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The accuracy of body temperature measurement is very important in children. The accuracy and reliability of the forehead skin thermometer (FST) and infrared tympanic thermometer (TT) are inconclusive.To determine: 1) the mean difference, agreement, and accuracy of body temperature detected in children by FST and ITT, as compared with the gold standard rectal mercury-in-glass thermometer (RMT); and, 2) the cut-off level for FST and ITT in the detection of feverChildren ≤ 2 years old with the chief complaint of "fever" were recruited for this study. Body temperature (BT) was measured by 3 different methods, including FST 5 times; ITT 3 times; and, RMT, 1 time, for each patient. Each measurement method was performed by 3 well-trained staff members, all of whom were blinded to the recorded data of the other methods. The mean difference in body temperature, agreement by Bland-Altman method, and the verified performance of FST and ITT by diagnostic test were assessed.A total 312 children were recruited. Body temperatures measured by FST and ITT were lower than those measured by RMT, with a mean difference of 1.04°C (p0.001) and 1.03°C (p0.001), respectively. In subgroup analysis by levels of fever the mean differences between rectal temperature and both forehead and ear temperature were statistically significantly different (p0.001) for all levels of fever. Regarding the diagnostic test to verify performance, the data revealed the most practical cut-off point to be 37.0°C for both FST and ITT as compared to the gold standard RMT.Both FST and ITT were found to be accurate temperature screening methods for daily clinical use. However, the cut-off points to detect fever should be lowered to 37.0°C to be consistent with gold standard measurement.

New topical treatments studied in adults have been published to be potentially effective in the treatment of hypertrophic scar and keloids. There is still no study in Thai children.To study the efficacy of 10% onion extract in silicone derivative gel for the prevention of hypertrophic scar and keloid in median sternotomy wound from open heart surgery in pediatric patients.Thirty-nine pediatric patients who had median sternotomy were recruited in this prospective randomized, double-blinded, placebo-controlled split-scar experimental study. The wound in each patient was divided into upper and lower parts, and the treatment with, either onion extract gel or placebo was randomly applied by block randomization onto each part of the wound twice daily after the seventh day postoperatively for six months. The incidence of scars, serial photographs of the wound, Vancouver Scar Scale (VSS), and adverse effect were assessed at each visit.Thirty patients with the mean age of 4.3 years completed the 6-month study period. Six patients (20%) in onion extract gel group had no scar compared to one patient (3.3%) in placebo group (p = 0.04). Of the 27 patients with hypertrophic scar nine were from onion extract gel group and 18 from the placebo group (p = 0.02). Keloid was not statistically significant diferent in both groups (p = 0.29). VSS was not statistically significant different in all visits. One case had a pustule on the part of the onion extract in silicone derivative application at the sixth month.Onion extract in silicone derivative gel can significantly decreased the incidence of hypertrophic scar from median sternotomy wound in pediatric patients. Keloid did not show statistically significant differences in both groups.

Atopic dermatitis (AD) is a common chronic inflammatory skin lesion in children. Topical corticosteroid is the mainstay of treatment.To compare the efficacy of moisturizer containing licochalcone A (LicA) and 1% hydrocortisone for the treatment of mild to moderate childhood AD.This was a multicenter randomized, prospective, split-side, double-blind study in 55 children between the age of three months and 14 years. Patients with AD were treated twice daily, simultaneously with either Lic A or 1% hydrocortisone on opposite sides of the lesion. The SCORAD and transepidermal water loss (TEWL) were performed at the baseline, 2-week, and 4-week visits. Lic A was used on both sides of the body for another four weeks to see the effects and TEWL.In a randomized period, both products were equally effective in the treatment. SCORAD decreased significantly from baseline for both treatments throughout the first four weeks (p0.001). There was no statistically significant difference in SCORAD between both treatments (p = 0.321 and p = 0.146 at week 2 and 4, respectively). Lic A had statistically significant decrease in TEWL (p = 0.027 and p = 0.03 at weeks 2 and 4, respectively). One patient had infection on skin lesions of both sides of the body. Forty-three patients continued to the period of using Lic A on both sides of the body. SCORAD and TEWL were comparable to the end of the randomized period and significantly lower from baseline (p0.001). Skin lesions flared up in three patients (7.5%).Lic A had a similar result in terms of SCORAD compared to 1% hydrocortisone for the treatment of mild and moderate AD. TEWL was significantly lower than baseline on the side that used Lic A. Continuing use of Lic A for four weeks can maintain clinical and barrier improvement.

Help eradicate or at least alleviating head lice in a primary school with malathion shampoo and to study clinical response and safety of malathion shampoo.All students were examined by using a fine-toothed lice comb to help detect live lice. Direct visual examination and the collection of nits for microscopic examination were performed to differentiate viable nits from empty nits. Diagnosis of head lice was made by the presence of lice. All students that had lice and/or nits were treated with malathion shampoo. Malathion shampoo was also provided for all family members. Pediculocidal efficacy was by the presence or absence of live lice. Blood for red blood cell cholinesterase activity was drawn in 32 volunteers before treatment and after the second treatment.At the first visit, 629 students were examined and 48 students had live head lice. The infestation rate was 13% in girls and 1.3% in boys. The cure rate was 93% after the first treatment. The reported side effects were nausea, a burning sensation, and irritation that was found in five (4%), 10 (7%) and three (2%) students respectively. The mean of RBC cholinesterase activity before and after two applications showed significant changes (p = 0.03). It was -7.5 +/- 4.1% reduction from the initial, but all were in the normal range. There was no report of clinical manifestation of malathion toxicity.Malathion shampoo is safe and effective in the treatment of head lice. There is significant skin absorption so a scalp examination for head lice should be done before subsequent application to avoid unnecessary exposure.

Survey the prevalence of cutaneous disorders in infants at the well baby clinic.This prospective study was conducted on 500 infants, aged between 1 month and 1-year-old.Mongolian spot and nevus simplex were the two most common congenital lesions in the present study. Seborrheic dermatitis was the most frequent skin findings arisen in infancy (apart from the neonatal period) and was on the third rank in overall cutaneous lesions.Skin infections especially tinea versicolor were easily missed.

The authors report a case of acute hemorrhagic edema of infancy in an 8-month-old boy with a history of recent vaccination prior to the illness. He was well in general, apart from mild fever diarrhea, and the rash compatible with acute hemorrhagic edema of infancy; though, he had unusual trunk and mucosal involvement. The diagnosis was confirmed by the histopathological findings and direct immunofluorescence of the lesion. Complete resolution spontaneously occurred within 3 weeks.

Atopic dermatitis (AD) is an immunological skin disease. It is common in pediatric populations and often requires topical steroid treatment. Moderate to severe AD may not respond to topical steroids. They often require systemic steroids, which may result in growth retardation. Protopic, a non-steroid, tacrolimus based ointment which is a calcinurin inhibitor has been proved to be effective in caucacian with AD.To evaluate safety and efficacy of 0.03% tacrolimus ointment (Protopic) in moderate to severe AD in pediatric patients age 2-12 years.This was a one month multicenter open-label clinical trial using tacrolimus ointment twice daily in 61 subjects with moderate to severe AD from September to December 2004. Efficacy assessments were measured by Physician's Global Evaluation of Clinical Response (PhGECR), Eczema area and Severity Index (EASI), Patient's Global Evaluation of Clinical Response (PaGECR), and Quality of Life (QOL). Safety assessment was measured by incidence rate of adverse events.Fifty-eight patients completed the studies. Twenty-two patients were male; thirty-nine patients were female. Twenty-nine patients had moderate AD. Thirty-two patients had severe AD. Three cases had discontinued treatment at the third week due to increase in severity. Over all PhGECR were significantly increased, 94% showed moderate improvement in PhGECR at week 4 or end of treatment (EOT)and 83% had better improvement in PaGECR at EOT Within 7 days, tacrolimus demonstrated rapid onset in reduction of EASI score and itch in patients. Mean QOL were significantly decreased at the end of the present study. Incidence of adverse events included application site burning (21%), itching (17%), pruritus (9%), infections(3%), and erythema and folliculitis (2%). Burning sensation, erythema, pruritus and itching were resolved after the first week.Topical tacrolimus ointment is effective and safe in moderate to severe AD. It significantly improved PhGECR, EASI, PaGECR, and QOL in pediatric patients after the first week of treatment and continued through the end of the study. The major adverse events were burning, itching, and pruritus, which were resolved within the first week of therapy.

Severity of irritant diaper dermatitis (IDD) from diarrhea varies from patient to patient depending on the nature of feces and the number of bowel movements. The purpose of the present study was to compare the effectiveness of dexpanthenol and zinc oxide ointment with ointment base in the treatment of irritant diaper dermatitis from acute diarrhea in children by measuring transepidermal water loss (TEWL).Forty-six children with diarrhea were prospectively, block randomized, investigator-blinded to receive dexpanthenol and zinc oxide ointment on one side and ointment base on the other side. TEWL was measured before and on days 1, 3, and 7 of treatment together with the assessment of severity score. The efficacy of treatment was defined by complete clearance of the lesion.TEWL in the treated and control side was not different before the application of the topical medication. In the present study, the efficacy of 5% dexpanthenol and zinc oxide ointment on D3 was 39% (18from 46 patients) compared to 32% in the ointment base side. On D7, the efficacy of the treated side was 58.7% and the ointment base side was 56%. The patients who still had skin lesions were those who had prolonged diarrhea. On the treated side, the mean of TEWL was lower than the control side on DI (p = 0.18) and had significant improvement on D3 (p = 0. 002). At the end of the present study, TEWL on the treated side was less than TEWL of the control side but it did not have statistical significance (p = 0.07). There was no rash or sign of abnormality on the treated side at the end of D7.In the treatment of lDD from acute diarrhea, 5% dexpanthenol and zinc oxide ointment significantly decreased TEWL in the treated side more than the ointment base on day 3 but the severity score was not significantly different on days 1, 3 and 7.

Primary congenital lymphedema is the rarest form of primary lymphedema. Lymphedema of the extremities presents at birth and rarely involves the genitalia. There has never been a reported case in Thailand. The authors herby report a case of a 6-year-old boy who presented with progressive swelling of the lower legs since birth. The edema progressed into his scrotum and his arms. There was no history of lymphangitis or cellulites. Physical examination revealed a generalized non-pitting edema of all extremities, more on the right leg than the left leg. Swelling of the scrotum and penis was also detected. A diagnosis of primary congenital lymphedema was confirmed with lymphoscintigraphy.

Febrile neutropenia is common in children with leukemia. Mucous membrane and skin are most common portals of entry for microorganisms in these patients. The aim of the present study was to find the prevalence of mucocutaneous findings infebrile neutropenic leukemic children. The authors prospectively examined children with fever with neutropenia in acute leukemia, aged 1-15 years, who were admitted to the Department of Pediatrics, King Chulalongkorn Memorial Hospital, between September 2000 and August 2001. During the study period, 46 children had 116 admissions, 51 of which were due to febrile neutropenia. Their cancer diagnoses were ALL (76%) and ANLL (24%). The prevalence of mucocutaneous findings was 86% (61% were from infections, 22% from mucositis and 4% from chemical phlebitis). Other detected sites of infection were lower respiratory tract (36%), urinary tract (32%), upper respiratory tract (11%), septicemia (11%) and unidentified (35%). Thirty-four percent of the patients had more than one site of infection. Gram-negative septicemia was the most common infection (15cases/71%) followed by gram positive (4cases/19%) and candida (2cases/10%). The prevalence of infection was found in severe neutropenia (absolute neutrophil count, ANC less than 500 cell/cu mm), moderate neutropenia (ANC, 500-1000 cell/cu mm) and mild neutropenia (ANC, 1001-1500 cell/cu mm) was 72%, 9% and 5%, respectively. Infection in patients in the severe neutropenia group was significantly more common than in moderate mild neutropenia groups (p0.01). Seven patients (15%) died, all of them had severe and prolonged neutropenia, for more than 7 days. Daily physical examination of skin and mucous membrane are suggested for proper and prompt diagnosis and treatment of febrile neutropenic children with acute leukemia to reduce mortality and morbidity in these patients. A Guideline for the use of antimicrobial agents in neutropenic patients with acute leukemia is proposed In conclusion, infection was commonly found in severe neutropenia. Mucocutaneous infection was the most common site of infection infebrile neutropenia in children with leukemia.

A 7-year-old boy suffered from jellyfish contact dermatitis and acute renal failure following a jellyfish sting. Three days before being admitted, he accidentally contacted a jellyfish on the left forearm, left thigh and trunk while wading at Pattaya beach, Eastern Thailand. Investigation revealed hemoglobinuria. Histologic findings of a renal biopsy indicated that acute tubular necrosis had caused acute renal failure in the present patient. Supportive treatments improved the dermatitis and renal function of this patient.

Hemangioma is the most common tumor of infancy and ulceration is the most frequent complication of hemangioma. The purpose of this report was to review the clinical features and management of ulcerated hemangioma. A retrospective study of ulcerated hemangioma at the outpatient pediatric dermatology clinic, King Chulalongkorn Memorial Hospital from 1992 to 2001 was performed. The medical records of 41 patients were reviewed. Twenty-eight females and 13 males were seen with a female/male ratio of 2.2: 1. Superficial hemangioma was the most common type (51%). Head and neck were the most frequently involved sites, affecting 21 cases (51%). Ulcerated hemangiomas were found on extremities, torso, and perineum of 9 patients (22%), 6 patients (15%) and 5 patients (12%), respectively. Ulceration was developed at a mean age of 3.9 months (range, 1-7 months). Conventional treatment with topical and/or systemic antibiotic was successfully used in 19 patients (46%). Oral prednisolone was used in 4 patients with large hemangiomas. The mean duration of treatment with oral prednisolone was 12 months. Flashlamp-pumped pulsed-dye laser (FPDL) was used in 16 patients who failed topical and/or systemic antibiotic. Fifteen patients (94%) healed within 1 to 3 treatments. Excision was done on a small superficial hemangioma on the cheek. In conclusion, head and neck were the most common sites of ulcerated hemangioma. Topical antibiotics and/or systemic antibiotics could be used as the first-line management of ulcerated hemangioma. FPDL was very effective in the treatment of ulcerated hemangioma.

The authors evaluated the value of the Cumulative Grade Point Average (GPAX), letters of recommendation and personal interview in predicting performance of first year residents at the Department of Pediatrics, Faculty of Medicine, Chulalongkorn University. The pre-residency data of 25 first year pediatric residents were compared to the results of the Pediatric In-training Examination (PIE) and clinical evaluation by faculty during the first 7 months of training. The Clinical Performance Rating Score (CPRS) developed by the Royal College of Pediatricians of Thailand was used for clinical performance evaluation. GPAX correlated strongly with PIE score (r = 0.69, p0.001) while letters or recommendation and interview score were not predictive. For the majority of residents who graduated from Chulalongkorn University, including the undergraduate program into the regression model improved this association (r = 0.90, p0.001). Interview score correlated moderately (r = 0.49, p = 0.02) with clinical performance measured by CPRS which entailed the evaluator to assess a resident in 6 specific areas. GPAX and letters of recommendation showed a trend toward positive correlation with clinical performance, but these associations were weak (r = 0.32-0.39). Further analysis of letters of recommendation found a significant difference between the score given by evaluators in community hospital settings compared to the score given by medical school faculty or evaluators in large regional or provincial hospitals. The authors conclude that the cognitive function of pediatric resident candidates can be assessed reliably by GPAX. Research on how to adjust for the variability of GPAX given by an individual undergraduate program will improve the residency selection process. A structured interview may correlate better with global clinical performance than GPAX or letters of recommendation but all methods are at best moderately predictive of clinical performance. Improvement can be made by continuous evaluation and adjustment of the selection process.

A retrospective study of hemangioma seen at the Pediatric Dermatology Clinic, Department of Pediatrics, Faculty of Medicine King Chulalongkorn Memorial Hospital from June 1991 to June 2000 was conducted. A total of 197 patients with 221 hemangiomas were followed-up from 6 months to 9 years. There were 134 girls and 63 boys (2.1:1), ranging in age from 6 months to 9 years. Twenty-two patients (11%) were premature neonates. Hemangiomas were presented at birth in 114 patients (58%), within the first month in 65 patients (33%), and after the age of 1 month in 18 patients (9%). Among the 197 patients, 18 patients (9%) had multiple locations. Types of hemangiomas were recorded as superficial, deep and combined in 84 (43%), 31 (16%) and 82 (41%), respectively. Head and neck were the most common sites of hemangiomas (65%), with 36 lesions (18%) on the trunk, 22 lesions (11%) on upper extremities, 22 lesions (11%) on lower extremities and 15 lesions (8%) on the perineum and buttock. Complications were found in 63 patients (32%) with 93 complications. Perineum and buttock had the highest rate of complication (60%), followed by the eyelid region (41%). Superficial hemangioma had the highest rate of complication (64%), followed by combined type (46%). Ulceration was the most common complication in the superficial and combined type. Obstruction was the most common complication in deep hemangioma. Management of hemangioma included observation, prednisolone, flashlamp-pumped pulsed-dye laser, topical therapy and excision in 68 per cent, 8.6 per cent, 10.7 per cent, 9.6 per cent, and 2.5 per cent, respectively. In conclusion, complications of hemangiomas are common. Close observation with regular follow-up will give better recognition and treatment of complications and associations.

Atopic dermatitis is a common skin disease in Thai children. The treatment of atopic dermatitis requires topical corticosteroids, emollients, systemic antihistamine as well as avoidance of the precipitating factors. A double blind multicenter placebo controlled study was conducted to assess the therapeutic efficacy of topical mometasone furoate 0.1 per cent cream in combination with loratadine syrup. Forty-eight patients, 23 boys and 25 girls, mean age 73.67 months, with atopic dermatitis were included in the study. The severity of the disease was measured by using the SCORAD index including the degree of erythema, dryness, edema/papulation, oozing/crusting, lichenification, and excoriation. Total area involved was measured and a target area of dermatitis was selected for specific evaluation. The degree of clinical signs and pruritic symptom was graded. The sensation of pruritus, disturbance of sleep due to pruritus, and feeling of sleepiness in the morning were recorded. Mometasone furoate 0.1 per cent cream was applied to all patients once daily. One group received loratadine syrup and another group received placebo syrup. They were followed-up on day 5, 8 and 15. The severity of atopic dermatitis and pruritus significantly decreased after 14 days of treatment in both groups (p0.001). There was no difference in therapeutic response between the loratadine and placebo groups (p = 0.99). All signs examined had decreased by the end of the study. The result demonstrated that 0.1 per cent mometasone therapy is very effective for treating childhood atopic dermatitis. Loratadine did not show beneficial effect when combined with good topical corticosteroid but it was safe and had no serious side effect on the children.

The evaporation rate (ER) from the skin was measured in 40 jaundiced preterm infants born at less than or equal to 34 weeks of gestation. The baseline measurements were executed in both the right and left side in 3 positions: upper arm, back and lower leg. The patients were randomly recruited to a treatment or a control group. The treatment group received 3.0 ml of clear topical ointment just before phototherapy. Conventional phototherapy was placed above the incubators in both groups. ER and ambient skin temperature were measured at the same point at 30 minutes and 5 hours during phototherapy. In the control group, ER was increased by 8.0 per cent (P value = 0.01) and 14.5 per cent (P value0.001) at 30 minutes and 5 hours during phototherapy, respectively. In the treatment group, clear topical ointment decreased ER by 19.2 per cent (P value0.001) and 13.2 per cent (P value = 0.003) at 30 minutes and 5 hours during phototherapy, respectively. Ambient skin temperature during phototherapy was increased significantly (P0.01) in both groups. Serum microbilirubin difference of pre and post phototherapy at 24 hours of phototherapy between the 2 groups was not significantly different (P = 0.38). The authors concluded that conventional phototherapy, in premature infants nursed in an incubator, increased transepidermal water loss (TEWL) significantly and the application of clear topical ointment on the skin of jaundiced preterm infants receiving conventional phototherapy in incubators reduce TEWL significantly, without effect on serum microbilirubin.