Atopic dermatitis (AD) is a common chronic skin condition in children that has a proven association with other atopic conditions and allergies. These associations, like the general pathophysiology of AD, are complex and not fully understood. While there is evidence for the efficacy of specific immunotherapy (SIT) in pediatric asthma and allergic rhinitis (AR), there is a lack of strong data to support its use in AD. IgE has been shown to be elevated in many patients with AD, but it is an unreliable biomarker due to variability and great fluctuation over time, poor positive predictive value for clinically relevant allergy, and poor correlation with disease state. In spite of this, almost all studies of SIT use either positive skin prick testing (SPT) or serum specific IgE levels to guide therapy. Allergen avoidance, with some exceptions, is generally not effective at controlling AD in children. The few studies that have investigated the efficacy of SIT in children with AD have produced conflicting results, and a lack of reproducibility with a standard treatment protocol. Limited studies have shown clinical improvement in mild to moderate AD cases, but no effect on more severe patients. Uncontrolled studies are difficult to interpret, due to the natural history of remission or “outgrowing” of AD over time in many patients without specific interventions. Drawbacks to SIT include the length of treatment, poor compliance, cost, and potential side effect profile. The potential for misdirection of time and energy away from skin directed therapy could negatively impact on AD outcomes.

To the Editor: As discussed by Bakhtiar et al, 1 telemedicine threatens to exacerbate disparities in medical care as a consequence of the ''digital divide.'' Safety-net hospitals care for patients on the wrong side of this divide. 2 These settings predominantly serve vulnerable populations that tend to have barriers to digital literacy beyond those treated in private institutions. [2][3][4] Accordingly, patient engagement in video calls has been challenging. [2][3][4] Video visits are associated with greater patient satisfaction and higher reimbursement than telephone visits. 4,5 However, participation in video calls often demands the navigation of a web-based portal application. Such portals have historically had low rates of adoption among low-income, skin-of-color, and non-English-speaking patients. 5 Correspondingly, during the pandemic, video encounters occur significantly less frequently in public health systems than in facilities caring for the middle class. [2][3][4] Here, we used a text message link to video conference with patients that were unable to connect via the patient portal during teledermatology visits in a safety-net hospital.

IMPORTANCE Current models of Goltz syndrome cannot estimate the overall neocollagenesis and marked shift in collagen types after ablative fractional laser resurfacing (AFR) within treated areas of focal dermal hypoplasia (FDH).OBJECTIVES To clinically improve FDH by using AFR to characterize the specific ratio of collagen types associated with observed clinical changes. DESIGN, SETTING, AND PARTICIPANTSThis case report of a girl with Goltz syndrome used extensive laboratory evaluation and multiple observers blinded to the patient's clinical status. Serial samples of clinically unaffected skin constituted internal control specimens, with clinical and histologic evaluations performed as part of a multicenter investigation. The analysis tested the hypothesis that thermal microtrauma caused by AFR created a unique environment that activated latent genes, inducing neocollagenesis and allowing the patient to adaptively produce the collagen subtype that was specifically deficient at baseline. INTERVENTIONSTwo AFR treatments were administered within an area of FDH. Histologic comparison of the pretreatment and posttreatment skin was performed using serial internal controls.MAIN OUTCOMES AND MEASURES Histologic changes, including Herovici collagen staining to differentiate between types I and III collagen, within a treated area of mosaically affected FDH compared with clinically unaffected skin. RESULTSThis female patient presented in the second decade of life with self-described red, itchy skin within a large plaque of FDH on her left posterior thigh and calf. After AFR, skin tightening and symptomatic relief were reported. Histologic findings demonstrated objective thickening of the dermal collagen. A marked shift in collagen predominance from type III (fetal/early wound) to type I (adult/mature) was observed.CONCLUSIONS AND RELEVANCE Although further study is needed, this report shows promising results and raises important questions about gene expression and the epigenetics of Goltz syndrome-associated mutations and the local effects of AFR. Coupled with more rigorous investigation, this novel technique may help reveal molecular workarounds permitting innovative therapies that take advantage of the subtly different collagens that exist within the skin.