Background/Objective: Atopic dermatitis (AD) in early childhood involves microbial dysbiosis. Skin and nasal microbiomes have been linked to AD severity, but not yet in an African cohort. Here, we aimed to explore how urban and rural stratification, disease severity, and inter-site bacterial overlap shape the skin and nasal microbiomes of children with AD in South Africa (ZA). Methods Children were recruited from urban Cape Town (CT) and rural Umtata (UM), ZA. We profiled the skin and nasal microbiomes of 197 children (87 healthy, 110 with AD; ages 12–36 months), totaling 502 samples, including both lesional and non-lesional skin sites in children with AD, in a cross-sectional study design. We used 16S rRNA V4–V5 sequencing for its accessibility and scalability to large sample sets. To address the limited species- and strain-level resolution of 16S data, we applied random forest (RF) machine-learning models to classify AD status with amplicon sequence variants (ASVs). We analyzed microbiome composition and diversity stratified by environment. Results We found that RF models could predict AD status using both skin and nasal microbiomes ( AUCs: skin = 0.70–0.82; nasal = 0.68 ), strongly driven by both Streptococcus and Staphylococcus . The correlations between skin–nasal microbiome were significantly stronger in children with AD compared to healthy controls, with overall higher correlations observed in rural UM (healthy r = 0.44 to AD r = 0.69 ) compared to urban CT (healthy r = 0.34 to AD r = 0.65 ). The skin microbiome diversity was higher in children from rural UM with healthy skin than those from urban CT ( p = 0.0012 ). However, children with AD in both groups showed significant alterations in their microbiome, with those in rural UM exhibiting greater beta diversity ( p = 0.001 ) than their urban CT counterparts ( p = 0.002 ). Conclusion In children with AD in South Africa, the environmental context is associated with microbial dysbiosis, and skin–nasal microbiomes reflect shared reservoirs. These findings highlight the value of geographically diverse studies with skin and mucocutaneous sampling in understanding pediatric AD.

Background: Parent/guardian engagement is central to broad sustained efforts to reduce sunburns in children and prevent skin cancer. A recent community survey conducted by the Census estimated that 1 in 5 people living in the US speak languages other than English at home. For these families, poor communication and language barriers may undercut efforts to prevent skin cancer.

What is known about this subject in regard to women and their families? Female adolescents are disproportionally affected by hidradenitis suppurativa (HS), leading to significant physical impairment and psychosocial distress. Uncontrolled pain is commonly reported in adult women with HS who seek care in the emergency department; however, data in pediatric patients is limited. What is new from this article as messages for women and their families? For female adolescents with HS, pain is a frequently reported symptom in the emergency department. Evidence-based guidelines for pain management in adolescent patients with HS are needed to optimize pain control and decrease reliance on HS-related care by emergency department providers. Most studies to date that have addressed emergency care and pain management in the setting of Hidradenitis suppurativa (HS) have focused on adults and provide scant if any data on pain management in adolescents.1–4 To better understand how pain associated with HS is managed in emergency settings, we performed a cross-sectional study of all patients between 13 and <19 years of age seen in the Rady Children’s Hospital-San Diego emergency department (ED) for HS-related care between February 2011 and February 2021. Patients outside of the age range at the time of the initial ED visit and without a documented diagnosis of HS were excluded. Patient demographics, documented pain scores (0–10 scale, from the pain visual analog scale), prescribed pain medications, medical vs. surgical management, and follow-up data were collected and analyzed. This study was approved by University of California San Diego Institutional Review Board. HS-related ED visits were documented in 95 patients and accounted for a total of 193 visits. Patients were mostly female 78.9% (n = 75) and identified as Hispanic/Latino 66.3% (n = 63), Non-Hispanic White 11.6% (n = 11), and Black/African American 17.9% (n = 17) (Table 1). Compared with other adolescent patients with HS, those who received care in the ED were younger (14.9 years vs 16.4 years) and made up of a higher portion of individuals who identified as Black/African American (17.9% vs 6.8%) and Hispanic/Latino (66.3% vs 53.4%). Few patients (n = 15, 15.8%) were hospitalized. The majority (85.3%) did not have a documented HS diagnosis on the initial ED encounter. Depression was present in 11.6% (n = 11) of patients with HS-associated ED visits compared to 10.0% (n = 40) in the entire HS adolescent cohort. Of the 193 ED visits, 43.5% (n = 84) were managed surgically with incision and drainage or excisional debridement. Table 1 - Adolescents with a diagnosis of HS and ED care Patient characteristic Adolescents with a diagnosis of HS who received care in ED (N = 95) Adolescents with a diagnosis of HS who did not receive care in ED (N = 399) P-value* Average age at HS diagnosis, years (range) 14.9 (13.0–18.6) 16.4 (13.0–18.9) <0.001* Sex, N (%) 0.96 Male 20 (21.1) 85 (21.3) Female 75 (78.9) 314 (78.7) Ethnicity/race, N (%) <0.001* Hispanic or Latino 63 (66.3) 213 (53.4) Asian and Pacific Islander 0 (0) 13 (3.3) Black/African American 17 (17.9) 27 (6.8) Non-Hispanic White 11 (11.6) 91 (22.8) Other/decline to answer 4 (4.2) 55 (13.8) Mood disorders, N (%) 0.66 Depression 11 (11.6) 40 (10.0) Anxiety 7 (7.4) 20 (5.0) ED, emergency department; HS, hidradenitis suppurativa.*P < 0.05 was considered statistically significant. The mean recorded pain score in the ED was 6 (SD 3.5) with pain medications administered in 47.9% (n = 90) of encounters (Fig. 1). The most common pain medication administered in the ED was ibuprofen (29.3%), followed by hydrocodone-acetaminophen (10.1%) and acetaminophen (7.4%). The mean pain score for the procedure group was 7 (SD 3.1) whereas those managed conservatively was 5 (SD 3.6). Among the patients who were prescribed pain medications at discharge (23.8%, n = 43 ED visits), ibuprofen was most common (8.8%), followed by hydrocodone-acetaminophen (7.3%) and acetaminophen (3.1%). Of the 73 patients (76.8%) with documented follow-up after discharge at the initial ED encounter, 42 patients were seen by general surgery, 28 by dermatology, 3 by plastic surgery, and 1 by gynecologic surgery. Patients with 3 or more ED visits (n = 18) were more likely to be hospitalized at some point in their care (P = 0.04) and ultimately receive care from a dermatologist (P = 0.03).Fig. 1.: Pain score distribution during HS-associated emergency department visits (n = 151 with available pain scores).For adolescent patients with HS, pain is a frequently reported symptom in the ED. Emergency care providers appear central to coordinating procedural intervention and outpatient follow-up for this population. The disparate utilization of ED services that we observed in part reflects the relatively high proportion of youth identified as Black/African American and Latino/Hispanic diagnosed with HS in the San Diego metropolitan area.5 Structural alternatives are needed to better address patient well-being and barriers to accessing appropriate care. Definitive HS diagnosis nearer to symptom onset, counseling regarding the appropriate use of non-steroidal anti-inflammatory drugs for pain control, and coordination between pediatric specialties (general surgery and dermatology) have the potential to yield better care for adolescent patients living with HS. Conflicts of interest None. Funding This study was supported through the Department of Dermatology at University of California San Diego (to GKH). Study approval Reviewed and approved by University of California San Diego IRB; approval #200845. Author contributions HP: Research design, writing of the article, performance of research, data analysis. CV: Research design, performance f research, writing of the article. KP, KN, and EK: Research design, performance of research. RI: Research design, writing of the article, data analysis, supervision. GH: Research design, writing of the article, performance of research, data analysis, and supervision. Acknowledgments We would like to thank the Research Informatics team at Rady Children’s Hospital, San Diego for performing EPIC SlicerDicer-based data extractions.

Nodular fasciitis (NF) is a myofibroblastic proliferation that is uncommonly present in pediatric patients. These benign neoplasms can masquerade as more insidious sarcomatous proliferations on both clinical exam and initial histopathologic review, often prompting undue concern in patients, parents, and providers. While immunohistochemical analysis of NF can be variable, adding to the diagnostic uncertainty, molecular analysis documenting ubiquitin-specific protease 6 (USP6) gene rearrangement can help confirm the diagnosis as an association between NF and USP6 overexpression was first identified 10 years ago in an analysis that found rearrangements of the involved locus in over 90% of studied samples. In this report, we review one case of NF located on the chin of a nine-year-old girl in which molecular testing was essential to secure the correct diagnosis, and provide a summary of documented cases of USP6 overexpression in transient pediatric neoplasms.

Within the last decade, several new therapeutic agents for pediatric atopic dermatitis and psoriasis have begun to emerge, revealing the potential for a broader array of available treatments in the future. Therapies that have been available only for adult atopic and psoriatic disease may also soon become available for use in pediatric populations. Much remains to be learned via clinical trials regarding knowledge of therapeutic mechanisms and safety profiles in children when using immune modulating therapies. We sought to explore the current pediatric clinical trial landscape for atopic dermatitis and psoriasis to understand emerging directions in the therapeutic pipeline. A review of current clinical trials registered on ClinicalTrials.gov as of April 2022 was completed. Sixty-one of 88 actively-accruing atopic dermatitis studies were interventional or drug related studies; 7 were specific to phosphodiesterase inhibitors, 9 to JAK inhibitors, 12 were related to monoclonal antibody use in the pediatric population. Thirty-one of 42 psoriasis studies were drug or treatment related studies; 16 involved monoclonal antibodies in pediatric populations, 3 involved PDE4 inhibitors, and 1 involved JAK inhibitors. Studies in both atopic dermatitis and psoriasis are also underway involving alternative treatments such as herbal supplementation, both in topical and oral forms. Increased availability of injection, oral, and topical treatments for the management of pediatric atopic and psoriatic disease is imperative due to the existence of both severe and refractory disease in the pediatric population. For pediatric patients who do not appropriate improvement in their disease with standard management, it is imperative for pediatric dermatologists to have access to the same broad array of immunomodulating agents available in the adult population. Background: Hidradenitis suppurativa (HS) is known to have a significant impact on quality of life; however, less attention has been given to evaluating the effect of HS on educational outcomes and identifying teenagers with HS who might be at increased risk of poor school performance. Objective: To design an evidence-based algorithm tool to identify teenagers with HS who are at risk of poor school performance. Methods: We performed PubMed searches to identify published data on school performance among adolescent patients with HS. The following terms/strings were completed in PubMed — 1. (hidradenitis suppurativa) AND (pediatric OR adolescent) AND (school performance) 2. (hidradenitis suppurativa) AND (pediatric OR adolescent) AND (school attendance) 3. (hidradenitis suppurativa) AND (pediatric OR adolescent) AND (school activities) 4. (hidradenitis suppurativa) AND (pediatric OR adolescent) AND (patient reported outcomes). We also reviewed dermatology-specific patient reported outcomes validated for patients age 12 – 19. Results: Patient-reported outcomes may help elucidate risk of poor school performance and identify patients who would benefit from an individualized education plan (IEP). Consideration should be given to (1) querying patients regarding failing grades or failure to complete coursework and (2) administering the Teenager's Quality of Life Index (T-QoL) to all teenagers with HS. If the “ physical wellbeing and future aspirations ” domain subscore of the T-QoL is high, the last step in the algorithm Chi-square (categorical Mann U (numeric vari-ables), log rank (overall multivariate Cox regression (independent survival of the management of erythema of infancy (AEI) is a rare, benign disease characterized by enlarging annular patches and plaques that resolve spontane-ously. Histopathology typically demonstrates perivascular mixed lymphohistiocytic infiltrate with increased eosinophils. We present two cases of AEI and a review of the literature. 3), erythema (palmoplantar [ n = 2], chest [ n = 1], labial [ n = 1]), urticarial ( n = 2), pustular ( n = 1), reticular pur-pura ( n = 1), and petechial ( n = 1). Rashes in three patients were associated with desquamative changes. Patients also exhibited conjunctival injection and hand and/or feet edema. Kawasaki disease criteria were met in 11 (16.2%) patients. reported in the dermatologic literature in 1876 and classically described in the rash of secondary syphilis. We present a pediatric case of extragenital lichen sclerosus presenting with a corymbiform pattern. Additionally, we present results of a review of the literature in which we searched the adult and pediatric literature on extragenital lichen sclerosus to identify previously reported cases with a corymbiform pattern demonstrated in published photographs. In this review, we identified 29 additional cases of extragenital lichen sclerosus published in the English literature with photographs which we feel demonstrate the corymbiform pattern. Of these cases, 3.45% of authors described the pattern as corymbiform. Other terms used to describe this morphology included coalescing/agglomerating/confluent lesions in 20.7% of cases, well-defined/demarcated in 13.8% of cases, surround-ing atrophic changes/plaques in 6.89% of cases, jagged and demar-cated edges in 3.45% of cases, and satellite papules in 3.45% of cases. corymbiform is an under-reported and under-recognized pattern of presentation of extragenital lichen sclerosus. Dupilumab treatment is not associated with an increased overall risk of Background: Patients with atopic dermatitis (AD) present an increased risk of infections, including skin infections. Previous studies in children aged 6 to 11 years and adolescents showed that dupilumab is not associated with an increased risk of overall infections and is associated with lower risks of skin infections compared with placebo. Here we report the impact of dupilumab treatment on infections, including skin infections, in children aged 6 months to 5 years with moderate-to-severe AD. Methods: a to subcutaneous Background: Atopic dermatitis (AD) is heterogenous in distribution pattern. It can affect any anatomic site, and shifts in affected sites can be seen over time. In young children, this may present as localized severe disease, including on the face and neck. Methods: In LIBERTY AD PRESCHOOL, a double-blind, placebo-controlled trial (NCT03346434, part B), children aged 6 months to 5 years with moderate-to-severe AD (Investigator's Global Assessment score ≥ 3) were randomized 1:1 to subcutaneous dupilumab every 4 weeks (q4w; 200 mg if baseline weight ≥ 5 to <15 kg, 300 mg if ≥ 15 to <30 kg) or placebo with concomitant low-potency topical corticosteroids (TCS) for 16 weeks. Improvement in AD signs across anatomical regions was assessed using unweighted Eczema Area and Severity Index (EASI) body region scores (range 0 – 72). Results: 162 patients were randomized to dupilumab ( n = 83) or placebo ( n = 79). Baseline mean (standard error [SE]) imputed EASI body region scores in the dupilumab/placebo groups were: head, 28.8 (18.1)/24.5 (15.5); trunk, 29.7 (16.3)/27.8 (15.1); Epidermolysis bullosa (EB) is a rare multisystem genetic disease affecting the integrity of epithelial tissues. EASE (NCT03068780) was a randomized, Phase 3, double-blind, controlled study evaluating Oleogel-S10 (birch triterpenes) efficacy and safety vs control gel in patients with EB (N = 223). Patients with dystrophic EB (RDEB, DDEB) or junctional EB (JEB) with a partial thickness target wound (10-50 cm2, between 21-days-9-months duration) entered the study. The primary endpoint was met in the overall cohort with a higher percentage of first complete target wound closure within Day 45 with Oleogel-S10 vs control gel ( p = 0.013). We report analysis from the double-blind phase of EASE for the DEB subtype of EB, who comprised the majority population ( n = 195; 87.4%). Of these, almost 90% had recessive DEB (RDEB). In the DEB group ( n = 195), 44.3% on Oleogel-S10 vs. 29.6% on control gel achieved the primary endpoint of first complete target wound closure within Day 45 ( p = 0.017). At baseline, BSAP and EBDASI scores were comparable in both groups. At Day 90, BSAP improved from baseline to a greater extent with Oleogel-S10 vs control gel ( (cid:1) 4.4 vs (cid:1) 2.4) and EBDASI scores comparable (Oleogel-S10 – 3.9 vs control gel (cid:1) 3.5). Adverse events (AEs) were comparable in both groups (Oleogel-S10 80.4% vs control gel 77.6%); serious AEs were low (7.2% vs 5.1%) and related AEs were comparable (23.7% vs 20.4%). No patient deaths due to TEAEs were reported. Background: The ALLEGRO phase 2b/3 trial investigated the efficacy and safety of ritlecitinib, an oral JAK3/TEC inhibitor, in patients with alopecia areata (AA) up to 48 weeks. This subanalysis ritlecitinib in adolescent patients aged 12 17 years. includes a wide range of keratinizing disorders. We report response rates evaluated using Visual Index for Ichthyosis Severity (VIIS) and Investigator Global Assessment (IGA) scores in children and adults with X-linked recessive (XLRI) or autosomal recessive lamellar (ARCI-LI) ichthyosis following treatment with TMB-001, a novel topical isotretinoin ointment formulation. The primary aim of the current study is to investigate the incidence of chilblains before and during the pandemic. The secondary aim is to characterize the relationship between ambient temperature, community COVID-19 infection rates, and the onset of chilblains. identify local mean in and month prior chilblains onset infection rates as measured by the daily case rate per 100,000 and positivity rate, for the 30 and 60 days prior to chilblains onset and presentation to descriptive statistics to the frequency of chilblains and patient demographic characteristics. Additionally, the incidence of chilblains was correlated average and community infection rates pandemic patient during the pandemic. frequency of Atopic dermatitis is an disorder disparities in absenteeism in children with atopic dermatitis; on disparities in dermatology dysfun

Background There are no widely accepted pediatric guidelines on who should undergo biopsy of the nail apparatus to screen for subungual melanoma (SUM). Reported cases of pre-adolescent children diagnosed with SUM presenting as melanonychia remain controversial. Further, observed age differences in the incidence of acral lentiginous melanoma are complicated by reported ethnic differences in adult prevalence and survival rates. Methods We conducted a retrospective chart review of Rady Children’s Hospital San Diego, a tertiary hospital system, with over 2 million patients in its electronic health records to identify patients diagnosed with melanonychia younger than 12 years and biopsies in these children, between January 1, 2010, and July 31, 2021. Results There were 623,805 patients younger than 12 years of age seen in the outpatient setting. Average age was 7.2 years for melanonychia diagnosis, and 5.1 years for those biopsied. Nail apparatus biopsies were performed in 22 different individuals and involved the hand 17/22 (77%) and the foot 5/22 (23%). The presence of Hutchinson’s sign was documented in 9/22 (41%) patients. Males were diagnosed with melanonychia and underwent biopsy more often than females. Many of the biopsies were performed in Hispanic/Latino 11/22 (50%) and Asian/Pacific Islander 3/22 (14%) patients. Discussion Regardless of reported ethnicity, biopsy of nail apparatus is highly unlikely to uncover invasive ALM in children younger than 12 years. Prospective studies are needed to understand how incidence of melanonychia, age, gender, and ethnicity/race influence parental and clinicians’ perceptions of melanoma risk.

Pediatric hidradenitis suppurativa (HS) is a chronic inflammatory disorder that often occurs after puberty and can have a significant impact on quality of life and psychosocial health. Early diagnosis with carefully optimized holistic care are essential for improved outcomes in pediatric HS. In this review, we address diagnosis, epidemiology, associated comorbidities, and management of HS in the pediatric population.

Hidradenitis suppurativa (HS) is a chronic, dermatologic illness increasingly recognized in the pediatric population. For adolescents with HS, pain and scars can result in long-lasting psychosocial distress and functional impairment. Existing data on HS demonstrate that prevalence varies widely by race/ethnicity but there is no clear explanation as to why.1Garg A. Wertenteil S. Baltz R. Strunk A. Finelt N. Prevalence estimates for hidradenitis suppurativa among children and adolescents in the United States: a gender- and age-adjusted population analysis.J Invest Dermatol. 2018; 138: 2152-2156Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar In particular, studies of pediatric population with HS often fail to explore race as a social determinant of health. In contrast, use of neighborhood-level data in conjunction with patient demographics, such as race, allows for the consideration of environmental and socioeconomic factors that may otherwise function as unexplored confounders. To estimate the prevalence of adolescent population with HS at the neighborhood level in San Diego County, we performed an institutional review board-approved retrospective chart review of patients aged 15 to 19 years diagnosed with HS, seen between February 10, 2011, and February 10, 2021, at Rady Children's Hospital. Individuals with International Classification of Diseases, Tenth Revision code-based diagnosis of HS were identified and their current home addresses were converted to a US Census Bureau defined census tract. Census tracts were then mapped onto specific neighborhoods (collections of census tracts) as defined by the city of San Diego.2San Diego Region 2010 CENSUS TRACTS with Subregional Areas. San Diego Association of Governments.https://www.sandag.org/uploads/publicationid/publicationid_1738_15634.pdfDate accessed: January 18, 2022Google Scholar In regards to race/ethnicity, patients seen at Rady Children's Hospital appear to be representative of the pediatric population in San Diego.3Park H.H. Conic R.R.Z. Zhang S. et al.Oral glycopyrrolate for primary focal hyperhidrosis in a pediatric population: a cross-sectional study.JAAD Int. 2021; 4: 65-66Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar To ensure patient confidentiality and reliability of prevalence estimates, neighborhoods with a low absolute number of cases (<30) were then excluded from further analysis. Neighborhoods with adolescent HS prevalence higher than estimates previously published by Garg et al1Garg A. Wertenteil S. Baltz R. Strunk A. Finelt N. Prevalence estimates for hidradenitis suppurativa among children and adolescents in the United States: a gender- and age-adjusted population analysis.J Invest Dermatol. 2018; 138: 2152-2156Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar were then characterized using available data on race/ethnicity, poverty, and Climate Equity Index (CEI) Score.1Garg A. Wertenteil S. Baltz R. Strunk A. Finelt N. Prevalence estimates for hidradenitis suppurativa among children and adolescents in the United States: a gender- and age-adjusted population analysis.J Invest Dermatol. 2018; 138: 2152-2156Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar The CEI score, developed by the city of San Diego, quantifies neighborhood access to opportunity using pollution burden and walkability among a total of 35 indicators.4The City of San Diego's 2015 Climate Action Plan. 2019 San Diego's Climate Equity Index Report. 2019. Accessed January 25, 2022. https://www.sandiego.gov/sites/default/files/2019_climate_equity_index_report.pdfGoogle Scholar A total of 569 patients with HS (aged 15-19 years) were identified in 34 neighborhoods. Of these neighborhoods, only 7 met the threshold of >30 cases. Among these 7 neighborhoods, HS prevalence (per 100,000) was 409 for Latinos/Hispanics and 709 for African American/Blacks (Table I). These 7 neighborhoods have an above average percentage of adolescents living in poverty (Table I) and residents identified as Black/African American (13%) and Latino/Hispanic (62%) (Fig 1). In contrast, Blacks/African Americans and Latinos/Hispanics make up, respectively, 4% and 54% of San Diegans aged 15 to 19 years. All 5 neighborhoods for which CEI scores are available contained ≥1 census tracts identified as having below-average access to opportunity.Table INeighborhood poverty and prevalence of adolescents living with HSNeighborhoodHS casesAdolescent population (15-19 y)HS prevalence per 100,000Adolescents living in poverty (%)∗Percentage of adolescents aged 12 to 17 years living below 100% Federal Poverty Level, as reported by the San Diego County. The average percent for ages 12 to 17 years in San Diego County overall is 16.8%.14811,33242429.923910,53837025.233914,51026934.1438781448627.653811,65732619.6634744345727.9732582954914.2HS, Hidradenitis suppurativa.∗ Percentage of adolescents aged 12 to 17 years living below 100% Federal Poverty Level, as reported by the San Diego County. The average percent for ages 12 to 17 years in San Diego County overall is 16.8%. Open table in a new tab HS, Hidradenitis suppurativa. In the United States, racial residential segregation appears essential to understanding many observed racial disparities in health, yet to our knowledge, this study is the first to explore neighborhood-level data in adolescent patients with HS.5Williams D.R. Collins C. Racial residential segregation: a fundamental cause of racial disparities in health.Public Health Rep. 2001; 116: 404-416Crossref PubMed Scopus (1842) Google Scholar Our findings raise important questions regarding how structural inequalities may impact the care and well-being of adolescents living with HS. HS prevalence is high among Black/African Americans; however, attributing this observation to genetic susceptibility may inappropriately bias future studies. Importantly, our aggregated data should not be applied to infer individual risk or correlation. Future studies are needed to examine early-life exposures and possible environmental factors that may impact the care and well-being of adolescents living with HS. None disclosed. We would like to thank the Research Informatics team at Rady Children's Hospital San Diego for performing EPIC SlicerDicer-based data extractions and Dr. Jill Johnston, Assistant Professor of Population and Public Health Sciences and Spatial Sciences, for critical feedback regarding methodology.

Hidradenitis suppurativa (HS) is a chronic dermatologic illness that is often considered as a disease that affects adults; however, there is a growing understanding that HS among adolescents often goes undiagnosed and undertreated. HS is associated with adolescent depression, and for some individuals living with HS, the pain that results from simply sitting at a desk to do school work is daunting. Adolescents are uniquely vulnerable to disruptions in care because diminished relationships with family or peers and poor academic performance can have a long-lasting impact. Adolescents with HS are asked to face these pivotal challenges when they have limited resources to serve as their own advocates. For example, African American girls between the age of 15 and 17 years are known to face structural barriers to accessing medical care and have the highest prevalence of HS (estimated at 525 per 100,000 vs 28 per 100,000 in the general pediatric population).1Garg A. Kirby J.S. Lavian J. Lin G. Strunk A. Sex- and age-adjusted population analysis of prevalence estimates for hidradenitis suppurativa in the United States.JAMA Dermatol. 2017; 153: 760-764Google Scholar We designed a practical visit guide for dermatologists caring for adolescent patients with moderate-to-severe HS that incorporates the best practices for transitioning to adult care and the management of HS (Table I).2White P. Cooley W.C. Boudreau A.D. et al.Supporting the health care transition from adolescence to adulthood in the medical home.Pediatrics. 2018; 142: e20182587Google Scholar, 3Alikhan A. Sayed C. Alavi A. et al.North American clinical management guidelines for hidradenitis suppurativa: a publication from the United States and Canadian Hidradenitis Suppurativa Foundations: part I: diagnosis, evaluation, and the use of complementary and procedural management.J Am Acad Dermatol. 2019; 81: 76-90Google Scholar, 4Flood K.S. Porter M.L. Kimball A.B. A visit guide for hidradenitis suppurativa—managing a complex disease in a busy clinic.J Am Acad Dermatol. 2021; 84: e155-e160Google Scholar The visit guide organizes information on care and the transition of care during quarterly clinic visits to be scheduled over 2 years. Additionally, it includes age-specific recommendations from the American Academy of Pediatrics on vaccinations, reproductive health, and screening for elevated body mass index and depression. We included recommendations for monitoring while on adalimumab, which has been approved by the Food and Drug Administration for adolescents with moderate-to-severe disease.Table IVisit guide to the management of moderate-to-severe HS∗The American Academy of Pediatrics recommendations for the transition of care for pediatric patients with chronic disease start at the age of 12 years. Our recommendations start at the age of 14 years to correspond with around the age of HS onset for most patients with pediatric HS. Given the role of biologics in the management of moderate-to-severe HS, dermatology providers are needed to help ensure that vaccinations are completed following the most up-to-date recommendations for these patients.Visit activityBaseline†Represents clinic visit in which provider initiates the process to begin transition to adult care.3 mo6 mo9 mo12 mo15 mo18 mo21 mo>24 moSeverity assessmentHS Hurley staging•••••••••T-QoL•••••••••BMI screening•••Depression screening (PHQ-9)•••••Systemic medication monitoring‡We included recommendations for TB monitoring while on adalimumab, which has been approved by the Food and Drug Administration for adolescents with moderate-to-severe HS.Counsel regarding transitioning specialist care, including identification of adult provider•••Laboratory parameters—TB, complete metabolic panel using liver function tests•••Assess for active TB and/or other severe or opportunistic infections•••••••••Discuss timing for vaccinations commonly required by colleges and employers•Contraception and pregnancy counselingCounsel regarding the process of transitioning care, including identification of reproductive health provider•••BMI, Body mass index; HS, hidradenitis suppurativa; PHQ, patient health questionnaire; TB, tuberculosis; T-QoL, teenage quality of life index.∗ The American Academy of Pediatrics recommendations for the transition of care for pediatric patients with chronic disease start at the age of 12 years. Our recommendations start at the age of 14 years to correspond with around the age of HS onset for most patients with pediatric HS. Given the role of biologics in the management of moderate-to-severe HS, dermatology providers are needed to help ensure that vaccinations are completed following the most up-to-date recommendations for these patients.† Represents clinic visit in which provider initiates the process to begin transition to adult care.‡ We included recommendations for TB monitoring while on adalimumab, which has been approved by the Food and Drug Administration for adolescents with moderate-to-severe HS. Open table in a new tab BMI, Body mass index; HS, hidradenitis suppurativa; PHQ, patient health questionnaire; TB, tuberculosis; T-QoL, teenage quality of life index. For patients with HS, care providers should actively partner with patients, their families, and other specialists to improve the transition from a parent-supervised approach to a young adult patient-centered approach. The absence of resources dedicated to pediatric HS may hide the true burden of this disease and missed opportunities to improve the health of young adults. Prospective studies are needed to better understand the barriers that adolescents face during the transitioning of care for chronic skin disorders and the efficacy of proposed solutions, such as visit guides, to improve patient well-being. None disclosed.

To the Editor: Primary focal hyperhidrosis (PFH) is characterized by uncontrollable, excessive sweating in an otherwise healthy individual—typically involving the axillae, palms, and soles.1Remington C. Ruth J. Hebert A.A. Primary hyperhidrosis in children: a review of therapeutics.Pediatr Dermatol. 2021; 38: 561-567Crossref PubMed Scopus (0) Google Scholar Hyperhidrosis can negatively impact the psychosocial well-being of adolescent patients and is associated with depression in adults.2Paller A.S. Shah P.R. Silverio A.M. Wagner A. Chamlin S.L. Mancini A.J. Oral glycopyrrolate as second-line treatment for primary pediatric hyperhidrosis.J Am Acad Dermatol. 2012; 67: 918-923Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar,3Bahar R. Zhou P. Liu Y. et al.The prevalence of anxiety and depression in patients with or without hyperhidrosis (HH).J Am Acad Dermatol. 2016; 75: 1126-1133Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar When topical therapy is inadequate to manage hyperhidrosis, treatment with oral glycopyrrolate should be considered.1Remington C. Ruth J. Hebert A.A. Primary hyperhidrosis in children: a review of therapeutics.Pediatr Dermatol. 2021; 38: 561-567Crossref PubMed Scopus (0) Google Scholar,2Paller A.S. Shah P.R. Silverio A.M. Wagner A. Chamlin S.L. Mancini A.J. Oral glycopyrrolate as second-line treatment for primary pediatric hyperhidrosis.J Am Acad Dermatol. 2012; 67: 918-923Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar,4Kumar M.G. Foreman R.S. Berk D.R. Bayliss S.J. Oral glycopyrrolate for refractory pediatric and adolescent hyperhidrosis.Pediatr Dermatol. 2014; 31: e28-e30Crossref PubMed Scopus (17) Google Scholar However, there are few studies and no widely accepted guidelines on the use of this systemic medication to treat pediatric patients with PFH. Uniquely challenging for adolescents is the need to balance adverse side-effects with treatment approaches that increase participation in school and extracurricular activities during developmentally critical periods. We conducted a retrospective chart review of patients <19 years old at initial diagnosis of PFH seen at Rady Children's Specialists of San Diego Dermatology Clinics between February 10, 2011 and February 10, 2021. Inclusion in this study and the clinical data were based on EPIC SlicerDicer searches of the >2 million patients in our electronic health records using the following International Classification of Diseases codes: 705.2, L74.510, L74.511, L75.512, L75.513, and L74.519. Analyses were performed using the t test, chi-square test, and logistic regression. This study was approved by the University of California San Diego institutional review board. Patients seeking care for hyperhidrosis were predominantly female (61.9%) and the median age at initial presentation to dermatology was 14.6 years (Table I). The patient's racial/ethnic identification was reflective of the San Diego metropolitan area. Fifteen percent (n = 191) with a median age of 15.7 years were prescribed oral glycopyrrolate at a mean daily dose of 3.3 mg (0.056 mg/kg/d) (Table II). Of these patients, the following sites of involvement were reported: 24 (12.6%) hands only, 17 (8.9%) axillae only, 0 (0.0) feet only, 48 (25.1%) palmoplantar, 24 (12.6%) hands and axillae, and 81 (42.4%) >2 anatomic areas. On multivariate analysis, older age (odds ratio 1.16, 95% CI 1.09-1.23, P < .001) and female gender (odds ratio 1.79, 95% CI 1.27-2.53, P < .001) were positively associated with electronic prescriptions for oral glycopyrrolate, whereas insurance type and race were not.Table IPatient characteristics overall (N = 1299) and prescriptions for oral glycopyrrolatePatient characteristicsTotal (N = 1299)Oral glycopyrrolate therapy (N = 191)No oral glycopyrrolate therapy (N = 1108)P value∗P value statistically significant if α < .05Median age at initial visit (range), years14.6 (0.43-18.97)15.2 (7.3-18.8)14.4 (0.43-18.97)<.001Female sex, % (n)61.9 (804)72.3 (138)60.1 (666).002Race, % (n).23 Hispanic50.3 (653)52.9 (101)49.8 (552) White40.5 (526)36.6 (70)41.2 (456) Asian/Pacific Islander3.2 (41)2.6 (5)3.2 (36) Black/African American2.5 (33)4.7 (9)2.2 (24) No race specified3.5 (46)3.1 (6)3.6 (40)Insurance type, % (n).3 Unknown/uninsured61.4 (797)67.5 (129)60.3 (668) Private23.6 (306)20.4 (39)24.1 (267) Public7.9 (102)6.3 (12)8.1 (90) Other government insurance7.2 (94)5.8 (11)7.5 (83)∗ P value statistically significant if α < .05 Open table in a new tab Table IIPatients treated with oral glycopyrrolateOral glycopyrrolate therapy (N = 191)Median age in years when prescribed oral glycopyrrolate (range)15.7 (8.2-19.1)Location of involvement, % (n) Hands only13.1 (25) Axillae only8.9 (17) Feet only0.0 (0) Palmoplantar25.7 (49) Hands and axillae12.6 (24) Multifocal (>2 locations)39.8 (76)Specified38.7 (74)Not specified1.0 (2)Mean dose (mg/day)3.3Mean weight-based dose (mg/kg/day)0.056 Open table in a new tab Body image and peer relationships are central to adolescent development, yet their influence on treating hyperhidrosis is not well understood. This study provides evidence that patient-provider decisions regarding treatment are not neutral with respect to sex and age and that a sizable proportion of patients diagnosed with PFH are <15 years old. It is plausible that for children and adolescents, regardless of perceived benefit, families and providers might not feel comfortable using a long-term systemic medication for this disorder. Less clear is an explanation for how gender norms might influence treatment. We speculate that the mean weight-based dose of 0.06 kg per day glycopyrrolate observed likely reflects a balance of provider comfort and dose efficacy. Our findings do not determine a causal relationship or assess the efficacy of oral glycopyrrolate but rather provide insight into designing future studies. Prospective studies are needed that address efficacy and evidence-based dosing strategies, as well as quality of life and shared decision-making in children and adolescents. None disclosed. The Research Informatics team at Rady Children's Hospital San Diego performed the EPIC SlicerDicer-based data extractions.

To better understand the dynamics of HIV-specific neutralizing antibody (NAb), we examined associations between viral genetic diversity and the NAb response against a multi-subtype panel of heterologous viruses in a well-characterized, therapy-naïve primary infection cohort. Using next generation sequencing (NGS), we computed sequence-based measures of diversity within HIV-1 env, gag and pol, and compared them to NAb breadth and potency as calculated by a neutralization score. Contemporaneous env diversity and the neutralization score were positively correlated (p=0.0033), as were the neutralization score and estimated duration of infection (EDI) (p=0.0038), and env diversity and EDI (p=0.0005). Neither early env diversity nor baseline viral load correlated with future NAb breadth and potency (p>0.05). Taken together, it is unlikely that neutralizing capability in our cohort was conditioned on viral diversity, but rather that env evolution was driven by the level of NAb selective pressure.

Objective Characterize intra-individual HIV-1 subtype B pol evolution in antiretroviral naive individuals. Design Longitudinal cohort study of individuals enrolled during primary infection. Methods Eligible individuals were antiretroviral naïve participants enrolled in the cohort from December 1997-December 2005 and having at least two blood samples available with the first one collected within a year of their estimated date of infection. Population-based pol sequences were generated from collected blood samples and analyzed for genetic divergence over time in respect to dual infection status, HLA, CD4 count and viral load. Results 93 participants were observed for a median of 1.8 years (Mean = 2.2 years, SD = 1.9 years). All participants classified as mono-infected had less than 0.7% divergence between any two of their pol sequences using the Tamura-Nei model (TN93), while individuals with dual infection had up to 7.0% divergence. The global substitution rates (substitutions/nucleotide/year) for mono and dually infected individuals were significantly different (p<0.001); however, substitution rates were not associated with HLA haplotype, CD4 or viral load. Conclusions Even after a maximum of almost 9 years of follow-up, all mono-infected participants had less than 1% divergence between baseline and longitudinal sequences, while participants with dual infection had 10 times greater divergence. These data support the use of HIV-1 pol sequence data to evaluate transmission events, networks and HIV-1 dual infection.

Since HIV-1 Tat has been associated with neurocognitive dysfunction, we investigated 60 HIV-1 subtype B-infected individuals who were characterized for neurocognitive functioning and had paired CSF and blood plasma samples available. To avoid issues with repeated sampling, we generated population-based HIV-1 tat sequences from each compartment and evaluated these data using a battery of phylogenetic, statistical, and machine learning tools. These analyses identified position HXB2 5905 within the cysteine-rich domain of tat as a signature of CSF-derived HIV-1, and a higher number of mixed bases in CSF, as measure of diversity, was associated with HIV-associated neurocognitive disorder. Since identified mutations were synonymous, we evaluated the predicted secondary RNA structures, which showed that this mutation altered secondary structure. As a measure of divergence, the genetic distance between the blood and CSF-derived tat was inversely correlated with current and nadir CD4+ T cell counts. These data suggest that specific HIV-1 features of tat influence neurotropism and neurocognitive impairment.