Heidi Splete

ORLANDO - Limiting treatment of actinic keratoses to cryosurgery is a disservice to patients, according to Dr. Neil A. Fenske.

Every patient with AKs deserves consideration for field therapy, he said at the Orlando Dermatology Aesthetic and Clinical Conference. Mutated cells occur not only within the visible AKs, but also in the surrounding, normal-looking skin.

"Most patients don't have one AK," said Dr. Fenske of the Moffitt Cancer Center at the University of South Florida in Tampa. Data based on mathematical models suggest that 6%-10% of typical patients with an average of eight AKs will develop at least one squamous cell carcinoma over a 10-year period.

For more complete treatment, following cryosurgery with field therapy a week later. Field therapy using methyl aminolevulinate (MAL) plus a red light–emitting diode (LED) is an up-and-coming option.

MAL has a higher relative porphyrin enrichment in AKs than in normal skin, and is able to penetrate deeply compared with 5-aminolevulinic acid, Dr. Fenske explained. In addition, the red LED at 630 nm requires a lower light dose than other light options, so there is less heating of the skin.

Dr. Fenske cited a study of MAL-PDT plus red LED at 630 nm in which 14 patients with a total of 223 AKs on the scalp and face underwent two treatments. The total number of AKs decreased by 55% after the first treatment and by 62% after the second treatment. Although global photodamage scores improved, pain was an issue (J. Dermatolog. Treat. 2010;21:252-7).

Dr. Fenske said he often uses aminolevulinic acid plus blue light, but to treat and kill bacteria deep in the sebaceous glands, "I would use red light and [MAL]," he said.

Dr. Fenske disclosed serving as a consultant and speaker for Graceway Pharmaceuticals, and serving as a speaker for Sanofi-Aventis.

ORLANDO - Limiting treatment of actinic keratoses to cryosurgery is a disservice to patients, according to Dr. Neil A. Fenske.

Every patient with AKs deserves consideration for field therapy, he said at the Orlando Dermatology Aesthetic and Clinical Conference. Mutated cells occur not only within the visible AKs, but also in the surrounding, normal-looking skin.

"Most patients don't have one AK," said Dr. Fenske of the Moffitt Cancer Center at the University of South Florida in Tampa. Data based on mathematical models suggest that 6%-10% of typical patients with an average of eight AKs will develop at least one squamous cell carcinoma over a 10-year period.

For more complete treatment, following cryosurgery with field therapy a week later. Field therapy using methyl aminolevulinate (MAL) plus a red light–emitting diode (LED) is an up-and-coming option.

MAL has a higher relative porphyrin enrichment in AKs than in normal skin, and is able to penetrate deeply compared with 5-aminolevulinic acid, Dr. Fenske explained. In addition, the red LED at 630 nm requires a lower light dose than other light options, so there is less heating of the skin.

Dr. Fenske cited a study of MAL-PDT plus red LED at 630 nm in which 14 patients with a total of 223 AKs on the scalp and face underwent two treatments. The total number of AKs decreased by 55% after the first treatment and by 62% after the second treatment. Although global photodamage scores improved, pain was an issue (J. Dermatolog. Treat. 2010;21:252-7).

Dr. Fenske said he often uses aminolevulinic acid plus blue light, but to treat and kill bacteria deep in the sebaceous glands, "I would use red light and [MAL]," he said.

Dr. Fenske disclosed serving as a consultant and speaker for Graceway Pharmaceuticals, and serving as a speaker for Sanofi-Aventis.

ORLANDO - Limiting treatment of actinic keratoses to cryosurgery is a disservice to patients, according to Dr. Neil A. Fenske.

Every patient with AKs deserves consideration for field therapy, he said at the Orlando Dermatology Aesthetic and Clinical Conference. Mutated cells occur not only within the visible AKs, but also in the surrounding, normal-looking skin.

"Most patients don't have one AK," said Dr. Fenske of the Moffitt Cancer Center at the University of South Florida in Tampa. Data based on mathematical models suggest that 6%-10% of typical patients with an average of eight AKs will develop at least one squamous cell carcinoma over a 10-year period.

For more complete treatment, following cryosurgery with field therapy a week later. Field therapy using methyl aminolevulinate (MAL) plus a red light–emitting diode (LED) is an up-and-coming option.

MAL has a higher relative porphyrin enrichment in AKs than in normal skin, and is able to penetrate deeply compared with 5-aminolevulinic acid, Dr. Fenske explained. In addition, the red LED at 630 nm requires a lower light dose than other light options, so there is less heating of the skin.

Dr. Fenske cited a study of MAL-PDT plus red LED at 630 nm in which 14 patients with a total of 223 AKs on the scalp and face underwent two treatments. The total number of AKs decreased by 55% after the first treatment and by 62% after the second treatment. Although global photodamage scores improved, pain was an issue (J. Dermatolog. Treat. 2010;21:252-7).

Dr. Fenske said he often uses aminolevulinic acid plus blue light, but to treat and kill bacteria deep in the sebaceous glands, "I would use red light and [MAL]," he said.

Dr. Fenske disclosed serving as a consultant and speaker for Graceway Pharmaceuticals, and serving as a speaker for Sanofi-Aventis.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

ORLANDO – "The diameter of a single hair shaft is tens of thousands of nanometers," said Dr. Adam Friedman. Nanotechnology is the branch of technology related to dimensions and tolerances ranging from 0.1 to 100 nanometers.

"At this size, matter behaves somewhat differently," Dr. Friedman, of Albert Einstein College of Medicine in New York, said. As the size of material decreases, the surface area relative to volume decreases. There is more surface to interact with the environment.

"The three properties of matter – chemical, optical, and physical – can be manipulated and exploited at the nano scale," Dr. Friedman said. For example, something that is too bulky at the macro level to go into an aqueous vehicle can be distributed more easily in nano form. And "if something is smaller than the wavelength of visible light, guess what? It is going to be invisible," he said at the Orlando Dermatology Aesthetic and Clinical Conference.

By the year 2012, nanotechnology is predicted to be a $12 billion industry in the United States, and the cosmetic and cosmeceutical industries are leading the way, Dr. Friedman noted. He discussed several nanomaterials with diagnostic and therapeutic applications for dermatologists:

• Nanoparticles. The term nanoparticle is somewhat generic, Dr. Friedman said. The term refers to a small object that behaves as a whole unit in terms of its transport and properties. Nanoparticles can be derived from organic and nonorganic materials. For example, gold nanoparticles can be used to introduce an antibody or targeting molecule into the body to target tumors. Once the tumors are bound to the gold, they can be treated using selective photolysis, in which radiation is used to heat the gold enough to kill the tumor cells. In one study of mice, hollow gold nanoparticles were used to successfully treat melanoma, said Dr. Friedman. Silver nanoparticles are already in products ranging from clothing to plastic food storage containers, to take advantage of their antimicrobial properties, he said.

• Nanoemulsions. Nanoemulsions are already widely used in dermatology, in emollients, and as delivery vehicles for antiaging products. Nanoemulsions have an appealing nongreasy texture, are invisible, and penetrate the skin rapidly, Dr. Friedman said. Nanoemulsion products currently on the market include L’Oréal Plenitude Revitalift and Caudalie Vinosun Anti-Aging Suncare.

• Quantum dots. "These highly fluorescent nanoscale crystals absorb a broad range of wavelengths; however, they only re-emit one color," said Dr. Friedman. In dermatology, quantum dots are being used to identify sentinel lymph nodes in patients with melanoma and Merkel cell carcinoma.

• Nanomagnets. Nanosized magnetic materials "no longer exhibit a net magnetic force," Dr. Friedman said. These materials could be used to create magnetic field–directed imaging or therapy.

• Nanopigments. Many currently available sunblocks include nanoparticles of titanium or zinc oxide, such as SunVex Dailywear lotions and ZinClear Nano Zinc Oxide.

About safety: "From a purely theoretical standpoint, nanoparticles should be harmful," said Dr. Friedman. The same properties that make nanoparticles useful could come with side effects. Improved skin penetration can be beneficial for dermatology, but factors that determine the potential toxicity of nanoparticles include size, chemical purity, and the activity of the surface.

The current international stance on nanoparticle safety is that it is unlikely that significant amounts of the zinc or titanium used in sunblock products will result in local or systemic toxicity. However, "the safety of nanoscale zinc and titanium in sunscreen must be fully addressed," Dr. Friedman said. In 2009, the American Academy of Dermatology established a task force to study nanotechnology and educate the dermatology community, the public, and policy makers.

Dermatologists who are intrigued by the potential of nanotechnology can join the fledgling Nanodermatology Society, which had its first meeting for the 2011 AAD annual meeting in New Orleans. For more information, visit the society's Web site at www.nanodermsociety.org.

Dr. Friedman serves on the advisory board of Makefield Therapeutics.

ORLANDO – "The diameter of a single hair shaft is tens of thousands of nanometers," said Dr. Adam Friedman. Nanotechnology is the branch of technology related to dimensions and tolerances ranging from 0.1 to 100 nanometers.

"At this size, matter behaves somewhat differently," Dr. Friedman, of Albert Einstein College of Medicine in New York, said. As the size of material decreases, the surface area relative to volume decreases. There is more surface to interact with the environment.

"The three properties of matter – chemical, optical, and physical – can be manipulated and exploited at the nano scale," Dr. Friedman said. For example, something that is too bulky at the macro level to go into an aqueous vehicle can be distributed more easily in nano form. And "if something is smaller than the wavelength of visible light, guess what? It is going to be invisible," he said at the Orlando Dermatology Aesthetic and Clinical Conference.

By the year 2012, nanotechnology is predicted to be a $12 billion industry in the United States, and the cosmetic and cosmeceutical industries are leading the way, Dr. Friedman noted. He discussed several nanomaterials with diagnostic and therapeutic applications for dermatologists:

• Nanoparticles. The term nanoparticle is somewhat generic, Dr. Friedman said. The term refers to a small object that behaves as a whole unit in terms of its transport and properties. Nanoparticles can be derived from organic and nonorganic materials. For example, gold nanoparticles can be used to introduce an antibody or targeting molecule into the body to target tumors. Once the tumors are bound to the gold, they can be treated using selective photolysis, in which radiation is used to heat the gold enough to kill the tumor cells. In one study of mice, hollow gold nanoparticles were used to successfully treat melanoma, said Dr. Friedman. Silver nanoparticles are already in products ranging from clothing to plastic food storage containers, to take advantage of their antimicrobial properties, he said.

• Nanoemulsions. Nanoemulsions are already widely used in dermatology, in emollients, and as delivery vehicles for antiaging products. Nanoemulsions have an appealing nongreasy texture, are invisible, and penetrate the skin rapidly, Dr. Friedman said. Nanoemulsion products currently on the market include L’Oréal Plenitude Revitalift and Caudalie Vinosun Anti-Aging Suncare.

• Quantum dots. "These highly fluorescent nanoscale crystals absorb a broad range of wavelengths; however, they only re-emit one color," said Dr. Friedman. In dermatology, quantum dots are being used to identify sentinel lymph nodes in patients with melanoma and Merkel cell carcinoma.

• Nanomagnets. Nanosized magnetic materials "no longer exhibit a net magnetic force," Dr. Friedman said. These materials could be used to create magnetic field–directed imaging or therapy.

• Nanopigments. Many currently available sunblocks include nanoparticles of titanium or zinc oxide, such as SunVex Dailywear lotions and ZinClear Nano Zinc Oxide.

About safety: "From a purely theoretical standpoint, nanoparticles should be harmful," said Dr. Friedman. The same properties that make nanoparticles useful could come with side effects. Improved skin penetration can be beneficial for dermatology, but factors that determine the potential toxicity of nanoparticles include size, chemical purity, and the activity of the surface.

The current international stance on nanoparticle safety is that it is unlikely that significant amounts of the zinc or titanium used in sunblock products will result in local or systemic toxicity. However, "the safety of nanoscale zinc and titanium in sunscreen must be fully addressed," Dr. Friedman said. In 2009, the American Academy of Dermatology established a task force to study nanotechnology and educate the dermatology community, the public, and policy makers.

Dermatologists who are intrigued by the potential of nanotechnology can join the fledgling Nanodermatology Society, which had its first meeting for the 2011 AAD annual meeting in New Orleans. For more information, visit the society's Web site at www.nanodermsociety.org.

Dr. Friedman serves on the advisory board of Makefield Therapeutics.

ORLANDO – "The diameter of a single hair shaft is tens of thousands of nanometers," said Dr. Adam Friedman. Nanotechnology is the branch of technology related to dimensions and tolerances ranging from 0.1 to 100 nanometers.

"At this size, matter behaves somewhat differently," Dr. Friedman, of Albert Einstein College of Medicine in New York, said. As the size of material decreases, the surface area relative to volume decreases. There is more surface to interact with the environment.

"The three properties of matter – chemical, optical, and physical – can be manipulated and exploited at the nano scale," Dr. Friedman said. For example, something that is too bulky at the macro level to go into an aqueous vehicle can be distributed more easily in nano form. And "if something is smaller than the wavelength of visible light, guess what? It is going to be invisible," he said at the Orlando Dermatology Aesthetic and Clinical Conference.

By the year 2012, nanotechnology is predicted to be a $12 billion industry in the United States, and the cosmetic and cosmeceutical industries are leading the way, Dr. Friedman noted. He discussed several nanomaterials with diagnostic and therapeutic applications for dermatologists:

• Nanoparticles. The term nanoparticle is somewhat generic, Dr. Friedman said. The term refers to a small object that behaves as a whole unit in terms of its transport and properties. Nanoparticles can be derived from organic and nonorganic materials. For example, gold nanoparticles can be used to introduce an antibody or targeting molecule into the body to target tumors. Once the tumors are bound to the gold, they can be treated using selective photolysis, in which radiation is used to heat the gold enough to kill the tumor cells. In one study of mice, hollow gold nanoparticles were used to successfully treat melanoma, said Dr. Friedman. Silver nanoparticles are already in products ranging from clothing to plastic food storage containers, to take advantage of their antimicrobial properties, he said.

• Nanoemulsions. Nanoemulsions are already widely used in dermatology, in emollients, and as delivery vehicles for antiaging products. Nanoemulsions have an appealing nongreasy texture, are invisible, and penetrate the skin rapidly, Dr. Friedman said. Nanoemulsion products currently on the market include L’Oréal Plenitude Revitalift and Caudalie Vinosun Anti-Aging Suncare.

• Quantum dots. "These highly fluorescent nanoscale crystals absorb a broad range of wavelengths; however, they only re-emit one color," said Dr. Friedman. In dermatology, quantum dots are being used to identify sentinel lymph nodes in patients with melanoma and Merkel cell carcinoma.

• Nanomagnets. Nanosized magnetic materials "no longer exhibit a net magnetic force," Dr. Friedman said. These materials could be used to create magnetic field–directed imaging or therapy.

• Nanopigments. Many currently available sunblocks include nanoparticles of titanium or zinc oxide, such as SunVex Dailywear lotions and ZinClear Nano Zinc Oxide.

About safety: "From a purely theoretical standpoint, nanoparticles should be harmful," said Dr. Friedman. The same properties that make nanoparticles useful could come with side effects. Improved skin penetration can be beneficial for dermatology, but factors that determine the potential toxicity of nanoparticles include size, chemical purity, and the activity of the surface.

The current international stance on nanoparticle safety is that it is unlikely that significant amounts of the zinc or titanium used in sunblock products will result in local or systemic toxicity. However, "the safety of nanoscale zinc and titanium in sunscreen must be fully addressed," Dr. Friedman said. In 2009, the American Academy of Dermatology established a task force to study nanotechnology and educate the dermatology community, the public, and policy makers.

Dermatologists who are intrigued by the potential of nanotechnology can join the fledgling Nanodermatology Society, which had its first meeting for the 2011 AAD annual meeting in New Orleans. For more information, visit the society's Web site at www.nanodermsociety.org.

Dr. Friedman serves on the advisory board of Makefield Therapeutics.

Prenatal surgery to repair myelomeningoceles significantly reduced the need for shunts at 1 year of age and improved children’s motor function at age 30 months, compared with children who had surgery after birth, based on data from a randomized trial of 183 pregnant women.

The results, published online Feb. 9 in the New England Journal of Medicine, reflect data from 158 children who were evaluated at 12 months of age and 134 children evaluated at 30 months. Data collection is ongoing.

The surgery to repair the opening in the spine is usually performed after birth, but data from animal studies suggest that prenatal surgery could result in fewer complications, said Dr. N. Scott Adzick of the Children’s Hospital of Philadelphia and his colleagues.

In the Management of Myelomeningocele Study (MOMS), 183 volunteer women with singleton pregnancies were randomized to prenatal surgery before the 26th week of pregnancy or surgery for their infants after birth (N. Engl. J. Med. 2011 Feb. 9 [doi:10.1056/NEJMoa1014379]).

The children were examined for two primary outcomes. The first outcome, at age 12 months, was patient death or the need for a shunt. The second outcome, at age 30 months, was a composite score of motor function and brain development. The score was based on the Bayley Scales of Infant Development II (BSID-II) Mental Development Index and the difference between each child’s actual ability and their expected motor function based on the severity of their spinal defects.

Death or the need for a shunt was significantly less likely in the prenatal surgery group, compared with the postnatal surgery group (68% vs. 98%). The rates of shunt placement were significantly lower in the prenatal surgery group, compared with the postnatal surgery group (40% vs. 82%).

All the fetuses in the study suffered from hindbrain herniation, in which the base of the brain is pulled into the spinal canal. But at 12 months, 36% of the children in the prenatal surgery group had no evidence of hindbrain herniation, compared with 4% in the postnatal surgery group. In addition, infants in the prenatal surgery group had lower rates of moderate or severe hindbrain herniation than the postnatal surgery group (25% vs. 67%).

In addition, infants in the prenatal surgery group scored an average of 21% higher on measures of mental and motor function, compared with the postnatal surgery group, with primary outcome scores of 149 vs. 123, respectively.

Infants who underwent prenatal surgery were born at a mean 34.1 weeks of pregnancy, compared with a mean 37.3 weeks of pregnancy for the postnatal surgery group. Significantly more infants in the prenatal surgery group had respiratory distress syndrome, compared with the postnatal surgery group (21% vs. 6%).

In terms of secondary outcomes, children in the prenatal surgery group were more likely to be able to walk without crutches or other orthotic devices, compared with the postnatal surgery group (21% vs. 42%).

The mean age of the pregnant women was 29 years. Each fetus had a myelomeningocele located between the T1 and S1 vertebrae, evidence of hindbrain herniation, and a gestational age of 19.0-25.9 weeks. Exclusion criteria included body mass index of 35 kg/m2 or higher, increased risk for preterm birth, and fetal anomalies unrelated to the myelomeningocele.

Approximately one-third of the women in the prenatal surgery group showed uterine thinning or an area of dehiscence at the time of delivery. Women undergoing prenatal surgery must understand that they will require a cesarean delivery for the current pregnancy and any future pregnancies, they added.

Myelomeningocele, a severe form of spina bifida in which the backbone and spinal canal do not close completely before birth, occurs in approximately 4 of every 10,000 births in the United States, Dr. Diana L. Farmer, division chief of pediatric surgery at the University of California, San Francisco, said in a teleconference. Dr. Farmer was one of several researchers on the study who took part in a teleconference to present the study findings.

The study was not large enough to show an impact of gestational age on the results, but data collection is ongoing. "This is a priceless cohort of patients that we will follow for a longer period of time," Dr. Farmer said. She noted that the National Institutes of Health has agreed to fund follow-up of the patients until age 6-9 years. Future studies will include whether the children in the prenatal surgery group remain free of shunts, maintain improved motor function, and require fewer procedures compared with the postnatal group, she said.

Although the surgery is highly specialized and more research is needed, the results suggest that ob.gyns. can recommend the procedure to appropriate patients at this time, Dr. Farmer said.

"At the present time, it would be responsible to inform families that this represents an additional option in care that they could consider," she said. "The decision to undergo fetal surgery is quite individual and different for every patient, but I think families need to know that this is one option in the armamentarium."

The study was sponsored by the National Institutes of Health.

Prenatal surgery to repair myelomeningoceles significantly reduced the need for shunts at 1 year of age and improved children’s motor function at age 30 months, compared with children who had surgery after birth, based on data from a randomized trial of 183 pregnant women.

The results, published online Feb. 9 in the New England Journal of Medicine, reflect data from 158 children who were evaluated at 12 months of age and 134 children evaluated at 30 months. Data collection is ongoing.

The surgery to repair the opening in the spine is usually performed after birth, but data from animal studies suggest that prenatal surgery could result in fewer complications, said Dr. N. Scott Adzick of the Children’s Hospital of Philadelphia and his colleagues.

In the Management of Myelomeningocele Study (MOMS), 183 volunteer women with singleton pregnancies were randomized to prenatal surgery before the 26th week of pregnancy or surgery for their infants after birth (N. Engl. J. Med. 2011 Feb. 9 [doi:10.1056/NEJMoa1014379]).

The children were examined for two primary outcomes. The first outcome, at age 12 months, was patient death or the need for a shunt. The second outcome, at age 30 months, was a composite score of motor function and brain development. The score was based on the Bayley Scales of Infant Development II (BSID-II) Mental Development Index and the difference between each child’s actual ability and their expected motor function based on the severity of their spinal defects.

Death or the need for a shunt was significantly less likely in the prenatal surgery group, compared with the postnatal surgery group (68% vs. 98%). The rates of shunt placement were significantly lower in the prenatal surgery group, compared with the postnatal surgery group (40% vs. 82%).

All the fetuses in the study suffered from hindbrain herniation, in which the base of the brain is pulled into the spinal canal. But at 12 months, 36% of the children in the prenatal surgery group had no evidence of hindbrain herniation, compared with 4% in the postnatal surgery group. In addition, infants in the prenatal surgery group had lower rates of moderate or severe hindbrain herniation than the postnatal surgery group (25% vs. 67%).

In addition, infants in the prenatal surgery group scored an average of 21% higher on measures of mental and motor function, compared with the postnatal surgery group, with primary outcome scores of 149 vs. 123, respectively.

Infants who underwent prenatal surgery were born at a mean 34.1 weeks of pregnancy, compared with a mean 37.3 weeks of pregnancy for the postnatal surgery group. Significantly more infants in the prenatal surgery group had respiratory distress syndrome, compared with the postnatal surgery group (21% vs. 6%).

In terms of secondary outcomes, children in the prenatal surgery group were more likely to be able to walk without crutches or other orthotic devices, compared with the postnatal surgery group (21% vs. 42%).

The mean age of the pregnant women was 29 years. Each fetus had a myelomeningocele located between the T1 and S1 vertebrae, evidence of hindbrain herniation, and a gestational age of 19.0-25.9 weeks. Exclusion criteria included body mass index of 35 kg/m2 or higher, increased risk for preterm birth, and fetal anomalies unrelated to the myelomeningocele.

Approximately one-third of the women in the prenatal surgery group showed uterine thinning or an area of dehiscence at the time of delivery. Women undergoing prenatal surgery must understand that they will require a cesarean delivery for the current pregnancy and any future pregnancies, they added.

Myelomeningocele, a severe form of spina bifida in which the backbone and spinal canal do not close completely before birth, occurs in approximately 4 of every 10,000 births in the United States, Dr. Diana L. Farmer, division chief of pediatric surgery at the University of California, San Francisco, said in a teleconference. Dr. Farmer was one of several researchers on the study who took part in a teleconference to present the study findings.

The study was not large enough to show an impact of gestational age on the results, but data collection is ongoing. "This is a priceless cohort of patients that we will follow for a longer period of time," Dr. Farmer said. She noted that the National Institutes of Health has agreed to fund follow-up of the patients until age 6-9 years. Future studies will include whether the children in the prenatal surgery group remain free of shunts, maintain improved motor function, and require fewer procedures compared with the postnatal group, she said.

Although the surgery is highly specialized and more research is needed, the results suggest that ob.gyns. can recommend the procedure to appropriate patients at this time, Dr. Farmer said.

"At the present time, it would be responsible to inform families that this represents an additional option in care that they could consider," she said. "The decision to undergo fetal surgery is quite individual and different for every patient, but I think families need to know that this is one option in the armamentarium."

The study was sponsored by the National Institutes of Health.

Prenatal surgery to repair myelomeningoceles significantly reduced the need for shunts at 1 year of age and improved children’s motor function at age 30 months, compared with children who had surgery after birth, based on data from a randomized trial of 183 pregnant women.

The results, published online Feb. 9 in the New England Journal of Medicine, reflect data from 158 children who were evaluated at 12 months of age and 134 children evaluated at 30 months. Data collection is ongoing.

The surgery to repair the opening in the spine is usually performed after birth, but data from animal studies suggest that prenatal surgery could result in fewer complications, said Dr. N. Scott Adzick of the Children’s Hospital of Philadelphia and his colleagues.

In the Management of Myelomeningocele Study (MOMS), 183 volunteer women with singleton pregnancies were randomized to prenatal surgery before the 26th week of pregnancy or surgery for their infants after birth (N. Engl. J. Med. 2011 Feb. 9 [doi:10.1056/NEJMoa1014379]).

The children were examined for two primary outcomes. The first outcome, at age 12 months, was patient death or the need for a shunt. The second outcome, at age 30 months, was a composite score of motor function and brain development. The score was based on the Bayley Scales of Infant Development II (BSID-II) Mental Development Index and the difference between each child’s actual ability and their expected motor function based on the severity of their spinal defects.

Death or the need for a shunt was significantly less likely in the prenatal surgery group, compared with the postnatal surgery group (68% vs. 98%). The rates of shunt placement were significantly lower in the prenatal surgery group, compared with the postnatal surgery group (40% vs. 82%).

All the fetuses in the study suffered from hindbrain herniation, in which the base of the brain is pulled into the spinal canal. But at 12 months, 36% of the children in the prenatal surgery group had no evidence of hindbrain herniation, compared with 4% in the postnatal surgery group. In addition, infants in the prenatal surgery group had lower rates of moderate or severe hindbrain herniation than the postnatal surgery group (25% vs. 67%).

In addition, infants in the prenatal surgery group scored an average of 21% higher on measures of mental and motor function, compared with the postnatal surgery group, with primary outcome scores of 149 vs. 123, respectively.

Infants who underwent prenatal surgery were born at a mean 34.1 weeks of pregnancy, compared with a mean 37.3 weeks of pregnancy for the postnatal surgery group. Significantly more infants in the prenatal surgery group had respiratory distress syndrome, compared with the postnatal surgery group (21% vs. 6%).

In terms of secondary outcomes, children in the prenatal surgery group were more likely to be able to walk without crutches or other orthotic devices, compared with the postnatal surgery group (21% vs. 42%).

The mean age of the pregnant women was 29 years. Each fetus had a myelomeningocele located between the T1 and S1 vertebrae, evidence of hindbrain herniation, and a gestational age of 19.0-25.9 weeks. Exclusion criteria included body mass index of 35 kg/m2 or higher, increased risk for preterm birth, and fetal anomalies unrelated to the myelomeningocele.

Approximately one-third of the women in the prenatal surgery group showed uterine thinning or an area of dehiscence at the time of delivery. Women undergoing prenatal surgery must understand that they will require a cesarean delivery for the current pregnancy and any future pregnancies, they added.

Myelomeningocele, a severe form of spina bifida in which the backbone and spinal canal do not close completely before birth, occurs in approximately 4 of every 10,000 births in the United States, Dr. Diana L. Farmer, division chief of pediatric surgery at the University of California, San Francisco, said in a teleconference. Dr. Farmer was one of several researchers on the study who took part in a teleconference to present the study findings.

The study was not large enough to show an impact of gestational age on the results, but data collection is ongoing. "This is a priceless cohort of patients that we will follow for a longer period of time," Dr. Farmer said. She noted that the National Institutes of Health has agreed to fund follow-up of the patients until age 6-9 years. Future studies will include whether the children in the prenatal surgery group remain free of shunts, maintain improved motor function, and require fewer procedures compared with the postnatal group, she said.

Although the surgery is highly specialized and more research is needed, the results suggest that ob.gyns. can recommend the procedure to appropriate patients at this time, Dr. Farmer said.

"At the present time, it would be responsible to inform families that this represents an additional option in care that they could consider," she said. "The decision to undergo fetal surgery is quite individual and different for every patient, but I think families need to know that this is one option in the armamentarium."

The study was sponsored by the National Institutes of Health.

Prenatal surgery to repair myelomeningoceles significantly reduced the need for shunts at 1 year of age and improved children’s motor function at age 30 months, compared with children who had surgery after birth, based on data from a randomized trial of 183 pregnant women.

The results, published online Feb. 9 in the New England Journal of Medicine, reflect data from 158 children who were evaluated at 12 months of age and 134 children evaluated at 30 months. Data collection is ongoing.

The surgery to repair the opening in the spine is usually performed after birth, but data from animal studies suggest that prenatal surgery could result in fewer complications, said Dr. N. Scott Adzick of the Children’s Hospital of Philadelphia and his colleagues.

In the Management of Myelomeningocele Study (MOMS), 183 volunteer women with singleton pregnancies were randomized to prenatal surgery before the 26th week of pregnancy or surgery for their infants after birth (N. Engl. J. Med. 2011 Feb. 9 [doi:10.1056/NEJMoa1014379]).

The children were examined for two primary outcomes. The first outcome, at age 12 months, was patient death or the need for a shunt. The second outcome, at age 30 months, was a composite score of motor function and brain development. The score was based on the Bayley Scales of Infant Development II (BSID-II) Mental Development Index and the difference between each child’s actual ability and their expected motor function based on the severity of their spinal defects.

Death or the need for a shunt was significantly less likely in the prenatal surgery group, compared with the postnatal surgery group (68% vs. 98%). The rates of shunt placement were significantly lower in the prenatal surgery group, compared with the postnatal surgery group (40% vs. 82%).

All the fetuses in the study suffered from hindbrain herniation, in which the base of the brain is pulled into the spinal canal. But at 12 months, 36% of the children in the prenatal surgery group had no evidence of hindbrain herniation, compared with 4% in the postnatal surgery group. In addition, infants in the prenatal surgery group had lower rates of moderate or severe hindbrain herniation than the postnatal surgery group (25% vs. 67%).

In addition, infants in the prenatal surgery group scored an average of 21% higher on measures of mental and motor function, compared with the postnatal surgery group, with primary outcome scores of 149 vs. 123, respectively.

Infants who underwent prenatal surgery were born at a mean 34.1 weeks of pregnancy, compared with a mean 37.3 weeks of pregnancy for the postnatal surgery group. Significantly more infants in the prenatal surgery group had respiratory distress syndrome, compared with the postnatal surgery group (21% vs. 6%).

In terms of secondary outcomes, children in the prenatal surgery group were more likely to be able to walk without crutches or other orthotic devices, compared with the postnatal surgery group (21% vs. 42%).

The mean age of the pregnant women was 29 years. Each fetus had a myelomeningocele located between the T1 and S1 vertebrae, evidence of hindbrain herniation, and a gestational age of 19.0-25.9 weeks. Exclusion criteria included body mass index of 35 kg/m2 or higher, increased risk for preterm birth, and fetal anomalies unrelated to the myelomeningocele.

Approximately one-third of the women in the prenatal surgery group showed uterine thinning or an area of dehiscence at the time of delivery. Women undergoing prenatal surgery must understand that they will require a cesarean delivery for the current pregnancy and any future pregnancies, they added.

Myelomeningocele, a severe form of spina bifida in which the backbone and spinal canal do not close completely before birth, occurs in approximately 4 of every 10,000 births in the United States, Dr. Diana L. Farmer, division chief of pediatric surgery at the University of California, San Francisco, said in a teleconference. Dr. Farmer was one of several researchers on the study who took part in a teleconference to present the study findings.

The study was not large enough to show an impact of gestational age on the results, but data collection is ongoing. "This is a priceless cohort of patients that we will follow for a longer period of time," Dr. Farmer said. She noted that the National Institutes of Health has agreed to fund follow-up of the patients until age 6-9 years. Future studies will include whether the children in the prenatal surgery group remain free of shunts, maintain improved motor function, and require fewer procedures compared with the postnatal group, she said.

Although the surgery is highly specialized and more research is needed, the results suggest that ob.gyns. can recommend the procedure to appropriate patients at this time, Dr. Farmer said.

"At the present time, it would be responsible to inform families that this represents an additional option in care that they could consider," she said. "The decision to undergo fetal surgery is quite individual and different for every patient, but I think families need to know that this is one option in the armamentarium."

The study was sponsored by the National Institutes of Health.

Prenatal surgery to repair myelomeningoceles significantly reduced the need for shunts at 1 year of age and improved children’s motor function at age 30 months, compared with children who had surgery after birth, based on data from a randomized trial of 183 pregnant women.

The results, published online Feb. 9 in the New England Journal of Medicine, reflect data from 158 children who were evaluated at 12 months of age and 134 children evaluated at 30 months. Data collection is ongoing.

The surgery to repair the opening in the spine is usually performed after birth, but data from animal studies suggest that prenatal surgery could result in fewer complications, said Dr. N. Scott Adzick of the Children’s Hospital of Philadelphia and his colleagues.

In the Management of Myelomeningocele Study (MOMS), 183 volunteer women with singleton pregnancies were randomized to prenatal surgery before the 26th week of pregnancy or surgery for their infants after birth (N. Engl. J. Med. 2011 Feb. 9 [doi:10.1056/NEJMoa1014379]).

The children were examined for two primary outcomes. The first outcome, at age 12 months, was patient death or the need for a shunt. The second outcome, at age 30 months, was a composite score of motor function and brain development. The score was based on the Bayley Scales of Infant Development II (BSID-II) Mental Development Index and the difference between each child’s actual ability and their expected motor function based on the severity of their spinal defects.

Death or the need for a shunt was significantly less likely in the prenatal surgery group, compared with the postnatal surgery group (68% vs. 98%). The rates of shunt placement were significantly lower in the prenatal surgery group, compared with the postnatal surgery group (40% vs. 82%).

All the fetuses in the study suffered from hindbrain herniation, in which the base of the brain is pulled into the spinal canal. But at 12 months, 36% of the children in the prenatal surgery group had no evidence of hindbrain herniation, compared with 4% in the postnatal surgery group. In addition, infants in the prenatal surgery group had lower rates of moderate or severe hindbrain herniation than the postnatal surgery group (25% vs. 67%).

In addition, infants in the prenatal surgery group scored an average of 21% higher on measures of mental and motor function, compared with the postnatal surgery group, with primary outcome scores of 149 vs. 123, respectively.

Infants who underwent prenatal surgery were born at a mean 34.1 weeks of pregnancy, compared with a mean 37.3 weeks of pregnancy for the postnatal surgery group. Significantly more infants in the prenatal surgery group had respiratory distress syndrome, compared with the postnatal surgery group (21% vs. 6%).

In terms of secondary outcomes, children in the prenatal surgery group were more likely to be able to walk without crutches or other orthotic devices, compared with the postnatal surgery group (21% vs. 42%).

The mean age of the pregnant women was 29 years. Each fetus had a myelomeningocele located between the T1 and S1 vertebrae, evidence of hindbrain herniation, and a gestational age of 19.0-25.9 weeks. Exclusion criteria included body mass index of 35 kg/m2 or higher, increased risk for preterm birth, and fetal anomalies unrelated to the myelomeningocele.

Approximately one-third of the women in the prenatal surgery group showed uterine thinning or an area of dehiscence at the time of delivery. Women undergoing prenatal surgery must understand that they will require a cesarean delivery for the current pregnancy and any future pregnancies, they added.

Myelomeningocele, a severe form of spina bifida in which the backbone and spinal canal do not close completely before birth, occurs in approximately 4 of every 10,000 births in the United States, Dr. Diana L. Farmer, division chief of pediatric surgery at the University of California, San Francisco, said in a teleconference. Dr. Farmer was one of several researchers on the study who took part in a teleconference to present the study findings.

The study was not large enough to show an impact of gestational age on the results, but data collection is ongoing. "This is a priceless cohort of patients that we will follow for a longer period of time," Dr. Farmer said. She noted that the National Institutes of Health has agreed to fund follow-up of the patients until age 6-9 years. Future studies will include whether the children in the prenatal surgery group remain free of shunts, maintain improved motor function, and require fewer procedures compared with the postnatal group, she said.

Although the surgery is highly specialized and more research is needed, the results suggest that ob.gyns. can recommend the procedure to appropriate patients at this time, Dr. Farmer said.

"At the present time, it would be responsible to inform families that this represents an additional option in care that they could consider," she said. "The decision to undergo fetal surgery is quite individual and different for every patient, but I think families need to know that this is one option in the armamentarium."

The study was sponsored by the National Institutes of Health.

Prenatal surgery to repair myelomeningoceles significantly reduced the need for shunts at 1 year of age and improved children’s motor function at age 30 months, compared with children who had surgery after birth, based on data from a randomized trial of 183 pregnant women.

The results, published online Feb. 9 in the New England Journal of Medicine, reflect data from 158 children who were evaluated at 12 months of age and 134 children evaluated at 30 months. Data collection is ongoing.

The surgery to repair the opening in the spine is usually performed after birth, but data from animal studies suggest that prenatal surgery could result in fewer complications, said Dr. N. Scott Adzick of the Children’s Hospital of Philadelphia and his colleagues.

In the Management of Myelomeningocele Study (MOMS), 183 volunteer women with singleton pregnancies were randomized to prenatal surgery before the 26th week of pregnancy or surgery for their infants after birth (N. Engl. J. Med. 2011 Feb. 9 [doi:10.1056/NEJMoa1014379]).

The children were examined for two primary outcomes. The first outcome, at age 12 months, was patient death or the need for a shunt. The second outcome, at age 30 months, was a composite score of motor function and brain development. The score was based on the Bayley Scales of Infant Development II (BSID-II) Mental Development Index and the difference between each child’s actual ability and their expected motor function based on the severity of their spinal defects.

Death or the need for a shunt was significantly less likely in the prenatal surgery group, compared with the postnatal surgery group (68% vs. 98%). The rates of shunt placement were significantly lower in the prenatal surgery group, compared with the postnatal surgery group (40% vs. 82%).

All the fetuses in the study suffered from hindbrain herniation, in which the base of the brain is pulled into the spinal canal. But at 12 months, 36% of the children in the prenatal surgery group had no evidence of hindbrain herniation, compared with 4% in the postnatal surgery group. In addition, infants in the prenatal surgery group had lower rates of moderate or severe hindbrain herniation than the postnatal surgery group (25% vs. 67%).

In addition, infants in the prenatal surgery group scored an average of 21% higher on measures of mental and motor function, compared with the postnatal surgery group, with primary outcome scores of 149 vs. 123, respectively.

Infants who underwent prenatal surgery were born at a mean 34.1 weeks of pregnancy, compared with a mean 37.3 weeks of pregnancy for the postnatal surgery group. Significantly more infants in the prenatal surgery group had respiratory distress syndrome, compared with the postnatal surgery group (21% vs. 6%).

In terms of secondary outcomes, children in the prenatal surgery group were more likely to be able to walk without crutches or other orthotic devices, compared with the postnatal surgery group (21% vs. 42%).

The mean age of the pregnant women was 29 years. Each fetus had a myelomeningocele located between the T1 and S1 vertebrae, evidence of hindbrain herniation, and a gestational age of 19.0-25.9 weeks. Exclusion criteria included body mass index of 35 kg/m2 or higher, increased risk for preterm birth, and fetal anomalies unrelated to the myelomeningocele.

Approximately one-third of the women in the prenatal surgery group showed uterine thinning or an area of dehiscence at the time of delivery. Women undergoing prenatal surgery must understand that they will require a cesarean delivery for the current pregnancy and any future pregnancies, they added.

Myelomeningocele, a severe form of spina bifida in which the backbone and spinal canal do not close completely before birth, occurs in approximately 4 of every 10,000 births in the United States, Dr. Diana L. Farmer, division chief of pediatric surgery at the University of California, San Francisco, said in a teleconference. Dr. Farmer was one of several researchers on the study who took part in a teleconference to present the study findings.

The study was not large enough to show an impact of gestational age on the results, but data collection is ongoing. "This is a priceless cohort of patients that we will follow for a longer period of time," Dr. Farmer said. She noted that the National Institutes of Health has agreed to fund follow-up of the patients until age 6-9 years. Future studies will include whether the children in the prenatal surgery group remain free of shunts, maintain improved motor function, and require fewer procedures compared with the postnatal group, she said.

Although the surgery is highly specialized and more research is needed, the results suggest that ob.gyns. can recommend the procedure to appropriate patients at this time, Dr. Farmer said.

"At the present time, it would be responsible to inform families that this represents an additional option in care that they could consider," she said. "The decision to undergo fetal surgery is quite individual and different for every patient, but I think families need to know that this is one option in the armamentarium."

The study was sponsored by the National Institutes of Health.

ORLANDO – The photodynamic therapy protocol that works best on the face is not necessarily the best protocol for the scalp, according to Dr. Amy Forman Taub of Northwestern University in Chicago.

The main indications for PDT are actinic keratoses, acne, and photorejuvenation, but other indications include psoriasis, vulvar neoplasia, methicillin-resistant Staphylococcus aureus, and onychomycosis.

"For long-term cosmesis, nothing stands up like PDT," said Dr. Taub at the Orlando Dermatology Aesthetic and Clinical Conference. She explained her protocols for using PDT for actinic keratoses on different parts of the body.

• Scalp. To treat actinic keratoses on the scalp, Dr. Taub recommended incubation for 60-90 minutes with 5-aminolevulinic acid (5-ALA), followed by exposure to blue light at 2-4 inches for 20 minutes. Next, prescribe emollients for morning use and fluticasone for nighttime use. Check the scalp at 4 weeks. Repeat the PDT protocol after 8 weeks. Check the patient again in 12-16 weeks and biopsy any residual lesions, Dr. Taub said.

• Face. For severe actinic keratoses on the face, Dr. Taub recommended incubation with 5-ALA for 1 hour, followed by exposure to blue light for 16 minutes. Next, instruct the patient to apply zinc oxide sunscreen on top of topical emollients in the morning, and to use topical emollients at night. If 20% or fewer lesions remain at a 4-week follow-up visit, use an alternate therapy. But if more than 20% of the lesions remain, repeat the PDT with 90 minutes of incubation and 1 minute of blue light, Dr. Taub advised.

• Arms and hands. Be sure to elevate the arms so they are 2-4 inches from the light source, Dr. Taub said. She recommended using the push-up handles sold at sporting goods stores to elevate a patient’s arms for more effective PDT. Her preferred protocol for treatment of the arms and hands is to incubate with 5-ALA for 2 hours using Saran Wrap and gloves for occlusion, followed by exposure to blue light for 20 minutes. Repeat the procedure in 4-8 weeks, then examine the patient 12 weeks later and biopsy any residual lesions.

• Legs and feet. When planning PDT for the legs, remove or biopsy any lesions 4 weeks before PDT, said Dr. Taub. She recommended dividing the legs into four quadrants that each take one stick of ALA: upper, lower, anterior, and posterior. Perform the PDT on each quadrant separately, she said. Incubate the area for 2-3 hours, ideally after 1 week of 5-fluorouracil treatment. Next, expose the quadrant to blue light for 20 minutes. Repeat the protocol 8 weeks later, and re-evaluate the patient 12 weeks after the second treatment, she said.

Tricky areas such as the arms, legs, and chest can respond especially well to intense pulsed light (IPL)-PDT, Dr. Taub noted. The cost to the patient is higher, but she has seen dramatic improvements. Another option is to do one IPL-PDT treatment and follow with a blue light treatment if necessary, she said.

Dr. Taub disclosed serving as a consultant and speaker for, and receiving research funding from, DUSA Pharmaceuticals and Syneron.

ORLANDO – The photodynamic therapy protocol that works best on the face is not necessarily the best protocol for the scalp, according to Dr. Amy Forman Taub of Northwestern University in Chicago.

The main indications for PDT are actinic keratoses, acne, and photorejuvenation, but other indications include psoriasis, vulvar neoplasia, methicillin-resistant Staphylococcus aureus, and onychomycosis.

"For long-term cosmesis, nothing stands up like PDT," said Dr. Taub at the Orlando Dermatology Aesthetic and Clinical Conference. She explained her protocols for using PDT for actinic keratoses on different parts of the body.

• Scalp. To treat actinic keratoses on the scalp, Dr. Taub recommended incubation for 60-90 minutes with 5-aminolevulinic acid (5-ALA), followed by exposure to blue light at 2-4 inches for 20 minutes. Next, prescribe emollients for morning use and fluticasone for nighttime use. Check the scalp at 4 weeks. Repeat the PDT protocol after 8 weeks. Check the patient again in 12-16 weeks and biopsy any residual lesions, Dr. Taub said.

• Face. For severe actinic keratoses on the face, Dr. Taub recommended incubation with 5-ALA for 1 hour, followed by exposure to blue light for 16 minutes. Next, instruct the patient to apply zinc oxide sunscreen on top of topical emollients in the morning, and to use topical emollients at night. If 20% or fewer lesions remain at a 4-week follow-up visit, use an alternate therapy. But if more than 20% of the lesions remain, repeat the PDT with 90 minutes of incubation and 1 minute of blue light, Dr. Taub advised.

• Arms and hands. Be sure to elevate the arms so they are 2-4 inches from the light source, Dr. Taub said. She recommended using the push-up handles sold at sporting goods stores to elevate a patient’s arms for more effective PDT. Her preferred protocol for treatment of the arms and hands is to incubate with 5-ALA for 2 hours using Saran Wrap and gloves for occlusion, followed by exposure to blue light for 20 minutes. Repeat the procedure in 4-8 weeks, then examine the patient 12 weeks later and biopsy any residual lesions.

• Legs and feet. When planning PDT for the legs, remove or biopsy any lesions 4 weeks before PDT, said Dr. Taub. She recommended dividing the legs into four quadrants that each take one stick of ALA: upper, lower, anterior, and posterior. Perform the PDT on each quadrant separately, she said. Incubate the area for 2-3 hours, ideally after 1 week of 5-fluorouracil treatment. Next, expose the quadrant to blue light for 20 minutes. Repeat the protocol 8 weeks later, and re-evaluate the patient 12 weeks after the second treatment, she said.

Tricky areas such as the arms, legs, and chest can respond especially well to intense pulsed light (IPL)-PDT, Dr. Taub noted. The cost to the patient is higher, but she has seen dramatic improvements. Another option is to do one IPL-PDT treatment and follow with a blue light treatment if necessary, she said.

Dr. Taub disclosed serving as a consultant and speaker for, and receiving research funding from, DUSA Pharmaceuticals and Syneron.

ORLANDO – The photodynamic therapy protocol that works best on the face is not necessarily the best protocol for the scalp, according to Dr. Amy Forman Taub of Northwestern University in Chicago.

The main indications for PDT are actinic keratoses, acne, and photorejuvenation, but other indications include psoriasis, vulvar neoplasia, methicillin-resistant Staphylococcus aureus, and onychomycosis.

"For long-term cosmesis, nothing stands up like PDT," said Dr. Taub at the Orlando Dermatology Aesthetic and Clinical Conference. She explained her protocols for using PDT for actinic keratoses on different parts of the body.

• Scalp. To treat actinic keratoses on the scalp, Dr. Taub recommended incubation for 60-90 minutes with 5-aminolevulinic acid (5-ALA), followed by exposure to blue light at 2-4 inches for 20 minutes. Next, prescribe emollients for morning use and fluticasone for nighttime use. Check the scalp at 4 weeks. Repeat the PDT protocol after 8 weeks. Check the patient again in 12-16 weeks and biopsy any residual lesions, Dr. Taub said.

• Face. For severe actinic keratoses on the face, Dr. Taub recommended incubation with 5-ALA for 1 hour, followed by exposure to blue light for 16 minutes. Next, instruct the patient to apply zinc oxide sunscreen on top of topical emollients in the morning, and to use topical emollients at night. If 20% or fewer lesions remain at a 4-week follow-up visit, use an alternate therapy. But if more than 20% of the lesions remain, repeat the PDT with 90 minutes of incubation and 1 minute of blue light, Dr. Taub advised.

• Arms and hands. Be sure to elevate the arms so they are 2-4 inches from the light source, Dr. Taub said. She recommended using the push-up handles sold at sporting goods stores to elevate a patient’s arms for more effective PDT. Her preferred protocol for treatment of the arms and hands is to incubate with 5-ALA for 2 hours using Saran Wrap and gloves for occlusion, followed by exposure to blue light for 20 minutes. Repeat the procedure in 4-8 weeks, then examine the patient 12 weeks later and biopsy any residual lesions.

• Legs and feet. When planning PDT for the legs, remove or biopsy any lesions 4 weeks before PDT, said Dr. Taub. She recommended dividing the legs into four quadrants that each take one stick of ALA: upper, lower, anterior, and posterior. Perform the PDT on each quadrant separately, she said. Incubate the area for 2-3 hours, ideally after 1 week of 5-fluorouracil treatment. Next, expose the quadrant to blue light for 20 minutes. Repeat the protocol 8 weeks later, and re-evaluate the patient 12 weeks after the second treatment, she said.

Tricky areas such as the arms, legs, and chest can respond especially well to intense pulsed light (IPL)-PDT, Dr. Taub noted. The cost to the patient is higher, but she has seen dramatic improvements. Another option is to do one IPL-PDT treatment and follow with a blue light treatment if necessary, she said.

Dr. Taub disclosed serving as a consultant and speaker for, and receiving research funding from, DUSA Pharmaceuticals and Syneron.

In October 2010, when a cholera outbreak erupted in Haiti, doctors from around the world responded to the outbreak, including Dr. Kwan Kew Lai. In December, she spent a week in the island nation, sponsored by Medical Teams International Disaster Response, treating cholera patients of all ages at the Northwest Haiti Christian Mission in St. Louis du Nord.

Photo credit: Dr. Kwan Kew Lai

Dr. Lai is no novice to providing medical relief services overseas. In 2009, she worked treating HIV/AIDS patients as part of the Global Medic Force. Here, Dr. Lai discusses her experience in Haiti.

How did you learn about Medical Teams International Disaster Response?

I found out about the group immediately after the earthquake last year, when I searched the Internet for a team to go to Haiti to help care for patients there. I was asked to go with Partners in Development (PID) as a physician for their response team. MTI required me to formally apply to be on their team, which I did. They asked for descriptions of my previous experience with international work, as well as letters of recommendation. Last April, I was interviewed by phone, and later I was accepted to join their disaster response team.

In October, when the cholera epidemic began in Haiti, MTI contacted team members to go. But I was in West Africa at the time, completing HIV/AIDS mentoring work for the Institute of Human Virology, Nigeria, and Global Medic Force, Abuja, Nigeria, so I could not respond immediately. In December, I heard from MTI again, and they asked me to be ready to go in a few days. Our team included six doctors and a nurse.

Did you have any previous experience in treating cholera?

I had no previous experience in treating cholera patients, except that when I was in South Africa in 2009, near the border of Zimbabwe, I arrived at the end of a cholera outbreak among the refugees. So I did see a few cases in the hospital then.

What steps did the medical team take to avoid becoming ill themselves?

We used a lot of hand sanitizer; there were no sinks at St. Louis du Nord. We were vigilant about cleaning our hands between patients and before meals. MTI provided gloves, but they were used only for starting IVs and in cases when there might be possible contact with body fluids. No masks were required because cholera is spread via the fecal-oral route through contaminated food or water.

What were some of the challenges of treating cholera in Haiti?

There seemed to be a difference in opinion between Haitian doctors and visiting doctors as to how vigorously a dehydrated patient should be resuscitated. The World Health Organization guidelines were posted on the walls and I believe in giving fluids aggressively, but our Haitian counterparts seemed to be more conservative and tended to turn the fluids down. So there was an ongoing battle. Our team would turn up the fluids only to find the fluids turned down shortly thereafter.

The language barrier is an issue, because we did not have an interpreter with us all the time. It was especially difficult to communicate with the Haitian nurses.

The lack of accessibility to clean water continues to be a concern, especially when patients are sent home to unsanitary conditions.

There were also cultural differences. Some Haitians believe in fate. If a patient seemed to them to be dying, they accepted it and thought that it was time for him to go, so there should not be any heroic measures. However, to us cholera is an extremely treatable condition. Vigorous hydration can generally save a life.

What was your basic treatment strategy for most patients?

Our standard treatment strategy was to do a quick assessment of the patient’s state of hydration. Patients with severe hydration generally received an IV immediately. Patients who were moderately or slightly dehydrated, with no persistent vomiting, were generally encouraged to drink oral rehydration solution (ORS).

The elderly and very young cholera patients are at the greatest risk of dying from extreme dehydration. Patients who arrived at the clinic from long distances, and those who had been ill for several days, were also at increased risk of dying. Lack of clean water plays a major role in the spread of cholera. Malnutrition, which is common in Haiti, certainly does not help the immune system to fight infections. Near Port-au-Prince, we saw people washing their clothes and bathing in dirty river water; we were not at all sure where their drinking water came from.

At St. Louis du Nord, we were lucky to have ample supplies of intravenous fluids provided by MTI and delivered by the United Nations Humanitarian Services. We also had a good supply of clean water. Space was limited, and patients were put on cots and even on the floor. The floor and the cots were constantly being washed with bleach. Patients were provided with basins to use as toilets for their diarrhea, since cholera cots were in short supply and constantly soiled.

What was the setup at the hospital where you worked?

From Dr. Lai’s blog: The cholera treatment area was divided into three areas: the so-called ICU, which held the sickest patients, all of whom were on IVs and encouraged to take ORS; the step-down unit (where patients were taking ORS and had been discharged from the ICU, but who still had diarrhea and some vomiting); and the ready-to-discharge unit (patients on ORS who were ready to be discharged).

In the units with the less severe cases, patients and their relatives slept on mats on the floor. After the first few days, we were told that the patient count had decreased by half. There were 20 or so patients in this area. In the ICU there were about 25 patients lying on cots, some of which were diarrheal cots, with holes in the center. The ward was surprisingly free from strong stench. Many of the patients had the classic glazed look, with sunken and listless eyes, and were either restless or motionless.

What were some of the specific cases that you managed?

From Dr. Lai’s blog: One day, two men carried a sick woman in on a bed-frame. She had been sick for 5 days with vomiting and diarrhea, and it was rumored that they had to travel for 2 hours to come to the mission. The woman was not able to answer questions; her eyes were glazed and she was dehydrated. I examined her and felt her belly and asked if she was pregnant. She turned out to be 7 months pregnant. I told my interpreter that we would need to put two IVs in her. She asked me why. I replied that she was very dry, having been sick for 5 days and that she was pregnant. My interpreter looked at me and said, "Is the second IV for the baby?" Her face brightened up at the idea. The woman improved within 2 hours, after initially only being able to whisper to us.

Another case was a baby being breast-fed by her mother. One of the doctors placed an intraosseous line in the tibia, but it wasn’t working, so we used a nasogastric tube. After 100 to 200 cc of fluids were pushed into her, she became quite feisty. IVs and ORS made a huge difference for so many of these patients.

Interview by Heidi Splete. Blog excerpts are from haiticholeraoutbreakkwankew.blogspot.com.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, send an e-mail to [email protected].

In October 2010, when a cholera outbreak erupted in Haiti, doctors from around the world responded to the outbreak, including Dr. Kwan Kew Lai. In December, she spent a week in the island nation, sponsored by Medical Teams International Disaster Response, treating cholera patients of all ages at the Northwest Haiti Christian Mission in St. Louis du Nord.

Photo credit: Dr. Kwan Kew Lai

Dr. Lai is no novice to providing medical relief services overseas. In 2009, she worked treating HIV/AIDS patients as part of the Global Medic Force. Here, Dr. Lai discusses her experience in Haiti.

How did you learn about Medical Teams International Disaster Response?

I found out about the group immediately after the earthquake last year, when I searched the Internet for a team to go to Haiti to help care for patients there. I was asked to go with Partners in Development (PID) as a physician for their response team. MTI required me to formally apply to be on their team, which I did. They asked for descriptions of my previous experience with international work, as well as letters of recommendation. Last April, I was interviewed by phone, and later I was accepted to join their disaster response team.

In October, when the cholera epidemic began in Haiti, MTI contacted team members to go. But I was in West Africa at the time, completing HIV/AIDS mentoring work for the Institute of Human Virology, Nigeria, and Global Medic Force, Abuja, Nigeria, so I could not respond immediately. In December, I heard from MTI again, and they asked me to be ready to go in a few days. Our team included six doctors and a nurse.

Did you have any previous experience in treating cholera?

I had no previous experience in treating cholera patients, except that when I was in South Africa in 2009, near the border of Zimbabwe, I arrived at the end of a cholera outbreak among the refugees. So I did see a few cases in the hospital then.

What steps did the medical team take to avoid becoming ill themselves?

We used a lot of hand sanitizer; there were no sinks at St. Louis du Nord. We were vigilant about cleaning our hands between patients and before meals. MTI provided gloves, but they were used only for starting IVs and in cases when there might be possible contact with body fluids. No masks were required because cholera is spread via the fecal-oral route through contaminated food or water.

What were some of the challenges of treating cholera in Haiti?

There seemed to be a difference in opinion between Haitian doctors and visiting doctors as to how vigorously a dehydrated patient should be resuscitated. The World Health Organization guidelines were posted on the walls and I believe in giving fluids aggressively, but our Haitian counterparts seemed to be more conservative and tended to turn the fluids down. So there was an ongoing battle. Our team would turn up the fluids only to find the fluids turned down shortly thereafter.

The language barrier is an issue, because we did not have an interpreter with us all the time. It was especially difficult to communicate with the Haitian nurses.

The lack of accessibility to clean water continues to be a concern, especially when patients are sent home to unsanitary conditions.

There were also cultural differences. Some Haitians believe in fate. If a patient seemed to them to be dying, they accepted it and thought that it was time for him to go, so there should not be any heroic measures. However, to us cholera is an extremely treatable condition. Vigorous hydration can generally save a life.

What was your basic treatment strategy for most patients?

Our standard treatment strategy was to do a quick assessment of the patient’s state of hydration. Patients with severe hydration generally received an IV immediately. Patients who were moderately or slightly dehydrated, with no persistent vomiting, were generally encouraged to drink oral rehydration solution (ORS).

The elderly and very young cholera patients are at the greatest risk of dying from extreme dehydration. Patients who arrived at the clinic from long distances, and those who had been ill for several days, were also at increased risk of dying. Lack of clean water plays a major role in the spread of cholera. Malnutrition, which is common in Haiti, certainly does not help the immune system to fight infections. Near Port-au-Prince, we saw people washing their clothes and bathing in dirty river water; we were not at all sure where their drinking water came from.

At St. Louis du Nord, we were lucky to have ample supplies of intravenous fluids provided by MTI and delivered by the United Nations Humanitarian Services. We also had a good supply of clean water. Space was limited, and patients were put on cots and even on the floor. The floor and the cots were constantly being washed with bleach. Patients were provided with basins to use as toilets for their diarrhea, since cholera cots were in short supply and constantly soiled.

What was the setup at the hospital where you worked?

From Dr. Lai’s blog: The cholera treatment area was divided into three areas: the so-called ICU, which held the sickest patients, all of whom were on IVs and encouraged to take ORS; the step-down unit (where patients were taking ORS and had been discharged from the ICU, but who still had diarrhea and some vomiting); and the ready-to-discharge unit (patients on ORS who were ready to be discharged).

In the units with the less severe cases, patients and their relatives slept on mats on the floor. After the first few days, we were told that the patient count had decreased by half. There were 20 or so patients in this area. In the ICU there were about 25 patients lying on cots, some of which were diarrheal cots, with holes in the center. The ward was surprisingly free from strong stench. Many of the patients had the classic glazed look, with sunken and listless eyes, and were either restless or motionless.

What were some of the specific cases that you managed?

From Dr. Lai’s blog: One day, two men carried a sick woman in on a bed-frame. She had been sick for 5 days with vomiting and diarrhea, and it was rumored that they had to travel for 2 hours to come to the mission. The woman was not able to answer questions; her eyes were glazed and she was dehydrated. I examined her and felt her belly and asked if she was pregnant. She turned out to be 7 months pregnant. I told my interpreter that we would need to put two IVs in her. She asked me why. I replied that she was very dry, having been sick for 5 days and that she was pregnant. My interpreter looked at me and said, "Is the second IV for the baby?" Her face brightened up at the idea. The woman improved within 2 hours, after initially only being able to whisper to us.

Another case was a baby being breast-fed by her mother. One of the doctors placed an intraosseous line in the tibia, but it wasn’t working, so we used a nasogastric tube. After 100 to 200 cc of fluids were pushed into her, she became quite feisty. IVs and ORS made a huge difference for so many of these patients.

Interview by Heidi Splete. Blog excerpts are from haiticholeraoutbreakkwankew.blogspot.com.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, send an e-mail to [email protected].

In October 2010, when a cholera outbreak erupted in Haiti, doctors from around the world responded to the outbreak, including Dr. Kwan Kew Lai. In December, she spent a week in the island nation, sponsored by Medical Teams International Disaster Response, treating cholera patients of all ages at the Northwest Haiti Christian Mission in St. Louis du Nord.

Photo credit: Dr. Kwan Kew Lai

Dr. Lai is no novice to providing medical relief services overseas. In 2009, she worked treating HIV/AIDS patients as part of the Global Medic Force. Here, Dr. Lai discusses her experience in Haiti.

How did you learn about Medical Teams International Disaster Response?

I found out about the group immediately after the earthquake last year, when I searched the Internet for a team to go to Haiti to help care for patients there. I was asked to go with Partners in Development (PID) as a physician for their response team. MTI required me to formally apply to be on their team, which I did. They asked for descriptions of my previous experience with international work, as well as letters of recommendation. Last April, I was interviewed by phone, and later I was accepted to join their disaster response team.

In October, when the cholera epidemic began in Haiti, MTI contacted team members to go. But I was in West Africa at the time, completing HIV/AIDS mentoring work for the Institute of Human Virology, Nigeria, and Global Medic Force, Abuja, Nigeria, so I could not respond immediately. In December, I heard from MTI again, and they asked me to be ready to go in a few days. Our team included six doctors and a nurse.

Did you have any previous experience in treating cholera?

I had no previous experience in treating cholera patients, except that when I was in South Africa in 2009, near the border of Zimbabwe, I arrived at the end of a cholera outbreak among the refugees. So I did see a few cases in the hospital then.

What steps did the medical team take to avoid becoming ill themselves?

We used a lot of hand sanitizer; there were no sinks at St. Louis du Nord. We were vigilant about cleaning our hands between patients and before meals. MTI provided gloves, but they were used only for starting IVs and in cases when there might be possible contact with body fluids. No masks were required because cholera is spread via the fecal-oral route through contaminated food or water.

What were some of the challenges of treating cholera in Haiti?

There seemed to be a difference in opinion between Haitian doctors and visiting doctors as to how vigorously a dehydrated patient should be resuscitated. The World Health Organization guidelines were posted on the walls and I believe in giving fluids aggressively, but our Haitian counterparts seemed to be more conservative and tended to turn the fluids down. So there was an ongoing battle. Our team would turn up the fluids only to find the fluids turned down shortly thereafter.

The language barrier is an issue, because we did not have an interpreter with us all the time. It was especially difficult to communicate with the Haitian nurses.

The lack of accessibility to clean water continues to be a concern, especially when patients are sent home to unsanitary conditions.

There were also cultural differences. Some Haitians believe in fate. If a patient seemed to them to be dying, they accepted it and thought that it was time for him to go, so there should not be any heroic measures. However, to us cholera is an extremely treatable condition. Vigorous hydration can generally save a life.

What was your basic treatment strategy for most patients?

Our standard treatment strategy was to do a quick assessment of the patient’s state of hydration. Patients with severe hydration generally received an IV immediately. Patients who were moderately or slightly dehydrated, with no persistent vomiting, were generally encouraged to drink oral rehydration solution (ORS).

The elderly and very young cholera patients are at the greatest risk of dying from extreme dehydration. Patients who arrived at the clinic from long distances, and those who had been ill for several days, were also at increased risk of dying. Lack of clean water plays a major role in the spread of cholera. Malnutrition, which is common in Haiti, certainly does not help the immune system to fight infections. Near Port-au-Prince, we saw people washing their clothes and bathing in dirty river water; we were not at all sure where their drinking water came from.

At St. Louis du Nord, we were lucky to have ample supplies of intravenous fluids provided by MTI and delivered by the United Nations Humanitarian Services. We also had a good supply of clean water. Space was limited, and patients were put on cots and even on the floor. The floor and the cots were constantly being washed with bleach. Patients were provided with basins to use as toilets for their diarrhea, since cholera cots were in short supply and constantly soiled.

What was the setup at the hospital where you worked?

From Dr. Lai’s blog: The cholera treatment area was divided into three areas: the so-called ICU, which held the sickest patients, all of whom were on IVs and encouraged to take ORS; the step-down unit (where patients were taking ORS and had been discharged from the ICU, but who still had diarrhea and some vomiting); and the ready-to-discharge unit (patients on ORS who were ready to be discharged).

In the units with the less severe cases, patients and their relatives slept on mats on the floor. After the first few days, we were told that the patient count had decreased by half. There were 20 or so patients in this area. In the ICU there were about 25 patients lying on cots, some of which were diarrheal cots, with holes in the center. The ward was surprisingly free from strong stench. Many of the patients had the classic glazed look, with sunken and listless eyes, and were either restless or motionless.

What were some of the specific cases that you managed?

From Dr. Lai’s blog: One day, two men carried a sick woman in on a bed-frame. She had been sick for 5 days with vomiting and diarrhea, and it was rumored that they had to travel for 2 hours to come to the mission. The woman was not able to answer questions; her eyes were glazed and she was dehydrated. I examined her and felt her belly and asked if she was pregnant. She turned out to be 7 months pregnant. I told my interpreter that we would need to put two IVs in her. She asked me why. I replied that she was very dry, having been sick for 5 days and that she was pregnant. My interpreter looked at me and said, "Is the second IV for the baby?" Her face brightened up at the idea. The woman improved within 2 hours, after initially only being able to whisper to us.

Another case was a baby being breast-fed by her mother. One of the doctors placed an intraosseous line in the tibia, but it wasn’t working, so we used a nasogastric tube. After 100 to 200 cc of fluids were pushed into her, she became quite feisty. IVs and ORS made a huge difference for so many of these patients.

Interview by Heidi Splete. Blog excerpts are from haiticholeraoutbreakkwankew.blogspot.com.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, send an e-mail to [email protected].

ORLANDO – Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice, Dr. Sundaram said at the Orlando Dermatology Aesthetic and Clinical Conference.

Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO – Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice, Dr. Sundaram said at the Orlando Dermatology Aesthetic and Clinical Conference.

Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO – Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice, Dr. Sundaram said at the Orlando Dermatology Aesthetic and Clinical Conference.

Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.