Damian McNamara

HOLLYWOOD, FLA. — The nighttime void volumes of people with an overactive bladder or primary insomnia were each significantly lower than controls, in an unexpected finding from a small pilot study.

“This is the first study to evaluate sleep and bladder diaries of insomniacs, people with overactive bladders, and controls,” said Dr. Cindy L. Amundsen, a urogynecologist at Duke University in Durham, N.C.

The objective was to compare the nighttime bladder symptoms between 10 people with overactive bladder (OAB), 10 people with insomnia, and 5 control patients with neither condition.

Some patients said “they've been told for years they had an overactive bladder, but [they] acted more like insomniacs and vice versa,” she said at the annual meeting of the American Urogynecologic Society.

All participants completed 7-day sleep diaries that included the number of awakenings and the duration of sleep. They also filled out 3-day bladder diaries with timing and volume of all voids.

Dr. Amundsen and her colleagues had expected to find notably lower nighttime urinary volumes in the participants with detrusor overactivity because of a greater voiding frequency. However, they recorded lower average nighttime void volumes in both the cohort with OAB (211 mL) and with insomnia (294 mL), compared with controls (460 mL). The study was funded by grants from Astellas Pharma and GlaxoSmithKline. Dr. Amundsen and her associates reported no relevant disclosures.

The mean daytime voided volume was statistically lower in the OAB patients (171 mL), compared with the insomnia patients (246 mL) and controls (291 mL).

The OAB patients had a significantly greater number of voids in 24 hours despite comparable total urine output per day. The total mean number of voids was 11.5 in the OAB group, 6.4 in the insomnia group, and 6.1 in controls. The total number of nocturia episodes likewise was significantly higher in the OAB group at 2.9, compared with 0.4 in insomniacs and 0.3 in controls.

All participants rated their perceived urgency on a 1-5 scale in the bladder diaries. The mean degree of urgency was 2.6 in the OAB group, 1.5 in the insomnia group, and 1.6 for the controls.

There was no significant difference in age or body mass index between the groups. Eligibility criteria for the OAB cohort included 3 or more months of symptoms, eight or more voids in a typical 24 hours, and two or more nocturia episodes per night. Those in the primary insomnia group reported awakening two or more times per night.

In addition, participants with OAB tended to void more quickly after awakening at night. “Polysomnogram and cystogram information was not presented here. But insomniacs spend more time being awake before they void compared to OAB patients. They are up 6-10 minutes, [and voiding is] almost an afterthought, whereas OAB patients void within 2 minutes in general,” she said.

In related data presented as a poster at the meeting, she and her colleagues found mean total sleep time was 423 minutes for the same 10 patients in the OAB group, 295 minutes for the insomniacs, and 444 minutes for controls.

Nocturia caused all the awakenings in the OAB group. In contrast to insomniacs, the participants with OAB were able to fall back to sleep faster—the mean time awake after sleep onset was 39 minutes in this group, compared with 103 minutes in insomniacs and 14 minutes in controls. These differences were statistically significant, and confirmed the sleep-disrupting effects of nocturia in the OAB group, the researchers noted.

HOLLYWOOD, FLA. — The nighttime void volumes of people with an overactive bladder or primary insomnia were each significantly lower than controls, in an unexpected finding from a small pilot study.

“This is the first study to evaluate sleep and bladder diaries of insomniacs, people with overactive bladders, and controls,” said Dr. Cindy L. Amundsen, a urogynecologist at Duke University in Durham, N.C.

The objective was to compare the nighttime bladder symptoms between 10 people with overactive bladder (OAB), 10 people with insomnia, and 5 control patients with neither condition.

Some patients said “they've been told for years they had an overactive bladder, but [they] acted more like insomniacs and vice versa,” she said at the annual meeting of the American Urogynecologic Society.

All participants completed 7-day sleep diaries that included the number of awakenings and the duration of sleep. They also filled out 3-day bladder diaries with timing and volume of all voids.

Dr. Amundsen and her colleagues had expected to find notably lower nighttime urinary volumes in the participants with detrusor overactivity because of a greater voiding frequency. However, they recorded lower average nighttime void volumes in both the cohort with OAB (211 mL) and with insomnia (294 mL), compared with controls (460 mL). The study was funded by grants from Astellas Pharma and GlaxoSmithKline. Dr. Amundsen and her associates reported no relevant disclosures.

The mean daytime voided volume was statistically lower in the OAB patients (171 mL), compared with the insomnia patients (246 mL) and controls (291 mL).

The OAB patients had a significantly greater number of voids in 24 hours despite comparable total urine output per day. The total mean number of voids was 11.5 in the OAB group, 6.4 in the insomnia group, and 6.1 in controls. The total number of nocturia episodes likewise was significantly higher in the OAB group at 2.9, compared with 0.4 in insomniacs and 0.3 in controls.

All participants rated their perceived urgency on a 1-5 scale in the bladder diaries. The mean degree of urgency was 2.6 in the OAB group, 1.5 in the insomnia group, and 1.6 for the controls.

There was no significant difference in age or body mass index between the groups. Eligibility criteria for the OAB cohort included 3 or more months of symptoms, eight or more voids in a typical 24 hours, and two or more nocturia episodes per night. Those in the primary insomnia group reported awakening two or more times per night.

In addition, participants with OAB tended to void more quickly after awakening at night. “Polysomnogram and cystogram information was not presented here. But insomniacs spend more time being awake before they void compared to OAB patients. They are up 6-10 minutes, [and voiding is] almost an afterthought, whereas OAB patients void within 2 minutes in general,” she said.

In related data presented as a poster at the meeting, she and her colleagues found mean total sleep time was 423 minutes for the same 10 patients in the OAB group, 295 minutes for the insomniacs, and 444 minutes for controls.

Nocturia caused all the awakenings in the OAB group. In contrast to insomniacs, the participants with OAB were able to fall back to sleep faster—the mean time awake after sleep onset was 39 minutes in this group, compared with 103 minutes in insomniacs and 14 minutes in controls. These differences were statistically significant, and confirmed the sleep-disrupting effects of nocturia in the OAB group, the researchers noted.

HOLLYWOOD, FLA. — The nighttime void volumes of people with an overactive bladder or primary insomnia were each significantly lower than controls, in an unexpected finding from a small pilot study.

“This is the first study to evaluate sleep and bladder diaries of insomniacs, people with overactive bladders, and controls,” said Dr. Cindy L. Amundsen, a urogynecologist at Duke University in Durham, N.C.

The objective was to compare the nighttime bladder symptoms between 10 people with overactive bladder (OAB), 10 people with insomnia, and 5 control patients with neither condition.

Some patients said “they've been told for years they had an overactive bladder, but [they] acted more like insomniacs and vice versa,” she said at the annual meeting of the American Urogynecologic Society.

All participants completed 7-day sleep diaries that included the number of awakenings and the duration of sleep. They also filled out 3-day bladder diaries with timing and volume of all voids.

Dr. Amundsen and her colleagues had expected to find notably lower nighttime urinary volumes in the participants with detrusor overactivity because of a greater voiding frequency. However, they recorded lower average nighttime void volumes in both the cohort with OAB (211 mL) and with insomnia (294 mL), compared with controls (460 mL). The study was funded by grants from Astellas Pharma and GlaxoSmithKline. Dr. Amundsen and her associates reported no relevant disclosures.

The mean daytime voided volume was statistically lower in the OAB patients (171 mL), compared with the insomnia patients (246 mL) and controls (291 mL).

The OAB patients had a significantly greater number of voids in 24 hours despite comparable total urine output per day. The total mean number of voids was 11.5 in the OAB group, 6.4 in the insomnia group, and 6.1 in controls. The total number of nocturia episodes likewise was significantly higher in the OAB group at 2.9, compared with 0.4 in insomniacs and 0.3 in controls.

All participants rated their perceived urgency on a 1-5 scale in the bladder diaries. The mean degree of urgency was 2.6 in the OAB group, 1.5 in the insomnia group, and 1.6 for the controls.

There was no significant difference in age or body mass index between the groups. Eligibility criteria for the OAB cohort included 3 or more months of symptoms, eight or more voids in a typical 24 hours, and two or more nocturia episodes per night. Those in the primary insomnia group reported awakening two or more times per night.

In addition, participants with OAB tended to void more quickly after awakening at night. “Polysomnogram and cystogram information was not presented here. But insomniacs spend more time being awake before they void compared to OAB patients. They are up 6-10 minutes, [and voiding is] almost an afterthought, whereas OAB patients void within 2 minutes in general,” she said.

In related data presented as a poster at the meeting, she and her colleagues found mean total sleep time was 423 minutes for the same 10 patients in the OAB group, 295 minutes for the insomniacs, and 444 minutes for controls.

Nocturia caused all the awakenings in the OAB group. In contrast to insomniacs, the participants with OAB were able to fall back to sleep faster—the mean time awake after sleep onset was 39 minutes in this group, compared with 103 minutes in insomniacs and 14 minutes in controls. These differences were statistically significant, and confirmed the sleep-disrupting effects of nocturia in the OAB group, the researchers noted.

PHOENIX — Cosmetic dermatology procedures require patient education and thorough consent, a panel of four physicians agreed during a discussion of how best to manage any complications that do occur.

Among the questions that were discussed: Do you give a patient a refund if a complication occurs? Do you charge an unhappy patient for a touch-up? When does a complication with hyaluronic acid warrant reversal with hyaluronidase? Also, is it necessary to get informed consent each time an established patient comes in for a series of treatments?

Dr. Ken K. Lee posed these and other questions as he moderated this session at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

If a bruise occurs under the eye, for example, do you give a refund or offer free services? asked Dr. Lee, director of dermatologic and laser surgery at Oregon Health and Science University, Portland.

"Bruises do occur. It's in the informed consent; that is the beauty of the multiple consent form," said Dr. Timothy Flynn, who is in private practice in Cary, N.C. Be compassionate and discuss strategies to avoid bruising the next time, he said. "But, no, I would not give a refund—it is within the expected risks."

"I would not give a refund either," said Dr. Joel L. Cohen, a dermatologist in Englewood, Colo. But, "I might see if they can meet with someone in my office about makeup, at no charge."

Dr. Dee Anna Glaser agreed. "I do pulsed dye laser if they are very upset about this, at no charge. But we don't give refunds." Dr. Glaser is a professor of dermatology at St. Louis University.

Dr. Lee asked the panel for advice when a cosmetic patient presents with a bluish tinge or a Tyndall effect from a more diffuse nodule in their tear trough 1 month after hyaluronic acid injection.

Calculate how much hyaluronic acid was injected, and use hyaluronidase to reverse the effect, Dr. Flynn suggested.

"Tell the patient you are going to melt it away. You have to warn them you are going to melt most of the hyaluronic acid in their face" as well, he said.

"I rarely use hyaluronidase," said Dr. Roberta D. Sengelmann, a dermatologic surgeon in private practice in Santa Barbara, Calif., and St. Louis. "If you use the hyaluronidase, you will really erase their correction." Instead, she discusses camouflage and other options with the patient.

Dr. Lee also asked about treating a woman with "rock hard nodules" under her eyes, for example, 1 year after poly-

Dr. Sengelmann said she would do a biopsy. Dr. Glaser said 1 year is unusually long for such a complication to arise—most develop within the first few months post treatment.

Dr. Sengelmann asked the panel if they charge for hyaluronidase if a patient is referred for a Tyndall effect complication. "I don't charge for the hyaluronidase … or charge them anything extra," Dr. Flynn said. "I kind of feel bad for these people."

"If it's my complication, I do not charge them," Dr. Cohen said. "If it's someone else's patient … I do." He estimated that hyaluronidase costs about $50 for a single-use vial. "There is a risk of anaphylaxis. You need to get their consent," he added.

Dr. Lee next asked the panel if they typically charge when outcomes do not meet their own or the patient's expectations.

"If the problem was not enough volume, we charge for whatever we use in terms of filler," Dr. Flynn said. "Toxins are sometimes different. With an unhappy patient, I can treat with more toxin at no charge."

One challenge is when a patient is willing or able to pay for only a small amount of product but wants a full effect. Dr. Cohen suggested handing a mirror to a one-syringe patient. "Ask them at that point if they want an additional syringe now or later," he said. "Sometimes if I look at a patient a few weeks later and I see I could have done better, I give them a little more at no charge."

Dr. Glaser also offered a strategy with botulinum toxin. "Sometimes when I am really trying to get the patient to use a little more toxin and they are reluctant, I tell them I will do the next 5 U for free this time and if they like the result, they will pay next time."

Dr. Sengelmann typically asks her new patients to return 2–3 weeks after an initial treatment to address any concerns. "If I feel I did not achieve a result, I will give them 5 U, sometimes 10. That is a great way to build rapport with patients."

How dermatologists get consent and whether they should get it for every treatment were Dr. Lee's next concerns.

"The nurse provides the consent form. I come back in the room and ask if they have any questions, and I cosign it," Dr. Sengelmann said. "They sign the same consent each time they come in for a treatment."

"I usually don't sign for Botox and fillers, the nurse signs it," Dr. Glaser said. "We have a form with multiple lines, and we get consent for each and every patient."

In Dr. Cohen's practice, a medical assistant asks patients to sign the consent form. "But I review what can happen [such as] bruising, lumps, and bumps." He also asks patients to let him know if they experience excessive pain or "anything purple they don't think is bruising."

Dr. Glaser said that she has "to remind [patients] that even though they have had no complication to date, the risk is the same with each and every injection."

"I re-consent every time," Dr. Flynn said. "I just want to remind everyone there are more and more attorneys graduating each and every year. Remember the trial attorneys are not your friends."

How do you get informed consent? Do you get it every time an established patient comes in for treatment?

Source Dr. Lee

'They sign the same consent each time they come in for a treatment.'

Source Dr. Sengelmann

A medical assistant asks patients to sign the consent form, 'but I review what can happen.'

Source Dr. Cohen

'We have a form with multiple lines, and we get consent for each and every patient.'

Source Dr. Glaser

PHOENIX — Cosmetic dermatology procedures require patient education and thorough consent, a panel of four physicians agreed during a discussion of how best to manage any complications that do occur.

Among the questions that were discussed: Do you give a patient a refund if a complication occurs? Do you charge an unhappy patient for a touch-up? When does a complication with hyaluronic acid warrant reversal with hyaluronidase? Also, is it necessary to get informed consent each time an established patient comes in for a series of treatments?

Dr. Ken K. Lee posed these and other questions as he moderated this session at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

If a bruise occurs under the eye, for example, do you give a refund or offer free services? asked Dr. Lee, director of dermatologic and laser surgery at Oregon Health and Science University, Portland.

"Bruises do occur. It's in the informed consent; that is the beauty of the multiple consent form," said Dr. Timothy Flynn, who is in private practice in Cary, N.C. Be compassionate and discuss strategies to avoid bruising the next time, he said. "But, no, I would not give a refund—it is within the expected risks."

"I would not give a refund either," said Dr. Joel L. Cohen, a dermatologist in Englewood, Colo. But, "I might see if they can meet with someone in my office about makeup, at no charge."

Dr. Dee Anna Glaser agreed. "I do pulsed dye laser if they are very upset about this, at no charge. But we don't give refunds." Dr. Glaser is a professor of dermatology at St. Louis University.

Dr. Lee asked the panel for advice when a cosmetic patient presents with a bluish tinge or a Tyndall effect from a more diffuse nodule in their tear trough 1 month after hyaluronic acid injection.

Calculate how much hyaluronic acid was injected, and use hyaluronidase to reverse the effect, Dr. Flynn suggested.

"Tell the patient you are going to melt it away. You have to warn them you are going to melt most of the hyaluronic acid in their face" as well, he said.

"I rarely use hyaluronidase," said Dr. Roberta D. Sengelmann, a dermatologic surgeon in private practice in Santa Barbara, Calif., and St. Louis. "If you use the hyaluronidase, you will really erase their correction." Instead, she discusses camouflage and other options with the patient.

Dr. Lee also asked about treating a woman with "rock hard nodules" under her eyes, for example, 1 year after poly-

Dr. Sengelmann said she would do a biopsy. Dr. Glaser said 1 year is unusually long for such a complication to arise—most develop within the first few months post treatment.

Dr. Sengelmann asked the panel if they charge for hyaluronidase if a patient is referred for a Tyndall effect complication. "I don't charge for the hyaluronidase … or charge them anything extra," Dr. Flynn said. "I kind of feel bad for these people."

"If it's my complication, I do not charge them," Dr. Cohen said. "If it's someone else's patient … I do." He estimated that hyaluronidase costs about $50 for a single-use vial. "There is a risk of anaphylaxis. You need to get their consent," he added.

Dr. Lee next asked the panel if they typically charge when outcomes do not meet their own or the patient's expectations.

"If the problem was not enough volume, we charge for whatever we use in terms of filler," Dr. Flynn said. "Toxins are sometimes different. With an unhappy patient, I can treat with more toxin at no charge."

One challenge is when a patient is willing or able to pay for only a small amount of product but wants a full effect. Dr. Cohen suggested handing a mirror to a one-syringe patient. "Ask them at that point if they want an additional syringe now or later," he said. "Sometimes if I look at a patient a few weeks later and I see I could have done better, I give them a little more at no charge."

Dr. Glaser also offered a strategy with botulinum toxin. "Sometimes when I am really trying to get the patient to use a little more toxin and they are reluctant, I tell them I will do the next 5 U for free this time and if they like the result, they will pay next time."

Dr. Sengelmann typically asks her new patients to return 2–3 weeks after an initial treatment to address any concerns. "If I feel I did not achieve a result, I will give them 5 U, sometimes 10. That is a great way to build rapport with patients."

How dermatologists get consent and whether they should get it for every treatment were Dr. Lee's next concerns.

"The nurse provides the consent form. I come back in the room and ask if they have any questions, and I cosign it," Dr. Sengelmann said. "They sign the same consent each time they come in for a treatment."

"I usually don't sign for Botox and fillers, the nurse signs it," Dr. Glaser said. "We have a form with multiple lines, and we get consent for each and every patient."

In Dr. Cohen's practice, a medical assistant asks patients to sign the consent form. "But I review what can happen [such as] bruising, lumps, and bumps." He also asks patients to let him know if they experience excessive pain or "anything purple they don't think is bruising."

Dr. Glaser said that she has "to remind [patients] that even though they have had no complication to date, the risk is the same with each and every injection."

"I re-consent every time," Dr. Flynn said. "I just want to remind everyone there are more and more attorneys graduating each and every year. Remember the trial attorneys are not your friends."

How do you get informed consent? Do you get it every time an established patient comes in for treatment?

Source Dr. Lee

'They sign the same consent each time they come in for a treatment.'

Source Dr. Sengelmann

A medical assistant asks patients to sign the consent form, 'but I review what can happen.'

Source Dr. Cohen

'We have a form with multiple lines, and we get consent for each and every patient.'

Source Dr. Glaser

PHOENIX — Cosmetic dermatology procedures require patient education and thorough consent, a panel of four physicians agreed during a discussion of how best to manage any complications that do occur.

Among the questions that were discussed: Do you give a patient a refund if a complication occurs? Do you charge an unhappy patient for a touch-up? When does a complication with hyaluronic acid warrant reversal with hyaluronidase? Also, is it necessary to get informed consent each time an established patient comes in for a series of treatments?

Dr. Ken K. Lee posed these and other questions as he moderated this session at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

If a bruise occurs under the eye, for example, do you give a refund or offer free services? asked Dr. Lee, director of dermatologic and laser surgery at Oregon Health and Science University, Portland.

"Bruises do occur. It's in the informed consent; that is the beauty of the multiple consent form," said Dr. Timothy Flynn, who is in private practice in Cary, N.C. Be compassionate and discuss strategies to avoid bruising the next time, he said. "But, no, I would not give a refund—it is within the expected risks."

"I would not give a refund either," said Dr. Joel L. Cohen, a dermatologist in Englewood, Colo. But, "I might see if they can meet with someone in my office about makeup, at no charge."

Dr. Dee Anna Glaser agreed. "I do pulsed dye laser if they are very upset about this, at no charge. But we don't give refunds." Dr. Glaser is a professor of dermatology at St. Louis University.

Dr. Lee asked the panel for advice when a cosmetic patient presents with a bluish tinge or a Tyndall effect from a more diffuse nodule in their tear trough 1 month after hyaluronic acid injection.

Calculate how much hyaluronic acid was injected, and use hyaluronidase to reverse the effect, Dr. Flynn suggested.

"Tell the patient you are going to melt it away. You have to warn them you are going to melt most of the hyaluronic acid in their face" as well, he said.

"I rarely use hyaluronidase," said Dr. Roberta D. Sengelmann, a dermatologic surgeon in private practice in Santa Barbara, Calif., and St. Louis. "If you use the hyaluronidase, you will really erase their correction." Instead, she discusses camouflage and other options with the patient.

Dr. Lee also asked about treating a woman with "rock hard nodules" under her eyes, for example, 1 year after poly-

Dr. Sengelmann said she would do a biopsy. Dr. Glaser said 1 year is unusually long for such a complication to arise—most develop within the first few months post treatment.

Dr. Sengelmann asked the panel if they charge for hyaluronidase if a patient is referred for a Tyndall effect complication. "I don't charge for the hyaluronidase … or charge them anything extra," Dr. Flynn said. "I kind of feel bad for these people."

"If it's my complication, I do not charge them," Dr. Cohen said. "If it's someone else's patient … I do." He estimated that hyaluronidase costs about $50 for a single-use vial. "There is a risk of anaphylaxis. You need to get their consent," he added.

Dr. Lee next asked the panel if they typically charge when outcomes do not meet their own or the patient's expectations.

"If the problem was not enough volume, we charge for whatever we use in terms of filler," Dr. Flynn said. "Toxins are sometimes different. With an unhappy patient, I can treat with more toxin at no charge."

One challenge is when a patient is willing or able to pay for only a small amount of product but wants a full effect. Dr. Cohen suggested handing a mirror to a one-syringe patient. "Ask them at that point if they want an additional syringe now or later," he said. "Sometimes if I look at a patient a few weeks later and I see I could have done better, I give them a little more at no charge."

Dr. Glaser also offered a strategy with botulinum toxin. "Sometimes when I am really trying to get the patient to use a little more toxin and they are reluctant, I tell them I will do the next 5 U for free this time and if they like the result, they will pay next time."

Dr. Sengelmann typically asks her new patients to return 2–3 weeks after an initial treatment to address any concerns. "If I feel I did not achieve a result, I will give them 5 U, sometimes 10. That is a great way to build rapport with patients."

How dermatologists get consent and whether they should get it for every treatment were Dr. Lee's next concerns.

"The nurse provides the consent form. I come back in the room and ask if they have any questions, and I cosign it," Dr. Sengelmann said. "They sign the same consent each time they come in for a treatment."

"I usually don't sign for Botox and fillers, the nurse signs it," Dr. Glaser said. "We have a form with multiple lines, and we get consent for each and every patient."

In Dr. Cohen's practice, a medical assistant asks patients to sign the consent form. "But I review what can happen [such as] bruising, lumps, and bumps." He also asks patients to let him know if they experience excessive pain or "anything purple they don't think is bruising."

Dr. Glaser said that she has "to remind [patients] that even though they have had no complication to date, the risk is the same with each and every injection."

"I re-consent every time," Dr. Flynn said. "I just want to remind everyone there are more and more attorneys graduating each and every year. Remember the trial attorneys are not your friends."

How do you get informed consent? Do you get it every time an established patient comes in for treatment?

Source Dr. Lee

'They sign the same consent each time they come in for a treatment.'

Source Dr. Sengelmann

A medical assistant asks patients to sign the consent form, 'but I review what can happen.'

Source Dr. Cohen

'We have a form with multiple lines, and we get consent for each and every patient.'

Source Dr. Glaser

PHOENIX — Cosmetic dermatologists need to remain ethical in how they choose and promote a product or procedure, as well as how they market their practice to patients, according to Dr. Susan H. Weinkle.

Disclose all industry financial relationships to avoid bias, or even the perception of bias. “If you would be embarrassed in any way to discuss your relationship with a pharmaceutical company with your patients or colleagues, it may be time to reassess,” Dr. Weinkle said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Ethical patient counseling is also important. “If you use off-label products in your office, you have to make sure the patient understands what it means,” Dr. Weinkle said. Prior to approval of a cosmetic indication for poly-L-lactic acid injection (Sculptura Aesthetic, Sanofi-Aventis) in July 2009. "I had to explain to all patients it was approved for HIV atrophy, and I was choosing to use for an off-label indication."

Dermatologists are under scrutiny from the government and consumer advocates. “We are obliged to maintain a high standard of safety and maintain the public trust,” Dr. Weinkle said. “When I recommend something, I have to know I am recommending it for the right reason. Would I use it to treat myself and my mother?” Choose a particular laser, for example, because it is the best treatment for a particular patient, not because a payment needs to be made on the device.

Participation on industry advisory panels is appropriate for faculty, she said. It also is ethical to accept reasonable reimbursement for travel, lodging, and meal expenses from industry. Progress in medicine is made in part because of alliances between physicians and industry. At the same time, it is imperative to avoid professional bias or even the appearance of such bias. “If we are working for a company or doing a project—we are human beings—we have to acknowledge there could be professional bias,” she said.

Full disclosure of all relevant conflicts of interest includes interactions with the media, such as granting an interview to a magazine or television station. Also, if you do medical writing, beware of too much delegation. “If you write an article for one of our journals, make sure you are involved and review it,” she said. Disclose any role of other people involved.

Remain ethical when marketing or promoting cosmetic dermatology services. “There are more advertisements near my practice for dermatologists than attorneys,” said Dr. Weinkle, a private practice dermatologist in Bradenton, Fla. She said she had no relevant disclosures related to this presentation.

A final tip from Dr. Weinkle: Review the American Medical Association's Code of Medical Ethics, which is available at www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.shtml.

Visit www.youtube.com/SkinAndAllergyNews for a video interview with Dr. Weinkle explaining more about ethics and bias.

PHOENIX — Cosmetic dermatologists need to remain ethical in how they choose and promote a product or procedure, as well as how they market their practice to patients, according to Dr. Susan H. Weinkle.

Disclose all industry financial relationships to avoid bias, or even the perception of bias. “If you would be embarrassed in any way to discuss your relationship with a pharmaceutical company with your patients or colleagues, it may be time to reassess,” Dr. Weinkle said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Ethical patient counseling is also important. “If you use off-label products in your office, you have to make sure the patient understands what it means,” Dr. Weinkle said. Prior to approval of a cosmetic indication for poly-L-lactic acid injection (Sculptura Aesthetic, Sanofi-Aventis) in July 2009. "I had to explain to all patients it was approved for HIV atrophy, and I was choosing to use for an off-label indication."

Dermatologists are under scrutiny from the government and consumer advocates. “We are obliged to maintain a high standard of safety and maintain the public trust,” Dr. Weinkle said. “When I recommend something, I have to know I am recommending it for the right reason. Would I use it to treat myself and my mother?” Choose a particular laser, for example, because it is the best treatment for a particular patient, not because a payment needs to be made on the device.

Participation on industry advisory panels is appropriate for faculty, she said. It also is ethical to accept reasonable reimbursement for travel, lodging, and meal expenses from industry. Progress in medicine is made in part because of alliances between physicians and industry. At the same time, it is imperative to avoid professional bias or even the appearance of such bias. “If we are working for a company or doing a project—we are human beings—we have to acknowledge there could be professional bias,” she said.

Full disclosure of all relevant conflicts of interest includes interactions with the media, such as granting an interview to a magazine or television station. Also, if you do medical writing, beware of too much delegation. “If you write an article for one of our journals, make sure you are involved and review it,” she said. Disclose any role of other people involved.

Remain ethical when marketing or promoting cosmetic dermatology services. “There are more advertisements near my practice for dermatologists than attorneys,” said Dr. Weinkle, a private practice dermatologist in Bradenton, Fla. She said she had no relevant disclosures related to this presentation.

A final tip from Dr. Weinkle: Review the American Medical Association's Code of Medical Ethics, which is available at www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.shtml.

Visit www.youtube.com/SkinAndAllergyNews for a video interview with Dr. Weinkle explaining more about ethics and bias.

PHOENIX — Cosmetic dermatologists need to remain ethical in how they choose and promote a product or procedure, as well as how they market their practice to patients, according to Dr. Susan H. Weinkle.

Disclose all industry financial relationships to avoid bias, or even the perception of bias. “If you would be embarrassed in any way to discuss your relationship with a pharmaceutical company with your patients or colleagues, it may be time to reassess,” Dr. Weinkle said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Ethical patient counseling is also important. “If you use off-label products in your office, you have to make sure the patient understands what it means,” Dr. Weinkle said. Prior to approval of a cosmetic indication for poly-L-lactic acid injection (Sculptura Aesthetic, Sanofi-Aventis) in July 2009. "I had to explain to all patients it was approved for HIV atrophy, and I was choosing to use for an off-label indication."

Dermatologists are under scrutiny from the government and consumer advocates. “We are obliged to maintain a high standard of safety and maintain the public trust,” Dr. Weinkle said. “When I recommend something, I have to know I am recommending it for the right reason. Would I use it to treat myself and my mother?” Choose a particular laser, for example, because it is the best treatment for a particular patient, not because a payment needs to be made on the device.

Participation on industry advisory panels is appropriate for faculty, she said. It also is ethical to accept reasonable reimbursement for travel, lodging, and meal expenses from industry. Progress in medicine is made in part because of alliances between physicians and industry. At the same time, it is imperative to avoid professional bias or even the appearance of such bias. “If we are working for a company or doing a project—we are human beings—we have to acknowledge there could be professional bias,” she said.

Full disclosure of all relevant conflicts of interest includes interactions with the media, such as granting an interview to a magazine or television station. Also, if you do medical writing, beware of too much delegation. “If you write an article for one of our journals, make sure you are involved and review it,” she said. Disclose any role of other people involved.

Remain ethical when marketing or promoting cosmetic dermatology services. “There are more advertisements near my practice for dermatologists than attorneys,” said Dr. Weinkle, a private practice dermatologist in Bradenton, Fla. She said she had no relevant disclosures related to this presentation.

A final tip from Dr. Weinkle: Review the American Medical Association's Code of Medical Ethics, which is available at www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.shtml.

Visit www.youtube.com/SkinAndAllergyNews for a video interview with Dr. Weinkle explaining more about ethics and bias.

PHOENIX — Adding laser lipolysis to radiofrequency tightening procedures for submental and jowl area fat did not significantly increase patient satisfaction, based on the results of a small study.

"So my take-home message [is] maybe less is more," Dr. Susan Van Dyke said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

She and her colleagues studied 36 patients. One group of 13 patients received monopolar radiofrequency treatment alone; 10 were treated with laser lipolysis alone; and 13 were treated with a combination at the same sitting.

The investigators compared patient satisfaction and blinded evaluator assessment among the different fat reduction treatments. Patient satisfaction "in private practice is what it is all about," said Dr. Van Dyke, a cosmetic dermatologist in private practice in Paradise Valley, Ariz.

Monopolar radiofrequency provides immediate collagen contracting with better remodeling over time. The treatment can produce a nice improvement in the neckline and jawline—a better contour, Dr. Van Dyke said. "You get nice tightening with radiofrequency alone." Patients were treated to the usual end point of some discomfort, described as, "It hurts, but I can tolerate it for a while."

The patients and blinded assessors rated submental tightening on a 1- to 5-point scale at 6 months. Radiofrequency treatment alone yielded an average 3.6 patient satisfaction rating. Blinded raters, who gauged response using standardized clinical photos, gave this treatment an average rating of 3.4.

Laser lipolysis uses a laser to heat and dissolve fat cells and a 1- to 2-mm cannula to drain the liquefied fat. The patients in the laser lipolysis monotherapy group were treated with a 10-W device with a 1,064-nm Nd:YAG laser. The treatment end point was a surface temperature of 102°–104°F.

Average patient satisfaction with this approach was 3.1. Blinded observers rated response higher, an average of 3.9. "We had six complications," Dr. Van Dyke said. "All resolved, but this may be why patients were not as satisfied."

Patients in the combined treatment group rated their satisfaction an average of 3.6. "Combined treatment seemed to be just as good as radiofrequency by itself; both were rated 3.6 by patients," Dr. Van Dyke said.

The blinded raters gave the combination an average score of 3.7, slightly below their 3.9 rating for results with laser lipolysis alone.

"I care about the satisfaction of my patients," Dr. Van Dyke said. "From a clinical standpoint, patients like the radiofrequency and the combination, and are a little less enthusiastic about laser lipolysis alone."

Dr. Van Dyke is on the speakers bureau for Solta Medical Inc., Lumenis Ltd., Stiefel Laboratories Inc. (RevaléSkin), and Valeant Pharmaceuticals International and is a stockholder in Medicis Pharmaceutical Corp. and Allergan Inc.

PHOENIX — Adding laser lipolysis to radiofrequency tightening procedures for submental and jowl area fat did not significantly increase patient satisfaction, based on the results of a small study.

"So my take-home message [is] maybe less is more," Dr. Susan Van Dyke said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

She and her colleagues studied 36 patients. One group of 13 patients received monopolar radiofrequency treatment alone; 10 were treated with laser lipolysis alone; and 13 were treated with a combination at the same sitting.

The investigators compared patient satisfaction and blinded evaluator assessment among the different fat reduction treatments. Patient satisfaction "in private practice is what it is all about," said Dr. Van Dyke, a cosmetic dermatologist in private practice in Paradise Valley, Ariz.

Monopolar radiofrequency provides immediate collagen contracting with better remodeling over time. The treatment can produce a nice improvement in the neckline and jawline—a better contour, Dr. Van Dyke said. "You get nice tightening with radiofrequency alone." Patients were treated to the usual end point of some discomfort, described as, "It hurts, but I can tolerate it for a while."

The patients and blinded assessors rated submental tightening on a 1- to 5-point scale at 6 months. Radiofrequency treatment alone yielded an average 3.6 patient satisfaction rating. Blinded raters, who gauged response using standardized clinical photos, gave this treatment an average rating of 3.4.

Laser lipolysis uses a laser to heat and dissolve fat cells and a 1- to 2-mm cannula to drain the liquefied fat. The patients in the laser lipolysis monotherapy group were treated with a 10-W device with a 1,064-nm Nd:YAG laser. The treatment end point was a surface temperature of 102°–104°F.

Average patient satisfaction with this approach was 3.1. Blinded observers rated response higher, an average of 3.9. "We had six complications," Dr. Van Dyke said. "All resolved, but this may be why patients were not as satisfied."

Patients in the combined treatment group rated their satisfaction an average of 3.6. "Combined treatment seemed to be just as good as radiofrequency by itself; both were rated 3.6 by patients," Dr. Van Dyke said.

The blinded raters gave the combination an average score of 3.7, slightly below their 3.9 rating for results with laser lipolysis alone.

"I care about the satisfaction of my patients," Dr. Van Dyke said. "From a clinical standpoint, patients like the radiofrequency and the combination, and are a little less enthusiastic about laser lipolysis alone."

Dr. Van Dyke is on the speakers bureau for Solta Medical Inc., Lumenis Ltd., Stiefel Laboratories Inc. (RevaléSkin), and Valeant Pharmaceuticals International and is a stockholder in Medicis Pharmaceutical Corp. and Allergan Inc.

PHOENIX — Adding laser lipolysis to radiofrequency tightening procedures for submental and jowl area fat did not significantly increase patient satisfaction, based on the results of a small study.

"So my take-home message [is] maybe less is more," Dr. Susan Van Dyke said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

She and her colleagues studied 36 patients. One group of 13 patients received monopolar radiofrequency treatment alone; 10 were treated with laser lipolysis alone; and 13 were treated with a combination at the same sitting.

The investigators compared patient satisfaction and blinded evaluator assessment among the different fat reduction treatments. Patient satisfaction "in private practice is what it is all about," said Dr. Van Dyke, a cosmetic dermatologist in private practice in Paradise Valley, Ariz.

Monopolar radiofrequency provides immediate collagen contracting with better remodeling over time. The treatment can produce a nice improvement in the neckline and jawline—a better contour, Dr. Van Dyke said. "You get nice tightening with radiofrequency alone." Patients were treated to the usual end point of some discomfort, described as, "It hurts, but I can tolerate it for a while."

The patients and blinded assessors rated submental tightening on a 1- to 5-point scale at 6 months. Radiofrequency treatment alone yielded an average 3.6 patient satisfaction rating. Blinded raters, who gauged response using standardized clinical photos, gave this treatment an average rating of 3.4.

Laser lipolysis uses a laser to heat and dissolve fat cells and a 1- to 2-mm cannula to drain the liquefied fat. The patients in the laser lipolysis monotherapy group were treated with a 10-W device with a 1,064-nm Nd:YAG laser. The treatment end point was a surface temperature of 102°–104°F.

Average patient satisfaction with this approach was 3.1. Blinded observers rated response higher, an average of 3.9. "We had six complications," Dr. Van Dyke said. "All resolved, but this may be why patients were not as satisfied."

Patients in the combined treatment group rated their satisfaction an average of 3.6. "Combined treatment seemed to be just as good as radiofrequency by itself; both were rated 3.6 by patients," Dr. Van Dyke said.

The blinded raters gave the combination an average score of 3.7, slightly below their 3.9 rating for results with laser lipolysis alone.

"I care about the satisfaction of my patients," Dr. Van Dyke said. "From a clinical standpoint, patients like the radiofrequency and the combination, and are a little less enthusiastic about laser lipolysis alone."

Dr. Van Dyke is on the speakers bureau for Solta Medical Inc., Lumenis Ltd., Stiefel Laboratories Inc. (RevaléSkin), and Valeant Pharmaceuticals International and is a stockholder in Medicis Pharmaceutical Corp. and Allergan Inc.

PHOENIX — Fractional CO₂ lasers provide greater accuracy, control, and predictability for skin resurfacing than do chemical peels, according to Dr. Kimberly Butterwick. However, Dr. Gary Monheit countered that peels are more efficient, safe, and reliable than lasers.

"We know in today's economy [dermatologists are asking] is a laser really worth it?" Dr. Butterwick said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

She estimated that an ablative fractional CO₂ laser costs about $1,500 per patient in the first year, but said the device pays off in the long run. "You can make more money treating more patients. You end up working less hard [compared with chemical peels] and making good money," she said.

Patients are willing to pay more for the results provided by laser resurfacing, according to Dr. Butterwick, who is in private practice in San Diego. "Patients will pay $1,000 more if you say they will have a better experience, and you will get rid of more lines."

"The big thing about lasers versus chemical peels is how deep you can go and still be safe," Dr. Butterwick said. A patient concerned with rhytids along his or her upper lip, for example, can be treated safely with a laser.

"If the lines are not too deep, one treatment tends to get rid of the lion's share of the lines above the mouth," she said. Peels can be used, but there is a risk of adverse outcomes. "Scarring and a decreased oral aperture can result with a deeper peel around the mouth," she said.

Laser resurfacing is also less painful, Dr. Butterwick said. "Patients do not require meds, so they can drive there and back, and they don't have to rely on a friend or tell their husband."

A quicker, easier recovery is another benefit of fractional CO₂ lasers. "No longer is there the 2-week redness and healing we saw with older CO₂ lasers. Patients can be functional while they are recovering and can get back to work sooner," she said. "Everyone is healed and in makeup within 6 days in our practice."

The opportunities for instruction are another distinction between the fractional CO₂ laser and chemical peel resurfacing. "You can get education and training in lasers, and you can hardly get any training in peels any more," Dr. Butterwick said.

However, in a subsequent presentation at the meeting, Dr. Monheit argued that chemical peels have a longer track record. "Peels remain the most popular, reliable, and efficacious method of skin resurfacing after more than 75 plus years," said Dr. Monheit, who is in private practice in Birmingham, Ala.

"Chemical peels yield predictable results with safety and efficacy," he said. "You can really [predict] what the patient will have in a reliable period of time."

There is no laser "that can produce results as efficiently and safely as chemical peeling," Dr. Monheit said. "I'm seeing a resurgence back to chemical peels because the laser hype has not delivered all it said it would."

Also, chemical peels "can be tailored to patients' needs and downtime, for example, a lunchtime superficial peel," he said.

Dr. Butterwick and Dr. Monheit reported no relevant disclosures.

'I'm seeing a resurgence back to chemical peels because the laser hype has not delivered all it said it would.'

Source Dr. Monheit

With the laser, 'you end up working less hard [compared with chemical peels] and making good money.'

Source Dr. Butterwick

PHOENIX — Fractional CO₂ lasers provide greater accuracy, control, and predictability for skin resurfacing than do chemical peels, according to Dr. Kimberly Butterwick. However, Dr. Gary Monheit countered that peels are more efficient, safe, and reliable than lasers.

"We know in today's economy [dermatologists are asking] is a laser really worth it?" Dr. Butterwick said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

She estimated that an ablative fractional CO₂ laser costs about $1,500 per patient in the first year, but said the device pays off in the long run. "You can make more money treating more patients. You end up working less hard [compared with chemical peels] and making good money," she said.

Patients are willing to pay more for the results provided by laser resurfacing, according to Dr. Butterwick, who is in private practice in San Diego. "Patients will pay $1,000 more if you say they will have a better experience, and you will get rid of more lines."

"The big thing about lasers versus chemical peels is how deep you can go and still be safe," Dr. Butterwick said. A patient concerned with rhytids along his or her upper lip, for example, can be treated safely with a laser.

"If the lines are not too deep, one treatment tends to get rid of the lion's share of the lines above the mouth," she said. Peels can be used, but there is a risk of adverse outcomes. "Scarring and a decreased oral aperture can result with a deeper peel around the mouth," she said.

Laser resurfacing is also less painful, Dr. Butterwick said. "Patients do not require meds, so they can drive there and back, and they don't have to rely on a friend or tell their husband."

A quicker, easier recovery is another benefit of fractional CO₂ lasers. "No longer is there the 2-week redness and healing we saw with older CO₂ lasers. Patients can be functional while they are recovering and can get back to work sooner," she said. "Everyone is healed and in makeup within 6 days in our practice."

The opportunities for instruction are another distinction between the fractional CO₂ laser and chemical peel resurfacing. "You can get education and training in lasers, and you can hardly get any training in peels any more," Dr. Butterwick said.

However, in a subsequent presentation at the meeting, Dr. Monheit argued that chemical peels have a longer track record. "Peels remain the most popular, reliable, and efficacious method of skin resurfacing after more than 75 plus years," said Dr. Monheit, who is in private practice in Birmingham, Ala.

"Chemical peels yield predictable results with safety and efficacy," he said. "You can really [predict] what the patient will have in a reliable period of time."

There is no laser "that can produce results as efficiently and safely as chemical peeling," Dr. Monheit said. "I'm seeing a resurgence back to chemical peels because the laser hype has not delivered all it said it would."

Also, chemical peels "can be tailored to patients' needs and downtime, for example, a lunchtime superficial peel," he said.

Dr. Butterwick and Dr. Monheit reported no relevant disclosures.

'I'm seeing a resurgence back to chemical peels because the laser hype has not delivered all it said it would.'

Source Dr. Monheit

With the laser, 'you end up working less hard [compared with chemical peels] and making good money.'

Source Dr. Butterwick

PHOENIX — Fractional CO₂ lasers provide greater accuracy, control, and predictability for skin resurfacing than do chemical peels, according to Dr. Kimberly Butterwick. However, Dr. Gary Monheit countered that peels are more efficient, safe, and reliable than lasers.

"We know in today's economy [dermatologists are asking] is a laser really worth it?" Dr. Butterwick said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

She estimated that an ablative fractional CO₂ laser costs about $1,500 per patient in the first year, but said the device pays off in the long run. "You can make more money treating more patients. You end up working less hard [compared with chemical peels] and making good money," she said.

Patients are willing to pay more for the results provided by laser resurfacing, according to Dr. Butterwick, who is in private practice in San Diego. "Patients will pay $1,000 more if you say they will have a better experience, and you will get rid of more lines."

"The big thing about lasers versus chemical peels is how deep you can go and still be safe," Dr. Butterwick said. A patient concerned with rhytids along his or her upper lip, for example, can be treated safely with a laser.

"If the lines are not too deep, one treatment tends to get rid of the lion's share of the lines above the mouth," she said. Peels can be used, but there is a risk of adverse outcomes. "Scarring and a decreased oral aperture can result with a deeper peel around the mouth," she said.

Laser resurfacing is also less painful, Dr. Butterwick said. "Patients do not require meds, so they can drive there and back, and they don't have to rely on a friend or tell their husband."

A quicker, easier recovery is another benefit of fractional CO₂ lasers. "No longer is there the 2-week redness and healing we saw with older CO₂ lasers. Patients can be functional while they are recovering and can get back to work sooner," she said. "Everyone is healed and in makeup within 6 days in our practice."

The opportunities for instruction are another distinction between the fractional CO₂ laser and chemical peel resurfacing. "You can get education and training in lasers, and you can hardly get any training in peels any more," Dr. Butterwick said.

However, in a subsequent presentation at the meeting, Dr. Monheit argued that chemical peels have a longer track record. "Peels remain the most popular, reliable, and efficacious method of skin resurfacing after more than 75 plus years," said Dr. Monheit, who is in private practice in Birmingham, Ala.

"Chemical peels yield predictable results with safety and efficacy," he said. "You can really [predict] what the patient will have in a reliable period of time."

There is no laser "that can produce results as efficiently and safely as chemical peeling," Dr. Monheit said. "I'm seeing a resurgence back to chemical peels because the laser hype has not delivered all it said it would."

Also, chemical peels "can be tailored to patients' needs and downtime, for example, a lunchtime superficial peel," he said.

Dr. Butterwick and Dr. Monheit reported no relevant disclosures.

'I'm seeing a resurgence back to chemical peels because the laser hype has not delivered all it said it would.'

Source Dr. Monheit

With the laser, 'you end up working less hard [compared with chemical peels] and making good money.'

Source Dr. Butterwick

HOLLYWOOD, FLA. — In a military-based health care system with no out-of-pocket medication expenses, 35% of nearly 8,000 adults did not refill their prescription for an overactive bladder treatment, according to a retrospective, observational study.

However, among the 65% who did refill their antimuscarinic prescription at least once, most compliance measures were superior to those in previously published studies, suggesting copayment or out-of-pocket expenses might be a deterrent, Dr. Christine L. Sears said. Antimuscarinic medications are often prescribed as first-line treatment for symptoms of overactive bladder, a common condition. Other investigators have estimated the prevalence at 12%-16% among adult women (Eur. Urol. 2006;50:1306–14; Eur. Urol. 2009;55:783–91).

Because previous reports in the United States regarding compliance with these medications assessed patients with pharmacy copayments, Dr. Sears and her colleagues assessed compliance in a health care system where patients do not pay for medication.

They identified 7,858 adult patients in the national capital region, including Washington, D.C., Maryland, and Virginia, from pharmacy dispensing records from January 2003 to December 2006.

The median duration of medication adherence for all patients was 273 days. But when the 2,760 patients (35%) who never refilled their prescription were excluded, the median duration was 582 days.

“Our [35%] nonpersistence rate is really lower than in previous published studies,” Dr. Sears said at the annual meeting of the American Urogynecologic Society. For example, researchers in one study reported a 45% nonpersistence rate in 1,117 patients (J. Manag. Care Pharm. 2008;14:291–301). The current study included 5,501 women (70% of the total) and 2,357 men. Compliance was better among women, said Dr. Sears of the department of urology at the National Naval Medical Center, Bethesda, Md. For example, among patients who refilled the prescription at least once, women remained on their medication a median of 606 days, compared with 547 days among men.

Dr. Sears and her colleagues also assessed the medication possession ratio (MPR). An MPR of 1.0 reflects 100% compliance, calculated as the sum of the supply of medication divided by the number of days it is prescribed. An MPR greater than 1.0 would result from early medication refilling, and a ratio less than 1.0 would indicate a lapse in refilling. The overall median MPR in the study was 0.82. Men had a significantly higher median MPR (0.86) than women (0.81), Dr. Sears added.

The medication switch rate was almost 26%. This means that of the 5,098 patients who refilled their prescriptions, 1,305 changed medications or dosage at least once. Dr. Sears said the overall switch rate was similar to that reported in other antimuscarinic agent studies.

The most commonly used antimuscarinic agent was tolterodine extended release (Detrol LA) with 4,716 prescriptions. Dr. Sears and her associates reported no relevant financial disclosures.

Not surprisingly, overall compliance was better with the extended-release medications than with the immediate-release formulations, Dr. Sears said. For example, patients prescribed tolterodine extended release had a significantly higher MPR, 0.89, compared with those prescribed oxybutynin immediate release, 0.68.

The small sample size of patients prescribed oxybutynin extended release is a limitation of the study, Dr. Sears said. In addition, although they had access to the medical records, the investigators did not assess patient demographic or health care data because this information was not included in the study's institutional review board application.

HOLLYWOOD, FLA. — In a military-based health care system with no out-of-pocket medication expenses, 35% of nearly 8,000 adults did not refill their prescription for an overactive bladder treatment, according to a retrospective, observational study.

However, among the 65% who did refill their antimuscarinic prescription at least once, most compliance measures were superior to those in previously published studies, suggesting copayment or out-of-pocket expenses might be a deterrent, Dr. Christine L. Sears said. Antimuscarinic medications are often prescribed as first-line treatment for symptoms of overactive bladder, a common condition. Other investigators have estimated the prevalence at 12%-16% among adult women (Eur. Urol. 2006;50:1306–14; Eur. Urol. 2009;55:783–91).

Because previous reports in the United States regarding compliance with these medications assessed patients with pharmacy copayments, Dr. Sears and her colleagues assessed compliance in a health care system where patients do not pay for medication.

They identified 7,858 adult patients in the national capital region, including Washington, D.C., Maryland, and Virginia, from pharmacy dispensing records from January 2003 to December 2006.

The median duration of medication adherence for all patients was 273 days. But when the 2,760 patients (35%) who never refilled their prescription were excluded, the median duration was 582 days.

“Our [35%] nonpersistence rate is really lower than in previous published studies,” Dr. Sears said at the annual meeting of the American Urogynecologic Society. For example, researchers in one study reported a 45% nonpersistence rate in 1,117 patients (J. Manag. Care Pharm. 2008;14:291–301). The current study included 5,501 women (70% of the total) and 2,357 men. Compliance was better among women, said Dr. Sears of the department of urology at the National Naval Medical Center, Bethesda, Md. For example, among patients who refilled the prescription at least once, women remained on their medication a median of 606 days, compared with 547 days among men.

Dr. Sears and her colleagues also assessed the medication possession ratio (MPR). An MPR of 1.0 reflects 100% compliance, calculated as the sum of the supply of medication divided by the number of days it is prescribed. An MPR greater than 1.0 would result from early medication refilling, and a ratio less than 1.0 would indicate a lapse in refilling. The overall median MPR in the study was 0.82. Men had a significantly higher median MPR (0.86) than women (0.81), Dr. Sears added.

The medication switch rate was almost 26%. This means that of the 5,098 patients who refilled their prescriptions, 1,305 changed medications or dosage at least once. Dr. Sears said the overall switch rate was similar to that reported in other antimuscarinic agent studies.

The most commonly used antimuscarinic agent was tolterodine extended release (Detrol LA) with 4,716 prescriptions. Dr. Sears and her associates reported no relevant financial disclosures.

Not surprisingly, overall compliance was better with the extended-release medications than with the immediate-release formulations, Dr. Sears said. For example, patients prescribed tolterodine extended release had a significantly higher MPR, 0.89, compared with those prescribed oxybutynin immediate release, 0.68.

The small sample size of patients prescribed oxybutynin extended release is a limitation of the study, Dr. Sears said. In addition, although they had access to the medical records, the investigators did not assess patient demographic or health care data because this information was not included in the study's institutional review board application.

HOLLYWOOD, FLA. — In a military-based health care system with no out-of-pocket medication expenses, 35% of nearly 8,000 adults did not refill their prescription for an overactive bladder treatment, according to a retrospective, observational study.

However, among the 65% who did refill their antimuscarinic prescription at least once, most compliance measures were superior to those in previously published studies, suggesting copayment or out-of-pocket expenses might be a deterrent, Dr. Christine L. Sears said. Antimuscarinic medications are often prescribed as first-line treatment for symptoms of overactive bladder, a common condition. Other investigators have estimated the prevalence at 12%-16% among adult women (Eur. Urol. 2006;50:1306–14; Eur. Urol. 2009;55:783–91).

Because previous reports in the United States regarding compliance with these medications assessed patients with pharmacy copayments, Dr. Sears and her colleagues assessed compliance in a health care system where patients do not pay for medication.

They identified 7,858 adult patients in the national capital region, including Washington, D.C., Maryland, and Virginia, from pharmacy dispensing records from January 2003 to December 2006.

The median duration of medication adherence for all patients was 273 days. But when the 2,760 patients (35%) who never refilled their prescription were excluded, the median duration was 582 days.

“Our [35%] nonpersistence rate is really lower than in previous published studies,” Dr. Sears said at the annual meeting of the American Urogynecologic Society. For example, researchers in one study reported a 45% nonpersistence rate in 1,117 patients (J. Manag. Care Pharm. 2008;14:291–301). The current study included 5,501 women (70% of the total) and 2,357 men. Compliance was better among women, said Dr. Sears of the department of urology at the National Naval Medical Center, Bethesda, Md. For example, among patients who refilled the prescription at least once, women remained on their medication a median of 606 days, compared with 547 days among men.

Dr. Sears and her colleagues also assessed the medication possession ratio (MPR). An MPR of 1.0 reflects 100% compliance, calculated as the sum of the supply of medication divided by the number of days it is prescribed. An MPR greater than 1.0 would result from early medication refilling, and a ratio less than 1.0 would indicate a lapse in refilling. The overall median MPR in the study was 0.82. Men had a significantly higher median MPR (0.86) than women (0.81), Dr. Sears added.

The medication switch rate was almost 26%. This means that of the 5,098 patients who refilled their prescriptions, 1,305 changed medications or dosage at least once. Dr. Sears said the overall switch rate was similar to that reported in other antimuscarinic agent studies.

The most commonly used antimuscarinic agent was tolterodine extended release (Detrol LA) with 4,716 prescriptions. Dr. Sears and her associates reported no relevant financial disclosures.

Not surprisingly, overall compliance was better with the extended-release medications than with the immediate-release formulations, Dr. Sears said. For example, patients prescribed tolterodine extended release had a significantly higher MPR, 0.89, compared with those prescribed oxybutynin immediate release, 0.68.

The small sample size of patients prescribed oxybutynin extended release is a limitation of the study, Dr. Sears said. In addition, although they had access to the medical records, the investigators did not assess patient demographic or health care data because this information was not included in the study's institutional review board application.

PHOENIX — California Governor Arnold Schwarzenegger signed a bill into law that raises public awareness about the risks of cosmetic surgery and targets the aggressive marketing of services that make the risks “seem almost nonexistent,” California State Assemblywoman Wilmer Amina Carter said.

Known also as the “Donda West Act,” the law is named after Kanye West's mother, who died of complications following liposuction and mammaplasty. The law requires a physical examination 30 days before a patient undergoes a cosmetic surgery procedure.

“People may think they are well enough for cosmetic surgery, but [they] are not always,” said Ms. Carter, who introduced the legislation, known officially as AB 1116. She spoke at the joint annual meeting of American Society for Dermatologic Surgery (ASDS) and the American Society of Cosmetic Dermatology & Aesthetic Surgery.

Earlier this year the governor vetoed a second patient safety bill also sponsored by Ms. Carter. That legislation would have increased enforcement of patient safety laws specifically addressing medi-spa-based cosmetic procedures and laser hair removal retail chains.

“The bill made it through with only one 'no' vote before Governor Schwarzenegger vetoed it,” said Dr. Robert A. Weiss, a private practice dermatologist in Hunt Valley, Md.

“We're having budgetary issues in California, as are most states. The Governor is very adamant about getting things done, and is holding some bills hostage to get things he wants done,” Ms. Carter, who introduced the bill to the assembly, said. “It is not the fault of the bill—it's relevant.”

Known as AB 252, the bill aimed to increase penalties and enforcement related to existing California law that prohibits corporate medi-spas and hair removal chains from hiring medical directors who provide supervision in name only. If it had become law, the Medical Board of California would be authorized to remove the medical license of any physician who allowed his or her license to be used for a nonphysician to establish a medi-spa, commonly known as a “rent-a-doc” scheme. The ASDS and CalDerm co-sponsored the bill.

“There is a growing trend for elective cosmetic surgery but the public is not always aware of the risks,” Ms. Carter said. She cited the case of a patient treated at a medi-spa located on an upper floor of a mall. Something went wrong, and there was no doctor on site. Ambulance workers could not get the patient down through the mall and the patient had to be lowered through a window. “It's those kinds of things we have to protect patients from.”

“When I became an elected official, I decided one of my goals was to author legislation to protect our citizens from harm,” Ms. Carter said. She vowed to continue working on patient safety issues.

PHOENIX — California Governor Arnold Schwarzenegger signed a bill into law that raises public awareness about the risks of cosmetic surgery and targets the aggressive marketing of services that make the risks “seem almost nonexistent,” California State Assemblywoman Wilmer Amina Carter said.

Known also as the “Donda West Act,” the law is named after Kanye West's mother, who died of complications following liposuction and mammaplasty. The law requires a physical examination 30 days before a patient undergoes a cosmetic surgery procedure.

“People may think they are well enough for cosmetic surgery, but [they] are not always,” said Ms. Carter, who introduced the legislation, known officially as AB 1116. She spoke at the joint annual meeting of American Society for Dermatologic Surgery (ASDS) and the American Society of Cosmetic Dermatology & Aesthetic Surgery.

Earlier this year the governor vetoed a second patient safety bill also sponsored by Ms. Carter. That legislation would have increased enforcement of patient safety laws specifically addressing medi-spa-based cosmetic procedures and laser hair removal retail chains.

“The bill made it through with only one 'no' vote before Governor Schwarzenegger vetoed it,” said Dr. Robert A. Weiss, a private practice dermatologist in Hunt Valley, Md.

“We're having budgetary issues in California, as are most states. The Governor is very adamant about getting things done, and is holding some bills hostage to get things he wants done,” Ms. Carter, who introduced the bill to the assembly, said. “It is not the fault of the bill—it's relevant.”

Known as AB 252, the bill aimed to increase penalties and enforcement related to existing California law that prohibits corporate medi-spas and hair removal chains from hiring medical directors who provide supervision in name only. If it had become law, the Medical Board of California would be authorized to remove the medical license of any physician who allowed his or her license to be used for a nonphysician to establish a medi-spa, commonly known as a “rent-a-doc” scheme. The ASDS and CalDerm co-sponsored the bill.

“There is a growing trend for elective cosmetic surgery but the public is not always aware of the risks,” Ms. Carter said. She cited the case of a patient treated at a medi-spa located on an upper floor of a mall. Something went wrong, and there was no doctor on site. Ambulance workers could not get the patient down through the mall and the patient had to be lowered through a window. “It's those kinds of things we have to protect patients from.”

“When I became an elected official, I decided one of my goals was to author legislation to protect our citizens from harm,” Ms. Carter said. She vowed to continue working on patient safety issues.

PHOENIX — California Governor Arnold Schwarzenegger signed a bill into law that raises public awareness about the risks of cosmetic surgery and targets the aggressive marketing of services that make the risks “seem almost nonexistent,” California State Assemblywoman Wilmer Amina Carter said.

Known also as the “Donda West Act,” the law is named after Kanye West's mother, who died of complications following liposuction and mammaplasty. The law requires a physical examination 30 days before a patient undergoes a cosmetic surgery procedure.

“People may think they are well enough for cosmetic surgery, but [they] are not always,” said Ms. Carter, who introduced the legislation, known officially as AB 1116. She spoke at the joint annual meeting of American Society for Dermatologic Surgery (ASDS) and the American Society of Cosmetic Dermatology & Aesthetic Surgery.

Earlier this year the governor vetoed a second patient safety bill also sponsored by Ms. Carter. That legislation would have increased enforcement of patient safety laws specifically addressing medi-spa-based cosmetic procedures and laser hair removal retail chains.

“The bill made it through with only one 'no' vote before Governor Schwarzenegger vetoed it,” said Dr. Robert A. Weiss, a private practice dermatologist in Hunt Valley, Md.

“We're having budgetary issues in California, as are most states. The Governor is very adamant about getting things done, and is holding some bills hostage to get things he wants done,” Ms. Carter, who introduced the bill to the assembly, said. “It is not the fault of the bill—it's relevant.”

Known as AB 252, the bill aimed to increase penalties and enforcement related to existing California law that prohibits corporate medi-spas and hair removal chains from hiring medical directors who provide supervision in name only. If it had become law, the Medical Board of California would be authorized to remove the medical license of any physician who allowed his or her license to be used for a nonphysician to establish a medi-spa, commonly known as a “rent-a-doc” scheme. The ASDS and CalDerm co-sponsored the bill.

“There is a growing trend for elective cosmetic surgery but the public is not always aware of the risks,” Ms. Carter said. She cited the case of a patient treated at a medi-spa located on an upper floor of a mall. Something went wrong, and there was no doctor on site. Ambulance workers could not get the patient down through the mall and the patient had to be lowered through a window. “It's those kinds of things we have to protect patients from.”

“When I became an elected official, I decided one of my goals was to author legislation to protect our citizens from harm,” Ms. Carter said. She vowed to continue working on patient safety issues.

SAN FRANCISCO — Insulin resistance may be present in patients with acanthosis nigricans, particularly if they are overweight or obese, and research increasingly supports a link between these conditions.

A high level of clinical suspicion may be warranted, Dr. Jeffrey P. Callen said at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF). “Sometimes it is a very subtle finding.”

Dr. Callen, chief of dermatology and professor of medicine at the University of Louisville (Ky.), cited the case of an overweight young woman he saw for acne treatment. She had no menstrual irregularities, which can signal polycystic ovary syndrome, a condition also linked with insulin resistance. “Basically the reason we were alert to the fact that she was insulin resistant is, during her complete examination, we noticed a velvety discoloration on the back of her neck, in a folded area of the skin.”

The patient was referred to her primary care physician and tested positive for insulin resistance.

An insulin sensitizer such as metformin can help such a patient lose weight, after which their acanthosis nigricans would likely improve as well, said Dr. Callen. Some reports in the literature support use of insulin sensitizers to indirectly improve acanthosis nigricans (Ann. Pharmacother. 2008;42:1090–4), whereas others only point to modest benefits (J. Drugs. Dermatol. 2006;5:884–9).

The clinical association became stronger after researchers found 78 (36%) of 216 patients newly diagnosed with type 2 diabetes also had acanthosis nigricans on the back of their necks (Endocr. Pract. 2004;10:101–6). Investigators at the University of Texas Southwestern in Dallas found risk varied by body mass index and ethnicity in this retrospective study. “They found those who had acanthosis nigricans were most often insulin resistant, overweight, and more of them were people of color,” Dr. Callen said. For example, 50 of 95 African American and 28 of 78 Hispanic diabetics in the study had acanthosis nigricans, compared with 1 of 39 whites and 0 of 4 Asians.

More recently, researchers found a higher prevalence of insulin resistance among obese women with acanthosis nigricans, compared with others without the skin hyperpigmentation (J. Dermatol. 2009;36:209–12). Specifically, 5 of 32 participants (16%) with acanthosis nigricans had insulin resistance, compared with none of the 34 women without the dermatologic condition.

Acanthosis nigricans is a clinical diagnosis and histopathology generally is not required. Affected patients often come to a dermatologist “because they've noticed this hyperpigmentation on folded areas of the skin—the back of the neck or under the arms.” Although Dr. Callen sometimes orders fasting and postprandial insulin levels for patients with acanthosis nigricans, he thought most dermatologists would refer a patient for further work-up.

Dr. Callen disclosed no relevant conflicts of interest. SDEF and this news organization are owned by Elsevier.

To see a video of Dr. Callen discussing this association, visit www.youtube.com/SkinAndAllergyNews

SAN FRANCISCO — Insulin resistance may be present in patients with acanthosis nigricans, particularly if they are overweight or obese, and research increasingly supports a link between these conditions.

A high level of clinical suspicion may be warranted, Dr. Jeffrey P. Callen said at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF). “Sometimes it is a very subtle finding.”

Dr. Callen, chief of dermatology and professor of medicine at the University of Louisville (Ky.), cited the case of an overweight young woman he saw for acne treatment. She had no menstrual irregularities, which can signal polycystic ovary syndrome, a condition also linked with insulin resistance. “Basically the reason we were alert to the fact that she was insulin resistant is, during her complete examination, we noticed a velvety discoloration on the back of her neck, in a folded area of the skin.”

The patient was referred to her primary care physician and tested positive for insulin resistance.

An insulin sensitizer such as metformin can help such a patient lose weight, after which their acanthosis nigricans would likely improve as well, said Dr. Callen. Some reports in the literature support use of insulin sensitizers to indirectly improve acanthosis nigricans (Ann. Pharmacother. 2008;42:1090–4), whereas others only point to modest benefits (J. Drugs. Dermatol. 2006;5:884–9).

The clinical association became stronger after researchers found 78 (36%) of 216 patients newly diagnosed with type 2 diabetes also had acanthosis nigricans on the back of their necks (Endocr. Pract. 2004;10:101–6). Investigators at the University of Texas Southwestern in Dallas found risk varied by body mass index and ethnicity in this retrospective study. “They found those who had acanthosis nigricans were most often insulin resistant, overweight, and more of them were people of color,” Dr. Callen said. For example, 50 of 95 African American and 28 of 78 Hispanic diabetics in the study had acanthosis nigricans, compared with 1 of 39 whites and 0 of 4 Asians.

More recently, researchers found a higher prevalence of insulin resistance among obese women with acanthosis nigricans, compared with others without the skin hyperpigmentation (J. Dermatol. 2009;36:209–12). Specifically, 5 of 32 participants (16%) with acanthosis nigricans had insulin resistance, compared with none of the 34 women without the dermatologic condition.

Acanthosis nigricans is a clinical diagnosis and histopathology generally is not required. Affected patients often come to a dermatologist “because they've noticed this hyperpigmentation on folded areas of the skin—the back of the neck or under the arms.” Although Dr. Callen sometimes orders fasting and postprandial insulin levels for patients with acanthosis nigricans, he thought most dermatologists would refer a patient for further work-up.

Dr. Callen disclosed no relevant conflicts of interest. SDEF and this news organization are owned by Elsevier.

To see a video of Dr. Callen discussing this association, visit www.youtube.com/SkinAndAllergyNews

SAN FRANCISCO — Insulin resistance may be present in patients with acanthosis nigricans, particularly if they are overweight or obese, and research increasingly supports a link between these conditions.

A high level of clinical suspicion may be warranted, Dr. Jeffrey P. Callen said at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF). “Sometimes it is a very subtle finding.”

Dr. Callen, chief of dermatology and professor of medicine at the University of Louisville (Ky.), cited the case of an overweight young woman he saw for acne treatment. She had no menstrual irregularities, which can signal polycystic ovary syndrome, a condition also linked with insulin resistance. “Basically the reason we were alert to the fact that she was insulin resistant is, during her complete examination, we noticed a velvety discoloration on the back of her neck, in a folded area of the skin.”

The patient was referred to her primary care physician and tested positive for insulin resistance.

An insulin sensitizer such as metformin can help such a patient lose weight, after which their acanthosis nigricans would likely improve as well, said Dr. Callen. Some reports in the literature support use of insulin sensitizers to indirectly improve acanthosis nigricans (Ann. Pharmacother. 2008;42:1090–4), whereas others only point to modest benefits (J. Drugs. Dermatol. 2006;5:884–9).

The clinical association became stronger after researchers found 78 (36%) of 216 patients newly diagnosed with type 2 diabetes also had acanthosis nigricans on the back of their necks (Endocr. Pract. 2004;10:101–6). Investigators at the University of Texas Southwestern in Dallas found risk varied by body mass index and ethnicity in this retrospective study. “They found those who had acanthosis nigricans were most often insulin resistant, overweight, and more of them were people of color,” Dr. Callen said. For example, 50 of 95 African American and 28 of 78 Hispanic diabetics in the study had acanthosis nigricans, compared with 1 of 39 whites and 0 of 4 Asians.

More recently, researchers found a higher prevalence of insulin resistance among obese women with acanthosis nigricans, compared with others without the skin hyperpigmentation (J. Dermatol. 2009;36:209–12). Specifically, 5 of 32 participants (16%) with acanthosis nigricans had insulin resistance, compared with none of the 34 women without the dermatologic condition.

Acanthosis nigricans is a clinical diagnosis and histopathology generally is not required. Affected patients often come to a dermatologist “because they've noticed this hyperpigmentation on folded areas of the skin—the back of the neck or under the arms.” Although Dr. Callen sometimes orders fasting and postprandial insulin levels for patients with acanthosis nigricans, he thought most dermatologists would refer a patient for further work-up.

Dr. Callen disclosed no relevant conflicts of interest. SDEF and this news organization are owned by Elsevier.

To see a video of Dr. Callen discussing this association, visit www.youtube.com/SkinAndAllergyNews

SAN FRANCISCO — Because children generally respond better to vitiligo interventions than adults, early recognition and treatment are crucial, Dr. Pearl E. Grimes said.

"These patients need you. I strongly encourage you to be a little more aggressive when children with vitiligo come into your practice," Dr. Grimes said at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"This is one of the tragedies of not treating kids; if I compare every therapy—grafting, steroids, [psoralen plus ultraviolet A]—children for some reason give you an enhanced clinical response and are able to maintain pigmentation for a long time," Dr. Grimes said.

Stabilization, repigmentation, psychological well-being, and improved quality of life are among the goals of childhood vitiligo treatment.

"I work very hard in my patients to attain stabilization, which is just as important as repigmentation," Dr. Grimes said. She also evaluates the child with vitiligo for associated diseases. For example, it is important to check for chronic autoimmune disorders, especially Hashimoto thyroiditis, she said.

"Often we as dermatologists are the ones who establish this diagnosis," said Dr. Grimes, director of the Vitiligo and Pigmentation Institute of Southern California in Los Angeles.

Hyperthyroidism, hypothyroidism, diabetes, rheumatoid arthritis, and alopecia areata also occur with vitiligo. She recommended thyroid-stimulating hormone and thyroid peroxidase antibody testing at a minimum, as well as regular testing for thyroid microsomal and antinuclear antibodies.

Dr. Grimes emphasized the importance of psychological counseling for children with vitiligo. "Some of these kids really do need to be referred … to help them cope with the burden of this disease," she said. Without proper counseling, "they become 'fossilized' in the pain of the disease and carry it to their adult lives," added Dr. Grimes, also of the dermatology department at the University of California, Los Angeles.

There are multiple subtypes of vitiligo. Children have an increased prevalence of segmental vitiligo, compared with adults "and that can be a good thing," Dr. Grimes said. This subtype typically becomes quiescent in 95% of children within 6–12 months.

More good news is that autologous skin grafting can be very effective for segmental vitiligo. "I really believe this is the only type of vitiligo where I have the potential to cure it," Dr. Grimes said.

Corticosteroids, topical immunomodulators, narrow-band UVB phototherapy, targeted light and laser therapy, phototherapy, and surgery are other options. Topical steroid therapy is "the absolute mainstay" for a child with limited body surface involvement, she said.

Calcineurin inhibitors are moving to the forefront of therapy for vitiligo. Current data suggest that tacrolimus and pimecrolimus are appropriate for patients with limited involvement, Dr. Grimes said. She has performed clinical trials of Protopic (tacrolimus) for Astellas.

In general, the calcineurin inhibitors are well tolerated, Dr. Grimes said. However, "I am very cautious. I do not use [them] in combination with narrow-band UVB." Prescription of these agents also requires more counseling time with parents to review the black box warning.

SDEF and this news organization are owned by Elsevier.

For more on antioxidants, nutrition, and other aspects of childhood vitiligo, see a video interview with Dr. Grimes at www.youtube.com/SkinAndAllergyNews

'I work very hard in my patients to attain stabilization, which is just as important as repigmentation.'

Source DR. GRIMES

SAN FRANCISCO — Because children generally respond better to vitiligo interventions than adults, early recognition and treatment are crucial, Dr. Pearl E. Grimes said.

"These patients need you. I strongly encourage you to be a little more aggressive when children with vitiligo come into your practice," Dr. Grimes said at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"This is one of the tragedies of not treating kids; if I compare every therapy—grafting, steroids, [psoralen plus ultraviolet A]—children for some reason give you an enhanced clinical response and are able to maintain pigmentation for a long time," Dr. Grimes said.

Stabilization, repigmentation, psychological well-being, and improved quality of life are among the goals of childhood vitiligo treatment.

"I work very hard in my patients to attain stabilization, which is just as important as repigmentation," Dr. Grimes said. She also evaluates the child with vitiligo for associated diseases. For example, it is important to check for chronic autoimmune disorders, especially Hashimoto thyroiditis, she said.

"Often we as dermatologists are the ones who establish this diagnosis," said Dr. Grimes, director of the Vitiligo and Pigmentation Institute of Southern California in Los Angeles.

Hyperthyroidism, hypothyroidism, diabetes, rheumatoid arthritis, and alopecia areata also occur with vitiligo. She recommended thyroid-stimulating hormone and thyroid peroxidase antibody testing at a minimum, as well as regular testing for thyroid microsomal and antinuclear antibodies.

Dr. Grimes emphasized the importance of psychological counseling for children with vitiligo. "Some of these kids really do need to be referred … to help them cope with the burden of this disease," she said. Without proper counseling, "they become 'fossilized' in the pain of the disease and carry it to their adult lives," added Dr. Grimes, also of the dermatology department at the University of California, Los Angeles.

There are multiple subtypes of vitiligo. Children have an increased prevalence of segmental vitiligo, compared with adults "and that can be a good thing," Dr. Grimes said. This subtype typically becomes quiescent in 95% of children within 6–12 months.

More good news is that autologous skin grafting can be very effective for segmental vitiligo. "I really believe this is the only type of vitiligo where I have the potential to cure it," Dr. Grimes said.

Corticosteroids, topical immunomodulators, narrow-band UVB phototherapy, targeted light and laser therapy, phototherapy, and surgery are other options. Topical steroid therapy is "the absolute mainstay" for a child with limited body surface involvement, she said.

Calcineurin inhibitors are moving to the forefront of therapy for vitiligo. Current data suggest that tacrolimus and pimecrolimus are appropriate for patients with limited involvement, Dr. Grimes said. She has performed clinical trials of Protopic (tacrolimus) for Astellas.

In general, the calcineurin inhibitors are well tolerated, Dr. Grimes said. However, "I am very cautious. I do not use [them] in combination with narrow-band UVB." Prescription of these agents also requires more counseling time with parents to review the black box warning.

SDEF and this news organization are owned by Elsevier.

For more on antioxidants, nutrition, and other aspects of childhood vitiligo, see a video interview with Dr. Grimes at www.youtube.com/SkinAndAllergyNews

'I work very hard in my patients to attain stabilization, which is just as important as repigmentation.'

Source DR. GRIMES

SAN FRANCISCO — Because children generally respond better to vitiligo interventions than adults, early recognition and treatment are crucial, Dr. Pearl E. Grimes said.

"These patients need you. I strongly encourage you to be a little more aggressive when children with vitiligo come into your practice," Dr. Grimes said at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"This is one of the tragedies of not treating kids; if I compare every therapy—grafting, steroids, [psoralen plus ultraviolet A]—children for some reason give you an enhanced clinical response and are able to maintain pigmentation for a long time," Dr. Grimes said.

Stabilization, repigmentation, psychological well-being, and improved quality of life are among the goals of childhood vitiligo treatment.

"I work very hard in my patients to attain stabilization, which is just as important as repigmentation," Dr. Grimes said. She also evaluates the child with vitiligo for associated diseases. For example, it is important to check for chronic autoimmune disorders, especially Hashimoto thyroiditis, she said.

"Often we as dermatologists are the ones who establish this diagnosis," said Dr. Grimes, director of the Vitiligo and Pigmentation Institute of Southern California in Los Angeles.

Hyperthyroidism, hypothyroidism, diabetes, rheumatoid arthritis, and alopecia areata also occur with vitiligo. She recommended thyroid-stimulating hormone and thyroid peroxidase antibody testing at a minimum, as well as regular testing for thyroid microsomal and antinuclear antibodies.

Dr. Grimes emphasized the importance of psychological counseling for children with vitiligo. "Some of these kids really do need to be referred … to help them cope with the burden of this disease," she said. Without proper counseling, "they become 'fossilized' in the pain of the disease and carry it to their adult lives," added Dr. Grimes, also of the dermatology department at the University of California, Los Angeles.

There are multiple subtypes of vitiligo. Children have an increased prevalence of segmental vitiligo, compared with adults "and that can be a good thing," Dr. Grimes said. This subtype typically becomes quiescent in 95% of children within 6–12 months.

More good news is that autologous skin grafting can be very effective for segmental vitiligo. "I really believe this is the only type of vitiligo where I have the potential to cure it," Dr. Grimes said.

Corticosteroids, topical immunomodulators, narrow-band UVB phototherapy, targeted light and laser therapy, phototherapy, and surgery are other options. Topical steroid therapy is "the absolute mainstay" for a child with limited body surface involvement, she said.

Calcineurin inhibitors are moving to the forefront of therapy for vitiligo. Current data suggest that tacrolimus and pimecrolimus are appropriate for patients with limited involvement, Dr. Grimes said. She has performed clinical trials of Protopic (tacrolimus) for Astellas.

In general, the calcineurin inhibitors are well tolerated, Dr. Grimes said. However, "I am very cautious. I do not use [them] in combination with narrow-band UVB." Prescription of these agents also requires more counseling time with parents to review the black box warning.

SDEF and this news organization are owned by Elsevier.

For more on antioxidants, nutrition, and other aspects of childhood vitiligo, see a video interview with Dr. Grimes at www.youtube.com/SkinAndAllergyNews

'I work very hard in my patients to attain stabilization, which is just as important as repigmentation.'

Source DR. GRIMES

SAN FRANCISCO — Start simple and use a step-wise approach to treat children with atopic dermatitis, Dr. Sheila Fallon Friedlander recommended.

“Atopic dermatitis matters so much because it can become infected, can impair physical and psychologic function, and has a tremendous effect on family quality of life,” Dr. Friedlander said at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.

Using a ladder analogy, start at the bottom with repair of the skin barrier. The next rung is an intervention to short circuit inflammation. Then take care of itching, treat infections, address triggers, and educate patients and their family.

Is the family compliant? “This is extremely important. You need to get family to buy in to a treatment plan that is often complicated,” said Dr. Friedlander of the University of California, San Diego.

Consider the age of the child, severity and duration of disease, and how much body surface area is affected.

Bathing can be beneficial to atopic skin if it hydrates the stratum corneum and removes dirt, scales, and bugs, but breaks in the skin can occur during evaporation, so bathing and moisturizers together are better than either alone, Dr. Friedlander said.

She is a fan of ceramide-based creams for atopic dermatitis. “Ceramides can decrease the amount of steroid you use or perhaps you can use [them] instead of steroids and do as well,” she said.

If barrier repair does not work, the next step of the ladder is short circuiting inflammation. With corticosteroids for atopic dermatitis, use the weakest strength to do the job, blast and taper off, or consider weekend pulses of high potency steroids.

Topical calcineurin inhibitors are another therapeutic option. “There are a lot of data out there, so we know a lot about them,” she said.

Dr. Friedlander's relevant disclosures include being a consultant for Astellas, Graceway Pharmaceuticals, and Novartis. She also receives research support from Astellas, Novartis, Promius Pharma, and SkinMedica. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO — Start simple and use a step-wise approach to treat children with atopic dermatitis, Dr. Sheila Fallon Friedlander recommended.

“Atopic dermatitis matters so much because it can become infected, can impair physical and psychologic function, and has a tremendous effect on family quality of life,” Dr. Friedlander said at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.

Using a ladder analogy, start at the bottom with repair of the skin barrier. The next rung is an intervention to short circuit inflammation. Then take care of itching, treat infections, address triggers, and educate patients and their family.

Is the family compliant? “This is extremely important. You need to get family to buy in to a treatment plan that is often complicated,” said Dr. Friedlander of the University of California, San Diego.

Consider the age of the child, severity and duration of disease, and how much body surface area is affected.

Bathing can be beneficial to atopic skin if it hydrates the stratum corneum and removes dirt, scales, and bugs, but breaks in the skin can occur during evaporation, so bathing and moisturizers together are better than either alone, Dr. Friedlander said.

She is a fan of ceramide-based creams for atopic dermatitis. “Ceramides can decrease the amount of steroid you use or perhaps you can use [them] instead of steroids and do as well,” she said.

If barrier repair does not work, the next step of the ladder is short circuiting inflammation. With corticosteroids for atopic dermatitis, use the weakest strength to do the job, blast and taper off, or consider weekend pulses of high potency steroids.

Topical calcineurin inhibitors are another therapeutic option. “There are a lot of data out there, so we know a lot about them,” she said.

Dr. Friedlander's relevant disclosures include being a consultant for Astellas, Graceway Pharmaceuticals, and Novartis. She also receives research support from Astellas, Novartis, Promius Pharma, and SkinMedica. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO — Start simple and use a step-wise approach to treat children with atopic dermatitis, Dr. Sheila Fallon Friedlander recommended.

“Atopic dermatitis matters so much because it can become infected, can impair physical and psychologic function, and has a tremendous effect on family quality of life,” Dr. Friedlander said at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.

Using a ladder analogy, start at the bottom with repair of the skin barrier. The next rung is an intervention to short circuit inflammation. Then take care of itching, treat infections, address triggers, and educate patients and their family.

Is the family compliant? “This is extremely important. You need to get family to buy in to a treatment plan that is often complicated,” said Dr. Friedlander of the University of California, San Diego.

Consider the age of the child, severity and duration of disease, and how much body surface area is affected.

Bathing can be beneficial to atopic skin if it hydrates the stratum corneum and removes dirt, scales, and bugs, but breaks in the skin can occur during evaporation, so bathing and moisturizers together are better than either alone, Dr. Friedlander said.

She is a fan of ceramide-based creams for atopic dermatitis. “Ceramides can decrease the amount of steroid you use or perhaps you can use [them] instead of steroids and do as well,” she said.

If barrier repair does not work, the next step of the ladder is short circuiting inflammation. With corticosteroids for atopic dermatitis, use the weakest strength to do the job, blast and taper off, or consider weekend pulses of high potency steroids.

Topical calcineurin inhibitors are another therapeutic option. “There are a lot of data out there, so we know a lot about them,” she said.

Dr. Friedlander's relevant disclosures include being a consultant for Astellas, Graceway Pharmaceuticals, and Novartis. She also receives research support from Astellas, Novartis, Promius Pharma, and SkinMedica. SDEF and this news organization are owned by Elsevier.