The role of Botox? for acute sixth nerve palsy remains unsettled (Figure 3). It has been used to attempt to prevent or reduce the contracture of the antagonist medial rectus, and also to treat small postoperative deviations. The known occurrence of spontaneous recovery of some sixth nerve palsies clouds the interpretation of case-report studies. Reports sometimes include various etiologies, both traumatic and nontraumatic, lumped together. Hung reported a higher functional recovery rate in a retrospective study in 14 of 33 patients with acute complete traumatic sixth nerve palsies who were treated with Botox?.  Holmes reviewed the course of 84 patients with traumatic sixth nerve palsies, 22 of whom were treated with Botox? and the remainder treated conservatively. He found no difference in the outcome of the patients.  Biglan reported that 7 of 16 patients with sixth nerve palsy were controlled by Botox?, and that patients with long-standing or severe palsy did not get as positive a result as patients with more acute palsies or with better lateral rectus function.  In a study of nine children with brain neoplasms accompanied by sixth nerve palsies, treatment with Botox? was not felt to hasten recovery.  Eight patients with nontraumatic sixth nerve palsies were reported to have excellent results from Botox?, with seven having no diplopia in the long term.  Complications of Botox? included ptosis, induced hypertropia, subconjunctival hemorrhage, possible globe perforation, and failure to maintain an effect.
When children present to a physician with erythema, scaling or pruritis in the anogenital region, psoriasis should be part of the differential diagnosis. Psoriasis is particularly associated with chronic vulvovaginitis in the pediatric population (Fischer 2010). Diagnosis is usually made after a complete history and physical is made looking for other skin lesions, progression over time and family history (Trager 2004). Clinical presentation and history are usually enough for diagnosis. If diagnosis is not certain, biopsy can be taken for definitive histological certainty. Another less invasive option is the use of videodermatoscopy. On examination of psoriatic balanitis with videodermatoscopy, a consistent pattern of dilated, tortuous capillaries is seen in all patients (Lacarrubba 2004). If psoriatic involvement is limited to the genitals, systemic treatment is unnecessary. Along with hygiene and avoidance of irritating factors, treatment tends to focus on topical steroids, such as betamethasone, or liquor picis carbonis (LPC) cream (Trager 2004). If this is not successful, recent trials of immunomodulators like pimecromilus have had success (Amichai 2004).