corticosteroid creams

THE JOURNAL OF PEDIATRICS • www.jpeds.com 15% developed vision loss. Furthermore, most patients did not respond to the traditional therapy of topical and systemic corticosteroids or disease modifying medications such as methotrexate or azathioprine. Only a minority of the patients who received biologic modifiers, particularly anti-tumor necrosis factor antibodies, had a good response to therapy, although many of these patients had already developed complications. Thus, it is imperative to recognize these less common forms of uveitis and to treat these patients early with aggressive therapy, particularly biologic modifiers. Indeed, the positive results of a controlled study of adalimumab, a humanized anti-tumor necrosis factor antibody were recently published for adult patients with many of the types of uveitis described in this report. Article page 131 ▶

Defining outcomes — Thomas R. Welch, MD

No excuse for prescribing combination antifungal/ corticosteroid creams — Sarah S. Long, MD

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utcomes research” is hot these days. It seems that most any test or intervention we can imagine is being subject to scrutiny. Not a bad idea. The problem, of course, is exactly what “outcome” should we be assessing? All too often, what may be considered an “outcome” in a clinical trial, such as medication adherence or the result of a specific blood test, outcomes such as how the patient feels may be absent. In this volume of The Journal, a multinational group led by the estimable investigators at the Children’s Hospital at Westmead, Australia, looked at the measured outcomes in more than 200 published trials of chronic kidney disease in children. A mind-boggling 100 different outcome domains were identified in these trials. Obviously, this makes comparisons between studies a challenge. More importantly, the article highlights how infrequent are the “outcomes” that most parents would consider important: mortality and quality of life! Article page 110 ▶

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he brief report of Wheat et al is a wake-up call to all primary care physicians, especially pediatricians, who routinely treat children for superficial fungal infections or contact dermatitis. Combination antifungal/corticosteroid creams (such as Lotrisone and Mycolog II) are “bad medicine” for superficial fungal infections, with treatment outcomes documenting inferior clinical effectiveness and higher recurrence rates, higher purchase costs compared with topical antifungal agents alone, all the while incurring potential serious adverse local and systemic effects of corticosteroids. Pediatricians appeared to have missed this entirely—the regulations, the data, and the message, which pediatric dermatologists got loud and clear. Using a large insurance claims database from 2007 through 2014, the authors found that pediatricians “out-prescribed” family medicine physicians for antifungal/ corticosteroid combination topical agents, and the numbers of prescriptions for children 0 to 14 years of age continued to rise over the years despite data published on inferior effectiveness and heightened risk, and FDA revision of approval for combination products only at 17 years of age and only for certain conditions. Through the 8-year study, while pediatricians wrote prescriptions for >6000 antifungal/corticosteroid creams for diagnosis codes encompassing superficial fungal infections and contact dermatitis/eczema, pediatric dermatologists did not write a single prescription for a combination topical cream for the same codes. We pediatricians, specialists in the care of children, need to get educated—on both differentiating superficial dermatitis and prescribing optimal therapies. The authors provide strategies for use of separate, very short-term, mild-to-moderate potency corticosteroid cream at the beginning of topical antifungal therapy for patients with fungal infections who have an associated intense pruritis or inflammatory response. How does this happen? Is it a leftover of the days when the “diaper cream reps” were welcomed with free access to trainees and practitioners, stocking our samples closet and feeding our stomachs? Or do we assume that combinations are better, albeit more costly? Indeed, some are, such as an antibiotic combined with an inhibitor of a microbial resistance enzyme, or the miraculously combined antiretroviral therapies, or combination injectable vaccines. But for topical agents, at least, prescriber beware, some combination products actually are harmful. Article page 192 ▶ Volume 186

THE EDITORS’ PERSPECTIVES Is more oxygen better for our smallest babies, or maybe just our smallest babies? — Clyde J. Wright, MD

Do it yourself — Thomas R. Welch, MD

July 2017

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lthough the debate continues, many clinicians have shied away from targeting lower (85-89%) oxygen saturations in babies born at <28 weeks of gestation. Although the incidence of debilitating morbidities including bronchopulmonary dysplasia and retinopathy of prematurity is lower when oxygen saturations of 85-89% are targeted, there is a worrisome signal for increased mortality when these lower saturations are targeted. Perhaps we must accept the harm associated with higher oxygen saturation targets to prevent any real increased risk of mortality. Importantly, recent data suggest that maybe this isn’t true for all babies born at <28 weeks. It has recently been shown that small for gestational age infants enrolled in Surfactant Positive Pressure and Oxygen Trial had a higher mortality than appropriate for gestational age infants, and the highest mortality is seen in small for gestational age infants randomized to the lower oxygen saturation target (JAMA Pediatr 2016;170:292-4). In this volume of The Journal, DiFiore et al sought to characterize the achieved patterns of oxygenation in appropriate for gestational age and small for gestational age infant randomized to lower (85-89%) and higher (91-95%) saturation targets in Surfactant Positive Pressure and Oxygen Trial, and to determine whether the achieved oxygen saturation levels were associated with survival. These data are impressive and compelling. Analysis of data from more than 1000 infants was performed, and the results have the potential to dictate how we set oxygen saturation target goals in individual patients based on their in utero growth. Perhaps we have taken another step toward “personalizing” oxygen saturation targets in our highest risk infants, an important and commendable goal. Article page 49 ▶

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any studies require determination of the pubertal stage of child participants. The “tried and true” method for this, of course, is physician assessment. Increasingly, however, we are seeing studies in which children themselves are asked to rate their pubertal status using some sort of questionnaire. There have been a number of studies comparing self- vs physician-assessed pubertal status, but these have not included hormonal indicators of puberty. In this volume of The Journal, Chavarro et al studied a group of 248 Mexican children on whom they had self- and physician-assessment of pubertal status, as well as a number of hormonal markers of puberty. Allowing for the fact that there is probably no generally accepted single laboratory measure defining puberty, the global message of this study is that self-assessment is generally reliable. Although boys had a tendency to overestimate genital development, assessment of pubic hair and breast development by children was somewhat better than that assessed by physicians. With more and more studies examining changes in the timing and determinators of puberty, it is reassuring to learn that this method appears to be reliable. Article page 172 ▶

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