Diana Mahoney

BOSTON — A light-based therapy commonly used in cosmetic dermatology minimizes the occurrence and symptom intensity of radiation-induced dermatitis in breast cancer patients undergoing radiation treatment, according to the results of a recent investigation. The preventive therapy not only minimizes patient discomfort, but also prevents treatment interruptions necessitated by severe skin reactions, said Dr. M. Maitland DeLand at the annual meeting of the American Society for Laser Medicine and Surgery.

Postradiation dermatitis can include reactions ranging from mild to moderate dryness and peeling to significant erythema, hyperemia, and moist desquamation with loss of epidermal barrier, said Dr. DeLand, a radiation oncologist in Lafayette, La. The investigators hypothesized that targeting these areas with pulses of nonthermal low-energy light via arrays of light-emitting diodes (LED) would interrupt the postradiation inflammatory process and stimulate collagen synthesis, and by so doing strengthen the skin's defenses, she said.

In the pilot study, 18 of 19 women who received LED photomodulation therapy following radiotherapy for breast cancer experienced little to no radiation dermatitis, whereas all 28 matched controls who did not receive the light therapy experienced some degree of skin reaction, reported Dr. DeLand.

The women in the study were 35–80 years old. Prior to radiation therapy, all had undergone single lymph node sampling or axillary dissection; some had chemotherapy. The women in the photomodulation group received the LED treatment immediately following their daily radiation therapy, and were allowed to use a neutral pH ointment for dry skin after each session. The women in the control group followed the same radiation therapy protocol without the LED follow-up, and were also allowed to use the ointment.

Of the 19 women in the treatment group, 7 had no skin reactions, 11 had grade 1 reactions, and 1 patient had a grade 2 reaction. In contrast, 4 of the control patients had grade 1 reactions, 18 had grade 2 reactions, and 6 had grade 3 reactions. In the control group, the skin reactions—specifically, severe erythema and moist desquamation—led to treatment interruptions in 19 patients.

“Only one patient in the [treatment group] had a reaction severe enough to interrupt therapy,” Dr. DeLand said. “This is an important finding, because the efficacy of radiation therapy is based on a dose/time relationship. You really want to avoid treatment disruptions” to achieve the best biologic response, she said.

The LED therapy also appeared to provide long-lasting skin benefits. At 3 and 6 months post therapy, the skin texture and pigment of irradiated areas in the women in the treatment group were “excellent,” the breast tissue was smooth and supple, and the surgical scars were “barely visible,” Dr. DeLand said. In contrast, the women in the control group showed typical signs of late radiation effects, including some atrophy and pigmentary changes and, in some cases, radiation-induced fibrosis, edema, and dermal thickening, she said.

Because LED therapy is “quick, painless, and effective,” the treatment option should be made available to all women undergoing breast irradiation, Dr. DeLand concluded.

She reported receiving free use of the device for the investigation but has no financial interest in the manufacturer.

BOSTON — A light-based therapy commonly used in cosmetic dermatology minimizes the occurrence and symptom intensity of radiation-induced dermatitis in breast cancer patients undergoing radiation treatment, according to the results of a recent investigation. The preventive therapy not only minimizes patient discomfort, but also prevents treatment interruptions necessitated by severe skin reactions, said Dr. M. Maitland DeLand at the annual meeting of the American Society for Laser Medicine and Surgery.

Postradiation dermatitis can include reactions ranging from mild to moderate dryness and peeling to significant erythema, hyperemia, and moist desquamation with loss of epidermal barrier, said Dr. DeLand, a radiation oncologist in Lafayette, La. The investigators hypothesized that targeting these areas with pulses of nonthermal low-energy light via arrays of light-emitting diodes (LED) would interrupt the postradiation inflammatory process and stimulate collagen synthesis, and by so doing strengthen the skin's defenses, she said.

In the pilot study, 18 of 19 women who received LED photomodulation therapy following radiotherapy for breast cancer experienced little to no radiation dermatitis, whereas all 28 matched controls who did not receive the light therapy experienced some degree of skin reaction, reported Dr. DeLand.

The women in the study were 35–80 years old. Prior to radiation therapy, all had undergone single lymph node sampling or axillary dissection; some had chemotherapy. The women in the photomodulation group received the LED treatment immediately following their daily radiation therapy, and were allowed to use a neutral pH ointment for dry skin after each session. The women in the control group followed the same radiation therapy protocol without the LED follow-up, and were also allowed to use the ointment.

Of the 19 women in the treatment group, 7 had no skin reactions, 11 had grade 1 reactions, and 1 patient had a grade 2 reaction. In contrast, 4 of the control patients had grade 1 reactions, 18 had grade 2 reactions, and 6 had grade 3 reactions. In the control group, the skin reactions—specifically, severe erythema and moist desquamation—led to treatment interruptions in 19 patients.

“Only one patient in the [treatment group] had a reaction severe enough to interrupt therapy,” Dr. DeLand said. “This is an important finding, because the efficacy of radiation therapy is based on a dose/time relationship. You really want to avoid treatment disruptions” to achieve the best biologic response, she said.

The LED therapy also appeared to provide long-lasting skin benefits. At 3 and 6 months post therapy, the skin texture and pigment of irradiated areas in the women in the treatment group were “excellent,” the breast tissue was smooth and supple, and the surgical scars were “barely visible,” Dr. DeLand said. In contrast, the women in the control group showed typical signs of late radiation effects, including some atrophy and pigmentary changes and, in some cases, radiation-induced fibrosis, edema, and dermal thickening, she said.

Because LED therapy is “quick, painless, and effective,” the treatment option should be made available to all women undergoing breast irradiation, Dr. DeLand concluded.

She reported receiving free use of the device for the investigation but has no financial interest in the manufacturer.

BOSTON — A light-based therapy commonly used in cosmetic dermatology minimizes the occurrence and symptom intensity of radiation-induced dermatitis in breast cancer patients undergoing radiation treatment, according to the results of a recent investigation. The preventive therapy not only minimizes patient discomfort, but also prevents treatment interruptions necessitated by severe skin reactions, said Dr. M. Maitland DeLand at the annual meeting of the American Society for Laser Medicine and Surgery.

Postradiation dermatitis can include reactions ranging from mild to moderate dryness and peeling to significant erythema, hyperemia, and moist desquamation with loss of epidermal barrier, said Dr. DeLand, a radiation oncologist in Lafayette, La. The investigators hypothesized that targeting these areas with pulses of nonthermal low-energy light via arrays of light-emitting diodes (LED) would interrupt the postradiation inflammatory process and stimulate collagen synthesis, and by so doing strengthen the skin's defenses, she said.

In the pilot study, 18 of 19 women who received LED photomodulation therapy following radiotherapy for breast cancer experienced little to no radiation dermatitis, whereas all 28 matched controls who did not receive the light therapy experienced some degree of skin reaction, reported Dr. DeLand.

The women in the study were 35–80 years old. Prior to radiation therapy, all had undergone single lymph node sampling or axillary dissection; some had chemotherapy. The women in the photomodulation group received the LED treatment immediately following their daily radiation therapy, and were allowed to use a neutral pH ointment for dry skin after each session. The women in the control group followed the same radiation therapy protocol without the LED follow-up, and were also allowed to use the ointment.

Of the 19 women in the treatment group, 7 had no skin reactions, 11 had grade 1 reactions, and 1 patient had a grade 2 reaction. In contrast, 4 of the control patients had grade 1 reactions, 18 had grade 2 reactions, and 6 had grade 3 reactions. In the control group, the skin reactions—specifically, severe erythema and moist desquamation—led to treatment interruptions in 19 patients.

“Only one patient in the [treatment group] had a reaction severe enough to interrupt therapy,” Dr. DeLand said. “This is an important finding, because the efficacy of radiation therapy is based on a dose/time relationship. You really want to avoid treatment disruptions” to achieve the best biologic response, she said.

The LED therapy also appeared to provide long-lasting skin benefits. At 3 and 6 months post therapy, the skin texture and pigment of irradiated areas in the women in the treatment group were “excellent,” the breast tissue was smooth and supple, and the surgical scars were “barely visible,” Dr. DeLand said. In contrast, the women in the control group showed typical signs of late radiation effects, including some atrophy and pigmentary changes and, in some cases, radiation-induced fibrosis, edema, and dermal thickening, she said.

Because LED therapy is “quick, painless, and effective,” the treatment option should be made available to all women undergoing breast irradiation, Dr. DeLand concluded.

She reported receiving free use of the device for the investigation but has no financial interest in the manufacturer.

DALLAS — The steep decline in antireflux surgery since the 1990s may be caused by skepticism following publication of a study suggesting that most patients who undergo surgery eventually resume taking antireflux medication, said Dr. Jonathan F. Finks at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“Antireflux surgery took off in the 1990s, in large part because of the introduction of the laparoscopic Nissen fundoplication procedure,” said Dr. Finks of the division of gastrointestinal surgery at the University of Michigan in Ann Arbor.

Based on data obtained from the Nationwide Inpatient Sample, the number of patients older than age 18 who underwent antireflux surgery in the United States reached a peak at 32,907 in the year 2000. By 2003, the number undergoing surgery fell 27% to 23,998 patients.

“The rate of decline was approximately three times greater for patients in the 30- to 50-year-old age range than it was for patients older than 60,” Dr. Finks reported.

The discrepancy between the two age groups may be explained by an increased likelihood on the part of gastroenterologists to recommend surgery for patients who have had problems for a longer time and who have not attained sufficient relief from medication.

On the heels of the antireflux surgery boom, results of a 2-year randomized controlled trial comparing surgical and medical management of gastroesophageal reflux disease (GERD) were published (JAMA 2001;285:2331–8). The study showed that although patients in the surgical treatment group were less likely to regularly use antireflux medications than were patients in the medical antireflux therapy group, the use of antireflux medication in the surgical group was still substantial.

In addition, there were no differences between the treatment groups in esophagitis grade, incidence of esophageal cancer, frequency of treatment of esophageal stricture, subsequent antireflux operations, or satisfaction with antireflux therapy.

The findings did not question the efficacy of antireflux surgery—which continues to be performed primarily via laparoscopic techniques, according to the data—but rather the supremacy of surgery over other management options, said Dr. Finks.

“Surgery is considered effective, with stable and low mortality and splenectomy rates, and it is associated with good patient satisfaction, but the study findings gave cause to gastroenterologists to reconsider the indications for surgery,” he said.

Surgical intervention may have declined in recent years in part because of the availability of several new endoscopic therapies and increased access to proton pump inhibiting medications, which are inexpensive and available over the counter, he noted.

Reliance on Nationwide Inpatient Sample data might not provide an accurate accounting of the surgical intervention rates, noted Dr. Finks.

“It only represents inpatient procedures, but the trends have been observed in other investigations,” Dr. Finks said.

The bottom line, he said, is that both surgical and medical management of gastrointestinal reflux are reasonable options, but the decision on which approach to use should be based on an assessment of the risks and benefits for individual patients.

The findings do suggest “the need for prospective randomized clinical trials assessing the short- and long-term effectiveness of the range of current therapies,” Dr. Finks concluded.

Dr. Finks reported no conflicts of interest with respect to his presentation.

DALLAS — The steep decline in antireflux surgery since the 1990s may be caused by skepticism following publication of a study suggesting that most patients who undergo surgery eventually resume taking antireflux medication, said Dr. Jonathan F. Finks at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“Antireflux surgery took off in the 1990s, in large part because of the introduction of the laparoscopic Nissen fundoplication procedure,” said Dr. Finks of the division of gastrointestinal surgery at the University of Michigan in Ann Arbor.

Based on data obtained from the Nationwide Inpatient Sample, the number of patients older than age 18 who underwent antireflux surgery in the United States reached a peak at 32,907 in the year 2000. By 2003, the number undergoing surgery fell 27% to 23,998 patients.

“The rate of decline was approximately three times greater for patients in the 30- to 50-year-old age range than it was for patients older than 60,” Dr. Finks reported.

The discrepancy between the two age groups may be explained by an increased likelihood on the part of gastroenterologists to recommend surgery for patients who have had problems for a longer time and who have not attained sufficient relief from medication.

On the heels of the antireflux surgery boom, results of a 2-year randomized controlled trial comparing surgical and medical management of gastroesophageal reflux disease (GERD) were published (JAMA 2001;285:2331–8). The study showed that although patients in the surgical treatment group were less likely to regularly use antireflux medications than were patients in the medical antireflux therapy group, the use of antireflux medication in the surgical group was still substantial.

In addition, there were no differences between the treatment groups in esophagitis grade, incidence of esophageal cancer, frequency of treatment of esophageal stricture, subsequent antireflux operations, or satisfaction with antireflux therapy.

The findings did not question the efficacy of antireflux surgery—which continues to be performed primarily via laparoscopic techniques, according to the data—but rather the supremacy of surgery over other management options, said Dr. Finks.

“Surgery is considered effective, with stable and low mortality and splenectomy rates, and it is associated with good patient satisfaction, but the study findings gave cause to gastroenterologists to reconsider the indications for surgery,” he said.

Surgical intervention may have declined in recent years in part because of the availability of several new endoscopic therapies and increased access to proton pump inhibiting medications, which are inexpensive and available over the counter, he noted.

Reliance on Nationwide Inpatient Sample data might not provide an accurate accounting of the surgical intervention rates, noted Dr. Finks.

“It only represents inpatient procedures, but the trends have been observed in other investigations,” Dr. Finks said.

The bottom line, he said, is that both surgical and medical management of gastrointestinal reflux are reasonable options, but the decision on which approach to use should be based on an assessment of the risks and benefits for individual patients.

The findings do suggest “the need for prospective randomized clinical trials assessing the short- and long-term effectiveness of the range of current therapies,” Dr. Finks concluded.

Dr. Finks reported no conflicts of interest with respect to his presentation.

DALLAS — The steep decline in antireflux surgery since the 1990s may be caused by skepticism following publication of a study suggesting that most patients who undergo surgery eventually resume taking antireflux medication, said Dr. Jonathan F. Finks at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“Antireflux surgery took off in the 1990s, in large part because of the introduction of the laparoscopic Nissen fundoplication procedure,” said Dr. Finks of the division of gastrointestinal surgery at the University of Michigan in Ann Arbor.

Based on data obtained from the Nationwide Inpatient Sample, the number of patients older than age 18 who underwent antireflux surgery in the United States reached a peak at 32,907 in the year 2000. By 2003, the number undergoing surgery fell 27% to 23,998 patients.

“The rate of decline was approximately three times greater for patients in the 30- to 50-year-old age range than it was for patients older than 60,” Dr. Finks reported.

The discrepancy between the two age groups may be explained by an increased likelihood on the part of gastroenterologists to recommend surgery for patients who have had problems for a longer time and who have not attained sufficient relief from medication.

On the heels of the antireflux surgery boom, results of a 2-year randomized controlled trial comparing surgical and medical management of gastroesophageal reflux disease (GERD) were published (JAMA 2001;285:2331–8). The study showed that although patients in the surgical treatment group were less likely to regularly use antireflux medications than were patients in the medical antireflux therapy group, the use of antireflux medication in the surgical group was still substantial.

In addition, there were no differences between the treatment groups in esophagitis grade, incidence of esophageal cancer, frequency of treatment of esophageal stricture, subsequent antireflux operations, or satisfaction with antireflux therapy.

The findings did not question the efficacy of antireflux surgery—which continues to be performed primarily via laparoscopic techniques, according to the data—but rather the supremacy of surgery over other management options, said Dr. Finks.

“Surgery is considered effective, with stable and low mortality and splenectomy rates, and it is associated with good patient satisfaction, but the study findings gave cause to gastroenterologists to reconsider the indications for surgery,” he said.

Surgical intervention may have declined in recent years in part because of the availability of several new endoscopic therapies and increased access to proton pump inhibiting medications, which are inexpensive and available over the counter, he noted.

Reliance on Nationwide Inpatient Sample data might not provide an accurate accounting of the surgical intervention rates, noted Dr. Finks.

“It only represents inpatient procedures, but the trends have been observed in other investigations,” Dr. Finks said.

The bottom line, he said, is that both surgical and medical management of gastrointestinal reflux are reasonable options, but the decision on which approach to use should be based on an assessment of the risks and benefits for individual patients.

The findings do suggest “the need for prospective randomized clinical trials assessing the short- and long-term effectiveness of the range of current therapies,” Dr. Finks concluded.

Dr. Finks reported no conflicts of interest with respect to his presentation.

STOWE, VT. — Tangential excision is a reliable, expedient alternative to conventional excision for most basal cell carcinomas on the trunk, Dr. Glenn Goldman said at a dermatology conference sponsored by the University of Vermont.

Curettage is "relatively unreliable for most basal cell carcinomas" because it is associated with a higher level of recurrence, said Dr. Goldman of the division of dermatology at the university.

"I love curetting seborrheic keratoses, squamous cell carcinoma in situ without follicular involvement, and really tiny red-skinned basal cell carcinomas, but for basal cell carcinomas that have a little bit of substance to them, [curettage] is not the best approach," he said.

On the other hand, conventional excision is surgical overkill for most basal cell carcinomas. "Most 'invasive' and even 'infiltrative' basal cell carcinomas on truncal extremities are shallow lesions, typically about 0.1 or 0.2 mm. If you do a standard excision on the back, you're cutting through centimeters of tissue in order to close the wound that really only needs to be a millimeter deep," he explained.

For tangential excision, a scalpel is used to shave a partial thickness of the dermis that includes the entire lesion. The approach "is much faster than curettage," Dr. Goldman said.

"I can do a tangential excision in one-quarter of the time it would take to curette the basal cell carcinoma. Also, tangential excision has a high cure rate, and there's no restriction on patient activity." Although tangential excisions on the trunk and extremities heal slowly, he noted, "the long-term scar is subtle."

Tangential excision also provides pathology samples of the lesions. "I send these to the lab and the pathologists do sections on them from one end to the other and provide a full pathology report with extent to margin information and so forth," Dr. Goldman said. "In my practice, this technique has been consistently successful. I've done hundreds of these and have only had two positive margins."

Performing a tangential excision takes "a bit of technique," he noted. The first step is to prep the area with alcohol and meticulously outline the lesion. After numbing the area with local anesthesia, he uses "a number 15 blade to make an incision in the papillary dermis. Next, take the blade and peel the lesion off like a shave biopsy. Toss it into a pathology bottle and there it is," he said.

After the procedure, apply pressure to the area to stop the bleeding. "Sometimes I add a little bit of aluminum chloride, but I don't ever cauterize," Dr. Goldman added.

In terms of billing for the procedure, "it's not a destruction, so it can't be billed that way, and it's not an excision because you don't penetrate to fat," he said. "You can bill it as a shave. … You may have to argue it a bit, but I've talked this over with our Medicare provider, and it is appropriate. You could also bill it as a biopsy," he said.

"One of the reasons I believe in this technique is that every patient I've ever seen who's come to me from somewhere else with hundreds of basal cells and many that have recurred after removal has not had any recurrences of the lesions I've taken off this way," Dr. Goldman concluded.

STOWE, VT. — Tangential excision is a reliable, expedient alternative to conventional excision for most basal cell carcinomas on the trunk, Dr. Glenn Goldman said at a dermatology conference sponsored by the University of Vermont.

Curettage is "relatively unreliable for most basal cell carcinomas" because it is associated with a higher level of recurrence, said Dr. Goldman of the division of dermatology at the university.

"I love curetting seborrheic keratoses, squamous cell carcinoma in situ without follicular involvement, and really tiny red-skinned basal cell carcinomas, but for basal cell carcinomas that have a little bit of substance to them, [curettage] is not the best approach," he said.

On the other hand, conventional excision is surgical overkill for most basal cell carcinomas. "Most 'invasive' and even 'infiltrative' basal cell carcinomas on truncal extremities are shallow lesions, typically about 0.1 or 0.2 mm. If you do a standard excision on the back, you're cutting through centimeters of tissue in order to close the wound that really only needs to be a millimeter deep," he explained.

For tangential excision, a scalpel is used to shave a partial thickness of the dermis that includes the entire lesion. The approach "is much faster than curettage," Dr. Goldman said.

"I can do a tangential excision in one-quarter of the time it would take to curette the basal cell carcinoma. Also, tangential excision has a high cure rate, and there's no restriction on patient activity." Although tangential excisions on the trunk and extremities heal slowly, he noted, "the long-term scar is subtle."

Tangential excision also provides pathology samples of the lesions. "I send these to the lab and the pathologists do sections on them from one end to the other and provide a full pathology report with extent to margin information and so forth," Dr. Goldman said. "In my practice, this technique has been consistently successful. I've done hundreds of these and have only had two positive margins."

Performing a tangential excision takes "a bit of technique," he noted. The first step is to prep the area with alcohol and meticulously outline the lesion. After numbing the area with local anesthesia, he uses "a number 15 blade to make an incision in the papillary dermis. Next, take the blade and peel the lesion off like a shave biopsy. Toss it into a pathology bottle and there it is," he said.

After the procedure, apply pressure to the area to stop the bleeding. "Sometimes I add a little bit of aluminum chloride, but I don't ever cauterize," Dr. Goldman added.

In terms of billing for the procedure, "it's not a destruction, so it can't be billed that way, and it's not an excision because you don't penetrate to fat," he said. "You can bill it as a shave. … You may have to argue it a bit, but I've talked this over with our Medicare provider, and it is appropriate. You could also bill it as a biopsy," he said.

"One of the reasons I believe in this technique is that every patient I've ever seen who's come to me from somewhere else with hundreds of basal cells and many that have recurred after removal has not had any recurrences of the lesions I've taken off this way," Dr. Goldman concluded.

STOWE, VT. — Tangential excision is a reliable, expedient alternative to conventional excision for most basal cell carcinomas on the trunk, Dr. Glenn Goldman said at a dermatology conference sponsored by the University of Vermont.

Curettage is "relatively unreliable for most basal cell carcinomas" because it is associated with a higher level of recurrence, said Dr. Goldman of the division of dermatology at the university.

"I love curetting seborrheic keratoses, squamous cell carcinoma in situ without follicular involvement, and really tiny red-skinned basal cell carcinomas, but for basal cell carcinomas that have a little bit of substance to them, [curettage] is not the best approach," he said.

On the other hand, conventional excision is surgical overkill for most basal cell carcinomas. "Most 'invasive' and even 'infiltrative' basal cell carcinomas on truncal extremities are shallow lesions, typically about 0.1 or 0.2 mm. If you do a standard excision on the back, you're cutting through centimeters of tissue in order to close the wound that really only needs to be a millimeter deep," he explained.

For tangential excision, a scalpel is used to shave a partial thickness of the dermis that includes the entire lesion. The approach "is much faster than curettage," Dr. Goldman said.

"I can do a tangential excision in one-quarter of the time it would take to curette the basal cell carcinoma. Also, tangential excision has a high cure rate, and there's no restriction on patient activity." Although tangential excisions on the trunk and extremities heal slowly, he noted, "the long-term scar is subtle."

Tangential excision also provides pathology samples of the lesions. "I send these to the lab and the pathologists do sections on them from one end to the other and provide a full pathology report with extent to margin information and so forth," Dr. Goldman said. "In my practice, this technique has been consistently successful. I've done hundreds of these and have only had two positive margins."

Performing a tangential excision takes "a bit of technique," he noted. The first step is to prep the area with alcohol and meticulously outline the lesion. After numbing the area with local anesthesia, he uses "a number 15 blade to make an incision in the papillary dermis. Next, take the blade and peel the lesion off like a shave biopsy. Toss it into a pathology bottle and there it is," he said.

After the procedure, apply pressure to the area to stop the bleeding. "Sometimes I add a little bit of aluminum chloride, but I don't ever cauterize," Dr. Goldman added.

In terms of billing for the procedure, "it's not a destruction, so it can't be billed that way, and it's not an excision because you don't penetrate to fat," he said. "You can bill it as a shave. … You may have to argue it a bit, but I've talked this over with our Medicare provider, and it is appropriate. You could also bill it as a biopsy," he said.

"One of the reasons I believe in this technique is that every patient I've ever seen who's come to me from somewhere else with hundreds of basal cells and many that have recurred after removal has not had any recurrences of the lesions I've taken off this way," Dr. Goldman concluded.

BOSTON — The ability to shift wavelength emissions "on the fly" makes infrared flashlamp technology a safe and effective option for hair removal in all skin types, Dr. E. Victor Ross said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 63 patients ranging in age from 16 to 50 years with Fitzpatrick skin types I-VI, laser hair removal with the Cutera ProWave 770 cooled sapphire infrared flashlamp handpiece resulted in a mean hair reduction 2 months after the final treatment of 35%–67%, depending on skin type, said Dr. Ross of the Naval Medical Center in San Diego, who authored the study with Dr. Min-Wei Christine Lee of Walnut Creek, Calif.

Study participants underwent hair removal treatment without anesthesia in the bikini area, axillae, lower legs, upper lip, and/or chin, with the axillae and facial regions being the most commonly treated zones.

Hair thickness ranged from medium to coarse across all skin types and hair color ranged from light brown in skin types I and II to brown, dark brown, and/or black in all skin types.

Depending on hair type and amount, patients underwent one to four treatments at 4-week intervals.

A touch screen interface on the flashlamp handpiece enabled clinicians to automatically select the most appropriate treatment mode, which corresponds to different current densities, based on skin type.

"The ability to control spectral emissions in this way enables rapid and precise parameter titration for specific hair and skin types," Dr. Ross said. "The objective is to optimize treatment to destroy the hair follicle while sparing surrounding tissue."

Treatment efficacy was evaluated by global assessment of hair counts from photographs taken immediately before each treatment session and 2 months following the final treatment. For skin types I and II, the mean hair reduction 2 months after the final treatment was 67%, compared with 55% for skin types III and IV and 35% for skin types V and VI.

In terms of side effects, "there was some mild crusting, mostly in darker skin types, that resolved quickly," Dr. Ross said.

The ability to optimize wavelength ranges to specific skin types enables "a nice balance between safety and efficacy," and produces results similar to those seen with Nd:YAG lasers or with very long pulse 810-nm diode lasers, he added.

Dr. Ross reported receiving equipment and research support from Cutera.

BOSTON — The ability to shift wavelength emissions "on the fly" makes infrared flashlamp technology a safe and effective option for hair removal in all skin types, Dr. E. Victor Ross said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 63 patients ranging in age from 16 to 50 years with Fitzpatrick skin types I-VI, laser hair removal with the Cutera ProWave 770 cooled sapphire infrared flashlamp handpiece resulted in a mean hair reduction 2 months after the final treatment of 35%–67%, depending on skin type, said Dr. Ross of the Naval Medical Center in San Diego, who authored the study with Dr. Min-Wei Christine Lee of Walnut Creek, Calif.

Study participants underwent hair removal treatment without anesthesia in the bikini area, axillae, lower legs, upper lip, and/or chin, with the axillae and facial regions being the most commonly treated zones.

Hair thickness ranged from medium to coarse across all skin types and hair color ranged from light brown in skin types I and II to brown, dark brown, and/or black in all skin types.

Depending on hair type and amount, patients underwent one to four treatments at 4-week intervals.

A touch screen interface on the flashlamp handpiece enabled clinicians to automatically select the most appropriate treatment mode, which corresponds to different current densities, based on skin type.

"The ability to control spectral emissions in this way enables rapid and precise parameter titration for specific hair and skin types," Dr. Ross said. "The objective is to optimize treatment to destroy the hair follicle while sparing surrounding tissue."

Treatment efficacy was evaluated by global assessment of hair counts from photographs taken immediately before each treatment session and 2 months following the final treatment. For skin types I and II, the mean hair reduction 2 months after the final treatment was 67%, compared with 55% for skin types III and IV and 35% for skin types V and VI.

In terms of side effects, "there was some mild crusting, mostly in darker skin types, that resolved quickly," Dr. Ross said.

The ability to optimize wavelength ranges to specific skin types enables "a nice balance between safety and efficacy," and produces results similar to those seen with Nd:YAG lasers or with very long pulse 810-nm diode lasers, he added.

Dr. Ross reported receiving equipment and research support from Cutera.

BOSTON — The ability to shift wavelength emissions "on the fly" makes infrared flashlamp technology a safe and effective option for hair removal in all skin types, Dr. E. Victor Ross said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 63 patients ranging in age from 16 to 50 years with Fitzpatrick skin types I-VI, laser hair removal with the Cutera ProWave 770 cooled sapphire infrared flashlamp handpiece resulted in a mean hair reduction 2 months after the final treatment of 35%–67%, depending on skin type, said Dr. Ross of the Naval Medical Center in San Diego, who authored the study with Dr. Min-Wei Christine Lee of Walnut Creek, Calif.

Study participants underwent hair removal treatment without anesthesia in the bikini area, axillae, lower legs, upper lip, and/or chin, with the axillae and facial regions being the most commonly treated zones.

Hair thickness ranged from medium to coarse across all skin types and hair color ranged from light brown in skin types I and II to brown, dark brown, and/or black in all skin types.

Depending on hair type and amount, patients underwent one to four treatments at 4-week intervals.

A touch screen interface on the flashlamp handpiece enabled clinicians to automatically select the most appropriate treatment mode, which corresponds to different current densities, based on skin type.

"The ability to control spectral emissions in this way enables rapid and precise parameter titration for specific hair and skin types," Dr. Ross said. "The objective is to optimize treatment to destroy the hair follicle while sparing surrounding tissue."

Treatment efficacy was evaluated by global assessment of hair counts from photographs taken immediately before each treatment session and 2 months following the final treatment. For skin types I and II, the mean hair reduction 2 months after the final treatment was 67%, compared with 55% for skin types III and IV and 35% for skin types V and VI.

In terms of side effects, "there was some mild crusting, mostly in darker skin types, that resolved quickly," Dr. Ross said.

The ability to optimize wavelength ranges to specific skin types enables "a nice balance between safety and efficacy," and produces results similar to those seen with Nd:YAG lasers or with very long pulse 810-nm diode lasers, he added.

Dr. Ross reported receiving equipment and research support from Cutera.

BOSTON — Monopolar radiofrequency energy delivered to the eyelids through a shallow treatment tip is an effective noninvasive option for rejuvenating both upper and lower eyelid skin, Dr. Brian S. Biesman said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a multicenter clinical trial, Dr. Biesman, who is in private practice in Nashville, Tenn., and his colleagues evaluated the efficacy of the ThermaCool radiofrequency system from Thermage outfitted with the newly designed shallow tip for tightening the eyelid skin of 72 patients ranging in age from 23 to 58 years.

Of the 72 patients treated at four medical centers, 64 underwent treatment of both upper and lower eyelids, 7 underwent upper eyelid treatment only, and 1 underwent only lower eyelid treatment. All of the patients were evaluated at 1 hour, 1 week, 1 month, 2 months, 4 months, and 6 months after treatment.

Based on physician assessment at the 6-month follow up, significant reductions in both upper eyelid hooding and skin tightening were noted in, respectively, 86% and 88% of the patients who underwent the procedure. The physicians reported lower eyelid tightening in 83% of the patients who had the procedure done.

In terms of adverse events, two patients at one center sustained burns that resolved without problem, and there were no ocular injuries.

The key to the "impressive results after only one treatment," said Dr. Biesman, was the shallow tip delivery device that he and his colleagues previously tested in a series of animal and experimental models.

The standard Thermage treatment tip is 1 cm by 1 cm. "The center heating zone [with that tip] is too far beneath the skin's surface to be safely used on the thin skin of an eyelid," Dr. Biesman noted.

The new shallow tip, at 0.5 cm by 0.5 cm, is a quarter of the size of the standard tip, which results in a treatment area of 0.25 cm

"By using a smaller electrode, the treatment is done more superficially," he said. "In the eyelid area, this means impacting the dermis without injuring the epidermis or the eyelid muscle."

The results of this trial suggest that the ThermaCool TC device with the shallow treatment tip is a viable option for eyelid tightening.

"The obvious benefits are that the procedure is quick, painless, and requires no anesthesia or downtime," Dr. Beisman commented.

Dr. Beisman reported receiving consulting fees, a research grant, and honoraria from Thermage.

BOSTON — Monopolar radiofrequency energy delivered to the eyelids through a shallow treatment tip is an effective noninvasive option for rejuvenating both upper and lower eyelid skin, Dr. Brian S. Biesman said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a multicenter clinical trial, Dr. Biesman, who is in private practice in Nashville, Tenn., and his colleagues evaluated the efficacy of the ThermaCool radiofrequency system from Thermage outfitted with the newly designed shallow tip for tightening the eyelid skin of 72 patients ranging in age from 23 to 58 years.

Of the 72 patients treated at four medical centers, 64 underwent treatment of both upper and lower eyelids, 7 underwent upper eyelid treatment only, and 1 underwent only lower eyelid treatment. All of the patients were evaluated at 1 hour, 1 week, 1 month, 2 months, 4 months, and 6 months after treatment.

Based on physician assessment at the 6-month follow up, significant reductions in both upper eyelid hooding and skin tightening were noted in, respectively, 86% and 88% of the patients who underwent the procedure. The physicians reported lower eyelid tightening in 83% of the patients who had the procedure done.

In terms of adverse events, two patients at one center sustained burns that resolved without problem, and there were no ocular injuries.

The key to the "impressive results after only one treatment," said Dr. Biesman, was the shallow tip delivery device that he and his colleagues previously tested in a series of animal and experimental models.

The standard Thermage treatment tip is 1 cm by 1 cm. "The center heating zone [with that tip] is too far beneath the skin's surface to be safely used on the thin skin of an eyelid," Dr. Biesman noted.

The new shallow tip, at 0.5 cm by 0.5 cm, is a quarter of the size of the standard tip, which results in a treatment area of 0.25 cm

"By using a smaller electrode, the treatment is done more superficially," he said. "In the eyelid area, this means impacting the dermis without injuring the epidermis or the eyelid muscle."

The results of this trial suggest that the ThermaCool TC device with the shallow treatment tip is a viable option for eyelid tightening.

"The obvious benefits are that the procedure is quick, painless, and requires no anesthesia or downtime," Dr. Beisman commented.

Dr. Beisman reported receiving consulting fees, a research grant, and honoraria from Thermage.

BOSTON — Monopolar radiofrequency energy delivered to the eyelids through a shallow treatment tip is an effective noninvasive option for rejuvenating both upper and lower eyelid skin, Dr. Brian S. Biesman said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a multicenter clinical trial, Dr. Biesman, who is in private practice in Nashville, Tenn., and his colleagues evaluated the efficacy of the ThermaCool radiofrequency system from Thermage outfitted with the newly designed shallow tip for tightening the eyelid skin of 72 patients ranging in age from 23 to 58 years.

Of the 72 patients treated at four medical centers, 64 underwent treatment of both upper and lower eyelids, 7 underwent upper eyelid treatment only, and 1 underwent only lower eyelid treatment. All of the patients were evaluated at 1 hour, 1 week, 1 month, 2 months, 4 months, and 6 months after treatment.

Based on physician assessment at the 6-month follow up, significant reductions in both upper eyelid hooding and skin tightening were noted in, respectively, 86% and 88% of the patients who underwent the procedure. The physicians reported lower eyelid tightening in 83% of the patients who had the procedure done.

In terms of adverse events, two patients at one center sustained burns that resolved without problem, and there were no ocular injuries.

The key to the "impressive results after only one treatment," said Dr. Biesman, was the shallow tip delivery device that he and his colleagues previously tested in a series of animal and experimental models.

The standard Thermage treatment tip is 1 cm by 1 cm. "The center heating zone [with that tip] is too far beneath the skin's surface to be safely used on the thin skin of an eyelid," Dr. Biesman noted.

The new shallow tip, at 0.5 cm by 0.5 cm, is a quarter of the size of the standard tip, which results in a treatment area of 0.25 cm

"By using a smaller electrode, the treatment is done more superficially," he said. "In the eyelid area, this means impacting the dermis without injuring the epidermis or the eyelid muscle."

The results of this trial suggest that the ThermaCool TC device with the shallow treatment tip is a viable option for eyelid tightening.

"The obvious benefits are that the procedure is quick, painless, and requires no anesthesia or downtime," Dr. Beisman commented.

Dr. Beisman reported receiving consulting fees, a research grant, and honoraria from Thermage.

BOSTON — Weight loss can significantly improve menstrual function in overweight adolescent and young adult females with polycystic ovary syndrome, while at the same time reducing some of the risk factors for long-term morbidity associated with the hormonal reproductive problem, said Dr. Rollyn M. Ornstein at the annual meeting of the Society for Adolescent Medicine.

In a 12-week prospective study of 24 females aged 12–22 years with polycystic ovary syndrome (PCOS) and a body mass index above the 85th percentile for their age, half of the subjects were randomized to the calorie-controlled National Cholesterol Education Program Step II Diet and half to a very-low-carbohydrate, high-protein, high-fat diet.

The latter diet was included to determine whether minimizing insulin response would independently impact the signs and symptoms of PCOS, because insulin resistance is thought to play a key role in the pathogenesis of the disorder, said Dr. Ornstein of Schneider Children's Hospital in New Hyde Park, N.Y.

All of the women in the study had fewer than six spontaneous menstrual cycles in the year prior to enrollment, and all underwent laboratory evaluation and assessment at baseline and at the end of the study, including a metabolic panel, fasting lipid profile, hormonal studies, a 2-hour oral glucose tolerance test, blood pressure testing, and waist circumference measuring, which is a marker for insulin resistance. Study participants attended biweekly nutrition and exercise counseling sessions, during which dietary compliance, menstrual history, blood pressure, and weight were recorded. Additionally, lipid profiles were recorded every 6 weeks.

Of the 24 participants, 16 (7 from the low-fat diet group and 9 from the low-carbohydrate group) completed the study. The average overall weight loss in this group was 6.5% and the average waist circumference reduction was 5.7 cm. Of the 16 completers, 12 menstruated during the study period, 8 with regularity.

“Weight loss appeared to play a big role in these results, as women who lost weight were 3.4 times more likely to have improved menstrual function, which is statistically significant,” said Dr. Ornstein.

There were no significant changes in any hormonal variables from baseline, nor were baseline hormone levels predictive of menses improvement or degree of weight loss by multiple regression analysis, reported Dr. Ornstein.

There were no statistically significant differences in outcome between the two diet treatment groups, “nor did the low-carbohydrate diet harm the lipid profile,” she said.

Although limited by the small sample size, the lack of an untreated control group, and the absence of ovulation confirmation, the findings of this study suggest that “weight management might be the preferable first-line treatment for this population compared with the standard use of oral contraceptives and other medications because it addresses menstrual dysfunction and risk factors for type 2 diabetes and cardiovascular disease, both of which have been associated with polycystic ovary syndrome,” said Dr. Ornstein.

Successfully implementing a weight management treatment protocol “requires ongoing nutritional counseling and support,” Dr. Ornstein noted. “It can be challenging, but it is possible,” she said, noting that 8 of the 16 women who completed the initial 12-week study continued to the 6-month follow-up, “losing an average of 10 pounds and, for most of them, continuing their menstrual cycles.””

BOSTON — Weight loss can significantly improve menstrual function in overweight adolescent and young adult females with polycystic ovary syndrome, while at the same time reducing some of the risk factors for long-term morbidity associated with the hormonal reproductive problem, said Dr. Rollyn M. Ornstein at the annual meeting of the Society for Adolescent Medicine.

In a 12-week prospective study of 24 females aged 12–22 years with polycystic ovary syndrome (PCOS) and a body mass index above the 85th percentile for their age, half of the subjects were randomized to the calorie-controlled National Cholesterol Education Program Step II Diet and half to a very-low-carbohydrate, high-protein, high-fat diet.

The latter diet was included to determine whether minimizing insulin response would independently impact the signs and symptoms of PCOS, because insulin resistance is thought to play a key role in the pathogenesis of the disorder, said Dr. Ornstein of Schneider Children's Hospital in New Hyde Park, N.Y.

All of the women in the study had fewer than six spontaneous menstrual cycles in the year prior to enrollment, and all underwent laboratory evaluation and assessment at baseline and at the end of the study, including a metabolic panel, fasting lipid profile, hormonal studies, a 2-hour oral glucose tolerance test, blood pressure testing, and waist circumference measuring, which is a marker for insulin resistance. Study participants attended biweekly nutrition and exercise counseling sessions, during which dietary compliance, menstrual history, blood pressure, and weight were recorded. Additionally, lipid profiles were recorded every 6 weeks.

Of the 24 participants, 16 (7 from the low-fat diet group and 9 from the low-carbohydrate group) completed the study. The average overall weight loss in this group was 6.5% and the average waist circumference reduction was 5.7 cm. Of the 16 completers, 12 menstruated during the study period, 8 with regularity.

“Weight loss appeared to play a big role in these results, as women who lost weight were 3.4 times more likely to have improved menstrual function, which is statistically significant,” said Dr. Ornstein.

There were no significant changes in any hormonal variables from baseline, nor were baseline hormone levels predictive of menses improvement or degree of weight loss by multiple regression analysis, reported Dr. Ornstein.

There were no statistically significant differences in outcome between the two diet treatment groups, “nor did the low-carbohydrate diet harm the lipid profile,” she said.

Although limited by the small sample size, the lack of an untreated control group, and the absence of ovulation confirmation, the findings of this study suggest that “weight management might be the preferable first-line treatment for this population compared with the standard use of oral contraceptives and other medications because it addresses menstrual dysfunction and risk factors for type 2 diabetes and cardiovascular disease, both of which have been associated with polycystic ovary syndrome,” said Dr. Ornstein.

Successfully implementing a weight management treatment protocol “requires ongoing nutritional counseling and support,” Dr. Ornstein noted. “It can be challenging, but it is possible,” she said, noting that 8 of the 16 women who completed the initial 12-week study continued to the 6-month follow-up, “losing an average of 10 pounds and, for most of them, continuing their menstrual cycles.””

BOSTON — Weight loss can significantly improve menstrual function in overweight adolescent and young adult females with polycystic ovary syndrome, while at the same time reducing some of the risk factors for long-term morbidity associated with the hormonal reproductive problem, said Dr. Rollyn M. Ornstein at the annual meeting of the Society for Adolescent Medicine.

In a 12-week prospective study of 24 females aged 12–22 years with polycystic ovary syndrome (PCOS) and a body mass index above the 85th percentile for their age, half of the subjects were randomized to the calorie-controlled National Cholesterol Education Program Step II Diet and half to a very-low-carbohydrate, high-protein, high-fat diet.

The latter diet was included to determine whether minimizing insulin response would independently impact the signs and symptoms of PCOS, because insulin resistance is thought to play a key role in the pathogenesis of the disorder, said Dr. Ornstein of Schneider Children's Hospital in New Hyde Park, N.Y.

All of the women in the study had fewer than six spontaneous menstrual cycles in the year prior to enrollment, and all underwent laboratory evaluation and assessment at baseline and at the end of the study, including a metabolic panel, fasting lipid profile, hormonal studies, a 2-hour oral glucose tolerance test, blood pressure testing, and waist circumference measuring, which is a marker for insulin resistance. Study participants attended biweekly nutrition and exercise counseling sessions, during which dietary compliance, menstrual history, blood pressure, and weight were recorded. Additionally, lipid profiles were recorded every 6 weeks.

Of the 24 participants, 16 (7 from the low-fat diet group and 9 from the low-carbohydrate group) completed the study. The average overall weight loss in this group was 6.5% and the average waist circumference reduction was 5.7 cm. Of the 16 completers, 12 menstruated during the study period, 8 with regularity.

“Weight loss appeared to play a big role in these results, as women who lost weight were 3.4 times more likely to have improved menstrual function, which is statistically significant,” said Dr. Ornstein.

There were no significant changes in any hormonal variables from baseline, nor were baseline hormone levels predictive of menses improvement or degree of weight loss by multiple regression analysis, reported Dr. Ornstein.

There were no statistically significant differences in outcome between the two diet treatment groups, “nor did the low-carbohydrate diet harm the lipid profile,” she said.

Although limited by the small sample size, the lack of an untreated control group, and the absence of ovulation confirmation, the findings of this study suggest that “weight management might be the preferable first-line treatment for this population compared with the standard use of oral contraceptives and other medications because it addresses menstrual dysfunction and risk factors for type 2 diabetes and cardiovascular disease, both of which have been associated with polycystic ovary syndrome,” said Dr. Ornstein.

Successfully implementing a weight management treatment protocol “requires ongoing nutritional counseling and support,” Dr. Ornstein noted. “It can be challenging, but it is possible,” she said, noting that 8 of the 16 women who completed the initial 12-week study continued to the 6-month follow-up, “losing an average of 10 pounds and, for most of them, continuing their menstrual cycles.””

SAN FRANCISCO — Among men with early-stage prostate cancer who choose watchful waiting as their primary treatment strategy, the rate of rise in prostate-specific antigen level is more predictive of survival than any single PSA value, Dr. Jennifer Cullen said at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

In a retrospective study of nearly 1,400 men with early prostate cancer being followed with watchful waiting rather than active intervention, those men with a PSA velocity (the rate of increase in PSA value) of less than 2 ng/mL per year during a mean follow-up time of nearly 5 years had a significantly better overall survival rate than did those men whose PSA velocity was 2 ng/mL per year or greater, said Dr. Cullen of the Department of Defense Center for Prostate Disease Research (CPDR) in Rockville, Md.

The study sample consisted of military-care beneficiaries from the CPDR database who were diagnosed with biopsy-proven, clinically localized prostate cancer between January 1989 and December 2003 and who did not receive any clinical intervention for their cancer for at least 6 months following diagnosis. Of the 1,369 men who met these criteria, the survival analysis was limited to 830 men who had record of at least one follow-up appointment in the first 3 years following diagnosis, “to be sure that no other therapy was chosen at some time point after their care in the [CPDR] database program,” Dr. Cullen said.

All participants had at least three PSA values recorded after diagnosis and were taken more than 3 months apart, to minimize the potential for noise-related inaccuracies that could occur in shorter intervals, she said. Mean patient age was 69 years, and mean follow-up time was nearly 5 years.

The investigators generated survival analyses for men with PSA velocities below 2 ng/mL and those with velocities equal to or greater than 2 ng/mL—a distinction that is literature driven, Dr. Cullen said.

After controlling for comorbidities, secondary treatment, and time to secondary treatment, “we observed significantly poorer survival for those men in the higher PSA velocity group independent of PSA value at diagnosis,” she said. “Only 56% of men in the higher-velocity category were alive at follow-up, compared with 87% of those with lower velocity values.”

On the heels of the recent report by the Scandinavian Prostate Cancer Group Study No. 4, a long-term trial showing small but statistically significant overall and disease-specific survival differences between watchful waiting and radical prostatectomy (N. Engl. J. Med. 2005;352:1977–84), the findings of this study shed light on how best to evaluate the survival potential associated with watchful waiting for a given patient, Dr. Cullen noted at the meeting, cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology. The Scandinavian study “did not specifically investigate factors that might impact survival in men who choose watchful waiting,” she said. “Our goal was to look for characteristics that might be predictive of better or worse outcomes.”

Although limited by its retrospective design, “our database is so large that we have the ability to do robust subset analyses such as this one,” Dr. Cullen said. The findings, though promising, need to be replicated in a nonmilitary population. In addition, she said, “we want to look at the relative impact of other survival predictors, including patient age, specific tumor characteristics, and Gleason scores, as well as the optimal frequency of PSA testing.”

SAN FRANCISCO — Among men with early-stage prostate cancer who choose watchful waiting as their primary treatment strategy, the rate of rise in prostate-specific antigen level is more predictive of survival than any single PSA value, Dr. Jennifer Cullen said at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

In a retrospective study of nearly 1,400 men with early prostate cancer being followed with watchful waiting rather than active intervention, those men with a PSA velocity (the rate of increase in PSA value) of less than 2 ng/mL per year during a mean follow-up time of nearly 5 years had a significantly better overall survival rate than did those men whose PSA velocity was 2 ng/mL per year or greater, said Dr. Cullen of the Department of Defense Center for Prostate Disease Research (CPDR) in Rockville, Md.

The study sample consisted of military-care beneficiaries from the CPDR database who were diagnosed with biopsy-proven, clinically localized prostate cancer between January 1989 and December 2003 and who did not receive any clinical intervention for their cancer for at least 6 months following diagnosis. Of the 1,369 men who met these criteria, the survival analysis was limited to 830 men who had record of at least one follow-up appointment in the first 3 years following diagnosis, “to be sure that no other therapy was chosen at some time point after their care in the [CPDR] database program,” Dr. Cullen said.

All participants had at least three PSA values recorded after diagnosis and were taken more than 3 months apart, to minimize the potential for noise-related inaccuracies that could occur in shorter intervals, she said. Mean patient age was 69 years, and mean follow-up time was nearly 5 years.

The investigators generated survival analyses for men with PSA velocities below 2 ng/mL and those with velocities equal to or greater than 2 ng/mL—a distinction that is literature driven, Dr. Cullen said.

After controlling for comorbidities, secondary treatment, and time to secondary treatment, “we observed significantly poorer survival for those men in the higher PSA velocity group independent of PSA value at diagnosis,” she said. “Only 56% of men in the higher-velocity category were alive at follow-up, compared with 87% of those with lower velocity values.”

On the heels of the recent report by the Scandinavian Prostate Cancer Group Study No. 4, a long-term trial showing small but statistically significant overall and disease-specific survival differences between watchful waiting and radical prostatectomy (N. Engl. J. Med. 2005;352:1977–84), the findings of this study shed light on how best to evaluate the survival potential associated with watchful waiting for a given patient, Dr. Cullen noted at the meeting, cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology. The Scandinavian study “did not specifically investigate factors that might impact survival in men who choose watchful waiting,” she said. “Our goal was to look for characteristics that might be predictive of better or worse outcomes.”

Although limited by its retrospective design, “our database is so large that we have the ability to do robust subset analyses such as this one,” Dr. Cullen said. The findings, though promising, need to be replicated in a nonmilitary population. In addition, she said, “we want to look at the relative impact of other survival predictors, including patient age, specific tumor characteristics, and Gleason scores, as well as the optimal frequency of PSA testing.”

SAN FRANCISCO — Among men with early-stage prostate cancer who choose watchful waiting as their primary treatment strategy, the rate of rise in prostate-specific antigen level is more predictive of survival than any single PSA value, Dr. Jennifer Cullen said at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

In a retrospective study of nearly 1,400 men with early prostate cancer being followed with watchful waiting rather than active intervention, those men with a PSA velocity (the rate of increase in PSA value) of less than 2 ng/mL per year during a mean follow-up time of nearly 5 years had a significantly better overall survival rate than did those men whose PSA velocity was 2 ng/mL per year or greater, said Dr. Cullen of the Department of Defense Center for Prostate Disease Research (CPDR) in Rockville, Md.

The study sample consisted of military-care beneficiaries from the CPDR database who were diagnosed with biopsy-proven, clinically localized prostate cancer between January 1989 and December 2003 and who did not receive any clinical intervention for their cancer for at least 6 months following diagnosis. Of the 1,369 men who met these criteria, the survival analysis was limited to 830 men who had record of at least one follow-up appointment in the first 3 years following diagnosis, “to be sure that no other therapy was chosen at some time point after their care in the [CPDR] database program,” Dr. Cullen said.

All participants had at least three PSA values recorded after diagnosis and were taken more than 3 months apart, to minimize the potential for noise-related inaccuracies that could occur in shorter intervals, she said. Mean patient age was 69 years, and mean follow-up time was nearly 5 years.

The investigators generated survival analyses for men with PSA velocities below 2 ng/mL and those with velocities equal to or greater than 2 ng/mL—a distinction that is literature driven, Dr. Cullen said.

After controlling for comorbidities, secondary treatment, and time to secondary treatment, “we observed significantly poorer survival for those men in the higher PSA velocity group independent of PSA value at diagnosis,” she said. “Only 56% of men in the higher-velocity category were alive at follow-up, compared with 87% of those with lower velocity values.”

On the heels of the recent report by the Scandinavian Prostate Cancer Group Study No. 4, a long-term trial showing small but statistically significant overall and disease-specific survival differences between watchful waiting and radical prostatectomy (N. Engl. J. Med. 2005;352:1977–84), the findings of this study shed light on how best to evaluate the survival potential associated with watchful waiting for a given patient, Dr. Cullen noted at the meeting, cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology. The Scandinavian study “did not specifically investigate factors that might impact survival in men who choose watchful waiting,” she said. “Our goal was to look for characteristics that might be predictive of better or worse outcomes.”

Although limited by its retrospective design, “our database is so large that we have the ability to do robust subset analyses such as this one,” Dr. Cullen said. The findings, though promising, need to be replicated in a nonmilitary population. In addition, she said, “we want to look at the relative impact of other survival predictors, including patient age, specific tumor characteristics, and Gleason scores, as well as the optimal frequency of PSA testing.”

STOWE, VT. — Drug-aggravated dermatologic diseases are far more elusive and less common than cutaneous drug reactions, said Dr. Peter W. Heald at a dermatology conference sponsored by the University of Vermont.

To help unmask some of the dermatologic impostors, Dr. Heald, professor of dermatology at Yale University, New Haven, Conn., presented a series of clinical cases from his own practice along with management pearls gleaned from personal experience and recent literature.

Interferon-Induced Cytokine Psoriasis

Cytokine psoriasis—a subset of psoriasis with a unique clinical appearance and therapy profile—started appearing with some frequency around 1990, not coincidentally around the time treatment with interferon for hepatitis C became more common, Dr. Heald said. “Over the past decade, we've started seeing tons of patients who are 1–2 months into interferon therapy coming in with psoriasis that's just gone crazy. They have acute, irritated, oozing lesions, sometimes with pruritus and often associated with palmar lesions and acral dermatitis,” he said. Of interest, the psoriatic lesions are not local to the interferon injection sites, but rather are all over the body and, if the patient has or is prone to psoriatic arthritis, that will be induced or aggravated as well.

Although the exact underlying mechanism for this is not fully understood, psoriasis is thought to be an immune-mediated disease with a cytokine profile predominantly of the T helper cell, type 1 (TH1) subset. Presumably, interferon-α triggers psoriasis by activating dendritic cells and T cells involved in the pathogenesis of the condition, according to Dr. Heald. “I'm not a big believer in interferon inducing new cases;” it is more likely that interferon causes problems in people who are prone to psoriasis or who have a mild case, he said. “If you've got a condition where you've already got a TH1-mediated process going on in the skin, and you feed that interferon, it's going to cause problems.”

The plan for managing this type of psoriasis is to treat the patients while they are completing their course of interferon therapy. “The usual regimen is etanercept—I start them on 50 mg twice a week—with or without prednisone for rapid onset of relief,” Dr. Heald said. “In my experience, the response to etanercept for this type of psoriasis is even better than [it is for] regular psoriasis.” At the end of the interferon course, patients can be safely tapered off of the etanercept, he said.

An important consideration in the management of these patients, said Dr. Heald, is to involve the treating physician in the decision process. “Let them know that you are going to start treatment and that you're comfortable using the anti-tumor necrosis factor therapy.”

Lithium Psoriasis

“It's not an unusual scenario to see someone on lithium for bipolar disorder getting worsening psoriasis that persists even after 2 months of methotrexate,” Dr. Heald said. “Clinically, it's quite similar to interferon-exacerbated psoriasis in that it is tough and doesn't melt away quickly with standard treatments.”

While the mechanism for this condition is also not well understood, it is suspected that lithium influences the proinflammatory cytokines in the “psoriatic cytokine network,” according to Dr. Heald. As with hepatitis C patients receiving interferon, treating psoriasis in patients on lithium requires treating through the condition with methotrexate or a biologic drug.

A unique management difficulty has to do with the nature of the patient population. “You have to be particularly careful because many of these bipolar patients may be prone to suicide,” said Dr. Heald. “If the bipolar patient is at risk for noncompliance or at times has gone out of control, you should be in a situation where you're controlling the modality—whether by having a nurse give [the patient] the methotrexate or biologic agent or by bringing the patient in for infliximab infusions.”

ACE Inhibitor Psoriasis

Many individuals with psoriasis take angiotensin-converting enzyme (ACE) inhibitors without incident. In a small subset of patients, however, the antihypertensive medication has been linked to the induction or exacerbation of psoriasis. At one point, ACE inhibitors were associated with an increase in skin kinin levels, but a recent study suggests that the presence in some patients' families of an ACE insertion allele may confer susceptibility to the development of psoriasis and may be the precursor to ACE inhibitor psoriasis exacerbation (Br. J. Dermatol. 2004;151:792–5).

A typical patient with this condition “is someone whose psoriasis has been stable but becomes more widespread and pruritic within 6 months of initiation [of] ACE inhibitor treatment,” according to Dr. Heald. “Often there will also be small, thin lesions in places where the patient hadn't had them before.”

The best way to determine if ACE inhibitors are linked to worsening psoriasis in a given patient is to ask if the psoriasis got more unruly with dose increases, which would suggest that the ACE inhibitor had a role in the psoriatic process, Dr. Heald said. If you suspect ACE inhibitor involvement, “talk with the patient's internist about switching medications,” he said, noting one caveat: “Often the first words out of the internist's mouth are 'let's put them on one of these new angiotensin receptor antagonists,' which may not be a good idea because there has been at least one report linking those to the development of pustular psoriasis.”

Because there are alternative antihypertensive medications, it's not necessary to treat the psoriasis through the ACE inhibitor therapy. “It's best to just go off that class of drugs completely,” said Dr. Heald. “If after 6 months off [the ACE inhibitor] there's no change in scenario, you can feel comfortable restarting the drug knowing you considered the possibility.”

β-Blocker Psoriasis

It's fairly common knowledge that β-blockers have some connection with psoriasis, but there is not a lot of literature to provide insight into the association, Dr. Heald said. “The literature has three scenarios that have occurred with β-blockers and psoriasis—two of which would be hard to miss. One is a psoriasiform drug eruption and the other is conversion to pustular psoriasis within 1 month of starting the drug,” he said. The third, less obvious scenario is an insidious worsening of psoriasis over time in the presence of a β-blocker on the medication list.

“There's no blood test that you can do and there are no good guidelines for pursuing [the association],” said Dr. Heald, who recommended running through a list of questions when considering the possibility of β-blocker psoriasis. “If the problem has arisen within 4 months of initiating the drug, you've got to pursue it. But before talking to the patient about an expensive therapy such as [etanercept], you have to ask yourself if you are really just treating what could be taken care of by eliminating just one drug off the medication list,” he said. If so, “that should lead you to question whether the risk of the medication for the psoriasis is more or less than the risk of switching away from the β-blocker.”

Because there are usually good alternatives for β-blockers in most patients, “I think a 12-week break makes sense,” Dr. Heald said. “Most studies show that if resolution is going to happen, it will be within 3 months of stopping the drug. If you recommend this to the patient and his or her [primary care physician] or cardiologist, you insert yourself as being a caring physician, because they know you're looking for a way to treat this without adding on another medication.”

Antimalarial Psoriasis

“I recently saw a patient who started on an antimalarial medication to treat symmetric polyarthritis with psoriasis. Within 2 weeks of starting the drug, he began to develop what I call a 'fill in the gap' type of psoriasis, in which erythema develops in between preexisting plaques,” Dr. Heald said. “We've seen a bunch of these cases because for a while at our Veterans [Affairs] hospital a patient had to fail an antimalarial before getting approval for treatment with a biologic for psoriatic arthritis.” To manage this condition, “we stop the drug immediately and switch over to something that can treat both [psoriasis and psoriatic arthritis] and possibly a prednisone taper,” Dr. Heald said. “I don't think psoriasis patients should ever be put on antimalarials. Hydroxychloroquine inhibits epidermal transglutaminase activity, which leads to irregular keratinization and dermoepidermal detachment and cleft formation. In psoriatics, this leads to an erythrodermic form of the disease.”

Efalizumab-Interruption Psoriasis

Most dermatologists have legions of happy psoriasis patients thanks to the efficacy of biologics for continuous control of their conditions, “but there is one little side to this that has not been published enough: the possibility of psoriasis exacerbation when treatment is interrupted,” said Dr. Heald, who has had patients weeks and even months into successful therapy whose psoriasis returns with a vengeance following two or three missed doses. “One of my patients went on a trip and forgot his medication for 3 days. He experienced an unbelievably quick, abrupt aggravation with lots of very pruritic new lesions and oozing lesions.” It's unclear what's behind this, he said, but it's possible that with an interruption in therapy “all those cells go barreling back into the skin and create this abrupt syndrome.”

To manage the reaction, “I have sometimes tried getting prednisone or cyclosporine in there right away just to get immediate control because these patients get so bad so quickly, and then [I] start another form of therapy.”

Pyoderma Gangrenosum

Although not common, the development of virulent pyoderma gangrenosum-type ulcers at the interferon injection sites of some patients receiving the drug for multiple sclerosis or hepatitis C, “appears to be the result of interferon aggravating one of the TH1 types of inflammatory processes that typically occurs within 3 months of starting the therapy,” Dr. Heald said. Biopsies of the affected areas may show neutrophil infiltrates of vasculitis.

“Because patients and their neurologists love the drug, they're not going to stop it, so they will want you to help manage them through it,” Dr. Heald said. This is particularly true for patients with multiple sclerosis. “Patients who are staying on interferon for MS can be taught how to do interlesional triamcinolone injections, which I've had the most success with.”

Vitiligo and Imiquimod

In some patients, the topical immunomodulator imiquimod can induce local interferon-α release and vitiligo hypopigmentation. “Probably, in patients prone to vitiligo, the imiquimod triggers an immunomodulating event that may enhance a latent cell-mediated process,” Dr. Heald said. “In the patients I've treated with this condition, nobody has developed vitiligo all over. It's been localized to the area of imiquimod application.” In terms of treatment, once imiquimod therapy is withdrawn, one of the other topical immunomodulator drugs may play a role, he said.

There are 'tons of patients who are 1–2 months into interferon therapy coming in with psoriasis that's just gone crazy.' DR. HEALD

STOWE, VT. — Drug-aggravated dermatologic diseases are far more elusive and less common than cutaneous drug reactions, said Dr. Peter W. Heald at a dermatology conference sponsored by the University of Vermont.

To help unmask some of the dermatologic impostors, Dr. Heald, professor of dermatology at Yale University, New Haven, Conn., presented a series of clinical cases from his own practice along with management pearls gleaned from personal experience and recent literature.

Interferon-Induced Cytokine Psoriasis

Cytokine psoriasis—a subset of psoriasis with a unique clinical appearance and therapy profile—started appearing with some frequency around 1990, not coincidentally around the time treatment with interferon for hepatitis C became more common, Dr. Heald said. “Over the past decade, we've started seeing tons of patients who are 1–2 months into interferon therapy coming in with psoriasis that's just gone crazy. They have acute, irritated, oozing lesions, sometimes with pruritus and often associated with palmar lesions and acral dermatitis,” he said. Of interest, the psoriatic lesions are not local to the interferon injection sites, but rather are all over the body and, if the patient has or is prone to psoriatic arthritis, that will be induced or aggravated as well.

Although the exact underlying mechanism for this is not fully understood, psoriasis is thought to be an immune-mediated disease with a cytokine profile predominantly of the T helper cell, type 1 (TH1) subset. Presumably, interferon-α triggers psoriasis by activating dendritic cells and T cells involved in the pathogenesis of the condition, according to Dr. Heald. “I'm not a big believer in interferon inducing new cases;” it is more likely that interferon causes problems in people who are prone to psoriasis or who have a mild case, he said. “If you've got a condition where you've already got a TH1-mediated process going on in the skin, and you feed that interferon, it's going to cause problems.”

The plan for managing this type of psoriasis is to treat the patients while they are completing their course of interferon therapy. “The usual regimen is etanercept—I start them on 50 mg twice a week—with or without prednisone for rapid onset of relief,” Dr. Heald said. “In my experience, the response to etanercept for this type of psoriasis is even better than [it is for] regular psoriasis.” At the end of the interferon course, patients can be safely tapered off of the etanercept, he said.

An important consideration in the management of these patients, said Dr. Heald, is to involve the treating physician in the decision process. “Let them know that you are going to start treatment and that you're comfortable using the anti-tumor necrosis factor therapy.”

Lithium Psoriasis

“It's not an unusual scenario to see someone on lithium for bipolar disorder getting worsening psoriasis that persists even after 2 months of methotrexate,” Dr. Heald said. “Clinically, it's quite similar to interferon-exacerbated psoriasis in that it is tough and doesn't melt away quickly with standard treatments.”

While the mechanism for this condition is also not well understood, it is suspected that lithium influences the proinflammatory cytokines in the “psoriatic cytokine network,” according to Dr. Heald. As with hepatitis C patients receiving interferon, treating psoriasis in patients on lithium requires treating through the condition with methotrexate or a biologic drug.

A unique management difficulty has to do with the nature of the patient population. “You have to be particularly careful because many of these bipolar patients may be prone to suicide,” said Dr. Heald. “If the bipolar patient is at risk for noncompliance or at times has gone out of control, you should be in a situation where you're controlling the modality—whether by having a nurse give [the patient] the methotrexate or biologic agent or by bringing the patient in for infliximab infusions.”

ACE Inhibitor Psoriasis

Many individuals with psoriasis take angiotensin-converting enzyme (ACE) inhibitors without incident. In a small subset of patients, however, the antihypertensive medication has been linked to the induction or exacerbation of psoriasis. At one point, ACE inhibitors were associated with an increase in skin kinin levels, but a recent study suggests that the presence in some patients' families of an ACE insertion allele may confer susceptibility to the development of psoriasis and may be the precursor to ACE inhibitor psoriasis exacerbation (Br. J. Dermatol. 2004;151:792–5).

A typical patient with this condition “is someone whose psoriasis has been stable but becomes more widespread and pruritic within 6 months of initiation [of] ACE inhibitor treatment,” according to Dr. Heald. “Often there will also be small, thin lesions in places where the patient hadn't had them before.”

The best way to determine if ACE inhibitors are linked to worsening psoriasis in a given patient is to ask if the psoriasis got more unruly with dose increases, which would suggest that the ACE inhibitor had a role in the psoriatic process, Dr. Heald said. If you suspect ACE inhibitor involvement, “talk with the patient's internist about switching medications,” he said, noting one caveat: “Often the first words out of the internist's mouth are 'let's put them on one of these new angiotensin receptor antagonists,' which may not be a good idea because there has been at least one report linking those to the development of pustular psoriasis.”

Because there are alternative antihypertensive medications, it's not necessary to treat the psoriasis through the ACE inhibitor therapy. “It's best to just go off that class of drugs completely,” said Dr. Heald. “If after 6 months off [the ACE inhibitor] there's no change in scenario, you can feel comfortable restarting the drug knowing you considered the possibility.”

β-Blocker Psoriasis

It's fairly common knowledge that β-blockers have some connection with psoriasis, but there is not a lot of literature to provide insight into the association, Dr. Heald said. “The literature has three scenarios that have occurred with β-blockers and psoriasis—two of which would be hard to miss. One is a psoriasiform drug eruption and the other is conversion to pustular psoriasis within 1 month of starting the drug,” he said. The third, less obvious scenario is an insidious worsening of psoriasis over time in the presence of a β-blocker on the medication list.

“There's no blood test that you can do and there are no good guidelines for pursuing [the association],” said Dr. Heald, who recommended running through a list of questions when considering the possibility of β-blocker psoriasis. “If the problem has arisen within 4 months of initiating the drug, you've got to pursue it. But before talking to the patient about an expensive therapy such as [etanercept], you have to ask yourself if you are really just treating what could be taken care of by eliminating just one drug off the medication list,” he said. If so, “that should lead you to question whether the risk of the medication for the psoriasis is more or less than the risk of switching away from the β-blocker.”

Because there are usually good alternatives for β-blockers in most patients, “I think a 12-week break makes sense,” Dr. Heald said. “Most studies show that if resolution is going to happen, it will be within 3 months of stopping the drug. If you recommend this to the patient and his or her [primary care physician] or cardiologist, you insert yourself as being a caring physician, because they know you're looking for a way to treat this without adding on another medication.”

Antimalarial Psoriasis

“I recently saw a patient who started on an antimalarial medication to treat symmetric polyarthritis with psoriasis. Within 2 weeks of starting the drug, he began to develop what I call a 'fill in the gap' type of psoriasis, in which erythema develops in between preexisting plaques,” Dr. Heald said. “We've seen a bunch of these cases because for a while at our Veterans [Affairs] hospital a patient had to fail an antimalarial before getting approval for treatment with a biologic for psoriatic arthritis.” To manage this condition, “we stop the drug immediately and switch over to something that can treat both [psoriasis and psoriatic arthritis] and possibly a prednisone taper,” Dr. Heald said. “I don't think psoriasis patients should ever be put on antimalarials. Hydroxychloroquine inhibits epidermal transglutaminase activity, which leads to irregular keratinization and dermoepidermal detachment and cleft formation. In psoriatics, this leads to an erythrodermic form of the disease.”

Efalizumab-Interruption Psoriasis

Most dermatologists have legions of happy psoriasis patients thanks to the efficacy of biologics for continuous control of their conditions, “but there is one little side to this that has not been published enough: the possibility of psoriasis exacerbation when treatment is interrupted,” said Dr. Heald, who has had patients weeks and even months into successful therapy whose psoriasis returns with a vengeance following two or three missed doses. “One of my patients went on a trip and forgot his medication for 3 days. He experienced an unbelievably quick, abrupt aggravation with lots of very pruritic new lesions and oozing lesions.” It's unclear what's behind this, he said, but it's possible that with an interruption in therapy “all those cells go barreling back into the skin and create this abrupt syndrome.”

To manage the reaction, “I have sometimes tried getting prednisone or cyclosporine in there right away just to get immediate control because these patients get so bad so quickly, and then [I] start another form of therapy.”

Pyoderma Gangrenosum

Although not common, the development of virulent pyoderma gangrenosum-type ulcers at the interferon injection sites of some patients receiving the drug for multiple sclerosis or hepatitis C, “appears to be the result of interferon aggravating one of the TH1 types of inflammatory processes that typically occurs within 3 months of starting the therapy,” Dr. Heald said. Biopsies of the affected areas may show neutrophil infiltrates of vasculitis.

“Because patients and their neurologists love the drug, they're not going to stop it, so they will want you to help manage them through it,” Dr. Heald said. This is particularly true for patients with multiple sclerosis. “Patients who are staying on interferon for MS can be taught how to do interlesional triamcinolone injections, which I've had the most success with.”

Vitiligo and Imiquimod

In some patients, the topical immunomodulator imiquimod can induce local interferon-α release and vitiligo hypopigmentation. “Probably, in patients prone to vitiligo, the imiquimod triggers an immunomodulating event that may enhance a latent cell-mediated process,” Dr. Heald said. “In the patients I've treated with this condition, nobody has developed vitiligo all over. It's been localized to the area of imiquimod application.” In terms of treatment, once imiquimod therapy is withdrawn, one of the other topical immunomodulator drugs may play a role, he said.

There are 'tons of patients who are 1–2 months into interferon therapy coming in with psoriasis that's just gone crazy.' DR. HEALD

STOWE, VT. — Drug-aggravated dermatologic diseases are far more elusive and less common than cutaneous drug reactions, said Dr. Peter W. Heald at a dermatology conference sponsored by the University of Vermont.

To help unmask some of the dermatologic impostors, Dr. Heald, professor of dermatology at Yale University, New Haven, Conn., presented a series of clinical cases from his own practice along with management pearls gleaned from personal experience and recent literature.

Interferon-Induced Cytokine Psoriasis

Cytokine psoriasis—a subset of psoriasis with a unique clinical appearance and therapy profile—started appearing with some frequency around 1990, not coincidentally around the time treatment with interferon for hepatitis C became more common, Dr. Heald said. “Over the past decade, we've started seeing tons of patients who are 1–2 months into interferon therapy coming in with psoriasis that's just gone crazy. They have acute, irritated, oozing lesions, sometimes with pruritus and often associated with palmar lesions and acral dermatitis,” he said. Of interest, the psoriatic lesions are not local to the interferon injection sites, but rather are all over the body and, if the patient has or is prone to psoriatic arthritis, that will be induced or aggravated as well.

Although the exact underlying mechanism for this is not fully understood, psoriasis is thought to be an immune-mediated disease with a cytokine profile predominantly of the T helper cell, type 1 (TH1) subset. Presumably, interferon-α triggers psoriasis by activating dendritic cells and T cells involved in the pathogenesis of the condition, according to Dr. Heald. “I'm not a big believer in interferon inducing new cases;” it is more likely that interferon causes problems in people who are prone to psoriasis or who have a mild case, he said. “If you've got a condition where you've already got a TH1-mediated process going on in the skin, and you feed that interferon, it's going to cause problems.”

The plan for managing this type of psoriasis is to treat the patients while they are completing their course of interferon therapy. “The usual regimen is etanercept—I start them on 50 mg twice a week—with or without prednisone for rapid onset of relief,” Dr. Heald said. “In my experience, the response to etanercept for this type of psoriasis is even better than [it is for] regular psoriasis.” At the end of the interferon course, patients can be safely tapered off of the etanercept, he said.

An important consideration in the management of these patients, said Dr. Heald, is to involve the treating physician in the decision process. “Let them know that you are going to start treatment and that you're comfortable using the anti-tumor necrosis factor therapy.”

Lithium Psoriasis

“It's not an unusual scenario to see someone on lithium for bipolar disorder getting worsening psoriasis that persists even after 2 months of methotrexate,” Dr. Heald said. “Clinically, it's quite similar to interferon-exacerbated psoriasis in that it is tough and doesn't melt away quickly with standard treatments.”

While the mechanism for this condition is also not well understood, it is suspected that lithium influences the proinflammatory cytokines in the “psoriatic cytokine network,” according to Dr. Heald. As with hepatitis C patients receiving interferon, treating psoriasis in patients on lithium requires treating through the condition with methotrexate or a biologic drug.

A unique management difficulty has to do with the nature of the patient population. “You have to be particularly careful because many of these bipolar patients may be prone to suicide,” said Dr. Heald. “If the bipolar patient is at risk for noncompliance or at times has gone out of control, you should be in a situation where you're controlling the modality—whether by having a nurse give [the patient] the methotrexate or biologic agent or by bringing the patient in for infliximab infusions.”

ACE Inhibitor Psoriasis

Many individuals with psoriasis take angiotensin-converting enzyme (ACE) inhibitors without incident. In a small subset of patients, however, the antihypertensive medication has been linked to the induction or exacerbation of psoriasis. At one point, ACE inhibitors were associated with an increase in skin kinin levels, but a recent study suggests that the presence in some patients' families of an ACE insertion allele may confer susceptibility to the development of psoriasis and may be the precursor to ACE inhibitor psoriasis exacerbation (Br. J. Dermatol. 2004;151:792–5).

A typical patient with this condition “is someone whose psoriasis has been stable but becomes more widespread and pruritic within 6 months of initiation [of] ACE inhibitor treatment,” according to Dr. Heald. “Often there will also be small, thin lesions in places where the patient hadn't had them before.”

The best way to determine if ACE inhibitors are linked to worsening psoriasis in a given patient is to ask if the psoriasis got more unruly with dose increases, which would suggest that the ACE inhibitor had a role in the psoriatic process, Dr. Heald said. If you suspect ACE inhibitor involvement, “talk with the patient's internist about switching medications,” he said, noting one caveat: “Often the first words out of the internist's mouth are 'let's put them on one of these new angiotensin receptor antagonists,' which may not be a good idea because there has been at least one report linking those to the development of pustular psoriasis.”

Because there are alternative antihypertensive medications, it's not necessary to treat the psoriasis through the ACE inhibitor therapy. “It's best to just go off that class of drugs completely,” said Dr. Heald. “If after 6 months off [the ACE inhibitor] there's no change in scenario, you can feel comfortable restarting the drug knowing you considered the possibility.”

β-Blocker Psoriasis

It's fairly common knowledge that β-blockers have some connection with psoriasis, but there is not a lot of literature to provide insight into the association, Dr. Heald said. “The literature has three scenarios that have occurred with β-blockers and psoriasis—two of which would be hard to miss. One is a psoriasiform drug eruption and the other is conversion to pustular psoriasis within 1 month of starting the drug,” he said. The third, less obvious scenario is an insidious worsening of psoriasis over time in the presence of a β-blocker on the medication list.

“There's no blood test that you can do and there are no good guidelines for pursuing [the association],” said Dr. Heald, who recommended running through a list of questions when considering the possibility of β-blocker psoriasis. “If the problem has arisen within 4 months of initiating the drug, you've got to pursue it. But before talking to the patient about an expensive therapy such as [etanercept], you have to ask yourself if you are really just treating what could be taken care of by eliminating just one drug off the medication list,” he said. If so, “that should lead you to question whether the risk of the medication for the psoriasis is more or less than the risk of switching away from the β-blocker.”

Because there are usually good alternatives for β-blockers in most patients, “I think a 12-week break makes sense,” Dr. Heald said. “Most studies show that if resolution is going to happen, it will be within 3 months of stopping the drug. If you recommend this to the patient and his or her [primary care physician] or cardiologist, you insert yourself as being a caring physician, because they know you're looking for a way to treat this without adding on another medication.”

Antimalarial Psoriasis

“I recently saw a patient who started on an antimalarial medication to treat symmetric polyarthritis with psoriasis. Within 2 weeks of starting the drug, he began to develop what I call a 'fill in the gap' type of psoriasis, in which erythema develops in between preexisting plaques,” Dr. Heald said. “We've seen a bunch of these cases because for a while at our Veterans [Affairs] hospital a patient had to fail an antimalarial before getting approval for treatment with a biologic for psoriatic arthritis.” To manage this condition, “we stop the drug immediately and switch over to something that can treat both [psoriasis and psoriatic arthritis] and possibly a prednisone taper,” Dr. Heald said. “I don't think psoriasis patients should ever be put on antimalarials. Hydroxychloroquine inhibits epidermal transglutaminase activity, which leads to irregular keratinization and dermoepidermal detachment and cleft formation. In psoriatics, this leads to an erythrodermic form of the disease.”

Efalizumab-Interruption Psoriasis

Most dermatologists have legions of happy psoriasis patients thanks to the efficacy of biologics for continuous control of their conditions, “but there is one little side to this that has not been published enough: the possibility of psoriasis exacerbation when treatment is interrupted,” said Dr. Heald, who has had patients weeks and even months into successful therapy whose psoriasis returns with a vengeance following two or three missed doses. “One of my patients went on a trip and forgot his medication for 3 days. He experienced an unbelievably quick, abrupt aggravation with lots of very pruritic new lesions and oozing lesions.” It's unclear what's behind this, he said, but it's possible that with an interruption in therapy “all those cells go barreling back into the skin and create this abrupt syndrome.”

To manage the reaction, “I have sometimes tried getting prednisone or cyclosporine in there right away just to get immediate control because these patients get so bad so quickly, and then [I] start another form of therapy.”

Pyoderma Gangrenosum

Although not common, the development of virulent pyoderma gangrenosum-type ulcers at the interferon injection sites of some patients receiving the drug for multiple sclerosis or hepatitis C, “appears to be the result of interferon aggravating one of the TH1 types of inflammatory processes that typically occurs within 3 months of starting the therapy,” Dr. Heald said. Biopsies of the affected areas may show neutrophil infiltrates of vasculitis.

“Because patients and their neurologists love the drug, they're not going to stop it, so they will want you to help manage them through it,” Dr. Heald said. This is particularly true for patients with multiple sclerosis. “Patients who are staying on interferon for MS can be taught how to do interlesional triamcinolone injections, which I've had the most success with.”

Vitiligo and Imiquimod

In some patients, the topical immunomodulator imiquimod can induce local interferon-α release and vitiligo hypopigmentation. “Probably, in patients prone to vitiligo, the imiquimod triggers an immunomodulating event that may enhance a latent cell-mediated process,” Dr. Heald said. “In the patients I've treated with this condition, nobody has developed vitiligo all over. It's been localized to the area of imiquimod application.” In terms of treatment, once imiquimod therapy is withdrawn, one of the other topical immunomodulator drugs may play a role, he said.

There are 'tons of patients who are 1–2 months into interferon therapy coming in with psoriasis that's just gone crazy.' DR. HEALD

BOSTON — Immediate initiation of depot medroxyprogesterone acetate to adolescent and young adult women seeking the contraceptive injection resulted in higher continuation rates and substantially diminished unintended pregnancy rates at 6 months, compared with the use of alternative, short-term hormonal methods meant to bridge the period between initial request and injection at a later date, Vaughn I. Rickert, Psy.D., said at the annual meeting of the Society for Adolescent Medicine.

In a study of 334 young women aged 14–26 years who asked for depot medroxyprogesterone acetate (DMPA) during a reproductive health visit at an urban family planning clinic, 101 women were randomized to receive their first DMPA (Depo-Provera) injection at the conclusion of the visit, and 233 were randomized to an alternative “quick start” bridge condition whereby they were offered their choice of either oral contraceptive pills, the transdermal patch, or the vaginal ring, said Dr. Rickert of the Mailman School of Public Health at Columbia University in New York.

Historically, the rationale for waiting to initiate hormonal contraception “was to be sure the patient was not pregnant and to keep from altering the bleeding pattern,” Dr. Rickert said. “Unfortunately, with the delayed initiation, many women don't take their first pill, and their motivation wanes.” Similarly, asking women to return to the clinic at a later date for a DMPA injection means that some won't come back for it, thus increasing the likelihood for unintended pregnancies.

The immediate contraception protocol was designed to avoid this outcome, according to Dr. Rickert. While the earlier study looked specifically at the efficacy of the approach with respect to oral contraceptives, the current study sought to determine whether immediate access to DMPA would lead to greater method continuation—and thus pregnancy prevention—over a 6-month period, compared with delaying the injection and providing alternative contraceptive options for the interim period.

All subjects in both conditions underwent a history, physical, pregnancy test, and structured interview at the initial visit. All were instructed to return to the clinic in 21 days for a repeat urine pregnancy test and, for those assigned to the alternative condition, to receive their first DMPA injection, Dr. Rickert said. In addition, the women were followed through two subsequent appointments for DMPA injections and structured interviews.

As of February 2006, 278 of the women had completed the study; 54 were between the ages of 14 and 17 years, 118 were between the ages of 18 and 21, and 106 were between 22 and 26 years.

“Continuation rates were statistically higher at 6 months in the [immediate] Depo group compared to the bridge group, meaning that more women in the Depo group received their third injection,” he said. Other factors independently associated with 6-month DMPA continuation rates included partners' awareness of DMPA use, returning for the pregnancy test visit, and history of emergency contraceptive pill use, “suggesting continuation is also affected by behaviors consistent with intentions not to become pregnant,” Dr. Rickert said.

The immediate DMPA group had significantly fewer pregnancies—2, compared with 23 in the bridge group—across the study period.

The findings support immediate administration of DMPA and suggest a potentially significant impact on continuation as well as avoidance of unintended pregnancies, Dr. Rickert concluded.

BOSTON — Immediate initiation of depot medroxyprogesterone acetate to adolescent and young adult women seeking the contraceptive injection resulted in higher continuation rates and substantially diminished unintended pregnancy rates at 6 months, compared with the use of alternative, short-term hormonal methods meant to bridge the period between initial request and injection at a later date, Vaughn I. Rickert, Psy.D., said at the annual meeting of the Society for Adolescent Medicine.

In a study of 334 young women aged 14–26 years who asked for depot medroxyprogesterone acetate (DMPA) during a reproductive health visit at an urban family planning clinic, 101 women were randomized to receive their first DMPA (Depo-Provera) injection at the conclusion of the visit, and 233 were randomized to an alternative “quick start” bridge condition whereby they were offered their choice of either oral contraceptive pills, the transdermal patch, or the vaginal ring, said Dr. Rickert of the Mailman School of Public Health at Columbia University in New York.

Historically, the rationale for waiting to initiate hormonal contraception “was to be sure the patient was not pregnant and to keep from altering the bleeding pattern,” Dr. Rickert said. “Unfortunately, with the delayed initiation, many women don't take their first pill, and their motivation wanes.” Similarly, asking women to return to the clinic at a later date for a DMPA injection means that some won't come back for it, thus increasing the likelihood for unintended pregnancies.

The immediate contraception protocol was designed to avoid this outcome, according to Dr. Rickert. While the earlier study looked specifically at the efficacy of the approach with respect to oral contraceptives, the current study sought to determine whether immediate access to DMPA would lead to greater method continuation—and thus pregnancy prevention—over a 6-month period, compared with delaying the injection and providing alternative contraceptive options for the interim period.

All subjects in both conditions underwent a history, physical, pregnancy test, and structured interview at the initial visit. All were instructed to return to the clinic in 21 days for a repeat urine pregnancy test and, for those assigned to the alternative condition, to receive their first DMPA injection, Dr. Rickert said. In addition, the women were followed through two subsequent appointments for DMPA injections and structured interviews.

As of February 2006, 278 of the women had completed the study; 54 were between the ages of 14 and 17 years, 118 were between the ages of 18 and 21, and 106 were between 22 and 26 years.

“Continuation rates were statistically higher at 6 months in the [immediate] Depo group compared to the bridge group, meaning that more women in the Depo group received their third injection,” he said. Other factors independently associated with 6-month DMPA continuation rates included partners' awareness of DMPA use, returning for the pregnancy test visit, and history of emergency contraceptive pill use, “suggesting continuation is also affected by behaviors consistent with intentions not to become pregnant,” Dr. Rickert said.

The immediate DMPA group had significantly fewer pregnancies—2, compared with 23 in the bridge group—across the study period.

The findings support immediate administration of DMPA and suggest a potentially significant impact on continuation as well as avoidance of unintended pregnancies, Dr. Rickert concluded.

BOSTON — Immediate initiation of depot medroxyprogesterone acetate to adolescent and young adult women seeking the contraceptive injection resulted in higher continuation rates and substantially diminished unintended pregnancy rates at 6 months, compared with the use of alternative, short-term hormonal methods meant to bridge the period between initial request and injection at a later date, Vaughn I. Rickert, Psy.D., said at the annual meeting of the Society for Adolescent Medicine.

In a study of 334 young women aged 14–26 years who asked for depot medroxyprogesterone acetate (DMPA) during a reproductive health visit at an urban family planning clinic, 101 women were randomized to receive their first DMPA (Depo-Provera) injection at the conclusion of the visit, and 233 were randomized to an alternative “quick start” bridge condition whereby they were offered their choice of either oral contraceptive pills, the transdermal patch, or the vaginal ring, said Dr. Rickert of the Mailman School of Public Health at Columbia University in New York.

Historically, the rationale for waiting to initiate hormonal contraception “was to be sure the patient was not pregnant and to keep from altering the bleeding pattern,” Dr. Rickert said. “Unfortunately, with the delayed initiation, many women don't take their first pill, and their motivation wanes.” Similarly, asking women to return to the clinic at a later date for a DMPA injection means that some won't come back for it, thus increasing the likelihood for unintended pregnancies.

The immediate contraception protocol was designed to avoid this outcome, according to Dr. Rickert. While the earlier study looked specifically at the efficacy of the approach with respect to oral contraceptives, the current study sought to determine whether immediate access to DMPA would lead to greater method continuation—and thus pregnancy prevention—over a 6-month period, compared with delaying the injection and providing alternative contraceptive options for the interim period.

All subjects in both conditions underwent a history, physical, pregnancy test, and structured interview at the initial visit. All were instructed to return to the clinic in 21 days for a repeat urine pregnancy test and, for those assigned to the alternative condition, to receive their first DMPA injection, Dr. Rickert said. In addition, the women were followed through two subsequent appointments for DMPA injections and structured interviews.

As of February 2006, 278 of the women had completed the study; 54 were between the ages of 14 and 17 years, 118 were between the ages of 18 and 21, and 106 were between 22 and 26 years.

“Continuation rates were statistically higher at 6 months in the [immediate] Depo group compared to the bridge group, meaning that more women in the Depo group received their third injection,” he said. Other factors independently associated with 6-month DMPA continuation rates included partners' awareness of DMPA use, returning for the pregnancy test visit, and history of emergency contraceptive pill use, “suggesting continuation is also affected by behaviors consistent with intentions not to become pregnant,” Dr. Rickert said.

The immediate DMPA group had significantly fewer pregnancies—2, compared with 23 in the bridge group—across the study period.

The findings support immediate administration of DMPA and suggest a potentially significant impact on continuation as well as avoidance of unintended pregnancies, Dr. Rickert concluded.

SAN FRANCISCO — Prostatitis can quickly lead to surges in prostate-specific antigen levels, potentially undermining the use of the biomarker's rate of change to help detect cancer, Dr. Scott Eggener said at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

Previous studies have shown that prostate-specific antigen (PSA) velocity can be a valuable tool for assessing prostate cancer risk. Specifically, PSA velocity elevations of 2.0 ng/mL per year or higher have been identified as significant with respect to the risk of dying of prostate cancer, said Dr. Eggener of Memorial Sloan-Kettering Cancer Center in New York. It has also been suggested, however, that certain conditions, such as prostatitis and benign prostatic hyperplasia, could be confounding variables for rising PSA velocities.

Dr. Eggener and his colleagues analyzed records from 1,851 men enrolled in a community-based prostate cancer screening trial. At the time of their first biopsy, 468 men were diagnosed with prostate cancer, and 135 were diagnosed with prostatitis.

All of the men had a normal digital rectal exam and a calculable PSA velocity for the year prior to biopsy.

“What we found, relative to rising PSA velocity, was a general trend for decreasing cancer detection rate and a corresponding trend for increasing prostatitis,” Dr. Eggener said at the symposium, which was cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology.

Specifically, 30% of the men with a PSA velocity of 0–1.99 ng/mL in the year before biopsy had prostate cancer, and 5% had prostatitis. In comparison, among men with a PSA velocity of 2.0–3.99 ng/mL, 22% had cancer on first biopsy, and 8% had prostatitis.

Men whose PSA velocities were greater than 4.0 ng/mL were equally likely to have prostatitis or prostate cancer, with 13% being diagnosed with each condition.

The risk of cancer diagnosis peaked relative to PSA velocity increases of 0.3–0.5 ng/mL per year, and the risk of prostatitis diagnosis rose substantially with PSA velocity increases of more than 2.0 ng/mL per year, Dr. Eggener said.

“Men with prostatitis often have dramatic rises in PSA prompting biopsy, but subsequently have a significant drop in PSA in the year or two following biopsy,” he said.

Men with a normal digital rectal exam, elevated PSA, and a high PSA velocity should therefore undergo repeat PSA testing. “If any symptoms or laboratory findings suggest prostatitis, they should undergo appropriate evaluation and treatment,” he said.

Dr. Eggener stressed that PSA velocity continues to be “very useful in assessing prostate cancer risk,” but that dramatic increases over short periods of time should raise suspicion of prostatitis, in addition to prostate cancer.

SAN FRANCISCO — Prostatitis can quickly lead to surges in prostate-specific antigen levels, potentially undermining the use of the biomarker's rate of change to help detect cancer, Dr. Scott Eggener said at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

Previous studies have shown that prostate-specific antigen (PSA) velocity can be a valuable tool for assessing prostate cancer risk. Specifically, PSA velocity elevations of 2.0 ng/mL per year or higher have been identified as significant with respect to the risk of dying of prostate cancer, said Dr. Eggener of Memorial Sloan-Kettering Cancer Center in New York. It has also been suggested, however, that certain conditions, such as prostatitis and benign prostatic hyperplasia, could be confounding variables for rising PSA velocities.

Dr. Eggener and his colleagues analyzed records from 1,851 men enrolled in a community-based prostate cancer screening trial. At the time of their first biopsy, 468 men were diagnosed with prostate cancer, and 135 were diagnosed with prostatitis.

All of the men had a normal digital rectal exam and a calculable PSA velocity for the year prior to biopsy.

“What we found, relative to rising PSA velocity, was a general trend for decreasing cancer detection rate and a corresponding trend for increasing prostatitis,” Dr. Eggener said at the symposium, which was cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology.

Specifically, 30% of the men with a PSA velocity of 0–1.99 ng/mL in the year before biopsy had prostate cancer, and 5% had prostatitis. In comparison, among men with a PSA velocity of 2.0–3.99 ng/mL, 22% had cancer on first biopsy, and 8% had prostatitis.

Men whose PSA velocities were greater than 4.0 ng/mL were equally likely to have prostatitis or prostate cancer, with 13% being diagnosed with each condition.

The risk of cancer diagnosis peaked relative to PSA velocity increases of 0.3–0.5 ng/mL per year, and the risk of prostatitis diagnosis rose substantially with PSA velocity increases of more than 2.0 ng/mL per year, Dr. Eggener said.

“Men with prostatitis often have dramatic rises in PSA prompting biopsy, but subsequently have a significant drop in PSA in the year or two following biopsy,” he said.

Men with a normal digital rectal exam, elevated PSA, and a high PSA velocity should therefore undergo repeat PSA testing. “If any symptoms or laboratory findings suggest prostatitis, they should undergo appropriate evaluation and treatment,” he said.

Dr. Eggener stressed that PSA velocity continues to be “very useful in assessing prostate cancer risk,” but that dramatic increases over short periods of time should raise suspicion of prostatitis, in addition to prostate cancer.

SAN FRANCISCO — Prostatitis can quickly lead to surges in prostate-specific antigen levels, potentially undermining the use of the biomarker's rate of change to help detect cancer, Dr. Scott Eggener said at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

Previous studies have shown that prostate-specific antigen (PSA) velocity can be a valuable tool for assessing prostate cancer risk. Specifically, PSA velocity elevations of 2.0 ng/mL per year or higher have been identified as significant with respect to the risk of dying of prostate cancer, said Dr. Eggener of Memorial Sloan-Kettering Cancer Center in New York. It has also been suggested, however, that certain conditions, such as prostatitis and benign prostatic hyperplasia, could be confounding variables for rising PSA velocities.

Dr. Eggener and his colleagues analyzed records from 1,851 men enrolled in a community-based prostate cancer screening trial. At the time of their first biopsy, 468 men were diagnosed with prostate cancer, and 135 were diagnosed with prostatitis.

All of the men had a normal digital rectal exam and a calculable PSA velocity for the year prior to biopsy.

“What we found, relative to rising PSA velocity, was a general trend for decreasing cancer detection rate and a corresponding trend for increasing prostatitis,” Dr. Eggener said at the symposium, which was cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology.

Specifically, 30% of the men with a PSA velocity of 0–1.99 ng/mL in the year before biopsy had prostate cancer, and 5% had prostatitis. In comparison, among men with a PSA velocity of 2.0–3.99 ng/mL, 22% had cancer on first biopsy, and 8% had prostatitis.

Men whose PSA velocities were greater than 4.0 ng/mL were equally likely to have prostatitis or prostate cancer, with 13% being diagnosed with each condition.

The risk of cancer diagnosis peaked relative to PSA velocity increases of 0.3–0.5 ng/mL per year, and the risk of prostatitis diagnosis rose substantially with PSA velocity increases of more than 2.0 ng/mL per year, Dr. Eggener said.

“Men with prostatitis often have dramatic rises in PSA prompting biopsy, but subsequently have a significant drop in PSA in the year or two following biopsy,” he said.

Men with a normal digital rectal exam, elevated PSA, and a high PSA velocity should therefore undergo repeat PSA testing. “If any symptoms or laboratory findings suggest prostatitis, they should undergo appropriate evaluation and treatment,” he said.

Dr. Eggener stressed that PSA velocity continues to be “very useful in assessing prostate cancer risk,” but that dramatic increases over short periods of time should raise suspicion of prostatitis, in addition to prostate cancer.