Heidi Splete

BAL HARBOUR, FLA. — Although there is no single classification for neonatal rashes, subdividing these conditions into infectious versus noninfectious conditions, and further separating them by lesion type, provides a framework for diagnosing infants with skin disease, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

For example, infectious lesions in newborns may be characterized as either vesiculopustular or those that present with bullae, erosions, or ulcers, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

Vesiculopustular conditions include staphylococcal pustulosis. This condition occurs most often in the diaper area, and patients present with relatively few lesions. Rarely, the lesions are accompanied by bacteremia, cellulitis, meningitis, or pneumonia. Although Staphylococcus aureus is the most common cause of pustulosis, group A or B streptococcus, Listeria, and Pseudomonas also can cause pustulosis.

Another infectious vesiculopustular condition is congenital candidiasis, which usually occurs within the first 6 days of life, and can be associated with maternal vulvovaginitis. The infant with congenital candidiasis presents with erythematous papules and pustules on the soles and palms, usually caused by an ascending in utero infection. Risk factors for serious disease include low birth weight and a history of delivery room instrumentation, maternal intrauterine device, or cerclage. Also, these infants may have yellow discoloration, thickening, and ridging of their nails, sometimes with paronychial inflammation, Dr. Mancini noted.

A newborn with neonatal herpes—usually acquired from the mother during passage through the birth canal—usually presents with the characteristic vesicles on an erythematous base, often with clustering around the eyes. Neonatal herpes can affect the skin, eyes, and mucous membranes, as well as the central nervous system and other organs, and a significant number of benign cases may progress into a more serious disseminated form of herpes if they are not treated early, Dr. Mancini noted.

Infections in newborns that may present as bullae, erosions, or ulcers include bullous impetigo and staphylococcal scalded skin syndrome. A toxin secreted by S. aureus causes both of these conditions; bullous impetigo is the localized form, while scalded skin syndrome is a disseminated process based on hematogenous spread of the toxin.

Superficial peeling is a characteristic feature, but in severe cases the extensive skin peeling can require intensive care.

Other bullous or ulcerative infectious conditions in neonates include ecthyma gangrenosum, in which disk-shaped purple papules can evolve into bullae, erosions, and necrotic ulcers with eschar. This condition is most likely to occur in immunocompromised children, and indicates the presence of Pseudomonas aeruginosa bacteremia.

In the noninfectious category, conditions presenting as vesiculopustular lesions include erythema toxicum neonatorum, which presents as papules, pustules, and blotchy erythema.

This condition occurs in up to 50% of full-term neonates, but it is rare in premature infants with birth weights of less than 2,500 g, Dr. Mancini said. The condition arises within the first 2 days of life, and usually resolves over the next week or two.

Transient neonatal pustular melanosis is more common in darker skin, compared with lighter skin; as many as 5% of African American newborns have this condition, Dr. Mancini said. Prominent pustules, especially on the palms and soles, characterize the condition, as does a lack of erythema. After rupture, peripheral collarettes of scale are seen, and hyperpigmentation develops, which may last for several months.

Neonatal acne, also known as neonatal cephalic pustulosis, usually presents within the first 2–3 weeks of life, and resolves within a few weeks or a few months. The papulopustules tend to appear on the cheeks, but not on the trunk, and may be treated with a mild (2.5%) benzoyl peroxide or 2% erythromycin gel, if necessary. Topical antifungal cream also may be considered, given the occasional association of this condition with Malassezia species, but the lesions of neonatal acne usually resolve on their own with time.

Miliaria, or prickly heat, can be so extensive that it is misdiagnosed as atopic dermatitis and treated as such, with extensive application of emollients, which makes the condition worse, Dr. Mancini said. Prickly heat occurs in the summer due to humidity, but it can occur in the winter due to overbundling babies in cold weather. Parents can make the condition worse by overapplying an emollient, especially a greasy product. Miliaria presents as tiny, red papules and papulopustules, compared with the scaly plaques of eczema.

Finally, consider histiocytosis when faced with noninfectious, vesiculopustular lesions in infants. Histiocytosis is more common than congenital herpes, which is among the most common misdiagnoses in affected neonates, Dr. Mancini noted, and the lesions may become hemorrhagic.

Diagnostic pearls for neonatal histiocytosis include refractory or purpuric seborrheic dermatitis, eroded papules or nodules in areas of skin flexion, and crusted papules on the palms and soles.

Noninfectious bullous disorders include sucking blisters, a common and benign disorder caused by vigorous sucking of the affected body part by the fetus in utero.

Epidermolysis bullosa (EB) is an inherited mechanobullous disease and another source of noninfectious bullae. Infants with this condition present with blistering and open erosions, Dr. Mancini said. In addition, they may have large areas of aplasia cutis and mucosal involvement. The subtype of EB that the patient has determines the clinical presentation.

Mastocytosis is caused by an increase in cutaneous mast cells, and it can manifest as bullous lesions in infants. It presents with tan macules and papules that may have a “peau d'orange” (orange peel) appearance. Flushing, irritability, diarrhea, and respiratory distress are other potential features of this condition.

Finally, another category of noninfectious diagnoses are those that refer to a “red, scaly baby,” a neonate or infant who presents with widespread erythema and scaling. Diagnoses of this presentation include seborrheic dermatitis, atopic dermatitis, and psoriasis, Dr. Mancini said.

However, other conditions to consider include nutritional or metabolic disorders, immunodeficiency, ichthyoses, or ectodermal dysplasia.

“Cradle cap” is a characteristic presentation of seborrheic dermatitis in infants, which also may involve the groin, the umbilicus, and areas of skin flexion. By contrast, atopic dermatitis tends to spare the diaper area, and often involves the extremities.

Cradle cap can often be associated with a S. aureus colonization or infection. Psoriasis has some clinical overlap with seborrhea; it often occurs in the diaper area and scalp, and it can be triggered by infection with group A streptococcus.

Consider immunodeficiency in any baby with eczema or seborrheic dermatitis that resists treatment, Dr. Mancini said.

Another cause of red, scaly lesions in the infant is neonatal lupus, a diagnosis which should not be missed. It presents as scaly, erythematous patches and plaques that are sometimes diffuse, but most often occur in the periorbital area, which creates a “raccoon eye” presentation. Atrophy or telangiectasia also may be present. The mothers of children with neonatal lupus likely have anti-Ro, anti-La, or anti-U1 ribonucleoprotein antibodies, he noted, and the condition can be associated with congenital heart block.

BAL HARBOUR, FLA. — Although there is no single classification for neonatal rashes, subdividing these conditions into infectious versus noninfectious conditions, and further separating them by lesion type, provides a framework for diagnosing infants with skin disease, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

For example, infectious lesions in newborns may be characterized as either vesiculopustular or those that present with bullae, erosions, or ulcers, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

Vesiculopustular conditions include staphylococcal pustulosis. This condition occurs most often in the diaper area, and patients present with relatively few lesions. Rarely, the lesions are accompanied by bacteremia, cellulitis, meningitis, or pneumonia. Although Staphylococcus aureus is the most common cause of pustulosis, group A or B streptococcus, Listeria, and Pseudomonas also can cause pustulosis.

Another infectious vesiculopustular condition is congenital candidiasis, which usually occurs within the first 6 days of life, and can be associated with maternal vulvovaginitis. The infant with congenital candidiasis presents with erythematous papules and pustules on the soles and palms, usually caused by an ascending in utero infection. Risk factors for serious disease include low birth weight and a history of delivery room instrumentation, maternal intrauterine device, or cerclage. Also, these infants may have yellow discoloration, thickening, and ridging of their nails, sometimes with paronychial inflammation, Dr. Mancini noted.

A newborn with neonatal herpes—usually acquired from the mother during passage through the birth canal—usually presents with the characteristic vesicles on an erythematous base, often with clustering around the eyes. Neonatal herpes can affect the skin, eyes, and mucous membranes, as well as the central nervous system and other organs, and a significant number of benign cases may progress into a more serious disseminated form of herpes if they are not treated early, Dr. Mancini noted.

Infections in newborns that may present as bullae, erosions, or ulcers include bullous impetigo and staphylococcal scalded skin syndrome. A toxin secreted by S. aureus causes both of these conditions; bullous impetigo is the localized form, while scalded skin syndrome is a disseminated process based on hematogenous spread of the toxin.

Superficial peeling is a characteristic feature, but in severe cases the extensive skin peeling can require intensive care.

Other bullous or ulcerative infectious conditions in neonates include ecthyma gangrenosum, in which disk-shaped purple papules can evolve into bullae, erosions, and necrotic ulcers with eschar. This condition is most likely to occur in immunocompromised children, and indicates the presence of Pseudomonas aeruginosa bacteremia.

In the noninfectious category, conditions presenting as vesiculopustular lesions include erythema toxicum neonatorum, which presents as papules, pustules, and blotchy erythema.

This condition occurs in up to 50% of full-term neonates, but it is rare in premature infants with birth weights of less than 2,500 g, Dr. Mancini said. The condition arises within the first 2 days of life, and usually resolves over the next week or two.

Transient neonatal pustular melanosis is more common in darker skin, compared with lighter skin; as many as 5% of African American newborns have this condition, Dr. Mancini said. Prominent pustules, especially on the palms and soles, characterize the condition, as does a lack of erythema. After rupture, peripheral collarettes of scale are seen, and hyperpigmentation develops, which may last for several months.

Neonatal acne, also known as neonatal cephalic pustulosis, usually presents within the first 2–3 weeks of life, and resolves within a few weeks or a few months. The papulopustules tend to appear on the cheeks, but not on the trunk, and may be treated with a mild (2.5%) benzoyl peroxide or 2% erythromycin gel, if necessary. Topical antifungal cream also may be considered, given the occasional association of this condition with Malassezia species, but the lesions of neonatal acne usually resolve on their own with time.

Miliaria, or prickly heat, can be so extensive that it is misdiagnosed as atopic dermatitis and treated as such, with extensive application of emollients, which makes the condition worse, Dr. Mancini said. Prickly heat occurs in the summer due to humidity, but it can occur in the winter due to overbundling babies in cold weather. Parents can make the condition worse by overapplying an emollient, especially a greasy product. Miliaria presents as tiny, red papules and papulopustules, compared with the scaly plaques of eczema.

Finally, consider histiocytosis when faced with noninfectious, vesiculopustular lesions in infants. Histiocytosis is more common than congenital herpes, which is among the most common misdiagnoses in affected neonates, Dr. Mancini noted, and the lesions may become hemorrhagic.

Diagnostic pearls for neonatal histiocytosis include refractory or purpuric seborrheic dermatitis, eroded papules or nodules in areas of skin flexion, and crusted papules on the palms and soles.

Noninfectious bullous disorders include sucking blisters, a common and benign disorder caused by vigorous sucking of the affected body part by the fetus in utero.

Epidermolysis bullosa (EB) is an inherited mechanobullous disease and another source of noninfectious bullae. Infants with this condition present with blistering and open erosions, Dr. Mancini said. In addition, they may have large areas of aplasia cutis and mucosal involvement. The subtype of EB that the patient has determines the clinical presentation.

Mastocytosis is caused by an increase in cutaneous mast cells, and it can manifest as bullous lesions in infants. It presents with tan macules and papules that may have a “peau d'orange” (orange peel) appearance. Flushing, irritability, diarrhea, and respiratory distress are other potential features of this condition.

Finally, another category of noninfectious diagnoses are those that refer to a “red, scaly baby,” a neonate or infant who presents with widespread erythema and scaling. Diagnoses of this presentation include seborrheic dermatitis, atopic dermatitis, and psoriasis, Dr. Mancini said.

However, other conditions to consider include nutritional or metabolic disorders, immunodeficiency, ichthyoses, or ectodermal dysplasia.

“Cradle cap” is a characteristic presentation of seborrheic dermatitis in infants, which also may involve the groin, the umbilicus, and areas of skin flexion. By contrast, atopic dermatitis tends to spare the diaper area, and often involves the extremities.

Cradle cap can often be associated with a S. aureus colonization or infection. Psoriasis has some clinical overlap with seborrhea; it often occurs in the diaper area and scalp, and it can be triggered by infection with group A streptococcus.

Consider immunodeficiency in any baby with eczema or seborrheic dermatitis that resists treatment, Dr. Mancini said.

Another cause of red, scaly lesions in the infant is neonatal lupus, a diagnosis which should not be missed. It presents as scaly, erythematous patches and plaques that are sometimes diffuse, but most often occur in the periorbital area, which creates a “raccoon eye” presentation. Atrophy or telangiectasia also may be present. The mothers of children with neonatal lupus likely have anti-Ro, anti-La, or anti-U1 ribonucleoprotein antibodies, he noted, and the condition can be associated with congenital heart block.

BAL HARBOUR, FLA. — Although there is no single classification for neonatal rashes, subdividing these conditions into infectious versus noninfectious conditions, and further separating them by lesion type, provides a framework for diagnosing infants with skin disease, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

For example, infectious lesions in newborns may be characterized as either vesiculopustular or those that present with bullae, erosions, or ulcers, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

Vesiculopustular conditions include staphylococcal pustulosis. This condition occurs most often in the diaper area, and patients present with relatively few lesions. Rarely, the lesions are accompanied by bacteremia, cellulitis, meningitis, or pneumonia. Although Staphylococcus aureus is the most common cause of pustulosis, group A or B streptococcus, Listeria, and Pseudomonas also can cause pustulosis.

Another infectious vesiculopustular condition is congenital candidiasis, which usually occurs within the first 6 days of life, and can be associated with maternal vulvovaginitis. The infant with congenital candidiasis presents with erythematous papules and pustules on the soles and palms, usually caused by an ascending in utero infection. Risk factors for serious disease include low birth weight and a history of delivery room instrumentation, maternal intrauterine device, or cerclage. Also, these infants may have yellow discoloration, thickening, and ridging of their nails, sometimes with paronychial inflammation, Dr. Mancini noted.

A newborn with neonatal herpes—usually acquired from the mother during passage through the birth canal—usually presents with the characteristic vesicles on an erythematous base, often with clustering around the eyes. Neonatal herpes can affect the skin, eyes, and mucous membranes, as well as the central nervous system and other organs, and a significant number of benign cases may progress into a more serious disseminated form of herpes if they are not treated early, Dr. Mancini noted.

Infections in newborns that may present as bullae, erosions, or ulcers include bullous impetigo and staphylococcal scalded skin syndrome. A toxin secreted by S. aureus causes both of these conditions; bullous impetigo is the localized form, while scalded skin syndrome is a disseminated process based on hematogenous spread of the toxin.

Superficial peeling is a characteristic feature, but in severe cases the extensive skin peeling can require intensive care.

Other bullous or ulcerative infectious conditions in neonates include ecthyma gangrenosum, in which disk-shaped purple papules can evolve into bullae, erosions, and necrotic ulcers with eschar. This condition is most likely to occur in immunocompromised children, and indicates the presence of Pseudomonas aeruginosa bacteremia.

In the noninfectious category, conditions presenting as vesiculopustular lesions include erythema toxicum neonatorum, which presents as papules, pustules, and blotchy erythema.

This condition occurs in up to 50% of full-term neonates, but it is rare in premature infants with birth weights of less than 2,500 g, Dr. Mancini said. The condition arises within the first 2 days of life, and usually resolves over the next week or two.

Transient neonatal pustular melanosis is more common in darker skin, compared with lighter skin; as many as 5% of African American newborns have this condition, Dr. Mancini said. Prominent pustules, especially on the palms and soles, characterize the condition, as does a lack of erythema. After rupture, peripheral collarettes of scale are seen, and hyperpigmentation develops, which may last for several months.

Neonatal acne, also known as neonatal cephalic pustulosis, usually presents within the first 2–3 weeks of life, and resolves within a few weeks or a few months. The papulopustules tend to appear on the cheeks, but not on the trunk, and may be treated with a mild (2.5%) benzoyl peroxide or 2% erythromycin gel, if necessary. Topical antifungal cream also may be considered, given the occasional association of this condition with Malassezia species, but the lesions of neonatal acne usually resolve on their own with time.

Miliaria, or prickly heat, can be so extensive that it is misdiagnosed as atopic dermatitis and treated as such, with extensive application of emollients, which makes the condition worse, Dr. Mancini said. Prickly heat occurs in the summer due to humidity, but it can occur in the winter due to overbundling babies in cold weather. Parents can make the condition worse by overapplying an emollient, especially a greasy product. Miliaria presents as tiny, red papules and papulopustules, compared with the scaly plaques of eczema.

Finally, consider histiocytosis when faced with noninfectious, vesiculopustular lesions in infants. Histiocytosis is more common than congenital herpes, which is among the most common misdiagnoses in affected neonates, Dr. Mancini noted, and the lesions may become hemorrhagic.

Diagnostic pearls for neonatal histiocytosis include refractory or purpuric seborrheic dermatitis, eroded papules or nodules in areas of skin flexion, and crusted papules on the palms and soles.

Noninfectious bullous disorders include sucking blisters, a common and benign disorder caused by vigorous sucking of the affected body part by the fetus in utero.

Epidermolysis bullosa (EB) is an inherited mechanobullous disease and another source of noninfectious bullae. Infants with this condition present with blistering and open erosions, Dr. Mancini said. In addition, they may have large areas of aplasia cutis and mucosal involvement. The subtype of EB that the patient has determines the clinical presentation.

Mastocytosis is caused by an increase in cutaneous mast cells, and it can manifest as bullous lesions in infants. It presents with tan macules and papules that may have a “peau d'orange” (orange peel) appearance. Flushing, irritability, diarrhea, and respiratory distress are other potential features of this condition.

Finally, another category of noninfectious diagnoses are those that refer to a “red, scaly baby,” a neonate or infant who presents with widespread erythema and scaling. Diagnoses of this presentation include seborrheic dermatitis, atopic dermatitis, and psoriasis, Dr. Mancini said.

However, other conditions to consider include nutritional or metabolic disorders, immunodeficiency, ichthyoses, or ectodermal dysplasia.

“Cradle cap” is a characteristic presentation of seborrheic dermatitis in infants, which also may involve the groin, the umbilicus, and areas of skin flexion. By contrast, atopic dermatitis tends to spare the diaper area, and often involves the extremities.

Cradle cap can often be associated with a S. aureus colonization or infection. Psoriasis has some clinical overlap with seborrhea; it often occurs in the diaper area and scalp, and it can be triggered by infection with group A streptococcus.

Consider immunodeficiency in any baby with eczema or seborrheic dermatitis that resists treatment, Dr. Mancini said.

Another cause of red, scaly lesions in the infant is neonatal lupus, a diagnosis which should not be missed. It presents as scaly, erythematous patches and plaques that are sometimes diffuse, but most often occur in the periorbital area, which creates a “raccoon eye” presentation. Atrophy or telangiectasia also may be present. The mothers of children with neonatal lupus likely have anti-Ro, anti-La, or anti-U1 ribonucleoprotein antibodies, he noted, and the condition can be associated with congenital heart block.

WASHINGTON — A total of 1.8 million U.S. youth aged 12–17 years—including about 17% of eighth graders—reported that they had initiated inhalant use within the year during the years 2002–2004.

This was according to data from the report by the National Survey on Drug Use and Health, “Characteristics of Recent Adolescent Inhalant Initiates.”

“Kids don't view inhalants as dangerous,” Dr. Nora D. Volkow, director of the National Institute on Drug Abuse said at a press conference.

They have it wrong—a single episode of “huffing” from seemingly innocuous products such as shoe polish, spray paint, or compressed air, computer keyboard cleaner can be deadly.

About 35% of the youth who had started using inhalants during the past year said they had used them for 1 day; 23% had used inhalants on 2–3 days, 14% on 6–12 days, and 19% on at least 13 days, according to the report, which was published by the Substance Abuse and Mental Health Services Administration.

The most commonly reported types of inhalants were glue, toluene (a solvent used in paint thinners), and shoe polish (30%); gasoline or lighter fluid (25%); whipped cream cartridges (whippets) or nitrous oxide (25%); and spray paints (23%).

Overall, these recent inhalant initiates were significantly more likely to be white, compared with the general population (70% vs. 62%), and significantly more likely to be 14–15 years old, compared with the general population (39% vs. 34%).

The chemicals in products that serve as inhalants cross the blood-brain barrier and produce a high, said Dr. Volkow.

However, the chemicals have catastrophic consequences on other parts of the body. Sudden cardiac death and suffocation or asphyxiation are the most common causes of death as a result of inhalant use.

The toxicity of the inhaled compounds can cause neurologic symptoms, as well. (See box.)

Products that are used as inhalants are widely available and unregulated, and they can become addictive. Inhalants are difficult to detect; these products don't show up on drug tests, and many children do not think of inhalants as drugs, Dr. Volkow said.

Education is the best way to prevent inhalant abuse, and education campaigns in the medical profession, as well as in the community, are the keys to addressing this problem, she emphasized.

Physicians can have an extraordinary impact on preventing inhalant abuse, because they are in a position to ask questions and educate their patients. “If the physician doesn't ask the question, he or she will never get an answer,” Dr. Volkow said in an interview.

Be vigilant about inhalant abuse, Dr. Volkow said, because studies have shown that children who have used inhalants are more likely to exhibit behavior problems and anger and to develop conduct disorder.

Inhalants also may serve as a starter. The survey data showed that 23% of recent inhalant initiates had not used cigarettes, alcohol, or marijuana prior to their first use of inhalants.

For a copy of the National Survey on Drug Use and Health report, visit www.samhsa.govwww.inhalants.orgwww.inhalantprevention.org

KATHRYN DALES, ILLUSTRATION

Telltale Signs and Symptoms of Abuse

Someone who is abusing inhalants may exhibit one or all of the following symptoms:

▸ Burning sensation on the tongue.

▸ Dazed, dizzy, or drunken-seeming appearance.

▸ Nausea and/or loss of appetite.

▸ Neurologic problems including peripheral neuropathy, loss of vision, severe cognitive impairment, and seizures.

▸ Red or runny eyes and/or nose.

▸ Signs of paint, correction fluid, or other chemical products in unusual places, such as the face or fingers.

▸ Slurred or disoriented speech.

▸ Unusual behaviors such as anxiety, irritability, anger, excitability, or restlessness with no discernable cause.

▸ Unusual odor on the breath or chemical odor on clothing.

Sources: U.S. Consumer Product Safety Commission and the National Inhalant Prevention Coalition

WASHINGTON — A total of 1.8 million U.S. youth aged 12–17 years—including about 17% of eighth graders—reported that they had initiated inhalant use within the year during the years 2002–2004.

This was according to data from the report by the National Survey on Drug Use and Health, “Characteristics of Recent Adolescent Inhalant Initiates.”

“Kids don't view inhalants as dangerous,” Dr. Nora D. Volkow, director of the National Institute on Drug Abuse said at a press conference.

They have it wrong—a single episode of “huffing” from seemingly innocuous products such as shoe polish, spray paint, or compressed air, computer keyboard cleaner can be deadly.

About 35% of the youth who had started using inhalants during the past year said they had used them for 1 day; 23% had used inhalants on 2–3 days, 14% on 6–12 days, and 19% on at least 13 days, according to the report, which was published by the Substance Abuse and Mental Health Services Administration.

The most commonly reported types of inhalants were glue, toluene (a solvent used in paint thinners), and shoe polish (30%); gasoline or lighter fluid (25%); whipped cream cartridges (whippets) or nitrous oxide (25%); and spray paints (23%).

Overall, these recent inhalant initiates were significantly more likely to be white, compared with the general population (70% vs. 62%), and significantly more likely to be 14–15 years old, compared with the general population (39% vs. 34%).

The chemicals in products that serve as inhalants cross the blood-brain barrier and produce a high, said Dr. Volkow.

However, the chemicals have catastrophic consequences on other parts of the body. Sudden cardiac death and suffocation or asphyxiation are the most common causes of death as a result of inhalant use.

The toxicity of the inhaled compounds can cause neurologic symptoms, as well. (See box.)

Products that are used as inhalants are widely available and unregulated, and they can become addictive. Inhalants are difficult to detect; these products don't show up on drug tests, and many children do not think of inhalants as drugs, Dr. Volkow said.

Education is the best way to prevent inhalant abuse, and education campaigns in the medical profession, as well as in the community, are the keys to addressing this problem, she emphasized.

Physicians can have an extraordinary impact on preventing inhalant abuse, because they are in a position to ask questions and educate their patients. “If the physician doesn't ask the question, he or she will never get an answer,” Dr. Volkow said in an interview.

Be vigilant about inhalant abuse, Dr. Volkow said, because studies have shown that children who have used inhalants are more likely to exhibit behavior problems and anger and to develop conduct disorder.

Inhalants also may serve as a starter. The survey data showed that 23% of recent inhalant initiates had not used cigarettes, alcohol, or marijuana prior to their first use of inhalants.

For a copy of the National Survey on Drug Use and Health report, visit www.samhsa.govwww.inhalants.orgwww.inhalantprevention.org

KATHRYN DALES, ILLUSTRATION

Telltale Signs and Symptoms of Abuse

Someone who is abusing inhalants may exhibit one or all of the following symptoms:

▸ Burning sensation on the tongue.

▸ Dazed, dizzy, or drunken-seeming appearance.

▸ Nausea and/or loss of appetite.

▸ Neurologic problems including peripheral neuropathy, loss of vision, severe cognitive impairment, and seizures.

▸ Red or runny eyes and/or nose.

▸ Signs of paint, correction fluid, or other chemical products in unusual places, such as the face or fingers.

▸ Slurred or disoriented speech.

▸ Unusual behaviors such as anxiety, irritability, anger, excitability, or restlessness with no discernable cause.

▸ Unusual odor on the breath or chemical odor on clothing.

Sources: U.S. Consumer Product Safety Commission and the National Inhalant Prevention Coalition

WASHINGTON — A total of 1.8 million U.S. youth aged 12–17 years—including about 17% of eighth graders—reported that they had initiated inhalant use within the year during the years 2002–2004.

This was according to data from the report by the National Survey on Drug Use and Health, “Characteristics of Recent Adolescent Inhalant Initiates.”

“Kids don't view inhalants as dangerous,” Dr. Nora D. Volkow, director of the National Institute on Drug Abuse said at a press conference.

They have it wrong—a single episode of “huffing” from seemingly innocuous products such as shoe polish, spray paint, or compressed air, computer keyboard cleaner can be deadly.

About 35% of the youth who had started using inhalants during the past year said they had used them for 1 day; 23% had used inhalants on 2–3 days, 14% on 6–12 days, and 19% on at least 13 days, according to the report, which was published by the Substance Abuse and Mental Health Services Administration.

The most commonly reported types of inhalants were glue, toluene (a solvent used in paint thinners), and shoe polish (30%); gasoline or lighter fluid (25%); whipped cream cartridges (whippets) or nitrous oxide (25%); and spray paints (23%).

Overall, these recent inhalant initiates were significantly more likely to be white, compared with the general population (70% vs. 62%), and significantly more likely to be 14–15 years old, compared with the general population (39% vs. 34%).

The chemicals in products that serve as inhalants cross the blood-brain barrier and produce a high, said Dr. Volkow.

However, the chemicals have catastrophic consequences on other parts of the body. Sudden cardiac death and suffocation or asphyxiation are the most common causes of death as a result of inhalant use.

The toxicity of the inhaled compounds can cause neurologic symptoms, as well. (See box.)

Products that are used as inhalants are widely available and unregulated, and they can become addictive. Inhalants are difficult to detect; these products don't show up on drug tests, and many children do not think of inhalants as drugs, Dr. Volkow said.

Education is the best way to prevent inhalant abuse, and education campaigns in the medical profession, as well as in the community, are the keys to addressing this problem, she emphasized.

Physicians can have an extraordinary impact on preventing inhalant abuse, because they are in a position to ask questions and educate their patients. “If the physician doesn't ask the question, he or she will never get an answer,” Dr. Volkow said in an interview.

Be vigilant about inhalant abuse, Dr. Volkow said, because studies have shown that children who have used inhalants are more likely to exhibit behavior problems and anger and to develop conduct disorder.

Inhalants also may serve as a starter. The survey data showed that 23% of recent inhalant initiates had not used cigarettes, alcohol, or marijuana prior to their first use of inhalants.

For a copy of the National Survey on Drug Use and Health report, visit www.samhsa.govwww.inhalants.orgwww.inhalantprevention.org

KATHRYN DALES, ILLUSTRATION

Telltale Signs and Symptoms of Abuse

Someone who is abusing inhalants may exhibit one or all of the following symptoms:

▸ Burning sensation on the tongue.

▸ Dazed, dizzy, or drunken-seeming appearance.

▸ Nausea and/or loss of appetite.

▸ Neurologic problems including peripheral neuropathy, loss of vision, severe cognitive impairment, and seizures.

▸ Red or runny eyes and/or nose.

▸ Signs of paint, correction fluid, or other chemical products in unusual places, such as the face or fingers.

▸ Slurred or disoriented speech.

▸ Unusual behaviors such as anxiety, irritability, anger, excitability, or restlessness with no discernable cause.

▸ Unusual odor on the breath or chemical odor on clothing.

Sources: U.S. Consumer Product Safety Commission and the National Inhalant Prevention Coalition

BAL HARBOUR, FLA. — Warts and molluscum in children are often more troubling to their parents, and it is acceptable to wait for them to resolve on their own, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

However, warts and molluscum are cosmetically unpleasant and can create social stigma. Some families insist on treatment, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

When treating warts and molluscum, use the specific reimbursement codes, he said. Use code 17000 for treatment of 1 wart, 17003 for each wart when there are 2–14 warts, and 17004 for more than 15 warts. When treating molluscum, use 17110 for treatment of fewer than 15 lesions, and 17111 for 15 or more lesions.

Warts

Warts occur in nearly 10% of children, Dr. Mancini said.

Skin-to-skin contact from other individuals with warts, or skin contact with public surfaces with moisture (such as locker room floors and showers), are among the most common sources of warts in children. In addition, autoinoculation (spreading the wart virus on one's own skin by scratching, or skin-to-skin contact) is a common way that warts spread.

There are two schools of thought regarding warts. Some doctors say treat them, while others suggest leaving them alone, he said. Much depends on the desires of the patient or, more commonly, the parents.

Arguments for leaving warts alone include the fact that they are generally benign, rarely symptomatic, and usually resolve spontaneously. Also, the most effective treatments can be traumatic for young children.

Arguments for treating warts include the social stigma, especially if the wart is on the face or another obvious location, and the contagious nature of warts, which may cause concern with regard to the child's socializing and playing with friends.

Categories of wart treatment include chemovesicants, cryotherapy, immunotherapy, intralesional injections, laser or ablative therapy, and even hypnosis, as well as homeopathic remedies. “Homeopathic remedies may have as much effect as anything that we can offer medically,” Dr. Mancini noted.

Chemovesicants include podophyllin and trichloroacetic acid, which are often tried for anogenital warts. “Salicylic acid is probably one of the most effective treatments for warts,” Dr. Mancini said. “But we need to teach parents that they may have to treat the wart for weeks or months.” Most over-the-counter (OTC) salicylic acid liquids are the same, and contain about 17% salicylic acid.

Some parents may ask about the use of duct tape for warts. “I think that duct tape is a useful adjunct,” Dr. Mancini said.

His strategy is to use duct tape in conjunction with salicylic acid. “I have parents apply the salicylic acid to the wart, let it dry for 30 seconds or so, then occlude with a piece of duct tape overnight and remove it in the morning,” he said. This method probably works via a debridement effect, but only if duct tape is used. “Scotch tape and masking tape aren't strong enough.” Some researchers have suggested that occlusion with duct tape alone is useful, possibly via an immune mechanism.

Cryotherapy is very effective against warts, but it can be quite painful. “We spray the skin and create a large, hemorrhagic blister, with the hope that when the blister falls off, the wart falls off with it,” Dr. Mancini said. “If the patient doesn't develop a blister, the treatment is usually not effective.”

Overzealous treatment of warts can result in significant wounds, he cautioned. Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area.

OTC cryotherapy has been available since 2003, and these products can be effective for small warts, but they are not nearly as effective as liquid nitrogen, he said. These over-the-counter methods utilize dimethyl ether/propane, the same ingredient found in Histofreeze, but the OTC methods don't reach the same temperature, and thus they are significantly less effective.

Liquid nitrogen is a good choice for older children, such as a 10-year-old with one or two warts who says, “I want these gone.”

However, Dr. Mancini has a “no hold” policy regarding cryotherapy. “If we would have to hold the child down to do it, I generally recommend against it.”

Patients who do not want cryotherapy may consider oral or topical immunotherapy or injection therapy.

Cimetidine is the most common oral therapy used for warts. “The bottom line is that it is worth a try,” Dr. Mancini said. “It does work in some patients; the success rate is probably near 30%.” He generally prescribes a relatively high dose, 30–40 mg/kg per day, divided and given twice daily.

Squaric acid, a topical immunotherapy, is a fairly painless wart treatment, and the recurrence rate is fairly low among patients who respond, Dr. Mancini said. Allergic contact dermatitis can occur with this treatment, but it is not usually limiting.

Imiquimod is approved for genital warts with a recommended application frequency of 3 times per week, but it can be effective as an off-label treatment for common warts in children when applied once or twice daily, Dr. Mancini said.

Chemotherapy, in the form of 5% 5-fluorouracil (5-FU), also can be used off-label for warts in children, and is particularly useful for flat warts. Dr. Mancini recommends an application of 5-FU to the wart 3 nights each week, with the caveat that this treatment can result in severe dermatitis.

The injection of fungal antigens into the warts has been shown to be effective in some patients, possibly by inducing a host immune response directed at the human papillomavirus-infected tissue. Candida antigen injections have demonstrated some effectiveness, and are injected into 1–3 warts at each of two or three visits. As with other forms of topical or injection immunotherapy, untreated lesions often resolve on a parallel time frame to the involution of treated lesions.

Finally, laser therapy can be used to treat warts. Laser therapy, which is usually done with a pulsed dye laser, probably works by targeting the blood supply to the wart.

Dr. Mancini generally reserves this mode of therapy as a last resort, and it often requires several treatment sessions.

Molluscum Contagiosum

Mollusca have become more common than warts in many practices, Dr. Mancini noted. The condition is spread by skin-to-skin contact and possibly via fomites. Public swimming pools frequently are cited as a potential source of infection transmission.

Mollusca present as dome-shaped waxy papules, and often occur in conjunction with an associated dermatitis (“molluscum dermatitis”). The spontaneous resolution rate is nearly 100%, he said, although it may take 12–18 months, or longer. Remind parents that when the molluscum lesions suddenly and synchronously turn red, it is a good sign; it usually signals that the host immune response has kicked in, Dr. Mancini noted.

Despite a physician's efforts at reassurance of their self-limiting nature, many families want to treat mollusca. Treatment options have some overlap with those used for warts, and include chemovesicants, curettage, cryotherapy, imiquimod, cidofovir, tretinoin cream (especially for the face), and laser treatments.

Cantharidin, made from the extract of the Chinese blister beetle (Cantharis vesicatoris) is clearly the most effective treatment for mollusca in children. When used correctly, it has been demonstrated as safe and effective in the treatment of mollusca.

Dr. Mancini cited a study from his practice in which 90% of 300 molluscum patients cleared after cantharidin treatment, and another 8% improved. “It was very well-tolerated, and about 95% of parents said that they would choose this therapy again for their child.”

Cantharidin is not approved by the Food and Drug Administration, but was nominated for inclusion on a list of bulk drug substances that may be used in compounding and applied by the physician in the professional office setting.

Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area. DR. MANCINI

Common warts are shown prior to treatment by Candida antigen injection therapy.

The warts have resolved following two injections into the lesions.

A host immune response (erythema, edema) is shown in two molluscum contagiosum lesions. Photos courtesy Dr. Anthony J. Mancini

BAL HARBOUR, FLA. — Warts and molluscum in children are often more troubling to their parents, and it is acceptable to wait for them to resolve on their own, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

However, warts and molluscum are cosmetically unpleasant and can create social stigma. Some families insist on treatment, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

When treating warts and molluscum, use the specific reimbursement codes, he said. Use code 17000 for treatment of 1 wart, 17003 for each wart when there are 2–14 warts, and 17004 for more than 15 warts. When treating molluscum, use 17110 for treatment of fewer than 15 lesions, and 17111 for 15 or more lesions.

Warts

Warts occur in nearly 10% of children, Dr. Mancini said.

Skin-to-skin contact from other individuals with warts, or skin contact with public surfaces with moisture (such as locker room floors and showers), are among the most common sources of warts in children. In addition, autoinoculation (spreading the wart virus on one's own skin by scratching, or skin-to-skin contact) is a common way that warts spread.

There are two schools of thought regarding warts. Some doctors say treat them, while others suggest leaving them alone, he said. Much depends on the desires of the patient or, more commonly, the parents.

Arguments for leaving warts alone include the fact that they are generally benign, rarely symptomatic, and usually resolve spontaneously. Also, the most effective treatments can be traumatic for young children.

Arguments for treating warts include the social stigma, especially if the wart is on the face or another obvious location, and the contagious nature of warts, which may cause concern with regard to the child's socializing and playing with friends.

Categories of wart treatment include chemovesicants, cryotherapy, immunotherapy, intralesional injections, laser or ablative therapy, and even hypnosis, as well as homeopathic remedies. “Homeopathic remedies may have as much effect as anything that we can offer medically,” Dr. Mancini noted.

Chemovesicants include podophyllin and trichloroacetic acid, which are often tried for anogenital warts. “Salicylic acid is probably one of the most effective treatments for warts,” Dr. Mancini said. “But we need to teach parents that they may have to treat the wart for weeks or months.” Most over-the-counter (OTC) salicylic acid liquids are the same, and contain about 17% salicylic acid.

Some parents may ask about the use of duct tape for warts. “I think that duct tape is a useful adjunct,” Dr. Mancini said.

His strategy is to use duct tape in conjunction with salicylic acid. “I have parents apply the salicylic acid to the wart, let it dry for 30 seconds or so, then occlude with a piece of duct tape overnight and remove it in the morning,” he said. This method probably works via a debridement effect, but only if duct tape is used. “Scotch tape and masking tape aren't strong enough.” Some researchers have suggested that occlusion with duct tape alone is useful, possibly via an immune mechanism.

Cryotherapy is very effective against warts, but it can be quite painful. “We spray the skin and create a large, hemorrhagic blister, with the hope that when the blister falls off, the wart falls off with it,” Dr. Mancini said. “If the patient doesn't develop a blister, the treatment is usually not effective.”

Overzealous treatment of warts can result in significant wounds, he cautioned. Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area.

OTC cryotherapy has been available since 2003, and these products can be effective for small warts, but they are not nearly as effective as liquid nitrogen, he said. These over-the-counter methods utilize dimethyl ether/propane, the same ingredient found in Histofreeze, but the OTC methods don't reach the same temperature, and thus they are significantly less effective.

Liquid nitrogen is a good choice for older children, such as a 10-year-old with one or two warts who says, “I want these gone.”

However, Dr. Mancini has a “no hold” policy regarding cryotherapy. “If we would have to hold the child down to do it, I generally recommend against it.”

Patients who do not want cryotherapy may consider oral or topical immunotherapy or injection therapy.

Cimetidine is the most common oral therapy used for warts. “The bottom line is that it is worth a try,” Dr. Mancini said. “It does work in some patients; the success rate is probably near 30%.” He generally prescribes a relatively high dose, 30–40 mg/kg per day, divided and given twice daily.

Squaric acid, a topical immunotherapy, is a fairly painless wart treatment, and the recurrence rate is fairly low among patients who respond, Dr. Mancini said. Allergic contact dermatitis can occur with this treatment, but it is not usually limiting.

Imiquimod is approved for genital warts with a recommended application frequency of 3 times per week, but it can be effective as an off-label treatment for common warts in children when applied once or twice daily, Dr. Mancini said.

Chemotherapy, in the form of 5% 5-fluorouracil (5-FU), also can be used off-label for warts in children, and is particularly useful for flat warts. Dr. Mancini recommends an application of 5-FU to the wart 3 nights each week, with the caveat that this treatment can result in severe dermatitis.

The injection of fungal antigens into the warts has been shown to be effective in some patients, possibly by inducing a host immune response directed at the human papillomavirus-infected tissue. Candida antigen injections have demonstrated some effectiveness, and are injected into 1–3 warts at each of two or three visits. As with other forms of topical or injection immunotherapy, untreated lesions often resolve on a parallel time frame to the involution of treated lesions.

Finally, laser therapy can be used to treat warts. Laser therapy, which is usually done with a pulsed dye laser, probably works by targeting the blood supply to the wart.

Dr. Mancini generally reserves this mode of therapy as a last resort, and it often requires several treatment sessions.

Molluscum Contagiosum

Mollusca have become more common than warts in many practices, Dr. Mancini noted. The condition is spread by skin-to-skin contact and possibly via fomites. Public swimming pools frequently are cited as a potential source of infection transmission.

Mollusca present as dome-shaped waxy papules, and often occur in conjunction with an associated dermatitis (“molluscum dermatitis”). The spontaneous resolution rate is nearly 100%, he said, although it may take 12–18 months, or longer. Remind parents that when the molluscum lesions suddenly and synchronously turn red, it is a good sign; it usually signals that the host immune response has kicked in, Dr. Mancini noted.

Despite a physician's efforts at reassurance of their self-limiting nature, many families want to treat mollusca. Treatment options have some overlap with those used for warts, and include chemovesicants, curettage, cryotherapy, imiquimod, cidofovir, tretinoin cream (especially for the face), and laser treatments.

Cantharidin, made from the extract of the Chinese blister beetle (Cantharis vesicatoris) is clearly the most effective treatment for mollusca in children. When used correctly, it has been demonstrated as safe and effective in the treatment of mollusca.

Dr. Mancini cited a study from his practice in which 90% of 300 molluscum patients cleared after cantharidin treatment, and another 8% improved. “It was very well-tolerated, and about 95% of parents said that they would choose this therapy again for their child.”

Cantharidin is not approved by the Food and Drug Administration, but was nominated for inclusion on a list of bulk drug substances that may be used in compounding and applied by the physician in the professional office setting.

Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area. DR. MANCINI

Common warts are shown prior to treatment by Candida antigen injection therapy.

The warts have resolved following two injections into the lesions.

A host immune response (erythema, edema) is shown in two molluscum contagiosum lesions. Photos courtesy Dr. Anthony J. Mancini

BAL HARBOUR, FLA. — Warts and molluscum in children are often more troubling to their parents, and it is acceptable to wait for them to resolve on their own, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.

However, warts and molluscum are cosmetically unpleasant and can create social stigma. Some families insist on treatment, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.

When treating warts and molluscum, use the specific reimbursement codes, he said. Use code 17000 for treatment of 1 wart, 17003 for each wart when there are 2–14 warts, and 17004 for more than 15 warts. When treating molluscum, use 17110 for treatment of fewer than 15 lesions, and 17111 for 15 or more lesions.

Warts

Warts occur in nearly 10% of children, Dr. Mancini said.

Skin-to-skin contact from other individuals with warts, or skin contact with public surfaces with moisture (such as locker room floors and showers), are among the most common sources of warts in children. In addition, autoinoculation (spreading the wart virus on one's own skin by scratching, or skin-to-skin contact) is a common way that warts spread.

There are two schools of thought regarding warts. Some doctors say treat them, while others suggest leaving them alone, he said. Much depends on the desires of the patient or, more commonly, the parents.

Arguments for leaving warts alone include the fact that they are generally benign, rarely symptomatic, and usually resolve spontaneously. Also, the most effective treatments can be traumatic for young children.

Arguments for treating warts include the social stigma, especially if the wart is on the face or another obvious location, and the contagious nature of warts, which may cause concern with regard to the child's socializing and playing with friends.

Categories of wart treatment include chemovesicants, cryotherapy, immunotherapy, intralesional injections, laser or ablative therapy, and even hypnosis, as well as homeopathic remedies. “Homeopathic remedies may have as much effect as anything that we can offer medically,” Dr. Mancini noted.

Chemovesicants include podophyllin and trichloroacetic acid, which are often tried for anogenital warts. “Salicylic acid is probably one of the most effective treatments for warts,” Dr. Mancini said. “But we need to teach parents that they may have to treat the wart for weeks or months.” Most over-the-counter (OTC) salicylic acid liquids are the same, and contain about 17% salicylic acid.

Some parents may ask about the use of duct tape for warts. “I think that duct tape is a useful adjunct,” Dr. Mancini said.

His strategy is to use duct tape in conjunction with salicylic acid. “I have parents apply the salicylic acid to the wart, let it dry for 30 seconds or so, then occlude with a piece of duct tape overnight and remove it in the morning,” he said. This method probably works via a debridement effect, but only if duct tape is used. “Scotch tape and masking tape aren't strong enough.” Some researchers have suggested that occlusion with duct tape alone is useful, possibly via an immune mechanism.

Cryotherapy is very effective against warts, but it can be quite painful. “We spray the skin and create a large, hemorrhagic blister, with the hope that when the blister falls off, the wart falls off with it,” Dr. Mancini said. “If the patient doesn't develop a blister, the treatment is usually not effective.”

Overzealous treatment of warts can result in significant wounds, he cautioned. Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area.

OTC cryotherapy has been available since 2003, and these products can be effective for small warts, but they are not nearly as effective as liquid nitrogen, he said. These over-the-counter methods utilize dimethyl ether/propane, the same ingredient found in Histofreeze, but the OTC methods don't reach the same temperature, and thus they are significantly less effective.

Liquid nitrogen is a good choice for older children, such as a 10-year-old with one or two warts who says, “I want these gone.”

However, Dr. Mancini has a “no hold” policy regarding cryotherapy. “If we would have to hold the child down to do it, I generally recommend against it.”

Patients who do not want cryotherapy may consider oral or topical immunotherapy or injection therapy.

Cimetidine is the most common oral therapy used for warts. “The bottom line is that it is worth a try,” Dr. Mancini said. “It does work in some patients; the success rate is probably near 30%.” He generally prescribes a relatively high dose, 30–40 mg/kg per day, divided and given twice daily.

Squaric acid, a topical immunotherapy, is a fairly painless wart treatment, and the recurrence rate is fairly low among patients who respond, Dr. Mancini said. Allergic contact dermatitis can occur with this treatment, but it is not usually limiting.

Imiquimod is approved for genital warts with a recommended application frequency of 3 times per week, but it can be effective as an off-label treatment for common warts in children when applied once or twice daily, Dr. Mancini said.

Chemotherapy, in the form of 5% 5-fluorouracil (5-FU), also can be used off-label for warts in children, and is particularly useful for flat warts. Dr. Mancini recommends an application of 5-FU to the wart 3 nights each week, with the caveat that this treatment can result in severe dermatitis.

The injection of fungal antigens into the warts has been shown to be effective in some patients, possibly by inducing a host immune response directed at the human papillomavirus-infected tissue. Candida antigen injections have demonstrated some effectiveness, and are injected into 1–3 warts at each of two or three visits. As with other forms of topical or injection immunotherapy, untreated lesions often resolve on a parallel time frame to the involution of treated lesions.

Finally, laser therapy can be used to treat warts. Laser therapy, which is usually done with a pulsed dye laser, probably works by targeting the blood supply to the wart.

Dr. Mancini generally reserves this mode of therapy as a last resort, and it often requires several treatment sessions.

Molluscum Contagiosum

Mollusca have become more common than warts in many practices, Dr. Mancini noted. The condition is spread by skin-to-skin contact and possibly via fomites. Public swimming pools frequently are cited as a potential source of infection transmission.

Mollusca present as dome-shaped waxy papules, and often occur in conjunction with an associated dermatitis (“molluscum dermatitis”). The spontaneous resolution rate is nearly 100%, he said, although it may take 12–18 months, or longer. Remind parents that when the molluscum lesions suddenly and synchronously turn red, it is a good sign; it usually signals that the host immune response has kicked in, Dr. Mancini noted.

Despite a physician's efforts at reassurance of their self-limiting nature, many families want to treat mollusca. Treatment options have some overlap with those used for warts, and include chemovesicants, curettage, cryotherapy, imiquimod, cidofovir, tretinoin cream (especially for the face), and laser treatments.

Cantharidin, made from the extract of the Chinese blister beetle (Cantharis vesicatoris) is clearly the most effective treatment for mollusca in children. When used correctly, it has been demonstrated as safe and effective in the treatment of mollusca.

Dr. Mancini cited a study from his practice in which 90% of 300 molluscum patients cleared after cantharidin treatment, and another 8% improved. “It was very well-tolerated, and about 95% of parents said that they would choose this therapy again for their child.”

Cantharidin is not approved by the Food and Drug Administration, but was nominated for inclusion on a list of bulk drug substances that may be used in compounding and applied by the physician in the professional office setting.

Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area. DR. MANCINI

Common warts are shown prior to treatment by Candida antigen injection therapy.

The warts have resolved following two injections into the lesions.

A host immune response (erythema, edema) is shown in two molluscum contagiosum lesions. Photos courtesy Dr. Anthony J. Mancini

DENVER – Age and low hostility are independent predictors of high blood pressure in women over a 10-year period, suggesting a link between certain personality traits and disease development, Jocelyne Leclerc reported in a poster presentation at the annual meeting of the American Psychosomatic Society.

Ms. Leclerc and her colleagues at the University of British Columbia, Vancouver, compared the results of ambulatory blood pressure monitoring and personality questionnaires of 112 healthy adults at baseline and again after 10 years. The study group included 54 men and 63 women; the average age was 40 years at baseline. Average blood pressure monitoring was conducted on predetermined days when the patients did not expect significant stressful events.

Overall, blood pressure and personality traits remained stable over the 10 years. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly correlated with depression at baseline. Baseline hostility predicted increased DBP 10 years later, and baseline SBP predicted hostility 10 years later.

Gender and family history may moderate the impact of personality on blood pressure, the investigators noted in the recently published study (Pers. Individ. Diff. 2006;40:1313–21).

Increased age and low hostility significantly predicted SBP among women, while high levels of self-deception were the only significant predictors of SBP and DBP over time among men.

“The observation of low hostility in women predicting high BP appears quite surprising,” the investigators noted. This finding suggests a need to consider “possibly differential adaptiveness of the same personality features of women and men.”

Among individuals with a family history of high blood pressure, age and high levels of self-deception were significant predictors of SBP, while self-deception was the lone significant predictor of DBP. Among those without a family history of high blood pressure, only age was a significant predictor of SBP, and no variables were significant predictors of DBP.

DENVER – Age and low hostility are independent predictors of high blood pressure in women over a 10-year period, suggesting a link between certain personality traits and disease development, Jocelyne Leclerc reported in a poster presentation at the annual meeting of the American Psychosomatic Society.

Ms. Leclerc and her colleagues at the University of British Columbia, Vancouver, compared the results of ambulatory blood pressure monitoring and personality questionnaires of 112 healthy adults at baseline and again after 10 years. The study group included 54 men and 63 women; the average age was 40 years at baseline. Average blood pressure monitoring was conducted on predetermined days when the patients did not expect significant stressful events.

Overall, blood pressure and personality traits remained stable over the 10 years. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly correlated with depression at baseline. Baseline hostility predicted increased DBP 10 years later, and baseline SBP predicted hostility 10 years later.

Gender and family history may moderate the impact of personality on blood pressure, the investigators noted in the recently published study (Pers. Individ. Diff. 2006;40:1313–21).

Increased age and low hostility significantly predicted SBP among women, while high levels of self-deception were the only significant predictors of SBP and DBP over time among men.

“The observation of low hostility in women predicting high BP appears quite surprising,” the investigators noted. This finding suggests a need to consider “possibly differential adaptiveness of the same personality features of women and men.”

Among individuals with a family history of high blood pressure, age and high levels of self-deception were significant predictors of SBP, while self-deception was the lone significant predictor of DBP. Among those without a family history of high blood pressure, only age was a significant predictor of SBP, and no variables were significant predictors of DBP.

DENVER – Age and low hostility are independent predictors of high blood pressure in women over a 10-year period, suggesting a link between certain personality traits and disease development, Jocelyne Leclerc reported in a poster presentation at the annual meeting of the American Psychosomatic Society.

Ms. Leclerc and her colleagues at the University of British Columbia, Vancouver, compared the results of ambulatory blood pressure monitoring and personality questionnaires of 112 healthy adults at baseline and again after 10 years. The study group included 54 men and 63 women; the average age was 40 years at baseline. Average blood pressure monitoring was conducted on predetermined days when the patients did not expect significant stressful events.

Overall, blood pressure and personality traits remained stable over the 10 years. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly correlated with depression at baseline. Baseline hostility predicted increased DBP 10 years later, and baseline SBP predicted hostility 10 years later.

Gender and family history may moderate the impact of personality on blood pressure, the investigators noted in the recently published study (Pers. Individ. Diff. 2006;40:1313–21).

Increased age and low hostility significantly predicted SBP among women, while high levels of self-deception were the only significant predictors of SBP and DBP over time among men.

“The observation of low hostility in women predicting high BP appears quite surprising,” the investigators noted. This finding suggests a need to consider “possibly differential adaptiveness of the same personality features of women and men.”

Among individuals with a family history of high blood pressure, age and high levels of self-deception were significant predictors of SBP, while self-deception was the lone significant predictor of DBP. Among those without a family history of high blood pressure, only age was a significant predictor of SBP, and no variables were significant predictors of DBP.

BALTIMORE – Recent estimates suggest that by the year 2050, one in four Americans either will have Alzheimer's disease or will be caring for someone who does, Dr. Thomas Finucane said at a meeting sponsored by the American Geriatrics Society and Johns Hopkins University.

“This is a big problem and [it's] going to get bigger,” said Dr. Finucane, a professor in the division of geriatric medicine and gerontology at Johns Hopkins University, Baltimore. The burden of Alzheimer's disease (AD) is daunting, especially in long-term care settings. In addition, few government programs exist to ease this burden in part because the federal government considers AD a social problem rather than a medical problem, he said.

When evaluating a patient for Alzheimer's disease, it is important to understand the definition of the disease, Dr. Finucane said. Dementia is defined as an acquired, severe loss of cognitive function. Sometimes the patient is not delirious and speaks coherently, but he or she still exhibits some evidence of cognitive impairment. The impairment must be global to meet the criteria for dementia, which means the patient suffers from amnesia, plus at least one of the following: aphasia (has a speech disorder), apraxia (can't perform a learned task), agnosia (can't recognize a familiar object), and disturbance of executive function (is unable to recognize a problem, plan, monitor, and execute a solution, and stop when the task has been completed).

Families of Alzheimer's patients should seek counseling and information about useful interventions, Dr. Finucane said. Many think of drug treatment first, but cholinesterase inhibitors, the drugs most often suggested for AD, do not benefit the daily lives of most patients, he noted. Yet many patients and family members insist on trying drug therapy, despite the expense and the potential side effects.

When family members or other caregivers insist on drug therapy, propose an end point for drug use, at which time the patient will discontinue the drug treatment if symptoms have not meaningfully improved, Dr. Finucane suggested.

Data on cholinesterase inhibitors from the medical literature show two important facts. First, the drugs have been associated with a statistically significant improvement in scores on psychometric tests, such as the Mini-Mental State Examination (MMSE). Second, patients, however, have been unable to tell whether they are taking the study drug or a placebo, and in any trials that ask about the quality of life of the patient and the caregiver, it is impossible to distinguish the effects of the drug from those of a placebo, Dr. Finucane said. “The science in some of these studies may be good, but the rhetoric of the research is purely promotional.”

He cited a non-industry-supported metaanalysis of 22 double-blind, randomized, controlled trials (RCTs) that included the use of donepezil, rivastigmine, and galantamine for AD (BMJ 2005;331:321–7). Overall, patients with AD who took any of these drugs showed improvements ranging from 1.5 to 3.9 points in favor of the drugs on the Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog), a 70-point scale. Improvement on the 30-point MMSE was less than 2 points in the RCTs. However, the investigators reported methodologic flaws and minimal clinical benefits, which led them to question the effectiveness of cholinesterase inhibitors for AD.

The American Academy of Neurology's position on AD is that treatment with cholinesterase inhibitors should be considered (not mandated), and that the current evidence shows only a small degree of benefit, Dr. Finucane noted.

Also, the evidence does not support arguments that drug therapy stabilizes AD. In a randomized, double-blind trial of nearly 500 elderly patients, there was no significant difference in the progression of disability after 3 years between patients who took either 5 or 10 mg of donepezil daily or a placebo (58% vs. 59%, respectively). There was a significant difference in scores on the Mini-Mental State Examination in favor of donepezil (in this case, 0.8 points) and a small (1 point on a scale of 18) benefit on the Bristol Activities of Daily Living Scale (Lancet 2004;363:2105–15).

“You will hear over and over that you can't afford to stop these drugs in a stable AD patient, because there is a risk of catastrophic reaction,” Dr. Finucane said. However, several studies were designed with a washout period, the subjects stopped taking the medications at the end of the trials, and no adverse events were reported.

“If there was a serious risk of catastrophic reactions from stopping the donepezil, it would have been evident during the washout period at the end of the study,” he said.

In a retrospective study of 22,890 patients aged 65 years and older in Pennsylvania (N. Engl. J. Med. 2005;353:2335–41), atypical antipsychotics and conventional antipsychotics were equally associated with risk of death in elderly patients, and the investigators wrote that use of any antipsychotics for AD should be avoided. In April 2005, the Food and Drug Administration issued a black box warning on the use of atypical antipsychotics to treat Alzheimer's.

Given the lack of evidence to support a genuine benefit from drug therapy, other nonpharmaceutical strategies can be used to help manage the symptoms and behavioral problems associated with AD. Simple empathy and thinking outside the box can work wonders. For example, simply positioning a person's wheelchair in a different direction so he or she is not looking at a person or object that triggers bad behavior can be amazingly helpful, Dr. Finucane said. “Don't confront the patients. Try to talk civilly to them,” he explained. For example, when Mom says she wants to go home, rather than arguing with her, suggest, “We are just fixing your dinner now. Why don't we finish that and then talk about this request of yours.”

Bad behavior toward caregivers is a chronic problem in long-term care facilities. However, education can be as helpful as medication in addressing this problem, Dr. Finucane said. The same is true for patients who touch caregivers inappropriately; try education before medication.

Finally, some AD patients have enough insight into their condition to become extremely depressed, and antidepressants can be helpful for managing their depressive symptoms, Dr. Finucane said. However, the bottom line remains that drug treatments for AD symptoms rarely are significantly helpful in improving the quality of patients' lives and their caregivers' lives.

BALTIMORE – Recent estimates suggest that by the year 2050, one in four Americans either will have Alzheimer's disease or will be caring for someone who does, Dr. Thomas Finucane said at a meeting sponsored by the American Geriatrics Society and Johns Hopkins University.

“This is a big problem and [it's] going to get bigger,” said Dr. Finucane, a professor in the division of geriatric medicine and gerontology at Johns Hopkins University, Baltimore. The burden of Alzheimer's disease (AD) is daunting, especially in long-term care settings. In addition, few government programs exist to ease this burden in part because the federal government considers AD a social problem rather than a medical problem, he said.

When evaluating a patient for Alzheimer's disease, it is important to understand the definition of the disease, Dr. Finucane said. Dementia is defined as an acquired, severe loss of cognitive function. Sometimes the patient is not delirious and speaks coherently, but he or she still exhibits some evidence of cognitive impairment. The impairment must be global to meet the criteria for dementia, which means the patient suffers from amnesia, plus at least one of the following: aphasia (has a speech disorder), apraxia (can't perform a learned task), agnosia (can't recognize a familiar object), and disturbance of executive function (is unable to recognize a problem, plan, monitor, and execute a solution, and stop when the task has been completed).

Families of Alzheimer's patients should seek counseling and information about useful interventions, Dr. Finucane said. Many think of drug treatment first, but cholinesterase inhibitors, the drugs most often suggested for AD, do not benefit the daily lives of most patients, he noted. Yet many patients and family members insist on trying drug therapy, despite the expense and the potential side effects.

When family members or other caregivers insist on drug therapy, propose an end point for drug use, at which time the patient will discontinue the drug treatment if symptoms have not meaningfully improved, Dr. Finucane suggested.

Data on cholinesterase inhibitors from the medical literature show two important facts. First, the drugs have been associated with a statistically significant improvement in scores on psychometric tests, such as the Mini-Mental State Examination (MMSE). Second, patients, however, have been unable to tell whether they are taking the study drug or a placebo, and in any trials that ask about the quality of life of the patient and the caregiver, it is impossible to distinguish the effects of the drug from those of a placebo, Dr. Finucane said. “The science in some of these studies may be good, but the rhetoric of the research is purely promotional.”

He cited a non-industry-supported metaanalysis of 22 double-blind, randomized, controlled trials (RCTs) that included the use of donepezil, rivastigmine, and galantamine for AD (BMJ 2005;331:321–7). Overall, patients with AD who took any of these drugs showed improvements ranging from 1.5 to 3.9 points in favor of the drugs on the Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog), a 70-point scale. Improvement on the 30-point MMSE was less than 2 points in the RCTs. However, the investigators reported methodologic flaws and minimal clinical benefits, which led them to question the effectiveness of cholinesterase inhibitors for AD.

The American Academy of Neurology's position on AD is that treatment with cholinesterase inhibitors should be considered (not mandated), and that the current evidence shows only a small degree of benefit, Dr. Finucane noted.

Also, the evidence does not support arguments that drug therapy stabilizes AD. In a randomized, double-blind trial of nearly 500 elderly patients, there was no significant difference in the progression of disability after 3 years between patients who took either 5 or 10 mg of donepezil daily or a placebo (58% vs. 59%, respectively). There was a significant difference in scores on the Mini-Mental State Examination in favor of donepezil (in this case, 0.8 points) and a small (1 point on a scale of 18) benefit on the Bristol Activities of Daily Living Scale (Lancet 2004;363:2105–15).

“You will hear over and over that you can't afford to stop these drugs in a stable AD patient, because there is a risk of catastrophic reaction,” Dr. Finucane said. However, several studies were designed with a washout period, the subjects stopped taking the medications at the end of the trials, and no adverse events were reported.

“If there was a serious risk of catastrophic reactions from stopping the donepezil, it would have been evident during the washout period at the end of the study,” he said.

In a retrospective study of 22,890 patients aged 65 years and older in Pennsylvania (N. Engl. J. Med. 2005;353:2335–41), atypical antipsychotics and conventional antipsychotics were equally associated with risk of death in elderly patients, and the investigators wrote that use of any antipsychotics for AD should be avoided. In April 2005, the Food and Drug Administration issued a black box warning on the use of atypical antipsychotics to treat Alzheimer's.

Given the lack of evidence to support a genuine benefit from drug therapy, other nonpharmaceutical strategies can be used to help manage the symptoms and behavioral problems associated with AD. Simple empathy and thinking outside the box can work wonders. For example, simply positioning a person's wheelchair in a different direction so he or she is not looking at a person or object that triggers bad behavior can be amazingly helpful, Dr. Finucane said. “Don't confront the patients. Try to talk civilly to them,” he explained. For example, when Mom says she wants to go home, rather than arguing with her, suggest, “We are just fixing your dinner now. Why don't we finish that and then talk about this request of yours.”

Bad behavior toward caregivers is a chronic problem in long-term care facilities. However, education can be as helpful as medication in addressing this problem, Dr. Finucane said. The same is true for patients who touch caregivers inappropriately; try education before medication.

Finally, some AD patients have enough insight into their condition to become extremely depressed, and antidepressants can be helpful for managing their depressive symptoms, Dr. Finucane said. However, the bottom line remains that drug treatments for AD symptoms rarely are significantly helpful in improving the quality of patients' lives and their caregivers' lives.

BALTIMORE – Recent estimates suggest that by the year 2050, one in four Americans either will have Alzheimer's disease or will be caring for someone who does, Dr. Thomas Finucane said at a meeting sponsored by the American Geriatrics Society and Johns Hopkins University.

“This is a big problem and [it's] going to get bigger,” said Dr. Finucane, a professor in the division of geriatric medicine and gerontology at Johns Hopkins University, Baltimore. The burden of Alzheimer's disease (AD) is daunting, especially in long-term care settings. In addition, few government programs exist to ease this burden in part because the federal government considers AD a social problem rather than a medical problem, he said.

When evaluating a patient for Alzheimer's disease, it is important to understand the definition of the disease, Dr. Finucane said. Dementia is defined as an acquired, severe loss of cognitive function. Sometimes the patient is not delirious and speaks coherently, but he or she still exhibits some evidence of cognitive impairment. The impairment must be global to meet the criteria for dementia, which means the patient suffers from amnesia, plus at least one of the following: aphasia (has a speech disorder), apraxia (can't perform a learned task), agnosia (can't recognize a familiar object), and disturbance of executive function (is unable to recognize a problem, plan, monitor, and execute a solution, and stop when the task has been completed).

Families of Alzheimer's patients should seek counseling and information about useful interventions, Dr. Finucane said. Many think of drug treatment first, but cholinesterase inhibitors, the drugs most often suggested for AD, do not benefit the daily lives of most patients, he noted. Yet many patients and family members insist on trying drug therapy, despite the expense and the potential side effects.

When family members or other caregivers insist on drug therapy, propose an end point for drug use, at which time the patient will discontinue the drug treatment if symptoms have not meaningfully improved, Dr. Finucane suggested.

Data on cholinesterase inhibitors from the medical literature show two important facts. First, the drugs have been associated with a statistically significant improvement in scores on psychometric tests, such as the Mini-Mental State Examination (MMSE). Second, patients, however, have been unable to tell whether they are taking the study drug or a placebo, and in any trials that ask about the quality of life of the patient and the caregiver, it is impossible to distinguish the effects of the drug from those of a placebo, Dr. Finucane said. “The science in some of these studies may be good, but the rhetoric of the research is purely promotional.”

He cited a non-industry-supported metaanalysis of 22 double-blind, randomized, controlled trials (RCTs) that included the use of donepezil, rivastigmine, and galantamine for AD (BMJ 2005;331:321–7). Overall, patients with AD who took any of these drugs showed improvements ranging from 1.5 to 3.9 points in favor of the drugs on the Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog), a 70-point scale. Improvement on the 30-point MMSE was less than 2 points in the RCTs. However, the investigators reported methodologic flaws and minimal clinical benefits, which led them to question the effectiveness of cholinesterase inhibitors for AD.

The American Academy of Neurology's position on AD is that treatment with cholinesterase inhibitors should be considered (not mandated), and that the current evidence shows only a small degree of benefit, Dr. Finucane noted.

Also, the evidence does not support arguments that drug therapy stabilizes AD. In a randomized, double-blind trial of nearly 500 elderly patients, there was no significant difference in the progression of disability after 3 years between patients who took either 5 or 10 mg of donepezil daily or a placebo (58% vs. 59%, respectively). There was a significant difference in scores on the Mini-Mental State Examination in favor of donepezil (in this case, 0.8 points) and a small (1 point on a scale of 18) benefit on the Bristol Activities of Daily Living Scale (Lancet 2004;363:2105–15).

“You will hear over and over that you can't afford to stop these drugs in a stable AD patient, because there is a risk of catastrophic reaction,” Dr. Finucane said. However, several studies were designed with a washout period, the subjects stopped taking the medications at the end of the trials, and no adverse events were reported.

“If there was a serious risk of catastrophic reactions from stopping the donepezil, it would have been evident during the washout period at the end of the study,” he said.

In a retrospective study of 22,890 patients aged 65 years and older in Pennsylvania (N. Engl. J. Med. 2005;353:2335–41), atypical antipsychotics and conventional antipsychotics were equally associated with risk of death in elderly patients, and the investigators wrote that use of any antipsychotics for AD should be avoided. In April 2005, the Food and Drug Administration issued a black box warning on the use of atypical antipsychotics to treat Alzheimer's.

Given the lack of evidence to support a genuine benefit from drug therapy, other nonpharmaceutical strategies can be used to help manage the symptoms and behavioral problems associated with AD. Simple empathy and thinking outside the box can work wonders. For example, simply positioning a person's wheelchair in a different direction so he or she is not looking at a person or object that triggers bad behavior can be amazingly helpful, Dr. Finucane said. “Don't confront the patients. Try to talk civilly to them,” he explained. For example, when Mom says she wants to go home, rather than arguing with her, suggest, “We are just fixing your dinner now. Why don't we finish that and then talk about this request of yours.”

Bad behavior toward caregivers is a chronic problem in long-term care facilities. However, education can be as helpful as medication in addressing this problem, Dr. Finucane said. The same is true for patients who touch caregivers inappropriately; try education before medication.

Finally, some AD patients have enough insight into their condition to become extremely depressed, and antidepressants can be helpful for managing their depressive symptoms, Dr. Finucane said. However, the bottom line remains that drug treatments for AD symptoms rarely are significantly helpful in improving the quality of patients' lives and their caregivers' lives.

DENVER – Depression significantly increased the rates of four types of cardiovascular conditions among Medicare patients aged 65 and older, compared with Medicare patients without depression, reported Dr. Lawson R. Wulsin in a poster presented at the annual meeting of the American Psychosomatic Society.

Dr. Wulsin, professor of psychiatry and family medicine at the University of Cincinnati, and his colleagues reviewed data from 177,760 Medicare patients who were enrolled in the 1998 Medicare Health Outcomes Study. Self-reported depression for at least 2 weeks during the year prior to the study was strongly associated with chest pain at rest (relative risk 2.79), myocardial infarction (relative risk 1.49), congestive heart failure (relative risk 1.81), and stroke (relative risk 1.78).

The significant increases in risk for these four conditions persisted when the patients reported depression or sadness either “much of the past year” or “most days during any 2 years of your life” –a finding that suggests a similar effect for both recent and long-term depression in older patients.

The results support the need for depression screening among older patients with cardiovascular disease and the need to identify factors that can mitigate these effects, the investigators reported. Their analyses of covariates, including age, gender, physical and mental functioning, smoking status, and diabetes status, are pending.

DENVER – Depression significantly increased the rates of four types of cardiovascular conditions among Medicare patients aged 65 and older, compared with Medicare patients without depression, reported Dr. Lawson R. Wulsin in a poster presented at the annual meeting of the American Psychosomatic Society.

Dr. Wulsin, professor of psychiatry and family medicine at the University of Cincinnati, and his colleagues reviewed data from 177,760 Medicare patients who were enrolled in the 1998 Medicare Health Outcomes Study. Self-reported depression for at least 2 weeks during the year prior to the study was strongly associated with chest pain at rest (relative risk 2.79), myocardial infarction (relative risk 1.49), congestive heart failure (relative risk 1.81), and stroke (relative risk 1.78).

The significant increases in risk for these four conditions persisted when the patients reported depression or sadness either “much of the past year” or “most days during any 2 years of your life” –a finding that suggests a similar effect for both recent and long-term depression in older patients.

The results support the need for depression screening among older patients with cardiovascular disease and the need to identify factors that can mitigate these effects, the investigators reported. Their analyses of covariates, including age, gender, physical and mental functioning, smoking status, and diabetes status, are pending.

DENVER – Depression significantly increased the rates of four types of cardiovascular conditions among Medicare patients aged 65 and older, compared with Medicare patients without depression, reported Dr. Lawson R. Wulsin in a poster presented at the annual meeting of the American Psychosomatic Society.

Dr. Wulsin, professor of psychiatry and family medicine at the University of Cincinnati, and his colleagues reviewed data from 177,760 Medicare patients who were enrolled in the 1998 Medicare Health Outcomes Study. Self-reported depression for at least 2 weeks during the year prior to the study was strongly associated with chest pain at rest (relative risk 2.79), myocardial infarction (relative risk 1.49), congestive heart failure (relative risk 1.81), and stroke (relative risk 1.78).

The significant increases in risk for these four conditions persisted when the patients reported depression or sadness either “much of the past year” or “most days during any 2 years of your life” –a finding that suggests a similar effect for both recent and long-term depression in older patients.

The results support the need for depression screening among older patients with cardiovascular disease and the need to identify factors that can mitigate these effects, the investigators reported. Their analyses of covariates, including age, gender, physical and mental functioning, smoking status, and diabetes status, are pending.

Escitalopram: Age Appears Relevant

Escitalopram failed to significantly improve the symptoms of depression in children aged 6–11 years, but it did appear to improve symptoms in children aged 12–17 years, wrote Dr. Karen Dineen Wagner of the University of Texas, Galveston, and her colleagues.

The study included 264 children and adolescents aged 6–17 years who had been diagnosed with major depressive disorder. The Children's Depression Rating Scale-Revised (CDRS-R) served as the primary outcome measure (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:280–8).

The patients received either a placebo or 10 mg/day of escitalopram (Lexapro) for the first 4 weeks, with the option to increase the dosage up to 20 mg/day for the next 4 weeks, depending on the patient's response to the medication and tolerance.

Overall, the average changes in scores on the CDRS-R from baseline were not significantly different among the 102 escitalopram patients and 115 placebo patients who completed the study (−21.9 vs. −20.2).

However, a later analysis that adjusted for age group revealed significant improvements in CDRS-R scores from baseline among the 77 children aged 12–17 years who took escitalopram, compared with the 80 children aged 12–17 years who took a placebo, based on observed cases (−22.3 vs. −17.8).

In addition, adolescents in the escitalopram group showed significant improvements in symptoms based on several secondary outcome measures, including the Clinical Global Impressions-Severity scale.

Headaches and abdominal pain were the only reported adverse events that occurred in more than 10% of patients in either group, and the discontinuation rate in both groups was 1.5%.

The study was supported by Forest Laboratories, one of many companies from which Dr. Wagner has received research support.

Quetiapine May Ease Mania in Teens

Quetiapine was at least as effective as divalproex in alleviating manic symptoms in adolescents in a randomized, double-blind pilot study, wrote Dr. Melissa P. DelBello and her colleagues at the University of Cincinnati, Ohio.

The 28-day pilot study of 50 adolescents aged 12–18 years was the first known to directly compare an atypical antipsychotic with an antiepileptic in adolescents with mania, the researchers noted (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:305–13).

The study was supported by a grant from AstraZeneca Pharmaceuticals, which markets quetiapine (Seroquel), and is one of the many companies from which Dr. DelBello has received research funding.

The adolescents who received quetiapine started with a 100-mg dose on the first day, which was increased to 400 mg by days 4–7, up to a maximum of 600 mg/day. Those who received divalproex started with a 20-mg/kg dose on the first day, which was increased to achieve serum valproic acid levels of 80–120 μg/mL. At the end of the study, the mean doses were 412 mg/day to 422 mg/day in the quetiapine group, and a valproic acid level of 101 μg/mL in the divalproex group.

Overall, patients in both groups showed statistically significant improvements in their scores on the Young Mania Rating Scale at the end of the study, compared with their baseline scores. However, the response was quicker among the quetiapine patients, compared with divalproex patients, and the overall response rate on the Clinical Global Impressions-Bipolar Version-Improvement scale was significantly greater in the quetiapine group, compared with the divalproex group (72% vs. 40%).

Both medications were well tolerated, and no patient in either group withdrew because of adverse effects. There were no significant differences between the treatment groups in terms of age, gender, race, or age of onset of bipolar disorder.

Depression and Violence

Girls who display depressive symptoms during adolescence are at increased risk for physical violence at the hands of their intimate partners, reported Jocelyn A. Lehrer, Sc.D., of the University of California, San Francisco and her colleagues.

The investigators analyzed interview data from 1,659 girls in grades 7–12 at 80 high schools and 52 middle schools in the United States.

The data were part of the National Longitudinal Study of Adolescent Health, and the girls participated in three waves of at-home interviews; the second wave was 1 year after the first, and the third was 5–6 years after the second (Arch. Pediatr. Adolesc. Med. 2006;160:270–6).

Overall, 28% of girls who reported high levels of depression at baseline also reported some type of intimate partner violence within the past year at the third wave follow-up interview, compared with 17.5% of girls with lower levels of depressive symptoms. High levels of depression were defined as scores of 23 or higher on the Center for Epidemiologic Studies Depression Scale, and the incidence of violence was assessed using self-administered questionnaires.

Each increase of a single standard deviation in baseline depressive symptomatology was associated with a 3% increase in the odds of exposure to either mild, moderate, or severe degrees of partner violence.

Depressive symptoms have been associated with a range of risky behaviors in adolescence, and depressed teens may be more likely than their nondepressed peers to associate with risky peer groups, and to select intimate partners from these groups, the researchers noted. However, the question of whether depressive symptoms independently predict intimate partner violence or simply predict risk for partner violence remains uncertain.

Escitalopram: Age Appears Relevant

Escitalopram failed to significantly improve the symptoms of depression in children aged 6–11 years, but it did appear to improve symptoms in children aged 12–17 years, wrote Dr. Karen Dineen Wagner of the University of Texas, Galveston, and her colleagues.

The study included 264 children and adolescents aged 6–17 years who had been diagnosed with major depressive disorder. The Children's Depression Rating Scale-Revised (CDRS-R) served as the primary outcome measure (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:280–8).

The patients received either a placebo or 10 mg/day of escitalopram (Lexapro) for the first 4 weeks, with the option to increase the dosage up to 20 mg/day for the next 4 weeks, depending on the patient's response to the medication and tolerance.

Overall, the average changes in scores on the CDRS-R from baseline were not significantly different among the 102 escitalopram patients and 115 placebo patients who completed the study (−21.9 vs. −20.2).

However, a later analysis that adjusted for age group revealed significant improvements in CDRS-R scores from baseline among the 77 children aged 12–17 years who took escitalopram, compared with the 80 children aged 12–17 years who took a placebo, based on observed cases (−22.3 vs. −17.8).

In addition, adolescents in the escitalopram group showed significant improvements in symptoms based on several secondary outcome measures, including the Clinical Global Impressions-Severity scale.

Headaches and abdominal pain were the only reported adverse events that occurred in more than 10% of patients in either group, and the discontinuation rate in both groups was 1.5%.

The study was supported by Forest Laboratories, one of many companies from which Dr. Wagner has received research support.

Quetiapine May Ease Mania in Teens

Quetiapine was at least as effective as divalproex in alleviating manic symptoms in adolescents in a randomized, double-blind pilot study, wrote Dr. Melissa P. DelBello and her colleagues at the University of Cincinnati, Ohio.

The 28-day pilot study of 50 adolescents aged 12–18 years was the first known to directly compare an atypical antipsychotic with an antiepileptic in adolescents with mania, the researchers noted (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:305–13).

The study was supported by a grant from AstraZeneca Pharmaceuticals, which markets quetiapine (Seroquel), and is one of the many companies from which Dr. DelBello has received research funding.

The adolescents who received quetiapine started with a 100-mg dose on the first day, which was increased to 400 mg by days 4–7, up to a maximum of 600 mg/day. Those who received divalproex started with a 20-mg/kg dose on the first day, which was increased to achieve serum valproic acid levels of 80–120 μg/mL. At the end of the study, the mean doses were 412 mg/day to 422 mg/day in the quetiapine group, and a valproic acid level of 101 μg/mL in the divalproex group.

Overall, patients in both groups showed statistically significant improvements in their scores on the Young Mania Rating Scale at the end of the study, compared with their baseline scores. However, the response was quicker among the quetiapine patients, compared with divalproex patients, and the overall response rate on the Clinical Global Impressions-Bipolar Version-Improvement scale was significantly greater in the quetiapine group, compared with the divalproex group (72% vs. 40%).

Both medications were well tolerated, and no patient in either group withdrew because of adverse effects. There were no significant differences between the treatment groups in terms of age, gender, race, or age of onset of bipolar disorder.

Depression and Violence

Girls who display depressive symptoms during adolescence are at increased risk for physical violence at the hands of their intimate partners, reported Jocelyn A. Lehrer, Sc.D., of the University of California, San Francisco and her colleagues.

The investigators analyzed interview data from 1,659 girls in grades 7–12 at 80 high schools and 52 middle schools in the United States.

The data were part of the National Longitudinal Study of Adolescent Health, and the girls participated in three waves of at-home interviews; the second wave was 1 year after the first, and the third was 5–6 years after the second (Arch. Pediatr. Adolesc. Med. 2006;160:270–6).

Overall, 28% of girls who reported high levels of depression at baseline also reported some type of intimate partner violence within the past year at the third wave follow-up interview, compared with 17.5% of girls with lower levels of depressive symptoms. High levels of depression were defined as scores of 23 or higher on the Center for Epidemiologic Studies Depression Scale, and the incidence of violence was assessed using self-administered questionnaires.

Each increase of a single standard deviation in baseline depressive symptomatology was associated with a 3% increase in the odds of exposure to either mild, moderate, or severe degrees of partner violence.

Depressive symptoms have been associated with a range of risky behaviors in adolescence, and depressed teens may be more likely than their nondepressed peers to associate with risky peer groups, and to select intimate partners from these groups, the researchers noted. However, the question of whether depressive symptoms independently predict intimate partner violence or simply predict risk for partner violence remains uncertain.

Escitalopram: Age Appears Relevant

Escitalopram failed to significantly improve the symptoms of depression in children aged 6–11 years, but it did appear to improve symptoms in children aged 12–17 years, wrote Dr. Karen Dineen Wagner of the University of Texas, Galveston, and her colleagues.

The study included 264 children and adolescents aged 6–17 years who had been diagnosed with major depressive disorder. The Children's Depression Rating Scale-Revised (CDRS-R) served as the primary outcome measure (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:280–8).

The patients received either a placebo or 10 mg/day of escitalopram (Lexapro) for the first 4 weeks, with the option to increase the dosage up to 20 mg/day for the next 4 weeks, depending on the patient's response to the medication and tolerance.

Overall, the average changes in scores on the CDRS-R from baseline were not significantly different among the 102 escitalopram patients and 115 placebo patients who completed the study (−21.9 vs. −20.2).

However, a later analysis that adjusted for age group revealed significant improvements in CDRS-R scores from baseline among the 77 children aged 12–17 years who took escitalopram, compared with the 80 children aged 12–17 years who took a placebo, based on observed cases (−22.3 vs. −17.8).

In addition, adolescents in the escitalopram group showed significant improvements in symptoms based on several secondary outcome measures, including the Clinical Global Impressions-Severity scale.

Headaches and abdominal pain were the only reported adverse events that occurred in more than 10% of patients in either group, and the discontinuation rate in both groups was 1.5%.

The study was supported by Forest Laboratories, one of many companies from which Dr. Wagner has received research support.

Quetiapine May Ease Mania in Teens

Quetiapine was at least as effective as divalproex in alleviating manic symptoms in adolescents in a randomized, double-blind pilot study, wrote Dr. Melissa P. DelBello and her colleagues at the University of Cincinnati, Ohio.

The 28-day pilot study of 50 adolescents aged 12–18 years was the first known to directly compare an atypical antipsychotic with an antiepileptic in adolescents with mania, the researchers noted (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:305–13).

The study was supported by a grant from AstraZeneca Pharmaceuticals, which markets quetiapine (Seroquel), and is one of the many companies from which Dr. DelBello has received research funding.

The adolescents who received quetiapine started with a 100-mg dose on the first day, which was increased to 400 mg by days 4–7, up to a maximum of 600 mg/day. Those who received divalproex started with a 20-mg/kg dose on the first day, which was increased to achieve serum valproic acid levels of 80–120 μg/mL. At the end of the study, the mean doses were 412 mg/day to 422 mg/day in the quetiapine group, and a valproic acid level of 101 μg/mL in the divalproex group.

Overall, patients in both groups showed statistically significant improvements in their scores on the Young Mania Rating Scale at the end of the study, compared with their baseline scores. However, the response was quicker among the quetiapine patients, compared with divalproex patients, and the overall response rate on the Clinical Global Impressions-Bipolar Version-Improvement scale was significantly greater in the quetiapine group, compared with the divalproex group (72% vs. 40%).

Both medications were well tolerated, and no patient in either group withdrew because of adverse effects. There were no significant differences between the treatment groups in terms of age, gender, race, or age of onset of bipolar disorder.

Depression and Violence

Girls who display depressive symptoms during adolescence are at increased risk for physical violence at the hands of their intimate partners, reported Jocelyn A. Lehrer, Sc.D., of the University of California, San Francisco and her colleagues.

The investigators analyzed interview data from 1,659 girls in grades 7–12 at 80 high schools and 52 middle schools in the United States.

The data were part of the National Longitudinal Study of Adolescent Health, and the girls participated in three waves of at-home interviews; the second wave was 1 year after the first, and the third was 5–6 years after the second (Arch. Pediatr. Adolesc. Med. 2006;160:270–6).

Overall, 28% of girls who reported high levels of depression at baseline also reported some type of intimate partner violence within the past year at the third wave follow-up interview, compared with 17.5% of girls with lower levels of depressive symptoms. High levels of depression were defined as scores of 23 or higher on the Center for Epidemiologic Studies Depression Scale, and the incidence of violence was assessed using self-administered questionnaires.

Each increase of a single standard deviation in baseline depressive symptomatology was associated with a 3% increase in the odds of exposure to either mild, moderate, or severe degrees of partner violence.

Depressive symptoms have been associated with a range of risky behaviors in adolescence, and depressed teens may be more likely than their nondepressed peers to associate with risky peer groups, and to select intimate partners from these groups, the researchers noted. However, the question of whether depressive symptoms independently predict intimate partner violence or simply predict risk for partner violence remains uncertain.

WASHINGTON – The role of parental depression is not a consistent, equivalent risk factor for youth depression, Benjamin L. Hankin, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Parental depression can affect children in two main ways, Dr. Hankin noted. First, children can be exposed to such high levels of stress as a result of parental depression that the children's normal coping skills are unable to handle the initial stress and the children therefore develop depressive symptoms when confronted with additional outside stressors.

Second, depressed parents model poor skills for coping with stress, which leaves the child susceptible to depressive symptoms in the face of additional stress.

The extent to which parental depression is a risk factor for youth depression depends on the contextual domain of the stressor, said Dr. Hankin of the University of South Carolina, Columbia.

Dr. Hankin and his associates conducted a longitudinal study that included 421 8th and 10th -grade students from 18 suburban high schools in Chicago. About 55% were female and 87% were white. The youth were evaluated at baseline, 6 months, and 12 months.

The results were based on reports from both the parents and the youths. The data included self-report questionnaires and a 7-day reporting of events at each of the three measurement times using a daily diary in which the youth recorded the worst events of each day. Entries ranged from dropping books in the hallway and receiving poor test grades to fighting with a girlfriend or being kicked out of school.

The researchers analyzed the responses and divided the events into categories of interpersonal stressors, such as family, romantic, peer, and athletic. Parental depressive symptoms interacted with youth stressors to increase the odds of depression in the youth when the interpersonal stressors fell into the family or romantic categories, Dr. Hankin said.

In addition, parental depressive symptoms contributed to poor coping skills among youth. These poor coping skills, when combined with stressors in the family or romantic categories, left the youth more vulnerable to depressive symptoms, Dr. Hankin said. The results were consistent with the limited studies on depressive symptoms in youths whose parents are depressed.

In general, children of depressed parents are at increased risk of psychopathology resulting from internalizing disorders such as depression and anxiety and externalizing disorders such as oppositional disorder and aggression. Children with depressed parents are also more likely to demonstrate impairment in situations concerning school, social competency, and self-esteem.

In addition, the stress caused by a parent's depression disrupts the quality of the parent and child interaction. Such stress also limits the ability of the parent to be available to the child to mitigate the child's daily stressors, Dr. Hankin said.

KATHRYN DALES

WASHINGTON – The role of parental depression is not a consistent, equivalent risk factor for youth depression, Benjamin L. Hankin, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Parental depression can affect children in two main ways, Dr. Hankin noted. First, children can be exposed to such high levels of stress as a result of parental depression that the children's normal coping skills are unable to handle the initial stress and the children therefore develop depressive symptoms when confronted with additional outside stressors.

Second, depressed parents model poor skills for coping with stress, which leaves the child susceptible to depressive symptoms in the face of additional stress.

The extent to which parental depression is a risk factor for youth depression depends on the contextual domain of the stressor, said Dr. Hankin of the University of South Carolina, Columbia.

Dr. Hankin and his associates conducted a longitudinal study that included 421 8th and 10th -grade students from 18 suburban high schools in Chicago. About 55% were female and 87% were white. The youth were evaluated at baseline, 6 months, and 12 months.

The results were based on reports from both the parents and the youths. The data included self-report questionnaires and a 7-day reporting of events at each of the three measurement times using a daily diary in which the youth recorded the worst events of each day. Entries ranged from dropping books in the hallway and receiving poor test grades to fighting with a girlfriend or being kicked out of school.

The researchers analyzed the responses and divided the events into categories of interpersonal stressors, such as family, romantic, peer, and athletic. Parental depressive symptoms interacted with youth stressors to increase the odds of depression in the youth when the interpersonal stressors fell into the family or romantic categories, Dr. Hankin said.

In addition, parental depressive symptoms contributed to poor coping skills among youth. These poor coping skills, when combined with stressors in the family or romantic categories, left the youth more vulnerable to depressive symptoms, Dr. Hankin said. The results were consistent with the limited studies on depressive symptoms in youths whose parents are depressed.

In general, children of depressed parents are at increased risk of psychopathology resulting from internalizing disorders such as depression and anxiety and externalizing disorders such as oppositional disorder and aggression. Children with depressed parents are also more likely to demonstrate impairment in situations concerning school, social competency, and self-esteem.

In addition, the stress caused by a parent's depression disrupts the quality of the parent and child interaction. Such stress also limits the ability of the parent to be available to the child to mitigate the child's daily stressors, Dr. Hankin said.

KATHRYN DALES

WASHINGTON – The role of parental depression is not a consistent, equivalent risk factor for youth depression, Benjamin L. Hankin, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Parental depression can affect children in two main ways, Dr. Hankin noted. First, children can be exposed to such high levels of stress as a result of parental depression that the children's normal coping skills are unable to handle the initial stress and the children therefore develop depressive symptoms when confronted with additional outside stressors.

Second, depressed parents model poor skills for coping with stress, which leaves the child susceptible to depressive symptoms in the face of additional stress.

The extent to which parental depression is a risk factor for youth depression depends on the contextual domain of the stressor, said Dr. Hankin of the University of South Carolina, Columbia.

Dr. Hankin and his associates conducted a longitudinal study that included 421 8th and 10th -grade students from 18 suburban high schools in Chicago. About 55% were female and 87% were white. The youth were evaluated at baseline, 6 months, and 12 months.

The results were based on reports from both the parents and the youths. The data included self-report questionnaires and a 7-day reporting of events at each of the three measurement times using a daily diary in which the youth recorded the worst events of each day. Entries ranged from dropping books in the hallway and receiving poor test grades to fighting with a girlfriend or being kicked out of school.

The researchers analyzed the responses and divided the events into categories of interpersonal stressors, such as family, romantic, peer, and athletic. Parental depressive symptoms interacted with youth stressors to increase the odds of depression in the youth when the interpersonal stressors fell into the family or romantic categories, Dr. Hankin said.

In addition, parental depressive symptoms contributed to poor coping skills among youth. These poor coping skills, when combined with stressors in the family or romantic categories, left the youth more vulnerable to depressive symptoms, Dr. Hankin said. The results were consistent with the limited studies on depressive symptoms in youths whose parents are depressed.

In general, children of depressed parents are at increased risk of psychopathology resulting from internalizing disorders such as depression and anxiety and externalizing disorders such as oppositional disorder and aggression. Children with depressed parents are also more likely to demonstrate impairment in situations concerning school, social competency, and self-esteem.

In addition, the stress caused by a parent's depression disrupts the quality of the parent and child interaction. Such stress also limits the ability of the parent to be available to the child to mitigate the child's daily stressors, Dr. Hankin said.

KATHRYN DALES

SAN DIEGO — Tumors travel within the nerve structure, so if a Mohs surgeon has a habit of taking superficial margins, he or she will miss perineural tumors, Dr. Alexander Miller said at a meeting sponsored by the American Society for Mohs Surgery.

The nerve structure includes the endoneurium (nerve fibers), perineurium (mostly collagen), and epineurium (connective tissue). All these components vary with the nerve size, and tumors can travel through all of them.

"A perineural tumor doesn't care which nerve it gets into, and it will go anywhere and in any direction," Dr. Miller said. "It could attack several nerves simultaneously," said Dr. Miller of the University of California, Irvine.

About 60%–70% of perineural tumors are asymptomatic and unknown to the patient. With symptomatic tumors, patients report burning, aching, numbness, or even a complete lack of sensation. The nerves are rarely palpable, although they may be more palpable at points where they cross over bones.

Although most perineural invasion is localized, there are cases in which it travels far beyond the general body of the tumor. "Your challenge is to discriminate between localized and not localized," he said. The majority of perineural tumors are localized to areas within 1 cm or less of the general body of the tumor. That said, some invasions extend several centimeters beyond the general body of the tumor, Dr. Miller said.

"Perineural tumors are hard to see under the microscope, and some people forget to look," he said.

Tumors that are most likely to become perineurally invasive are basal cell carcinoma and squamous cell carcinoma, but microcystic adnexal carcinoma, neurotropic malignant melanoma, and other adnexal tumors, particularly salivary or sweat gland tumors, also are candidates for perineural invasion.

An estimated 1% of basal cell carcinomas have perineural invasion. Those most likely to become perineural are morphealike, micronodular, metatypical, and basal cells invading as long arms of tumor surrounded by concentric fibrous sleeves of collagen.

About 3%–4% of squamous cell carcinomas are perineural, usually those that are moderately to poorly differentiated, and show tumor spreading like a narrow cord.

Squamous cell carcinomas more than 2 cm in diameter or greater than 4-mm thickness are more likely to be perineural than smaller ones; if they are 8 mm in thickness the risk is substantial.

Most microcystic adnexal carcinomas, approximately 80%, invade perineurally and subclinically, and it is crucial for the Mohs surgeon to be aware of this, Dr. Miller said. "Take a wider margin than you would with other tumors, be careful about tracking out the edges, and get good-quality slides."

Regardless of the type of tumor, tumors that are perineurally invasive share a uniform histology and display similar behaviors.

"They all pretty much look the same once they get into the perineural space," Dr. Miller said. The tumor cells can be tightly packed, clustered, or in a line. "In order to tell the tumor of origin, you have to go back to the original histology and look elsewhere on the slide" he said.

The pattern of growth can be spotty or concentric, and perineural tumors tend to be multifocal. "It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve," he said.

"Be aware of multifocality in the subcutaneous layer," Dr. Miller advised. "If you have poor-quality slides that are consistently destroying fat, you may miss crucial structures." Obvious inflammation around a nerve is a helpful indicator of perineural invasion, he added.

Tumor depth has been shown to correlate with perineural invasion, as has tumor recurrence and fibrous sleeve growth. Also, pay attention to nerve orientation on the microscope slides. A tumor may invade concentrically around the nerve, or just crawl along a portion of the nerve circumference. When a tumor invades along only one edge of a nerve, it can easily be missed.

"Multiple Mohs sections and slides must be examined for perineural tumor, or you will miss it," Dr. Miller emphasized.

"When perineural tumors recur, they are unpleasant; they are deep, and they can grow subclinically for a long time," Dr. Miller said. "Meticulous, compulsive evaluation is needed to successfully treat these patients and prevent recurrence."

'It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve.' DR. MILLER

SAN DIEGO — Tumors travel within the nerve structure, so if a Mohs surgeon has a habit of taking superficial margins, he or she will miss perineural tumors, Dr. Alexander Miller said at a meeting sponsored by the American Society for Mohs Surgery.

The nerve structure includes the endoneurium (nerve fibers), perineurium (mostly collagen), and epineurium (connective tissue). All these components vary with the nerve size, and tumors can travel through all of them.

"A perineural tumor doesn't care which nerve it gets into, and it will go anywhere and in any direction," Dr. Miller said. "It could attack several nerves simultaneously," said Dr. Miller of the University of California, Irvine.

About 60%–70% of perineural tumors are asymptomatic and unknown to the patient. With symptomatic tumors, patients report burning, aching, numbness, or even a complete lack of sensation. The nerves are rarely palpable, although they may be more palpable at points where they cross over bones.

Although most perineural invasion is localized, there are cases in which it travels far beyond the general body of the tumor. "Your challenge is to discriminate between localized and not localized," he said. The majority of perineural tumors are localized to areas within 1 cm or less of the general body of the tumor. That said, some invasions extend several centimeters beyond the general body of the tumor, Dr. Miller said.

"Perineural tumors are hard to see under the microscope, and some people forget to look," he said.

Tumors that are most likely to become perineurally invasive are basal cell carcinoma and squamous cell carcinoma, but microcystic adnexal carcinoma, neurotropic malignant melanoma, and other adnexal tumors, particularly salivary or sweat gland tumors, also are candidates for perineural invasion.

An estimated 1% of basal cell carcinomas have perineural invasion. Those most likely to become perineural are morphealike, micronodular, metatypical, and basal cells invading as long arms of tumor surrounded by concentric fibrous sleeves of collagen.

About 3%–4% of squamous cell carcinomas are perineural, usually those that are moderately to poorly differentiated, and show tumor spreading like a narrow cord.

Squamous cell carcinomas more than 2 cm in diameter or greater than 4-mm thickness are more likely to be perineural than smaller ones; if they are 8 mm in thickness the risk is substantial.

Most microcystic adnexal carcinomas, approximately 80%, invade perineurally and subclinically, and it is crucial for the Mohs surgeon to be aware of this, Dr. Miller said. "Take a wider margin than you would with other tumors, be careful about tracking out the edges, and get good-quality slides."

Regardless of the type of tumor, tumors that are perineurally invasive share a uniform histology and display similar behaviors.

"They all pretty much look the same once they get into the perineural space," Dr. Miller said. The tumor cells can be tightly packed, clustered, or in a line. "In order to tell the tumor of origin, you have to go back to the original histology and look elsewhere on the slide" he said.

The pattern of growth can be spotty or concentric, and perineural tumors tend to be multifocal. "It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve," he said.

"Be aware of multifocality in the subcutaneous layer," Dr. Miller advised. "If you have poor-quality slides that are consistently destroying fat, you may miss crucial structures." Obvious inflammation around a nerve is a helpful indicator of perineural invasion, he added.

Tumor depth has been shown to correlate with perineural invasion, as has tumor recurrence and fibrous sleeve growth. Also, pay attention to nerve orientation on the microscope slides. A tumor may invade concentrically around the nerve, or just crawl along a portion of the nerve circumference. When a tumor invades along only one edge of a nerve, it can easily be missed.

"Multiple Mohs sections and slides must be examined for perineural tumor, or you will miss it," Dr. Miller emphasized.

"When perineural tumors recur, they are unpleasant; they are deep, and they can grow subclinically for a long time," Dr. Miller said. "Meticulous, compulsive evaluation is needed to successfully treat these patients and prevent recurrence."

'It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve.' DR. MILLER

SAN DIEGO — Tumors travel within the nerve structure, so if a Mohs surgeon has a habit of taking superficial margins, he or she will miss perineural tumors, Dr. Alexander Miller said at a meeting sponsored by the American Society for Mohs Surgery.

The nerve structure includes the endoneurium (nerve fibers), perineurium (mostly collagen), and epineurium (connective tissue). All these components vary with the nerve size, and tumors can travel through all of them.

"A perineural tumor doesn't care which nerve it gets into, and it will go anywhere and in any direction," Dr. Miller said. "It could attack several nerves simultaneously," said Dr. Miller of the University of California, Irvine.

About 60%–70% of perineural tumors are asymptomatic and unknown to the patient. With symptomatic tumors, patients report burning, aching, numbness, or even a complete lack of sensation. The nerves are rarely palpable, although they may be more palpable at points where they cross over bones.

Although most perineural invasion is localized, there are cases in which it travels far beyond the general body of the tumor. "Your challenge is to discriminate between localized and not localized," he said. The majority of perineural tumors are localized to areas within 1 cm or less of the general body of the tumor. That said, some invasions extend several centimeters beyond the general body of the tumor, Dr. Miller said.

"Perineural tumors are hard to see under the microscope, and some people forget to look," he said.

Tumors that are most likely to become perineurally invasive are basal cell carcinoma and squamous cell carcinoma, but microcystic adnexal carcinoma, neurotropic malignant melanoma, and other adnexal tumors, particularly salivary or sweat gland tumors, also are candidates for perineural invasion.

An estimated 1% of basal cell carcinomas have perineural invasion. Those most likely to become perineural are morphealike, micronodular, metatypical, and basal cells invading as long arms of tumor surrounded by concentric fibrous sleeves of collagen.

About 3%–4% of squamous cell carcinomas are perineural, usually those that are moderately to poorly differentiated, and show tumor spreading like a narrow cord.

Squamous cell carcinomas more than 2 cm in diameter or greater than 4-mm thickness are more likely to be perineural than smaller ones; if they are 8 mm in thickness the risk is substantial.

Most microcystic adnexal carcinomas, approximately 80%, invade perineurally and subclinically, and it is crucial for the Mohs surgeon to be aware of this, Dr. Miller said. "Take a wider margin than you would with other tumors, be careful about tracking out the edges, and get good-quality slides."

Regardless of the type of tumor, tumors that are perineurally invasive share a uniform histology and display similar behaviors.

"They all pretty much look the same once they get into the perineural space," Dr. Miller said. The tumor cells can be tightly packed, clustered, or in a line. "In order to tell the tumor of origin, you have to go back to the original histology and look elsewhere on the slide" he said.

The pattern of growth can be spotty or concentric, and perineural tumors tend to be multifocal. "It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve," he said.

"Be aware of multifocality in the subcutaneous layer," Dr. Miller advised. "If you have poor-quality slides that are consistently destroying fat, you may miss crucial structures." Obvious inflammation around a nerve is a helpful indicator of perineural invasion, he added.

Tumor depth has been shown to correlate with perineural invasion, as has tumor recurrence and fibrous sleeve growth. Also, pay attention to nerve orientation on the microscope slides. A tumor may invade concentrically around the nerve, or just crawl along a portion of the nerve circumference. When a tumor invades along only one edge of a nerve, it can easily be missed.

"Multiple Mohs sections and slides must be examined for perineural tumor, or you will miss it," Dr. Miller emphasized.

"When perineural tumors recur, they are unpleasant; they are deep, and they can grow subclinically for a long time," Dr. Miller said. "Meticulous, compulsive evaluation is needed to successfully treat these patients and prevent recurrence."

'It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve.' DR. MILLER

SAN DIEGO — The use of zinc chloride fixative paste may be controversial, but its judicious application can increase the melanoma-clearing properties of Mohs surgery, Dr. Norman A. Brooks said at a meeting sponsored by the American Society for Mohs Surgery.

"Zinc chloride fixative paste is an amazing substance; it has the ability to cure cancer right out of the bone," said Dr. Brooks, a Mohs surgeon in private practice in Encino, Calif.

Application of the paste has been shown to freeze melanomatous tissue in place. This process kills the tissue, which can then be removed using Mohs surgery.

Dr. Frederic Mohs did not invent the paste, but he did fine-tune the standard formula, which is still in use today.

The use of zinc chloride fixative paste for the treatment of skin conditions has not been approved by the Food and Drug Administration, and patients should not apply it themselves or buy it online. The paste is powerful, toxic, and potentially scar causing, and it must be handled carefully, Dr. Brooks said.

It does, however, appear to work. Studies have shown higher cure rates in melanoma patients when the paste was used prior to excision of the cancer with Mohs surgery, he noted.

The application of zinc chloride fixative paste is a two-step process. The paste can't penetrate the outer keratin layer of the skin, so it's necessary to apply a saturated dichloroacetic or trichloroacetic acid solution to the area. When the area turns white, that means the acid has dissolved the keratin and the paste can be applied. The paste is applied in a layer 1- to 2-mm thick, with a narrow margin around the clinical melanoma that includes subclinical extensions. A dry, sterile cotton ball is then applied with clear plastic adhesive tape as an occlusive dressing to hold the paste in place.

Approximately 24 hours later, the killed tissue is excised and a wall of white, fixed tissue will be visible, Dr. Brooks said. The excised specimen can be preserved in formaldehyde, embedded in paraffin, and sectioned for examination.

The use of zinc chloride paste is not a substitution for Mohs surgery, but it can be a supplement to it. "If used preoperatively, after a biopsy, it can cure patients even more effectively than surgery alone," Dr. Brooks said.

Zinc chloride paste does not get the publicity of cancer treatments such as interferon because it is not FDA approved, Dr. Brooks noted. Companies that might consider seeking FDA approval balk at the multimillion-dollar cost of a toxicity study. Although the paste is made of naturally occurring ingredients, the toxicity study is cost prohibitive and no company has been willing to put up the money.

"I don't blame them. That would be financially insane," Dr. Brooks said. But that doesn't mean Mohs surgeons can't use the paste if they get informed consent from patients.

"You need to tell the patient that this is not an FDA-approved drug; it is a naturally occurring substance, and it can improve the outcome of the surgery by reducing the risk of recurrence," Dr. Brooks said.

The formula for zinc paste perfected by Dr. Mohs has been published and can be found in the Mohs surgery literature.

Many patients with cancer are now receiving preoperative treatments such as chemotherapy, and the use of zinc chloride fixative paste prior to excision of the cancer can be another effective strategy when properly applied, Dr. Brooks said.

A biopsy was performed on a 1.8-mm-thick amelanotic melanoma of the left arm.

Zinc chloride fixative paste was applied to the fresh tissue site with a 2- to 3-mm margin.

A dressing held the zinc chloride paste in place for 24 hours before Mohs excision.

Conventional excision of a deep wide margin was done a week after applying paste.

No sentinel node involvement was seen on this patient at time of fresh tissue excision. Photos courtesy Dr. Norman A. Brooks

SAN DIEGO — The use of zinc chloride fixative paste may be controversial, but its judicious application can increase the melanoma-clearing properties of Mohs surgery, Dr. Norman A. Brooks said at a meeting sponsored by the American Society for Mohs Surgery.

"Zinc chloride fixative paste is an amazing substance; it has the ability to cure cancer right out of the bone," said Dr. Brooks, a Mohs surgeon in private practice in Encino, Calif.

Application of the paste has been shown to freeze melanomatous tissue in place. This process kills the tissue, which can then be removed using Mohs surgery.

Dr. Frederic Mohs did not invent the paste, but he did fine-tune the standard formula, which is still in use today.

The use of zinc chloride fixative paste for the treatment of skin conditions has not been approved by the Food and Drug Administration, and patients should not apply it themselves or buy it online. The paste is powerful, toxic, and potentially scar causing, and it must be handled carefully, Dr. Brooks said.

It does, however, appear to work. Studies have shown higher cure rates in melanoma patients when the paste was used prior to excision of the cancer with Mohs surgery, he noted.

The application of zinc chloride fixative paste is a two-step process. The paste can't penetrate the outer keratin layer of the skin, so it's necessary to apply a saturated dichloroacetic or trichloroacetic acid solution to the area. When the area turns white, that means the acid has dissolved the keratin and the paste can be applied. The paste is applied in a layer 1- to 2-mm thick, with a narrow margin around the clinical melanoma that includes subclinical extensions. A dry, sterile cotton ball is then applied with clear plastic adhesive tape as an occlusive dressing to hold the paste in place.

Approximately 24 hours later, the killed tissue is excised and a wall of white, fixed tissue will be visible, Dr. Brooks said. The excised specimen can be preserved in formaldehyde, embedded in paraffin, and sectioned for examination.

The use of zinc chloride paste is not a substitution for Mohs surgery, but it can be a supplement to it. "If used preoperatively, after a biopsy, it can cure patients even more effectively than surgery alone," Dr. Brooks said.

Zinc chloride paste does not get the publicity of cancer treatments such as interferon because it is not FDA approved, Dr. Brooks noted. Companies that might consider seeking FDA approval balk at the multimillion-dollar cost of a toxicity study. Although the paste is made of naturally occurring ingredients, the toxicity study is cost prohibitive and no company has been willing to put up the money.

"I don't blame them. That would be financially insane," Dr. Brooks said. But that doesn't mean Mohs surgeons can't use the paste if they get informed consent from patients.

"You need to tell the patient that this is not an FDA-approved drug; it is a naturally occurring substance, and it can improve the outcome of the surgery by reducing the risk of recurrence," Dr. Brooks said.

The formula for zinc paste perfected by Dr. Mohs has been published and can be found in the Mohs surgery literature.

Many patients with cancer are now receiving preoperative treatments such as chemotherapy, and the use of zinc chloride fixative paste prior to excision of the cancer can be another effective strategy when properly applied, Dr. Brooks said.

A biopsy was performed on a 1.8-mm-thick amelanotic melanoma of the left arm.

Zinc chloride fixative paste was applied to the fresh tissue site with a 2- to 3-mm margin.

A dressing held the zinc chloride paste in place for 24 hours before Mohs excision.

Conventional excision of a deep wide margin was done a week after applying paste.

No sentinel node involvement was seen on this patient at time of fresh tissue excision. Photos courtesy Dr. Norman A. Brooks

SAN DIEGO — The use of zinc chloride fixative paste may be controversial, but its judicious application can increase the melanoma-clearing properties of Mohs surgery, Dr. Norman A. Brooks said at a meeting sponsored by the American Society for Mohs Surgery.

"Zinc chloride fixative paste is an amazing substance; it has the ability to cure cancer right out of the bone," said Dr. Brooks, a Mohs surgeon in private practice in Encino, Calif.

Application of the paste has been shown to freeze melanomatous tissue in place. This process kills the tissue, which can then be removed using Mohs surgery.

Dr. Frederic Mohs did not invent the paste, but he did fine-tune the standard formula, which is still in use today.

The use of zinc chloride fixative paste for the treatment of skin conditions has not been approved by the Food and Drug Administration, and patients should not apply it themselves or buy it online. The paste is powerful, toxic, and potentially scar causing, and it must be handled carefully, Dr. Brooks said.

It does, however, appear to work. Studies have shown higher cure rates in melanoma patients when the paste was used prior to excision of the cancer with Mohs surgery, he noted.

The application of zinc chloride fixative paste is a two-step process. The paste can't penetrate the outer keratin layer of the skin, so it's necessary to apply a saturated dichloroacetic or trichloroacetic acid solution to the area. When the area turns white, that means the acid has dissolved the keratin and the paste can be applied. The paste is applied in a layer 1- to 2-mm thick, with a narrow margin around the clinical melanoma that includes subclinical extensions. A dry, sterile cotton ball is then applied with clear plastic adhesive tape as an occlusive dressing to hold the paste in place.

Approximately 24 hours later, the killed tissue is excised and a wall of white, fixed tissue will be visible, Dr. Brooks said. The excised specimen can be preserved in formaldehyde, embedded in paraffin, and sectioned for examination.

The use of zinc chloride paste is not a substitution for Mohs surgery, but it can be a supplement to it. "If used preoperatively, after a biopsy, it can cure patients even more effectively than surgery alone," Dr. Brooks said.

Zinc chloride paste does not get the publicity of cancer treatments such as interferon because it is not FDA approved, Dr. Brooks noted. Companies that might consider seeking FDA approval balk at the multimillion-dollar cost of a toxicity study. Although the paste is made of naturally occurring ingredients, the toxicity study is cost prohibitive and no company has been willing to put up the money.

"I don't blame them. That would be financially insane," Dr. Brooks said. But that doesn't mean Mohs surgeons can't use the paste if they get informed consent from patients.

"You need to tell the patient that this is not an FDA-approved drug; it is a naturally occurring substance, and it can improve the outcome of the surgery by reducing the risk of recurrence," Dr. Brooks said.

The formula for zinc paste perfected by Dr. Mohs has been published and can be found in the Mohs surgery literature.

Many patients with cancer are now receiving preoperative treatments such as chemotherapy, and the use of zinc chloride fixative paste prior to excision of the cancer can be another effective strategy when properly applied, Dr. Brooks said.

A biopsy was performed on a 1.8-mm-thick amelanotic melanoma of the left arm.

Zinc chloride fixative paste was applied to the fresh tissue site with a 2- to 3-mm margin.

A dressing held the zinc chloride paste in place for 24 hours before Mohs excision.

Conventional excision of a deep wide margin was done a week after applying paste.

No sentinel node involvement was seen on this patient at time of fresh tissue excision. Photos courtesy Dr. Norman A. Brooks