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Fig 1. A and B, Patients with excised primary scalp tumors and in-transit metastatic leiomyosarcoma. C and D, Images from the same patient with an excised primary scalp tumor showing 2 in-transit metastases (C) and 3 more metastatic tumors after 3 years (D). Dotted arrows indicate excision site of primary leiomyosarcoma tumors; solid arrows, metastasis. 3. Winchester DS, Hocker TL, Brewer JD, et al. Leiomyosarcoma of the skin: clinical, histopathologic, and prognostic factors that influence outcomes. J Am Acad Dermatol. 2014;71(5): 919-925. 4. Fauth CT, Bruecks AK, Temple W, Arlette JP, DiFrancesco LM. Superficial leiomyosarcoma: a clinicopathologic review and update. J Cutan Pathol. 2010;37(2):269-276. http://dx.doi.org/10.1016/j.jaad.2015.01.033
Propranolol to treat infantile hemangioma (IH) in patients with congenital heart disease To the Editor: Although propranolol has long been used for treating hypertension, angina pectoris, tachyarrhythmia, and myocardial infarction in adults, clinical trials to determine its safety in pediatric patients with infantile hemangioma
J AM ACAD DERMATOL
Letters 913
VOLUME 72, NUMBER 5
Table I. Clinical data of oral propranolol therapy for infantile hemangioma in children with congenital cardiac defects Patient
Type of hemangioma
Sex
Location
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
F F F M M F F M M M F F M F F M M M
Periorbital Forehead Lip Neck Arm Chest Nose Lip Forehead Eyelid Cheek Lip Cheek Arm Cheek Arm Chest Cheek
Deep Mixed Mixed Mixed Mixed Mixed Mixed Deep Superficial Superficial Mixed Mixed Mixed Mixed Mixed Mixed Mixed Mixed
19 20 21
F F F
Cheek Lip Lip
Deep Mixed Mixed
Age at initiation, mo
Treatment duration, mo
Clinical response
Cardiac abnormality
3 4 4 3 3 6 6 3 2 3 17 2 6 7 2 3 2 4
10 8 4 9 6 9 4 8 12 10 12 8 11 5 15 12 9 4
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Good Good Good Good Good Good Good Good
3 2 2
3 4 12
Good Fair Fair
ASD ASD Trivial MR PFO PDA Trivial MR Trivial TR ASD ASD ASD Trivial MR ASD, VSD, PDA PS ASD MR PFO Trivial MR VSD with partial aneurysm form ASD, trivial TR ASD PFO
Significant adverse effect
None None None None None None None None None None None None None None None None None None None None None
ASD, Atrial septal defect; F, female; M, male; MR, mitral regurgitation; PDA, patent ductus arteriosus; PFO, patent foramen ovale; PS, pulmonary stenosis; TR, tricuspid regurgitation; VSD, ventricular septal defect.
(IH) are ongoing.1 Reports of propranolol use in patients with IH and congenital heart disease are scarce. A total of 21 patients with congenital heart disease and IH treated with propranolol participated in this prospective study (Table I). The study protocol was approved by our institutional review board and informed consent was obtained from all parents. Before propranolol was initiated, electrocardiography and Doppler echocardiographic examination were performed by a pediatric cardiologist to identify any pre-existing cardiac abnormality. Serial photographs and echocardiograms were obtained to evaluate the effect of treatment. Propranolol was started in hospital at 0.5 mg/kg/d and increased to 2.0 mg/kg/d. Heart rate, blood pressure, and blood glucose level were monitored during the initial 3 days of hospitalization. Hemodynamic variables were compared with age-related normal values. When no adverse effect was identified, the patient was discharged home and followed up every 2 to 4 weeks. Clinical response and adverse effects were evaluated at each clinic visit. All patients had 1 or more congenital heart defects. These included atrial septal defect, mitral
regurgitation, ventricular septal defect, and pulmonary stenosis (Table I). No patient had a diagnosis of PHACE ( posterior fossa malformatione hemangiomaearterial anomaliesecardiac defectse eye abnormalitiesesternal cleft and supraumbilical raphe) syndrome. The pediatric cardiologists permitted the administration of propranolol because these congenital heart defects are not absolute contraindications for propranolol use, and the target propranolol dose of 2 mg/kg/d for IH is well tolerated. During propranolol treatment, all patients had normal (age-adjusted) heart rate and blood pressure measurements. They tolerated propranolol well, and no major adverse effects were noted. Of the 21 patients, 19 (90.5%) eventually showed a good to excellent IH response, with minimal residual lesions, over a mean follow-up period of 8.2 months. A small number of studies address complications, such as hypotension, sinus bradycardia, and hypoglycemia, associated with propranolol use in patients with IH.2 Despite a large number of clinical trials performed over the past 40 years, no significant cardiovascular event has been recorded in children on chronic beta-blocker therapy.3 Betlloch-Mas et al4 reported no serious adverse effects in 2 infants with
J AM ACAD DERMATOL
914 Letters
MAY 2015
atrial septal defect and 1 infant with persistent patent ductus arteriosus administered propranolol for IH. Our experience indicates that oral propranolol can be administered to infants with asymptomatic cardiac abnormalities. Some researchers propose that echocardiography is unnecessary as a routine screening tool before the initiation of propranolol in the absence of abnormal clinical findings.5 Our results support this recommendation. Hyang-Suk You, MD,a Hoon-Soo Kim, MD,a ByungSoo Kim, MD, PhD,a,b Moon-Bum Kim, MD, PhD,a,b and Hyun-Chang Ko, MDa,c Department of Dermatology, School of Medicine, Pusan National University, Yangsana; Biomedical Research Institute, Pusan National University Hospital, Busanb; and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Busan,c Korea Funding sources: None. Conflicts of interest: None declared. Correspondence to: Hyun-Chang Ko, MD, Department of Dermatology, School of Medicine, Pusan National University, Geumo-ro 20, Mulgeum-eup, Yangsan, Gyeongsangnam-do 626-770, Korea E-mail: [email protected] REFERENCES 1. Schupp CJ, Kleber JB, Gunther P, Holland-Cunz S. Propranolol therapy in 55 infants with infantile hemangioma: dosage, duration, adverse effects, and outcome. Pediatr Dermatol. 2011;28:640-644. 2. de Graaf M, Breur JM, Raphael MF, Vos M, Breugem CC, Pasmans SG. Adverse effects of propranolol when used in the treatment of hemangiomas: a case series of 28 infants. J Am Acad Dermatol. 2011;65:320-327. 3. Love JN, Sikka N. Are 1-2 tablets dangerous? Beta-blocker exposure in toddlers. J Emerg Med. 2004;26:309-314. 4. Betlloch-Mas I, Martinez-Miravete MT, Lucas-Costa A, Martin de Lara AI, Selva-Otalaurruchi J. Outpatient treatment of infantile hemangiomas with propranolol: a prospective study. Actas Dermosifiliogr. 2012;103:806-815. 5. Drolet BA, Frommelt PC, Chamlin SL, et al. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics. 2012;131:128-140. http://dx.doi.org/10.1016/j.jaad.2015.01.034
Frequent indoor tanning among New Jersey high school students To the Editor: Indoor tanning among children increases their lifetime risk for developing melanoma by 85%.1 Additionally, individuals who tan indoors 10 or more times have a 34% increased
risk for developing melanoma.2 In this study, we examined the prevalence and correlates of frequent indoor tanning among New Jersey high school students. The data were drawn from the 2012 New Jersey Youth Tobacco Survey, which was completed by 1850 high school students ( grades 9-12) in 27 public schools throughout New Jersey (overall participation rate ¼ 60.3%). Several questions related to indoor tanning were included in the survey, which focused primarily on tobacco-related issues. In 2013, commercial indoor tanning was banned in New Jersey for minors under the age of 17 years. The results of this study provide the necessary basis for assessing the subsequent impact of the ban on indoor tanning rates among minors in New Jersey. Standard parental consent and student assent procedures were used. The study received institutional review board approval. Additional information regarding the study is available elsewhere.3 Participants reported their sex, age, race/ ethnicity, whether they currently smoke (ie, smoked at least 1 cigarette in the past 30 days), and the number of times they tanned indoors in the past year (ie, used a tanning bed or booth with tanning lamps, not including getting a spray-on tan). Students who reported any past-year indoor tanning indicated whether they had done so before a special occasion, before a vacation, and/or to improve their mood. They also reported whether they had used social media related to indoor tanning salons (ie, ‘‘visited, followed, liked, or become a fan of a tanning salon on sites like Facebook, Twitter, or YouTube’’). Finally, they indicated how hard it would be to stop indoor tanning. To take into account the complex sample survey design, the data were analyzed using SUDAAN (RTI International, Research Triangle Park, NC). All percentages were weighted to adjust for probability of selection and nonresponse. Of the 1754 students who answered the question about use of indoor tanning, 8.5% (N ¼ 146) reported indoor tanning in the past year, 38.0% of whom were denoted as frequent indoor tanners (ie, $10 past-year indoor tanning sessions). Descriptive statistics regarding the students who reported past-year indoor tanning are shown in Table I. Results of 2 analyses indicated that students who had tanned indoors in the past year did not differ in age from individuals who had not (P ¼ .076) but the past-year indoor tanners were significantly more likely to be female (66.1% vs 48.4%, P ¼ .0093) and current smokers (25.0% vs 7.4%, P ¼ .0017) and were less likely to be denoted as non-Hispanic other race/ethnicity (4.4% vs 14.4%, P ¼ .0034).
912 Letters
MAY 2015
Fig 1. A and B, Patients with excised primary scalp tumors and in-transit metastatic leiomyosarcoma. C and D, Images from the same patient with an excised primary scalp tumor showing 2 in-transit metastases (C) and 3 more metastatic tumors after 3 years (D). Dotted arrows indicate excision site of primary leiomyosarcoma tumors; solid arrows, metastasis. 3. Winchester DS, Hocker TL, Brewer JD, et al. Leiomyosarcoma of the skin: clinical, histopathologic, and prognostic factors that influence outcomes. J Am Acad Dermatol. 2014;71(5): 919-925. 4. Fauth CT, Bruecks AK, Temple W, Arlette JP, DiFrancesco LM. Superficial leiomyosarcoma: a clinicopathologic review and update. J Cutan Pathol. 2010;37(2):269-276. http://dx.doi.org/10.1016/j.jaad.2015.01.033
Propranolol to treat infantile hemangioma (IH) in patients with congenital heart disease To the Editor: Although propranolol has long been used for treating hypertension, angina pectoris, tachyarrhythmia, and myocardial infarction in adults, clinical trials to determine its safety in pediatric patients with infantile hemangioma
J AM ACAD DERMATOL
Letters 913
VOLUME 72, NUMBER 5
Table I. Clinical data of oral propranolol therapy for infantile hemangioma in children with congenital cardiac defects Patient
Type of hemangioma
Sex
Location
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
F F F M M F F M M M F F M F F M M M
Periorbital Forehead Lip Neck Arm Chest Nose Lip Forehead Eyelid Cheek Lip Cheek Arm Cheek Arm Chest Cheek
Deep Mixed Mixed Mixed Mixed Mixed Mixed Deep Superficial Superficial Mixed Mixed Mixed Mixed Mixed Mixed Mixed Mixed
19 20 21
F F F
Cheek Lip Lip
Deep Mixed Mixed
Age at initiation, mo
Treatment duration, mo
Clinical response
Cardiac abnormality
3 4 4 3 3 6 6 3 2 3 17 2 6 7 2 3 2 4
10 8 4 9 6 9 4 8 12 10 12 8 11 5 15 12 9 4
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Good Good Good Good Good Good Good Good
3 2 2
3 4 12
Good Fair Fair
ASD ASD Trivial MR PFO PDA Trivial MR Trivial TR ASD ASD ASD Trivial MR ASD, VSD, PDA PS ASD MR PFO Trivial MR VSD with partial aneurysm form ASD, trivial TR ASD PFO
Significant adverse effect
None None None None None None None None None None None None None None None None None None None None None
ASD, Atrial septal defect; F, female; M, male; MR, mitral regurgitation; PDA, patent ductus arteriosus; PFO, patent foramen ovale; PS, pulmonary stenosis; TR, tricuspid regurgitation; VSD, ventricular septal defect.
(IH) are ongoing.1 Reports of propranolol use in patients with IH and congenital heart disease are scarce. A total of 21 patients with congenital heart disease and IH treated with propranolol participated in this prospective study (Table I). The study protocol was approved by our institutional review board and informed consent was obtained from all parents. Before propranolol was initiated, electrocardiography and Doppler echocardiographic examination were performed by a pediatric cardiologist to identify any pre-existing cardiac abnormality. Serial photographs and echocardiograms were obtained to evaluate the effect of treatment. Propranolol was started in hospital at 0.5 mg/kg/d and increased to 2.0 mg/kg/d. Heart rate, blood pressure, and blood glucose level were monitored during the initial 3 days of hospitalization. Hemodynamic variables were compared with age-related normal values. When no adverse effect was identified, the patient was discharged home and followed up every 2 to 4 weeks. Clinical response and adverse effects were evaluated at each clinic visit. All patients had 1 or more congenital heart defects. These included atrial septal defect, mitral
regurgitation, ventricular septal defect, and pulmonary stenosis (Table I). No patient had a diagnosis of PHACE ( posterior fossa malformatione hemangiomaearterial anomaliesecardiac defectse eye abnormalitiesesternal cleft and supraumbilical raphe) syndrome. The pediatric cardiologists permitted the administration of propranolol because these congenital heart defects are not absolute contraindications for propranolol use, and the target propranolol dose of 2 mg/kg/d for IH is well tolerated. During propranolol treatment, all patients had normal (age-adjusted) heart rate and blood pressure measurements. They tolerated propranolol well, and no major adverse effects were noted. Of the 21 patients, 19 (90.5%) eventually showed a good to excellent IH response, with minimal residual lesions, over a mean follow-up period of 8.2 months. A small number of studies address complications, such as hypotension, sinus bradycardia, and hypoglycemia, associated with propranolol use in patients with IH.2 Despite a large number of clinical trials performed over the past 40 years, no significant cardiovascular event has been recorded in children on chronic beta-blocker therapy.3 Betlloch-Mas et al4 reported no serious adverse effects in 2 infants with
J AM ACAD DERMATOL
914 Letters
MAY 2015
atrial septal defect and 1 infant with persistent patent ductus arteriosus administered propranolol for IH. Our experience indicates that oral propranolol can be administered to infants with asymptomatic cardiac abnormalities. Some researchers propose that echocardiography is unnecessary as a routine screening tool before the initiation of propranolol in the absence of abnormal clinical findings.5 Our results support this recommendation. Hyang-Suk You, MD,a Hoon-Soo Kim, MD,a ByungSoo Kim, MD, PhD,a,b Moon-Bum Kim, MD, PhD,a,b and Hyun-Chang Ko, MDa,c Department of Dermatology, School of Medicine, Pusan National University, Yangsana; Biomedical Research Institute, Pusan National University Hospital, Busanb; and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Busan,c Korea Funding sources: None. Conflicts of interest: None declared. Correspondence to: Hyun-Chang Ko, MD, Department of Dermatology, School of Medicine, Pusan National University, Geumo-ro 20, Mulgeum-eup, Yangsan, Gyeongsangnam-do 626-770, Korea E-mail: [email protected] REFERENCES 1. Schupp CJ, Kleber JB, Gunther P, Holland-Cunz S. Propranolol therapy in 55 infants with infantile hemangioma: dosage, duration, adverse effects, and outcome. Pediatr Dermatol. 2011;28:640-644. 2. de Graaf M, Breur JM, Raphael MF, Vos M, Breugem CC, Pasmans SG. Adverse effects of propranolol when used in the treatment of hemangiomas: a case series of 28 infants. J Am Acad Dermatol. 2011;65:320-327. 3. Love JN, Sikka N. Are 1-2 tablets dangerous? Beta-blocker exposure in toddlers. J Emerg Med. 2004;26:309-314. 4. Betlloch-Mas I, Martinez-Miravete MT, Lucas-Costa A, Martin de Lara AI, Selva-Otalaurruchi J. Outpatient treatment of infantile hemangiomas with propranolol: a prospective study. Actas Dermosifiliogr. 2012;103:806-815. 5. Drolet BA, Frommelt PC, Chamlin SL, et al. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics. 2012;131:128-140. http://dx.doi.org/10.1016/j.jaad.2015.01.034
Frequent indoor tanning among New Jersey high school students To the Editor: Indoor tanning among children increases their lifetime risk for developing melanoma by 85%.1 Additionally, individuals who tan indoors 10 or more times have a 34% increased
risk for developing melanoma.2 In this study, we examined the prevalence and correlates of frequent indoor tanning among New Jersey high school students. The data were drawn from the 2012 New Jersey Youth Tobacco Survey, which was completed by 1850 high school students ( grades 9-12) in 27 public schools throughout New Jersey (overall participation rate ¼ 60.3%). Several questions related to indoor tanning were included in the survey, which focused primarily on tobacco-related issues. In 2013, commercial indoor tanning was banned in New Jersey for minors under the age of 17 years. The results of this study provide the necessary basis for assessing the subsequent impact of the ban on indoor tanning rates among minors in New Jersey. Standard parental consent and student assent procedures were used. The study received institutional review board approval. Additional information regarding the study is available elsewhere.3 Participants reported their sex, age, race/ ethnicity, whether they currently smoke (ie, smoked at least 1 cigarette in the past 30 days), and the number of times they tanned indoors in the past year (ie, used a tanning bed or booth with tanning lamps, not including getting a spray-on tan). Students who reported any past-year indoor tanning indicated whether they had done so before a special occasion, before a vacation, and/or to improve their mood. They also reported whether they had used social media related to indoor tanning salons (ie, ‘‘visited, followed, liked, or become a fan of a tanning salon on sites like Facebook, Twitter, or YouTube’’). Finally, they indicated how hard it would be to stop indoor tanning. To take into account the complex sample survey design, the data were analyzed using SUDAAN (RTI International, Research Triangle Park, NC). All percentages were weighted to adjust for probability of selection and nonresponse. Of the 1754 students who answered the question about use of indoor tanning, 8.5% (N ¼ 146) reported indoor tanning in the past year, 38.0% of whom were denoted as frequent indoor tanners (ie, $10 past-year indoor tanning sessions). Descriptive statistics regarding the students who reported past-year indoor tanning are shown in Table I. Results of 2 analyses indicated that students who had tanned indoors in the past year did not differ in age from individuals who had not (P ¼ .076) but the past-year indoor tanners were significantly more likely to be female (66.1% vs 48.4%, P ¼ .0093) and current smokers (25.0% vs 7.4%, P ¼ .0017) and were less likely to be denoted as non-Hispanic other race/ethnicity (4.4% vs 14.4%, P ¼ .0034).
