Heidi Splete

Biologics and systemic therapies command much of the spotlight for treating psoriasis, but topical therapy remains an effective option for many psoriasis patients, according to Dr. Linda Stein Gold.

In fact, up to 80% of psoriasis patients can be adequately treated with topical therapy (N. Engl. J. Med. 2005;352:1899-912), said Dr. Stein Gold at the Skin Disease Education Foundation’s (SDEF’s) annual Las Vegas dermatology seminar.

She offered several principles to help clinicians make the most of topical therapies by troubleshooting potential problems.

• Check the amount. One gram of most topical psoriasis products covers 4% of body surface area per application, so a 60-gram tube should treat 4% of body surface area for a month, said Dr. Stein Gold, citing guidelines developed by Dr. Alan Menter and his colleagues and approved by the American Academy of Dermatology in 2009.

• Don’t miss corticosteroid allergies. "We are missing this," said Dr. Stein Gold, director of dermatology research at Henry Ford Hospital in Detroit. Suspect a possible allergy if a patient returns with a worsening rash after using hydrocortisone, for example. Data have shown that between 0.2% and 5% of all dermatitis patients have a steroid allergy. "Allergy to the active molecule or to the vehicle should be suspected in all patients who don’t respond as expected to topical steroids," she noted.

• Visit (or revisit) vitamin D. Another plus for topical therapy is the usefulness of topical vitamin D for tricky areas, such as the forehead, armpit, groin, and the area behind the ears. Data from a randomized trial of 75 patients found calcitriol ointment to be significantly more effective against target lesions and better tolerated by patients than calcipotriene ointment (Br. J. Dermatol. 2003;148:326-33).

• Don’t forget coal tar. Simple, but effective, coal tar is a proven safe topical psoriasis treatment and is available in several vehicles, including solution and foam. Data from a study of more than 13,000 patients with psoriasis and eczema found that coal tar was safe, and that it did not increase the risk for skin cancer (J. Invest. Dermatol. 2010;130:953-61).

The future of topical psoriasis therapy is not static, said Dr. Stein Gold. New molecules – notably topical Janus kinase inhibitors and phosphodiesterase-4 inhibitors – are currently being explored in clinical trials.

Dr. Stein Gold disclosed relationships with Leo, Medicis, and other companies. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

Biologics and systemic therapies command much of the spotlight for treating psoriasis, but topical therapy remains an effective option for many psoriasis patients, according to Dr. Linda Stein Gold.

In fact, up to 80% of psoriasis patients can be adequately treated with topical therapy (N. Engl. J. Med. 2005;352:1899-912), said Dr. Stein Gold at the Skin Disease Education Foundation’s (SDEF’s) annual Las Vegas dermatology seminar.

She offered several principles to help clinicians make the most of topical therapies by troubleshooting potential problems.

• Check the amount. One gram of most topical psoriasis products covers 4% of body surface area per application, so a 60-gram tube should treat 4% of body surface area for a month, said Dr. Stein Gold, citing guidelines developed by Dr. Alan Menter and his colleagues and approved by the American Academy of Dermatology in 2009.

• Don’t miss corticosteroid allergies. "We are missing this," said Dr. Stein Gold, director of dermatology research at Henry Ford Hospital in Detroit. Suspect a possible allergy if a patient returns with a worsening rash after using hydrocortisone, for example. Data have shown that between 0.2% and 5% of all dermatitis patients have a steroid allergy. "Allergy to the active molecule or to the vehicle should be suspected in all patients who don’t respond as expected to topical steroids," she noted.

• Visit (or revisit) vitamin D. Another plus for topical therapy is the usefulness of topical vitamin D for tricky areas, such as the forehead, armpit, groin, and the area behind the ears. Data from a randomized trial of 75 patients found calcitriol ointment to be significantly more effective against target lesions and better tolerated by patients than calcipotriene ointment (Br. J. Dermatol. 2003;148:326-33).

• Don’t forget coal tar. Simple, but effective, coal tar is a proven safe topical psoriasis treatment and is available in several vehicles, including solution and foam. Data from a study of more than 13,000 patients with psoriasis and eczema found that coal tar was safe, and that it did not increase the risk for skin cancer (J. Invest. Dermatol. 2010;130:953-61).

The future of topical psoriasis therapy is not static, said Dr. Stein Gold. New molecules – notably topical Janus kinase inhibitors and phosphodiesterase-4 inhibitors – are currently being explored in clinical trials.

Dr. Stein Gold disclosed relationships with Leo, Medicis, and other companies. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

Biologics and systemic therapies command much of the spotlight for treating psoriasis, but topical therapy remains an effective option for many psoriasis patients, according to Dr. Linda Stein Gold.

In fact, up to 80% of psoriasis patients can be adequately treated with topical therapy (N. Engl. J. Med. 2005;352:1899-912), said Dr. Stein Gold at the Skin Disease Education Foundation’s (SDEF’s) annual Las Vegas dermatology seminar.

She offered several principles to help clinicians make the most of topical therapies by troubleshooting potential problems.

• Check the amount. One gram of most topical psoriasis products covers 4% of body surface area per application, so a 60-gram tube should treat 4% of body surface area for a month, said Dr. Stein Gold, citing guidelines developed by Dr. Alan Menter and his colleagues and approved by the American Academy of Dermatology in 2009.

• Don’t miss corticosteroid allergies. "We are missing this," said Dr. Stein Gold, director of dermatology research at Henry Ford Hospital in Detroit. Suspect a possible allergy if a patient returns with a worsening rash after using hydrocortisone, for example. Data have shown that between 0.2% and 5% of all dermatitis patients have a steroid allergy. "Allergy to the active molecule or to the vehicle should be suspected in all patients who don’t respond as expected to topical steroids," she noted.

• Visit (or revisit) vitamin D. Another plus for topical therapy is the usefulness of topical vitamin D for tricky areas, such as the forehead, armpit, groin, and the area behind the ears. Data from a randomized trial of 75 patients found calcitriol ointment to be significantly more effective against target lesions and better tolerated by patients than calcipotriene ointment (Br. J. Dermatol. 2003;148:326-33).

• Don’t forget coal tar. Simple, but effective, coal tar is a proven safe topical psoriasis treatment and is available in several vehicles, including solution and foam. Data from a study of more than 13,000 patients with psoriasis and eczema found that coal tar was safe, and that it did not increase the risk for skin cancer (J. Invest. Dermatol. 2010;130:953-61).

The future of topical psoriasis therapy is not static, said Dr. Stein Gold. New molecules – notably topical Janus kinase inhibitors and phosphodiesterase-4 inhibitors – are currently being explored in clinical trials.

Dr. Stein Gold disclosed relationships with Leo, Medicis, and other companies. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

Biologics and systemic therapies command much of the spotlight for treating psoriasis, but topical therapy remains an effective option for many psoriasis patients, according to Dr. Linda Stein Gold.

In fact, up to 80% of psoriasis patients can be adequately treated with topical therapy (N. Engl. J. Med. 2005;352:1899-912), said Dr. Stein Gold at the Skin Disease Education Foundation’s (SDEF’s) annual Las Vegas dermatology seminar.

She offered several principles to help clinicians make the most of topical therapies by troubleshooting potential problems.

• Check the amount. One gram of most topical psoriasis products covers 4% of body surface area per application, so a 60-gram tube should treat 4% of body surface area for a month, said Dr. Stein Gold, citing guidelines developed by Dr. Alan Menter and his colleagues and approved by the American Academy of Dermatology in 2009.

• Don’t miss corticosteroid allergies. "We are missing this," said Dr. Stein Gold, director of dermatology research at Henry Ford Hospital in Detroit. Suspect a possible allergy if a patient returns with a worsening rash after using hydrocortisone, for example. Data have shown that between 0.2% and 5% of all dermatitis patients have a steroid allergy. "Allergy to the active molecule or to the vehicle should be suspected in all patients who don’t respond as expected to topical steroids," she noted.

• Visit (or revisit) vitamin D. Another plus for topical therapy is the usefulness of topical vitamin D for tricky areas, such as the forehead, armpit, groin, and the area behind the ears. Data from a randomized trial of 75 patients found calcitriol ointment to be significantly more effective against target lesions and better tolerated by patients than calcipotriene ointment (Br. J. Dermatol. 2003;148:326-33).

• Don’t forget coal tar. Simple, but effective, coal tar is a proven safe topical psoriasis treatment and is available in several vehicles, including solution and foam. Data from a study of more than 13,000 patients with psoriasis and eczema found that coal tar was safe, and that it did not increase the risk for skin cancer (J. Invest. Dermatol. 2010;130:953-61).

The future of topical psoriasis therapy is not static, said Dr. Stein Gold. New molecules – notably topical Janus kinase inhibitors and phosphodiesterase-4 inhibitors – are currently being explored in clinical trials.

Dr. Stein Gold disclosed relationships with Leo, Medicis, and other companies. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

Biologics and systemic therapies command much of the spotlight for treating psoriasis, but topical therapy remains an effective option for many psoriasis patients, according to Dr. Linda Stein Gold.

In fact, up to 80% of psoriasis patients can be adequately treated with topical therapy (N. Engl. J. Med. 2005;352:1899-912), said Dr. Stein Gold at the Skin Disease Education Foundation’s (SDEF’s) annual Las Vegas dermatology seminar.

She offered several principles to help clinicians make the most of topical therapies by troubleshooting potential problems.

• Check the amount. One gram of most topical psoriasis products covers 4% of body surface area per application, so a 60-gram tube should treat 4% of body surface area for a month, said Dr. Stein Gold, citing guidelines developed by Dr. Alan Menter and his colleagues and approved by the American Academy of Dermatology in 2009.

• Don’t miss corticosteroid allergies. "We are missing this," said Dr. Stein Gold, director of dermatology research at Henry Ford Hospital in Detroit. Suspect a possible allergy if a patient returns with a worsening rash after using hydrocortisone, for example. Data have shown that between 0.2% and 5% of all dermatitis patients have a steroid allergy. "Allergy to the active molecule or to the vehicle should be suspected in all patients who don’t respond as expected to topical steroids," she noted.

• Visit (or revisit) vitamin D. Another plus for topical therapy is the usefulness of topical vitamin D for tricky areas, such as the forehead, armpit, groin, and the area behind the ears. Data from a randomized trial of 75 patients found calcitriol ointment to be significantly more effective against target lesions and better tolerated by patients than calcipotriene ointment (Br. J. Dermatol. 2003;148:326-33).

• Don’t forget coal tar. Simple, but effective, coal tar is a proven safe topical psoriasis treatment and is available in several vehicles, including solution and foam. Data from a study of more than 13,000 patients with psoriasis and eczema found that coal tar was safe, and that it did not increase the risk for skin cancer (J. Invest. Dermatol. 2010;130:953-61).

The future of topical psoriasis therapy is not static, said Dr. Stein Gold. New molecules – notably topical Janus kinase inhibitors and phosphodiesterase-4 inhibitors – are currently being explored in clinical trials.

Dr. Stein Gold disclosed relationships with Leo, Medicis, and other companies. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

Biologics and systemic therapies command much of the spotlight for treating psoriasis, but topical therapy remains an effective option for many psoriasis patients, according to Dr. Linda Stein Gold.

In fact, up to 80% of psoriasis patients can be adequately treated with topical therapy (N. Engl. J. Med. 2005;352:1899-912), said Dr. Stein Gold at the Skin Disease Education Foundation’s (SDEF’s) annual Las Vegas dermatology seminar.

She offered several principles to help clinicians make the most of topical therapies by troubleshooting potential problems.

• Check the amount. One gram of most topical psoriasis products covers 4% of body surface area per application, so a 60-gram tube should treat 4% of body surface area for a month, said Dr. Stein Gold, citing guidelines developed by Dr. Alan Menter and his colleagues and approved by the American Academy of Dermatology in 2009.

• Don’t miss corticosteroid allergies. "We are missing this," said Dr. Stein Gold, director of dermatology research at Henry Ford Hospital in Detroit. Suspect a possible allergy if a patient returns with a worsening rash after using hydrocortisone, for example. Data have shown that between 0.2% and 5% of all dermatitis patients have a steroid allergy. "Allergy to the active molecule or to the vehicle should be suspected in all patients who don’t respond as expected to topical steroids," she noted.

• Visit (or revisit) vitamin D. Another plus for topical therapy is the usefulness of topical vitamin D for tricky areas, such as the forehead, armpit, groin, and the area behind the ears. Data from a randomized trial of 75 patients found calcitriol ointment to be significantly more effective against target lesions and better tolerated by patients than calcipotriene ointment (Br. J. Dermatol. 2003;148:326-33).

• Don’t forget coal tar. Simple, but effective, coal tar is a proven safe topical psoriasis treatment and is available in several vehicles, including solution and foam. Data from a study of more than 13,000 patients with psoriasis and eczema found that coal tar was safe, and that it did not increase the risk for skin cancer (J. Invest. Dermatol. 2010;130:953-61).

The future of topical psoriasis therapy is not static, said Dr. Stein Gold. New molecules – notably topical Janus kinase inhibitors and phosphodiesterase-4 inhibitors – are currently being explored in clinical trials.

Dr. Stein Gold disclosed relationships with Leo, Medicis, and other companies. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

WASHINGTON – Vaccination against the flu is on an upswing in the United States, with more than half of eligible children receiving the vaccine last year, but it’s important to keep the momentum going and encourage early vaccination this season, according to a panel of health care professionals.

"Don’t hesitate, vaccinate," said Dr. Howard K. Koh, assistant secretary for health at the U.S. Department for Health and Human Services. Dr. Koh was one of several health officials, who spoke today at a press conference sponsored by the National Foundation for Infectious Diseases (NFID).

Heidi Splete/IMNG Medical Media

This year, an ample supply and multiple choices of vaccines should make it easy for health care providers to get vaccinated themselves and promote vaccination for their patients, said Dr. Koh. The Affordable Care Act provides coverage of all recommended vaccines, including flu vaccine, he noted. The flu is "predictably unpredictable" and hit hard and early last year, so there is no reason to delay vaccination, he said.

Flu vaccination for children aged 6 months to 17 years reached an all-time high of 57% last year, a 5% increase from the previous year, said Dr. Anne Schuchat, assistant surgeon general and director of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases. Flu vaccination is now recommended for everyone, and even the historically vaccination-resistant 18-49-year-old age group showed an increase to 31% last year, up 2.5% from the 2010-2011 season, which is encouraging, Dr. Schuchat said.

Approximately 135 million influenza vaccine doses are expected to be available in locations including doctors’ offices, hospitals, pharmacies, and workplaces, said Dr. William Schaffner, immediate past president of the NFID and an infectious disease specialist at Vanderbilt University Hospital in Nashville, Tenn.

This year’s options include not only the trivalent vaccine but also a quadrivalent option that is designed to provide immunity to two types of A and two types of B influenza strains. The quadrivalent vaccine is available as a standard intramuscular shot and as a nasal spray. The trivalent vaccine is available in five variations: a standard intramuscular shot, an egg-free shot, a transdermal shot (smaller needles, for the needle-phobic), a high-dose vaccine specifically for adults aged 65 years and older, and a cell-culture vaccine (for adults aged 18 years and older). Additional details for health care professionals about the different types of vaccines and this year’s flu outlook are available on the CDC’s seasonal flu website.

Overall, 72% of health care personnel were vaccinated against the flu last year, including 92% of physicians, based on data from an Internet survey, Physician assistants, nurses, nurse practitioners, and pharmacists had vaccination rates greater than 80%, while nonclinical health care personnel, such as housekeeping and food service staff, came in at 65%.

In addition to keeping their patients safe by getting vaccinated themselves, clinicians can boost flu vaccination rates for their patients by discussing the benefits with them, said Dr. Schuchat. For example, data show that pregnant women are significantly more likely to be vaccinated against the flu if their doctor recommends the vaccine and makes it available in the office, she said.

Several online tools related to the flu and flu vaccination are available this season via vaccines.gov. The tools can be used by consumers as well as clinicians, and include an interactive map that tracks vaccination patterns in communities and a vaccine finder that allows users to type in their zip code and identify places close to home where the flu vaccine is available.

[email protected]

On Twitter @hsplete

WASHINGTON – Vaccination against the flu is on an upswing in the United States, with more than half of eligible children receiving the vaccine last year, but it’s important to keep the momentum going and encourage early vaccination this season, according to a panel of health care professionals.

"Don’t hesitate, vaccinate," said Dr. Howard K. Koh, assistant secretary for health at the U.S. Department for Health and Human Services. Dr. Koh was one of several health officials, who spoke today at a press conference sponsored by the National Foundation for Infectious Diseases (NFID).

Heidi Splete/IMNG Medical Media

This year, an ample supply and multiple choices of vaccines should make it easy for health care providers to get vaccinated themselves and promote vaccination for their patients, said Dr. Koh. The Affordable Care Act provides coverage of all recommended vaccines, including flu vaccine, he noted. The flu is "predictably unpredictable" and hit hard and early last year, so there is no reason to delay vaccination, he said.

Flu vaccination for children aged 6 months to 17 years reached an all-time high of 57% last year, a 5% increase from the previous year, said Dr. Anne Schuchat, assistant surgeon general and director of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases. Flu vaccination is now recommended for everyone, and even the historically vaccination-resistant 18-49-year-old age group showed an increase to 31% last year, up 2.5% from the 2010-2011 season, which is encouraging, Dr. Schuchat said.

Approximately 135 million influenza vaccine doses are expected to be available in locations including doctors’ offices, hospitals, pharmacies, and workplaces, said Dr. William Schaffner, immediate past president of the NFID and an infectious disease specialist at Vanderbilt University Hospital in Nashville, Tenn.

This year’s options include not only the trivalent vaccine but also a quadrivalent option that is designed to provide immunity to two types of A and two types of B influenza strains. The quadrivalent vaccine is available as a standard intramuscular shot and as a nasal spray. The trivalent vaccine is available in five variations: a standard intramuscular shot, an egg-free shot, a transdermal shot (smaller needles, for the needle-phobic), a high-dose vaccine specifically for adults aged 65 years and older, and a cell-culture vaccine (for adults aged 18 years and older). Additional details for health care professionals about the different types of vaccines and this year’s flu outlook are available on the CDC’s seasonal flu website.

Overall, 72% of health care personnel were vaccinated against the flu last year, including 92% of physicians, based on data from an Internet survey, Physician assistants, nurses, nurse practitioners, and pharmacists had vaccination rates greater than 80%, while nonclinical health care personnel, such as housekeeping and food service staff, came in at 65%.

In addition to keeping their patients safe by getting vaccinated themselves, clinicians can boost flu vaccination rates for their patients by discussing the benefits with them, said Dr. Schuchat. For example, data show that pregnant women are significantly more likely to be vaccinated against the flu if their doctor recommends the vaccine and makes it available in the office, she said.

Several online tools related to the flu and flu vaccination are available this season via vaccines.gov. The tools can be used by consumers as well as clinicians, and include an interactive map that tracks vaccination patterns in communities and a vaccine finder that allows users to type in their zip code and identify places close to home where the flu vaccine is available.

[email protected]

On Twitter @hsplete

WASHINGTON – Vaccination against the flu is on an upswing in the United States, with more than half of eligible children receiving the vaccine last year, but it’s important to keep the momentum going and encourage early vaccination this season, according to a panel of health care professionals.

"Don’t hesitate, vaccinate," said Dr. Howard K. Koh, assistant secretary for health at the U.S. Department for Health and Human Services. Dr. Koh was one of several health officials, who spoke today at a press conference sponsored by the National Foundation for Infectious Diseases (NFID).

Heidi Splete/IMNG Medical Media

This year, an ample supply and multiple choices of vaccines should make it easy for health care providers to get vaccinated themselves and promote vaccination for their patients, said Dr. Koh. The Affordable Care Act provides coverage of all recommended vaccines, including flu vaccine, he noted. The flu is "predictably unpredictable" and hit hard and early last year, so there is no reason to delay vaccination, he said.

Flu vaccination for children aged 6 months to 17 years reached an all-time high of 57% last year, a 5% increase from the previous year, said Dr. Anne Schuchat, assistant surgeon general and director of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases. Flu vaccination is now recommended for everyone, and even the historically vaccination-resistant 18-49-year-old age group showed an increase to 31% last year, up 2.5% from the 2010-2011 season, which is encouraging, Dr. Schuchat said.

Approximately 135 million influenza vaccine doses are expected to be available in locations including doctors’ offices, hospitals, pharmacies, and workplaces, said Dr. William Schaffner, immediate past president of the NFID and an infectious disease specialist at Vanderbilt University Hospital in Nashville, Tenn.

This year’s options include not only the trivalent vaccine but also a quadrivalent option that is designed to provide immunity to two types of A and two types of B influenza strains. The quadrivalent vaccine is available as a standard intramuscular shot and as a nasal spray. The trivalent vaccine is available in five variations: a standard intramuscular shot, an egg-free shot, a transdermal shot (smaller needles, for the needle-phobic), a high-dose vaccine specifically for adults aged 65 years and older, and a cell-culture vaccine (for adults aged 18 years and older). Additional details for health care professionals about the different types of vaccines and this year’s flu outlook are available on the CDC’s seasonal flu website.

Overall, 72% of health care personnel were vaccinated against the flu last year, including 92% of physicians, based on data from an Internet survey, Physician assistants, nurses, nurse practitioners, and pharmacists had vaccination rates greater than 80%, while nonclinical health care personnel, such as housekeeping and food service staff, came in at 65%.

In addition to keeping their patients safe by getting vaccinated themselves, clinicians can boost flu vaccination rates for their patients by discussing the benefits with them, said Dr. Schuchat. For example, data show that pregnant women are significantly more likely to be vaccinated against the flu if their doctor recommends the vaccine and makes it available in the office, she said.

Several online tools related to the flu and flu vaccination are available this season via vaccines.gov. The tools can be used by consumers as well as clinicians, and include an interactive map that tracks vaccination patterns in communities and a vaccine finder that allows users to type in their zip code and identify places close to home where the flu vaccine is available.

[email protected]

On Twitter @hsplete

Physicians miss 99.9% of their opportunities to counsel patients about use of sunscreen, and dermatologists pass up 98% of those teaching moments, based on data from approximately 18 billion patient visits recorded between January 1989 and December 2010. The findings were published online on Sept. 4 in JAMA Dermatology.

Despite the rising incidence of skin cancer and recommendations from medical organizations that clinicians counsel patients about sun-protective behaviors, "sun-protection counseling ranks among the lowest topics of primary prevention discussed between physicians and patients," said Dr. Kristie Akamine of Wake Forest University in Winston-Salem, N.C., and her colleagues.

To identify trends in sunscreen recommendations by different specialties, the researchers reviewed data from the National Ambulatory Medical Care Survey (NAMCS), an ongoing survey conducted by the National Center for Health Statistics (JAMA Dermatol. 2013 Sept. 4 [doi:10.1001/jamadermatol.2013.4741]).

Thinkstockphotos.com

Overall, sunscreen was recommended at only 12.9 million of 18.3 billion patient visits (0.07%). Most of the appointments at which sunscreen was recommended were visits to a dermatologist (86%), followed by visits to family physicians or general practitioners (10%), pediatricians (1.4%), other specialists (1.4%), and internists (1.1%).

Although dermatologists were the most frequent recommenders of sunscreen, the mention of sunscreen was recorded at only 1.6% of all dermatology visits and 11% of visits associated with a diagnosis of skin cancer, the researchers said. Of note, dermatologists recommended use of sunscreen to skin cancer patients less frequently than did general/family physicians (11% vs. 56%), they added.

Overall, sunscreen was least often recommended for children younger than 10 years; by contrast, patients in their 70s were most likely to receive a recommendation for sunscreen use.

In addition, white patients were nine times more likely than black patients to receive a recommendation for sunscreen use.

Across all specialties, patients with a diagnosis of actinic keratosis accounted for 21% of the visits at which sunscreen was recommended.

The study was limited by several factors, including the cross-sectional nature of the data, which included both new and follow-up visits, and the lack of information about whether sunscreen was discussed at an earlier visit or not documented by the physician on the survey report, Dr. Akamine and her associates noted.

The results, however, suggest that sunscreen use recommendation is less frequent than advised by multiple medical organizations. "The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protection behaviors, which patients should be counseled about at outpatient visits," the researchers said.

Lead author Dr. Akamine had no financial conflicts to disclose. Corresponding author Dr. Steven Feldman disclosed financial relationships with multiple pharmaceutical companies, but this study was not sponsored by a pharmaceutical company.

[email protected]

On Twitter @hsplete

Physicians miss 99.9% of their opportunities to counsel patients about use of sunscreen, and dermatologists pass up 98% of those teaching moments, based on data from approximately 18 billion patient visits recorded between January 1989 and December 2010. The findings were published online on Sept. 4 in JAMA Dermatology.

Despite the rising incidence of skin cancer and recommendations from medical organizations that clinicians counsel patients about sun-protective behaviors, "sun-protection counseling ranks among the lowest topics of primary prevention discussed between physicians and patients," said Dr. Kristie Akamine of Wake Forest University in Winston-Salem, N.C., and her colleagues.

To identify trends in sunscreen recommendations by different specialties, the researchers reviewed data from the National Ambulatory Medical Care Survey (NAMCS), an ongoing survey conducted by the National Center for Health Statistics (JAMA Dermatol. 2013 Sept. 4 [doi:10.1001/jamadermatol.2013.4741]).

Thinkstockphotos.com

Overall, sunscreen was recommended at only 12.9 million of 18.3 billion patient visits (0.07%). Most of the appointments at which sunscreen was recommended were visits to a dermatologist (86%), followed by visits to family physicians or general practitioners (10%), pediatricians (1.4%), other specialists (1.4%), and internists (1.1%).

Although dermatologists were the most frequent recommenders of sunscreen, the mention of sunscreen was recorded at only 1.6% of all dermatology visits and 11% of visits associated with a diagnosis of skin cancer, the researchers said. Of note, dermatologists recommended use of sunscreen to skin cancer patients less frequently than did general/family physicians (11% vs. 56%), they added.

Overall, sunscreen was least often recommended for children younger than 10 years; by contrast, patients in their 70s were most likely to receive a recommendation for sunscreen use.

In addition, white patients were nine times more likely than black patients to receive a recommendation for sunscreen use.

Across all specialties, patients with a diagnosis of actinic keratosis accounted for 21% of the visits at which sunscreen was recommended.

The study was limited by several factors, including the cross-sectional nature of the data, which included both new and follow-up visits, and the lack of information about whether sunscreen was discussed at an earlier visit or not documented by the physician on the survey report, Dr. Akamine and her associates noted.

The results, however, suggest that sunscreen use recommendation is less frequent than advised by multiple medical organizations. "The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protection behaviors, which patients should be counseled about at outpatient visits," the researchers said.

Lead author Dr. Akamine had no financial conflicts to disclose. Corresponding author Dr. Steven Feldman disclosed financial relationships with multiple pharmaceutical companies, but this study was not sponsored by a pharmaceutical company.

[email protected]

On Twitter @hsplete

Physicians miss 99.9% of their opportunities to counsel patients about use of sunscreen, and dermatologists pass up 98% of those teaching moments, based on data from approximately 18 billion patient visits recorded between January 1989 and December 2010. The findings were published online on Sept. 4 in JAMA Dermatology.

Despite the rising incidence of skin cancer and recommendations from medical organizations that clinicians counsel patients about sun-protective behaviors, "sun-protection counseling ranks among the lowest topics of primary prevention discussed between physicians and patients," said Dr. Kristie Akamine of Wake Forest University in Winston-Salem, N.C., and her colleagues.

To identify trends in sunscreen recommendations by different specialties, the researchers reviewed data from the National Ambulatory Medical Care Survey (NAMCS), an ongoing survey conducted by the National Center for Health Statistics (JAMA Dermatol. 2013 Sept. 4 [doi:10.1001/jamadermatol.2013.4741]).

Thinkstockphotos.com

Overall, sunscreen was recommended at only 12.9 million of 18.3 billion patient visits (0.07%). Most of the appointments at which sunscreen was recommended were visits to a dermatologist (86%), followed by visits to family physicians or general practitioners (10%), pediatricians (1.4%), other specialists (1.4%), and internists (1.1%).

Although dermatologists were the most frequent recommenders of sunscreen, the mention of sunscreen was recorded at only 1.6% of all dermatology visits and 11% of visits associated with a diagnosis of skin cancer, the researchers said. Of note, dermatologists recommended use of sunscreen to skin cancer patients less frequently than did general/family physicians (11% vs. 56%), they added.

Overall, sunscreen was least often recommended for children younger than 10 years; by contrast, patients in their 70s were most likely to receive a recommendation for sunscreen use.

In addition, white patients were nine times more likely than black patients to receive a recommendation for sunscreen use.

Across all specialties, patients with a diagnosis of actinic keratosis accounted for 21% of the visits at which sunscreen was recommended.

The study was limited by several factors, including the cross-sectional nature of the data, which included both new and follow-up visits, and the lack of information about whether sunscreen was discussed at an earlier visit or not documented by the physician on the survey report, Dr. Akamine and her associates noted.

The results, however, suggest that sunscreen use recommendation is less frequent than advised by multiple medical organizations. "The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protection behaviors, which patients should be counseled about at outpatient visits," the researchers said.

Lead author Dr. Akamine had no financial conflicts to disclose. Corresponding author Dr. Steven Feldman disclosed financial relationships with multiple pharmaceutical companies, but this study was not sponsored by a pharmaceutical company.

[email protected]

On Twitter @hsplete

Fair-skinned people are known to be at higher risk for skin cancer and other problems associated with too much exposure to the sun. But people with skin of color are also vulnerable to the harmful effects of ultraviolet rays emitted by both the sun and indoor tanning beds, said Dr. Adam Friedman, director of dermatologic research, division of dermatology, Montefiore Medical Center in New York.

"Darker skin has more reactive melanocytes, or pigment-making cells, and has more and stronger melanosomes, which are small packets that contain skin pigment, both of which provide some inherent protection against UV rays but not enough, he said. "This unique biological difference in darker skin causes the harmful effects of UV exposure to occur more slowly in people of color, and the effects require more direct sun exposure. But the damage does happen, from cosmetic problems such as premature aging of the skin to serious conditions such as skin cancer."

"There are three major misconceptions that I encounter with my patients in the Bronx," Dr. Friedman said.

• Darker skin makes one immune to the harmful effects of the sun.

• There is no risk of exposure on cloudy days.

• One needs to get vitamin D via sun exposure.

"All three are completely false, and ultimately they perpetuate and result in improper skin protection," he noted.

"Skin cancer is rarer in people with skin of color, but it does occur and can be extremely serious when diagnosis is delayed," Dr. Friedman said. For example, melanoma, the most deadly form of skin cancer, is more than 20 times more common in whites than in African Americans, but people with darker skin are at greater risk of late diagnosis with advanced, thicker melanomas and lower survival rates. In fact, the overall 5-year melanoma survival rate for African Americans is only 77%, versus 91% for Caucasians, he said.

"I advise all of my patients to routinely check their own skin for any changes in appearance, and to see a dermatologist annually for a full body exam," Dr. Friedman emphasized.

Traditional sunscreens, especially those containing mineral-based agents such as titanium dioxide and zinc oxide, do not blend well when used on darker skin. The resulting chalky appearance is unacceptable to many patients, Dr. Friedman said. Fortunately, new formulations are changing that.

The newer sunscreens combine several agents to both decrease the concentration needed of each and allow for a synergistic effect between them, "ultimately offering a better sunscreen formula that can blend well into any skin type," said Dr. Friedman. Patients should look for products containing micronized or nanosized zinc oxide or titanium dioxide, which do not scatter light in the visible spectrum (to which older versions of these products owe their chalky appearance) but are highly effective at blocking UV radiation, he advised. Products that combine these mineral agents with multiple chemical blockers such as ecamsule, avobenzone, and cinoxate are particularly effective and cosmetically acceptable. Patients may be most likely to use sunscreens that utilize vehicles that enhance dispersal of these ingredients to limit clumping and phase separation, such as talc and Bentone gel.

In addition, pH stabilizers such as dimethicone are important, as the skin acidity in skin of color is lower and needs to be maintained to prevent degradation of skin adhesion proteins. Dr. Friedman recommends that his skin of color patients use SPF 30 broad-spectrum sunscreen, generously applied, and lip balm with an SPF of at least 30.

Dr. Friedman often hears from patients that they avoid sunscreen because it prevents them from getting vitamin D from the sun, which they believe is the best source. "You can enjoy the best of both worlds – use sunscreen when you spend time outdoors and take a vitamin D supplement, which is a very effective way to get adequate daily intake," he said. He advises his patients to remain vigilant about how much sun exposure they get. "Sunscreen alone is not enough to protect you from skin cancer, especially between the hours of 10:00 a.m. and 2:00 p.m. I encourage all of my patients to seek shade during that time of day and wear hats, sunglasses, and protective clothing if possible," he said.

Dr. Friedman had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Fair-skinned people are known to be at higher risk for skin cancer and other problems associated with too much exposure to the sun. But people with skin of color are also vulnerable to the harmful effects of ultraviolet rays emitted by both the sun and indoor tanning beds, said Dr. Adam Friedman, director of dermatologic research, division of dermatology, Montefiore Medical Center in New York.

"Darker skin has more reactive melanocytes, or pigment-making cells, and has more and stronger melanosomes, which are small packets that contain skin pigment, both of which provide some inherent protection against UV rays but not enough, he said. "This unique biological difference in darker skin causes the harmful effects of UV exposure to occur more slowly in people of color, and the effects require more direct sun exposure. But the damage does happen, from cosmetic problems such as premature aging of the skin to serious conditions such as skin cancer."

"There are three major misconceptions that I encounter with my patients in the Bronx," Dr. Friedman said.

• Darker skin makes one immune to the harmful effects of the sun.

• There is no risk of exposure on cloudy days.

• One needs to get vitamin D via sun exposure.

"All three are completely false, and ultimately they perpetuate and result in improper skin protection," he noted.

"Skin cancer is rarer in people with skin of color, but it does occur and can be extremely serious when diagnosis is delayed," Dr. Friedman said. For example, melanoma, the most deadly form of skin cancer, is more than 20 times more common in whites than in African Americans, but people with darker skin are at greater risk of late diagnosis with advanced, thicker melanomas and lower survival rates. In fact, the overall 5-year melanoma survival rate for African Americans is only 77%, versus 91% for Caucasians, he said.

"I advise all of my patients to routinely check their own skin for any changes in appearance, and to see a dermatologist annually for a full body exam," Dr. Friedman emphasized.

Traditional sunscreens, especially those containing mineral-based agents such as titanium dioxide and zinc oxide, do not blend well when used on darker skin. The resulting chalky appearance is unacceptable to many patients, Dr. Friedman said. Fortunately, new formulations are changing that.

The newer sunscreens combine several agents to both decrease the concentration needed of each and allow for a synergistic effect between them, "ultimately offering a better sunscreen formula that can blend well into any skin type," said Dr. Friedman. Patients should look for products containing micronized or nanosized zinc oxide or titanium dioxide, which do not scatter light in the visible spectrum (to which older versions of these products owe their chalky appearance) but are highly effective at blocking UV radiation, he advised. Products that combine these mineral agents with multiple chemical blockers such as ecamsule, avobenzone, and cinoxate are particularly effective and cosmetically acceptable. Patients may be most likely to use sunscreens that utilize vehicles that enhance dispersal of these ingredients to limit clumping and phase separation, such as talc and Bentone gel.

In addition, pH stabilizers such as dimethicone are important, as the skin acidity in skin of color is lower and needs to be maintained to prevent degradation of skin adhesion proteins. Dr. Friedman recommends that his skin of color patients use SPF 30 broad-spectrum sunscreen, generously applied, and lip balm with an SPF of at least 30.

Dr. Friedman often hears from patients that they avoid sunscreen because it prevents them from getting vitamin D from the sun, which they believe is the best source. "You can enjoy the best of both worlds – use sunscreen when you spend time outdoors and take a vitamin D supplement, which is a very effective way to get adequate daily intake," he said. He advises his patients to remain vigilant about how much sun exposure they get. "Sunscreen alone is not enough to protect you from skin cancer, especially between the hours of 10:00 a.m. and 2:00 p.m. I encourage all of my patients to seek shade during that time of day and wear hats, sunglasses, and protective clothing if possible," he said.

Dr. Friedman had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Fair-skinned people are known to be at higher risk for skin cancer and other problems associated with too much exposure to the sun. But people with skin of color are also vulnerable to the harmful effects of ultraviolet rays emitted by both the sun and indoor tanning beds, said Dr. Adam Friedman, director of dermatologic research, division of dermatology, Montefiore Medical Center in New York.

"Darker skin has more reactive melanocytes, or pigment-making cells, and has more and stronger melanosomes, which are small packets that contain skin pigment, both of which provide some inherent protection against UV rays but not enough, he said. "This unique biological difference in darker skin causes the harmful effects of UV exposure to occur more slowly in people of color, and the effects require more direct sun exposure. But the damage does happen, from cosmetic problems such as premature aging of the skin to serious conditions such as skin cancer."

"There are three major misconceptions that I encounter with my patients in the Bronx," Dr. Friedman said.

• Darker skin makes one immune to the harmful effects of the sun.

• There is no risk of exposure on cloudy days.

• One needs to get vitamin D via sun exposure.

"All three are completely false, and ultimately they perpetuate and result in improper skin protection," he noted.

"Skin cancer is rarer in people with skin of color, but it does occur and can be extremely serious when diagnosis is delayed," Dr. Friedman said. For example, melanoma, the most deadly form of skin cancer, is more than 20 times more common in whites than in African Americans, but people with darker skin are at greater risk of late diagnosis with advanced, thicker melanomas and lower survival rates. In fact, the overall 5-year melanoma survival rate for African Americans is only 77%, versus 91% for Caucasians, he said.

"I advise all of my patients to routinely check their own skin for any changes in appearance, and to see a dermatologist annually for a full body exam," Dr. Friedman emphasized.

Traditional sunscreens, especially those containing mineral-based agents such as titanium dioxide and zinc oxide, do not blend well when used on darker skin. The resulting chalky appearance is unacceptable to many patients, Dr. Friedman said. Fortunately, new formulations are changing that.

The newer sunscreens combine several agents to both decrease the concentration needed of each and allow for a synergistic effect between them, "ultimately offering a better sunscreen formula that can blend well into any skin type," said Dr. Friedman. Patients should look for products containing micronized or nanosized zinc oxide or titanium dioxide, which do not scatter light in the visible spectrum (to which older versions of these products owe their chalky appearance) but are highly effective at blocking UV radiation, he advised. Products that combine these mineral agents with multiple chemical blockers such as ecamsule, avobenzone, and cinoxate are particularly effective and cosmetically acceptable. Patients may be most likely to use sunscreens that utilize vehicles that enhance dispersal of these ingredients to limit clumping and phase separation, such as talc and Bentone gel.

In addition, pH stabilizers such as dimethicone are important, as the skin acidity in skin of color is lower and needs to be maintained to prevent degradation of skin adhesion proteins. Dr. Friedman recommends that his skin of color patients use SPF 30 broad-spectrum sunscreen, generously applied, and lip balm with an SPF of at least 30.

Dr. Friedman often hears from patients that they avoid sunscreen because it prevents them from getting vitamin D from the sun, which they believe is the best source. "You can enjoy the best of both worlds – use sunscreen when you spend time outdoors and take a vitamin D supplement, which is a very effective way to get adequate daily intake," he said. He advises his patients to remain vigilant about how much sun exposure they get. "Sunscreen alone is not enough to protect you from skin cancer, especially between the hours of 10:00 a.m. and 2:00 p.m. I encourage all of my patients to seek shade during that time of day and wear hats, sunglasses, and protective clothing if possible," he said.

Dr. Friedman had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Fair-skinned people are known to be at higher risk for skin cancer and other problems associated with too much exposure to the sun. But people with skin of color are also vulnerable to the harmful effects of ultraviolet rays emitted by both the sun and indoor tanning beds, said Dr. Adam Friedman, director of dermatologic research, division of dermatology, Montefiore Medical Center in New York.

"Darker skin has more reactive melanocytes, or pigment-making cells, and has more and stronger melanosomes, which are small packets that contain skin pigment, both of which provide some inherent protection against UV rays but not enough, he said. "This unique biological difference in darker skin causes the harmful effects of UV exposure to occur more slowly in people of color, and the effects require more direct sun exposure. But the damage does happen, from cosmetic problems such as premature aging of the skin to serious conditions such as skin cancer."

"There are three major misconceptions that I encounter with my patients in the Bronx," Dr. Friedman said.

• Darker skin makes one immune to the harmful effects of the sun.

• There is no risk of exposure on cloudy days.

• One needs to get vitamin D via sun exposure.

"All three are completely false, and ultimately they perpetuate and result in improper skin protection," he noted.

"Skin cancer is rarer in people with skin of color, but it does occur and can be extremely serious when diagnosis is delayed," Dr. Friedman said. For example, melanoma, the most deadly form of skin cancer, is more than 20 times more common in whites than in African Americans, but people with darker skin are at greater risk of late diagnosis with advanced, thicker melanomas and lower survival rates. In fact, the overall 5-year melanoma survival rate for African Americans is only 77%, versus 91% for Caucasians, he said.

"I advise all of my patients to routinely check their own skin for any changes in appearance, and to see a dermatologist annually for a full body exam," Dr. Friedman emphasized.

Traditional sunscreens, especially those containing mineral-based agents such as titanium dioxide and zinc oxide, do not blend well when used on darker skin. The resulting chalky appearance is unacceptable to many patients, Dr. Friedman said. Fortunately, new formulations are changing that.

The newer sunscreens combine several agents to both decrease the concentration needed of each and allow for a synergistic effect between them, "ultimately offering a better sunscreen formula that can blend well into any skin type," said Dr. Friedman. Patients should look for products containing micronized or nanosized zinc oxide or titanium dioxide, which do not scatter light in the visible spectrum (to which older versions of these products owe their chalky appearance) but are highly effective at blocking UV radiation, he advised. Products that combine these mineral agents with multiple chemical blockers such as ecamsule, avobenzone, and cinoxate are particularly effective and cosmetically acceptable. Patients may be most likely to use sunscreens that utilize vehicles that enhance dispersal of these ingredients to limit clumping and phase separation, such as talc and Bentone gel.

In addition, pH stabilizers such as dimethicone are important, as the skin acidity in skin of color is lower and needs to be maintained to prevent degradation of skin adhesion proteins. Dr. Friedman recommends that his skin of color patients use SPF 30 broad-spectrum sunscreen, generously applied, and lip balm with an SPF of at least 30.

Dr. Friedman often hears from patients that they avoid sunscreen because it prevents them from getting vitamin D from the sun, which they believe is the best source. "You can enjoy the best of both worlds – use sunscreen when you spend time outdoors and take a vitamin D supplement, which is a very effective way to get adequate daily intake," he said. He advises his patients to remain vigilant about how much sun exposure they get. "Sunscreen alone is not enough to protect you from skin cancer, especially between the hours of 10:00 a.m. and 2:00 p.m. I encourage all of my patients to seek shade during that time of day and wear hats, sunglasses, and protective clothing if possible," he said.

Dr. Friedman had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Fair-skinned people are known to be at higher risk for skin cancer and other problems associated with too much exposure to the sun. But people with skin of color are also vulnerable to the harmful effects of ultraviolet rays emitted by both the sun and indoor tanning beds, said Dr. Adam Friedman, director of dermatologic research, division of dermatology, Montefiore Medical Center in New York.

"Darker skin has more reactive melanocytes, or pigment-making cells, and has more and stronger melanosomes, which are small packets that contain skin pigment, both of which provide some inherent protection against UV rays but not enough, he said. "This unique biological difference in darker skin causes the harmful effects of UV exposure to occur more slowly in people of color, and the effects require more direct sun exposure. But the damage does happen, from cosmetic problems such as premature aging of the skin to serious conditions such as skin cancer."

"There are three major misconceptions that I encounter with my patients in the Bronx," Dr. Friedman said.

• Darker skin makes one immune to the harmful effects of the sun.

• There is no risk of exposure on cloudy days.

• One needs to get vitamin D via sun exposure.

"All three are completely false, and ultimately they perpetuate and result in improper skin protection," he noted.

"Skin cancer is rarer in people with skin of color, but it does occur and can be extremely serious when diagnosis is delayed," Dr. Friedman said. For example, melanoma, the most deadly form of skin cancer, is more than 20 times more common in whites than in African Americans, but people with darker skin are at greater risk of late diagnosis with advanced, thicker melanomas and lower survival rates. In fact, the overall 5-year melanoma survival rate for African Americans is only 77%, versus 91% for Caucasians, he said.

"I advise all of my patients to routinely check their own skin for any changes in appearance, and to see a dermatologist annually for a full body exam," Dr. Friedman emphasized.

Traditional sunscreens, especially those containing mineral-based agents such as titanium dioxide and zinc oxide, do not blend well when used on darker skin. The resulting chalky appearance is unacceptable to many patients, Dr. Friedman said. Fortunately, new formulations are changing that.

The newer sunscreens combine several agents to both decrease the concentration needed of each and allow for a synergistic effect between them, "ultimately offering a better sunscreen formula that can blend well into any skin type," said Dr. Friedman. Patients should look for products containing micronized or nanosized zinc oxide or titanium dioxide, which do not scatter light in the visible spectrum (to which older versions of these products owe their chalky appearance) but are highly effective at blocking UV radiation, he advised. Products that combine these mineral agents with multiple chemical blockers such as ecamsule, avobenzone, and cinoxate are particularly effective and cosmetically acceptable. Patients may be most likely to use sunscreens that utilize vehicles that enhance dispersal of these ingredients to limit clumping and phase separation, such as talc and Bentone gel.

In addition, pH stabilizers such as dimethicone are important, as the skin acidity in skin of color is lower and needs to be maintained to prevent degradation of skin adhesion proteins. Dr. Friedman recommends that his skin of color patients use SPF 30 broad-spectrum sunscreen, generously applied, and lip balm with an SPF of at least 30.

Dr. Friedman often hears from patients that they avoid sunscreen because it prevents them from getting vitamin D from the sun, which they believe is the best source. "You can enjoy the best of both worlds – use sunscreen when you spend time outdoors and take a vitamin D supplement, which is a very effective way to get adequate daily intake," he said. He advises his patients to remain vigilant about how much sun exposure they get. "Sunscreen alone is not enough to protect you from skin cancer, especially between the hours of 10:00 a.m. and 2:00 p.m. I encourage all of my patients to seek shade during that time of day and wear hats, sunglasses, and protective clothing if possible," he said.

Dr. Friedman had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Fair-skinned people are known to be at higher risk for skin cancer and other problems associated with too much exposure to the sun. But people with skin of color are also vulnerable to the harmful effects of ultraviolet rays emitted by both the sun and indoor tanning beds, said Dr. Adam Friedman, director of dermatologic research, division of dermatology, Montefiore Medical Center in New York.

"Darker skin has more reactive melanocytes, or pigment-making cells, and has more and stronger melanosomes, which are small packets that contain skin pigment, both of which provide some inherent protection against UV rays but not enough, he said. "This unique biological difference in darker skin causes the harmful effects of UV exposure to occur more slowly in people of color, and the effects require more direct sun exposure. But the damage does happen, from cosmetic problems such as premature aging of the skin to serious conditions such as skin cancer."

"There are three major misconceptions that I encounter with my patients in the Bronx," Dr. Friedman said.

• Darker skin makes one immune to the harmful effects of the sun.

• There is no risk of exposure on cloudy days.

• One needs to get vitamin D via sun exposure.

"All three are completely false, and ultimately they perpetuate and result in improper skin protection," he noted.

"Skin cancer is rarer in people with skin of color, but it does occur and can be extremely serious when diagnosis is delayed," Dr. Friedman said. For example, melanoma, the most deadly form of skin cancer, is more than 20 times more common in whites than in African Americans, but people with darker skin are at greater risk of late diagnosis with advanced, thicker melanomas and lower survival rates. In fact, the overall 5-year melanoma survival rate for African Americans is only 77%, versus 91% for Caucasians, he said.

"I advise all of my patients to routinely check their own skin for any changes in appearance, and to see a dermatologist annually for a full body exam," Dr. Friedman emphasized.

Traditional sunscreens, especially those containing mineral-based agents such as titanium dioxide and zinc oxide, do not blend well when used on darker skin. The resulting chalky appearance is unacceptable to many patients, Dr. Friedman said. Fortunately, new formulations are changing that.

The newer sunscreens combine several agents to both decrease the concentration needed of each and allow for a synergistic effect between them, "ultimately offering a better sunscreen formula that can blend well into any skin type," said Dr. Friedman. Patients should look for products containing micronized or nanosized zinc oxide or titanium dioxide, which do not scatter light in the visible spectrum (to which older versions of these products owe their chalky appearance) but are highly effective at blocking UV radiation, he advised. Products that combine these mineral agents with multiple chemical blockers such as ecamsule, avobenzone, and cinoxate are particularly effective and cosmetically acceptable. Patients may be most likely to use sunscreens that utilize vehicles that enhance dispersal of these ingredients to limit clumping and phase separation, such as talc and Bentone gel.

In addition, pH stabilizers such as dimethicone are important, as the skin acidity in skin of color is lower and needs to be maintained to prevent degradation of skin adhesion proteins. Dr. Friedman recommends that his skin of color patients use SPF 30 broad-spectrum sunscreen, generously applied, and lip balm with an SPF of at least 30.

Dr. Friedman often hears from patients that they avoid sunscreen because it prevents them from getting vitamin D from the sun, which they believe is the best source. "You can enjoy the best of both worlds – use sunscreen when you spend time outdoors and take a vitamin D supplement, which is a very effective way to get adequate daily intake," he said. He advises his patients to remain vigilant about how much sun exposure they get. "Sunscreen alone is not enough to protect you from skin cancer, especially between the hours of 10:00 a.m. and 2:00 p.m. I encourage all of my patients to seek shade during that time of day and wear hats, sunglasses, and protective clothing if possible," he said.

Dr. Friedman had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Blood cultures did not improve the assessment of children hospitalized with uncomplicated skin and soft tissue infections, based on data from a review of more than 500 children. The findings were published online Aug. 5 in Pediatrics.

Some current guidelines suggest obtaining blood cultures from children with skin and soft tissue infections (SSTIs) to help identify bacteremia and prevent sepsis, but the value of the test is unknown and evidence to support its use is limited, said Dr. Jay R. Malone of the University of Oklahoma, Oklahoma City, and colleagues.

The researchers compared 482 children with uncomplicated SSTIs and 98 children with complicated SSTIs (cSSTIs) who were admitted to a single hospital between Jan. 1, 2007, and Dec. 31, 2009, for cellulitis or abscesses. The average age of the children with SSTIs was 3 years, approximately half were male. The average age of the cSSTI children was significantly older (6 years) and included significantly more males (64%). Approximately half of the children in both groups had received at least one dose of antibiotics prior to hospital admission, and about one quarter of children in both groups presented with temperatures greater than 37.9 degrees Celsius.

Overall, none of the 482 children with uncomplicated SSTIs had positive blood cultures (although 3 were contaminated), compared with 10 positive cultures (12.5%) among 98 children with cSSTIs (Pediatrics 2013 Aug. 5 [doi: 10.1542/peds.2013-1384).

However, blood cultures were significantly more frequent for children with uncomplicated SSTIs compared to those with cSSTIs (94% vs. 82%), and those who had blood cultures were significantly more likely than were those who did not have cultures to have a C-reactive protein drawn (98% vs. 74%).

"This could be a result of a greater percentage of children with cSSTI being admitted to surgical services that may perform laboratory investigations less often than medical services," the researchers noted.

The most common infection sites for the uncomplicated SSTI group were the extremities (32%) and buttocks or perineum (27%), while the most common infection sites for the cSSTI group were the face or neck (39%) and extremities (24%).

Overall, the average length of hospital stay was 3 days for children with uncomplicated SSTIs, compared with 7 days for those with cSSTIs. However, the average length of hospital stay was almost a day longer for children with uncomplicated SSTIs who had blood cultures, compared with those who did not (.91 days; a significant difference).

The study was limited by several factors, including the retrospective design, the impact of antibiotics on the blood cultures, and the limited population of children who presented to an emergency department with SSTIs and were admitted to the hospital. Yet the results show that blood cultures in children with uncomplicated SSTIs yield a very low number of positive results, and do not appear to provide clinical value, the researchers said.

"Given the limited value of these tests, physicians might reasonably limit their use to children with complicated infections," they noted.

More research is needed on several fronts, including studies to define the criteria for hospitalizing children with SSTIs and to determine the risk of bacteremia in infants younger than 60 days, they added.

The researchers had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Blood cultures did not improve the assessment of children hospitalized with uncomplicated skin and soft tissue infections, based on data from a review of more than 500 children. The findings were published online Aug. 5 in Pediatrics.

Some current guidelines suggest obtaining blood cultures from children with skin and soft tissue infections (SSTIs) to help identify bacteremia and prevent sepsis, but the value of the test is unknown and evidence to support its use is limited, said Dr. Jay R. Malone of the University of Oklahoma, Oklahoma City, and colleagues.

The researchers compared 482 children with uncomplicated SSTIs and 98 children with complicated SSTIs (cSSTIs) who were admitted to a single hospital between Jan. 1, 2007, and Dec. 31, 2009, for cellulitis or abscesses. The average age of the children with SSTIs was 3 years, approximately half were male. The average age of the cSSTI children was significantly older (6 years) and included significantly more males (64%). Approximately half of the children in both groups had received at least one dose of antibiotics prior to hospital admission, and about one quarter of children in both groups presented with temperatures greater than 37.9 degrees Celsius.

Overall, none of the 482 children with uncomplicated SSTIs had positive blood cultures (although 3 were contaminated), compared with 10 positive cultures (12.5%) among 98 children with cSSTIs (Pediatrics 2013 Aug. 5 [doi: 10.1542/peds.2013-1384).

However, blood cultures were significantly more frequent for children with uncomplicated SSTIs compared to those with cSSTIs (94% vs. 82%), and those who had blood cultures were significantly more likely than were those who did not have cultures to have a C-reactive protein drawn (98% vs. 74%).

"This could be a result of a greater percentage of children with cSSTI being admitted to surgical services that may perform laboratory investigations less often than medical services," the researchers noted.

The most common infection sites for the uncomplicated SSTI group were the extremities (32%) and buttocks or perineum (27%), while the most common infection sites for the cSSTI group were the face or neck (39%) and extremities (24%).

Overall, the average length of hospital stay was 3 days for children with uncomplicated SSTIs, compared with 7 days for those with cSSTIs. However, the average length of hospital stay was almost a day longer for children with uncomplicated SSTIs who had blood cultures, compared with those who did not (.91 days; a significant difference).

The study was limited by several factors, including the retrospective design, the impact of antibiotics on the blood cultures, and the limited population of children who presented to an emergency department with SSTIs and were admitted to the hospital. Yet the results show that blood cultures in children with uncomplicated SSTIs yield a very low number of positive results, and do not appear to provide clinical value, the researchers said.

"Given the limited value of these tests, physicians might reasonably limit their use to children with complicated infections," they noted.

More research is needed on several fronts, including studies to define the criteria for hospitalizing children with SSTIs and to determine the risk of bacteremia in infants younger than 60 days, they added.

The researchers had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Blood cultures did not improve the assessment of children hospitalized with uncomplicated skin and soft tissue infections, based on data from a review of more than 500 children. The findings were published online Aug. 5 in Pediatrics.

Some current guidelines suggest obtaining blood cultures from children with skin and soft tissue infections (SSTIs) to help identify bacteremia and prevent sepsis, but the value of the test is unknown and evidence to support its use is limited, said Dr. Jay R. Malone of the University of Oklahoma, Oklahoma City, and colleagues.

The researchers compared 482 children with uncomplicated SSTIs and 98 children with complicated SSTIs (cSSTIs) who were admitted to a single hospital between Jan. 1, 2007, and Dec. 31, 2009, for cellulitis or abscesses. The average age of the children with SSTIs was 3 years, approximately half were male. The average age of the cSSTI children was significantly older (6 years) and included significantly more males (64%). Approximately half of the children in both groups had received at least one dose of antibiotics prior to hospital admission, and about one quarter of children in both groups presented with temperatures greater than 37.9 degrees Celsius.

Overall, none of the 482 children with uncomplicated SSTIs had positive blood cultures (although 3 were contaminated), compared with 10 positive cultures (12.5%) among 98 children with cSSTIs (Pediatrics 2013 Aug. 5 [doi: 10.1542/peds.2013-1384).

However, blood cultures were significantly more frequent for children with uncomplicated SSTIs compared to those with cSSTIs (94% vs. 82%), and those who had blood cultures were significantly more likely than were those who did not have cultures to have a C-reactive protein drawn (98% vs. 74%).

"This could be a result of a greater percentage of children with cSSTI being admitted to surgical services that may perform laboratory investigations less often than medical services," the researchers noted.

The most common infection sites for the uncomplicated SSTI group were the extremities (32%) and buttocks or perineum (27%), while the most common infection sites for the cSSTI group were the face or neck (39%) and extremities (24%).

Overall, the average length of hospital stay was 3 days for children with uncomplicated SSTIs, compared with 7 days for those with cSSTIs. However, the average length of hospital stay was almost a day longer for children with uncomplicated SSTIs who had blood cultures, compared with those who did not (.91 days; a significant difference).

The study was limited by several factors, including the retrospective design, the impact of antibiotics on the blood cultures, and the limited population of children who presented to an emergency department with SSTIs and were admitted to the hospital. Yet the results show that blood cultures in children with uncomplicated SSTIs yield a very low number of positive results, and do not appear to provide clinical value, the researchers said.

"Given the limited value of these tests, physicians might reasonably limit their use to children with complicated infections," they noted.

More research is needed on several fronts, including studies to define the criteria for hospitalizing children with SSTIs and to determine the risk of bacteremia in infants younger than 60 days, they added.

The researchers had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Blood cultures did not improve the assessment of children hospitalized with uncomplicated skin and soft tissue infections, based on data from a review of more than 500 children. The findings were published online Aug. 5 in Pediatrics.

Some current guidelines suggest obtaining blood cultures from children with skin and soft tissue infections (SSTIs) to help identify bacteremia and prevent sepsis, but the value of the test is unknown and evidence to support its use is limited, said Dr. Jay R. Malone of the University of Oklahoma, Oklahoma City, and colleagues.

The researchers compared 482 children with uncomplicated SSTIs and 98 children with complicated SSTIs (cSSTIs) who were admitted to a single hospital between Jan. 1, 2007, and Dec. 31, 2009, for cellulitis or abscesses. The average age of the children with SSTIs was 3 years, approximately half were male. The average age of the cSSTI children was significantly older (6 years) and included significantly more males (64%). Approximately half of the children in both groups had received at least one dose of antibiotics prior to hospital admission, and about one quarter of children in both groups presented with temperatures greater than 37.9 degrees Celsius.

Overall, none of the 482 children with uncomplicated SSTIs had positive blood cultures (although 3 were contaminated), compared with 10 positive cultures (12.5%) among 98 children with cSSTIs (Pediatrics 2013 Aug. 5 [doi: 10.1542/peds.2013-1384).

However, blood cultures were significantly more frequent for children with uncomplicated SSTIs compared to those with cSSTIs (94% vs. 82%), and those who had blood cultures were significantly more likely than were those who did not have cultures to have a C-reactive protein drawn (98% vs. 74%).

"This could be a result of a greater percentage of children with cSSTI being admitted to surgical services that may perform laboratory investigations less often than medical services," the researchers noted.

The most common infection sites for the uncomplicated SSTI group were the extremities (32%) and buttocks or perineum (27%), while the most common infection sites for the cSSTI group were the face or neck (39%) and extremities (24%).

Overall, the average length of hospital stay was 3 days for children with uncomplicated SSTIs, compared with 7 days for those with cSSTIs. However, the average length of hospital stay was almost a day longer for children with uncomplicated SSTIs who had blood cultures, compared with those who did not (.91 days; a significant difference).

The study was limited by several factors, including the retrospective design, the impact of antibiotics on the blood cultures, and the limited population of children who presented to an emergency department with SSTIs and were admitted to the hospital. Yet the results show that blood cultures in children with uncomplicated SSTIs yield a very low number of positive results, and do not appear to provide clinical value, the researchers said.

"Given the limited value of these tests, physicians might reasonably limit their use to children with complicated infections," they noted.

More research is needed on several fronts, including studies to define the criteria for hospitalizing children with SSTIs and to determine the risk of bacteremia in infants younger than 60 days, they added.

The researchers had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Blood cultures did not improve the assessment of children hospitalized with uncomplicated skin and soft tissue infections, based on data from a review of more than 500 children. The findings were published online Aug. 5 in Pediatrics.

Some current guidelines suggest obtaining blood cultures from children with skin and soft tissue infections (SSTIs) to help identify bacteremia and prevent sepsis, but the value of the test is unknown and evidence to support its use is limited, said Dr. Jay R. Malone of the University of Oklahoma, Oklahoma City, and colleagues.

The researchers compared 482 children with uncomplicated SSTIs and 98 children with complicated SSTIs (cSSTIs) who were admitted to a single hospital between Jan. 1, 2007, and Dec. 31, 2009, for cellulitis or abscesses. The average age of the children with SSTIs was 3 years, approximately half were male. The average age of the cSSTI children was significantly older (6 years) and included significantly more males (64%). Approximately half of the children in both groups had received at least one dose of antibiotics prior to hospital admission, and about one quarter of children in both groups presented with temperatures greater than 37.9 degrees Celsius.

Overall, none of the 482 children with uncomplicated SSTIs had positive blood cultures (although 3 were contaminated), compared with 10 positive cultures (12.5%) among 98 children with cSSTIs (Pediatrics 2013 Aug. 5 [doi: 10.1542/peds.2013-1384).

However, blood cultures were significantly more frequent for children with uncomplicated SSTIs compared to those with cSSTIs (94% vs. 82%), and those who had blood cultures were significantly more likely than were those who did not have cultures to have a C-reactive protein drawn (98% vs. 74%).

"This could be a result of a greater percentage of children with cSSTI being admitted to surgical services that may perform laboratory investigations less often than medical services," the researchers noted.

The most common infection sites for the uncomplicated SSTI group were the extremities (32%) and buttocks or perineum (27%), while the most common infection sites for the cSSTI group were the face or neck (39%) and extremities (24%).

Overall, the average length of hospital stay was 3 days for children with uncomplicated SSTIs, compared with 7 days for those with cSSTIs. However, the average length of hospital stay was almost a day longer for children with uncomplicated SSTIs who had blood cultures, compared with those who did not (.91 days; a significant difference).

The study was limited by several factors, including the retrospective design, the impact of antibiotics on the blood cultures, and the limited population of children who presented to an emergency department with SSTIs and were admitted to the hospital. Yet the results show that blood cultures in children with uncomplicated SSTIs yield a very low number of positive results, and do not appear to provide clinical value, the researchers said.

"Given the limited value of these tests, physicians might reasonably limit their use to children with complicated infections," they noted.

More research is needed on several fronts, including studies to define the criteria for hospitalizing children with SSTIs and to determine the risk of bacteremia in infants younger than 60 days, they added.

The researchers had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

Blood cultures did not improve the assessment of children hospitalized with uncomplicated skin and soft tissue infections, based on data from a review of more than 500 children. The findings were published online Aug. 5 in Pediatrics.

Some current guidelines suggest obtaining blood cultures from children with skin and soft tissue infections (SSTIs) to help identify bacteremia and prevent sepsis, but the value of the test is unknown and evidence to support its use is limited, said Dr. Jay R. Malone of the University of Oklahoma, Oklahoma City, and colleagues.

The researchers compared 482 children with uncomplicated SSTIs and 98 children with complicated SSTIs (cSSTIs) who were admitted to a single hospital between Jan. 1, 2007, and Dec. 31, 2009, for cellulitis or abscesses. The average age of the children with SSTIs was 3 years, approximately half were male. The average age of the cSSTI children was significantly older (6 years) and included significantly more males (64%). Approximately half of the children in both groups had received at least one dose of antibiotics prior to hospital admission, and about one quarter of children in both groups presented with temperatures greater than 37.9 degrees Celsius.

Overall, none of the 482 children with uncomplicated SSTIs had positive blood cultures (although 3 were contaminated), compared with 10 positive cultures (12.5%) among 98 children with cSSTIs (Pediatrics 2013 Aug. 5 [doi: 10.1542/peds.2013-1384).

However, blood cultures were significantly more frequent for children with uncomplicated SSTIs compared to those with cSSTIs (94% vs. 82%), and those who had blood cultures were significantly more likely than were those who did not have cultures to have a C-reactive protein drawn (98% vs. 74%).

"This could be a result of a greater percentage of children with cSSTI being admitted to surgical services that may perform laboratory investigations less often than medical services," the researchers noted.

The most common infection sites for the uncomplicated SSTI group were the extremities (32%) and buttocks or perineum (27%), while the most common infection sites for the cSSTI group were the face or neck (39%) and extremities (24%).

Overall, the average length of hospital stay was 3 days for children with uncomplicated SSTIs, compared with 7 days for those with cSSTIs. However, the average length of hospital stay was almost a day longer for children with uncomplicated SSTIs who had blood cultures, compared with those who did not (.91 days; a significant difference).

The study was limited by several factors, including the retrospective design, the impact of antibiotics on the blood cultures, and the limited population of children who presented to an emergency department with SSTIs and were admitted to the hospital. Yet the results show that blood cultures in children with uncomplicated SSTIs yield a very low number of positive results, and do not appear to provide clinical value, the researchers said.

"Given the limited value of these tests, physicians might reasonably limit their use to children with complicated infections," they noted.

More research is needed on several fronts, including studies to define the criteria for hospitalizing children with SSTIs and to determine the risk of bacteremia in infants younger than 60 days, they added.

The researchers had no financial conflicts to disclose.

[email protected]

On Twitter @hsplete

WASHINGTON – To make scalp surgery seamless, remember what makes the scalp unique: hair and tension, Dr. Mark Welch said.

The scalp is "a bloodless plain," said Dr. Welch of the Skin Cancer Surgery Center in Bethesda, Md.

Also, the scalp is painless, so it’s possible to go beyond the field of anesthesia, he noted at the Atlantic Dermatological Conference.

To keep hair out of the surgical field, Dr. Welch uses a razor to shave the immediate area, and then tapes down the surrounding hair. "The surrounding hair will find its way into your surgery site and wound," he said. Alternatively, moistening the hair with saline or water can keep it away from the surgical field. Tubular bandaging also can be used to hold the hair away from the surgery site.

The tension on the scalp presents a unique surgical challenge, said Dr. Welch. "The scalp skin is holding the weight of the body; there’s lots of tension up there."

Dr. Welch said he starts with a temporary pulley stitch to decrease the distance across the wound, which allows easier placement of subcutaneous stitches. "Then the pulley stitch can come out," he said.

"One technique I use a lot is preplaced subcutaneous sutures," Dr. Welch said. "You leave yourself a tail long enough to tie, then go posterior to the first subcutaneous stitch, and then go back and tie the first stitch, then the second, then go to the external stitches."

Dr. Welch said he uses a running stitch for external stitches. "On the last external running stitch, go out and come back in on the same side, and angle it back slightly." This technique allows for a more perpendicular closing to the wound edge, he explained.

Dr. Welch cited one case of a large defect in a patient with skin cancer on the scalp. He opted for a pulley stitch with gel foam in the center, and some silver nitrate. The wound was essentially healed in 8 weeks, even without the defect being completely closed.

For scalp dressings, Dr. Welch said he often prefers a Xeroform gauze bolster, which he sews in place, "so we don’t have to use any tape." When the stitches come out after a week, flexible collodion can be used. "It hardens, and over the next 3 or 4 weeks of shampooing, it flakes off."

When using wraps, Dr. Welch recommends combining vertical and horizontal wraps to create tension and promote healing.

He said he had no financial conflicts to disclose.

[email protected]

WASHINGTON – To make scalp surgery seamless, remember what makes the scalp unique: hair and tension, Dr. Mark Welch said.

The scalp is "a bloodless plain," said Dr. Welch of the Skin Cancer Surgery Center in Bethesda, Md.

Also, the scalp is painless, so it’s possible to go beyond the field of anesthesia, he noted at the Atlantic Dermatological Conference.

To keep hair out of the surgical field, Dr. Welch uses a razor to shave the immediate area, and then tapes down the surrounding hair. "The surrounding hair will find its way into your surgery site and wound," he said. Alternatively, moistening the hair with saline or water can keep it away from the surgical field. Tubular bandaging also can be used to hold the hair away from the surgery site.

The tension on the scalp presents a unique surgical challenge, said Dr. Welch. "The scalp skin is holding the weight of the body; there’s lots of tension up there."

Dr. Welch said he starts with a temporary pulley stitch to decrease the distance across the wound, which allows easier placement of subcutaneous stitches. "Then the pulley stitch can come out," he said.

"One technique I use a lot is preplaced subcutaneous sutures," Dr. Welch said. "You leave yourself a tail long enough to tie, then go posterior to the first subcutaneous stitch, and then go back and tie the first stitch, then the second, then go to the external stitches."

Dr. Welch said he uses a running stitch for external stitches. "On the last external running stitch, go out and come back in on the same side, and angle it back slightly." This technique allows for a more perpendicular closing to the wound edge, he explained.

Dr. Welch cited one case of a large defect in a patient with skin cancer on the scalp. He opted for a pulley stitch with gel foam in the center, and some silver nitrate. The wound was essentially healed in 8 weeks, even without the defect being completely closed.

For scalp dressings, Dr. Welch said he often prefers a Xeroform gauze bolster, which he sews in place, "so we don’t have to use any tape." When the stitches come out after a week, flexible collodion can be used. "It hardens, and over the next 3 or 4 weeks of shampooing, it flakes off."

When using wraps, Dr. Welch recommends combining vertical and horizontal wraps to create tension and promote healing.

He said he had no financial conflicts to disclose.

[email protected]

WASHINGTON – To make scalp surgery seamless, remember what makes the scalp unique: hair and tension, Dr. Mark Welch said.

The scalp is "a bloodless plain," said Dr. Welch of the Skin Cancer Surgery Center in Bethesda, Md.

Also, the scalp is painless, so it’s possible to go beyond the field of anesthesia, he noted at the Atlantic Dermatological Conference.

To keep hair out of the surgical field, Dr. Welch uses a razor to shave the immediate area, and then tapes down the surrounding hair. "The surrounding hair will find its way into your surgery site and wound," he said. Alternatively, moistening the hair with saline or water can keep it away from the surgical field. Tubular bandaging also can be used to hold the hair away from the surgery site.

The tension on the scalp presents a unique surgical challenge, said Dr. Welch. "The scalp skin is holding the weight of the body; there’s lots of tension up there."

Dr. Welch said he starts with a temporary pulley stitch to decrease the distance across the wound, which allows easier placement of subcutaneous stitches. "Then the pulley stitch can come out," he said.

"One technique I use a lot is preplaced subcutaneous sutures," Dr. Welch said. "You leave yourself a tail long enough to tie, then go posterior to the first subcutaneous stitch, and then go back and tie the first stitch, then the second, then go to the external stitches."

Dr. Welch said he uses a running stitch for external stitches. "On the last external running stitch, go out and come back in on the same side, and angle it back slightly." This technique allows for a more perpendicular closing to the wound edge, he explained.

Dr. Welch cited one case of a large defect in a patient with skin cancer on the scalp. He opted for a pulley stitch with gel foam in the center, and some silver nitrate. The wound was essentially healed in 8 weeks, even without the defect being completely closed.

For scalp dressings, Dr. Welch said he often prefers a Xeroform gauze bolster, which he sews in place, "so we don’t have to use any tape." When the stitches come out after a week, flexible collodion can be used. "It hardens, and over the next 3 or 4 weeks of shampooing, it flakes off."

When using wraps, Dr. Welch recommends combining vertical and horizontal wraps to create tension and promote healing.

He said he had no financial conflicts to disclose.

[email protected]

WASHINGTON – There’s a lot of anxiety about nail surgery, particularly nail biopsies, for both physicians and patients, according to Dr. Maral K. Skelsey.

The goals of successful nail surgery are threefold: avoid complications, reduce patient pain and anxiety, and optimize pathologic diagnosis, said Dr. Skelsey of Georgetown University Medical Center in Washington.

Because nail surgery is often performed to obtain a clinical diagnosis, a good specimen is needed to allow the dermatopathologist to make a diagnosis, she noted at the Atlantic Dermatological Conference.

Approach preoperative assessment for nail surgery as any other surgery, said Dr. Skelsey. Take a full history, including information about vascular impairment, arterial disease, latex allergies, and a history of anticoagulant use. "We don’t stop anticoagulants, usually," Dr. Skelsey noted, but she does assess the prothrombin time (PT/INR) within 1 week.

Also, don’t underestimate the value of an x-ray. "One thing I have found physicians don’t do often" is to x-ray to check for bony changes and any anatomic abnormalities, she said.

To help optimize nail surgery outcomes, Dr. Skelsey recommended the following preoperative instructions for patients: Remove nail polish, scrub the area with povidone-iodine twice daily for 3 days prior to surgery, bring open-toed shoes (for toenail surgeries), arrange for a ride home, and plan to elevate the hand or foot as much as possible for the first 48 hours following the procedure.

Also, it "will help reduce morbidity if you tell your patients ahead of time to reduce their exercise and activity" immediately after the procedure, she said.

The right tools "will make your nail surgery much more successful," Dr. Skelsey said. Her essential tools: a nail splitter, nail nipper, and nail elevator.

Allow the patient to recline with goggles and ear phones to reduce anxiety during the procedure, she said.

For anesthesia, "I always use a 30-gauge needle, injecting very slowly," she said. She prefers a wing block, injecting slowly at a 45-degree angle towards the bone. This injection also acts as a volumetric tourniquet.

When obtaining the specimen during nail surgery, "visualize the location of the pathology by reflecting the proximal nail fold with a suture of skin hook and full or partial nail avulsion," said Dr. Skelsey.

"You can use a punch biopsy for longitudinal melanonychia less than 3 mm," she noted, but for anything more than 3 mm, a transverse excision or shave biopsy with a tangential excision is needed.

After the biopsy, Dr. Skelsey said that she applies an absorbable gelatin sponge saturated in aluminum chloride.

"What’s very important is giving your dermatopathologist a good specimen," she said. Don’t forget to ink the margins and orient the specimen. "You don’t want to go through all this trouble and have someone tell you there is nothing there," she added. She also recommended using separate, labelled formalin jars for the nail plate, bed, and matrix.

Dr. Skelsey said that she had no financial conflicts to disclose.

[email protected]

WASHINGTON – There’s a lot of anxiety about nail surgery, particularly nail biopsies, for both physicians and patients, according to Dr. Maral K. Skelsey.

The goals of successful nail surgery are threefold: avoid complications, reduce patient pain and anxiety, and optimize pathologic diagnosis, said Dr. Skelsey of Georgetown University Medical Center in Washington.

Because nail surgery is often performed to obtain a clinical diagnosis, a good specimen is needed to allow the dermatopathologist to make a diagnosis, she noted at the Atlantic Dermatological Conference.

Approach preoperative assessment for nail surgery as any other surgery, said Dr. Skelsey. Take a full history, including information about vascular impairment, arterial disease, latex allergies, and a history of anticoagulant use. "We don’t stop anticoagulants, usually," Dr. Skelsey noted, but she does assess the prothrombin time (PT/INR) within 1 week.

Also, don’t underestimate the value of an x-ray. "One thing I have found physicians don’t do often" is to x-ray to check for bony changes and any anatomic abnormalities, she said.

To help optimize nail surgery outcomes, Dr. Skelsey recommended the following preoperative instructions for patients: Remove nail polish, scrub the area with povidone-iodine twice daily for 3 days prior to surgery, bring open-toed shoes (for toenail surgeries), arrange for a ride home, and plan to elevate the hand or foot as much as possible for the first 48 hours following the procedure.

Also, it "will help reduce morbidity if you tell your patients ahead of time to reduce their exercise and activity" immediately after the procedure, she said.

The right tools "will make your nail surgery much more successful," Dr. Skelsey said. Her essential tools: a nail splitter, nail nipper, and nail elevator.

Allow the patient to recline with goggles and ear phones to reduce anxiety during the procedure, she said.

For anesthesia, "I always use a 30-gauge needle, injecting very slowly," she said. She prefers a wing block, injecting slowly at a 45-degree angle towards the bone. This injection also acts as a volumetric tourniquet.

When obtaining the specimen during nail surgery, "visualize the location of the pathology by reflecting the proximal nail fold with a suture of skin hook and full or partial nail avulsion," said Dr. Skelsey.

"You can use a punch biopsy for longitudinal melanonychia less than 3 mm," she noted, but for anything more than 3 mm, a transverse excision or shave biopsy with a tangential excision is needed.

After the biopsy, Dr. Skelsey said that she applies an absorbable gelatin sponge saturated in aluminum chloride.

"What’s very important is giving your dermatopathologist a good specimen," she said. Don’t forget to ink the margins and orient the specimen. "You don’t want to go through all this trouble and have someone tell you there is nothing there," she added. She also recommended using separate, labelled formalin jars for the nail plate, bed, and matrix.

Dr. Skelsey said that she had no financial conflicts to disclose.

[email protected]

WASHINGTON – There’s a lot of anxiety about nail surgery, particularly nail biopsies, for both physicians and patients, according to Dr. Maral K. Skelsey.

The goals of successful nail surgery are threefold: avoid complications, reduce patient pain and anxiety, and optimize pathologic diagnosis, said Dr. Skelsey of Georgetown University Medical Center in Washington.

Because nail surgery is often performed to obtain a clinical diagnosis, a good specimen is needed to allow the dermatopathologist to make a diagnosis, she noted at the Atlantic Dermatological Conference.

Approach preoperative assessment for nail surgery as any other surgery, said Dr. Skelsey. Take a full history, including information about vascular impairment, arterial disease, latex allergies, and a history of anticoagulant use. "We don’t stop anticoagulants, usually," Dr. Skelsey noted, but she does assess the prothrombin time (PT/INR) within 1 week.

Also, don’t underestimate the value of an x-ray. "One thing I have found physicians don’t do often" is to x-ray to check for bony changes and any anatomic abnormalities, she said.

To help optimize nail surgery outcomes, Dr. Skelsey recommended the following preoperative instructions for patients: Remove nail polish, scrub the area with povidone-iodine twice daily for 3 days prior to surgery, bring open-toed shoes (for toenail surgeries), arrange for a ride home, and plan to elevate the hand or foot as much as possible for the first 48 hours following the procedure.

Also, it "will help reduce morbidity if you tell your patients ahead of time to reduce their exercise and activity" immediately after the procedure, she said.

The right tools "will make your nail surgery much more successful," Dr. Skelsey said. Her essential tools: a nail splitter, nail nipper, and nail elevator.

Allow the patient to recline with goggles and ear phones to reduce anxiety during the procedure, she said.

For anesthesia, "I always use a 30-gauge needle, injecting very slowly," she said. She prefers a wing block, injecting slowly at a 45-degree angle towards the bone. This injection also acts as a volumetric tourniquet.

When obtaining the specimen during nail surgery, "visualize the location of the pathology by reflecting the proximal nail fold with a suture of skin hook and full or partial nail avulsion," said Dr. Skelsey.

"You can use a punch biopsy for longitudinal melanonychia less than 3 mm," she noted, but for anything more than 3 mm, a transverse excision or shave biopsy with a tangential excision is needed.

After the biopsy, Dr. Skelsey said that she applies an absorbable gelatin sponge saturated in aluminum chloride.

"What’s very important is giving your dermatopathologist a good specimen," she said. Don’t forget to ink the margins and orient the specimen. "You don’t want to go through all this trouble and have someone tell you there is nothing there," she added. She also recommended using separate, labelled formalin jars for the nail plate, bed, and matrix.

Dr. Skelsey said that she had no financial conflicts to disclose.

[email protected]