Damian McNamara

NEW ORLEANS – Suspect an allergic reaction to inactive ingredients in topical corticosteroids when patients do not improve despite usual treatment regimens, a retrospective study suggests.

"An allergy prevalence of 4% for an emulsifier widely used in corticosteroids and personal care products is very important," Brienne Danielle Cressey said at this year’s annual meeting of the American Contact Dermatitis Society.

Ms. Cressey and her associates in the dermatology department at Tufts Medical Center, Boston, reviewed charts of 591 patients who were patch-tested between November 2008 and May 2010. They found that 24 of these patients (4.1%) had positive reactions to a sorbitan emulsifier found in many corticosteroid formulations.

Specifically, 3.9% reacted positively to sorbitan sesquioleate (SSO); 0.85% to sorbitan monooleate (SMO); and 0.7% to both.

"It was thought previously to be an uncommon allergen," said Ms. Cressey, a student at the Maine Medical Center Tufts University School of Medicine (class of 2013) in Portland. In a previous study conducted at Tufts University, researchers found an 8.9% prevalence of sorbitan allergy among 112 dermatitis patients (Dermatitis 2008;19:323-7).

Even though sorbitan allergy was less common in the current study, "we feel it’s still an important allergen, with a prevalence greater than 1%." These emulsifiers are not included in the standard patch-testing series, Ms. Cressey said.

Patients were patch-tested using the Tufts Medical Center standard series and a preservative series containing SSO in 20% petrolatum and SMO 5% in petrolatum. Results were read at 48 and 72 hours. The majority were weak reactors: 22 patients were + and 2 were ++. "Our only two patients with 2+ reactions were children with generalized dermatitis," Ms. Cressey said.

Only one patient reacted to any of the four different corticosteroid screening chemicals tested, confirming that these reactions were caused by the sorbitan emulsifiers.

In the positive reaction group, the average duration of contact dermatitis was 43 months, the mean age was 40 years, and 46% were atopic. Dermatitis of the upper extremity and face was the most common.

The sources of sorbitan exposure were personal care products (10 patients), topical corticosteroids (9 patients), and ingestion (5 patients). Ingestion included, for example, sorbitans as a medication ingredient, Ms. Cressey said. "One patient with axillary dermatitis was using deodorant with sorbitol," she added.

The fact that the majority of reactions to SSO were weak raises a question as to whether this emulsifier is a contact or irritant allergen, Ms. Cressey said. Because 27 of 591 patients also were questionable for SSO reactions, "SSO is most likely not an irritant," she said.

In addition to topical corticosteroids, sorbitol-based emulsifiers are found in topical antibiotics, topical antifungals, topical retinoids, and moisturizing creams and lotions (Dermatitis 2008;19:339-41). This publication includes a list of products that commonly contain SSO, sorbitol, and sorbitol derivatives.

Ms. Cressey said that she had no relevant disclosures.

NEW ORLEANS – Suspect an allergic reaction to inactive ingredients in topical corticosteroids when patients do not improve despite usual treatment regimens, a retrospective study suggests.

"An allergy prevalence of 4% for an emulsifier widely used in corticosteroids and personal care products is very important," Brienne Danielle Cressey said at this year’s annual meeting of the American Contact Dermatitis Society.

Ms. Cressey and her associates in the dermatology department at Tufts Medical Center, Boston, reviewed charts of 591 patients who were patch-tested between November 2008 and May 2010. They found that 24 of these patients (4.1%) had positive reactions to a sorbitan emulsifier found in many corticosteroid formulations.

Specifically, 3.9% reacted positively to sorbitan sesquioleate (SSO); 0.85% to sorbitan monooleate (SMO); and 0.7% to both.

"It was thought previously to be an uncommon allergen," said Ms. Cressey, a student at the Maine Medical Center Tufts University School of Medicine (class of 2013) in Portland. In a previous study conducted at Tufts University, researchers found an 8.9% prevalence of sorbitan allergy among 112 dermatitis patients (Dermatitis 2008;19:323-7).

Even though sorbitan allergy was less common in the current study, "we feel it’s still an important allergen, with a prevalence greater than 1%." These emulsifiers are not included in the standard patch-testing series, Ms. Cressey said.

Patients were patch-tested using the Tufts Medical Center standard series and a preservative series containing SSO in 20% petrolatum and SMO 5% in petrolatum. Results were read at 48 and 72 hours. The majority were weak reactors: 22 patients were + and 2 were ++. "Our only two patients with 2+ reactions were children with generalized dermatitis," Ms. Cressey said.

Only one patient reacted to any of the four different corticosteroid screening chemicals tested, confirming that these reactions were caused by the sorbitan emulsifiers.

In the positive reaction group, the average duration of contact dermatitis was 43 months, the mean age was 40 years, and 46% were atopic. Dermatitis of the upper extremity and face was the most common.

The sources of sorbitan exposure were personal care products (10 patients), topical corticosteroids (9 patients), and ingestion (5 patients). Ingestion included, for example, sorbitans as a medication ingredient, Ms. Cressey said. "One patient with axillary dermatitis was using deodorant with sorbitol," she added.

The fact that the majority of reactions to SSO were weak raises a question as to whether this emulsifier is a contact or irritant allergen, Ms. Cressey said. Because 27 of 591 patients also were questionable for SSO reactions, "SSO is most likely not an irritant," she said.

In addition to topical corticosteroids, sorbitol-based emulsifiers are found in topical antibiotics, topical antifungals, topical retinoids, and moisturizing creams and lotions (Dermatitis 2008;19:339-41). This publication includes a list of products that commonly contain SSO, sorbitol, and sorbitol derivatives.

Ms. Cressey said that she had no relevant disclosures.

NEW ORLEANS – Suspect an allergic reaction to inactive ingredients in topical corticosteroids when patients do not improve despite usual treatment regimens, a retrospective study suggests.

"An allergy prevalence of 4% for an emulsifier widely used in corticosteroids and personal care products is very important," Brienne Danielle Cressey said at this year’s annual meeting of the American Contact Dermatitis Society.

Ms. Cressey and her associates in the dermatology department at Tufts Medical Center, Boston, reviewed charts of 591 patients who were patch-tested between November 2008 and May 2010. They found that 24 of these patients (4.1%) had positive reactions to a sorbitan emulsifier found in many corticosteroid formulations.

Specifically, 3.9% reacted positively to sorbitan sesquioleate (SSO); 0.85% to sorbitan monooleate (SMO); and 0.7% to both.

"It was thought previously to be an uncommon allergen," said Ms. Cressey, a student at the Maine Medical Center Tufts University School of Medicine (class of 2013) in Portland. In a previous study conducted at Tufts University, researchers found an 8.9% prevalence of sorbitan allergy among 112 dermatitis patients (Dermatitis 2008;19:323-7).

Even though sorbitan allergy was less common in the current study, "we feel it’s still an important allergen, with a prevalence greater than 1%." These emulsifiers are not included in the standard patch-testing series, Ms. Cressey said.

Patients were patch-tested using the Tufts Medical Center standard series and a preservative series containing SSO in 20% petrolatum and SMO 5% in petrolatum. Results were read at 48 and 72 hours. The majority were weak reactors: 22 patients were + and 2 were ++. "Our only two patients with 2+ reactions were children with generalized dermatitis," Ms. Cressey said.

Only one patient reacted to any of the four different corticosteroid screening chemicals tested, confirming that these reactions were caused by the sorbitan emulsifiers.

In the positive reaction group, the average duration of contact dermatitis was 43 months, the mean age was 40 years, and 46% were atopic. Dermatitis of the upper extremity and face was the most common.

The sources of sorbitan exposure were personal care products (10 patients), topical corticosteroids (9 patients), and ingestion (5 patients). Ingestion included, for example, sorbitans as a medication ingredient, Ms. Cressey said. "One patient with axillary dermatitis was using deodorant with sorbitol," she added.

The fact that the majority of reactions to SSO were weak raises a question as to whether this emulsifier is a contact or irritant allergen, Ms. Cressey said. Because 27 of 591 patients also were questionable for SSO reactions, "SSO is most likely not an irritant," she said.

In addition to topical corticosteroids, sorbitol-based emulsifiers are found in topical antibiotics, topical antifungals, topical retinoids, and moisturizing creams and lotions (Dermatitis 2008;19:339-41). This publication includes a list of products that commonly contain SSO, sorbitol, and sorbitol derivatives.

Ms. Cressey said that she had no relevant disclosures.

NEW ORLEANS – Suspect an allergic reaction to inactive ingredients in topical corticosteroids when patients do not improve despite usual treatment regimens, a retrospective study suggests.

"An allergy prevalence of 4% for an emulsifier widely used in corticosteroids and personal care products is very important," Brienne Danielle Cressey said at this year’s annual meeting of the American Contact Dermatitis Society.

Ms. Cressey and her associates in the dermatology department at Tufts Medical Center, Boston, reviewed charts of 591 patients who were patch-tested between November 2008 and May 2010. They found that 24 of these patients (4.1%) had positive reactions to a sorbitan emulsifier found in many corticosteroid formulations.

Specifically, 3.9% reacted positively to sorbitan sesquioleate (SSO); 0.85% to sorbitan monooleate (SMO); and 0.7% to both.

"It was thought previously to be an uncommon allergen," said Ms. Cressey, a student at the Maine Medical Center Tufts University School of Medicine (class of 2013) in Portland. In a previous study conducted at Tufts University, researchers found an 8.9% prevalence of sorbitan allergy among 112 dermatitis patients (Dermatitis 2008;19:323-7).

Even though sorbitan allergy was less common in the current study, "we feel it’s still an important allergen, with a prevalence greater than 1%." These emulsifiers are not included in the standard patch-testing series, Ms. Cressey said.

Patients were patch-tested using the Tufts Medical Center standard series and a preservative series containing SSO in 20% petrolatum and SMO 5% in petrolatum. Results were read at 48 and 72 hours. The majority were weak reactors: 22 patients were + and 2 were ++. "Our only two patients with 2+ reactions were children with generalized dermatitis," Ms. Cressey said.

Only one patient reacted to any of the four different corticosteroid screening chemicals tested, confirming that these reactions were caused by the sorbitan emulsifiers.

In the positive reaction group, the average duration of contact dermatitis was 43 months, the mean age was 40 years, and 46% were atopic. Dermatitis of the upper extremity and face was the most common.

The sources of sorbitan exposure were personal care products (10 patients), topical corticosteroids (9 patients), and ingestion (5 patients). Ingestion included, for example, sorbitans as a medication ingredient, Ms. Cressey said. "One patient with axillary dermatitis was using deodorant with sorbitol," she added.

The fact that the majority of reactions to SSO were weak raises a question as to whether this emulsifier is a contact or irritant allergen, Ms. Cressey said. Because 27 of 591 patients also were questionable for SSO reactions, "SSO is most likely not an irritant," she said.

In addition to topical corticosteroids, sorbitol-based emulsifiers are found in topical antibiotics, topical antifungals, topical retinoids, and moisturizing creams and lotions (Dermatitis 2008;19:339-41). This publication includes a list of products that commonly contain SSO, sorbitol, and sorbitol derivatives.

Ms. Cressey said that she had no relevant disclosures.

NEW ORLEANS – Suspect an allergic reaction to inactive ingredients in topical corticosteroids when patients do not improve despite usual treatment regimens, a retrospective study suggests.

"An allergy prevalence of 4% for an emulsifier widely used in corticosteroids and personal care products is very important," Brienne Danielle Cressey said at this year’s annual meeting of the American Contact Dermatitis Society.

Ms. Cressey and her associates in the dermatology department at Tufts Medical Center, Boston, reviewed charts of 591 patients who were patch-tested between November 2008 and May 2010. They found that 24 of these patients (4.1%) had positive reactions to a sorbitan emulsifier found in many corticosteroid formulations.

Specifically, 3.9% reacted positively to sorbitan sesquioleate (SSO); 0.85% to sorbitan monooleate (SMO); and 0.7% to both.

"It was thought previously to be an uncommon allergen," said Ms. Cressey, a student at the Maine Medical Center Tufts University School of Medicine (class of 2013) in Portland. In a previous study conducted at Tufts University, researchers found an 8.9% prevalence of sorbitan allergy among 112 dermatitis patients (Dermatitis 2008;19:323-7).

Even though sorbitan allergy was less common in the current study, "we feel it’s still an important allergen, with a prevalence greater than 1%." These emulsifiers are not included in the standard patch-testing series, Ms. Cressey said.

Patients were patch-tested using the Tufts Medical Center standard series and a preservative series containing SSO in 20% petrolatum and SMO 5% in petrolatum. Results were read at 48 and 72 hours. The majority were weak reactors: 22 patients were + and 2 were ++. "Our only two patients with 2+ reactions were children with generalized dermatitis," Ms. Cressey said.

Only one patient reacted to any of the four different corticosteroid screening chemicals tested, confirming that these reactions were caused by the sorbitan emulsifiers.

In the positive reaction group, the average duration of contact dermatitis was 43 months, the mean age was 40 years, and 46% were atopic. Dermatitis of the upper extremity and face was the most common.

The sources of sorbitan exposure were personal care products (10 patients), topical corticosteroids (9 patients), and ingestion (5 patients). Ingestion included, for example, sorbitans as a medication ingredient, Ms. Cressey said. "One patient with axillary dermatitis was using deodorant with sorbitol," she added.

The fact that the majority of reactions to SSO were weak raises a question as to whether this emulsifier is a contact or irritant allergen, Ms. Cressey said. Because 27 of 591 patients also were questionable for SSO reactions, "SSO is most likely not an irritant," she said.

In addition to topical corticosteroids, sorbitol-based emulsifiers are found in topical antibiotics, topical antifungals, topical retinoids, and moisturizing creams and lotions (Dermatitis 2008;19:339-41). This publication includes a list of products that commonly contain SSO, sorbitol, and sorbitol derivatives.

Ms. Cressey said that she had no relevant disclosures.

NEW ORLEANS – Suspect an allergic reaction to inactive ingredients in topical corticosteroids when patients do not improve despite usual treatment regimens, a retrospective study suggests.

"An allergy prevalence of 4% for an emulsifier widely used in corticosteroids and personal care products is very important," Brienne Danielle Cressey said at this year’s annual meeting of the American Contact Dermatitis Society.

Ms. Cressey and her associates in the dermatology department at Tufts Medical Center, Boston, reviewed charts of 591 patients who were patch-tested between November 2008 and May 2010. They found that 24 of these patients (4.1%) had positive reactions to a sorbitan emulsifier found in many corticosteroid formulations.

Specifically, 3.9% reacted positively to sorbitan sesquioleate (SSO); 0.85% to sorbitan monooleate (SMO); and 0.7% to both.

"It was thought previously to be an uncommon allergen," said Ms. Cressey, a student at the Maine Medical Center Tufts University School of Medicine (class of 2013) in Portland. In a previous study conducted at Tufts University, researchers found an 8.9% prevalence of sorbitan allergy among 112 dermatitis patients (Dermatitis 2008;19:323-7).

Even though sorbitan allergy was less common in the current study, "we feel it’s still an important allergen, with a prevalence greater than 1%." These emulsifiers are not included in the standard patch-testing series, Ms. Cressey said.

Patients were patch-tested using the Tufts Medical Center standard series and a preservative series containing SSO in 20% petrolatum and SMO 5% in petrolatum. Results were read at 48 and 72 hours. The majority were weak reactors: 22 patients were + and 2 were ++. "Our only two patients with 2+ reactions were children with generalized dermatitis," Ms. Cressey said.

Only one patient reacted to any of the four different corticosteroid screening chemicals tested, confirming that these reactions were caused by the sorbitan emulsifiers.

In the positive reaction group, the average duration of contact dermatitis was 43 months, the mean age was 40 years, and 46% were atopic. Dermatitis of the upper extremity and face was the most common.

The sources of sorbitan exposure were personal care products (10 patients), topical corticosteroids (9 patients), and ingestion (5 patients). Ingestion included, for example, sorbitans as a medication ingredient, Ms. Cressey said. "One patient with axillary dermatitis was using deodorant with sorbitol," she added.

The fact that the majority of reactions to SSO were weak raises a question as to whether this emulsifier is a contact or irritant allergen, Ms. Cressey said. Because 27 of 591 patients also were questionable for SSO reactions, "SSO is most likely not an irritant," she said.

In addition to topical corticosteroids, sorbitol-based emulsifiers are found in topical antibiotics, topical antifungals, topical retinoids, and moisturizing creams and lotions (Dermatitis 2008;19:339-41). This publication includes a list of products that commonly contain SSO, sorbitol, and sorbitol derivatives.

Ms. Cressey said that she had no relevant disclosures.

MIAMI BEACH – It borders on heresy, but dermatologists should consider no longer prescribing any full-dose antibiotic to combat acne because of side effects, antibiotic resistance, and a number of effective alternative therapies, Dr. Theodore Rosen said.

"Should we stop using antibiotics for acne? I’m going to take the absolute affirmative," Dr. Rosen said at the South Beach Symposium. "Everybody in this room should go back to their practice and not write another prescription for an oral antibiotic to treat acne."

As his rationale, Dr. Rosen cited the risks of gastrointestinal side effects, overgrowth of gram-negative microbes, fixed drug eruptions and other rare allergic reactions, and dyschromia. Other rare side effects of antibiotic use include autoimmune disease; pseudotumor cerebri and other neurologic conditions; and hepatic, renal, and hematologic adverse events, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

Two of Dr. Rosen’s patients had adverse reactions to doxycycline, one experiencing a fixed drug eruption and one urticaria. In addition, minocycline can cause cutaneous, oral, and/or ophthalmologic dyschromia. Pseudomembranous ulcerative colitis can result from the overgrowth of Clostridium difficile after clindamycin use, but "it’s not just clindamycin – it can be any antibiotic administered over a long enough period of time in a susceptible patient," Dr. Rosen added.

In countering Dr. Rosen’s arguments, session moderator Dr. James Q. Del Rosso said, "If we didn’t prescribe because of side effects, we couldn’t give topical bacitracin over the counter because people occasionally die from anaphylaxis. So nothing is perfect."

Dr. Del Rosso also noted that without oral antibiotics, there would be essentially no therapies between topical treatments for mild acne and isotretinoin to combat more severe cases. "You are going to have a group of unhappy patients who have smoldering, continuing inflammatory disease that is just going to lead to more scarring," said Dr. Del Ross, residency director at Valley Hospital Medical Center in Las Vegas.

To bolster his case, Dr. Rosen cited two studies that demonstrated similar efficacy between an oral antibiotic and benzoyl peroxide for acne. One compared patients taking 100 mg doxycycline with those using 5% topical benzoyl peroxide (Int. J. Dermatol. 2006;45:1438-9).

In the other study, researchers contrasted five antimicrobial regimens to benzoyl peroxide (Lancet 2004;364:2188-95). Dr. Rosen noted that both trials enrolled patients with mild to moderate acne and not severe disease, but said there was "no difference whatsoever in either of these studies" between antibiotics and benzoyl peroxide.

Further evidence that antibiotics might not be necessary includes a study in which researchers showed that a 6% benzoyl peroxide wash reduced strains of antibiotic-resistant Propionibacterium acnes, Dr. Rosen said (Cutis 2008;82:417-21). "We don’t need another oral antibiotic to do that."

"The fact is that those topical therapies are for a different subset of patients," Dr. Del Rosso said. "They don’t necessarily address the moderate to severe patients. When you look in those patients, the maximum you get is about a 40% lesion reduction. That means 60% of the acne is still there after 12 weeks."

Antibiotic-resistant P. acnes reflects both individual patient and global issues, Dr. Rosen said (J. Drugs Dermatol. 2010;9:655-64). "There are P. acnes that are inherently antibiotic resistant before you prescribe the antibiotic."

In the study of 6% benzoyl peroxide wash, patients untreated for acne at baseline already demonstrated some resistance to various antibiotics, he said, "because we misuse, overuse, and abuse" these agents. Antibiotic use for acne can worsen the already serious public health problem of drug resistance, Dr. Rosen emphasized.

"If you take all the evidence, I don’t think we should be using full-dosage antibiotics anymore for acne," he said. "There are alternatives that can do the same things without the same risk."

If you do still prescribe antibiotics, limit the duration of therapy, avoid combining oral and topical antibacterial agents, and use an adjunct like benzoyl peroxide, he recommended.

Dr. Rosen said that he had no relevant disclosures.

MIAMI BEACH – It borders on heresy, but dermatologists should consider no longer prescribing any full-dose antibiotic to combat acne because of side effects, antibiotic resistance, and a number of effective alternative therapies, Dr. Theodore Rosen said.

"Should we stop using antibiotics for acne? I’m going to take the absolute affirmative," Dr. Rosen said at the South Beach Symposium. "Everybody in this room should go back to their practice and not write another prescription for an oral antibiotic to treat acne."

As his rationale, Dr. Rosen cited the risks of gastrointestinal side effects, overgrowth of gram-negative microbes, fixed drug eruptions and other rare allergic reactions, and dyschromia. Other rare side effects of antibiotic use include autoimmune disease; pseudotumor cerebri and other neurologic conditions; and hepatic, renal, and hematologic adverse events, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

Two of Dr. Rosen’s patients had adverse reactions to doxycycline, one experiencing a fixed drug eruption and one urticaria. In addition, minocycline can cause cutaneous, oral, and/or ophthalmologic dyschromia. Pseudomembranous ulcerative colitis can result from the overgrowth of Clostridium difficile after clindamycin use, but "it’s not just clindamycin – it can be any antibiotic administered over a long enough period of time in a susceptible patient," Dr. Rosen added.

In countering Dr. Rosen’s arguments, session moderator Dr. James Q. Del Rosso said, "If we didn’t prescribe because of side effects, we couldn’t give topical bacitracin over the counter because people occasionally die from anaphylaxis. So nothing is perfect."

Dr. Del Rosso also noted that without oral antibiotics, there would be essentially no therapies between topical treatments for mild acne and isotretinoin to combat more severe cases. "You are going to have a group of unhappy patients who have smoldering, continuing inflammatory disease that is just going to lead to more scarring," said Dr. Del Ross, residency director at Valley Hospital Medical Center in Las Vegas.

To bolster his case, Dr. Rosen cited two studies that demonstrated similar efficacy between an oral antibiotic and benzoyl peroxide for acne. One compared patients taking 100 mg doxycycline with those using 5% topical benzoyl peroxide (Int. J. Dermatol. 2006;45:1438-9).

In the other study, researchers contrasted five antimicrobial regimens to benzoyl peroxide (Lancet 2004;364:2188-95). Dr. Rosen noted that both trials enrolled patients with mild to moderate acne and not severe disease, but said there was "no difference whatsoever in either of these studies" between antibiotics and benzoyl peroxide.

Further evidence that antibiotics might not be necessary includes a study in which researchers showed that a 6% benzoyl peroxide wash reduced strains of antibiotic-resistant Propionibacterium acnes, Dr. Rosen said (Cutis 2008;82:417-21). "We don’t need another oral antibiotic to do that."

"The fact is that those topical therapies are for a different subset of patients," Dr. Del Rosso said. "They don’t necessarily address the moderate to severe patients. When you look in those patients, the maximum you get is about a 40% lesion reduction. That means 60% of the acne is still there after 12 weeks."

Antibiotic-resistant P. acnes reflects both individual patient and global issues, Dr. Rosen said (J. Drugs Dermatol. 2010;9:655-64). "There are P. acnes that are inherently antibiotic resistant before you prescribe the antibiotic."

In the study of 6% benzoyl peroxide wash, patients untreated for acne at baseline already demonstrated some resistance to various antibiotics, he said, "because we misuse, overuse, and abuse" these agents. Antibiotic use for acne can worsen the already serious public health problem of drug resistance, Dr. Rosen emphasized.

"If you take all the evidence, I don’t think we should be using full-dosage antibiotics anymore for acne," he said. "There are alternatives that can do the same things without the same risk."

If you do still prescribe antibiotics, limit the duration of therapy, avoid combining oral and topical antibacterial agents, and use an adjunct like benzoyl peroxide, he recommended.

Dr. Rosen said that he had no relevant disclosures.

MIAMI BEACH – It borders on heresy, but dermatologists should consider no longer prescribing any full-dose antibiotic to combat acne because of side effects, antibiotic resistance, and a number of effective alternative therapies, Dr. Theodore Rosen said.

"Should we stop using antibiotics for acne? I’m going to take the absolute affirmative," Dr. Rosen said at the South Beach Symposium. "Everybody in this room should go back to their practice and not write another prescription for an oral antibiotic to treat acne."

As his rationale, Dr. Rosen cited the risks of gastrointestinal side effects, overgrowth of gram-negative microbes, fixed drug eruptions and other rare allergic reactions, and dyschromia. Other rare side effects of antibiotic use include autoimmune disease; pseudotumor cerebri and other neurologic conditions; and hepatic, renal, and hematologic adverse events, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

Two of Dr. Rosen’s patients had adverse reactions to doxycycline, one experiencing a fixed drug eruption and one urticaria. In addition, minocycline can cause cutaneous, oral, and/or ophthalmologic dyschromia. Pseudomembranous ulcerative colitis can result from the overgrowth of Clostridium difficile after clindamycin use, but "it’s not just clindamycin – it can be any antibiotic administered over a long enough period of time in a susceptible patient," Dr. Rosen added.

In countering Dr. Rosen’s arguments, session moderator Dr. James Q. Del Rosso said, "If we didn’t prescribe because of side effects, we couldn’t give topical bacitracin over the counter because people occasionally die from anaphylaxis. So nothing is perfect."

Dr. Del Rosso also noted that without oral antibiotics, there would be essentially no therapies between topical treatments for mild acne and isotretinoin to combat more severe cases. "You are going to have a group of unhappy patients who have smoldering, continuing inflammatory disease that is just going to lead to more scarring," said Dr. Del Ross, residency director at Valley Hospital Medical Center in Las Vegas.

To bolster his case, Dr. Rosen cited two studies that demonstrated similar efficacy between an oral antibiotic and benzoyl peroxide for acne. One compared patients taking 100 mg doxycycline with those using 5% topical benzoyl peroxide (Int. J. Dermatol. 2006;45:1438-9).

In the other study, researchers contrasted five antimicrobial regimens to benzoyl peroxide (Lancet 2004;364:2188-95). Dr. Rosen noted that both trials enrolled patients with mild to moderate acne and not severe disease, but said there was "no difference whatsoever in either of these studies" between antibiotics and benzoyl peroxide.

Further evidence that antibiotics might not be necessary includes a study in which researchers showed that a 6% benzoyl peroxide wash reduced strains of antibiotic-resistant Propionibacterium acnes, Dr. Rosen said (Cutis 2008;82:417-21). "We don’t need another oral antibiotic to do that."

"The fact is that those topical therapies are for a different subset of patients," Dr. Del Rosso said. "They don’t necessarily address the moderate to severe patients. When you look in those patients, the maximum you get is about a 40% lesion reduction. That means 60% of the acne is still there after 12 weeks."

Antibiotic-resistant P. acnes reflects both individual patient and global issues, Dr. Rosen said (J. Drugs Dermatol. 2010;9:655-64). "There are P. acnes that are inherently antibiotic resistant before you prescribe the antibiotic."

In the study of 6% benzoyl peroxide wash, patients untreated for acne at baseline already demonstrated some resistance to various antibiotics, he said, "because we misuse, overuse, and abuse" these agents. Antibiotic use for acne can worsen the already serious public health problem of drug resistance, Dr. Rosen emphasized.

"If you take all the evidence, I don’t think we should be using full-dosage antibiotics anymore for acne," he said. "There are alternatives that can do the same things without the same risk."

If you do still prescribe antibiotics, limit the duration of therapy, avoid combining oral and topical antibacterial agents, and use an adjunct like benzoyl peroxide, he recommended.

Dr. Rosen said that he had no relevant disclosures.

MIAMI BEACH – It borders on heresy, but dermatologists should consider no longer prescribing any full-dose antibiotic to combat acne because of side effects, antibiotic resistance, and a number of effective alternative therapies, Dr. Theodore Rosen said.

"Should we stop using antibiotics for acne? I’m going to take the absolute affirmative," Dr. Rosen said at the South Beach Symposium. "Everybody in this room should go back to their practice and not write another prescription for an oral antibiotic to treat acne."

As his rationale, Dr. Rosen cited the risks of gastrointestinal side effects, overgrowth of gram-negative microbes, fixed drug eruptions and other rare allergic reactions, and dyschromia. Other rare side effects of antibiotic use include autoimmune disease; pseudotumor cerebri and other neurologic conditions; and hepatic, renal, and hematologic adverse events, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

Two of Dr. Rosen’s patients had adverse reactions to doxycycline, one experiencing a fixed drug eruption and one urticaria. In addition, minocycline can cause cutaneous, oral, and/or ophthalmologic dyschromia. Pseudomembranous ulcerative colitis can result from the overgrowth of Clostridium difficile after clindamycin use, but "it’s not just clindamycin – it can be any antibiotic administered over a long enough period of time in a susceptible patient," Dr. Rosen added.

In countering Dr. Rosen’s arguments, session moderator Dr. James Q. Del Rosso said, "If we didn’t prescribe because of side effects, we couldn’t give topical bacitracin over the counter because people occasionally die from anaphylaxis. So nothing is perfect."

Dr. Del Rosso also noted that without oral antibiotics, there would be essentially no therapies between topical treatments for mild acne and isotretinoin to combat more severe cases. "You are going to have a group of unhappy patients who have smoldering, continuing inflammatory disease that is just going to lead to more scarring," said Dr. Del Ross, residency director at Valley Hospital Medical Center in Las Vegas.

To bolster his case, Dr. Rosen cited two studies that demonstrated similar efficacy between an oral antibiotic and benzoyl peroxide for acne. One compared patients taking 100 mg doxycycline with those using 5% topical benzoyl peroxide (Int. J. Dermatol. 2006;45:1438-9).

In the other study, researchers contrasted five antimicrobial regimens to benzoyl peroxide (Lancet 2004;364:2188-95). Dr. Rosen noted that both trials enrolled patients with mild to moderate acne and not severe disease, but said there was "no difference whatsoever in either of these studies" between antibiotics and benzoyl peroxide.

Further evidence that antibiotics might not be necessary includes a study in which researchers showed that a 6% benzoyl peroxide wash reduced strains of antibiotic-resistant Propionibacterium acnes, Dr. Rosen said (Cutis 2008;82:417-21). "We don’t need another oral antibiotic to do that."

"The fact is that those topical therapies are for a different subset of patients," Dr. Del Rosso said. "They don’t necessarily address the moderate to severe patients. When you look in those patients, the maximum you get is about a 40% lesion reduction. That means 60% of the acne is still there after 12 weeks."

Antibiotic-resistant P. acnes reflects both individual patient and global issues, Dr. Rosen said (J. Drugs Dermatol. 2010;9:655-64). "There are P. acnes that are inherently antibiotic resistant before you prescribe the antibiotic."

In the study of 6% benzoyl peroxide wash, patients untreated for acne at baseline already demonstrated some resistance to various antibiotics, he said, "because we misuse, overuse, and abuse" these agents. Antibiotic use for acne can worsen the already serious public health problem of drug resistance, Dr. Rosen emphasized.

"If you take all the evidence, I don’t think we should be using full-dosage antibiotics anymore for acne," he said. "There are alternatives that can do the same things without the same risk."

If you do still prescribe antibiotics, limit the duration of therapy, avoid combining oral and topical antibacterial agents, and use an adjunct like benzoyl peroxide, he recommended.

Dr. Rosen said that he had no relevant disclosures.

MIAMI BEACH – It borders on heresy, but dermatologists should consider no longer prescribing any full-dose antibiotic to combat acne because of side effects, antibiotic resistance, and a number of effective alternative therapies, Dr. Theodore Rosen said.

"Should we stop using antibiotics for acne? I’m going to take the absolute affirmative," Dr. Rosen said at the South Beach Symposium. "Everybody in this room should go back to their practice and not write another prescription for an oral antibiotic to treat acne."

As his rationale, Dr. Rosen cited the risks of gastrointestinal side effects, overgrowth of gram-negative microbes, fixed drug eruptions and other rare allergic reactions, and dyschromia. Other rare side effects of antibiotic use include autoimmune disease; pseudotumor cerebri and other neurologic conditions; and hepatic, renal, and hematologic adverse events, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

Two of Dr. Rosen’s patients had adverse reactions to doxycycline, one experiencing a fixed drug eruption and one urticaria. In addition, minocycline can cause cutaneous, oral, and/or ophthalmologic dyschromia. Pseudomembranous ulcerative colitis can result from the overgrowth of Clostridium difficile after clindamycin use, but "it’s not just clindamycin – it can be any antibiotic administered over a long enough period of time in a susceptible patient," Dr. Rosen added.

In countering Dr. Rosen’s arguments, session moderator Dr. James Q. Del Rosso said, "If we didn’t prescribe because of side effects, we couldn’t give topical bacitracin over the counter because people occasionally die from anaphylaxis. So nothing is perfect."

Dr. Del Rosso also noted that without oral antibiotics, there would be essentially no therapies between topical treatments for mild acne and isotretinoin to combat more severe cases. "You are going to have a group of unhappy patients who have smoldering, continuing inflammatory disease that is just going to lead to more scarring," said Dr. Del Ross, residency director at Valley Hospital Medical Center in Las Vegas.

To bolster his case, Dr. Rosen cited two studies that demonstrated similar efficacy between an oral antibiotic and benzoyl peroxide for acne. One compared patients taking 100 mg doxycycline with those using 5% topical benzoyl peroxide (Int. J. Dermatol. 2006;45:1438-9).

In the other study, researchers contrasted five antimicrobial regimens to benzoyl peroxide (Lancet 2004;364:2188-95). Dr. Rosen noted that both trials enrolled patients with mild to moderate acne and not severe disease, but said there was "no difference whatsoever in either of these studies" between antibiotics and benzoyl peroxide.

Further evidence that antibiotics might not be necessary includes a study in which researchers showed that a 6% benzoyl peroxide wash reduced strains of antibiotic-resistant Propionibacterium acnes, Dr. Rosen said (Cutis 2008;82:417-21). "We don’t need another oral antibiotic to do that."

"The fact is that those topical therapies are for a different subset of patients," Dr. Del Rosso said. "They don’t necessarily address the moderate to severe patients. When you look in those patients, the maximum you get is about a 40% lesion reduction. That means 60% of the acne is still there after 12 weeks."

Antibiotic-resistant P. acnes reflects both individual patient and global issues, Dr. Rosen said (J. Drugs Dermatol. 2010;9:655-64). "There are P. acnes that are inherently antibiotic resistant before you prescribe the antibiotic."

In the study of 6% benzoyl peroxide wash, patients untreated for acne at baseline already demonstrated some resistance to various antibiotics, he said, "because we misuse, overuse, and abuse" these agents. Antibiotic use for acne can worsen the already serious public health problem of drug resistance, Dr. Rosen emphasized.

"If you take all the evidence, I don’t think we should be using full-dosage antibiotics anymore for acne," he said. "There are alternatives that can do the same things without the same risk."

If you do still prescribe antibiotics, limit the duration of therapy, avoid combining oral and topical antibacterial agents, and use an adjunct like benzoyl peroxide, he recommended.

Dr. Rosen said that he had no relevant disclosures.

MIAMI BEACH – It borders on heresy, but dermatologists should consider no longer prescribing any full-dose antibiotic to combat acne because of side effects, antibiotic resistance, and a number of effective alternative therapies, Dr. Theodore Rosen said.

"Should we stop using antibiotics for acne? I’m going to take the absolute affirmative," Dr. Rosen said at the South Beach Symposium. "Everybody in this room should go back to their practice and not write another prescription for an oral antibiotic to treat acne."

As his rationale, Dr. Rosen cited the risks of gastrointestinal side effects, overgrowth of gram-negative microbes, fixed drug eruptions and other rare allergic reactions, and dyschromia. Other rare side effects of antibiotic use include autoimmune disease; pseudotumor cerebri and other neurologic conditions; and hepatic, renal, and hematologic adverse events, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

Two of Dr. Rosen’s patients had adverse reactions to doxycycline, one experiencing a fixed drug eruption and one urticaria. In addition, minocycline can cause cutaneous, oral, and/or ophthalmologic dyschromia. Pseudomembranous ulcerative colitis can result from the overgrowth of Clostridium difficile after clindamycin use, but "it’s not just clindamycin – it can be any antibiotic administered over a long enough period of time in a susceptible patient," Dr. Rosen added.

In countering Dr. Rosen’s arguments, session moderator Dr. James Q. Del Rosso said, "If we didn’t prescribe because of side effects, we couldn’t give topical bacitracin over the counter because people occasionally die from anaphylaxis. So nothing is perfect."

Dr. Del Rosso also noted that without oral antibiotics, there would be essentially no therapies between topical treatments for mild acne and isotretinoin to combat more severe cases. "You are going to have a group of unhappy patients who have smoldering, continuing inflammatory disease that is just going to lead to more scarring," said Dr. Del Ross, residency director at Valley Hospital Medical Center in Las Vegas.

To bolster his case, Dr. Rosen cited two studies that demonstrated similar efficacy between an oral antibiotic and benzoyl peroxide for acne. One compared patients taking 100 mg doxycycline with those using 5% topical benzoyl peroxide (Int. J. Dermatol. 2006;45:1438-9).

In the other study, researchers contrasted five antimicrobial regimens to benzoyl peroxide (Lancet 2004;364:2188-95). Dr. Rosen noted that both trials enrolled patients with mild to moderate acne and not severe disease, but said there was "no difference whatsoever in either of these studies" between antibiotics and benzoyl peroxide.

Further evidence that antibiotics might not be necessary includes a study in which researchers showed that a 6% benzoyl peroxide wash reduced strains of antibiotic-resistant Propionibacterium acnes, Dr. Rosen said (Cutis 2008;82:417-21). "We don’t need another oral antibiotic to do that."

"The fact is that those topical therapies are for a different subset of patients," Dr. Del Rosso said. "They don’t necessarily address the moderate to severe patients. When you look in those patients, the maximum you get is about a 40% lesion reduction. That means 60% of the acne is still there after 12 weeks."

Antibiotic-resistant P. acnes reflects both individual patient and global issues, Dr. Rosen said (J. Drugs Dermatol. 2010;9:655-64). "There are P. acnes that are inherently antibiotic resistant before you prescribe the antibiotic."

In the study of 6% benzoyl peroxide wash, patients untreated for acne at baseline already demonstrated some resistance to various antibiotics, he said, "because we misuse, overuse, and abuse" these agents. Antibiotic use for acne can worsen the already serious public health problem of drug resistance, Dr. Rosen emphasized.

"If you take all the evidence, I don’t think we should be using full-dosage antibiotics anymore for acne," he said. "There are alternatives that can do the same things without the same risk."

If you do still prescribe antibiotics, limit the duration of therapy, avoid combining oral and topical antibacterial agents, and use an adjunct like benzoyl peroxide, he recommended.

Dr. Rosen said that he had no relevant disclosures.

NAPLES, FLA. - Endovascular aneurysm repair is associated with better long-term survival compared with open abdominal aortic aneurysm surgery, although re-intervention rates for the two techniques were similar in a single-center, retrospective study.

In a registry of 1,066 endovascular aneurysm repair (EVAR) and 920 open abdominal aortic aneurysm (AAA) procedures, all-cause mortality in the first 100 months was 25% following EVAR and 39% after open repair. The mortality disparity was significant, even though the EVAR patients tended to be older and had more comorbidities, such as hypertension or diabetes, Dr. Brenton E. Quinney said at the meeting.

One-year mortality was 16% in the EVAR group and 28% in the open-repair group. At 5 years, mortality rose to 36% and 48%, respectively. “EVAR had better immediate, mid-term, and long-term survival out to 9 years,” said Dr. Quinney, a vascular surgery fellow at the University of Alabama at Birmingham.

To compare durability of EVAR vs. open AAA, they examined EVAR cases performed from 1999 to 2009 and open repairs from 1985 to 2009 at the University of Alabama.

Secondary interventions were vascular (aortic graft-related or remote procedures, such as carotid surgery) or nonvascular (incisional or gastrointestinal surgery). “Patients required more secondary vascular procedures after EVAR,” Dr. Quinney said. In contrast, “patients required more nonvascular procedures after open AAA repair.”

Dr. Quinney and his associates found 12.3% of EVAR versus 5.1% of open surgery cases required graft-related subsequent procedures. “However, when we add GI complications and laparotomy complications, both groups are virtually identical with overall re-intervention rates,” Dr. Quinney said. Specifically, 21.9% of the EVAR and 21.1% of the open cases required a re-intervention during the 290-month follow-up (mean, 27 months).

In the EVAR group, the graft-related secondary interventions were mostly minimally invasive transfemoral procedures (131 cases, or 56%). Subsequent nonaortic vascular procedures included 63 cases of infra-inguinal bypass, 13 thoracic aortic aneurysms (TAAs), and 4 gastrointestinal bleed repairs, he said.

In the open-surgery group, graft-related re-interventions were mostly secondary aneurysm repairs (23 cases). There were also 34 infra-inguinal bypass procedures and 22 TAA repairs in this group. All 97 nonvascular secondary surgeries in the study occurred in patients who initially underwent open surgery.

“What would be your preferred approach to a healthy 54-year-old male patient when this man wants you to make the decision?” asked study discussant Dr. Karthikeshwar Kasirajan, director of clinical research, division of vascular surgery, at Emory University in Atlanta.

“In a 54-year-old with suitable anatomy for AAA, we would probably recommend EVAR,” Dr. Quinney replied.

Limitations include the retrospective study design based on nonvascular procedures from medical records and patient reports. Also, the registry at the University of Alabama tracks only procedures, not patients, so “one patient could have had multiple procedures,” he said.

These findings demonstrating a long-term survival benefit with EVAR differ from the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial (N. Engl. J. Med. 2005;352:2398-405). EVAR showed an early postoperative survival advantage versus open repair in the DREAM trial, but “mortality equalized at 1 year,” Dr. Quinney said.

Secondary intervention rates in this patient population vary, partly because of different follow-up times, Dr. Quinney said, noting that a comparison of 444 EVAR and 437 open-repair outcomes during a mean 1.8-year follow-up found essentially equivalent rates of secondary interventions (JAMA 2009;302:1535-42). Another study showed a 9.8% re-intervention rate among 543 EVAR cases, compared with 5.8% of 539 open repairs over 4 years (Lancet 2004;364:843-8).

Dr. Quinney said he had no relevant disclosures. Dr. Kasirajan receives support from W.L. Gore and Medtronic.

NAPLES, FLA. - Endovascular aneurysm repair is associated with better long-term survival compared with open abdominal aortic aneurysm surgery, although re-intervention rates for the two techniques were similar in a single-center, retrospective study.

In a registry of 1,066 endovascular aneurysm repair (EVAR) and 920 open abdominal aortic aneurysm (AAA) procedures, all-cause mortality in the first 100 months was 25% following EVAR and 39% after open repair. The mortality disparity was significant, even though the EVAR patients tended to be older and had more comorbidities, such as hypertension or diabetes, Dr. Brenton E. Quinney said at the meeting.

One-year mortality was 16% in the EVAR group and 28% in the open-repair group. At 5 years, mortality rose to 36% and 48%, respectively. “EVAR had better immediate, mid-term, and long-term survival out to 9 years,” said Dr. Quinney, a vascular surgery fellow at the University of Alabama at Birmingham.

To compare durability of EVAR vs. open AAA, they examined EVAR cases performed from 1999 to 2009 and open repairs from 1985 to 2009 at the University of Alabama.

Secondary interventions were vascular (aortic graft-related or remote procedures, such as carotid surgery) or nonvascular (incisional or gastrointestinal surgery). “Patients required more secondary vascular procedures after EVAR,” Dr. Quinney said. In contrast, “patients required more nonvascular procedures after open AAA repair.”

Dr. Quinney and his associates found 12.3% of EVAR versus 5.1% of open surgery cases required graft-related subsequent procedures. “However, when we add GI complications and laparotomy complications, both groups are virtually identical with overall re-intervention rates,” Dr. Quinney said. Specifically, 21.9% of the EVAR and 21.1% of the open cases required a re-intervention during the 290-month follow-up (mean, 27 months).

In the EVAR group, the graft-related secondary interventions were mostly minimally invasive transfemoral procedures (131 cases, or 56%). Subsequent nonaortic vascular procedures included 63 cases of infra-inguinal bypass, 13 thoracic aortic aneurysms (TAAs), and 4 gastrointestinal bleed repairs, he said.

In the open-surgery group, graft-related re-interventions were mostly secondary aneurysm repairs (23 cases). There were also 34 infra-inguinal bypass procedures and 22 TAA repairs in this group. All 97 nonvascular secondary surgeries in the study occurred in patients who initially underwent open surgery.

“What would be your preferred approach to a healthy 54-year-old male patient when this man wants you to make the decision?” asked study discussant Dr. Karthikeshwar Kasirajan, director of clinical research, division of vascular surgery, at Emory University in Atlanta.

“In a 54-year-old with suitable anatomy for AAA, we would probably recommend EVAR,” Dr. Quinney replied.

Limitations include the retrospective study design based on nonvascular procedures from medical records and patient reports. Also, the registry at the University of Alabama tracks only procedures, not patients, so “one patient could have had multiple procedures,” he said.

These findings demonstrating a long-term survival benefit with EVAR differ from the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial (N. Engl. J. Med. 2005;352:2398-405). EVAR showed an early postoperative survival advantage versus open repair in the DREAM trial, but “mortality equalized at 1 year,” Dr. Quinney said.

Secondary intervention rates in this patient population vary, partly because of different follow-up times, Dr. Quinney said, noting that a comparison of 444 EVAR and 437 open-repair outcomes during a mean 1.8-year follow-up found essentially equivalent rates of secondary interventions (JAMA 2009;302:1535-42). Another study showed a 9.8% re-intervention rate among 543 EVAR cases, compared with 5.8% of 539 open repairs over 4 years (Lancet 2004;364:843-8).

Dr. Quinney said he had no relevant disclosures. Dr. Kasirajan receives support from W.L. Gore and Medtronic.

NAPLES, FLA. - Endovascular aneurysm repair is associated with better long-term survival compared with open abdominal aortic aneurysm surgery, although re-intervention rates for the two techniques were similar in a single-center, retrospective study.

In a registry of 1,066 endovascular aneurysm repair (EVAR) and 920 open abdominal aortic aneurysm (AAA) procedures, all-cause mortality in the first 100 months was 25% following EVAR and 39% after open repair. The mortality disparity was significant, even though the EVAR patients tended to be older and had more comorbidities, such as hypertension or diabetes, Dr. Brenton E. Quinney said at the meeting.

One-year mortality was 16% in the EVAR group and 28% in the open-repair group. At 5 years, mortality rose to 36% and 48%, respectively. “EVAR had better immediate, mid-term, and long-term survival out to 9 years,” said Dr. Quinney, a vascular surgery fellow at the University of Alabama at Birmingham.

To compare durability of EVAR vs. open AAA, they examined EVAR cases performed from 1999 to 2009 and open repairs from 1985 to 2009 at the University of Alabama.

Secondary interventions were vascular (aortic graft-related or remote procedures, such as carotid surgery) or nonvascular (incisional or gastrointestinal surgery). “Patients required more secondary vascular procedures after EVAR,” Dr. Quinney said. In contrast, “patients required more nonvascular procedures after open AAA repair.”

Dr. Quinney and his associates found 12.3% of EVAR versus 5.1% of open surgery cases required graft-related subsequent procedures. “However, when we add GI complications and laparotomy complications, both groups are virtually identical with overall re-intervention rates,” Dr. Quinney said. Specifically, 21.9% of the EVAR and 21.1% of the open cases required a re-intervention during the 290-month follow-up (mean, 27 months).

In the EVAR group, the graft-related secondary interventions were mostly minimally invasive transfemoral procedures (131 cases, or 56%). Subsequent nonaortic vascular procedures included 63 cases of infra-inguinal bypass, 13 thoracic aortic aneurysms (TAAs), and 4 gastrointestinal bleed repairs, he said.

In the open-surgery group, graft-related re-interventions were mostly secondary aneurysm repairs (23 cases). There were also 34 infra-inguinal bypass procedures and 22 TAA repairs in this group. All 97 nonvascular secondary surgeries in the study occurred in patients who initially underwent open surgery.

“What would be your preferred approach to a healthy 54-year-old male patient when this man wants you to make the decision?” asked study discussant Dr. Karthikeshwar Kasirajan, director of clinical research, division of vascular surgery, at Emory University in Atlanta.

“In a 54-year-old with suitable anatomy for AAA, we would probably recommend EVAR,” Dr. Quinney replied.

Limitations include the retrospective study design based on nonvascular procedures from medical records and patient reports. Also, the registry at the University of Alabama tracks only procedures, not patients, so “one patient could have had multiple procedures,” he said.

These findings demonstrating a long-term survival benefit with EVAR differ from the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial (N. Engl. J. Med. 2005;352:2398-405). EVAR showed an early postoperative survival advantage versus open repair in the DREAM trial, but “mortality equalized at 1 year,” Dr. Quinney said.

Secondary intervention rates in this patient population vary, partly because of different follow-up times, Dr. Quinney said, noting that a comparison of 444 EVAR and 437 open-repair outcomes during a mean 1.8-year follow-up found essentially equivalent rates of secondary interventions (JAMA 2009;302:1535-42). Another study showed a 9.8% re-intervention rate among 543 EVAR cases, compared with 5.8% of 539 open repairs over 4 years (Lancet 2004;364:843-8).

Dr. Quinney said he had no relevant disclosures. Dr. Kasirajan receives support from W.L. Gore and Medtronic.

Major Finding: In all, 7 of 16 patients with Marfan syndrome had successful endovascular treatment of their aortas.

Data Source: Review of endovascular repairs at the University of Florida, Gainesville, from 2000 to 2010.

Disclosures: Dr. Waterman and Dr. Endean said they had no relevant disclosures.

NAPLES, FLA. — Some patients with Marfan syndrome benefit from endovascular aortic repair, according to a review of 16 patients who were treated at the University of Florida, Gainesville, between January 2000 and June 2010.

Most patients had a history of multiple interventions, which points to the complexity of Marfan syndrome and a need to follow patients closely over the long term, Dr. Alyson L. Waterman said at the meeting.

Dr. Waterman and her associates reviewed their experience with endovascular abdominal aorta repair (EVAR) and thoracic endovascular aorta repair (TEVAR) for Marfan syndrome patients at the University of Florida.

After a median of 8.3 months, seven patients had clinical and radiographic evidence of successful treatment. Another six patients were primary treatment failures (for example, they had a type I endovascular leak or had persistent false lumen flow), and two patients had a secondary treatment failure, that is, initial success followed by proximal or distal aortic failure unrelated to the original intervention site. The remaining patient was lost to follow-up.

“Results are sobering but support [the concept that] some Marfan syndrome patients benefit from endovascular therapy,” said Dr. Waterman of the department of surgery at the University of Florida, Gainesville.

The main causes of death in Marfan syndrome are aortic dissection and rupture, Dr. Waterman said. She pointed out that open surgery is still required for repair of the ascending aorta, but endovascular intervention is an option for descending thoracic and abdominal aorta repair for those with this connective-tissue disorder.

The 16 Marfan syndrome patients in the series underwent a total of 19 relevant procedures (1 EVAR, 15 TEVAR, and 3 combined procedures). The median patient age was 52 years. Three patients had a secondary TEVAR within 28 months of their index intervention.

In all, 15 of the patients had previous surgery (from 17 years to 1 week prior) of the ascending aorta or arch.

Chronic dissection and/or aneurysmal dilation of the descending aorta were the indications for elective intervention in 13 patients. Two acute dissection/malperfusion cases and one anastomotic disruption early after an open surgery led to emergency intervention in three patients.

Four of the TEVAR procedures required adjunctive endovascular procedures. They comprised one subclavian artery embolization, one vertebral artery stent, one renal artery stent, and one celiac and superior mesenteric artery stent.

All four EVAR procedures required complex adjunctive endovascular procedures involving visceral arteries.

Five patients died during follow-up. Of them, two died perioperatively: the patient who underwent emergent TEVAR for anastomotic disruption, and a patient who required multivisceral revascularization in conjunction with a second TEVAR. Two patients died following discharge: one because of a respiratory failure at 3 months, and the other because of a cardiac arrest after 4 months.

The remaining patient died more than 6 years after EVAR from advanced age (84 years).

“This is clearly a group for whom treatment options are difficult at best,” said study discussant Dr. Eric D. Endean of the University of Kentucky, Lexington.

All were deemed poor candidates for open surgery, and they had a history of an average of almost two previous aortic operations. Six (38%) were classified as primary treatment failures, all required open repair, and half died, Dr. Endean commented. “Results are indeed sobering.”

“As you point out, diagnosis of Marfan syndrome was based on clinical diagnosis,” Dr. Endean said. He asked how confident Dr. Waterman is about the diagnoses in her series.

“That is one of the difficulties with Marfan syndrome; a lot is based on clinical diagnosis alone.” Not all patients undergo genetic screening for the fibrillin-1 mutation, she said.

A small population that makes the study “essentially a case series” is a limitation, Dr. Waterman said.

“Open surgery still has a big role in replacement of these aortas because these aortas are not genetically normal,” Dr. Waterman said.

However, there is still a place for endovascular therapy and a need to identify which patients are likely to benefit, she explained.

Dr. Waterman added that the cardiologists at University of Florida also treat Marfan syndrome patients, and they have yet to look at these patient populations at the two institutions combined.

Major Finding: In all, 7 of 16 patients with Marfan syndrome had successful endovascular treatment of their aortas.

Data Source: Review of endovascular repairs at the University of Florida, Gainesville, from 2000 to 2010.

Disclosures: Dr. Waterman and Dr. Endean said they had no relevant disclosures.

NAPLES, FLA. — Some patients with Marfan syndrome benefit from endovascular aortic repair, according to a review of 16 patients who were treated at the University of Florida, Gainesville, between January 2000 and June 2010.

Most patients had a history of multiple interventions, which points to the complexity of Marfan syndrome and a need to follow patients closely over the long term, Dr. Alyson L. Waterman said at the meeting.

Dr. Waterman and her associates reviewed their experience with endovascular abdominal aorta repair (EVAR) and thoracic endovascular aorta repair (TEVAR) for Marfan syndrome patients at the University of Florida.

After a median of 8.3 months, seven patients had clinical and radiographic evidence of successful treatment. Another six patients were primary treatment failures (for example, they had a type I endovascular leak or had persistent false lumen flow), and two patients had a secondary treatment failure, that is, initial success followed by proximal or distal aortic failure unrelated to the original intervention site. The remaining patient was lost to follow-up.

“Results are sobering but support [the concept that] some Marfan syndrome patients benefit from endovascular therapy,” said Dr. Waterman of the department of surgery at the University of Florida, Gainesville.

The main causes of death in Marfan syndrome are aortic dissection and rupture, Dr. Waterman said. She pointed out that open surgery is still required for repair of the ascending aorta, but endovascular intervention is an option for descending thoracic and abdominal aorta repair for those with this connective-tissue disorder.

The 16 Marfan syndrome patients in the series underwent a total of 19 relevant procedures (1 EVAR, 15 TEVAR, and 3 combined procedures). The median patient age was 52 years. Three patients had a secondary TEVAR within 28 months of their index intervention.

In all, 15 of the patients had previous surgery (from 17 years to 1 week prior) of the ascending aorta or arch.

Chronic dissection and/or aneurysmal dilation of the descending aorta were the indications for elective intervention in 13 patients. Two acute dissection/malperfusion cases and one anastomotic disruption early after an open surgery led to emergency intervention in three patients.

Four of the TEVAR procedures required adjunctive endovascular procedures. They comprised one subclavian artery embolization, one vertebral artery stent, one renal artery stent, and one celiac and superior mesenteric artery stent.

All four EVAR procedures required complex adjunctive endovascular procedures involving visceral arteries.

Five patients died during follow-up. Of them, two died perioperatively: the patient who underwent emergent TEVAR for anastomotic disruption, and a patient who required multivisceral revascularization in conjunction with a second TEVAR. Two patients died following discharge: one because of a respiratory failure at 3 months, and the other because of a cardiac arrest after 4 months.

The remaining patient died more than 6 years after EVAR from advanced age (84 years).

“This is clearly a group for whom treatment options are difficult at best,” said study discussant Dr. Eric D. Endean of the University of Kentucky, Lexington.

All were deemed poor candidates for open surgery, and they had a history of an average of almost two previous aortic operations. Six (38%) were classified as primary treatment failures, all required open repair, and half died, Dr. Endean commented. “Results are indeed sobering.”

“As you point out, diagnosis of Marfan syndrome was based on clinical diagnosis,” Dr. Endean said. He asked how confident Dr. Waterman is about the diagnoses in her series.

“That is one of the difficulties with Marfan syndrome; a lot is based on clinical diagnosis alone.” Not all patients undergo genetic screening for the fibrillin-1 mutation, she said.

A small population that makes the study “essentially a case series” is a limitation, Dr. Waterman said.

“Open surgery still has a big role in replacement of these aortas because these aortas are not genetically normal,” Dr. Waterman said.

However, there is still a place for endovascular therapy and a need to identify which patients are likely to benefit, she explained.

Dr. Waterman added that the cardiologists at University of Florida also treat Marfan syndrome patients, and they have yet to look at these patient populations at the two institutions combined.

Major Finding: In all, 7 of 16 patients with Marfan syndrome had successful endovascular treatment of their aortas.

Data Source: Review of endovascular repairs at the University of Florida, Gainesville, from 2000 to 2010.

Disclosures: Dr. Waterman and Dr. Endean said they had no relevant disclosures.

NAPLES, FLA. — Some patients with Marfan syndrome benefit from endovascular aortic repair, according to a review of 16 patients who were treated at the University of Florida, Gainesville, between January 2000 and June 2010.

Most patients had a history of multiple interventions, which points to the complexity of Marfan syndrome and a need to follow patients closely over the long term, Dr. Alyson L. Waterman said at the meeting.

Dr. Waterman and her associates reviewed their experience with endovascular abdominal aorta repair (EVAR) and thoracic endovascular aorta repair (TEVAR) for Marfan syndrome patients at the University of Florida.

After a median of 8.3 months, seven patients had clinical and radiographic evidence of successful treatment. Another six patients were primary treatment failures (for example, they had a type I endovascular leak or had persistent false lumen flow), and two patients had a secondary treatment failure, that is, initial success followed by proximal or distal aortic failure unrelated to the original intervention site. The remaining patient was lost to follow-up.

“Results are sobering but support [the concept that] some Marfan syndrome patients benefit from endovascular therapy,” said Dr. Waterman of the department of surgery at the University of Florida, Gainesville.

The main causes of death in Marfan syndrome are aortic dissection and rupture, Dr. Waterman said. She pointed out that open surgery is still required for repair of the ascending aorta, but endovascular intervention is an option for descending thoracic and abdominal aorta repair for those with this connective-tissue disorder.

The 16 Marfan syndrome patients in the series underwent a total of 19 relevant procedures (1 EVAR, 15 TEVAR, and 3 combined procedures). The median patient age was 52 years. Three patients had a secondary TEVAR within 28 months of their index intervention.

In all, 15 of the patients had previous surgery (from 17 years to 1 week prior) of the ascending aorta or arch.

Chronic dissection and/or aneurysmal dilation of the descending aorta were the indications for elective intervention in 13 patients. Two acute dissection/malperfusion cases and one anastomotic disruption early after an open surgery led to emergency intervention in three patients.

Four of the TEVAR procedures required adjunctive endovascular procedures. They comprised one subclavian artery embolization, one vertebral artery stent, one renal artery stent, and one celiac and superior mesenteric artery stent.

All four EVAR procedures required complex adjunctive endovascular procedures involving visceral arteries.

Five patients died during follow-up. Of them, two died perioperatively: the patient who underwent emergent TEVAR for anastomotic disruption, and a patient who required multivisceral revascularization in conjunction with a second TEVAR. Two patients died following discharge: one because of a respiratory failure at 3 months, and the other because of a cardiac arrest after 4 months.

The remaining patient died more than 6 years after EVAR from advanced age (84 years).

“This is clearly a group for whom treatment options are difficult at best,” said study discussant Dr. Eric D. Endean of the University of Kentucky, Lexington.

All were deemed poor candidates for open surgery, and they had a history of an average of almost two previous aortic operations. Six (38%) were classified as primary treatment failures, all required open repair, and half died, Dr. Endean commented. “Results are indeed sobering.”

“As you point out, diagnosis of Marfan syndrome was based on clinical diagnosis,” Dr. Endean said. He asked how confident Dr. Waterman is about the diagnoses in her series.

“That is one of the difficulties with Marfan syndrome; a lot is based on clinical diagnosis alone.” Not all patients undergo genetic screening for the fibrillin-1 mutation, she said.

A small population that makes the study “essentially a case series” is a limitation, Dr. Waterman said.

“Open surgery still has a big role in replacement of these aortas because these aortas are not genetically normal,” Dr. Waterman said.

However, there is still a place for endovascular therapy and a need to identify which patients are likely to benefit, she explained.

Dr. Waterman added that the cardiologists at University of Florida also treat Marfan syndrome patients, and they have yet to look at these patient populations at the two institutions combined.

NAPLES, FLA. — An exponential increase in ambulatory endovascular procedures for peripheral arterial disease is occurring in Florida, and it mirrors a nationwide trend, Dr. Michael S. Hong said at the meeting.

This shift to more ambulatory-based interventions is leading to decreases in open bypass procedures and major amputations, he said. This finding is from a study of discharges for peripheral arterial disease from Florida hospitals since 2000 and from ambulatory centers since 2004.

Approximately four out of five endovascular interventions for claudication, for example, are now performed in an ambulatory setting in Florida (approximately 8,000 vs. 2,000 done in a hospital setting), Dr. Hong said.

“With critical limb ischemia, the number of endovascular ambulatory interventions is much less than [that for] claudication, but we see an increase in the absolute number and in the proportion done in an ambulatory setting over time,” said Dr. Hong, a research resident in the department of surgery at the University of Florida, Gainesville.

At the same time, inpatient procedures are still increasing for critical limb ischemia, Dr. Hong said. “Inpatient endovascular procedures are predominantly now for more advanced peripheral arterial disease.”

“Interventionists might consider these more dangerous and hence want to perform them more in the hospital,” said study discussant Dr. Russell H. Samson, who is a vascular surgeon at Doctors Hospital of Sarasota (Fla.). In addition, critical limb ischemia repairs “are very equipment intensive and the equipment is expensive.”

Importantly, overall patient safety has not been compromised with a move toward more outpatient procedures, Dr. Hong said. “From our data, with only two deaths and 20 transferred … this shift to the ambulatory setting has not compromised patient safety.”

He and his associates reviewed 10 years of ICD-9 inpatient codes and 6 years of outpatient CPT codes for endovascular angioplasty, atherectomy, and peripheral stent procedures. They also assessed ICD-9 codes for open bypasses.

Among the findings is that lower extremity bypass procedures in the state dropped from 5,294 in 2000 to 3,636 in 2008, a 31% decrease.

In just 5 years (2004–2008), ambulatory endovascular procedures grew from 3,014 to an estimated 6,670, which Dr. Hong described as “an exponential increase.” (The 2008 figure is an annual projection based on data available from the first three quarters of that year.)

In 2008, the number of endovascular interventions in both settings exceeded the number of open bypasses by nearly threefold (12,419 vs. 3,636). Although hospital-based endovascular procedures increased from 2,698 to 5,748 in 2008, “inpatient management … numbers seem to have plateaued over the last several years,” Dr. Hong said.

Dr. Samson commented, “There is a shift for performing these procedures from hospitals to outpatient settings. However, only 3% are being done in freestanding facilities and the rest are at centers affiliated with hospitals.”

Dr. Hong confirmed that 97% of the ambulatory endovascular interventions were performed at hospital-affiliated centers, but added that some were done at freestanding cardiac catheter centers.

The researchers also assessed amputation numbers and trends. They found a 43% decrease in major amputations (defined as above knee to the ankle), from 2,833 in 2000 to 1,609 in 2008. At the same time, the number of minor amputations (from the forefoot to toe) remained relatively stable, from 1,354 to 1,362. “If you put them together with major amputations, the overall rate is down,” Dr. Hong said.

Not surprisingly, the overall shift to ambulatory interventions was associated with “substantially lower charges overall,” Dr. Hong said. The total mean charge for open bypass was $62,946, compared with $57,995 for hospital-based endovascular interventions and $32,719 for ambulatory endovascular procedures. Total charges increased each year by approximately 21% in the hospital setting and by 10% in the ambulatory setting, he added.

One potential study limitation is the reliance on coder input into the AHCA (Agency for Health Care Administration) database. “But there is nothing here to suggest any significant adverse problems so far,” Dr. Hong said.

Another limitation of the study is that cost-to-charge ratios vary by hospital, Dr. Hong said. He added, however, that “a comparison between procedures still provides a good estimate of relative costs.” Because AHCA is an administrative database, there was no clinical information on ankle brachial index or TASC (TransAtlantic InterSociety Consensus) lesion classification. Also, it is unknown if the deidentified data included patients who underwent multiple procedures.

Dr. Hong and Dr. Samson said that they had no relevant disclosures.

NAPLES, FLA. — An exponential increase in ambulatory endovascular procedures for peripheral arterial disease is occurring in Florida, and it mirrors a nationwide trend, Dr. Michael S. Hong said at the meeting.

This shift to more ambulatory-based interventions is leading to decreases in open bypass procedures and major amputations, he said. This finding is from a study of discharges for peripheral arterial disease from Florida hospitals since 2000 and from ambulatory centers since 2004.

Approximately four out of five endovascular interventions for claudication, for example, are now performed in an ambulatory setting in Florida (approximately 8,000 vs. 2,000 done in a hospital setting), Dr. Hong said.

“With critical limb ischemia, the number of endovascular ambulatory interventions is much less than [that for] claudication, but we see an increase in the absolute number and in the proportion done in an ambulatory setting over time,” said Dr. Hong, a research resident in the department of surgery at the University of Florida, Gainesville.

At the same time, inpatient procedures are still increasing for critical limb ischemia, Dr. Hong said. “Inpatient endovascular procedures are predominantly now for more advanced peripheral arterial disease.”

“Interventionists might consider these more dangerous and hence want to perform them more in the hospital,” said study discussant Dr. Russell H. Samson, who is a vascular surgeon at Doctors Hospital of Sarasota (Fla.). In addition, critical limb ischemia repairs “are very equipment intensive and the equipment is expensive.”

Importantly, overall patient safety has not been compromised with a move toward more outpatient procedures, Dr. Hong said. “From our data, with only two deaths and 20 transferred … this shift to the ambulatory setting has not compromised patient safety.”

He and his associates reviewed 10 years of ICD-9 inpatient codes and 6 years of outpatient CPT codes for endovascular angioplasty, atherectomy, and peripheral stent procedures. They also assessed ICD-9 codes for open bypasses.

Among the findings is that lower extremity bypass procedures in the state dropped from 5,294 in 2000 to 3,636 in 2008, a 31% decrease.

In just 5 years (2004–2008), ambulatory endovascular procedures grew from 3,014 to an estimated 6,670, which Dr. Hong described as “an exponential increase.” (The 2008 figure is an annual projection based on data available from the first three quarters of that year.)

In 2008, the number of endovascular interventions in both settings exceeded the number of open bypasses by nearly threefold (12,419 vs. 3,636). Although hospital-based endovascular procedures increased from 2,698 to 5,748 in 2008, “inpatient management … numbers seem to have plateaued over the last several years,” Dr. Hong said.

Dr. Samson commented, “There is a shift for performing these procedures from hospitals to outpatient settings. However, only 3% are being done in freestanding facilities and the rest are at centers affiliated with hospitals.”

Dr. Hong confirmed that 97% of the ambulatory endovascular interventions were performed at hospital-affiliated centers, but added that some were done at freestanding cardiac catheter centers.

The researchers also assessed amputation numbers and trends. They found a 43% decrease in major amputations (defined as above knee to the ankle), from 2,833 in 2000 to 1,609 in 2008. At the same time, the number of minor amputations (from the forefoot to toe) remained relatively stable, from 1,354 to 1,362. “If you put them together with major amputations, the overall rate is down,” Dr. Hong said.

Not surprisingly, the overall shift to ambulatory interventions was associated with “substantially lower charges overall,” Dr. Hong said. The total mean charge for open bypass was $62,946, compared with $57,995 for hospital-based endovascular interventions and $32,719 for ambulatory endovascular procedures. Total charges increased each year by approximately 21% in the hospital setting and by 10% in the ambulatory setting, he added.

One potential study limitation is the reliance on coder input into the AHCA (Agency for Health Care Administration) database. “But there is nothing here to suggest any significant adverse problems so far,” Dr. Hong said.

Another limitation of the study is that cost-to-charge ratios vary by hospital, Dr. Hong said. He added, however, that “a comparison between procedures still provides a good estimate of relative costs.” Because AHCA is an administrative database, there was no clinical information on ankle brachial index or TASC (TransAtlantic InterSociety Consensus) lesion classification. Also, it is unknown if the deidentified data included patients who underwent multiple procedures.

Dr. Hong and Dr. Samson said that they had no relevant disclosures.

NAPLES, FLA. — An exponential increase in ambulatory endovascular procedures for peripheral arterial disease is occurring in Florida, and it mirrors a nationwide trend, Dr. Michael S. Hong said at the meeting.

This shift to more ambulatory-based interventions is leading to decreases in open bypass procedures and major amputations, he said. This finding is from a study of discharges for peripheral arterial disease from Florida hospitals since 2000 and from ambulatory centers since 2004.

Approximately four out of five endovascular interventions for claudication, for example, are now performed in an ambulatory setting in Florida (approximately 8,000 vs. 2,000 done in a hospital setting), Dr. Hong said.

“With critical limb ischemia, the number of endovascular ambulatory interventions is much less than [that for] claudication, but we see an increase in the absolute number and in the proportion done in an ambulatory setting over time,” said Dr. Hong, a research resident in the department of surgery at the University of Florida, Gainesville.

At the same time, inpatient procedures are still increasing for critical limb ischemia, Dr. Hong said. “Inpatient endovascular procedures are predominantly now for more advanced peripheral arterial disease.”

“Interventionists might consider these more dangerous and hence want to perform them more in the hospital,” said study discussant Dr. Russell H. Samson, who is a vascular surgeon at Doctors Hospital of Sarasota (Fla.). In addition, critical limb ischemia repairs “are very equipment intensive and the equipment is expensive.”

Importantly, overall patient safety has not been compromised with a move toward more outpatient procedures, Dr. Hong said. “From our data, with only two deaths and 20 transferred … this shift to the ambulatory setting has not compromised patient safety.”

He and his associates reviewed 10 years of ICD-9 inpatient codes and 6 years of outpatient CPT codes for endovascular angioplasty, atherectomy, and peripheral stent procedures. They also assessed ICD-9 codes for open bypasses.

Among the findings is that lower extremity bypass procedures in the state dropped from 5,294 in 2000 to 3,636 in 2008, a 31% decrease.

In just 5 years (2004–2008), ambulatory endovascular procedures grew from 3,014 to an estimated 6,670, which Dr. Hong described as “an exponential increase.” (The 2008 figure is an annual projection based on data available from the first three quarters of that year.)

In 2008, the number of endovascular interventions in both settings exceeded the number of open bypasses by nearly threefold (12,419 vs. 3,636). Although hospital-based endovascular procedures increased from 2,698 to 5,748 in 2008, “inpatient management … numbers seem to have plateaued over the last several years,” Dr. Hong said.

Dr. Samson commented, “There is a shift for performing these procedures from hospitals to outpatient settings. However, only 3% are being done in freestanding facilities and the rest are at centers affiliated with hospitals.”

Dr. Hong confirmed that 97% of the ambulatory endovascular interventions were performed at hospital-affiliated centers, but added that some were done at freestanding cardiac catheter centers.

The researchers also assessed amputation numbers and trends. They found a 43% decrease in major amputations (defined as above knee to the ankle), from 2,833 in 2000 to 1,609 in 2008. At the same time, the number of minor amputations (from the forefoot to toe) remained relatively stable, from 1,354 to 1,362. “If you put them together with major amputations, the overall rate is down,” Dr. Hong said.

Not surprisingly, the overall shift to ambulatory interventions was associated with “substantially lower charges overall,” Dr. Hong said. The total mean charge for open bypass was $62,946, compared with $57,995 for hospital-based endovascular interventions and $32,719 for ambulatory endovascular procedures. Total charges increased each year by approximately 21% in the hospital setting and by 10% in the ambulatory setting, he added.

One potential study limitation is the reliance on coder input into the AHCA (Agency for Health Care Administration) database. “But there is nothing here to suggest any significant adverse problems so far,” Dr. Hong said.

Another limitation of the study is that cost-to-charge ratios vary by hospital, Dr. Hong said. He added, however, that “a comparison between procedures still provides a good estimate of relative costs.” Because AHCA is an administrative database, there was no clinical information on ankle brachial index or TASC (TransAtlantic InterSociety Consensus) lesion classification. Also, it is unknown if the deidentified data included patients who underwent multiple procedures.

Dr. Hong and Dr. Samson said that they had no relevant disclosures.

NEW ORLEANS – There could come a day when cardiologists and dermatologists closely confer on patients with suspected severe mitral valve prolapse in an effort to save lives from sudden cardiac death, according to Dr. Paolo Romanelli.

Following his positive findings of an association between elevated proteoglycan biopsy results and severe mitral valve prolapse reported in a letter (J. Am. Acad. Dermatol. 2008;59:168-9), Dr. Romanelli continued to spread the word at this year’s annual meeting of the American Academy of Dermatology.

"Skin biopsy may be a useful adjunct to echocardiography in the detection of clinically significant mitral valve prolapse," Dr. Romanelli said. "Knowing the extent of the skin involvement in such patients would provide new insights into the pathogenesis of possible cardiac complications."

Dr. Romanelli and his associates compared eight patients with echocardiography-proven severe mitral valve prolapse (MVP) and six controls with no cardiac symptoms. They took two 4-mm punch biopsies from normal-appearing forearm skin of each participant to test for proteoglycan mucin levels.

Their theory that myxomatous changes in the skin could predict severe MVP is based on multiple studies in the scientific literature, starting with a study of 237 MVP patients that linked cases of sudden death to myxomatous degeneration of their mitral valves (N. Engl. J. Med. 1985;313:1305-9).

MVP is characterized by accumulation of mucinous material in valve leaflets, membranous and atrial septum, and mitral and tricuspid valve rings. Most people with primary MVP remain asymptomatic and do not require treatment, Dr. Romanelli said. In rare cases, however, severe consequences – including sudden death – can occur (N. Engl. J. Med. 1999;341:1-7).

Dr. Romanelli’s study demonstrated that quantitative proteoglycan analysis was greater among patients with MVP (0.6 mg/g), compared with controls (0.4 mg/g). In addition, semiquantitative assessment of proteoglycan deposition by hematoxylin-eosin staining and colloidal iron staining was a mean 3.4 in MVP patients, compared with 1.0 in controls, noted Dr. Romanelli of the department of dermatology and cutaneous surgery at the University of Miami.

All participants were younger than 55 years. All of the MVP patients were comorbid with conditions that included atrial fibrillation, palpitations, and mild chest discomfort.

A number of dermatologic conditions are associated with MVP, Dr. Romanelli said, such as Marfan and Ehlers-Danlos syndrome, cutis laxa, and other connective tissue diseases with a genetic basis.

The study findings need to be validated, Dr. Romanelli said. Nevertheless, he said he foresees a time when a skin biopsy will predict the subset of patients at greatest risk for arrhythmias and sudden death from MVP. Once identified, further work-up of their cardiac conduction systems would be indicated.

Dr. Romanelli said that he had no relevant disclosures.

NEW ORLEANS – There could come a day when cardiologists and dermatologists closely confer on patients with suspected severe mitral valve prolapse in an effort to save lives from sudden cardiac death, according to Dr. Paolo Romanelli.

Following his positive findings of an association between elevated proteoglycan biopsy results and severe mitral valve prolapse reported in a letter (J. Am. Acad. Dermatol. 2008;59:168-9), Dr. Romanelli continued to spread the word at this year’s annual meeting of the American Academy of Dermatology.

"Skin biopsy may be a useful adjunct to echocardiography in the detection of clinically significant mitral valve prolapse," Dr. Romanelli said. "Knowing the extent of the skin involvement in such patients would provide new insights into the pathogenesis of possible cardiac complications."

Dr. Romanelli and his associates compared eight patients with echocardiography-proven severe mitral valve prolapse (MVP) and six controls with no cardiac symptoms. They took two 4-mm punch biopsies from normal-appearing forearm skin of each participant to test for proteoglycan mucin levels.

Their theory that myxomatous changes in the skin could predict severe MVP is based on multiple studies in the scientific literature, starting with a study of 237 MVP patients that linked cases of sudden death to myxomatous degeneration of their mitral valves (N. Engl. J. Med. 1985;313:1305-9).

MVP is characterized by accumulation of mucinous material in valve leaflets, membranous and atrial septum, and mitral and tricuspid valve rings. Most people with primary MVP remain asymptomatic and do not require treatment, Dr. Romanelli said. In rare cases, however, severe consequences – including sudden death – can occur (N. Engl. J. Med. 1999;341:1-7).

Dr. Romanelli’s study demonstrated that quantitative proteoglycan analysis was greater among patients with MVP (0.6 mg/g), compared with controls (0.4 mg/g). In addition, semiquantitative assessment of proteoglycan deposition by hematoxylin-eosin staining and colloidal iron staining was a mean 3.4 in MVP patients, compared with 1.0 in controls, noted Dr. Romanelli of the department of dermatology and cutaneous surgery at the University of Miami.

All participants were younger than 55 years. All of the MVP patients were comorbid with conditions that included atrial fibrillation, palpitations, and mild chest discomfort.

A number of dermatologic conditions are associated with MVP, Dr. Romanelli said, such as Marfan and Ehlers-Danlos syndrome, cutis laxa, and other connective tissue diseases with a genetic basis.

The study findings need to be validated, Dr. Romanelli said. Nevertheless, he said he foresees a time when a skin biopsy will predict the subset of patients at greatest risk for arrhythmias and sudden death from MVP. Once identified, further work-up of their cardiac conduction systems would be indicated.

Dr. Romanelli said that he had no relevant disclosures.

NEW ORLEANS – There could come a day when cardiologists and dermatologists closely confer on patients with suspected severe mitral valve prolapse in an effort to save lives from sudden cardiac death, according to Dr. Paolo Romanelli.

Following his positive findings of an association between elevated proteoglycan biopsy results and severe mitral valve prolapse reported in a letter (J. Am. Acad. Dermatol. 2008;59:168-9), Dr. Romanelli continued to spread the word at this year’s annual meeting of the American Academy of Dermatology.

"Skin biopsy may be a useful adjunct to echocardiography in the detection of clinically significant mitral valve prolapse," Dr. Romanelli said. "Knowing the extent of the skin involvement in such patients would provide new insights into the pathogenesis of possible cardiac complications."

Dr. Romanelli and his associates compared eight patients with echocardiography-proven severe mitral valve prolapse (MVP) and six controls with no cardiac symptoms. They took two 4-mm punch biopsies from normal-appearing forearm skin of each participant to test for proteoglycan mucin levels.

Their theory that myxomatous changes in the skin could predict severe MVP is based on multiple studies in the scientific literature, starting with a study of 237 MVP patients that linked cases of sudden death to myxomatous degeneration of their mitral valves (N. Engl. J. Med. 1985;313:1305-9).

MVP is characterized by accumulation of mucinous material in valve leaflets, membranous and atrial septum, and mitral and tricuspid valve rings. Most people with primary MVP remain asymptomatic and do not require treatment, Dr. Romanelli said. In rare cases, however, severe consequences – including sudden death – can occur (N. Engl. J. Med. 1999;341:1-7).

Dr. Romanelli’s study demonstrated that quantitative proteoglycan analysis was greater among patients with MVP (0.6 mg/g), compared with controls (0.4 mg/g). In addition, semiquantitative assessment of proteoglycan deposition by hematoxylin-eosin staining and colloidal iron staining was a mean 3.4 in MVP patients, compared with 1.0 in controls, noted Dr. Romanelli of the department of dermatology and cutaneous surgery at the University of Miami.

All participants were younger than 55 years. All of the MVP patients were comorbid with conditions that included atrial fibrillation, palpitations, and mild chest discomfort.

A number of dermatologic conditions are associated with MVP, Dr. Romanelli said, such as Marfan and Ehlers-Danlos syndrome, cutis laxa, and other connective tissue diseases with a genetic basis.

The study findings need to be validated, Dr. Romanelli said. Nevertheless, he said he foresees a time when a skin biopsy will predict the subset of patients at greatest risk for arrhythmias and sudden death from MVP. Once identified, further work-up of their cardiac conduction systems would be indicated.

Dr. Romanelli said that he had no relevant disclosures.

NEW ORLEANS – There could come a day when cardiologists and dermatologists closely confer on patients with suspected severe mitral valve prolapse in an effort to save lives from sudden cardiac death, according to Dr. Paolo Romanelli.

Following his positive findings of an association between elevated proteoglycan biopsy results and severe mitral valve prolapse reported in a letter (J. Am. Acad. Dermatol. 2008;59:168-9), Dr. Romanelli continued to spread the word at this year’s annual meeting of the American Academy of Dermatology.

"Skin biopsy may be a useful adjunct to echocardiography in the detection of clinically significant mitral valve prolapse," Dr. Romanelli said. "Knowing the extent of the skin involvement in such patients would provide new insights into the pathogenesis of possible cardiac complications."

Dr. Romanelli and his associates compared eight patients with echocardiography-proven severe mitral valve prolapse (MVP) and six controls with no cardiac symptoms. They took two 4-mm punch biopsies from normal-appearing forearm skin of each participant to test for proteoglycan mucin levels.

Their theory that myxomatous changes in the skin could predict severe MVP is based on multiple studies in the scientific literature, starting with a study of 237 MVP patients that linked cases of sudden death to myxomatous degeneration of their mitral valves (N. Engl. J. Med. 1985;313:1305-9).

MVP is characterized by accumulation of mucinous material in valve leaflets, membranous and atrial septum, and mitral and tricuspid valve rings. Most people with primary MVP remain asymptomatic and do not require treatment, Dr. Romanelli said. In rare cases, however, severe consequences – including sudden death – can occur (N. Engl. J. Med. 1999;341:1-7).

Dr. Romanelli’s study demonstrated that quantitative proteoglycan analysis was greater among patients with MVP (0.6 mg/g), compared with controls (0.4 mg/g). In addition, semiquantitative assessment of proteoglycan deposition by hematoxylin-eosin staining and colloidal iron staining was a mean 3.4 in MVP patients, compared with 1.0 in controls, noted Dr. Romanelli of the department of dermatology and cutaneous surgery at the University of Miami.

All participants were younger than 55 years. All of the MVP patients were comorbid with conditions that included atrial fibrillation, palpitations, and mild chest discomfort.

A number of dermatologic conditions are associated with MVP, Dr. Romanelli said, such as Marfan and Ehlers-Danlos syndrome, cutis laxa, and other connective tissue diseases with a genetic basis.

The study findings need to be validated, Dr. Romanelli said. Nevertheless, he said he foresees a time when a skin biopsy will predict the subset of patients at greatest risk for arrhythmias and sudden death from MVP. Once identified, further work-up of their cardiac conduction systems would be indicated.

Dr. Romanelli said that he had no relevant disclosures.

NEW ORLEANS – There could come a day when cardiologists and dermatologists closely confer on patients with suspected severe mitral valve prolapse in an effort to save lives from sudden cardiac death, according to Dr. Paolo Romanelli.

Following his positive findings of an association between elevated proteoglycan biopsy results and severe mitral valve prolapse reported in a letter (J. Am. Acad. Dermatol. 2008;59:168-9), Dr. Romanelli continued to spread the word at this year’s annual meeting of the American Academy of Dermatology.

"Skin biopsy may be a useful adjunct to echocardiography in the detection of clinically significant mitral valve prolapse," Dr. Romanelli said. "Knowing the extent of the skin involvement in such patients would provide new insights into the pathogenesis of possible cardiac complications."

Dr. Romanelli and his associates compared eight patients with echocardiography-proven severe mitral valve prolapse (MVP) and six controls with no cardiac symptoms. They took two 4-mm punch biopsies from normal-appearing forearm skin of each participant to test for proteoglycan mucin levels.

Their theory that myxomatous changes in the skin could predict severe MVP is based on multiple studies in the scientific literature, starting with a study of 237 MVP patients that linked cases of sudden death to myxomatous degeneration of their mitral valves (N. Engl. J. Med. 1985;313:1305-9).

MVP is characterized by accumulation of mucinous material in valve leaflets, membranous and atrial septum, and mitral and tricuspid valve rings. Most people with primary MVP remain asymptomatic and do not require treatment, Dr. Romanelli said. In rare cases, however, severe consequences – including sudden death – can occur (N. Engl. J. Med. 1999;341:1-7).

Dr. Romanelli’s study demonstrated that quantitative proteoglycan analysis was greater among patients with MVP (0.6 mg/g), compared with controls (0.4 mg/g). In addition, semiquantitative assessment of proteoglycan deposition by hematoxylin-eosin staining and colloidal iron staining was a mean 3.4 in MVP patients, compared with 1.0 in controls, noted Dr. Romanelli of the department of dermatology and cutaneous surgery at the University of Miami.

All participants were younger than 55 years. All of the MVP patients were comorbid with conditions that included atrial fibrillation, palpitations, and mild chest discomfort.

A number of dermatologic conditions are associated with MVP, Dr. Romanelli said, such as Marfan and Ehlers-Danlos syndrome, cutis laxa, and other connective tissue diseases with a genetic basis.

The study findings need to be validated, Dr. Romanelli said. Nevertheless, he said he foresees a time when a skin biopsy will predict the subset of patients at greatest risk for arrhythmias and sudden death from MVP. Once identified, further work-up of their cardiac conduction systems would be indicated.

Dr. Romanelli said that he had no relevant disclosures.

NEW ORLEANS – There could come a day when cardiologists and dermatologists closely confer on patients with suspected severe mitral valve prolapse in an effort to save lives from sudden cardiac death, according to Dr. Paolo Romanelli.

Following his positive findings of an association between elevated proteoglycan biopsy results and severe mitral valve prolapse reported in a letter (J. Am. Acad. Dermatol. 2008;59:168-9), Dr. Romanelli continued to spread the word at this year’s annual meeting of the American Academy of Dermatology.

"Skin biopsy may be a useful adjunct to echocardiography in the detection of clinically significant mitral valve prolapse," Dr. Romanelli said. "Knowing the extent of the skin involvement in such patients would provide new insights into the pathogenesis of possible cardiac complications."

Dr. Romanelli and his associates compared eight patients with echocardiography-proven severe mitral valve prolapse (MVP) and six controls with no cardiac symptoms. They took two 4-mm punch biopsies from normal-appearing forearm skin of each participant to test for proteoglycan mucin levels.

Their theory that myxomatous changes in the skin could predict severe MVP is based on multiple studies in the scientific literature, starting with a study of 237 MVP patients that linked cases of sudden death to myxomatous degeneration of their mitral valves (N. Engl. J. Med. 1985;313:1305-9).

MVP is characterized by accumulation of mucinous material in valve leaflets, membranous and atrial septum, and mitral and tricuspid valve rings. Most people with primary MVP remain asymptomatic and do not require treatment, Dr. Romanelli said. In rare cases, however, severe consequences – including sudden death – can occur (N. Engl. J. Med. 1999;341:1-7).

Dr. Romanelli’s study demonstrated that quantitative proteoglycan analysis was greater among patients with MVP (0.6 mg/g), compared with controls (0.4 mg/g). In addition, semiquantitative assessment of proteoglycan deposition by hematoxylin-eosin staining and colloidal iron staining was a mean 3.4 in MVP patients, compared with 1.0 in controls, noted Dr. Romanelli of the department of dermatology and cutaneous surgery at the University of Miami.

All participants were younger than 55 years. All of the MVP patients were comorbid with conditions that included atrial fibrillation, palpitations, and mild chest discomfort.

A number of dermatologic conditions are associated with MVP, Dr. Romanelli said, such as Marfan and Ehlers-Danlos syndrome, cutis laxa, and other connective tissue diseases with a genetic basis.

The study findings need to be validated, Dr. Romanelli said. Nevertheless, he said he foresees a time when a skin biopsy will predict the subset of patients at greatest risk for arrhythmias and sudden death from MVP. Once identified, further work-up of their cardiac conduction systems would be indicated.

Dr. Romanelli said that he had no relevant disclosures.

NEW ORLEANS – There could come a day when cardiologists and dermatologists closely confer on patients with suspected severe mitral valve prolapse in an effort to save lives from sudden cardiac death, according to Dr. Paolo Romanelli.

Following his positive findings of an association between elevated proteoglycan biopsy results and severe mitral valve prolapse reported in a letter (J. Am. Acad. Dermatol. 2008;59:168-9), Dr. Romanelli continued to spread the word at this year’s annual meeting of the American Academy of Dermatology.

"Skin biopsy may be a useful adjunct to echocardiography in the detection of clinically significant mitral valve prolapse," Dr. Romanelli said. "Knowing the extent of the skin involvement in such patients would provide new insights into the pathogenesis of possible cardiac complications."

Dr. Romanelli and his associates compared eight patients with echocardiography-proven severe mitral valve prolapse (MVP) and six controls with no cardiac symptoms. They took two 4-mm punch biopsies from normal-appearing forearm skin of each participant to test for proteoglycan mucin levels.

Their theory that myxomatous changes in the skin could predict severe MVP is based on multiple studies in the scientific literature, starting with a study of 237 MVP patients that linked cases of sudden death to myxomatous degeneration of their mitral valves (N. Engl. J. Med. 1985;313:1305-9).

MVP is characterized by accumulation of mucinous material in valve leaflets, membranous and atrial septum, and mitral and tricuspid valve rings. Most people with primary MVP remain asymptomatic and do not require treatment, Dr. Romanelli said. In rare cases, however, severe consequences – including sudden death – can occur (N. Engl. J. Med. 1999;341:1-7).

Dr. Romanelli’s study demonstrated that quantitative proteoglycan analysis was greater among patients with MVP (0.6 mg/g), compared with controls (0.4 mg/g). In addition, semiquantitative assessment of proteoglycan deposition by hematoxylin-eosin staining and colloidal iron staining was a mean 3.4 in MVP patients, compared with 1.0 in controls, noted Dr. Romanelli of the department of dermatology and cutaneous surgery at the University of Miami.

All participants were younger than 55 years. All of the MVP patients were comorbid with conditions that included atrial fibrillation, palpitations, and mild chest discomfort.

A number of dermatologic conditions are associated with MVP, Dr. Romanelli said, such as Marfan and Ehlers-Danlos syndrome, cutis laxa, and other connective tissue diseases with a genetic basis.

The study findings need to be validated, Dr. Romanelli said. Nevertheless, he said he foresees a time when a skin biopsy will predict the subset of patients at greatest risk for arrhythmias and sudden death from MVP. Once identified, further work-up of their cardiac conduction systems would be indicated.

Dr. Romanelli said that he had no relevant disclosures.

NEW ORLEANS – There could come a day when cardiologists and dermatologists closely confer on patients with suspected severe mitral valve prolapse in an effort to save lives from sudden cardiac death, according to Dr. Paolo Romanelli.

Following his positive findings of an association between elevated proteoglycan biopsy results and severe mitral valve prolapse reported in a letter (J. Am. Acad. Dermatol. 2008;59:168-9), Dr. Romanelli continued to spread the word at this year’s annual meeting of the American Academy of Dermatology.

"Skin biopsy may be a useful adjunct to echocardiography in the detection of clinically significant mitral valve prolapse," Dr. Romanelli said. "Knowing the extent of the skin involvement in such patients would provide new insights into the pathogenesis of possible cardiac complications."

Dr. Romanelli and his associates compared eight patients with echocardiography-proven severe mitral valve prolapse (MVP) and six controls with no cardiac symptoms. They took two 4-mm punch biopsies from normal-appearing forearm skin of each participant to test for proteoglycan mucin levels.

Their theory that myxomatous changes in the skin could predict severe MVP is based on multiple studies in the scientific literature, starting with a study of 237 MVP patients that linked cases of sudden death to myxomatous degeneration of their mitral valves (N. Engl. J. Med. 1985;313:1305-9).

MVP is characterized by accumulation of mucinous material in valve leaflets, membranous and atrial septum, and mitral and tricuspid valve rings. Most people with primary MVP remain asymptomatic and do not require treatment, Dr. Romanelli said. In rare cases, however, severe consequences – including sudden death – can occur (N. Engl. J. Med. 1999;341:1-7).

Dr. Romanelli’s study demonstrated that quantitative proteoglycan analysis was greater among patients with MVP (0.6 mg/g), compared with controls (0.4 mg/g). In addition, semiquantitative assessment of proteoglycan deposition by hematoxylin-eosin staining and colloidal iron staining was a mean 3.4 in MVP patients, compared with 1.0 in controls, noted Dr. Romanelli of the department of dermatology and cutaneous surgery at the University of Miami.

All participants were younger than 55 years. All of the MVP patients were comorbid with conditions that included atrial fibrillation, palpitations, and mild chest discomfort.

A number of dermatologic conditions are associated with MVP, Dr. Romanelli said, such as Marfan and Ehlers-Danlos syndrome, cutis laxa, and other connective tissue diseases with a genetic basis.

The study findings need to be validated, Dr. Romanelli said. Nevertheless, he said he foresees a time when a skin biopsy will predict the subset of patients at greatest risk for arrhythmias and sudden death from MVP. Once identified, further work-up of their cardiac conduction systems would be indicated.

Dr. Romanelli said that he had no relevant disclosures.

NEW ORLEANS – There could come a day when cardiologists and dermatologists closely confer on patients with suspected severe mitral valve prolapse in an effort to save lives from sudden cardiac death, according to Dr. Paolo Romanelli.

Following his positive findings of an association between elevated proteoglycan biopsy results and severe mitral valve prolapse reported in a letter (J. Am. Acad. Dermatol. 2008;59:168-9), Dr. Romanelli continued to spread the word at this year’s annual meeting of the American Academy of Dermatology.

"Skin biopsy may be a useful adjunct to echocardiography in the detection of clinically significant mitral valve prolapse," Dr. Romanelli said. "Knowing the extent of the skin involvement in such patients would provide new insights into the pathogenesis of possible cardiac complications."

Dr. Romanelli and his associates compared eight patients with echocardiography-proven severe mitral valve prolapse (MVP) and six controls with no cardiac symptoms. They took two 4-mm punch biopsies from normal-appearing forearm skin of each participant to test for proteoglycan mucin levels.

Their theory that myxomatous changes in the skin could predict severe MVP is based on multiple studies in the scientific literature, starting with a study of 237 MVP patients that linked cases of sudden death to myxomatous degeneration of their mitral valves (N. Engl. J. Med. 1985;313:1305-9).

MVP is characterized by accumulation of mucinous material in valve leaflets, membranous and atrial septum, and mitral and tricuspid valve rings. Most people with primary MVP remain asymptomatic and do not require treatment, Dr. Romanelli said. In rare cases, however, severe consequences – including sudden death – can occur (N. Engl. J. Med. 1999;341:1-7).

Dr. Romanelli’s study demonstrated that quantitative proteoglycan analysis was greater among patients with MVP (0.6 mg/g), compared with controls (0.4 mg/g). In addition, semiquantitative assessment of proteoglycan deposition by hematoxylin-eosin staining and colloidal iron staining was a mean 3.4 in MVP patients, compared with 1.0 in controls, noted Dr. Romanelli of the department of dermatology and cutaneous surgery at the University of Miami.

All participants were younger than 55 years. All of the MVP patients were comorbid with conditions that included atrial fibrillation, palpitations, and mild chest discomfort.

A number of dermatologic conditions are associated with MVP, Dr. Romanelli said, such as Marfan and Ehlers-Danlos syndrome, cutis laxa, and other connective tissue diseases with a genetic basis.

The study findings need to be validated, Dr. Romanelli said. Nevertheless, he said he foresees a time when a skin biopsy will predict the subset of patients at greatest risk for arrhythmias and sudden death from MVP. Once identified, further work-up of their cardiac conduction systems would be indicated.

Dr. Romanelli said that he had no relevant disclosures.