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Introduction There is some evidence to suggest that the prevalence of atopic dermatitis (AD) in Asia is rising. We have therefore developed an algorithm for the topical treatment of AD throughout South and East Asia for use by primary care physicians, pediatricians and dermatologists. Methods Nine AD experts from South and East Asia and one from Europe developed the algorithm based upon treatment guidelines, relevant literature and local treatment practices. The algorithm outlines current best practice for the use of emollients, topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI), with the intention of simplifying the treatment regimen of mild-to-moderate AD in South and East Asia. Results Patients with AD should bathe and cleanse affected skin to remove crusts and scales daily. Emollients should also be applied daily as a maintenance treatment. When selecting appropriate topical anti-inflammatory treatment for AD flares, several factors should be taken into consideration, including the patient’s age, attitude to treatment options and site of AD lesions. Given the concerns regarding the risk of skin atrophy with use of TCS, a TCI should be used to treat AD lesions in sensitive skin areas: pimecrolimus is recommended for mild-to-moderate AD in these locations, while tacrolimus should be considered for moderate and severe cases. Either pimecrolimus or tacrolimus is recommended for flares in other, non-sensitive body locations. A proactive or intermittent maintenance treatment strategy involving regular emollient use and twice-weekly application of a TCI to previously affected areas is encouraged to reduce the risk of flares. Conclusions The algorithm proposed here is intended to simplify the topical treatment of mild-to-moderate AD in daily practice in South and East Asian countries.

BACKGROUND To define the role of topical timolol maleate (TTM) in the treatment of infantile haemangiomata (IH). METHODS In this single-centre randomised controlled trial, we included all

BACKGROUND Anaphylaxis is a significant health burden in most Western countries, but there are little published data on the incidence and pattern of anaphylaxis in Asia. We aim to determine the incidence rate and pattern of anaphylaxis over the past decade among the pediatric population in Hong Kong. METHODS Medical records of patients presenting with allergy-related symptoms during the period 2010 to 2019 were examined. Pediatric patients aged below 18 years who fulfilled the diagnostic criteria for anaphylaxis laid out by the NIAID/FAAN were analyzed. Incidence rates were calculated using population statistics as the denominator. All information pertaining to the anaphylaxis events and patients' characteristics was retrieved using standardized data collection forms. RESULTS The overall 10-year estimated incidence of anaphylaxis was 9.76 per 100,000 person-years, with a rising trend of anaphylaxis incidence across time. Food-induced anaphylaxis accounted for the majority of hospital presentations, of which peanut and shellfish were the top food triggers in our population. Majority of anaphylaxis episodes were of Grade 4 severity, and young age was a significant predictor of severe allergic reactions. Half of the anaphylaxis episodes were misdiagnosed and adrenaline was only utilized in 42.2% of cases, of which 9.4% were administered adrenaline prior to hospital arrival. CONCLUSIONS An increasing trend of anaphylaxis incidence over the past decade is evident in Hong Kong children, with a discrepantly low accuracy in diagnosis and suboptimal management of anaphylaxis. There is a pressing need to heighten public and physicians' awareness of the distinctive features of anaphylaxis in the pediatric age-group.

Background: Alopecia Areata (AA) is a systemic autoimmune condition that usually starts in childhood. Objective: This article aims to review genetics, therapy, prognosis, and recent patents for AA. Methods: We used clinical queries and keywords “alopecia areata” AND “childhood” as a search engine. Patents were searched using the key term “alopecia areata” in Patents.google.com and freepatentsonline. com. Results: Due to an immune-mediated damage to the hair follicles, hair is lost from the scalp and other areas of the body temporarily or even permanently. Children with AA are generally healthy. Evidence of genetic association and increased predisposition for AA was found by studying families with affected members. Pathophysiologically, T- lymphocytes attack hair follicles and cause inflammation and destruction of the hair follicles and hair loss. In mild cases, there would be well-demarcated round patchy scalp hair loss. The pathognomonic “exclamation mark hairs” may be seen at the lesion periphery. In more severe cases, the hair loss may affect the whole scalp and even the whole body. The clinical course is also variable, which may range from transient episodes of recurrent patchy hair loss to an indolent gradually deteriorating severe hair loss. The treatment of AA depends on factors including patients’ age, the extent of the hair loss, duration of disease, psychological impact, availability and side effect profile of the treatments. For localized patchy alopecia, topical application of corticosteroids and/or intralesional corticosteroids are the treatment of choice. Other topical treatments include minoxidil, anthralin, coal tar and immunotherapy. In severe resistant cases, systemic immunosuppressants may be considered. Although herbal medicine, acupuncture, complementary and alternative medicine may be tried on children in some Asian communities, the evidence to support these practices is lacking. To date, only a few recent patents exist in topical treatments, including Il-31, laser and herbal medications. Clinical efficacy is pending for these treatment modalities. Conclusions: None of the established therapeutic options are curative. However, newer treatment modalities, including excimer laser, interleukin-31 antibodies and biologics, are evolving so that there may be significant advances in treatment in the near future. AA can be psychosocially devastating. It is important to assess the quality of life, degree of anxiety, social phobia and mood of the patients and their families. Psychological support is imperative for those who are adversely affected psychosocially.

To define the role of topical timolol maleate (TTM) in the treatment of infantile haemangiomata (IH).In this single-centre randomised controlled trial, we included all1-year-old infants within a 13-month period presenting with small (2 cm) superficial IH located at high-risk areas (i.e. tip of ears, tip of nose, eyelids, acral areas, facial areas, scalp, neck, buttocks, perineum and axilla). Patients either received 12 months of 0.5% TTM solution (study group) or watchful waiting (control group). The primary outcome was IH with development of complications that required additional interventions. The secondary outcomes included side effects of TTM and change in IH size.Forty-two children were eligible to the study. Patients who received TTM were noted to have significantly fewer complications than the control group (4.2% versus 29%, odds ratio 9.58 [95% confidence interval: 1.01-91.62], p = 0.04). Mean IH volume percentage reduction was significantly more for the TTM group and no-TTM group at 3, 6 and 12 months.TTM is an effective and safe treatment option to reduce complications, IH volume and the need for further intervention for infants with small superficial IH located at high-risk areas.There is a lack of reliable signs to predict ulceration, disfigurement and other complications for high-risk IH. Treatment options range from watchful waiting to early systemic treatment, with TTM a novel and promising treatment. The exact role of TTM remains unanswered due to a lack of evidence-based research. TTM is effective and safe for infants with superficial IH of2 cm in high-risk areas. Early TTM use on IH can reduce complications, IH volume and the need for further treatment.

Effective management of atopic dermatitis (AD) involves the treatment of a defective skin barrier. Patients with AD are therefore advised to use moisturizers regularly. To date, there are few comparative studies involving moisturizers in patients with AD, and no classification system exists to objectively determine which types of moisturizers are best suited to specific AD phenotypes. With this in mind, a group of experts from allergy and immunology, adult and pediatric dermatology, and pediatrics centers within Southeast Asia met to review current data and practice, and to develop recommendations regarding the use of moisturizers in patients with AD within the Asia-Pacific region. Chronicity and severity of AD, along with patient age, treatment compliance, and economic background should all be taken into account when selecting an appropriate moisturizer for AD patients. Other considerations include adjuvant properties of the product, cosmetic acceptability, and availability over the counter. Well-defined clinical phenotypes of AD could optimally benefit from specific moisturizers. It is hoped that future studies may identify such differences by means of filaggrin mutation subtypes, confocal microscopic evaluation, pH, transepidermal water loss or presence of allergy specific IgE. Recommendations to improve the regular use of moisturizers among AD patients include measures that focus on treatment compliance, patient and caregiver education, appropriate treatment goals, avoidance of sensitizing agents, and collaboration with other relevant specialists.

Topical corticosteroids (CSs) are the mainstay of treatment for eczema but CS phobia and fears are prevalent and influence therapeutic efficacy.To quantify if CS acceptability and fear affect patients' quality-of-life (QoL).Patients with eczema managed in the pediatric dermatology outpatient clinic of a university hospital were surveyed. Nottingham Eczema Severity Score (NESS) for severity, Children's Dermatology Life Quality Index (CDLQI) for QoL, CS fear, acceptability and reported frequency of CS use were measured with quantified questions.CS fears were prevalent among parents and caregivers of patients with eczema. Fifty-eight percent of parents reported general acceptability of CS as being very good or good, and many applied CS to their child regularly every week. However,40% of parents reported CS fear "always" or "often", 41% reported that they "always" or "often" apply CS only when eczema got worse, 57% would discuss CS fear with their doctors, 30% would request CS-sparing medications and 14% "always" or "often" use traditional Chinese herbal medicine. Fears were predominantly interpersonal and less often iatrogenic in nature. Skin problems were the most concerned side effects of CS. CS acceptability, frequency of CS usage, CS fear and usage of alternative medications were independent domains in eczema management: CS fears correlated with CDLQI; CS usage frequency correlated with NESS and negatively with parental education; and CS acceptability correlated with parental education. Ordinal logistic regressions showed worse QoL was associated with more CS fear (odds ratio: 1.092 [95% CI: 1.023-1.165], p = 0.008).The extent of CS fears is independent of CS acceptability, but correlates with patients' QoL. Desensitization of parental CS fears should be integral part of eczema education and therapeutics in order to improve therapeutic efficacy and patients' QoL.

Introduction Vascularity and pigmentation are two important indicators of the maturing status of hypertrophic scars. We used the dermoscope to measure vascularity and pigmentation of hypertrophic scars to examine its validity and reliability. Materials and method Eighteen subjects were assessed using the Vancouver Scar Scale (VSS), spectrocolorimeter and dermoscope. Correlations between the measurements by these tools and reliability parameters were examined. Results A strong correlation was found between the redness measured by spectrocolorimeter and the RGB redness values of dermoscope pictures (r = 0.890). A correlation was found between the lightness measured by spectrocolorimeter and the lightness of dermoscope pictures (r = 0.536), and between the lightness by spectrocolorimeter and the blanched dermoscope pictures (r = 0.448). The calculated RGB values of redness of the dermoscope correlated with the VSS vascularity score (r = 0.625); the transformed VSS pigmentation score correlated with the lightness of the blanched dermoscope pictures (r = 0.783). The intra-class correlation coefficient (3, 1) of the dermoscope was 0.980 for the redness measurement and 0.965 for the lightness measurement, while the intra-class correlation coefficient (2, 2) was 0.930 for the dermoscope redness measurement and 0.871 for the dermoscope lightness. Conclusion The dermoscope is a promising objective tool for vascularity and pigmentation assessments of hypertrophic scars with good validity and reliability.

Due to the increasing incidences of malignant melanoma, there is a rising demand for assistive technologies for its early diagnosis and improving the survival rate. The commonly used visual screening method is with limited accuracy as the early phase of melanoma shares many clinical features with an atypical nevus, while conventional dermoscopes are not user-friendly in terms of setup time and operations. Therefore, the development of an intelligent and handy system to assist the accurate screening and long-term monitoring of melanocytic skin lesions is crucial for early diagnosis and prevention of melanoma. In this paper, an advanced design of non-invasive and non-radioactive dermoscopy system was reported. Computer-aided simulations were conducted for optimizing the optical design and uniform illumination distribution. Functional prototype and the software system were further developed, which could enable image capturing at 10x amplified and general modes, convenient data transmission, analysis of dermoscopic features (e.g., asymmetry, border irregularity, color, diameter and dermoscopic structure) for assisting the early detection of melanoma, extract patient information (e.g. code, lesion location) and integrate with dermoscopic images, thus further support long term monitoring of diagnostic analysis results. A clinical trial study was further conducted on 185 Chinese children (0-18 years old). The results showed that for all subjects, skin conditions diagnosed based on the developed system accurately confirmed the diagnoses by conventional clinical procedures. Besides, clinical analysis on dermoscopic features and a potential standard approach by the developed system to support identifying specific melanocytic patterns for dermoscopic examination in Chinese children were also reported.

We report a multicenter study of Chinese children in Hong Kong with systemic lupus erythematosus (SLE) nephritis. Children were included if: they fulfilled the ACR criteria, had significant proteinuria or casturia, were Chinese and younger than 19 years and had been diagnosed with SLE between January 1990 and December 2003. Investigators in each center retrieved data on clinical features, biopsy reports, treatment and outcome of these patients. There were 128 patients (eight boys, 120 girls; mean age: 11.9+/-2.8 years). About 50% presented with multisystem illness and 40% with nephritic/nephrotic symptoms. Negative anti-dsDNA antibodies were found in 6% of the patients. Renal biopsy revealed WHO Class II, III, IV and V nephritis in 13 (10%), 22 (17%), 69 (54%) and 13 (10%) patients, respectively. The clinical severity of the nephritis did not accurately predict renal biopsy findings. The follow-up period ranged from 1 to 16.5 years (mean+/-SD: 5.76+/-3.61 years). During the study five patients died (two from lupus flare, one from cardiomyopathy, two from infections). Four patients had endstage renal failure (ESRF) (one died during a lupus flare). All deaths and end-stage renal failure occurred in the Class IV nephritis group. Chronic organ damage was infrequent in the survivors. The actuarial patient survival rates at 5, 10 and 15 years of age were 95.3, 91.8, and 91.8%, respectively. For Class IV nephritis patients, the survival rates without ESRF at 5, 10, and 15 years were 91.5, 82.3 and 76%, respectively. The survival and chronic morbidity rates of the Chinese SLE children in the present study are comparable to those of other published studies.

Objective To evaluate the dermoscopic features of common skin problems in Chinese children. Design A case series with retrospective qualitative analysis of dermoscopic features of common skin problems in Chinese children. Setting A regional hospital in Hong Kong. Participants Dermoscopic image database, from 1 May 2013 to 31 October 2013, of 185 Chinese children (aged 0 to 18 years). Results Dermoscopic features of common paediatric skin problems in Chinese children were identified. These features corresponded with the known dermoscopic features reported in the western medical literature. New dermoscopic features were identified in cafe-au-lait macules. Conclusion Dermoscopic features of common skin problems in Chinese children were consistent with those reported in western medical literature. Dermoscopy has a role in managing children with skin problems.

Epidermolysis bullosa (EB) is a heterogeneous group of congenital blistering diseases that are usually present in the neonatal period. They are characterized by blister formation in response to rubbing or frictional trauma. EB is classified into three major categories, each with many subtypes based on the precise location at which separation or blistering occurs, namely epidermolysis bullosa simplex (EBS), junctional epidermolysis bullosa (JEB), and dystrophic epidermolysis bullosa (DEB). We describe the causes and ages of death of three cases of EB in Hong Kong. A 24-year-old male with EBD diagnosed in the neonatal period lived a withdrawn life after completing secondary school and died of metastaic squamous cell carcinoma. Two neonates of consanguineous Pakistani parents, one with JEB and the other with EB-Pyloric Atresia variant, died of sepsis in infancy. We performed an extensive literature review of the causes and ages of death of these diseases. EB is a heterogeneous inherited blistering skin disease associated with significant morbidity and mortality. EBS is occasionally associated with death at early ages with sepsis. Patients with JEB usually died of sepsis at young age. DEB patients often survive to adulthood and die of cardiopulmonary and renal complications. Squamous cell carcinoma and metastases are unique in DEB.

Purpose To determine the prevalence, risk factors for and patterns of hypertension in Chinese adolescents based on a territory-wide school based screening programme in Hong Kong. Methods Cross-sectional anthropometric and oscillometric blood pressure (BP) measurements and lifestyle information were obtained as part of a growth survey of students from randomly selected secondary schools in Hong Kong. Those with blood pressure ≥95th centile were screened a second or third time. Hypertension is defined as elevated blood pressure on three separate occasions. The independent effects of age, sex, body mass index, high waist circumference (≥85th centile), sleep duration, family history of hypertension and frequency of exercise on hypertension were explored by multivariate analysis. Results Among the 6193 students screened, the prevalence of elevated blood pressure on the first, second and third screens was 9.54%, 2.77% and 1.44% respectively. Hypertension was more likely to be systolic. High waist circumference (≥85th centile) was independently associated with a higher risk of hypertension (adjusted OR 2.4), while exercising twice or more per week was protective (adjusted OR 0.28). Conclusions The prevalence of hypertension in Hong Kong Chinese adolescents is 1.44%. The current study shows high waist circumference is a predictor of hypertension in adolescents, while increased physical activity is a protective factor. Incorporating waist circumference into screening protocols may increase the sensitivity of cardiovascular risk stratification. Healthcare providers should be strong advocates helping to prevent obesity and promote physical activity in adolescents and children.

Vanishing white matter disease is a rare neurological disease. The majority of patients reported are Caucasian individuals. We describe the first Chinese patient with typical clinical and radiological features genetically confirmed to have vanishing white matter disease for a mutation in EIF2B4, followed by a brief review of the disease.

To report the clinical, laboratory, and radiologic features of children with severe acute respiratory syndrome (SARS) and to examine the difference between the younger and older age groups.Retrospective descriptive cohort study.A regional hospital in Hong Kong.Children younger than 18 yrs with SARS.Twenty-one children were included, with a mean age of 10.7 +/- 5.1 yrs. Children with SARS presented with fever, nonproductive cough, malaise, chills, headache, myalgia, and loss of appetite. Examination of the chest showed minimal auscultatory findings. Common laboratory findings included lymphopenia, thrombocytopenia, and mild elevations of activated partial thromboplastin time, alanine transaminase, lactic dehydrogenase, and creatine phosphokinase. Bacteriologic and virologic studies were all negative for common pathogens. Unilateral focal opacity was the commonest finding in chest radiography. High-resolution computerized tomography of the thorax was an early diagnostic tool if the chest radiograph was negative. The clinical course was less severe in comparison with adult patients. However, adolescents (age,or =12 yrs) resembled adults in their clinical features. When compared with the younger age group, the adolescents had significantly higher temperatures, more constitutional upset, and a greater need for steroid treatment. Children younger than 12 yrs seemed less ill but had more coughing. On the whole, the outcome was favorable.Severe acute respiratory syndrome affects children, but the course is less severe. Nevertheless, the disease could have a significant psychosocial impact on children because of the potential seriousness of the disease in their adult family members.

Pak-Chiu Tong was omitted from the list of authors. The correct list is given above. The authors apologize for this error.