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This article addresses the critical shortage in the pediatric dermatology workforce despite growing demand. It explores barriers including limited early exposure, mentorship, and lengthy, costly training pathways. The authors propose new models to streamline training, including alternative residency tracks and combined programs, while emphasizing the importance of mentorship, educational resources, and institutional support. They recommend actionable strategies like requiring pediatric dermatology exposure during training and increasing preliminary pediatric positions. The article calls for collaboration and innovation to expand access, improve training pathways, and ultimately increase the number of practicing pediatric dermatologists.
Pediatric dermatology has historically seen a shortage of dermatologists relative to demand, leading to limited access for patients, which is amplified in underserved communities. Telemedicine has emerged as an attractive means to supplement clinical care and a tool that may assist in overcoming many of the barriers present in pediatric dermatology. Studies have found that teledermatology increases access to care, decreases wait-times and provides cost savings for patients and health care systems, all while maintaining high patient and provider satisfaction. Despite limitations, telemedicine remains a powerful resource with the ability to expand access to pediatric dermatologists.
Pediatric dermatology remains an underserved subspecialty due to workforce shortages, geographic disparities, and systemic barriers. This 4-year, single-center initiative implemented 15 targeted interventions, including optimization of provider roles, referral redesign, teledermatology expansion, and electronic health record-based scheduling strategies, to improve access and efficiency. The program achieved sustained improvements in fill rates, reduced no-shows, and decreased appointment lag times, enabling same-day appointments. By combining structural workflow redesign with technology-driven solutions, the initiative demonstrates a replicable model for expanding equitable access to pediatric dermatology care and may inform similar efforts in other underserved medical fields.
There are life-threatening pediatric skin conditions in dermatology that require immediate recognition by pediatric clinicians. This article provides a review of these conditions including diagnostic pearls, beneficial testing, and therapeutic approaches. When these diseases are in the differential, a dermatologist should be consulted early to assist with diagnosis and management. There are barriers to accessing pediatric dermatologists that must be addressed to improve outcomes for patients.
Pediatric dermatoses presenting as follicular papules are common entities encountered in clinical practice. These are a heterogeneous group of disorders of infectious or noninfectious origin that commonly present as regularly spaced, small papules with or without perifollicular inflammation. Inflammatory causes include follicular eczema, pityriasis rubra pilaris, lichen nitidus, follicular seborrheic dermatitis, keratosis pilaris and its variants, keratosis circumscripta, follicular psoriasis, lichen spinulosus, follicular lichen planus, follicular mucinosis, perforating folliculitis, follicular porokeratosis, and follicular dermographism. These conditions may arise due to filaggrin mutations, keratinization defects, autoimmunity, or microbial triggers. Nutritional causes include phrynoderma and scurvy, while connective tissue diseases such as dermatomyositis and chronic cutaneous lupus erythematosus are autoimmune. Additional categories include infectious, genetic, hormonal, environmental, frictional, malignant, nevus-related, iatrogenic, and idiopathic entities. An early and accurate diagnosis is essential for proper management and reducing disease-associated apprehension in children and/or their parents. This review attempts to describe the role of history taking and clinical examination, including morphology, location, pattern of distribution, and associated features, while dealing with a child with follicular-based papules. In addition, it delineates the role of dermoscopy and pathological examination in reaching a correct diagnosis. Furthermore, it describes the available treatment options and disease course of various follicle-based dermatoses.
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Pediatric cutaneous mastocytosis is a heterogeneous mast cell disorder that typically presents as cutaneous disease with a benign and self-limiting course. Despite its favorable prognosis, children with cutaneous mastocytosis may experience symptom-related effects on daily functioning that have not been comprehensively characterized. Data on sleep disturbances and QoL in pediatric cutaneous mastocytosis, unfortunately, remain limited. This study aimed to evaluate the relationship between sleep parameters and dermatology-related QoL and assess whether disease severity modifies the association between sleep disturbances and QoL. Thirty-five children with confirmed cutaneous mastocytosis and 50 healthy controls were enrolled. Disease severity was assessed with SCORing MAstocytosis (SCORMA) Index. Sleep characteristics were evaluated with Children's Sleep Habits Questionnaire (CSHQ), and dermatology-related QoL was assessed with Children's Dermatology Life Quality Index (CDLQI). Children with cutaneous mastocytosis exhibited significantly higher total CSHQ scores compared with controls (median 47.0 vs 39.0, respectively) (p = 0.004), with a markedly higher proportion exceeding the clinical screening threshold for sleep disturbance (85.7% vs 31.4%, respectively) (p < 0.001). Patients demonstrated increased bedtime resistance, sleep anxiety, night wakings, parasomnias, and daytime sleepiness. CDLQI impairment was generally mild, with 94.2% of patients reporting no or small impact. CDLQI scores correlated strongly with SCORMA scores (ρ = 0.57, p < 0.001) but were not significantly associated with overall sleep disturbance.  Children with cutaneous mastocytosis frequently exhibit sleep disturbances, whereas the impact on dermatology-related QoL was generally mild in most patients. Notably, sleep problems were highly prevalent even when dermatology-related QoL impact was minimal, indicating that dermatology-specific QoL instruments may not fully capture the sleep-related burden of pediatric cutaneous mastocytosis. These findings support the integration of routine sleep and dermatology-related QoL screening into the comprehensive management of pediatric cutaneous mastocytosis. • Cutaneous mastocytosis in children generally has a favorable prognosis, but symptoms such as pruritus and flushing may affect daily functioning. • Data regarding sleep disturbances and dermatology-related quality of life in pediatric cutaneous mastocytosis are limited. • Children with cutaneous mastocytosis had significantly more sleep disturbances than healthy controls, with most patients exceeding the clinical screening threshold for sleep problems. • Sleep disturbances were common even among patients reporting minimal impairment in dermatology-related quality of life, suggesting that dermatology-specific QoL measures may underestimate disease burden.
Anogenital complaints are prevalent among pediatric patients in both primary care and specialty care settings (ie, dermatology, urology, gynecology). Sensitive area examination is a critical diagnostic tool in pediatric patient care. Unfortunately, even experienced practitioners may lack formal training and confidence in performing anogenital exams. In this article, we provide a simple yet systematic approach to the pediatric anogenital exam, which outlines key components before, during and after the exam. We hope to empower physicians to confidently execute a pediatric anogenital exam while maintaining comfort for the patient and laying the foundation for a life-long practice of anogenital and sexual health.
Pediatricians and pediatric subspecialists receive lower rates of compensation than their colleagues who care for adult patients. Systemic financial structures within the American health care system disincentivize both individual providers and larger health care systems from investing in pediatric care. The disproportionate overvaluation of procedural care over cognitive care in our Relative Value Unit designation structure encourages systems to focus their care energies on adult patients. In addition, the primary insurer of pediatric patients, Medicaid, systematically reimburses at lower rates than Medicare and commercial insurances.
Atopic dermatitis (AD) is a leading dermatological condition presenting in children and adolescents. Nearly one-fifth of children globally are diagnosed with AD, with higher prevalence and increased disease burden observed among racial minority groups, particularly children of African and Asian descent. Systemic therapies are a key component of managing moderate-to-severe atopic dermatitis; however, their safety and efficacy profiles may vary among pediatric patients with skin of color due to differences in disease phenotype, immune response, and underrepresentation in clinical trials. We aimed to investigate the literature for ethnic and racial representation of pediatric patients with AD in clinical trials of advanced systemic therapies. A rapid review was conducted, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 16 studies representing 21 clinical trials and 3148 patients were included. White patients represented over half of the total participant population investigated across all studies. Asian and Black demographics were the least represented at 16.7% and 9.4%, respectively. None of the clinical trials that were analyzed conducted a subset analysis of therapy outcomes for racial and/or ethnic variability. Although Black and Asian populations are disproportionately affected by atopic dermatitis, our review provides strong evidence of their continued underrepresentation in pediatric dermatological AD clinical trials. Adequate representation may be achieved by addressing frequent barriers, including mistrust in healthcare research, language barriers, lack of trial awareness, and logistical challenges of clinical trial participation.
Transplant-acquired atopy and allergic disorders, including atopic dermatitis and eosinophilic gastrointestinal disorders, are known complications of organ transplantation. They have been noted to be more prevalent following liver transplantation than other solid organ transplantations. The pathophysiology is unknown; however, tacrolimus immunosuppression has been hypothesized to play a role via T helper 2 cell predominance, leading to increased interleukin-4 and interleukin-13 expression. Dupilumab, a monoclonal antibody that downregulates interleukin-4, interleukin-13, and the T helper 2 cell pathway, is effective for atopic dermatitis and eosinophilic esophagitis, though there is a paucity of data regarding its use and safety in pediatric liver transplant recipients. We report a series of cases of pediatric liver transplant recipients from a single center who developed severe atopic dermatitis or eosinophilic esophagitis that was refractory to routine treatments and immunosuppression changes. These atopic conditions also severely affected their quality of life. After initiation of dupilumab, the patients had improvement in both their atopic conditions and quality of life. Patients who did not have evidence of graft dysfunction or rejection prior to initiation of dupilumab maintained normal biochemical graft function. Patients who had rejection prior to starting dupilumab did not develop acute worsening of their graft function or rejection. In this case series, dupilumab was seen to be effective for pediatric liver transplant recipients who developed atopic dermatitis or eosinophilic esophagitis that was refractory to routine treatment and immunosuppression changes. While receiving dupilumab, these patients did not develop worsening graft function or rejection.
Atopic dermatitis (AD) is a common chronic skin inflammation, which affects 15-20% of children worldwide. Gut microbiota and its metabolites are crucial modulators of the "gut-skin axis" in atopic dermatogenesis. However, systematic investigations integrating microbiome and metabolome profiling in mild-to-moderate pediatric AD remain limited. To characterize gut microbiota and metabolic profiles in children with mild-to-moderate AD versus healthy controls, and to identify potential biomarkers and mechanistic pathways involved in disease pathogenesis. This single-center case-control study investigated 53 children diagnosed with AD and 16 healthy participants, and collected their fecal samples for microbial and metabonomic analysis. Mild-moderate pediatric AD patients exhibited significantly increased gut microbial richness and distinct β-diversity compared to controls (PERMANOVA, R²=0.025, P = 0.017). Bacteroidota was enriched while Actinomycetota was depleted in AD patients (P < 0.05). At genus level, Parabacteroides and Klebsiella increased, whereas Bifidobacterium decreased in AD. Species-level analysis revealed enrichment of bacteroides_plebeius, bacteroides_thetaiotaomicron, bacteroides_xylanisolvens, and parabacteroides_merdae in AD. A combined biomarker panel (Bacteroidota, Parabacteroides, and four key species) demonstrated promising exploratory diagnostic potential (AUC = 0.941, accuracy 84.6%), although these results require external validation in larger independent cohorts. Spearman analysis showed correlations between gut microbiome and clinical severity indicators. Thermodesulfobacteriota, Actinomycetota, Bifidobacterium, and specific ruminococcus strains positively correlated with the severity of AD. Metabolomics identified 68 differentially accumulated metabolites, primarily involved in lipid metabolism and nucleotide metabolism. Bacteroides species showed significant positive correlations with isovaleric acid levels in microbiota-metabolite analyses. Mild-to-moderate pediatric AD is characterized by distinct gut microbiota dysbiosis and metabolic alterations involving lipid metabolism. Cross-sectionally identified microbial features show exploratory associations with AD status, but causal inference is not possible. These hypothesis-generating findings support further investigation of the gut-skin axis in AD development and provide a rationale for future interventional studies targeting the microbiome and metabolome.
Lichen sclerosus (LS) is a chronic inflammatory dermatosis that is frequently underdiagnosed in pediatric patients, especially girls presenting with persistent urinary symptoms. We aimed to characterize the clinical features and treatment outcomes in children with LS who presented with urinary symptoms. This retrospective study evaluated 88 children diagnosed with LS at a pediatric nephrology center, all of whom presented with urinary symptoms. Diagnosis was based on clinical and dermatoscopic findings. The mean age at diagnosis was 6.0 years, with a median delay of 8 months. Dysuria (79.5%) and pyuria (87.5%) were the most common symptoms, although only 45.5% had confirmed urinary tract infections. Among 60 patients followed (mean duration = 16.8 months), topical pimecrolimus resolved symptoms in 88.3% and improved skin lesions in 66.6%. Lichen sclerosus should be included in the differential diagnosis for children with urinary symptoms. Clinical awareness and early diagnosis can lead to avoiding unnecessary investigations.
Laser procedures are safe and effective for various medical conditions in the pediatric population. Laser therapies are viewed as elective or cosmetic rather than medically necessary leading to their denial. Laser therapy can be deemed experimental or investigational, due to a lack of sufficient high-quality evidence showing that the treatment is safe, effective, and necessary for a medical condition. There is also lack of specific Current Procedural Terminology codes leading to the use of unlisted procedure codes that cause an increase in denials or initiation of prior authorizations. Overall, insurance coverage of laser procedures in pediatric patients is highly inconsistent.
Pediatric immunological and allergic conditions represent a broad spectrum, ranging from highly prevalent polygenic disorders (e.g., food allergy, atopic dermatitis, asthma, and allergic rhinitis) to rarer monogenic primary atopic disorders. The management of these conditions has undergone a paradigm shift in recent years. Moving away from a "one-size-fits-all" approach, precision medicine aims to deliver the right treatment to the right patient at the right time. By integrating clinical phenotypes with molecular endotypes and using specific biomarkers and "Omics" techniques, scientists and clinicians can now employ targeted biological therapies that significantly improve patient outcomes. By identifying early therapeutic windows and specific biomarkers, pediatric specialists can implement personalized interventions that halt the atopic march and mitigate the global burden of chronic allergic diseases. By shifting the focus from symptom management to the neutralization of specific molecular pathways, it is now possible to achieve better disease control, reduce side effects associated with broad-spectrum treatments such as systemic corticosteroids, and improve the quality of life for patients with refractory allergic diseases. This review, generated during a seminar funded by the Clemens von Pirquet Foundation, aims to delineate the "rare to common" pipeline, illustrating how precision medicine tools, including multi-omics, biomarkers, and artificial intelligence methods, can connect mechanistic pathways across the immunological spectrum.
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Dissecting cellulitis of the scalp (DCS) is a rare, chronic inflammatory scalp disorder that is characterized by painful, recurrent nodules, abscesses, fistulas, and sinus tracts that can lead to scarring alopecia. We present the case of an 11-year-old Black female with painful, pruritic scalp nodules and hair loss of several months' duration. The patient's clinical and histopathologic presentation was consistent with DCS. After failure to improve with numerous oral/topical antibiotics and topical/intra-lesional corticosteroid therapies, the patient achieved an excellent clinical response to oral isotretinoin. The treatment of DCS remains a challenge for dermatologists due to the lack of standardized, evidence-based guidelines. Given the complexity of treating DCS, especially in the pediatric population, raising awareness for effective management options may lead to enhanced patient outcomes.
Herpes zoster (HZ), caused by varicella zoster virus reactivation, is uncommon in immunocompetent children without prior varicella exposure. We describe a 22-month-old boy who developed HZ 4 months after varicella vaccination, presenting with a unilateral dermatomal vesicular rash. Serological testing was positive for IgM. No maternal or postnatal varicella exposure was reported, and the child had no immunodeficiency. This case underscores the rare possibility of HZ in vaccinated young children lacking traditional risk factors, highlighting the need for clinical vigilance even in atypical populations. Further investigation into triggers of early VZV reactivation postvaccination is warranted.