Innovative Therapeutics in Pediatric Dermatology

Although clinical trials for new drugs are often limited in children because of safety concerns or restrictions, new therapies or novel strategies with old drugs have recently expanded dermatologic armamentarium for pediatric patients. Oral propranolol is currently the first choice in the treatment of alarming infantile hemangiomas. In atopic dermatitis, proactive strategy with topical calcineurin inhibitors can safely prevent disease exacerbation. Tacrolimus, in particular, is also useful for the treatment of vitiligo occurring in sensitive areas such as the eyelids. Among biologic drugs, use of etanercept is safe and efficient in children and adolescents with moderate-to-severe plaque psoriasis. Engineered tissues with special antimicrobial properties (silver-coated fabrics or engineered silk) are now used to treat eczema and fungal diseases in children. In athlete’s foot, the use of 5-finger socks can also be helpful.

Despite a plethora of new drugs for sundry dermatologic disorders, the armamentarium for pediatric patients remains limited because clinical trials often exclude this age group. Nevertheless, advances in understanding the physiology and molecular biology of infantile skin are improving the therapy for some pediatric and adolescent skin conditions. Advances have been observed in the following areas: infantile hemangiomas (IHs), atopic dermatitis (AD), cutaneous infections, and autoimmune dermatoses. Present and future approaches to some genetic skin diseases are also forthcoming.

Angiomas

IHs, among the most common tumors affecting children, most often arise in the first days or weeks after birth. Most IHs are benign vascular neoplasms with a self-limited course and transient cosmetic disfigurement. However, a significant minority of such lesions may cover an extensive surface (segmental hemangiomas) or may occur in sensitive and important areas (periorificial) and thus may cause major problems and require appropriate treatment. Complex cases include broad facial IH (including PHACE [ p osterior fossa malformations, h emangiomas, a rterial anomalies, c oarctation of the aorta and other cardiac defects, and e ye abnormalities] syndrome), periorbital and retrobulbar IH (associated with a risk of amblyopia), mandibular and central neck IH (with a potential for concomitant airway hemangiomas), and lumbosacral/perineal IH (including SACRAL [ s pinal dysraphism, a nogenital, c utaneous, r enal and urologic anomalies, associated with an a ngioma of l umbosacral localization]/PELVIS [ p erineal hemangioma, e xternal genitalia malformations, l ipomyelomeningocele, v esicorenal abnormalities, i mperforate anus, and s kin tag] syndrome, with potential risk for tethered spinal cord and/or genitourinary anomalies). All these should be managed in a multidisciplinary manner.

For uncomplicated IH, compression alone or in combination with other treatments (eg, glucocorticoids, laser ablation) is a well-established treatment regimen. However, this plan may be limited by the ease with which the treatment is applied, especially in neonates. In fact, the traditionally used pressure garments provide adequate compression, but they need to be custom-made and are usually expensive. Moreover, they are characterized by compliance difficulties with regards to comfort, restricted movement, and unsightly appearance; use of these garments can sometimes burden parents with psychosocial distress. Thus, pressure garments are generally used for lesions likely to cause important disfigurement. Another limitation of pressure garments is that they cannot be used to treat lesions in the periorificial area and must be avoided on lesions of the head until the fontanelles have closed because of the risk of bone deformity. Elastic bandages and Coban wraps (3M, St Paul, MN, USA) are more practical and have been used successfully but are suitable only for lesions located on the limbs.

Self-adhesive polyurethane strips designed for the treatment of hypertrophic scars can also be used to achieve mild yet effective compression of small (<5 cm), superficial, nonulcerated IHs. These strips (Hansaplast Scar Reducer, Beiersdorf, Germany) are elastic, self-adhesive, and almost transparent and can be cut to precisely fit the lesion. The method of use consists of stretching the strip sufficiently beyond the limits of the lesion before application so as to provide adequate compression. Flattening and blanching of the IH will indicate the correct application of the strip ( Figs. 1 and 2 ). After use, the strip is usually removed with ease without leaving adhesive residue. The strip can be used on almost all body parts and easily adapted to fit areas difficult to compress with elastic garments, such as the periorbital and zygomatic regions. The treatment is well tolerated except for rare, mild local irritation. Moreover, parents are often pleased to “do something” for the angioma in the child that does not involve the use of drugs. In the treatment of IH, the strip should be applied for 12 hours daily throughout the expansive phase of the lesion. Despite some obvious restrictions (IH located in diaper area, lips, eyelid, and areas without an underlying bony structure; large or deeply located lesions), in the authors’ experience, the compression obtained with this technique can be useful in selected cases (Restano and Gelmetti, personal observation, 2009). Although the efficacy of this method has clear limits, its safety and ease of use make it a useful tool in the broad spectrum of treatment of IH.