CUTIS. Dermoscopy was developed as an adjunctive. Do Not Copy

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1 A Pilot Tril of Dermoscopy s Rpid Assessment Tool in Peditric Dermtoses Nnette B. Silverberg, MD Dermoscopy is noninvsive technique to ssess skin rchitecture. A pilot study ws conducted using polrized dermoscopy s tool to monitor the peditric skin brrier. Ten peditric ptients (ge rnge, 1 14 yers) with mild to moderte topic dermtitis (AD), ichthyosis vulgris (IV), nd/or kertosis pilris (KP) prticipted in 4-week clinicl tril. After week of emollient usge lone, mid-potency topicl corticosteroid crem ws dded twice dily if necessry to tret erythem, dermtitis, or pruritus. The prticipnts were ssessed t weeks 0, 1, nd 4 using the eczem re nd severity index (EASI) for topic dermtitis, investigtor globl ssessment for topic dermtitis, children dermtology life qulity index (CDLQI), nd clinicl nd dermoscopic photogrphy. Dermoscopic ppernce demonstrted derml vsculr ectsi in AD nd KP, hyperkertosis nd prominence of the interkertinocyte spce in AD nd IV, nd widening of the folliculr orifice in KP. Improvements in these dermoscopic bnormlities were noted fter emollient usge, mirroring improvements in clinicl ppernce, EASI, nd CDLQI. Dermoscopy is promising tool to ssess loclized improvement in skin rchitecture in peditric dermtoses. Further studies nd development of scoring systems will be needed to pply this technology to clinicl prctice. Cutis. 2011;87: Dermoscopy ws developed s n djunctive tool in the evlution nd follow-up of melnocytic processes of the skin. Dermoscopy cn be conducted either with lens tht requires oil or with polrized light ttchment. 1 This ltter form of dermoscopy is esier to perform, s it is not messy nd cn be performed using lens ttchment for digitl cmer. Dermoscopy hs been described s n djunctive gent in the ssessment of wide vriety of peditric skin conditions in which mgnifiction- improved visuliztion of smll lesions, such s infesttions (eg, scbies, 2 lice 3 ), is needed. Becuse dermoscopy cn llow for visuliztion of both epiderml nd derml elements in the skin, usge hs been pplied in peditric dermtology to vriety of conditions in which the derml component plys n importnt role, such s vsculr disorders (eg, ngiom serpiginosum, 4 port-wine stins 5 ). Atopic dermtitis (AD), ichthyosis vulgris (IV), nd kertosis pilris (KP) re 3 peditric dermtoses with notble brrier ltertions mnifesting s xerosis. Although AD hs number of vlidted scores, difficulty exists for IV nd KP becuse of underrecognition nd lck of scoring systems. 6,7 The im of this study ws to look t whether dermoscopy could id in ssessment of these 3 clinicl conditions nd whether improved dermoscopic ppernce ws reflective of clinicl disese stte improvement. From the Deprtment of Dermtology, St. Luke s-roosevelt Hospitl Center, New York, New York, nd Columbi University College of Physicins nd Surgeons, New York, New York. This study ws supported by n unrestricted eductionl grnt from Expnscience Lbortories. Dr. Silverberg hs been speker for Expnscience Lbortories. This study ws presented t the 34th Annul Meeting of the Society for Peditric Dermtology; July 9 12, 2008; Slt Lke City, Uth. Correspondence: Nnette B. Silverberg, MD, Deprtment of Dermtology, St. Luke s-roosevelt Hospitl Center, 1090 Amsterdm Ave, Ste 11D, New York, NY (nsilverb@chpnet.org). Mterils nd Methods Ten peditric ptients (ge rnge, 1 14 yers) were sequentilly enrolled over 2 months bsed on their clinicl dignosis of mild to moderte AD, IV, nd/or 148

2 KP. Ptients nd prents/gurdins were required to provide informed consent to prticipte in 4-week clinicl tril pproved by the St. Luke s-roosevelt Hospitl Center institutionl review bord. Prticipnts were instructed to clense once dily with Mustel Steltopi Crem Clenser nd pply Mustel Steltopi Moisturizing Crem twice dily. Atopic dermtitis ws dignosed bsed on the criteri of Hnifin nd Rjk, 8 nd dignosis of IV ws mde bsed on moderte to severe hyperkertosis nd hyperlinerity of the nterior shins nd plmr hyperlinerity. The dignosis of KP ws mde bsed on the presence of kertotic folliculr ppules of the upper rms, upper thighs, nd/or cheeks. Exclusion criteri included sensitivity or llergy to ny ingredient of the topicl products, inbility to comply with the protocol, or inbility to withdrw from topicl corticosteroids. Prticipnts discontinued prior emollient or topicl prescription therpy usge prior to study initition. For the first week, prticipnts were instructed to pply only the products provided; fter the initil week of emollient use, prticipnts with AD or KP could dd prescription topicl corticosteroid (hydrocortisone butyrte crem 0.1% or fluticsone Ichthyosis vulgris (lone) 1 Kertosis pilris (lone) 3 Atopic dermtitis/ 1 ichthyosis vulgris propionte crem 0.05%) if necessry for erythem, dermtitis, or pruritus. The prticipnts nd prents/ gurdins were given Mustel Steltopi Crem All 3 dignoses 1 Clenser nd Moisturizing Crem, which contin sunflower oil distillte. Prticipnts were evluted t weeks 0, 1, nd 4 by clinicl evlution nd Age, y scoring scles including the eczem re nd severity index (EASI) 9,10 nd investigtor globl Rnge 1 14 ssessment, which gives the investigtor s overview of the severity of AD on 5-point scle. Presence of sleep disturbnce nd presence of pruritus were ssessed. Additionlly, ll prticipnts nd prents/ gurdins completed the children dermtology life qulity index (CDLQI) t ech visit. 11 Photogrphy ws performed using Cnon Power Shot A630 digitl cmer nd dermtoscopic lens ttchment with n optionl polrized light source, the DermLite Foto ttchment, which provides 43 to 163 mgnifiction nd 25-mm visul field of view. Trnsepiderml wter loss (TEWL) ws mesured with the VpoMeter, closed unventilted chmber system. 12 Three mesurements of TEWL (g/m 2 h) were tken both for unffected nd ffected skin nd were then verged. Results The demogrphics of the prticipnts re reviewed in Tble 1. Two prticipnts hd overlpping dignoses. All 3 prticipnt groups experienced clinicl, scoring, qulity of life, dermoscopic, nd TEWL improvements fter emollient usge with Mustel Steltopi Moisturizing Crem products both before nd fter the ddition of djunctive medictions. Trnsepiderml wter loss for ll 3 skin conditions (n58) improved both for unffected volr Tble 1. Prticipnt Demogrphics Dignosis, n Atopic dermtitis (lone) 4 Men 4.9 Prticipnts VOLUME 87, MARCH Sex, n Femle 6 Mle 4 Ethnicity, n Hispnic 5 Asin 2 Cucsin 2 Africn Americn 1

3 forerm skin nd for ffected skin sites (Tble 2). Trnsepiderml wter loss could not be obtined in 2 prticipnts younger thn 2 yers due to movement rtifct. For ese of review, the results hve been broken down by disese stte. Atopic Dermtitis Atopic dermtitis results re summrized in Tble 3. All prticipnts with AD demonstrted derml erythem, prominent derml vsculture, prominence of the interkertinocyte spces, nd epiderml hyperkertosis (Figure 1). One prticipnt lso demonstrted hyperkertosis t the tip of the hir follicles. Reductions in bckground erythem, interkertinocyte spce prominence, nd hyperkertosis were noted fter therpy, mirroring reductions in EASI, CDLQI, nd TEWL. Ichthyosis Vulgris Dt for the IV prticipnts re shown in Tble 4. The topic scores pply to only the 2 prticipnts with comorbid AD. Averge EASI scores trended slightly higher for the first 2 visits for AD prticipnts with IV (5.4 nd 2.5, respectively) thn those without IV (5.1 nd 2.2, respectively), but the number of prticipnts is too smll to drw true conclusion. The following prmeters were noted under dermoscopy: prominence of liner dermtoglyphic ptterning, rised or rgged kertinocyte borders, bckground erythem, nd presence of dull sheen. Physicl fetures re exemplified in Figure 2. Notble improvements in the skin microrelief pttern in IV prticipnts were seen, s demonstrted in Figure 3. Tble 2. TEWL for All Conditions Before nd After Therpy TEWL Bseline Week 1 Week 4 Unffected skin, g/m 2 h Affected skin, g/m 2 h Abbrevition: TEWL, trnsepiderml wter loss. Eight prticipnts evluted; TEWL could not be obtined in 2 prticipnts ged,2 yers. Tble 3. Prmeters Mesured in Atopic Dermtitis Prticipnts Prmeter Assessed Bseline Week 1 Week 4 EASI score IGA score b CDLQI Abbrevitions: EASI, eczem re nd severity index; IGA, investigtor globl ssessment; CDLQI, children dermtology life qulity index. The finl scores represent the cumultive results fter usge of Mustel Steltopi Crem Clenser nd Moisturizing Crem for 4 weeks, with usge of topicl clss V corticosteroids s needed for 3 weeks. b IGA score rnged from 0 (cler) to 5 (very severe disese)

4 Figure 1. Typicl ppernce of topic dermtitis under dermoscopy with prominence of interkertinocyte spces nd hyperkertosis. Kertosis Pilris Dt for KP prticipnts re shown in Tble 5. Kertosis pilris prticipnts demonstrted bckground derml vsculr ectsi nd folliculr hyperkertosis, ppering s widening nd irregulr-sized tips of the hir follicles of the ffected res; these fetures improved with emollient ppliction. esily visulized; hence, it is well-suited to identify folliculr hyperkertosis nd other rised lesions of the skin. With polriztion, deeper structures such s the vsculture re well-visulized. 1 The brrier hs been noted to be n essentil prt of the pthophysiology of AD, IV, nd KP ,14 Specificlly, muttions in the gene encoding filggrin hve been noted to prticipte in AD nd IV, cusing ssocited brrier bnormlities. 15,16 Furthermore, bnormlities in qulity of life, TEWL, nd clinicl disese severity hve been noted to correlte with ech other in the scoring nd evlution of AD Dermoscopy provides good mgnifiction of kertinocytes nd the surfce brrier structures; in IV, polriztion seems to enhnce visuliztion of irregulr kertinocyte borders. Dermoscopy lso helps to obvite underlying vsculr ectsi nd erythem, which ids in identifying ptients with kertosis pilris rubr fceii. 2 Dermoscopy lso demonstrted reductions in the following prmeters: bckground erythem, hyperkertosis, nd interkertinocyte spce prominence in prticipnts with AD, IV, nd KP. Eczem re nd severity index, CDLQI, nd TEWL lso improved. Given the overlp of genetic bnormlity of the filggrin gene in AD nd IV, similr rchitecturl ppernce under dermoscopy is not surprising. 14,15 Do Not This study Copy demonstrtes tht the dermoscopic Comment ppernce of AD nd IV, even in the bsence of Dermoscopy is useful djunct to peditric dermtology prctice in the evlution of pigmented chnges, nmely prominence of the interkertino- clinicl overlp, demonstrte similr dermoscopic nd vsculr lesions. 13 When performed without cyte spce nd hyperkertosis. Under dermoscopy, polriztion, superficil or epiderml structures re the presence of rgged-edge kertinocytes with Tble 4. Prmeters Mesured in Ichthyosis Vulgris Prticipnts Prmeter Assessed Bseline Week 1 Week 4 EASI score (n=2) b IGA score c CDLQI Abbrevitions: EASI, eczem re nd severity index; IGA, investigtor globl ssessment; CDLQI, children dermtology life qulity index. The finl scores represent the cumultive results fter usge of Mustel Steltopi Crem Clenser nd Moisturizing Crem for 4 weeks, with usge of topicl clss V corticosteroids s needed for 3 weeks. b Scores for 2 prticipnts with comorbid topic dermtitis. c IGA score rnged from 0 (cler) to 5 (very severe disese). VOLUME 87, MARCH

5 A B Figure 2. The right shin of 9-yer-old Asin girl with untreted ichthyosis vulgris demonstrted prominence of the skin lines (A). Dermoscopy of the shin re demonstrted extreme prominence nd rgged ppernce of the interkertinocyte spce nd irregulr kertinocyte borders (B). A B Figure 3. After 4 weeks of usge of Mustel Steltopi Moisturizing Crem, clinicl (A) nd dermoscopic (B) improvements were noted. The interkertinocyte spce ws less prominent nd irregulr kertinocytes were no longer noted, which equte to reduction in children dermtology life qulity index from 13 to 4. irregulr shpes seems to be limited to IV prticipnts, but the number of prticipnts in the pilot tril cnnot exclude overlp of this finding s well. Notble improvements in dryness, desqumtion, nd roughness hve been described in AD ptients using Mustel Steltopi Moisturizing Crem contining sunflower oil distillte, 17 which hs been shown to hve nti-inflmmtory properties These clinicl improvements re reflected by dermoscopic improvements in kertinocyte shpe, reductions in folliculr hyperkertosis, nd improvements in the ppernce of interkertinocyte spces. Dermoscopy ppers to be ble to identify underlying improvements in cutneous dermtoses. Although the smple size ws smll in this clinicl tril, the improvements in brrier stte re both notble nd reflective of the overll EASI nd CDLQI score; however, the popultion size is not lrge enough to ssess sttisticl significnce. The bsence of n IV score in the generl literture is due to difficulty in quntifiction of loclized disese severity. Usge of dermoscopy llows for the first visully quntifible prmeters of loclized disese severity for IV ptients. Recognition of underlying IV lso my be useful s severity mrker in topy, thus dermoscopic nlysis of trget res, such s the nterior shins, my be useful djunct to AD cre

6 Tble 5. Prmeters Mesured in Kertosis Pilris Prticipnts Prmeter Assessed Bseline Week 1 Week 4 EASI score (n=1) b IGA score c CDLQI Abbrevitions: EASI, eczem re nd severity index; IGA, investigtor globl ssessment; CDLQI, children dermtology life qulity index. The finl scores represent the cumultive results fter usge of Mustel Steltopi Crem Clenser nd Moisturizing Crem for 4 weeks, with usge of topicl clss V corticosteroids s needed for 3 weeks. b Scores for 1 prticipnt with comorbid topic dermtitis. c IGA score rnged from 0 (cler) to 5 (very severe disese). Further testing of interobserver differences nd reproducibility will be required in the future. Lrgerscle vlidtion of dermoscopy s solo tool for evlution of brrier-bsed skin disese lso will need to be performed. Conclusion Dermoscopic photogrphy with or without polrized light cn be used to demonstrte improvement in skin helth, such s improvements seen fter emollient usge for AD, IV, nd KP. Dermoscopic evlution of ll 3 conditions demonstrtes irregulr 2007;143:962. or rgged kertinocytes, prominence of the interkertinocyte spce, nd folliculr hyperkertosis. Prominent bckground erythem is notble in mny AD nd KP ptients, while kertinocyte irregulrities re more prominent in ptients with IV. This pilot study identifies severl wys in which dermoscopy my id in disese ssessment nd follow-up for ptients with AD, IV, nd KP, nmely presence of erythem, kertinocyte shpe nd regulrity, nd folliculr prominence. Dermoscopic improvements in erythem nd skin microrelief my prove useful to reflect improvements in TEWL, reduced sleep disturbnce nd pruritus, improved qulity of life, nd improved physicl ppernce, though lrger ptient subsets would be needed to vlidte this method. REFERENCES 1. Pn Y, Greu DS, Scope A, et l. Polrized nd nonpolrized dermoscopy: the explntion for the observed differences. Arch Dermtol. 2008;144: Executive Committee of Guideline for the Dignosis. Guideline for the dignosis nd tretment of scbies in Jpn (second edition). J Dermtol. 2008;35: Di Stefni A, Hofmnn-Wellenhof R, Zludek I. Dermoscopy for dignosis nd tretment monitoring of pediculosis cpitis. J Am Acd Dermtol. 2006;54: Ilknur T, Fetil E, Akrsu S, et l. Angiom serpiginosum: dermoscopy for dignosis, pulsed dye lser for tretment. J Dermtol. 2006;33: Vázquez-López F, Coto-Segur P, Fueyo-Csdo A, et l. Dermoscopy of port-wine stins. Arch Dermtol. 6. Bremmer SF, Hnifin JM, Simpson EL. Clinicl detection of ichthyosis vulgris in n topic dermtitis clinic: implictions for llergic respirtory disese nd prognosis [published online hed of print My 2, 2008]. J Am Acd Dermtol. 2008;59: Mrqueling AL, Gillim AE, Prendiville J, et l. Kertosis pilris rubr: common but underrecognized condition. Arch Dermtol. 2006;142: Hnifin JM, Rjk G. Dignostic fetures of topic dermtitis. Act Derm Venereol (Stockh). 1980;92(suppl): Brbier N, Pul C, Luger T, et l. Vlidtion of the Eczem Are nd Severity Index for topic dermtitis in cohort of 1550 ptients from the pimecrolimus crem 1% rndomized controlled clinicl trils progrmme. Br J Dermtol. 2004;150: Schmitt J, Lngn S, Willims HC; Europen Dermto- Epidemiology Network. Wht re the best outcome mesurements for topic eczem? systemtic review [published online hed of print October 1, 2007]. J Allergy Clin Immunol. 2007;120: Hon KL, Wong KY, Leung TF, et l. Comprison of skin hydrtion evlution sites nd correltions mong skin VOLUME 87, MARCH

7 hydrtion, trnsepiderml wter loss, SCORAD index, Nottinghm Eczem Severity Score, nd qulity of life in ptients with topic dermtitis. Am J Clin Dermtol. 2008;9: De Pepe K, Houben E, Adm R, et l. Vlidtion of the VpoMeter, closed unventilted chmber system to ssess trnsepiderml wter loss vs. the open chmber Tewmeter. Skin Res Technol. 2005;11: Duchrme EE, Silverberg NB. Selected pplictions of technology in the peditric dermtology office. Semin Cutn Med Surg. 2008;27: Gupt J, Grube E, Ericksen MB, et l. Intrinsiclly defective skin brrier function in children with topic dermtitis correltes with disese severity [published online hed of print Februry 4, 2008]. J Allergy Clin Immunol. 2008;121: Enomoto H, Hirt K, Otsuk K, et l. Filggrin null muttions re ssocited with topic dermtitis nd elevted levels of IgE in the Jpnese popultion: fmily nd cse-control study [published online hed of print June 3, 2008]. J Hum Genet. 2008;53: Smith FJ, Irvine AD, Terron-Kwitkowski A, et l. Lossof-function muttions in the gene encoding filggrin cuse ichthyosis vulgris [published online hed of print Jnury 29, 2006]. Nt Genet. 2006;38: Piccrdi N, Piccirilli A, Choulot J, et l. Sunflower oil oleo distillte for topy tretment: n in vitro nd clinicl evlution. J Invest Dermtol. 2001;117:A Dubusquoy L, Piccrdi N, Msik P, et l. Sunflower oleodistillte new nturl PPAR ctivtor with nti-inflmmtory properties. J Invest Dermtol. 2005; 124(4S):A Msik P, De Belilovsky C, Chdoutud B, et l. New nturl PPAR- gonist for childhood topic dermtitis: dermocorticoid-spring nd qulity. Poster presented t: 65th Annul Meeting of the Americn Acdemy of Dermtology; Februry 1-5, 2007; Wshington, DC