Analysis of Pediatric Procedural Dermatology at a Tertiary... : Indian Journal of Paediatric Dermatology (2024)

Introduction

Dermatological disorders are common in the general pediatric population and usually differ depending on age, region, race, and socioeconomic status.^[1-4] Pediatric patients often present with skin conditions that usually require some intervention for diagnosis or treatment. Pediatric procedural dermatology is a broad and emerging field. However, the procedures done in the pediatric cases require great expertise, skill, and knowledge on the part of the treating physician. These procedures can be divided based on diagnostic or therapeutic indications. The various diagnostic procedures can be punch biopsy for histopathology, autologous serum skin tests (ASST), slit-skin smear (SSS), etc., Similarly, the common therapeutic procedures are intralesional steroids (ILS), cryotherapy, radiofrequency cauterization (RFC), autologous platelet-rich plasma (PRP), chemical peeling, autologous skin therapy (AST), vitiligo surgery, lasers, etc., All these procedural-based dermatological therapies are vastly directed at the adult population, but when implemented in pediatric cases, various social and ethical challenges should be taken into consideration. The aim of our study is to describe the various procedures done for pediatric cases in a tertiary care teaching hospital from January 2019 to March 2022. A lack of similar studies or data in the pediatric population prompted us to undertake this study.

Objectives

1. To assess the frequency of various dermatological procedures in pediatric population with respect to the various diagnostic and therapeutic indications
2. To analyze the preoperative risks along with intra- and postoperative complications/side effects during the procedure in the pediatric population.

Materials and Methods

Study design

We conducted a hospital-based retrospective study from January 2019 to March 2022 using the data from medical records from the Department of Dermatology, Venereology, and Leprosy of a tertiary health-care teaching hospital in the eastern part of India. All the records were in the form of a patient information file with a duly signed consent form for future academic purposes. About 527 pediatric patients in the age group of 0–18 years who had presented to the dermatology outpatient clinic for either diagnostic or therapeutic procedures were taken into consideration. Before undertaking any procedure, the parent’s written informed consent was obtained. The patient data were recorded and analyzed, followed by proper approval by the Institutional Ethical Committee. The pediatric patients were divided based on their age groups into 0–5 years, 6–10 years, 11–15 years, and 16–18 years. All the data collected were analyzed using the descriptive statistics (SPSS version 26.0 (Chicago, USA)).

Inclusion criteria

All the pediatric patients belonging to the age group of 0–18 years, recorded in the hospital database, who had already attended the dermatology outpatient clinic for either diagnostic or therapeutic procedures were taken into consideration.

Exclusion criteria

• History of keloidal tendency
• Active viral or bacterial infection
• Bleeding disorders
• Anticoagulant therapy
• Congenital heart disease.

Results

Among the total of 527 pediatric patients who had attended the dermatology outpatient department for any procedure, 267 (50.66%) were male and 260 (49.33%) were female (male:female ratio 1.02:1). The mean age of patients was 12.59 (years) which were ranging from 0 to 18 years [Figure 1].

Out of the total, 47 patients (8.91%) were between the age group of 0-5 years, 102 patients (19.35%) were between 6-10 years, 187 patients (35.48%) were between 11-15 years, and 191 patients (36.24%) were between 16-18 years.

A total of 18 procedures were done in 527 patients as per the required indication, in multiple sessions (n = 787) which were further categorized into diagnostic (n=223) and therapeutic (n=564) procedures. About three diagnostic procedures had been done to confirm the clinically doubtful cases. Out of which the most commonly performed procedures for diagnostic purposes were punch biopsy (14.61%), followed by ASST (11.81%) and SSS (1.90%) [Table 1]. Punch biopsy was performed to confirm the clinically doubtful cases such as psoriasis, pityriasis rubra pilaris, chronic bullous disease of childhood (CBDC), discoid lupus erythematosus, lichen striatus, verrucous epidermal nevus, lichen planus, Hansen’s disease, and prurigo.

Similarly, 15 therapeutic procedures were used for the various types of dermatological indications in pediatric patients. From the total number of therapeutic procedures, ILS (21.34%) was the most frequently performed therapeutic procedure, followed by RFC (16.51%), AST (6.98%), cryotherapy (8.76%), nail surgery (2.79%), chemical peeling (2.79%), comedone extraction (2.66%), chemical cauterization (2.54%), neodymium-doped yttrium aluminum garnet (ND:YAG) laser (2.16%), PRP therapy (1.39%), diode laser (1.27%), measles, mumps, and rubella (MMR) vaccine injection (0.89%), fractional carbon dioxide (CO₂) laser (0.63%), suction blister epidermal grafting (SBEG) (0.63%), and platelet-rich fibrin (PRF) therapy (0.25%) [Table 2].

The most common dermatological diseases attended in our outpatient department for therapeutic procedures were keloid (18.90%), hypertrophic scar (7.39%), alopecia areata (6.84%), molluscum contagiosum (5.75%), nodular scabies (8.76%), verruca vulgaris (17.53%), chronic urticarial (4.38%), acne vulgaris (3.30%), milia (1.91%), in-growing toenails (25.20%), etc.

During the various dermatological procedures, some complications were documented as early and immediate side effects. The immediate side effects were mentioned in the form of pain associated with injection, erythema and edema, and burning sensation which had appeared within 24 h after the procedure. The early side effects were described as in the form of injection site reaction and secondary infection which was noted within 2–5 days after the procedure. Few patients also experienced anxiety and irritation which was recorded as pre- and intraoperative apprehensions [Table 3]. During the procedure, pain was noticed in almost all cases of therapeutic procedures such as ILS, AST, nail surgery, comedone extraction, PRP, MMR vaccine injection, PRF, and as well as diagnostic procedures such as punch biopsy and ASST. In a few cases, patients were irritable before the commencement of procedures such as ILS (12%) and AST (7%). The majority of patients were anxious before beginning procedures such as RFC (17%), cryotherapy (40%), nail surgery (97%), comedone extraction (9%), and punch biopsy (87%). Erythema and a burning sensation were most commonly recorded immediately following cryotherapy (57%), chemical peeling (97%), and fractional CO₂ laser (98%) procedures, but they were transient and disappeared on subsequent follow-up visits (day 5 of the procedure). Only burning sensation was mentioned in both the ND:YAG laser and the diode laser in the same proportion (98%). In very few pediatric procedure cases (2.6%), secondary infections were noticed in the form of yellowish crusting and oozing after procedures such as punch biopsies, despite antibiotic prophylaxis [Table 3]. Injection site reaction was never noticed during any type of injectable procedure.

Discussion

Diagnosing pediatric cases is very challenging. Confusing cases need some interventions both diagnostically and therapeutically for proper management. Keloids may lead to cosmetic disfigurement and functional impairment and affect the quality of life. Although several treatment options have been reported in the literature, no universally effective therapy has been found to date. Intralesional triamcinolone is an outpatient procedure that is widely used worldwide. In our study, we had administered ILS to the patients in the age group of 3–18 years, which is similar to a study by Artzi et al. as a therapeutic procedure.^[5]

Acne vulgaris is a very common physiological condition in adolescents. However, there is a paucity of data in literature regarding comedone extraction in the pediatric age group. In our setting, his/her procedure was performed in 12 to 18 year-old patients. Chemical peeling (salicylic acid 20%, glycolic acid 30%) was also done in a few acne patients which is comparable to therapeutic intervention done in a study by Sharma et al.^[6] Acne scars are rarely seen among teenagers. There is a paucity of literature regarding acne scar treatment in patients younger than 18 years. In our study, we used fractional CO₂ laser on three patients in the age group of 16–18 years with acne scars over their faces.

Topical anesthesia (eutectic mixture of local anesthetics) was used for procedures such as comedone extraction and fractional CO₂ laser, and local injectable xylocaine was used for mostly during the diagnostic procedure like biopsy. Minimal transient erythema was noticed occasionally in a few patients after topical formulation. However, no significant side effects related to injectable formulation were mentioned in the past records apart from pain during the injection.^[7]

Treatment of children with alopecia areata continues to be a challenge. Despite the fact that spontaneous recovery had occurred in the majority of cases, therapy is needed to stop the progression of the disease. In our study, we had given intralesional triamcinolone to 5–18 years patients as described in a study by Waśkiel Burnat et al.^[8]

Verruca is not commonly seen in the pediatric population. There is a great deal of variation in the data regarding the prevalence of verruca among the pediatric population. RFC was done on patients aged to 3–18 years. However, studies regarding the use of radiofrequency ablation in pediatric patients are lacking.

Molluscum contagiosum is a viral infection caused by the poxviridae group. It spreads rapidly and easily among children. The prevalence in the pediatric population varies from 5% to 11%.^[9] The rate of incidence in the pediatric population is seen in the age group of 1–8 years.^[10] However, the peak incidence is observed in the age group of 1–4 years.^[11] In our study, we included patients of age group of 1–15 years having molluscum contagiosum. Patients were treated with destructive methods such as radiofrequency ablation, chemical cauterization, and cryotherapy. In a study by Chapa et al., cryotherapy was applied to patients ranging between 1 and 51 years of age group, among which 73.5% were below 18 years of age which is nearly similar to our study.^[12]

Ingrown toenail is a very common problem in teenagers and young adults causing significant morbidity. In our study, we had done partial nail avulsion and segmental phenolization in teenagers (10–18 years) in cases of ingrown toenail which is almost comparable to the study done by Korkmaz et al.^[13]

In addition to the above therapeutic interventions, diagnostic procedures such as punch biopsy, SSS, and ASST were done in the pediatric population for better management of patients. In dermatological practice, a punch biopsy is performed when it is necessary to confirm the clinical diagnosis, excluding multiple other differential diagnoses, and also when there is no response to treatment. In our study, punch biopsy was done in patients between 4 months to 18 years of age to confirm the diagnosis of diseases such as psoriasis, pityriasis rubra pilaris, CBDC, discoid lupus erythematous, lichen striatus, verrucous epidermal nevus, lichen planus, Hansen’s disease, and prurigo. A similar study was conducted by Mahmud et al. where 14.3% of patients were below 18 years of age.^[14] ASST is currently the simplest and the most commonly used in vivo clinical test for the detection of autoantibody against either IgE or high-affinity IgE receptor.^[15] It is most widely used for urticaria and is relatively safe. There is no such study in the literature depicting the use of ASST in pediatric patients. However, in our study, we had done it on 15 to 18 year age group patients. There is a paucity of studies related to other procedures such as ND:YAG laser, fractional CO₂ laser, PRP, AST, MMR vaccine injection, and SBEG among the pediatric population for various diseases in previous decades. However, we conducted these procedures in our setting without any serious side effects or complications.

The side effects and complications encountered with both diagnostic and therapeutic procedures were mild. Anxiety and apprehensions were noticed before the procedures both in patients and in their parents. During the procedure, noncooperation was found in the pediatric patients that caused difficulty in conducting the procedure. The patient experienced pain, burning sensation, irritation, redness, and minimal swelling immediately after the procedures which were transient in nature and subsided within few days.^[16,17]

Future prospective

This study may encourage other physicians to conduct various procedures in the pediatric population for both diagnostic and therapeutic purposes for better patient management without any apprehension or hesitation.

Conclusions

Nowadays, there are varying morphologies of skin lesions in the pediatric population having many differentials. So for ease, diagnostic procedures are required for management. Therapeutic procedures are also helpful and uneventful for dermatologists in pediatric age groups in resolving the dilemma regarding various treatments as applied in adults. Simultaneously, prior counseling should be done, and proper asepsis should be maintained to avoid preoperative risks. And also, intra- and postprocedural side effects such as pain, edema, erythema, burning sensations, and irritation can be minimal and subsided within a few days. Therefore, parents’ cooperation and trust are necessary in performing the procedures for better care in pediatric patients.

Limitations of the study

As this is a retrospective study, long-term follow-ups could not be done to assess the efficacy of therapeutic procedures. Furthermore, delayed postoperative complications related to procedures were not taken into account.

Declaration of consent

The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The patients in this manuscript have given written informed consent to the publication of their case details.

References