.
Ulcerated hemangiomas can be treated with saline compresses, topical antibiotics (mupirocin, Bacitracin, metronidazole), occlusive dressings (DuoDERM, Vigilon, OmniDerm), pulsed dye laser therapy, systemic and intralesional steroids, excision, and 0.01% topical Becaplermin, Dr. Friedlander said.
▸ How about pediatric onychomycosis? Topical treatment options include ciclopirox, amorolfine lacquer, bifonazole with 40% urea, and topical terbinafine.
Terbinafine 5 mg/kg per day can be used for the fingernails 6 weeks or toenails 12 weeks, but don't exceed 250 mg.
Fluconazole 6 mg/kg can be used once per week for 12 weeks on the fingernails and 26 weeks on the toenails.
Itraconazole caps 5 mg/kg per day pulse therapy can be usedtwo pulses for the fingernails and three pulses for the toenails, she said.
▸ What can be done about atopic dermatitis? "Corticosteroids are very helpful, but they can cause thinning of the skin and skin atrophy," she said. "And if too much is absorbed, they can cause stunting of growth; so we have to be careful when we use them."
There is an emerging class of topical agents that focuses on barrier functionphysiologic moisturizers. Options include ceramide formulations in special delivery systems (Cerave, Epiceram); palmitoylethanolamide (PEA); MimyX, a cream containing endogenous fatty acid; and glycyrrhetinic acid/hyaluronic acid/shea butter combination cream (Atopiclair). "They're very expensive," she cautioned. "You should start out with Vaseline or Aquaphor."
Dr. Friedlander disclosed that she is a speaker on the speakers' bureau, a consultant, and/or involved with clinical research trials for the following companies: Novartis, Connetics Corp., Astellas Pharma Inc., Dermik Laboratories, and Graceway Pharmaceuticals.