Damian McNamara

CHICAGO - In contrast to claims made about some noninvasive body-contouring devices, cryolipolysis can and does work, Dr. Elizabeth Tanzi said.

However, careful patient selection and realistic expectations – on both the part of the patient and the physician – are essential to a successful outcome, said Dr. Tanzi, a private practice dermatologist in Washington, D.C.

"Noninvasive removal of fat to contour the body is a reality. However, as we've all been told: If something seems to be too good to be true, it probably is," Dr. Tanzi said. "There are limitations."

Educate patients that cryolipolysis is not a replacement for liposuction to remove large amounts of fat. The technique, instead, is best suited to flatten discreet bulges of fat – around the abdomen, the back, or the "love handles," for example, that are resistant to diet and exercise, Dr. Tanzi said at the annual meeting of the American Society for Dermatologic Surgery, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

You may need to counter some patient misperceptions about cryolipolysis as well. "This is not 'fat freezing,' no matter how many times you hear that in the media," she said.

This procedure, instead, relies on precise, controlled cooling of fat cells or adipocytes. This strategy exploits the natural vulnerability of adipocytes to prolonged cold exposure, Dr. Tanzi said, and causes the death of these cells without damage to surrounding tissues. The destroyed fat cells are cleared through the body's natural clearance mechanisms. The Food and Drug Administration approved a cryolipolysis device (CoolSculpting, Zeltiq) for marketing in September 2010.

You can tell inquisitive patients that a single cryolipolysis treatment reduced the fat layer an average of 22% for 32 patients in a prospective multicenter study, Dr. Tanzi said. Dr. Jeffrey Dover presented the results at the 2009 American Society for Laser Medicine and Surgery annual meeting.

Counsel patients that cryolipolysis results are not immediate, Dr. Tanzi said. Adipocytes appear intact immediately post treatment, followed by an inflammatory response seen at days 3, 5, and 7. It can take several months for fat cell clearance and full clinical results.

Patients also can expect temporary dulling of sensation in the treated area that typically resolves in 1-2 weeks, Dr. Tanzi said. Erythema can last minutes to hours post treatment but purpura is uncommon. In addition, patients might experience a "dull, deep soreness for several days. It is tolerable, and feels like they have just done a lot of sit-ups."

Patient and physician expectations have to be realistic, Dr. Tanzi said. "I get asked questions by patients over and over again. Does it really work? The answer is yes, but you have to define the terms." Cryolipolysis will improve the body’s contour, but it is not for skin tightening, for example, and it is not a weight loss strategy. "Yes, clothes fit better," she said. "Patients tell me about that, and now it’s part of my conversation in my consultation."

The noninvasive fat removal field – including cryolipolysis and the other body-contouring devices – is still in its infancy, Dr. Tanzi said in a follow-up interview.

Technology changes underway will expand the application of these technologies beyond the abdomen and love handle areas. "Soon we’ll be able to treat other areas, such as arms and thighs, to really get a nice contour improvement there as well," she said.

Dr. Tanzi disclosed that she is on the medical advisory board for Zeltiq.

CHICAGO - In contrast to claims made about some noninvasive body-contouring devices, cryolipolysis can and does work, Dr. Elizabeth Tanzi said.

However, careful patient selection and realistic expectations – on both the part of the patient and the physician – are essential to a successful outcome, said Dr. Tanzi, a private practice dermatologist in Washington, D.C.

"Noninvasive removal of fat to contour the body is a reality. However, as we've all been told: If something seems to be too good to be true, it probably is," Dr. Tanzi said. "There are limitations."

Educate patients that cryolipolysis is not a replacement for liposuction to remove large amounts of fat. The technique, instead, is best suited to flatten discreet bulges of fat – around the abdomen, the back, or the "love handles," for example, that are resistant to diet and exercise, Dr. Tanzi said at the annual meeting of the American Society for Dermatologic Surgery, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

You may need to counter some patient misperceptions about cryolipolysis as well. "This is not 'fat freezing,' no matter how many times you hear that in the media," she said.

This procedure, instead, relies on precise, controlled cooling of fat cells or adipocytes. This strategy exploits the natural vulnerability of adipocytes to prolonged cold exposure, Dr. Tanzi said, and causes the death of these cells without damage to surrounding tissues. The destroyed fat cells are cleared through the body's natural clearance mechanisms. The Food and Drug Administration approved a cryolipolysis device (CoolSculpting, Zeltiq) for marketing in September 2010.

You can tell inquisitive patients that a single cryolipolysis treatment reduced the fat layer an average of 22% for 32 patients in a prospective multicenter study, Dr. Tanzi said. Dr. Jeffrey Dover presented the results at the 2009 American Society for Laser Medicine and Surgery annual meeting.

Counsel patients that cryolipolysis results are not immediate, Dr. Tanzi said. Adipocytes appear intact immediately post treatment, followed by an inflammatory response seen at days 3, 5, and 7. It can take several months for fat cell clearance and full clinical results.

Patients also can expect temporary dulling of sensation in the treated area that typically resolves in 1-2 weeks, Dr. Tanzi said. Erythema can last minutes to hours post treatment but purpura is uncommon. In addition, patients might experience a "dull, deep soreness for several days. It is tolerable, and feels like they have just done a lot of sit-ups."

Patient and physician expectations have to be realistic, Dr. Tanzi said. "I get asked questions by patients over and over again. Does it really work? The answer is yes, but you have to define the terms." Cryolipolysis will improve the body’s contour, but it is not for skin tightening, for example, and it is not a weight loss strategy. "Yes, clothes fit better," she said. "Patients tell me about that, and now it’s part of my conversation in my consultation."

The noninvasive fat removal field – including cryolipolysis and the other body-contouring devices – is still in its infancy, Dr. Tanzi said in a follow-up interview.

Technology changes underway will expand the application of these technologies beyond the abdomen and love handle areas. "Soon we’ll be able to treat other areas, such as arms and thighs, to really get a nice contour improvement there as well," she said.

Dr. Tanzi disclosed that she is on the medical advisory board for Zeltiq.

CHICAGO - In contrast to claims made about some noninvasive body-contouring devices, cryolipolysis can and does work, Dr. Elizabeth Tanzi said.

However, careful patient selection and realistic expectations – on both the part of the patient and the physician – are essential to a successful outcome, said Dr. Tanzi, a private practice dermatologist in Washington, D.C.

"Noninvasive removal of fat to contour the body is a reality. However, as we've all been told: If something seems to be too good to be true, it probably is," Dr. Tanzi said. "There are limitations."

Educate patients that cryolipolysis is not a replacement for liposuction to remove large amounts of fat. The technique, instead, is best suited to flatten discreet bulges of fat – around the abdomen, the back, or the "love handles," for example, that are resistant to diet and exercise, Dr. Tanzi said at the annual meeting of the American Society for Dermatologic Surgery, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

You may need to counter some patient misperceptions about cryolipolysis as well. "This is not 'fat freezing,' no matter how many times you hear that in the media," she said.

This procedure, instead, relies on precise, controlled cooling of fat cells or adipocytes. This strategy exploits the natural vulnerability of adipocytes to prolonged cold exposure, Dr. Tanzi said, and causes the death of these cells without damage to surrounding tissues. The destroyed fat cells are cleared through the body's natural clearance mechanisms. The Food and Drug Administration approved a cryolipolysis device (CoolSculpting, Zeltiq) for marketing in September 2010.

You can tell inquisitive patients that a single cryolipolysis treatment reduced the fat layer an average of 22% for 32 patients in a prospective multicenter study, Dr. Tanzi said. Dr. Jeffrey Dover presented the results at the 2009 American Society for Laser Medicine and Surgery annual meeting.

Counsel patients that cryolipolysis results are not immediate, Dr. Tanzi said. Adipocytes appear intact immediately post treatment, followed by an inflammatory response seen at days 3, 5, and 7. It can take several months for fat cell clearance and full clinical results.

Patients also can expect temporary dulling of sensation in the treated area that typically resolves in 1-2 weeks, Dr. Tanzi said. Erythema can last minutes to hours post treatment but purpura is uncommon. In addition, patients might experience a "dull, deep soreness for several days. It is tolerable, and feels like they have just done a lot of sit-ups."

Patient and physician expectations have to be realistic, Dr. Tanzi said. "I get asked questions by patients over and over again. Does it really work? The answer is yes, but you have to define the terms." Cryolipolysis will improve the body’s contour, but it is not for skin tightening, for example, and it is not a weight loss strategy. "Yes, clothes fit better," she said. "Patients tell me about that, and now it’s part of my conversation in my consultation."

The noninvasive fat removal field – including cryolipolysis and the other body-contouring devices – is still in its infancy, Dr. Tanzi said in a follow-up interview.

Technology changes underway will expand the application of these technologies beyond the abdomen and love handle areas. "Soon we’ll be able to treat other areas, such as arms and thighs, to really get a nice contour improvement there as well," she said.

Dr. Tanzi disclosed that she is on the medical advisory board for Zeltiq.

SAN FRANCISCO – Dermatologists are seeing an increasing incidence of adult women with acne in their offices and they are a clear challenge to treat, Dr. Hilary E. Baldwin said.

Compared to teenagers, women in their 30s, 40s, and 50s – and their acne lesions – can be more resistant to treatment, Dr. Baldwin said at the seminar, which was sponsored by Skin Disease Education Foundation (SDEF).

“One of the problems of treating moderate to severe acne in the adult woman is that topical medications may not work particularly well. It may be that she is a little harder to treat, but also she has acne on the neck and the jaw, which is more sensitive skin, and the topical products tend to be quite irritating,” Dr. Baldwin said.

Acne after adolescence also can be more psychosocially devastating. Unlike a teenage girl, an affected woman may have no one else in her social group who has acne. And “because teenagers are supposed to have acne,” Dr. Baldwin said, “people will question: What is she doing wrong? Is she not eating right?”

Acne can have a detrimental effect on sexuality, motherhood, and/or returning to the workplace, and can deepen a midlife crisis, said Dr. Baldwin, who is vice chair of the department of dermatology at the State University of New York, Brooklyn.

With fewer topical agents in their armamentarium for the adult woman with acne, dermatologists tend to prescribe oral medication, Dr. Baldwin said.

Oral antibiotics are an example, such as anti-inflammatory dose doxycycline (acne is an off-label indication).

This agent does not kill Propionibacterium acnes, but it can improve acne through an anti-inflammatory effect that is similar to full-dose doxycycline, Dr. Baldwin said.

One caveat: If you prescribe an oral antibiotic, you may experience pushback from some patients, Dr. Baldwin said. “I have women who say that they get a yeast infection every time they get an antibiotic.” Strategies include antibiotic treatment through a yeast infection; a simultaneous prescription to prevent yeast growth; and/or selection of an antibiotic less likely to cause this effect. For example, extended-release minocycline may be less likely to spur yeast growth than traditional minocycline, she said.

Nonantibiotic alternatives for moderate to severe acne are limited, especially in women of child-bearing potential.

Oral hormonal contraceptives also can improve acne in adult women, Dr. Baldwin said. In the United States, ethinyl estradiol/norethindrone acetate (Estrostep, Warner Chilcott); drospirenone/ethinyl estradiol (Yaz, Bayer); and ethinyl estradiol/norgestimate (Ortho Tri-Cyclen, Ortho McNeil Janssen) are FDA-approved for acne treatment “and others with estrogen may be effective.”

Because their full acne-fighting effects can take up to 6 months, Dr. Baldwin recommended prescription of oral contraceptives in combination with a quicker onset agent. “For me it's a medication on top of a medication that is going to give more immediate improvement, one I can take them off when I start to see the oral contraceptive kick in.”

“The difference becomes significant with Yaz at about 6 months,” Dr. Baldwin said. “But waiting for 6 months for this to happen is not something most of our patients will do.”

Keep potential adverse effects of oral contraceptives in mind. Evidence in the literatures suggests there is no increased cardiovascular risk among non-smokers, Dr. Baldwin said.

In addition, studies indicate no increase risk of breast cancer. An increased likelihood for a thrombolic event is elevated during the first year then becomes normalized, she said.

The FDA added a black box warning to labeling for spironolactone (Aldactone, GD Searle, plus generics) in 2008 that cites an increased risk for tumors based on animal studies. The warning recommends use only for approved indications, “which acne is not,” Dr. Baldwin explained.

There have been five cases of breast cancer reported in women taking spironolactone and other medications, but there was “no clear link to the medication.” Also, a review article found no evidence of risk (J. Clin. Aesthet. Dermatol. 2009;2:16-22). Still you “need to discuss this risk with your patients,” Dr. Baldwin said.

“A recent Cochrane review [Cochrane Database Syst. Rev. 2009;(2):CD000194] on spironolactone which concluded that, although it was very helpful for hirsutism and for alopecia, that it had no evidence-based medicine to support its use in the treatment of acne,” Dr. Baldwin remarked in an interview.

“Now that flies in the face of numerous small studies which have demonstrated clearly over the years that spironolactone in doses from 50 to 200 mg per day are very helpful in the treatment of acne, especially in the adult woman,” she added.

The number of participants in these studies was “so small that it didn't pass muster for the Cochrane review,” Dr. Baldwin said. “I still believe spironolactone is an incredibly useful drug in the treatment of acne.”

An estimated 13%-15% of women in the United States have acne. The number has been increasing in recent past.

Dr. Baldwin said, however, it is unclear if the increase is due to greater awareness of quality acne therapy and/or a true increase in prevalence. She recommended www.acneandrosacea.org

Dr. Baldwin is a consultant and has received honoraria from Ortho, Galderma, Allergan, Coria, Graceway, GlaxoSmithKline, and L'Oreal. SDEF and this news organization are owned by Elsevier.

'I have women who say that they get a yeast infection every time they get an antibiotic.'

Source DR. BALDWIN

SAN FRANCISCO – Dermatologists are seeing an increasing incidence of adult women with acne in their offices and they are a clear challenge to treat, Dr. Hilary E. Baldwin said.

Compared to teenagers, women in their 30s, 40s, and 50s – and their acne lesions – can be more resistant to treatment, Dr. Baldwin said at the seminar, which was sponsored by Skin Disease Education Foundation (SDEF).

“One of the problems of treating moderate to severe acne in the adult woman is that topical medications may not work particularly well. It may be that she is a little harder to treat, but also she has acne on the neck and the jaw, which is more sensitive skin, and the topical products tend to be quite irritating,” Dr. Baldwin said.

Acne after adolescence also can be more psychosocially devastating. Unlike a teenage girl, an affected woman may have no one else in her social group who has acne. And “because teenagers are supposed to have acne,” Dr. Baldwin said, “people will question: What is she doing wrong? Is she not eating right?”

Acne can have a detrimental effect on sexuality, motherhood, and/or returning to the workplace, and can deepen a midlife crisis, said Dr. Baldwin, who is vice chair of the department of dermatology at the State University of New York, Brooklyn.

With fewer topical agents in their armamentarium for the adult woman with acne, dermatologists tend to prescribe oral medication, Dr. Baldwin said.

Oral antibiotics are an example, such as anti-inflammatory dose doxycycline (acne is an off-label indication).

This agent does not kill Propionibacterium acnes, but it can improve acne through an anti-inflammatory effect that is similar to full-dose doxycycline, Dr. Baldwin said.

One caveat: If you prescribe an oral antibiotic, you may experience pushback from some patients, Dr. Baldwin said. “I have women who say that they get a yeast infection every time they get an antibiotic.” Strategies include antibiotic treatment through a yeast infection; a simultaneous prescription to prevent yeast growth; and/or selection of an antibiotic less likely to cause this effect. For example, extended-release minocycline may be less likely to spur yeast growth than traditional minocycline, she said.

Nonantibiotic alternatives for moderate to severe acne are limited, especially in women of child-bearing potential.

Oral hormonal contraceptives also can improve acne in adult women, Dr. Baldwin said. In the United States, ethinyl estradiol/norethindrone acetate (Estrostep, Warner Chilcott); drospirenone/ethinyl estradiol (Yaz, Bayer); and ethinyl estradiol/norgestimate (Ortho Tri-Cyclen, Ortho McNeil Janssen) are FDA-approved for acne treatment “and others with estrogen may be effective.”

Because their full acne-fighting effects can take up to 6 months, Dr. Baldwin recommended prescription of oral contraceptives in combination with a quicker onset agent. “For me it's a medication on top of a medication that is going to give more immediate improvement, one I can take them off when I start to see the oral contraceptive kick in.”

“The difference becomes significant with Yaz at about 6 months,” Dr. Baldwin said. “But waiting for 6 months for this to happen is not something most of our patients will do.”

Keep potential adverse effects of oral contraceptives in mind. Evidence in the literatures suggests there is no increased cardiovascular risk among non-smokers, Dr. Baldwin said.

In addition, studies indicate no increase risk of breast cancer. An increased likelihood for a thrombolic event is elevated during the first year then becomes normalized, she said.

The FDA added a black box warning to labeling for spironolactone (Aldactone, GD Searle, plus generics) in 2008 that cites an increased risk for tumors based on animal studies. The warning recommends use only for approved indications, “which acne is not,” Dr. Baldwin explained.

There have been five cases of breast cancer reported in women taking spironolactone and other medications, but there was “no clear link to the medication.” Also, a review article found no evidence of risk (J. Clin. Aesthet. Dermatol. 2009;2:16-22). Still you “need to discuss this risk with your patients,” Dr. Baldwin said.

“A recent Cochrane review [Cochrane Database Syst. Rev. 2009;(2):CD000194] on spironolactone which concluded that, although it was very helpful for hirsutism and for alopecia, that it had no evidence-based medicine to support its use in the treatment of acne,” Dr. Baldwin remarked in an interview.

“Now that flies in the face of numerous small studies which have demonstrated clearly over the years that spironolactone in doses from 50 to 200 mg per day are very helpful in the treatment of acne, especially in the adult woman,” she added.

The number of participants in these studies was “so small that it didn't pass muster for the Cochrane review,” Dr. Baldwin said. “I still believe spironolactone is an incredibly useful drug in the treatment of acne.”

An estimated 13%-15% of women in the United States have acne. The number has been increasing in recent past.

Dr. Baldwin said, however, it is unclear if the increase is due to greater awareness of quality acne therapy and/or a true increase in prevalence. She recommended www.acneandrosacea.org

Dr. Baldwin is a consultant and has received honoraria from Ortho, Galderma, Allergan, Coria, Graceway, GlaxoSmithKline, and L'Oreal. SDEF and this news organization are owned by Elsevier.

'I have women who say that they get a yeast infection every time they get an antibiotic.'

Source DR. BALDWIN

SAN FRANCISCO – Dermatologists are seeing an increasing incidence of adult women with acne in their offices and they are a clear challenge to treat, Dr. Hilary E. Baldwin said.

Compared to teenagers, women in their 30s, 40s, and 50s – and their acne lesions – can be more resistant to treatment, Dr. Baldwin said at the seminar, which was sponsored by Skin Disease Education Foundation (SDEF).

“One of the problems of treating moderate to severe acne in the adult woman is that topical medications may not work particularly well. It may be that she is a little harder to treat, but also she has acne on the neck and the jaw, which is more sensitive skin, and the topical products tend to be quite irritating,” Dr. Baldwin said.

Acne after adolescence also can be more psychosocially devastating. Unlike a teenage girl, an affected woman may have no one else in her social group who has acne. And “because teenagers are supposed to have acne,” Dr. Baldwin said, “people will question: What is she doing wrong? Is she not eating right?”

Acne can have a detrimental effect on sexuality, motherhood, and/or returning to the workplace, and can deepen a midlife crisis, said Dr. Baldwin, who is vice chair of the department of dermatology at the State University of New York, Brooklyn.

With fewer topical agents in their armamentarium for the adult woman with acne, dermatologists tend to prescribe oral medication, Dr. Baldwin said.

Oral antibiotics are an example, such as anti-inflammatory dose doxycycline (acne is an off-label indication).

This agent does not kill Propionibacterium acnes, but it can improve acne through an anti-inflammatory effect that is similar to full-dose doxycycline, Dr. Baldwin said.

One caveat: If you prescribe an oral antibiotic, you may experience pushback from some patients, Dr. Baldwin said. “I have women who say that they get a yeast infection every time they get an antibiotic.” Strategies include antibiotic treatment through a yeast infection; a simultaneous prescription to prevent yeast growth; and/or selection of an antibiotic less likely to cause this effect. For example, extended-release minocycline may be less likely to spur yeast growth than traditional minocycline, she said.

Nonantibiotic alternatives for moderate to severe acne are limited, especially in women of child-bearing potential.

Oral hormonal contraceptives also can improve acne in adult women, Dr. Baldwin said. In the United States, ethinyl estradiol/norethindrone acetate (Estrostep, Warner Chilcott); drospirenone/ethinyl estradiol (Yaz, Bayer); and ethinyl estradiol/norgestimate (Ortho Tri-Cyclen, Ortho McNeil Janssen) are FDA-approved for acne treatment “and others with estrogen may be effective.”

Because their full acne-fighting effects can take up to 6 months, Dr. Baldwin recommended prescription of oral contraceptives in combination with a quicker onset agent. “For me it's a medication on top of a medication that is going to give more immediate improvement, one I can take them off when I start to see the oral contraceptive kick in.”

“The difference becomes significant with Yaz at about 6 months,” Dr. Baldwin said. “But waiting for 6 months for this to happen is not something most of our patients will do.”

Keep potential adverse effects of oral contraceptives in mind. Evidence in the literatures suggests there is no increased cardiovascular risk among non-smokers, Dr. Baldwin said.

In addition, studies indicate no increase risk of breast cancer. An increased likelihood for a thrombolic event is elevated during the first year then becomes normalized, she said.

The FDA added a black box warning to labeling for spironolactone (Aldactone, GD Searle, plus generics) in 2008 that cites an increased risk for tumors based on animal studies. The warning recommends use only for approved indications, “which acne is not,” Dr. Baldwin explained.

There have been five cases of breast cancer reported in women taking spironolactone and other medications, but there was “no clear link to the medication.” Also, a review article found no evidence of risk (J. Clin. Aesthet. Dermatol. 2009;2:16-22). Still you “need to discuss this risk with your patients,” Dr. Baldwin said.

“A recent Cochrane review [Cochrane Database Syst. Rev. 2009;(2):CD000194] on spironolactone which concluded that, although it was very helpful for hirsutism and for alopecia, that it had no evidence-based medicine to support its use in the treatment of acne,” Dr. Baldwin remarked in an interview.

“Now that flies in the face of numerous small studies which have demonstrated clearly over the years that spironolactone in doses from 50 to 200 mg per day are very helpful in the treatment of acne, especially in the adult woman,” she added.

The number of participants in these studies was “so small that it didn't pass muster for the Cochrane review,” Dr. Baldwin said. “I still believe spironolactone is an incredibly useful drug in the treatment of acne.”

An estimated 13%-15% of women in the United States have acne. The number has been increasing in recent past.

Dr. Baldwin said, however, it is unclear if the increase is due to greater awareness of quality acne therapy and/or a true increase in prevalence. She recommended www.acneandrosacea.org

Dr. Baldwin is a consultant and has received honoraria from Ortho, Galderma, Allergan, Coria, Graceway, GlaxoSmithKline, and L'Oreal. SDEF and this news organization are owned by Elsevier.

'I have women who say that they get a yeast infection every time they get an antibiotic.'

Source DR. BALDWIN

SAN FRANCISCO - Exposure to one or more irritant allergens can incite atopic dermatitis in pediatric patients, Dr. Sharon E. Jacob said.

Start by educating patients to avoid these common irritants: fragrance, formaldehyde, and cocamidopropyl betaine. "These are frequently used together and end up on the top list of allergens for children," she said.

Skin barrier repair is another essential component of a supersensitive skin regimen she recommends for these patients. Provide atopic patients with recommendations for cleansing, aseptic baths, and use of emollients and ceramides, she said.

The top 10 allergens (irritant and allergic) in pediatric patients, in order, are:

1. Nickel sulfate

2. Cobalt chloride

3. Thimerosal

4. Gold

5. Fragrance mix

6. Neomycin

7. Balsam of Peru

8. Colophony

9. Formaldehyde

10. Lanolin

Cocamidopropyl betaine, a common ingredient in shampoo, soaps, and toothpastes, comes in at number 16 on the list. Dr. Jacob compiled the list from the literature and presented it at a seminar on women’s and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"The allergens causing big problems in atopic pediatric patients are the same [most common] allergens in our general population," Dr. Jacob said.

In addition, urine that causes diaper dermatitis and soap that leads to hand dermatitis are common irritant exposures. "Any substance that acts as mild toxic substance can give you an irritant dermatitis, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital.

A meeting attendee asked about the safest diapers to recommend to parents. "Cloth is the best, but may not be practical," Dr. Jacob replied. Safer options include fragrance-free, dye-free diapers available at Whole Foods Market and the Huggies brand organic cotton diaper, she said.

In terms of differential diagnosis, keep in mind that irritant contact dermatitis is a nonimmunologic reaction – unlike agents that cause allergic contact dermatitis, Dr. Jacob said.

Fragrances are a challenge to avoid – they are in virtually every product with a scent, Dr. Jacob said. "It is very hard to find fragrance products these patients can use. Many have multiple ingredients."

One pearl is to recommend "fragrance-free" but not "unscented" products, Dr. Jacob said. Unscented items might contain a masking fragrance, she said. For example, she compared two "sensitive skin" deodorants with the same brand name and very similar packaging. One was labeled fragrance free and one unscented. However, the ingredient list on the unscented deodorant included parfum. "You cannot just go by the way it looks."

You can identify about 80% of fragrance allergies by patch testing with Balsam of Peru and Fragrance Mix 1, Dr. Jacob said. "When you add jasmine, ylang ylang, sandalwood, and narcissus, you get to 95%."

Also consider allergy to Lyral, "one of the new reported fragrance allergens," Dr. Jacob said. This potential allergen is included in the Fragrance Mix 2 series. Lyral, also known as hydroxyisohexyl 3-cyclohexene carboxaldehyde, is found in fine fragrances, many aerosol deodorants, and other personal care items.

Formaldehyde is a colorless, readily-soluble gas that is used extensively as a preservative. It has been a top allergen for 70 years, Dr. Jacob said, and has a potential role in systemic contact allergies. The artificial sweetener aspartame can metabolize to formaldehyde and some chewable "gummy" vitamins contain this ingredient, she said.

Another meeting attendee asked about tear-free shampoos and soaps for children that do not contain cocamidopropyl betaine. Dr. Jacob suggested the California Baby product line, but again cautioned that parents should read labels carefully and purchase the 'fragrance-free' items, versus products that contain 'essential oils.'

SDEF and this news organization are owned by Elsevier.

Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO - Exposure to one or more irritant allergens can incite atopic dermatitis in pediatric patients, Dr. Sharon E. Jacob said.

Start by educating patients to avoid these common irritants: fragrance, formaldehyde, and cocamidopropyl betaine. "These are frequently used together and end up on the top list of allergens for children," she said.

Skin barrier repair is another essential component of a supersensitive skin regimen she recommends for these patients. Provide atopic patients with recommendations for cleansing, aseptic baths, and use of emollients and ceramides, she said.

The top 10 allergens (irritant and allergic) in pediatric patients, in order, are:

1. Nickel sulfate

2. Cobalt chloride

3. Thimerosal

4. Gold

5. Fragrance mix

6. Neomycin

7. Balsam of Peru

8. Colophony

9. Formaldehyde

10. Lanolin

Cocamidopropyl betaine, a common ingredient in shampoo, soaps, and toothpastes, comes in at number 16 on the list. Dr. Jacob compiled the list from the literature and presented it at a seminar on women’s and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"The allergens causing big problems in atopic pediatric patients are the same [most common] allergens in our general population," Dr. Jacob said.

In addition, urine that causes diaper dermatitis and soap that leads to hand dermatitis are common irritant exposures. "Any substance that acts as mild toxic substance can give you an irritant dermatitis, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital.

A meeting attendee asked about the safest diapers to recommend to parents. "Cloth is the best, but may not be practical," Dr. Jacob replied. Safer options include fragrance-free, dye-free diapers available at Whole Foods Market and the Huggies brand organic cotton diaper, she said.

In terms of differential diagnosis, keep in mind that irritant contact dermatitis is a nonimmunologic reaction – unlike agents that cause allergic contact dermatitis, Dr. Jacob said.

Fragrances are a challenge to avoid – they are in virtually every product with a scent, Dr. Jacob said. "It is very hard to find fragrance products these patients can use. Many have multiple ingredients."

One pearl is to recommend "fragrance-free" but not "unscented" products, Dr. Jacob said. Unscented items might contain a masking fragrance, she said. For example, she compared two "sensitive skin" deodorants with the same brand name and very similar packaging. One was labeled fragrance free and one unscented. However, the ingredient list on the unscented deodorant included parfum. "You cannot just go by the way it looks."

You can identify about 80% of fragrance allergies by patch testing with Balsam of Peru and Fragrance Mix 1, Dr. Jacob said. "When you add jasmine, ylang ylang, sandalwood, and narcissus, you get to 95%."

Also consider allergy to Lyral, "one of the new reported fragrance allergens," Dr. Jacob said. This potential allergen is included in the Fragrance Mix 2 series. Lyral, also known as hydroxyisohexyl 3-cyclohexene carboxaldehyde, is found in fine fragrances, many aerosol deodorants, and other personal care items.

Formaldehyde is a colorless, readily-soluble gas that is used extensively as a preservative. It has been a top allergen for 70 years, Dr. Jacob said, and has a potential role in systemic contact allergies. The artificial sweetener aspartame can metabolize to formaldehyde and some chewable "gummy" vitamins contain this ingredient, she said.

Another meeting attendee asked about tear-free shampoos and soaps for children that do not contain cocamidopropyl betaine. Dr. Jacob suggested the California Baby product line, but again cautioned that parents should read labels carefully and purchase the 'fragrance-free' items, versus products that contain 'essential oils.'

SDEF and this news organization are owned by Elsevier.

Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO - Exposure to one or more irritant allergens can incite atopic dermatitis in pediatric patients, Dr. Sharon E. Jacob said.

Start by educating patients to avoid these common irritants: fragrance, formaldehyde, and cocamidopropyl betaine. "These are frequently used together and end up on the top list of allergens for children," she said.

Skin barrier repair is another essential component of a supersensitive skin regimen she recommends for these patients. Provide atopic patients with recommendations for cleansing, aseptic baths, and use of emollients and ceramides, she said.

The top 10 allergens (irritant and allergic) in pediatric patients, in order, are:

1. Nickel sulfate

2. Cobalt chloride

3. Thimerosal

4. Gold

5. Fragrance mix

6. Neomycin

7. Balsam of Peru

8. Colophony

9. Formaldehyde

10. Lanolin

Cocamidopropyl betaine, a common ingredient in shampoo, soaps, and toothpastes, comes in at number 16 on the list. Dr. Jacob compiled the list from the literature and presented it at a seminar on women’s and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"The allergens causing big problems in atopic pediatric patients are the same [most common] allergens in our general population," Dr. Jacob said.

In addition, urine that causes diaper dermatitis and soap that leads to hand dermatitis are common irritant exposures. "Any substance that acts as mild toxic substance can give you an irritant dermatitis, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital.

A meeting attendee asked about the safest diapers to recommend to parents. "Cloth is the best, but may not be practical," Dr. Jacob replied. Safer options include fragrance-free, dye-free diapers available at Whole Foods Market and the Huggies brand organic cotton diaper, she said.

In terms of differential diagnosis, keep in mind that irritant contact dermatitis is a nonimmunologic reaction – unlike agents that cause allergic contact dermatitis, Dr. Jacob said.

Fragrances are a challenge to avoid – they are in virtually every product with a scent, Dr. Jacob said. "It is very hard to find fragrance products these patients can use. Many have multiple ingredients."

One pearl is to recommend "fragrance-free" but not "unscented" products, Dr. Jacob said. Unscented items might contain a masking fragrance, she said. For example, she compared two "sensitive skin" deodorants with the same brand name and very similar packaging. One was labeled fragrance free and one unscented. However, the ingredient list on the unscented deodorant included parfum. "You cannot just go by the way it looks."

You can identify about 80% of fragrance allergies by patch testing with Balsam of Peru and Fragrance Mix 1, Dr. Jacob said. "When you add jasmine, ylang ylang, sandalwood, and narcissus, you get to 95%."

Also consider allergy to Lyral, "one of the new reported fragrance allergens," Dr. Jacob said. This potential allergen is included in the Fragrance Mix 2 series. Lyral, also known as hydroxyisohexyl 3-cyclohexene carboxaldehyde, is found in fine fragrances, many aerosol deodorants, and other personal care items.

Formaldehyde is a colorless, readily-soluble gas that is used extensively as a preservative. It has been a top allergen for 70 years, Dr. Jacob said, and has a potential role in systemic contact allergies. The artificial sweetener aspartame can metabolize to formaldehyde and some chewable "gummy" vitamins contain this ingredient, she said.

Another meeting attendee asked about tear-free shampoos and soaps for children that do not contain cocamidopropyl betaine. Dr. Jacob suggested the California Baby product line, but again cautioned that parents should read labels carefully and purchase the 'fragrance-free' items, versus products that contain 'essential oils.'

SDEF and this news organization are owned by Elsevier.

Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO – What do you consider when one of your atopic pediatric patients has recalcitrant dermatitis? Or a new-onset dermatitis that lasts longer than 2 months? It might be time to expand your differential diagnosis to consider contact dermatitis, Dr. Sharon Jacob said.

There is a high prevalence of allergic contact dermatitis in moderate to severe atopic patients. Also, think systemic allergic contact dermatitis in highly sensitized children. Although more commonly reported in adults, systemic allergies can affect pediatric patients, Dr. Jacob said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Exposure to nickel, cobalt, fragrances, formaldehyde and balsam of Peru – including from dietary sources – can trigger a systemic reaction. System allergy "should be considered in children with a positive patch test who fail to improve with skin contact avoidance," she said.

A diet devoid of the suspected trigger(s) for 6 weeks or more can make a difference for some recalcitrant children, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital. Such an avoidance diet improved the outcome for eight pediatric patients with systemic allergies, according to a recent report from Dr. Jacob and Dr. C. Matiz (Pediatr. Dermatol. 2010 Aug 27 [doi: 10.1111/j.1525-1470.2010.01130.x]).

An avoidance diet is particularly challenging for children with allergy to balsam of Peru. This allergen is found in many foods, including tomatoes, citrus, and certain spices, according to a study in adults (J. Am. Acad. Dermatol. 2001;45:377-81).

"The food we have the most problem with is ketchup. Ketchup and pizza are the bane of my existence," Dr. Jacob said. Keep the diet simple if possible and encourage adherence with incentives for the child, such as a points and rewards system, she added.

Be careful how you counsel these children, Dr. Jacob said. "Start off with the fact they cannot have asparagus – 'Yes!' – or spinach 'Yay!' Then mention ketchup, chocolate, and soda, and you become the evil contact derm pediatrician."

Sometimes an affected anatomic site is an important clinical clue. For example, Dr. Jacob described a 10-month-old child with generalized dermatitis who also presented with specific perioral dermatitis. "When we see this we think balsam of Peru." Involvement of the eyelids is another clinical clue.

Another interesting case Dr. Jacob presented was a toddler with a fragrance contact allergy that triggered a systemic reaction. Initially, however, she had to figure out how a toddler could have an allergy to fragrance. She discovered that the toddler became sensitized from "connubial contact" – or a physical transfer – of fragrance from the mother’s neck. Following this discovery, the child was doing well until a flare associated with vanilla teething wafers. "It’s amazing how much vanilla is everywhere."

When an allergen or chemical is transferred by the patient to another site on their body, it is called "ectopic dermatitis." Dr. Jacob cited the case of a 3-year-old whose older sister lacquered her fingernails, for example. The younger child scratched other areas and reacted to the tosylamide formaldehyde resin on her nails.

If you have a child whose controlled condition suddenly worsens in their atopic areas, consider these potential culprits: lanolin, neomycin, and bacitracin, Dr. Jacob said.

Lanolin is derived from the sebaceous gland in sheep. Although removed from most wool clothing during processing, it remains in cashmere clothing to keep it soft. "Lanolin is a top offender in children – because it is used in emollients," Dr. Jacob said.

Also assess these patients for exposure to plants in the Compositae family – including feverfew and chamomile. Keep in mind some components may be found in preparations you prescribe for their atopic dermatitis, such as bisabolol, an alcohol compound derived from chamomile and found in Aquaphor ointment (Beiersdorf Inc.) and sometimes prescribed for atopic dermatitis in children (Pediatr. Dermatol. 2010;27:103-4)

Also watch out for emulsifiers used in diaper creams and topical steroids, including sorbitan sesquioleate. Reports of contact dermatitis to this sorbitan are increasing (Dermatitis. 2008:19:339-41).

Dr. Jacob noted that patch testing of children for contact allergies is "off-label" – not approved by the Food and Drug Administration.

A meeting attendee asked Dr. Jacob about the youngest age patient that she will patch test. "I have patch tested a patient as young as 10 months old. But I generally do not patch test children under 5 years old unless absolutely indicated," she replied. She first tries "preemptive avoidance" of suspected allergens in these young children before patch testing.

SDEF and this news organization are owned by Elsevier. Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO – What do you consider when one of your atopic pediatric patients has recalcitrant dermatitis? Or a new-onset dermatitis that lasts longer than 2 months? It might be time to expand your differential diagnosis to consider contact dermatitis, Dr. Sharon Jacob said.

There is a high prevalence of allergic contact dermatitis in moderate to severe atopic patients. Also, think systemic allergic contact dermatitis in highly sensitized children. Although more commonly reported in adults, systemic allergies can affect pediatric patients, Dr. Jacob said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Exposure to nickel, cobalt, fragrances, formaldehyde and balsam of Peru – including from dietary sources – can trigger a systemic reaction. System allergy "should be considered in children with a positive patch test who fail to improve with skin contact avoidance," she said.

A diet devoid of the suspected trigger(s) for 6 weeks or more can make a difference for some recalcitrant children, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital. Such an avoidance diet improved the outcome for eight pediatric patients with systemic allergies, according to a recent report from Dr. Jacob and Dr. C. Matiz (Pediatr. Dermatol. 2010 Aug 27 [doi: 10.1111/j.1525-1470.2010.01130.x]).

An avoidance diet is particularly challenging for children with allergy to balsam of Peru. This allergen is found in many foods, including tomatoes, citrus, and certain spices, according to a study in adults (J. Am. Acad. Dermatol. 2001;45:377-81).

"The food we have the most problem with is ketchup. Ketchup and pizza are the bane of my existence," Dr. Jacob said. Keep the diet simple if possible and encourage adherence with incentives for the child, such as a points and rewards system, she added.

Be careful how you counsel these children, Dr. Jacob said. "Start off with the fact they cannot have asparagus – 'Yes!' – or spinach 'Yay!' Then mention ketchup, chocolate, and soda, and you become the evil contact derm pediatrician."

Sometimes an affected anatomic site is an important clinical clue. For example, Dr. Jacob described a 10-month-old child with generalized dermatitis who also presented with specific perioral dermatitis. "When we see this we think balsam of Peru." Involvement of the eyelids is another clinical clue.

Another interesting case Dr. Jacob presented was a toddler with a fragrance contact allergy that triggered a systemic reaction. Initially, however, she had to figure out how a toddler could have an allergy to fragrance. She discovered that the toddler became sensitized from "connubial contact" – or a physical transfer – of fragrance from the mother’s neck. Following this discovery, the child was doing well until a flare associated with vanilla teething wafers. "It’s amazing how much vanilla is everywhere."

When an allergen or chemical is transferred by the patient to another site on their body, it is called "ectopic dermatitis." Dr. Jacob cited the case of a 3-year-old whose older sister lacquered her fingernails, for example. The younger child scratched other areas and reacted to the tosylamide formaldehyde resin on her nails.

If you have a child whose controlled condition suddenly worsens in their atopic areas, consider these potential culprits: lanolin, neomycin, and bacitracin, Dr. Jacob said.

Lanolin is derived from the sebaceous gland in sheep. Although removed from most wool clothing during processing, it remains in cashmere clothing to keep it soft. "Lanolin is a top offender in children – because it is used in emollients," Dr. Jacob said.

Also assess these patients for exposure to plants in the Compositae family – including feverfew and chamomile. Keep in mind some components may be found in preparations you prescribe for their atopic dermatitis, such as bisabolol, an alcohol compound derived from chamomile and found in Aquaphor ointment (Beiersdorf Inc.) and sometimes prescribed for atopic dermatitis in children (Pediatr. Dermatol. 2010;27:103-4)

Also watch out for emulsifiers used in diaper creams and topical steroids, including sorbitan sesquioleate. Reports of contact dermatitis to this sorbitan are increasing (Dermatitis. 2008:19:339-41).

Dr. Jacob noted that patch testing of children for contact allergies is "off-label" – not approved by the Food and Drug Administration.

A meeting attendee asked Dr. Jacob about the youngest age patient that she will patch test. "I have patch tested a patient as young as 10 months old. But I generally do not patch test children under 5 years old unless absolutely indicated," she replied. She first tries "preemptive avoidance" of suspected allergens in these young children before patch testing.

SDEF and this news organization are owned by Elsevier. Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO – What do you consider when one of your atopic pediatric patients has recalcitrant dermatitis? Or a new-onset dermatitis that lasts longer than 2 months? It might be time to expand your differential diagnosis to consider contact dermatitis, Dr. Sharon Jacob said.

There is a high prevalence of allergic contact dermatitis in moderate to severe atopic patients. Also, think systemic allergic contact dermatitis in highly sensitized children. Although more commonly reported in adults, systemic allergies can affect pediatric patients, Dr. Jacob said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Exposure to nickel, cobalt, fragrances, formaldehyde and balsam of Peru – including from dietary sources – can trigger a systemic reaction. System allergy "should be considered in children with a positive patch test who fail to improve with skin contact avoidance," she said.

A diet devoid of the suspected trigger(s) for 6 weeks or more can make a difference for some recalcitrant children, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital. Such an avoidance diet improved the outcome for eight pediatric patients with systemic allergies, according to a recent report from Dr. Jacob and Dr. C. Matiz (Pediatr. Dermatol. 2010 Aug 27 [doi: 10.1111/j.1525-1470.2010.01130.x]).

An avoidance diet is particularly challenging for children with allergy to balsam of Peru. This allergen is found in many foods, including tomatoes, citrus, and certain spices, according to a study in adults (J. Am. Acad. Dermatol. 2001;45:377-81).

"The food we have the most problem with is ketchup. Ketchup and pizza are the bane of my existence," Dr. Jacob said. Keep the diet simple if possible and encourage adherence with incentives for the child, such as a points and rewards system, she added.

Be careful how you counsel these children, Dr. Jacob said. "Start off with the fact they cannot have asparagus – 'Yes!' – or spinach 'Yay!' Then mention ketchup, chocolate, and soda, and you become the evil contact derm pediatrician."

Sometimes an affected anatomic site is an important clinical clue. For example, Dr. Jacob described a 10-month-old child with generalized dermatitis who also presented with specific perioral dermatitis. "When we see this we think balsam of Peru." Involvement of the eyelids is another clinical clue.

Another interesting case Dr. Jacob presented was a toddler with a fragrance contact allergy that triggered a systemic reaction. Initially, however, she had to figure out how a toddler could have an allergy to fragrance. She discovered that the toddler became sensitized from "connubial contact" – or a physical transfer – of fragrance from the mother’s neck. Following this discovery, the child was doing well until a flare associated with vanilla teething wafers. "It’s amazing how much vanilla is everywhere."

When an allergen or chemical is transferred by the patient to another site on their body, it is called "ectopic dermatitis." Dr. Jacob cited the case of a 3-year-old whose older sister lacquered her fingernails, for example. The younger child scratched other areas and reacted to the tosylamide formaldehyde resin on her nails.

If you have a child whose controlled condition suddenly worsens in their atopic areas, consider these potential culprits: lanolin, neomycin, and bacitracin, Dr. Jacob said.

Lanolin is derived from the sebaceous gland in sheep. Although removed from most wool clothing during processing, it remains in cashmere clothing to keep it soft. "Lanolin is a top offender in children – because it is used in emollients," Dr. Jacob said.

Also assess these patients for exposure to plants in the Compositae family – including feverfew and chamomile. Keep in mind some components may be found in preparations you prescribe for their atopic dermatitis, such as bisabolol, an alcohol compound derived from chamomile and found in Aquaphor ointment (Beiersdorf Inc.) and sometimes prescribed for atopic dermatitis in children (Pediatr. Dermatol. 2010;27:103-4)

Also watch out for emulsifiers used in diaper creams and topical steroids, including sorbitan sesquioleate. Reports of contact dermatitis to this sorbitan are increasing (Dermatitis. 2008:19:339-41).

Dr. Jacob noted that patch testing of children for contact allergies is "off-label" – not approved by the Food and Drug Administration.

A meeting attendee asked Dr. Jacob about the youngest age patient that she will patch test. "I have patch tested a patient as young as 10 months old. But I generally do not patch test children under 5 years old unless absolutely indicated," she replied. She first tries "preemptive avoidance" of suspected allergens in these young children before patch testing.

SDEF and this news organization are owned by Elsevier. Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

CHICAGO – The rate of skin cancer screening by primary care physicians has increased, compared with relatively stable rates for breast, pelvic, and rectal examinations in this setting, according to a study.

"It is very encouraging that more primary care physicians are looking at patients’ skin to hopefully detect skin cancer earlier," Dr. Jeremy S. Bordeaux said . "Hopefully the outcome will be that when patients are diagnosed with melanoma, it will be at an earlier stage, and they will be more likely to live."

There are insufficient numbers of dermatologists to perform total body examinations for all patients in the United States. In addition, many patients at risk are more likely to see a primary care doctor, said Dr. Bordeaux, director of Mohs Micrographic and Dermatologic Surgery at University Hospitals and Case Western Reserve University in Cleveland.

Dr. Bordeaux sought to quantify primary-care physician skin cancer screening and counseling. He also wanted to identify factors associated with a higher likelihood for screening and counseling.

He assessed outpatient, nonurgent visits to office-based physicians in the years 1997-2000, and then compared those numbers with 2005 and 2006 using data from the National Ambulatory Medical Care Survey (NAMCS). He looked at prevalence in aggregate for skin cancer and breast cancer screening, pelvic and rectal examinations, and counseling about skin cancer prevention and tobacco cessation.

Primary care physicians screened 19% of white patients for skin cancer in the first time period, compared with 26% in 2005-2006, Dr. Bordeaux said at the meeting, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

In contrast, "the screening rates for everything else stayed pretty flat," Dr. Bordeaux said. For example, prevalence of screening for breast cancer increased only modestly to 36% (2005-2006) from 31% (1997-2000). For pelvic exams, the increase was 35% vs. 32%, respectively, and for rectal exams, 24% vs. 20%. Data were incomplete to compare percentages for skin cancer counseling between the two time periods.

Interestingly, Dr. Bordeaux said, "With nonwhite patients, there were the same trends, including the increase in skin cancer screening [26% vs. 19%]." In addition, nonwhite patient screening for breast cancer increased at a similarly modest rate between the two time periods: 34% vs. 30%, respectively. For pelvic exams, the increase was 34% vs. 31%, and for rectal exams, 22% vs. 19%. Tobacco cessation counseling rates increased 7% in 2005-2006 vs. 5% in the 1997-2000 time periods.

Certain factors were significantly associated with increased likelihood of skin screening by primary care physicians. "You are more likely to get screened if you are female, are seen by a physician – versus a physician extender and if you have private insurance," Dr. Bordeaux said.

Specifically, males were less likely to be screened (odds ratio, 0.82), compared with females. Patients who saw a doctor (versus a nonphysician) were more likely to be screened (OR, 3.02), as were those with private insurance (OR, 1.54), compared with Medicare or Medicaid patients.

Age made a significant difference in terms of skin cancer prevention counseling. Compared with younger patients, the study revealed that primary care physicians were less likely to counsel those aged 40 and older about sun-protective behaviors (OR, 0.64).

A second, prospective study is now underway, Dr. Bordeaux said. He plans to correlate the depth/severity of melanomas with history of complete skin examination screening by a dermatologist or primary care physician. The American Society for Dermatologic Surgery provided a Cutting Edge Research Grant to fund the study. Dr. Bordeaux had no relevant financial disclosures.

CHICAGO – The rate of skin cancer screening by primary care physicians has increased, compared with relatively stable rates for breast, pelvic, and rectal examinations in this setting, according to a study.

"It is very encouraging that more primary care physicians are looking at patients’ skin to hopefully detect skin cancer earlier," Dr. Jeremy S. Bordeaux said . "Hopefully the outcome will be that when patients are diagnosed with melanoma, it will be at an earlier stage, and they will be more likely to live."

There are insufficient numbers of dermatologists to perform total body examinations for all patients in the United States. In addition, many patients at risk are more likely to see a primary care doctor, said Dr. Bordeaux, director of Mohs Micrographic and Dermatologic Surgery at University Hospitals and Case Western Reserve University in Cleveland.

Dr. Bordeaux sought to quantify primary-care physician skin cancer screening and counseling. He also wanted to identify factors associated with a higher likelihood for screening and counseling.

He assessed outpatient, nonurgent visits to office-based physicians in the years 1997-2000, and then compared those numbers with 2005 and 2006 using data from the National Ambulatory Medical Care Survey (NAMCS). He looked at prevalence in aggregate for skin cancer and breast cancer screening, pelvic and rectal examinations, and counseling about skin cancer prevention and tobacco cessation.

Primary care physicians screened 19% of white patients for skin cancer in the first time period, compared with 26% in 2005-2006, Dr. Bordeaux said at the meeting, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

In contrast, "the screening rates for everything else stayed pretty flat," Dr. Bordeaux said. For example, prevalence of screening for breast cancer increased only modestly to 36% (2005-2006) from 31% (1997-2000). For pelvic exams, the increase was 35% vs. 32%, respectively, and for rectal exams, 24% vs. 20%. Data were incomplete to compare percentages for skin cancer counseling between the two time periods.

Interestingly, Dr. Bordeaux said, "With nonwhite patients, there were the same trends, including the increase in skin cancer screening [26% vs. 19%]." In addition, nonwhite patient screening for breast cancer increased at a similarly modest rate between the two time periods: 34% vs. 30%, respectively. For pelvic exams, the increase was 34% vs. 31%, and for rectal exams, 22% vs. 19%. Tobacco cessation counseling rates increased 7% in 2005-2006 vs. 5% in the 1997-2000 time periods.

Certain factors were significantly associated with increased likelihood of skin screening by primary care physicians. "You are more likely to get screened if you are female, are seen by a physician – versus a physician extender and if you have private insurance," Dr. Bordeaux said.

Specifically, males were less likely to be screened (odds ratio, 0.82), compared with females. Patients who saw a doctor (versus a nonphysician) were more likely to be screened (OR, 3.02), as were those with private insurance (OR, 1.54), compared with Medicare or Medicaid patients.

Age made a significant difference in terms of skin cancer prevention counseling. Compared with younger patients, the study revealed that primary care physicians were less likely to counsel those aged 40 and older about sun-protective behaviors (OR, 0.64).

A second, prospective study is now underway, Dr. Bordeaux said. He plans to correlate the depth/severity of melanomas with history of complete skin examination screening by a dermatologist or primary care physician. The American Society for Dermatologic Surgery provided a Cutting Edge Research Grant to fund the study. Dr. Bordeaux had no relevant financial disclosures.

CHICAGO – The rate of skin cancer screening by primary care physicians has increased, compared with relatively stable rates for breast, pelvic, and rectal examinations in this setting, according to a study.

"It is very encouraging that more primary care physicians are looking at patients’ skin to hopefully detect skin cancer earlier," Dr. Jeremy S. Bordeaux said . "Hopefully the outcome will be that when patients are diagnosed with melanoma, it will be at an earlier stage, and they will be more likely to live."

There are insufficient numbers of dermatologists to perform total body examinations for all patients in the United States. In addition, many patients at risk are more likely to see a primary care doctor, said Dr. Bordeaux, director of Mohs Micrographic and Dermatologic Surgery at University Hospitals and Case Western Reserve University in Cleveland.

Dr. Bordeaux sought to quantify primary-care physician skin cancer screening and counseling. He also wanted to identify factors associated with a higher likelihood for screening and counseling.

He assessed outpatient, nonurgent visits to office-based physicians in the years 1997-2000, and then compared those numbers with 2005 and 2006 using data from the National Ambulatory Medical Care Survey (NAMCS). He looked at prevalence in aggregate for skin cancer and breast cancer screening, pelvic and rectal examinations, and counseling about skin cancer prevention and tobacco cessation.

Primary care physicians screened 19% of white patients for skin cancer in the first time period, compared with 26% in 2005-2006, Dr. Bordeaux said at the meeting, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

In contrast, "the screening rates for everything else stayed pretty flat," Dr. Bordeaux said. For example, prevalence of screening for breast cancer increased only modestly to 36% (2005-2006) from 31% (1997-2000). For pelvic exams, the increase was 35% vs. 32%, respectively, and for rectal exams, 24% vs. 20%. Data were incomplete to compare percentages for skin cancer counseling between the two time periods.

Interestingly, Dr. Bordeaux said, "With nonwhite patients, there were the same trends, including the increase in skin cancer screening [26% vs. 19%]." In addition, nonwhite patient screening for breast cancer increased at a similarly modest rate between the two time periods: 34% vs. 30%, respectively. For pelvic exams, the increase was 34% vs. 31%, and for rectal exams, 22% vs. 19%. Tobacco cessation counseling rates increased 7% in 2005-2006 vs. 5% in the 1997-2000 time periods.

Certain factors were significantly associated with increased likelihood of skin screening by primary care physicians. "You are more likely to get screened if you are female, are seen by a physician – versus a physician extender and if you have private insurance," Dr. Bordeaux said.

Specifically, males were less likely to be screened (odds ratio, 0.82), compared with females. Patients who saw a doctor (versus a nonphysician) were more likely to be screened (OR, 3.02), as were those with private insurance (OR, 1.54), compared with Medicare or Medicaid patients.

Age made a significant difference in terms of skin cancer prevention counseling. Compared with younger patients, the study revealed that primary care physicians were less likely to counsel those aged 40 and older about sun-protective behaviors (OR, 0.64).

A second, prospective study is now underway, Dr. Bordeaux said. He plans to correlate the depth/severity of melanomas with history of complete skin examination screening by a dermatologist or primary care physician. The American Society for Dermatologic Surgery provided a Cutting Edge Research Grant to fund the study. Dr. Bordeaux had no relevant financial disclosures.

CHICAGO – The rate of skin cancer screening by primary care physicians has increased, compared with relatively stable rates for breast, pelvic, and rectal examinations in this setting, according to a study.

"It is very encouraging that more primary care physicians are looking at patients' skin to hopefully detect skin cancer earlier," Dr. Jeremy S. Bordeaux said . "Hopefully the outcome will be that when patients are diagnosed with melanoma, it will be at an earlier stage, and they will be more likely to live."

There are insufficient numbers of dermatologists to perform total body examinations for all patients in the United States. In addition, many patients at risk are more likely to see a primary care doctor, said Dr. Bordeaux, director of Mohs Micrographic and Dermatologic Surgery at University Hospitals and Case Western Reserve University in Cleveland.

Dr. Bordeaux sought to quantify primary-care physician skin cancer screening and counseling. He also wanted to identify factors associated with a higher likelihood for screening and counseling.

He assessed outpatient, nonurgent visits to office-based physicians in the years 1997-2000, and then compared those numbers with 2005 and 2006 using data from the National Ambulatory Medical Care Survey (NAMCS). He looked at prevalence in aggregate for skin cancer and breast cancer screening, pelvic and rectal examinations, and counseling about skin cancer prevention and tobacco cessation.

Primary care physicians screened 19% of white patients for skin cancer in the first time period, compared with 26% in 2005-2006, Dr. Bordeaux said at the meeting, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

In contrast, "the screening rates for everything else stayed pretty flat," Dr. Bordeaux said. For example, prevalence of screening for breast cancer increased only modestly to 36% (2005-2006) from 31% (1997-2000). For pelvic exams, the increase was 35% vs. 32%, respectively, and for rectal exams, 24% vs. 20%. Data were incomplete to compare percentages for skin cancer counseling between the two time periods.

Interestingly, Dr. Bordeaux said, "With nonwhite patients, there were the same trends, including the increase in skin cancer screening [26% vs. 19%]." In addition, nonwhite patient screening for breast cancer increased at a similarly modest rate between the two time periods: 34% vs. 30%, respectively. For pelvic exams, the increase was 34% vs. 31%, and for rectal exams, 22% vs. 19%. Tobacco cessation counseling rates increased 7% in 2005-2006 vs. 5% in the 1997-2000 time periods.

Certain factors were significantly associated with increased likelihood of skin screening by primary care physicians. "You are more likely to get screened if you are female, are seen by a physician – versus a physician extender and if you have private insurance," Dr. Bordeaux said.

Specifically, males were less likely to be screened (odds ratio, 0.82), compared with females. Patients who saw a doctor (versus a nonphysician) were more likely to be screened (OR, 3.02), as were those with private insurance (OR, 1.54), compared with Medicare or Medicaid patients.

Age made a significant difference in terms of skin cancer prevention counseling. Compared with younger patients, the study revealed that primary care physicians were less likely to counsel those aged 40 and older about sun-protective behaviors (OR, 0.64).

A second, prospective study is now underway, Dr. Bordeaux said. He plans to correlate the depth/severity of melanomas with history of complete skin examination screening by a dermatologist or primary care physician.

The American Society for Dermatologic Surgery provided a Cutting Edge Research Grant to fund the study. Dr. Bordeaux had no relevant financial disclosures.

CHICAGO – The rate of skin cancer screening by primary care physicians has increased, compared with relatively stable rates for breast, pelvic, and rectal examinations in this setting, according to a study.

"It is very encouraging that more primary care physicians are looking at patients' skin to hopefully detect skin cancer earlier," Dr. Jeremy S. Bordeaux said . "Hopefully the outcome will be that when patients are diagnosed with melanoma, it will be at an earlier stage, and they will be more likely to live."

There are insufficient numbers of dermatologists to perform total body examinations for all patients in the United States. In addition, many patients at risk are more likely to see a primary care doctor, said Dr. Bordeaux, director of Mohs Micrographic and Dermatologic Surgery at University Hospitals and Case Western Reserve University in Cleveland.

Dr. Bordeaux sought to quantify primary-care physician skin cancer screening and counseling. He also wanted to identify factors associated with a higher likelihood for screening and counseling.

He assessed outpatient, nonurgent visits to office-based physicians in the years 1997-2000, and then compared those numbers with 2005 and 2006 using data from the National Ambulatory Medical Care Survey (NAMCS). He looked at prevalence in aggregate for skin cancer and breast cancer screening, pelvic and rectal examinations, and counseling about skin cancer prevention and tobacco cessation.

Primary care physicians screened 19% of white patients for skin cancer in the first time period, compared with 26% in 2005-2006, Dr. Bordeaux said at the meeting, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

In contrast, "the screening rates for everything else stayed pretty flat," Dr. Bordeaux said. For example, prevalence of screening for breast cancer increased only modestly to 36% (2005-2006) from 31% (1997-2000). For pelvic exams, the increase was 35% vs. 32%, respectively, and for rectal exams, 24% vs. 20%. Data were incomplete to compare percentages for skin cancer counseling between the two time periods.

Interestingly, Dr. Bordeaux said, "With nonwhite patients, there were the same trends, including the increase in skin cancer screening [26% vs. 19%]." In addition, nonwhite patient screening for breast cancer increased at a similarly modest rate between the two time periods: 34% vs. 30%, respectively. For pelvic exams, the increase was 34% vs. 31%, and for rectal exams, 22% vs. 19%. Tobacco cessation counseling rates increased 7% in 2005-2006 vs. 5% in the 1997-2000 time periods.

Certain factors were significantly associated with increased likelihood of skin screening by primary care physicians. "You are more likely to get screened if you are female, are seen by a physician – versus a physician extender and if you have private insurance," Dr. Bordeaux said.

Specifically, males were less likely to be screened (odds ratio, 0.82), compared with females. Patients who saw a doctor (versus a nonphysician) were more likely to be screened (OR, 3.02), as were those with private insurance (OR, 1.54), compared with Medicare or Medicaid patients.

Age made a significant difference in terms of skin cancer prevention counseling. Compared with younger patients, the study revealed that primary care physicians were less likely to counsel those aged 40 and older about sun-protective behaviors (OR, 0.64).

A second, prospective study is now underway, Dr. Bordeaux said. He plans to correlate the depth/severity of melanomas with history of complete skin examination screening by a dermatologist or primary care physician.

The American Society for Dermatologic Surgery provided a Cutting Edge Research Grant to fund the study. Dr. Bordeaux had no relevant financial disclosures.

CHICAGO – The rate of skin cancer screening by primary care physicians has increased, compared with relatively stable rates for breast, pelvic, and rectal examinations in this setting, according to a study.

"It is very encouraging that more primary care physicians are looking at patients' skin to hopefully detect skin cancer earlier," Dr. Jeremy S. Bordeaux said . "Hopefully the outcome will be that when patients are diagnosed with melanoma, it will be at an earlier stage, and they will be more likely to live."

There are insufficient numbers of dermatologists to perform total body examinations for all patients in the United States. In addition, many patients at risk are more likely to see a primary care doctor, said Dr. Bordeaux, director of Mohs Micrographic and Dermatologic Surgery at University Hospitals and Case Western Reserve University in Cleveland.

Dr. Bordeaux sought to quantify primary-care physician skin cancer screening and counseling. He also wanted to identify factors associated with a higher likelihood for screening and counseling.

He assessed outpatient, nonurgent visits to office-based physicians in the years 1997-2000, and then compared those numbers with 2005 and 2006 using data from the National Ambulatory Medical Care Survey (NAMCS). He looked at prevalence in aggregate for skin cancer and breast cancer screening, pelvic and rectal examinations, and counseling about skin cancer prevention and tobacco cessation.

Primary care physicians screened 19% of white patients for skin cancer in the first time period, compared with 26% in 2005-2006, Dr. Bordeaux said at the meeting, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

In contrast, "the screening rates for everything else stayed pretty flat," Dr. Bordeaux said. For example, prevalence of screening for breast cancer increased only modestly to 36% (2005-2006) from 31% (1997-2000). For pelvic exams, the increase was 35% vs. 32%, respectively, and for rectal exams, 24% vs. 20%. Data were incomplete to compare percentages for skin cancer counseling between the two time periods.

Interestingly, Dr. Bordeaux said, "With nonwhite patients, there were the same trends, including the increase in skin cancer screening [26% vs. 19%]." In addition, nonwhite patient screening for breast cancer increased at a similarly modest rate between the two time periods: 34% vs. 30%, respectively. For pelvic exams, the increase was 34% vs. 31%, and for rectal exams, 22% vs. 19%. Tobacco cessation counseling rates increased 7% in 2005-2006 vs. 5% in the 1997-2000 time periods.

Certain factors were significantly associated with increased likelihood of skin screening by primary care physicians. "You are more likely to get screened if you are female, are seen by a physician – versus a physician extender and if you have private insurance," Dr. Bordeaux said.

Specifically, males were less likely to be screened (odds ratio, 0.82), compared with females. Patients who saw a doctor (versus a nonphysician) were more likely to be screened (OR, 3.02), as were those with private insurance (OR, 1.54), compared with Medicare or Medicaid patients.

Age made a significant difference in terms of skin cancer prevention counseling. Compared with younger patients, the study revealed that primary care physicians were less likely to counsel those aged 40 and older about sun-protective behaviors (OR, 0.64).

A second, prospective study is now underway, Dr. Bordeaux said. He plans to correlate the depth/severity of melanomas with history of complete skin examination screening by a dermatologist or primary care physician.

The American Society for Dermatologic Surgery provided a Cutting Edge Research Grant to fund the study. Dr. Bordeaux had no relevant financial disclosures.

CHICAGO - In contrast to claims made about some noninvasive body-contouring devices, cryolipolysis can and does work, Dr. Elizabeth Tanzi said.

However, careful patient selection and realistic expectations – on both the part of the patient and the physician – are essential to a successful outcome, said Dr. Tanzi, a private practice dermatologist in Washington, D.C.

"Noninvasive removal of fat to contour the body is a reality. However, as we've all been told: If something seems to be too good to be true, it probably is," Dr. Tanzi said. "There are limitations."

Educate patients that cryolipolysis is not a replacement for liposuction to remove large amounts of fat. The technique, instead, is best suited to flatten discreet bulges of fat – around the abdomen, the back, or the "love handles," for example, that are resistant to diet and exercise, Dr. Tanzi said at the annual meeting of the American Society for Dermatologic Surgery, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

You may need to counter some patient misperceptions about cryolipolysis as well. "This is not 'fat freezing,' no matter how many times you hear that in the media," she said.

This procedure, instead, relies on precise, controlled cooling of fat cells or adipocytes. This strategy exploits the natural vulnerability of adipocytes to prolonged cold exposure, Dr. Tanzi said, and causes the death of these cells without damage to surrounding tissues. The destroyed fat cells are cleared through the body's natural clearance mechanisms. The Food and Drug Administration approved a cryolipolysis device (CoolSculpting, Zeltiq) for marketing in September 2010.

You can tell inquisitive patients that a single cryolipolysis treatment reduced the fat layer an average of 22% for 32 patients in a prospective multicenter study, Dr. Tanzi said. Dr. Jeffrey Dover presented the results at the 2009 American Society for Laser Medicine and Surgery annual meeting.

Counsel patients that cryolipolysis results are not immediate, Dr. Tanzi said. Adipocytes appear intact immediately post treatment, followed by an inflammatory response seen at days 3, 5, and 7. It can take several months for fat cell clearance and full clinical results.

Patients also can expect temporary dulling of sensation in the treated area that typically resolves in 1-2 weeks, Dr. Tanzi said. Erythema can last minutes to hours post treatment but purpura is uncommon. In addition, patients might experience a "dull, deep soreness for several days. It is tolerable, and feels like they have just done a lot of sit-ups."

Patient and physician expectations have to be realistic, Dr. Tanzi said. "I get asked questions by patients over and over again. Does it really work? The answer is yes, but you have to define the terms." Cryolipolysis will improve the body’s contour, but it is not for skin tightening, for example, and it is not a weight loss strategy. "Yes, clothes fit better," she said. "Patients tell me about that, and now it’s part of my conversation in my consultation."

The noninvasive fat removal field – including cryolipolysis and the other body-contouring devices – is still in its infancy, Dr. Tanzi said in a follow-up interview.

Technology changes underway will expand the application of these technologies beyond the abdomen and love handle areas. "Soon we’ll be able to treat other areas, such as arms and thighs, to really get a nice contour improvement there as well," she said.

Dr. Tanzi disclosed that she is on the medical advisory board for Zeltiq.

CHICAGO - In contrast to claims made about some noninvasive body-contouring devices, cryolipolysis can and does work, Dr. Elizabeth Tanzi said.

However, careful patient selection and realistic expectations – on both the part of the patient and the physician – are essential to a successful outcome, said Dr. Tanzi, a private practice dermatologist in Washington, D.C.

"Noninvasive removal of fat to contour the body is a reality. However, as we've all been told: If something seems to be too good to be true, it probably is," Dr. Tanzi said. "There are limitations."

Educate patients that cryolipolysis is not a replacement for liposuction to remove large amounts of fat. The technique, instead, is best suited to flatten discreet bulges of fat – around the abdomen, the back, or the "love handles," for example, that are resistant to diet and exercise, Dr. Tanzi said at the annual meeting of the American Society for Dermatologic Surgery, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

You may need to counter some patient misperceptions about cryolipolysis as well. "This is not 'fat freezing,' no matter how many times you hear that in the media," she said.

This procedure, instead, relies on precise, controlled cooling of fat cells or adipocytes. This strategy exploits the natural vulnerability of adipocytes to prolonged cold exposure, Dr. Tanzi said, and causes the death of these cells without damage to surrounding tissues. The destroyed fat cells are cleared through the body's natural clearance mechanisms. The Food and Drug Administration approved a cryolipolysis device (CoolSculpting, Zeltiq) for marketing in September 2010.

You can tell inquisitive patients that a single cryolipolysis treatment reduced the fat layer an average of 22% for 32 patients in a prospective multicenter study, Dr. Tanzi said. Dr. Jeffrey Dover presented the results at the 2009 American Society for Laser Medicine and Surgery annual meeting.

Counsel patients that cryolipolysis results are not immediate, Dr. Tanzi said. Adipocytes appear intact immediately post treatment, followed by an inflammatory response seen at days 3, 5, and 7. It can take several months for fat cell clearance and full clinical results.

Patients also can expect temporary dulling of sensation in the treated area that typically resolves in 1-2 weeks, Dr. Tanzi said. Erythema can last minutes to hours post treatment but purpura is uncommon. In addition, patients might experience a "dull, deep soreness for several days. It is tolerable, and feels like they have just done a lot of sit-ups."

Patient and physician expectations have to be realistic, Dr. Tanzi said. "I get asked questions by patients over and over again. Does it really work? The answer is yes, but you have to define the terms." Cryolipolysis will improve the body’s contour, but it is not for skin tightening, for example, and it is not a weight loss strategy. "Yes, clothes fit better," she said. "Patients tell me about that, and now it’s part of my conversation in my consultation."

The noninvasive fat removal field – including cryolipolysis and the other body-contouring devices – is still in its infancy, Dr. Tanzi said in a follow-up interview.

Technology changes underway will expand the application of these technologies beyond the abdomen and love handle areas. "Soon we’ll be able to treat other areas, such as arms and thighs, to really get a nice contour improvement there as well," she said.

Dr. Tanzi disclosed that she is on the medical advisory board for Zeltiq.

CHICAGO - In contrast to claims made about some noninvasive body-contouring devices, cryolipolysis can and does work, Dr. Elizabeth Tanzi said.

However, careful patient selection and realistic expectations – on both the part of the patient and the physician – are essential to a successful outcome, said Dr. Tanzi, a private practice dermatologist in Washington, D.C.

"Noninvasive removal of fat to contour the body is a reality. However, as we've all been told: If something seems to be too good to be true, it probably is," Dr. Tanzi said. "There are limitations."

Educate patients that cryolipolysis is not a replacement for liposuction to remove large amounts of fat. The technique, instead, is best suited to flatten discreet bulges of fat – around the abdomen, the back, or the "love handles," for example, that are resistant to diet and exercise, Dr. Tanzi said at the annual meeting of the American Society for Dermatologic Surgery, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

You may need to counter some patient misperceptions about cryolipolysis as well. "This is not 'fat freezing,' no matter how many times you hear that in the media," she said.

This procedure, instead, relies on precise, controlled cooling of fat cells or adipocytes. This strategy exploits the natural vulnerability of adipocytes to prolonged cold exposure, Dr. Tanzi said, and causes the death of these cells without damage to surrounding tissues. The destroyed fat cells are cleared through the body's natural clearance mechanisms. The Food and Drug Administration approved a cryolipolysis device (CoolSculpting, Zeltiq) for marketing in September 2010.

You can tell inquisitive patients that a single cryolipolysis treatment reduced the fat layer an average of 22% for 32 patients in a prospective multicenter study, Dr. Tanzi said. Dr. Jeffrey Dover presented the results at the 2009 American Society for Laser Medicine and Surgery annual meeting.

Counsel patients that cryolipolysis results are not immediate, Dr. Tanzi said. Adipocytes appear intact immediately post treatment, followed by an inflammatory response seen at days 3, 5, and 7. It can take several months for fat cell clearance and full clinical results.

Patients also can expect temporary dulling of sensation in the treated area that typically resolves in 1-2 weeks, Dr. Tanzi said. Erythema can last minutes to hours post treatment but purpura is uncommon. In addition, patients might experience a "dull, deep soreness for several days. It is tolerable, and feels like they have just done a lot of sit-ups."

Patient and physician expectations have to be realistic, Dr. Tanzi said. "I get asked questions by patients over and over again. Does it really work? The answer is yes, but you have to define the terms." Cryolipolysis will improve the body’s contour, but it is not for skin tightening, for example, and it is not a weight loss strategy. "Yes, clothes fit better," she said. "Patients tell me about that, and now it’s part of my conversation in my consultation."

The noninvasive fat removal field – including cryolipolysis and the other body-contouring devices – is still in its infancy, Dr. Tanzi said in a follow-up interview.

Technology changes underway will expand the application of these technologies beyond the abdomen and love handle areas. "Soon we’ll be able to treat other areas, such as arms and thighs, to really get a nice contour improvement there as well," she said.

Dr. Tanzi disclosed that she is on the medical advisory board for Zeltiq.

CHICAGO - Some patients are ideal candidates for nonsurgical rhinoplasty to reshape the nose, according to experts.

Patients unready or unwilling to undergo surgery, for example, could opt for more temporary aesthetic changes through injectable products, two presenters noted at the annual meeting of the American Society for Dermatologic Surgery.

Photo credit: ©Dr. Vince Bertucci

Unlike more familiar facial cosmetic procedures, patients might need to be educated that injectables in the nose are a valid option, said Dr. Jean-François Tremblay, chief of the dermatologic surgery unit at the University of Montreal’s hospital center. Some will also need guidance as to what constitutes an ideal nose.

"We are not going to replace rhinoplasty, but there is a lot we can do with fillers in an in-and-out procedure," said Dr. Vince Bertucci, Immediate Past President of the Canadian Society for Dermatologic Surgery and the Medical Director of Bertucci MedSpa in Woodbridge, just outside Toronto.

Fillers can increase nasal tip projection and give the nose a longer, more refined appearance. Botulinum toxin can reduce dynamic changes that occur for some during facial expression, such as tip movement, "bunny lines," or alar flare. "Some patients with bunny lines really pull up their ali when they smile, but post botulinum toxin injection, they do not raise up as high," Dr. Bertucci said.

In some cases, fillers and botulinum toxin can be used in combination. Nasal tip droop is a common concern, Dr. Bertucci said. Botulinum toxin injected into the depressor septi nasi at the base of the columella can reverse this common effect of aging. He cautioned, however, the upper lip can be widened or elongated with this technique, and the upper lip tends to be already elongated in some elderly patients.

Photo credit: Damian McNamara

Dr. Bertucci emphasized the importance of knowing the nasal anatomy and danger zones. For example, inject botulinum toxin approximately half way between the nasal-facial junction and dorsum of the nose to avoid hitting the muscle that lifts the mouth. If the levator labii superioris alaeque nasi is inadvertently treated, the patient may end up with an unusual or asymmetric smile. "The message here is do not inject too far down the side of the nose."

The best candidates for nonsurgical rhinoplasty have minor deformities, not major deviations or bony anomalies, Dr. Tremblay said. Lower cost, little to no downtime, and the reversible or modifiable nature of the filler correction are among the appeals, he said. A temporary duration of effect can be a disadvantage. In addition, "we can only add volume and not remove anything," said Dr. Tremblay during the joint presentation.

An important caveat is patients who seek correction with injectables after a rhinoplasty require additional caution and expertise. "I would not recommend starting out on post-rhinoplasty patients," Dr. Bertucci said. Vascular changes and modification of bone and tissue from surgery can increase the risk of necrosis.

Regardless of history, begin by asking all patients what bothers them, Dr. Tremblay advised. "I want to understand their expectations, what their notion of an ideal nose is, and do a quick psychoanalysis 101." He added, "The rate of people having body dysmorphic disorder is higher when people complain about their noses versus other concerns. So it could be a sign someone does not have balanced psychological health."

Ensure you view the nose from all angles (frontal, lateral, and basal) and consider any aesthetic changes in the context of the entire face. "The basal view can show underlying anomalies that might explain superficial features we are trying to correct," Dr. Tremblay said.

An ideal nose "cannot be defined for any given individual without taking into consideration the rest of the facial features," Dr. Tremblay said. For example, he increased the chin projection of a woman who initially wanted the size of her nose reduced. She was happy with her nose after the chin augmentation.

Skin thickness varies in different parts of the nose. In general, the mid-nose skin tends to be thinner and more delicate than the proximal and distal areas. "So when you inject the mid-nose, keep in mind the need to [massage] material around so you don’t get a prominence," Dr. Bertucci said. Also avoid superficial placement and overcorrection with fillers (consider a staged correction). He added, "Injecting slowly is really important. It seems like a simple thing, but look at the skin as you inject is it blanching?"

A tip with filler enhancement on the dorsum of the nose is to pinch the skin and pull it gently up before injecting. Dr. Bertucci said, "I am still underneath the level of the skin, and I am off the vessels that may be lying on the bone or muscle."

"I also find that useful and that is what I do," Dr. Tremblay said. I try to generate with pinching the correction I am trying to achieve, and inject until I reach the volume I want."

A long-lasting but nonpermanent filler product is more ideal than a permanent one in the nose, Dr. Bertucci said. "This leaves you a way out, and the anatomy changes with age." Hyaluronic acid or calcium hydroxylapatite products are examples. In contrast, use of silicone can be riskier in terms of overcorrection and granulomatous effects.

A meeting attendee countered that he prefers silicone because hyaluronic acid corrections only last 2-3 months in his patients. Dr. Bertucci replied that, because of its permanent nature, "I would not use silicone unless you are very skilled in its use."

Injection-related pain, redness, bleeding, ecchymosis, and hematoma are possible complications regardless of the product type injected, Dr. Bertucci said.

Dr. Bertucci disclosed that he is a consultant for Allergan, Medicis Pharmaceutical Corp., and Merz Pharmaceutical, and an investigator for Allergen and Merz. Dr. Tromblay disclosed that he is a medical consultant for Allergan, Medicis, Canderm Pharma Inc., La Roche-Posay, Procter & Gamble, and Johnson & Johnson.

CHICAGO - Some patients are ideal candidates for nonsurgical rhinoplasty to reshape the nose, according to experts.

Patients unready or unwilling to undergo surgery, for example, could opt for more temporary aesthetic changes through injectable products, two presenters noted at the annual meeting of the American Society for Dermatologic Surgery.

Photo credit: ©Dr. Vince Bertucci

Unlike more familiar facial cosmetic procedures, patients might need to be educated that injectables in the nose are a valid option, said Dr. Jean-François Tremblay, chief of the dermatologic surgery unit at the University of Montreal’s hospital center. Some will also need guidance as to what constitutes an ideal nose.

"We are not going to replace rhinoplasty, but there is a lot we can do with fillers in an in-and-out procedure," said Dr. Vince Bertucci, Immediate Past President of the Canadian Society for Dermatologic Surgery and the Medical Director of Bertucci MedSpa in Woodbridge, just outside Toronto.

Fillers can increase nasal tip projection and give the nose a longer, more refined appearance. Botulinum toxin can reduce dynamic changes that occur for some during facial expression, such as tip movement, "bunny lines," or alar flare. "Some patients with bunny lines really pull up their ali when they smile, but post botulinum toxin injection, they do not raise up as high," Dr. Bertucci said.

In some cases, fillers and botulinum toxin can be used in combination. Nasal tip droop is a common concern, Dr. Bertucci said. Botulinum toxin injected into the depressor septi nasi at the base of the columella can reverse this common effect of aging. He cautioned, however, the upper lip can be widened or elongated with this technique, and the upper lip tends to be already elongated in some elderly patients.

Photo credit: Damian McNamara

Dr. Bertucci emphasized the importance of knowing the nasal anatomy and danger zones. For example, inject botulinum toxin approximately half way between the nasal-facial junction and dorsum of the nose to avoid hitting the muscle that lifts the mouth. If the levator labii superioris alaeque nasi is inadvertently treated, the patient may end up with an unusual or asymmetric smile. "The message here is do not inject too far down the side of the nose."

The best candidates for nonsurgical rhinoplasty have minor deformities, not major deviations or bony anomalies, Dr. Tremblay said. Lower cost, little to no downtime, and the reversible or modifiable nature of the filler correction are among the appeals, he said. A temporary duration of effect can be a disadvantage. In addition, "we can only add volume and not remove anything," said Dr. Tremblay during the joint presentation.

An important caveat is patients who seek correction with injectables after a rhinoplasty require additional caution and expertise. "I would not recommend starting out on post-rhinoplasty patients," Dr. Bertucci said. Vascular changes and modification of bone and tissue from surgery can increase the risk of necrosis.

Regardless of history, begin by asking all patients what bothers them, Dr. Tremblay advised. "I want to understand their expectations, what their notion of an ideal nose is, and do a quick psychoanalysis 101." He added, "The rate of people having body dysmorphic disorder is higher when people complain about their noses versus other concerns. So it could be a sign someone does not have balanced psychological health."

Ensure you view the nose from all angles (frontal, lateral, and basal) and consider any aesthetic changes in the context of the entire face. "The basal view can show underlying anomalies that might explain superficial features we are trying to correct," Dr. Tremblay said.

An ideal nose "cannot be defined for any given individual without taking into consideration the rest of the facial features," Dr. Tremblay said. For example, he increased the chin projection of a woman who initially wanted the size of her nose reduced. She was happy with her nose after the chin augmentation.

Skin thickness varies in different parts of the nose. In general, the mid-nose skin tends to be thinner and more delicate than the proximal and distal areas. "So when you inject the mid-nose, keep in mind the need to [massage] material around so you don’t get a prominence," Dr. Bertucci said. Also avoid superficial placement and overcorrection with fillers (consider a staged correction). He added, "Injecting slowly is really important. It seems like a simple thing, but look at the skin as you inject is it blanching?"

A tip with filler enhancement on the dorsum of the nose is to pinch the skin and pull it gently up before injecting. Dr. Bertucci said, "I am still underneath the level of the skin, and I am off the vessels that may be lying on the bone or muscle."

"I also find that useful and that is what I do," Dr. Tremblay said. I try to generate with pinching the correction I am trying to achieve, and inject until I reach the volume I want."

A long-lasting but nonpermanent filler product is more ideal than a permanent one in the nose, Dr. Bertucci said. "This leaves you a way out, and the anatomy changes with age." Hyaluronic acid or calcium hydroxylapatite products are examples. In contrast, use of silicone can be riskier in terms of overcorrection and granulomatous effects.

A meeting attendee countered that he prefers silicone because hyaluronic acid corrections only last 2-3 months in his patients. Dr. Bertucci replied that, because of its permanent nature, "I would not use silicone unless you are very skilled in its use."

Injection-related pain, redness, bleeding, ecchymosis, and hematoma are possible complications regardless of the product type injected, Dr. Bertucci said.

Dr. Bertucci disclosed that he is a consultant for Allergan, Medicis Pharmaceutical Corp., and Merz Pharmaceutical, and an investigator for Allergen and Merz. Dr. Tromblay disclosed that he is a medical consultant for Allergan, Medicis, Canderm Pharma Inc., La Roche-Posay, Procter & Gamble, and Johnson & Johnson.

CHICAGO - Some patients are ideal candidates for nonsurgical rhinoplasty to reshape the nose, according to experts.

Patients unready or unwilling to undergo surgery, for example, could opt for more temporary aesthetic changes through injectable products, two presenters noted at the annual meeting of the American Society for Dermatologic Surgery.

Photo credit: ©Dr. Vince Bertucci

Unlike more familiar facial cosmetic procedures, patients might need to be educated that injectables in the nose are a valid option, said Dr. Jean-François Tremblay, chief of the dermatologic surgery unit at the University of Montreal’s hospital center. Some will also need guidance as to what constitutes an ideal nose.

"We are not going to replace rhinoplasty, but there is a lot we can do with fillers in an in-and-out procedure," said Dr. Vince Bertucci, Immediate Past President of the Canadian Society for Dermatologic Surgery and the Medical Director of Bertucci MedSpa in Woodbridge, just outside Toronto.

Fillers can increase nasal tip projection and give the nose a longer, more refined appearance. Botulinum toxin can reduce dynamic changes that occur for some during facial expression, such as tip movement, "bunny lines," or alar flare. "Some patients with bunny lines really pull up their ali when they smile, but post botulinum toxin injection, they do not raise up as high," Dr. Bertucci said.

In some cases, fillers and botulinum toxin can be used in combination. Nasal tip droop is a common concern, Dr. Bertucci said. Botulinum toxin injected into the depressor septi nasi at the base of the columella can reverse this common effect of aging. He cautioned, however, the upper lip can be widened or elongated with this technique, and the upper lip tends to be already elongated in some elderly patients.

Photo credit: Damian McNamara

Dr. Bertucci emphasized the importance of knowing the nasal anatomy and danger zones. For example, inject botulinum toxin approximately half way between the nasal-facial junction and dorsum of the nose to avoid hitting the muscle that lifts the mouth. If the levator labii superioris alaeque nasi is inadvertently treated, the patient may end up with an unusual or asymmetric smile. "The message here is do not inject too far down the side of the nose."

The best candidates for nonsurgical rhinoplasty have minor deformities, not major deviations or bony anomalies, Dr. Tremblay said. Lower cost, little to no downtime, and the reversible or modifiable nature of the filler correction are among the appeals, he said. A temporary duration of effect can be a disadvantage. In addition, "we can only add volume and not remove anything," said Dr. Tremblay during the joint presentation.

An important caveat is patients who seek correction with injectables after a rhinoplasty require additional caution and expertise. "I would not recommend starting out on post-rhinoplasty patients," Dr. Bertucci said. Vascular changes and modification of bone and tissue from surgery can increase the risk of necrosis.

Regardless of history, begin by asking all patients what bothers them, Dr. Tremblay advised. "I want to understand their expectations, what their notion of an ideal nose is, and do a quick psychoanalysis 101." He added, "The rate of people having body dysmorphic disorder is higher when people complain about their noses versus other concerns. So it could be a sign someone does not have balanced psychological health."

Ensure you view the nose from all angles (frontal, lateral, and basal) and consider any aesthetic changes in the context of the entire face. "The basal view can show underlying anomalies that might explain superficial features we are trying to correct," Dr. Tremblay said.

An ideal nose "cannot be defined for any given individual without taking into consideration the rest of the facial features," Dr. Tremblay said. For example, he increased the chin projection of a woman who initially wanted the size of her nose reduced. She was happy with her nose after the chin augmentation.

Skin thickness varies in different parts of the nose. In general, the mid-nose skin tends to be thinner and more delicate than the proximal and distal areas. "So when you inject the mid-nose, keep in mind the need to [massage] material around so you don’t get a prominence," Dr. Bertucci said. Also avoid superficial placement and overcorrection with fillers (consider a staged correction). He added, "Injecting slowly is really important. It seems like a simple thing, but look at the skin as you inject is it blanching?"

A tip with filler enhancement on the dorsum of the nose is to pinch the skin and pull it gently up before injecting. Dr. Bertucci said, "I am still underneath the level of the skin, and I am off the vessels that may be lying on the bone or muscle."

"I also find that useful and that is what I do," Dr. Tremblay said. I try to generate with pinching the correction I am trying to achieve, and inject until I reach the volume I want."

A long-lasting but nonpermanent filler product is more ideal than a permanent one in the nose, Dr. Bertucci said. "This leaves you a way out, and the anatomy changes with age." Hyaluronic acid or calcium hydroxylapatite products are examples. In contrast, use of silicone can be riskier in terms of overcorrection and granulomatous effects.

A meeting attendee countered that he prefers silicone because hyaluronic acid corrections only last 2-3 months in his patients. Dr. Bertucci replied that, because of its permanent nature, "I would not use silicone unless you are very skilled in its use."

Injection-related pain, redness, bleeding, ecchymosis, and hematoma are possible complications regardless of the product type injected, Dr. Bertucci said.

Dr. Bertucci disclosed that he is a consultant for Allergan, Medicis Pharmaceutical Corp., and Merz Pharmaceutical, and an investigator for Allergen and Merz. Dr. Tromblay disclosed that he is a medical consultant for Allergan, Medicis, Canderm Pharma Inc., La Roche-Posay, Procter & Gamble, and Johnson & Johnson.

Massive transfusion protocols adopted from the military have conferred a significant survival advantage for some civilian trauma patients, but they remain controversial. Not everyone agrees that 10 or more units of packed red blood cells along with fresh frozen plasma and platelets in the first 24 hours for exsanguinating trauma patients should be the standard. The experience of three prominent researchers – Dr. Christopher Dente, Dr. Bryan Cotton, and Dr. Jeffry Kashuk – helps shed some light on developments in this emerging field.

Improved patient management is one advantage of the massive transfusion protocol (MTP), according to Dr. Dente, associate director of trauma at Grady Memorial Hospital in Atlanta. “I didn't think the effect it would have on how we can manage patients and how we can close their fascias earlier would be as profound as it is. The amount of bowel edema we see is much less as we reduced the amount of crystalloid. The ability to actually finish operations as opposed to doing damage-control laparotomy and leaving packs in – all of these things are more dramatic than I anticipated,” he said.

Empirical vs. tailored therapy, however, is still subject to debate. Currently, most protocols at civilian level I trauma centers dictate administration of a fixed 1:1:1 ratio of packed red blood cells, fresh frozen plasma (FFP), and platelets. This strategy was associated with increased survival at 6, 24, and 30 days and fewer ICU, ventilator, and hospital days, compared with patients who received lower proportions of FFP and platelets in a retrospective study of 466 trauma patients (Ann. Surg. 2008;248:447–58).

An empirical protocol increases efficiency, said Dr. Dente, by allowing the surgeon to start the process with a single phone call, after which the blood bank continues to make products for pick-up every half-hour.

Although survival improves with this empirical approach, there are concerns about “unbridled administration of fresh frozen plasma and platelets with objective evidence of their specific requirement,” Dr. Kashuk and his colleagues wrote in a review article (Ann. Surg. 2010;251:604–14).

Instead, Dr. Kashuk is a proponent of thromboelastography (TEG), a rapid, point-of-care test to determine the necessity and optimal ratio of blood products for a particular exsanguinating trauma patient.

The key with the ratio “is really trying to get back to the physiology and looking at function rather than numbers. No two patients are necessarily the same,” he said in an interview. “The difference between ratios can be enormous when approaching massive transfusion numbers. That's a lot of products being used if not absolutely necessary, especially considering the impact nationally on the blood banks, as well as the untoward effects, such as multiple organ failure.” Dr. Kashuk is a trauma surgeon at Pennsylvania State Milton S. Hershey Medical Center, Hershey.

“Unfortunately, thromboelastography is not readily available,” Dr. Dente said.

“We have seen a significant learning curve for adoption of this technology,” Dr. Kashuk said. Additional expense, time, and quality control to ensure accurate, reproducible results also are required, he added. “We have found, however, that once the team becomes comfortable with this approach, they begin to realize that old, standard lab values were essentially paramount to functioning in the dark.”

The identification of appropriate candidates for an MTP is another area of controversy. “We know about 25% of the most critically injured patients after trauma come in coagulopathic. Trying to identify these people is really the crux of the problem,” Dr. Dente said.

Several randomized, controlled trials of MTP are in the design phase, according to Dr. Dente. “The next step is to test this [empirical] protocol vs. a protocol that is more directed by point-of-care coagulation studies like thromboelastography,” he said.

Exactly how to identify which patients require an MTP also is unclear. Initiation of most protocols is based primarily on the surgeon's call, but some early predictive factors have been identified. For example, Dr. Dente and his colleagues demonstrated that gunshot patients were more likely to require an MTP if the bullet trajectory was multicavity or transpelvic or if the patient had significant, initial base deficit (J. Trauma 2010;68:298–304).

Scoring systems also can help to quickly identify candidates. For example, the ABC (Assessment of Blood Consumption) system, developed by Dr. Cotton and his colleagues, correctly identified 85% of 596 trauma patients who required a massive transfusion (J. Trauma 2009;66:346–52). ABC scoring is based on four factors: emergency department systolic blood pressure of 90 mm Hg or less; ED heart rate of 120 bpm or greater; a penetrating mechanism of injury; and positive fluid on abdominal ultrasound.

TASH (Trauma-Associated Severe Hemorrhage) is another scoring system (J. Trauma 2006;60:1228–36). “At the present time, one of several validated scoring systems – ABC, TASH – will rapidly identify those who require massive transfusion with an over-triage rate [positive predictive value] of about 50% and under-triage rate [negative predictive value] of about 5%,” said Dr. Cotton, who is on the surgery faculty in the division of acute care surgery at the University of Texas at Houston.

Another concern with MTPs is knowing when to call off the protocol. “You have to get a feel for when to stop, because if you forget to call [your blood bank], they are going to continue making products,” Dr. Dente said. “Once you get bleeding control as the operating surgeon, you have to communicate that. If you don't … you have the potential to actually waste products or to give products unnecessarily.”

Dr. Dente and his colleagues reviewed their MTP use at Grady Memorial and found a 27% overtriage rate, which meant that the protocol was activated for more than one-quarter of patients who never received a massive transfusion (J. Trauma 2010;68:298–304).

Overall resource use does not change significantly, but the timing does. “The goal of an MTP is to change the amount of transfusions on the back end,” Dr. Dente said.

Dr. Dente and Dr. Kashuk said they have no relevant financial disclosures. Dr. Cotton said he recently received a grant from Haemonetics Corp. (makers of a TEG system) for an investigator-initiated, multicenter study evaluating the ability of rapid TEG to describe coagulopathy in severely injured patients.

Dr. Christopher Dente supports the use of MTP in his hospital.

Source Courtesy Dr. Jamie Jones

Massive transfusion protocols adopted from the military have conferred a significant survival advantage for some civilian trauma patients, but they remain controversial. Not everyone agrees that 10 or more units of packed red blood cells along with fresh frozen plasma and platelets in the first 24 hours for exsanguinating trauma patients should be the standard. The experience of three prominent researchers – Dr. Christopher Dente, Dr. Bryan Cotton, and Dr. Jeffry Kashuk – helps shed some light on developments in this emerging field.

Improved patient management is one advantage of the massive transfusion protocol (MTP), according to Dr. Dente, associate director of trauma at Grady Memorial Hospital in Atlanta. “I didn't think the effect it would have on how we can manage patients and how we can close their fascias earlier would be as profound as it is. The amount of bowel edema we see is much less as we reduced the amount of crystalloid. The ability to actually finish operations as opposed to doing damage-control laparotomy and leaving packs in – all of these things are more dramatic than I anticipated,” he said.

Empirical vs. tailored therapy, however, is still subject to debate. Currently, most protocols at civilian level I trauma centers dictate administration of a fixed 1:1:1 ratio of packed red blood cells, fresh frozen plasma (FFP), and platelets. This strategy was associated with increased survival at 6, 24, and 30 days and fewer ICU, ventilator, and hospital days, compared with patients who received lower proportions of FFP and platelets in a retrospective study of 466 trauma patients (Ann. Surg. 2008;248:447–58).

An empirical protocol increases efficiency, said Dr. Dente, by allowing the surgeon to start the process with a single phone call, after which the blood bank continues to make products for pick-up every half-hour.

Although survival improves with this empirical approach, there are concerns about “unbridled administration of fresh frozen plasma and platelets with objective evidence of their specific requirement,” Dr. Kashuk and his colleagues wrote in a review article (Ann. Surg. 2010;251:604–14).

Instead, Dr. Kashuk is a proponent of thromboelastography (TEG), a rapid, point-of-care test to determine the necessity and optimal ratio of blood products for a particular exsanguinating trauma patient.

The key with the ratio “is really trying to get back to the physiology and looking at function rather than numbers. No two patients are necessarily the same,” he said in an interview. “The difference between ratios can be enormous when approaching massive transfusion numbers. That's a lot of products being used if not absolutely necessary, especially considering the impact nationally on the blood banks, as well as the untoward effects, such as multiple organ failure.” Dr. Kashuk is a trauma surgeon at Pennsylvania State Milton S. Hershey Medical Center, Hershey.

“Unfortunately, thromboelastography is not readily available,” Dr. Dente said.

“We have seen a significant learning curve for adoption of this technology,” Dr. Kashuk said. Additional expense, time, and quality control to ensure accurate, reproducible results also are required, he added. “We have found, however, that once the team becomes comfortable with this approach, they begin to realize that old, standard lab values were essentially paramount to functioning in the dark.”

The identification of appropriate candidates for an MTP is another area of controversy. “We know about 25% of the most critically injured patients after trauma come in coagulopathic. Trying to identify these people is really the crux of the problem,” Dr. Dente said.

Several randomized, controlled trials of MTP are in the design phase, according to Dr. Dente. “The next step is to test this [empirical] protocol vs. a protocol that is more directed by point-of-care coagulation studies like thromboelastography,” he said.

Exactly how to identify which patients require an MTP also is unclear. Initiation of most protocols is based primarily on the surgeon's call, but some early predictive factors have been identified. For example, Dr. Dente and his colleagues demonstrated that gunshot patients were more likely to require an MTP if the bullet trajectory was multicavity or transpelvic or if the patient had significant, initial base deficit (J. Trauma 2010;68:298–304).

Scoring systems also can help to quickly identify candidates. For example, the ABC (Assessment of Blood Consumption) system, developed by Dr. Cotton and his colleagues, correctly identified 85% of 596 trauma patients who required a massive transfusion (J. Trauma 2009;66:346–52). ABC scoring is based on four factors: emergency department systolic blood pressure of 90 mm Hg or less; ED heart rate of 120 bpm or greater; a penetrating mechanism of injury; and positive fluid on abdominal ultrasound.

TASH (Trauma-Associated Severe Hemorrhage) is another scoring system (J. Trauma 2006;60:1228–36). “At the present time, one of several validated scoring systems – ABC, TASH – will rapidly identify those who require massive transfusion with an over-triage rate [positive predictive value] of about 50% and under-triage rate [negative predictive value] of about 5%,” said Dr. Cotton, who is on the surgery faculty in the division of acute care surgery at the University of Texas at Houston.

Another concern with MTPs is knowing when to call off the protocol. “You have to get a feel for when to stop, because if you forget to call [your blood bank], they are going to continue making products,” Dr. Dente said. “Once you get bleeding control as the operating surgeon, you have to communicate that. If you don't … you have the potential to actually waste products or to give products unnecessarily.”

Dr. Dente and his colleagues reviewed their MTP use at Grady Memorial and found a 27% overtriage rate, which meant that the protocol was activated for more than one-quarter of patients who never received a massive transfusion (J. Trauma 2010;68:298–304).

Overall resource use does not change significantly, but the timing does. “The goal of an MTP is to change the amount of transfusions on the back end,” Dr. Dente said.

Dr. Dente and Dr. Kashuk said they have no relevant financial disclosures. Dr. Cotton said he recently received a grant from Haemonetics Corp. (makers of a TEG system) for an investigator-initiated, multicenter study evaluating the ability of rapid TEG to describe coagulopathy in severely injured patients.

Dr. Christopher Dente supports the use of MTP in his hospital.

Source Courtesy Dr. Jamie Jones

Massive transfusion protocols adopted from the military have conferred a significant survival advantage for some civilian trauma patients, but they remain controversial. Not everyone agrees that 10 or more units of packed red blood cells along with fresh frozen plasma and platelets in the first 24 hours for exsanguinating trauma patients should be the standard. The experience of three prominent researchers – Dr. Christopher Dente, Dr. Bryan Cotton, and Dr. Jeffry Kashuk – helps shed some light on developments in this emerging field.

Improved patient management is one advantage of the massive transfusion protocol (MTP), according to Dr. Dente, associate director of trauma at Grady Memorial Hospital in Atlanta. “I didn't think the effect it would have on how we can manage patients and how we can close their fascias earlier would be as profound as it is. The amount of bowel edema we see is much less as we reduced the amount of crystalloid. The ability to actually finish operations as opposed to doing damage-control laparotomy and leaving packs in – all of these things are more dramatic than I anticipated,” he said.

Empirical vs. tailored therapy, however, is still subject to debate. Currently, most protocols at civilian level I trauma centers dictate administration of a fixed 1:1:1 ratio of packed red blood cells, fresh frozen plasma (FFP), and platelets. This strategy was associated with increased survival at 6, 24, and 30 days and fewer ICU, ventilator, and hospital days, compared with patients who received lower proportions of FFP and platelets in a retrospective study of 466 trauma patients (Ann. Surg. 2008;248:447–58).

An empirical protocol increases efficiency, said Dr. Dente, by allowing the surgeon to start the process with a single phone call, after which the blood bank continues to make products for pick-up every half-hour.

Although survival improves with this empirical approach, there are concerns about “unbridled administration of fresh frozen plasma and platelets with objective evidence of their specific requirement,” Dr. Kashuk and his colleagues wrote in a review article (Ann. Surg. 2010;251:604–14).

Instead, Dr. Kashuk is a proponent of thromboelastography (TEG), a rapid, point-of-care test to determine the necessity and optimal ratio of blood products for a particular exsanguinating trauma patient.

The key with the ratio “is really trying to get back to the physiology and looking at function rather than numbers. No two patients are necessarily the same,” he said in an interview. “The difference between ratios can be enormous when approaching massive transfusion numbers. That's a lot of products being used if not absolutely necessary, especially considering the impact nationally on the blood banks, as well as the untoward effects, such as multiple organ failure.” Dr. Kashuk is a trauma surgeon at Pennsylvania State Milton S. Hershey Medical Center, Hershey.

“Unfortunately, thromboelastography is not readily available,” Dr. Dente said.

“We have seen a significant learning curve for adoption of this technology,” Dr. Kashuk said. Additional expense, time, and quality control to ensure accurate, reproducible results also are required, he added. “We have found, however, that once the team becomes comfortable with this approach, they begin to realize that old, standard lab values were essentially paramount to functioning in the dark.”

The identification of appropriate candidates for an MTP is another area of controversy. “We know about 25% of the most critically injured patients after trauma come in coagulopathic. Trying to identify these people is really the crux of the problem,” Dr. Dente said.

Several randomized, controlled trials of MTP are in the design phase, according to Dr. Dente. “The next step is to test this [empirical] protocol vs. a protocol that is more directed by point-of-care coagulation studies like thromboelastography,” he said.

Exactly how to identify which patients require an MTP also is unclear. Initiation of most protocols is based primarily on the surgeon's call, but some early predictive factors have been identified. For example, Dr. Dente and his colleagues demonstrated that gunshot patients were more likely to require an MTP if the bullet trajectory was multicavity or transpelvic or if the patient had significant, initial base deficit (J. Trauma 2010;68:298–304).

Scoring systems also can help to quickly identify candidates. For example, the ABC (Assessment of Blood Consumption) system, developed by Dr. Cotton and his colleagues, correctly identified 85% of 596 trauma patients who required a massive transfusion (J. Trauma 2009;66:346–52). ABC scoring is based on four factors: emergency department systolic blood pressure of 90 mm Hg or less; ED heart rate of 120 bpm or greater; a penetrating mechanism of injury; and positive fluid on abdominal ultrasound.

TASH (Trauma-Associated Severe Hemorrhage) is another scoring system (J. Trauma 2006;60:1228–36). “At the present time, one of several validated scoring systems – ABC, TASH – will rapidly identify those who require massive transfusion with an over-triage rate [positive predictive value] of about 50% and under-triage rate [negative predictive value] of about 5%,” said Dr. Cotton, who is on the surgery faculty in the division of acute care surgery at the University of Texas at Houston.

Another concern with MTPs is knowing when to call off the protocol. “You have to get a feel for when to stop, because if you forget to call [your blood bank], they are going to continue making products,” Dr. Dente said. “Once you get bleeding control as the operating surgeon, you have to communicate that. If you don't … you have the potential to actually waste products or to give products unnecessarily.”

Dr. Dente and his colleagues reviewed their MTP use at Grady Memorial and found a 27% overtriage rate, which meant that the protocol was activated for more than one-quarter of patients who never received a massive transfusion (J. Trauma 2010;68:298–304).

Overall resource use does not change significantly, but the timing does. “The goal of an MTP is to change the amount of transfusions on the back end,” Dr. Dente said.

Dr. Dente and Dr. Kashuk said they have no relevant financial disclosures. Dr. Cotton said he recently received a grant from Haemonetics Corp. (makers of a TEG system) for an investigator-initiated, multicenter study evaluating the ability of rapid TEG to describe coagulopathy in severely injured patients.

Dr. Christopher Dente supports the use of MTP in his hospital.

Source Courtesy Dr. Jamie Jones

MIAMI BEACH – Widespread screening for early Parkinson's disease with olfactory testing followed by neurologic imaging holds promise but is not yet practical, based on studies that have revealed the limitations of each method.

Olfactory impairment is common enough in premotor Parkinson's that some researchers propose using it as an early predictor of risk (Ann. Neurol. 2008;63:167-73).

However, olfactory testing has not garnered widespread adoption because it lacks sufficient specificity for population-based screening, Dr. Henk W. Berendse said at the congress. He and others have proposed coupling olfactory testing with highly specific brain imaging, such as dopamine transporter single-photon emission computed tomography (DAT SPECT).

There is a catch, though. The imaging would have to be done in a large number of individuals, many of whom would not develop Parkinson's disease, said Dr. Berendse, head of the movement disorders service at the VU University Medical Centre in Amsterdam.

In a subsequent presentation at the meeting, Dr. Andrew D. Siderowf of the neurology department at Pennsylvania Hospital in Philadelphia called population screening for Parkinson's disease a “numbers game.”

The incidence of Parkinson's disease is low, so the number of potentially identifiable cases in a population at any given time also is low, he said.

In 2005, the worldwide prevalence of the disease was estimated to be between 4.1 million and 4.6 million (Neurology 2007;68:384-6).

Dr. Berendse calculated that “if you expect to detect 125 patients in the premotor phase [of Parkinson's disease], somewhere between 1,000 and 7,000 individuals would have to undergo SPECT scans. Assuming a 10% prevalence of hyposmia, we would need to screen 70,000 individuals.”

The 10% prevalence of hyposmia is based on a study that screened 361 asymptomatic, 50- to 75-year-old relatives of patients with idiopathic Parkinson's. All of the relatives had olfactory testing, and the 40 who tested positive also had serial

Dr. Berendse and Dr. Siderowf had no relevant financial disclosures.

MIAMI BEACH – Widespread screening for early Parkinson's disease with olfactory testing followed by neurologic imaging holds promise but is not yet practical, based on studies that have revealed the limitations of each method.

Olfactory impairment is common enough in premotor Parkinson's that some researchers propose using it as an early predictor of risk (Ann. Neurol. 2008;63:167-73).

However, olfactory testing has not garnered widespread adoption because it lacks sufficient specificity for population-based screening, Dr. Henk W. Berendse said at the congress. He and others have proposed coupling olfactory testing with highly specific brain imaging, such as dopamine transporter single-photon emission computed tomography (DAT SPECT).

There is a catch, though. The imaging would have to be done in a large number of individuals, many of whom would not develop Parkinson's disease, said Dr. Berendse, head of the movement disorders service at the VU University Medical Centre in Amsterdam.

In a subsequent presentation at the meeting, Dr. Andrew D. Siderowf of the neurology department at Pennsylvania Hospital in Philadelphia called population screening for Parkinson's disease a “numbers game.”

The incidence of Parkinson's disease is low, so the number of potentially identifiable cases in a population at any given time also is low, he said.

In 2005, the worldwide prevalence of the disease was estimated to be between 4.1 million and 4.6 million (Neurology 2007;68:384-6).

Dr. Berendse calculated that “if you expect to detect 125 patients in the premotor phase [of Parkinson's disease], somewhere between 1,000 and 7,000 individuals would have to undergo SPECT scans. Assuming a 10% prevalence of hyposmia, we would need to screen 70,000 individuals.”

The 10% prevalence of hyposmia is based on a study that screened 361 asymptomatic, 50- to 75-year-old relatives of patients with idiopathic Parkinson's. All of the relatives had olfactory testing, and the 40 who tested positive also had serial

Dr. Berendse and Dr. Siderowf had no relevant financial disclosures.

MIAMI BEACH – Widespread screening for early Parkinson's disease with olfactory testing followed by neurologic imaging holds promise but is not yet practical, based on studies that have revealed the limitations of each method.

Olfactory impairment is common enough in premotor Parkinson's that some researchers propose using it as an early predictor of risk (Ann. Neurol. 2008;63:167-73).

However, olfactory testing has not garnered widespread adoption because it lacks sufficient specificity for population-based screening, Dr. Henk W. Berendse said at the congress. He and others have proposed coupling olfactory testing with highly specific brain imaging, such as dopamine transporter single-photon emission computed tomography (DAT SPECT).

There is a catch, though. The imaging would have to be done in a large number of individuals, many of whom would not develop Parkinson's disease, said Dr. Berendse, head of the movement disorders service at the VU University Medical Centre in Amsterdam.

In a subsequent presentation at the meeting, Dr. Andrew D. Siderowf of the neurology department at Pennsylvania Hospital in Philadelphia called population screening for Parkinson's disease a “numbers game.”

The incidence of Parkinson's disease is low, so the number of potentially identifiable cases in a population at any given time also is low, he said.

In 2005, the worldwide prevalence of the disease was estimated to be between 4.1 million and 4.6 million (Neurology 2007;68:384-6).

Dr. Berendse calculated that “if you expect to detect 125 patients in the premotor phase [of Parkinson's disease], somewhere between 1,000 and 7,000 individuals would have to undergo SPECT scans. Assuming a 10% prevalence of hyposmia, we would need to screen 70,000 individuals.”

The 10% prevalence of hyposmia is based on a study that screened 361 asymptomatic, 50- to 75-year-old relatives of patients with idiopathic Parkinson's. All of the relatives had olfactory testing, and the 40 who tested positive also had serial

Dr. Berendse and Dr. Siderowf had no relevant financial disclosures.