Kerri Wachter

PHILADELPHIA — Desonide emulsion foam significantly reduced pruritus among pediatric patients with moderate atopic dermatitis compared with the vehicle alone, according to the results of a randomized phase III study of more than 500 children and adolescents.

At week 4, 34% of patients in the desonide group had a pruritus score of 0 (no pruritus), compared with 9% in the vehicle group, Dr. Sheila F. Friedlander and her colleagues reported in a poster presented at the annual meeting of the Society for Pediatric Dermatology.

Desonide is a low-potency corticosteroid approved in the United States for the treatment of corticosteroid-responsive dermatoses. Ethanol-free desonide emulsion foam (Verdeso), developed by Connetics Corporation, is approved to treat mild-to-moderate atopic dermatitis (AD). The company funded this study, said Dr. Friedlander, a professor of pediatrics and medicine (dermatology) at the University of California, San Diego.

The multicenter trial included patients at least 3 months old but less than 18 years with moderate AD. Patients were assigned to age-based cohorts: 12 years to less than 18 years (cohort 1), 6 years to less than 12 years (cohort 2), 3 years to less than 6 years (cohort 3), and 3 months to less than 3 years (cohort 4).

In all, 581 patients were included in the study—387 in the desonide group and 194 in the vehicle group. The majority of patients (87%) completed the planned 4-week treatment period—93% of the desonide group and 77% of the vehicle group. There were no differences between the two groups in terms of baseline pruritus scores.

Patients or primary caregivers were instructed to apply the foam twice daily (mornings and evenings) to affected areas over a 4-week period. They were instructed to include the face and other thin-skinned areas, if affected. Efficacy was assessed during scheduled visits at baseline (day 1), week 2, week 4 (or end of treatment), and 3 weeks after the end of treatment.

Patients and/or caregivers were instructed to assess pruritus for 24 hours prior to each study visit, using a pruritus score table. The investigators did not assess pruritus. Patients who were not able to read and/or understand the score table had their pruritus scored by investigator interview. Pruritus was scored 0–4, with a score of 0 meaning no itching and a score of 4 meaning severe/constant itching (disrupting sleep and activities).

In addition, patients or caregivers completed the Dermatology Life Quality Index (DLQI) or the Children's Dermatology Life Quality Index questionnaire at baseline and again at week 4.

Patients in the desonide group had significantly decreased mean pruritus at week 2 and week 4 compared with those in the vehicle group. Importantly, no rebound phenomenon was observed 3 weeks after the end of treatment for either group. The average pruritus scores at weeks 2 and 4 did not vary by age cohort.

The average quality of life measure was significantly improved for the patients on desonide compared with those on vehicle alone at week 4.

Dr. Friedlander disclosed that she has received grants for educational activities from Connetics and several other pharmaceutical companies.

PHILADELPHIA — Desonide emulsion foam significantly reduced pruritus among pediatric patients with moderate atopic dermatitis compared with the vehicle alone, according to the results of a randomized phase III study of more than 500 children and adolescents.

At week 4, 34% of patients in the desonide group had a pruritus score of 0 (no pruritus), compared with 9% in the vehicle group, Dr. Sheila F. Friedlander and her colleagues reported in a poster presented at the annual meeting of the Society for Pediatric Dermatology.

Desonide is a low-potency corticosteroid approved in the United States for the treatment of corticosteroid-responsive dermatoses. Ethanol-free desonide emulsion foam (Verdeso), developed by Connetics Corporation, is approved to treat mild-to-moderate atopic dermatitis (AD). The company funded this study, said Dr. Friedlander, a professor of pediatrics and medicine (dermatology) at the University of California, San Diego.

The multicenter trial included patients at least 3 months old but less than 18 years with moderate AD. Patients were assigned to age-based cohorts: 12 years to less than 18 years (cohort 1), 6 years to less than 12 years (cohort 2), 3 years to less than 6 years (cohort 3), and 3 months to less than 3 years (cohort 4).

In all, 581 patients were included in the study—387 in the desonide group and 194 in the vehicle group. The majority of patients (87%) completed the planned 4-week treatment period—93% of the desonide group and 77% of the vehicle group. There were no differences between the two groups in terms of baseline pruritus scores.

Patients or primary caregivers were instructed to apply the foam twice daily (mornings and evenings) to affected areas over a 4-week period. They were instructed to include the face and other thin-skinned areas, if affected. Efficacy was assessed during scheduled visits at baseline (day 1), week 2, week 4 (or end of treatment), and 3 weeks after the end of treatment.

Patients and/or caregivers were instructed to assess pruritus for 24 hours prior to each study visit, using a pruritus score table. The investigators did not assess pruritus. Patients who were not able to read and/or understand the score table had their pruritus scored by investigator interview. Pruritus was scored 0–4, with a score of 0 meaning no itching and a score of 4 meaning severe/constant itching (disrupting sleep and activities).

In addition, patients or caregivers completed the Dermatology Life Quality Index (DLQI) or the Children's Dermatology Life Quality Index questionnaire at baseline and again at week 4.

Patients in the desonide group had significantly decreased mean pruritus at week 2 and week 4 compared with those in the vehicle group. Importantly, no rebound phenomenon was observed 3 weeks after the end of treatment for either group. The average pruritus scores at weeks 2 and 4 did not vary by age cohort.

The average quality of life measure was significantly improved for the patients on desonide compared with those on vehicle alone at week 4.

Dr. Friedlander disclosed that she has received grants for educational activities from Connetics and several other pharmaceutical companies.

PHILADELPHIA — Desonide emulsion foam significantly reduced pruritus among pediatric patients with moderate atopic dermatitis compared with the vehicle alone, according to the results of a randomized phase III study of more than 500 children and adolescents.

At week 4, 34% of patients in the desonide group had a pruritus score of 0 (no pruritus), compared with 9% in the vehicle group, Dr. Sheila F. Friedlander and her colleagues reported in a poster presented at the annual meeting of the Society for Pediatric Dermatology.

Desonide is a low-potency corticosteroid approved in the United States for the treatment of corticosteroid-responsive dermatoses. Ethanol-free desonide emulsion foam (Verdeso), developed by Connetics Corporation, is approved to treat mild-to-moderate atopic dermatitis (AD). The company funded this study, said Dr. Friedlander, a professor of pediatrics and medicine (dermatology) at the University of California, San Diego.

The multicenter trial included patients at least 3 months old but less than 18 years with moderate AD. Patients were assigned to age-based cohorts: 12 years to less than 18 years (cohort 1), 6 years to less than 12 years (cohort 2), 3 years to less than 6 years (cohort 3), and 3 months to less than 3 years (cohort 4).

In all, 581 patients were included in the study—387 in the desonide group and 194 in the vehicle group. The majority of patients (87%) completed the planned 4-week treatment period—93% of the desonide group and 77% of the vehicle group. There were no differences between the two groups in terms of baseline pruritus scores.

Patients or primary caregivers were instructed to apply the foam twice daily (mornings and evenings) to affected areas over a 4-week period. They were instructed to include the face and other thin-skinned areas, if affected. Efficacy was assessed during scheduled visits at baseline (day 1), week 2, week 4 (or end of treatment), and 3 weeks after the end of treatment.

Patients and/or caregivers were instructed to assess pruritus for 24 hours prior to each study visit, using a pruritus score table. The investigators did not assess pruritus. Patients who were not able to read and/or understand the score table had their pruritus scored by investigator interview. Pruritus was scored 0–4, with a score of 0 meaning no itching and a score of 4 meaning severe/constant itching (disrupting sleep and activities).

In addition, patients or caregivers completed the Dermatology Life Quality Index (DLQI) or the Children's Dermatology Life Quality Index questionnaire at baseline and again at week 4.

Patients in the desonide group had significantly decreased mean pruritus at week 2 and week 4 compared with those in the vehicle group. Importantly, no rebound phenomenon was observed 3 weeks after the end of treatment for either group. The average pruritus scores at weeks 2 and 4 did not vary by age cohort.

The average quality of life measure was significantly improved for the patients on desonide compared with those on vehicle alone at week 4.

Dr. Friedlander disclosed that she has received grants for educational activities from Connetics and several other pharmaceutical companies.

PHILADELPHIA — Children with systemic allergic contact dermatitis can benefit from diets that minimize ingestion of certain foods that contain key allergens, including nickel and cobalt, according to Dr. Catalina Matiz.

"We should be considering [an avoidance diet] in children with a proven contact dermatitis who fail to improve with contact avoidance," said Dr. Matiz, a pediatric dermatology postdoctoral fellow at Rady Children's Hospital in San Diego.

Systemic contact dermatitis (also known as systemically reactivated allergic contact dermatitis) occurs when an exquisitely sensitized person has a skin reaction after systemic exposure—oral ingestion, inhalation, intravenous/intramuscular/subcutaneous exposure. Nickel, cobalt, balsam of Peru (derived from the Myroxylon pereirae tree and used in perfume and as a flavoring), and formaldehyde derivatives are among the most common triggers of systemic contact dermatitis (SCD).

SCD can present in many ways, including disseminated erythematous papules, vesicular hand dermatitis (pompholyx), and areas of well-defined redness on the buttocks and/or upper inner thighs (baboon syndrome), Dr. Matiz said at the annual meeting of the Society for Pediatric Dermatology.

SCD can present at any age. Exposure to the allergen can cause a flare of the dermatitis in the same area where the initial episode of elicitation occurred, including patch test sites. Some patients may experience systemic symptoms such as nausea, vomiting, diarrhea, fever, malaise, and headaches.

To date, Dr. Matiz—working in the contact dermatology clinic at Rady with Dr. Sharon Jacob—has seen several children with SCD who improved with avoidance diets. Dr. Matiz discussed key foods to avoid for patients with SCD to nickel, cobalt, balsam of Peru, and formaldehyde.

Nickel

The most common presentation of nickel SCD is vesicular hand eczema. The average daily consumption of nickel is 0.22–0.35 mg/day. One study found that 1% of patients with nickel SCD would react to the nickel content of a normal diet—less than 0.5 mg/day (Contact Dermatitis 2006;54:79–86), Dr. Matiz noted.

Interestingly, there is some evidence to suggest that immunologic tolerance can result through small amounts leached into saliva from braces (Contact Dermatitis 2007;56:247–54). In fact, getting braces prior to ear piercings seems to be protective, she said.

Nickel can occur naturally in food or can be added inadvertently by processing, cooking, or storage. Foods that contain relatively high amounts of nickel include dark chocolate, seafood (especially shellfish), legumes, grains, and nuts.

One low-nickel diet has been proposed (J. Am. Acad. Dermatol. 1993;29:1002–7), but a low-nickel diet "is not very child-friendly," Dr. Matiz said. She and her colleagues recommend avoiding chocolate, seafood (especially shellfish), some legumes, grains, nuts, canned foods, leafy green vegetables, and multivitamin supplements/drinks with nickel.

Cobalt

"Cobalt is commonly associated with nickel dermatitis and also presents with vesicular hand eczema," said Dr. Matiz. Importantly, cobalt is a main component of vitamin B12. The average cobalt ingestion is 12 mcg/day.

Last year a point-based low-cobalt diet was published, in which food items were assigned points based on the amounts of cobalt (Contact Dermatitis 2008:59;361–5). Patients were limited to a total of 12 points per day. Flaxseed, chick peas, and lamb liver each count as 7 points. Buckwheat, chili with meat and beans, chocolate, and soy milk each count as 5 points. "Patients found that this was very easy for them to follow," said Dr. Matiz. In particular, patients should avoid Brazil nuts, cow liver, and homeopathic/herbal remedies.

Balsam of Peru

Systemic contact dermatitis caused by balsam of Peru presents as hand and face dermatitis. This natural extract from Myroxylon pereirae is composed of more than 400 different constituents, and therefore its components can show up in lots of products. Patients with SCD to balsam of Peru need to avoid products containing fragrance, for example.

In an adult population, 47% of the patients with balsam of Peru or fragrance mix allergy improved with diet (J. Am. Acad. Dermatol. 2001;45:377–81). Interestingly, the most provocative food allergens are tomatoes, citrus fruit peels, spices, sodas, chocolate, and chili. The specific allergens in tomatoes are cinnamic alcohol and coniferyl alcohol, both of which are found in balsam of Peru, said Dr. Matiz.

Patients on a diet to minimize balsam of Peru ingestion should avoid tomatoes and tomato-containing products, products containing citrus, flavoring agents, spices, wine, beer, gin, perfumed teas, tobacco, chocolate, cough medicines, ice cream, and soda.

Formaldehyde

Patients with SCD to formaldehyde often present with periorbital dermatitis. Formaldehyde is a ubiquitous contact allergen found in many products, including the sweetener aspartame. Aspartame is metabolized to methanol, which then results in the formation of formaldehyde and formate adducts.

Dr. Matiz illustrated how common formaldehyde compounds are with the story of a small boy who presented with severe periorbital dermatitis. Patch testing revealed an allergy to formaldehyde.

His mother was instructed to avoid using products containing formaldehyde, but the boy improved only minimally. He also had asthma and was being treated with albuterol and Singulair (montelukast) chewable tablets.

A little research turned up the fact that the chewable tablets contain aspartame. The boy was switched to the granule formulation, which does not contain aspartame, and he improved.

One food that should be avoided is chocolate, since it can contain nickel, cobalt, and balsam of Peru.

Source ©Monika Adamczyk/Fotolia.com

PHILADELPHIA — Children with systemic allergic contact dermatitis can benefit from diets that minimize ingestion of certain foods that contain key allergens, including nickel and cobalt, according to Dr. Catalina Matiz.

"We should be considering [an avoidance diet] in children with a proven contact dermatitis who fail to improve with contact avoidance," said Dr. Matiz, a pediatric dermatology postdoctoral fellow at Rady Children's Hospital in San Diego.

Systemic contact dermatitis (also known as systemically reactivated allergic contact dermatitis) occurs when an exquisitely sensitized person has a skin reaction after systemic exposure—oral ingestion, inhalation, intravenous/intramuscular/subcutaneous exposure. Nickel, cobalt, balsam of Peru (derived from the Myroxylon pereirae tree and used in perfume and as a flavoring), and formaldehyde derivatives are among the most common triggers of systemic contact dermatitis (SCD).

SCD can present in many ways, including disseminated erythematous papules, vesicular hand dermatitis (pompholyx), and areas of well-defined redness on the buttocks and/or upper inner thighs (baboon syndrome), Dr. Matiz said at the annual meeting of the Society for Pediatric Dermatology.

SCD can present at any age. Exposure to the allergen can cause a flare of the dermatitis in the same area where the initial episode of elicitation occurred, including patch test sites. Some patients may experience systemic symptoms such as nausea, vomiting, diarrhea, fever, malaise, and headaches.

To date, Dr. Matiz—working in the contact dermatology clinic at Rady with Dr. Sharon Jacob—has seen several children with SCD who improved with avoidance diets. Dr. Matiz discussed key foods to avoid for patients with SCD to nickel, cobalt, balsam of Peru, and formaldehyde.

Nickel

The most common presentation of nickel SCD is vesicular hand eczema. The average daily consumption of nickel is 0.22–0.35 mg/day. One study found that 1% of patients with nickel SCD would react to the nickel content of a normal diet—less than 0.5 mg/day (Contact Dermatitis 2006;54:79–86), Dr. Matiz noted.

Interestingly, there is some evidence to suggest that immunologic tolerance can result through small amounts leached into saliva from braces (Contact Dermatitis 2007;56:247–54). In fact, getting braces prior to ear piercings seems to be protective, she said.

Nickel can occur naturally in food or can be added inadvertently by processing, cooking, or storage. Foods that contain relatively high amounts of nickel include dark chocolate, seafood (especially shellfish), legumes, grains, and nuts.

One low-nickel diet has been proposed (J. Am. Acad. Dermatol. 1993;29:1002–7), but a low-nickel diet "is not very child-friendly," Dr. Matiz said. She and her colleagues recommend avoiding chocolate, seafood (especially shellfish), some legumes, grains, nuts, canned foods, leafy green vegetables, and multivitamin supplements/drinks with nickel.

Cobalt

"Cobalt is commonly associated with nickel dermatitis and also presents with vesicular hand eczema," said Dr. Matiz. Importantly, cobalt is a main component of vitamin B12. The average cobalt ingestion is 12 mcg/day.

Last year a point-based low-cobalt diet was published, in which food items were assigned points based on the amounts of cobalt (Contact Dermatitis 2008:59;361–5). Patients were limited to a total of 12 points per day. Flaxseed, chick peas, and lamb liver each count as 7 points. Buckwheat, chili with meat and beans, chocolate, and soy milk each count as 5 points. "Patients found that this was very easy for them to follow," said Dr. Matiz. In particular, patients should avoid Brazil nuts, cow liver, and homeopathic/herbal remedies.

Balsam of Peru

Systemic contact dermatitis caused by balsam of Peru presents as hand and face dermatitis. This natural extract from Myroxylon pereirae is composed of more than 400 different constituents, and therefore its components can show up in lots of products. Patients with SCD to balsam of Peru need to avoid products containing fragrance, for example.

In an adult population, 47% of the patients with balsam of Peru or fragrance mix allergy improved with diet (J. Am. Acad. Dermatol. 2001;45:377–81). Interestingly, the most provocative food allergens are tomatoes, citrus fruit peels, spices, sodas, chocolate, and chili. The specific allergens in tomatoes are cinnamic alcohol and coniferyl alcohol, both of which are found in balsam of Peru, said Dr. Matiz.

Patients on a diet to minimize balsam of Peru ingestion should avoid tomatoes and tomato-containing products, products containing citrus, flavoring agents, spices, wine, beer, gin, perfumed teas, tobacco, chocolate, cough medicines, ice cream, and soda.

Formaldehyde

Patients with SCD to formaldehyde often present with periorbital dermatitis. Formaldehyde is a ubiquitous contact allergen found in many products, including the sweetener aspartame. Aspartame is metabolized to methanol, which then results in the formation of formaldehyde and formate adducts.

Dr. Matiz illustrated how common formaldehyde compounds are with the story of a small boy who presented with severe periorbital dermatitis. Patch testing revealed an allergy to formaldehyde.

His mother was instructed to avoid using products containing formaldehyde, but the boy improved only minimally. He also had asthma and was being treated with albuterol and Singulair (montelukast) chewable tablets.

A little research turned up the fact that the chewable tablets contain aspartame. The boy was switched to the granule formulation, which does not contain aspartame, and he improved.

One food that should be avoided is chocolate, since it can contain nickel, cobalt, and balsam of Peru.

Source ©Monika Adamczyk/Fotolia.com

PHILADELPHIA — Children with systemic allergic contact dermatitis can benefit from diets that minimize ingestion of certain foods that contain key allergens, including nickel and cobalt, according to Dr. Catalina Matiz.

"We should be considering [an avoidance diet] in children with a proven contact dermatitis who fail to improve with contact avoidance," said Dr. Matiz, a pediatric dermatology postdoctoral fellow at Rady Children's Hospital in San Diego.

Systemic contact dermatitis (also known as systemically reactivated allergic contact dermatitis) occurs when an exquisitely sensitized person has a skin reaction after systemic exposure—oral ingestion, inhalation, intravenous/intramuscular/subcutaneous exposure. Nickel, cobalt, balsam of Peru (derived from the Myroxylon pereirae tree and used in perfume and as a flavoring), and formaldehyde derivatives are among the most common triggers of systemic contact dermatitis (SCD).

SCD can present in many ways, including disseminated erythematous papules, vesicular hand dermatitis (pompholyx), and areas of well-defined redness on the buttocks and/or upper inner thighs (baboon syndrome), Dr. Matiz said at the annual meeting of the Society for Pediatric Dermatology.

SCD can present at any age. Exposure to the allergen can cause a flare of the dermatitis in the same area where the initial episode of elicitation occurred, including patch test sites. Some patients may experience systemic symptoms such as nausea, vomiting, diarrhea, fever, malaise, and headaches.

To date, Dr. Matiz—working in the contact dermatology clinic at Rady with Dr. Sharon Jacob—has seen several children with SCD who improved with avoidance diets. Dr. Matiz discussed key foods to avoid for patients with SCD to nickel, cobalt, balsam of Peru, and formaldehyde.

Nickel

The most common presentation of nickel SCD is vesicular hand eczema. The average daily consumption of nickel is 0.22–0.35 mg/day. One study found that 1% of patients with nickel SCD would react to the nickel content of a normal diet—less than 0.5 mg/day (Contact Dermatitis 2006;54:79–86), Dr. Matiz noted.

Interestingly, there is some evidence to suggest that immunologic tolerance can result through small amounts leached into saliva from braces (Contact Dermatitis 2007;56:247–54). In fact, getting braces prior to ear piercings seems to be protective, she said.

Nickel can occur naturally in food or can be added inadvertently by processing, cooking, or storage. Foods that contain relatively high amounts of nickel include dark chocolate, seafood (especially shellfish), legumes, grains, and nuts.

One low-nickel diet has been proposed (J. Am. Acad. Dermatol. 1993;29:1002–7), but a low-nickel diet "is not very child-friendly," Dr. Matiz said. She and her colleagues recommend avoiding chocolate, seafood (especially shellfish), some legumes, grains, nuts, canned foods, leafy green vegetables, and multivitamin supplements/drinks with nickel.

Cobalt

"Cobalt is commonly associated with nickel dermatitis and also presents with vesicular hand eczema," said Dr. Matiz. Importantly, cobalt is a main component of vitamin B12. The average cobalt ingestion is 12 mcg/day.

Last year a point-based low-cobalt diet was published, in which food items were assigned points based on the amounts of cobalt (Contact Dermatitis 2008:59;361–5). Patients were limited to a total of 12 points per day. Flaxseed, chick peas, and lamb liver each count as 7 points. Buckwheat, chili with meat and beans, chocolate, and soy milk each count as 5 points. "Patients found that this was very easy for them to follow," said Dr. Matiz. In particular, patients should avoid Brazil nuts, cow liver, and homeopathic/herbal remedies.

Balsam of Peru

Systemic contact dermatitis caused by balsam of Peru presents as hand and face dermatitis. This natural extract from Myroxylon pereirae is composed of more than 400 different constituents, and therefore its components can show up in lots of products. Patients with SCD to balsam of Peru need to avoid products containing fragrance, for example.

In an adult population, 47% of the patients with balsam of Peru or fragrance mix allergy improved with diet (J. Am. Acad. Dermatol. 2001;45:377–81). Interestingly, the most provocative food allergens are tomatoes, citrus fruit peels, spices, sodas, chocolate, and chili. The specific allergens in tomatoes are cinnamic alcohol and coniferyl alcohol, both of which are found in balsam of Peru, said Dr. Matiz.

Patients on a diet to minimize balsam of Peru ingestion should avoid tomatoes and tomato-containing products, products containing citrus, flavoring agents, spices, wine, beer, gin, perfumed teas, tobacco, chocolate, cough medicines, ice cream, and soda.

Formaldehyde

Patients with SCD to formaldehyde often present with periorbital dermatitis. Formaldehyde is a ubiquitous contact allergen found in many products, including the sweetener aspartame. Aspartame is metabolized to methanol, which then results in the formation of formaldehyde and formate adducts.

Dr. Matiz illustrated how common formaldehyde compounds are with the story of a small boy who presented with severe periorbital dermatitis. Patch testing revealed an allergy to formaldehyde.

His mother was instructed to avoid using products containing formaldehyde, but the boy improved only minimally. He also had asthma and was being treated with albuterol and Singulair (montelukast) chewable tablets.

A little research turned up the fact that the chewable tablets contain aspartame. The boy was switched to the granule formulation, which does not contain aspartame, and he improved.

One food that should be avoided is chocolate, since it can contain nickel, cobalt, and balsam of Peru.

Source ©Monika Adamczyk/Fotolia.com

BOSTON — Lesion darkness would make a better criterion for identifying early melanomas than the 6-mm diameter cutoff in the ABCDE criteria currently used by dermatologists and patients, according to Dr. Stuart Goldsmith.

“It's recognized that all melanomas start as a single cell or a few cells. So microscopically, they're already cancer, but we're not even telling patients to look for small lesions,” he said.

“If we were doing okay [in terms of mortality], then it wouldn't matter. The fact is that we are not doing as well as we want to for our patients,” said Dr. Goldsmith, a dermatologist in Albany, Ga. “More than 8,000 Americans die every year of melanoma—most from cutaneous lesions, lesions on the skin that could have been removed when smaller than 6 mm and in time to save the patient's life.”

“Dermatology is simply not on the same page as other specialties in terms of cancer surveillance by the very existence of the diameter criterion,” he said. Even though most other specialties have had more success than dermatology in decreasing cancer mortality rates, other specialties are looking for smaller, earlier lesions, Dr. Goldsmith noted at the American Academy of Dermatology's Academy 2009 meeting.

For example, 2008 gastroenterology guidelines advocate the prevention of colorectal cancer by using colonoscopy to detect and excise nonobligate, smaller precursor lesions (CA Cancer J. Clin. 2008;58:130–60). Likewise, more advanced imaging is being used to detect breast cancer at earlier stages. Teenage girls are recommended to receive the human papillomavirus vaccine to decrease the risk of cervical cancer. The European Society for Medical Oncology has already eliminated the diameter criterion for melanoma detection (Ann. Oncol. 2009;20 Suppl. 4:129–31).

Although the ABCDE criteria are intended to enhance the diagnosis of early melanoma, Dr. Goldsmith related that some dermatologists suggest that elimination of the diameter criterion would lead to too many biopsies. “In other words, it's become a cost issue,” he said.

“I'm not saying that saving money shouldn't be a priority. It just shouldn't be a priority of these criteria,” he said.

Dr. Goldsmith contends that the concerns about cost are unjustified. He used data from his own practice (Medicare rates for 2009, Albany, Ga.) to develop a specific cost model to assess the argument that excision and pathology for smaller suspect lesions would increase costs. He used a cost of $94 for excisions 1–5 mm in diameter and a cost of $116.54 for excisions 6–10 mm in diameter. Pathologic evaluation (at Emory University in Atlanta) cost $66, yielding a total cost of $160 for lesions 1–5 mm and $182.54 for lesions 6–10 mm. In addition, either the excision or the cost of an additional procedure would likely be reduced in many patients because of the multiple procedure cost reductions, he explained.

“Assuming our society's accepted cost of $50,000 per quality-adjusted life-year saved, and rounding up to $200 per excision, if 1 in 250 excisions saved 1 year of one person's life, the cost would be justified,” he said. Given that the average life-years lost per fatal melanoma is 18.6 (based on Surveillance, Epidemiology and End Results data), the cost would be justified if 1 in every 4,650 small-diameter lesions excised would have prevented a death from melanoma. “This cost justification is valid even if there would be no costs savings,” he said.

Models to decrease the cost of melanoma have emphasized the need to diagnose earlier invasive and in situ disease. The estimated treatment of stage III and IV disease accounted for 90% of costs from melanoma. Disease caught earlier could avoid much of this cost (J. Am. Acad. Dermatol. 1998;38:669–80).

In terms of cost alone, an increase in small-diameter biopsies would not lead to unacceptable costs and may even result in cost savings, he said.

A cost analysis must also include a discussion of the number of lesions needed to excise (NNE) or biopsy to diagnose one melanoma. NNE should only be discussed in the context of sensitivity of melanoma diagnosis.

Dr. Goldsmith highlighted two articles from 2008. In the first study, the NNE for small-diameter lesions (those 6 mm and smaller) was 1 in 24, while the NNE for larger lesions was approximately 1 in 8 (Arch. Dermatol. 2008;144:469–74). The authors concluded that the 6-mm criterion remains useful and that their biopsy rate for smaller lesions was appropriate.

In the second article, however, the study's group of expert dermoscopists would not only have misdiagnosed but would have totally missed—would not have biopsied—29% of small-diameter melanomas. Lesions were evaluated using dermoscopic images with information given about the patient's age, sex, and lesion location (Arch. Dermatol. 2008;144:476–82).

Many patients express the preference to be safe rather than sorry if there is any risk of a lesion being a melanoma.

“That desire should be considered when evaluating the results of the two studies just discussed. Would a patient who would rather be safe than sorry think that a risk of 1 in 24 for the excision of a small-diameter lesion was appropriate if he or she was also given the information that the diagnosis of more than one in four small-diameter melanomas may be missed?” he asked.

Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.

Dr. Goldsmith next addressed lesion darkness. “The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.

The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128–31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929–34; and Arch. Dermatol. 1998;134:103–4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” said Dr. Goldsmith.

In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.

Dr. Goldsmith also provided evidence that increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013–7), recognition of change in melanomas (Br. J. Dermatol. 1999;141:783–7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103–4).

“Changing the D from diameter to dark would accomplish two goals: We would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions of concern,” he said. This change would represent a true evolution of the ABCDE criteria, he added.

Changing the criteria “would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions,” Dr. Stuart Goldsmith said.

Source Courtesy Dr. Stuart Goldsmith

Lesions found by patients are likely to be deeper or more advanced than this melanoma in-situ with a mixed pattern.

Source Courtesy kimggraphics

BOSTON — Lesion darkness would make a better criterion for identifying early melanomas than the 6-mm diameter cutoff in the ABCDE criteria currently used by dermatologists and patients, according to Dr. Stuart Goldsmith.

“It's recognized that all melanomas start as a single cell or a few cells. So microscopically, they're already cancer, but we're not even telling patients to look for small lesions,” he said.

“If we were doing okay [in terms of mortality], then it wouldn't matter. The fact is that we are not doing as well as we want to for our patients,” said Dr. Goldsmith, a dermatologist in Albany, Ga. “More than 8,000 Americans die every year of melanoma—most from cutaneous lesions, lesions on the skin that could have been removed when smaller than 6 mm and in time to save the patient's life.”

“Dermatology is simply not on the same page as other specialties in terms of cancer surveillance by the very existence of the diameter criterion,” he said. Even though most other specialties have had more success than dermatology in decreasing cancer mortality rates, other specialties are looking for smaller, earlier lesions, Dr. Goldsmith noted at the American Academy of Dermatology's Academy 2009 meeting.

For example, 2008 gastroenterology guidelines advocate the prevention of colorectal cancer by using colonoscopy to detect and excise nonobligate, smaller precursor lesions (CA Cancer J. Clin. 2008;58:130–60). Likewise, more advanced imaging is being used to detect breast cancer at earlier stages. Teenage girls are recommended to receive the human papillomavirus vaccine to decrease the risk of cervical cancer. The European Society for Medical Oncology has already eliminated the diameter criterion for melanoma detection (Ann. Oncol. 2009;20 Suppl. 4:129–31).

Although the ABCDE criteria are intended to enhance the diagnosis of early melanoma, Dr. Goldsmith related that some dermatologists suggest that elimination of the diameter criterion would lead to too many biopsies. “In other words, it's become a cost issue,” he said.

“I'm not saying that saving money shouldn't be a priority. It just shouldn't be a priority of these criteria,” he said.

Dr. Goldsmith contends that the concerns about cost are unjustified. He used data from his own practice (Medicare rates for 2009, Albany, Ga.) to develop a specific cost model to assess the argument that excision and pathology for smaller suspect lesions would increase costs. He used a cost of $94 for excisions 1–5 mm in diameter and a cost of $116.54 for excisions 6–10 mm in diameter. Pathologic evaluation (at Emory University in Atlanta) cost $66, yielding a total cost of $160 for lesions 1–5 mm and $182.54 for lesions 6–10 mm. In addition, either the excision or the cost of an additional procedure would likely be reduced in many patients because of the multiple procedure cost reductions, he explained.

“Assuming our society's accepted cost of $50,000 per quality-adjusted life-year saved, and rounding up to $200 per excision, if 1 in 250 excisions saved 1 year of one person's life, the cost would be justified,” he said. Given that the average life-years lost per fatal melanoma is 18.6 (based on Surveillance, Epidemiology and End Results data), the cost would be justified if 1 in every 4,650 small-diameter lesions excised would have prevented a death from melanoma. “This cost justification is valid even if there would be no costs savings,” he said.

Models to decrease the cost of melanoma have emphasized the need to diagnose earlier invasive and in situ disease. The estimated treatment of stage III and IV disease accounted for 90% of costs from melanoma. Disease caught earlier could avoid much of this cost (J. Am. Acad. Dermatol. 1998;38:669–80).

In terms of cost alone, an increase in small-diameter biopsies would not lead to unacceptable costs and may even result in cost savings, he said.

A cost analysis must also include a discussion of the number of lesions needed to excise (NNE) or biopsy to diagnose one melanoma. NNE should only be discussed in the context of sensitivity of melanoma diagnosis.

Dr. Goldsmith highlighted two articles from 2008. In the first study, the NNE for small-diameter lesions (those 6 mm and smaller) was 1 in 24, while the NNE for larger lesions was approximately 1 in 8 (Arch. Dermatol. 2008;144:469–74). The authors concluded that the 6-mm criterion remains useful and that their biopsy rate for smaller lesions was appropriate.

In the second article, however, the study's group of expert dermoscopists would not only have misdiagnosed but would have totally missed—would not have biopsied—29% of small-diameter melanomas. Lesions were evaluated using dermoscopic images with information given about the patient's age, sex, and lesion location (Arch. Dermatol. 2008;144:476–82).

Many patients express the preference to be safe rather than sorry if there is any risk of a lesion being a melanoma.

“That desire should be considered when evaluating the results of the two studies just discussed. Would a patient who would rather be safe than sorry think that a risk of 1 in 24 for the excision of a small-diameter lesion was appropriate if he or she was also given the information that the diagnosis of more than one in four small-diameter melanomas may be missed?” he asked.

Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.

Dr. Goldsmith next addressed lesion darkness. “The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.

The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128–31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929–34; and Arch. Dermatol. 1998;134:103–4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” said Dr. Goldsmith.

In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.

Dr. Goldsmith also provided evidence that increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013–7), recognition of change in melanomas (Br. J. Dermatol. 1999;141:783–7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103–4).

“Changing the D from diameter to dark would accomplish two goals: We would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions of concern,” he said. This change would represent a true evolution of the ABCDE criteria, he added.

Changing the criteria “would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions,” Dr. Stuart Goldsmith said.

Source Courtesy Dr. Stuart Goldsmith

Lesions found by patients are likely to be deeper or more advanced than this melanoma in-situ with a mixed pattern.

Source Courtesy kimggraphics

BOSTON — Lesion darkness would make a better criterion for identifying early melanomas than the 6-mm diameter cutoff in the ABCDE criteria currently used by dermatologists and patients, according to Dr. Stuart Goldsmith.

“It's recognized that all melanomas start as a single cell or a few cells. So microscopically, they're already cancer, but we're not even telling patients to look for small lesions,” he said.

“If we were doing okay [in terms of mortality], then it wouldn't matter. The fact is that we are not doing as well as we want to for our patients,” said Dr. Goldsmith, a dermatologist in Albany, Ga. “More than 8,000 Americans die every year of melanoma—most from cutaneous lesions, lesions on the skin that could have been removed when smaller than 6 mm and in time to save the patient's life.”

“Dermatology is simply not on the same page as other specialties in terms of cancer surveillance by the very existence of the diameter criterion,” he said. Even though most other specialties have had more success than dermatology in decreasing cancer mortality rates, other specialties are looking for smaller, earlier lesions, Dr. Goldsmith noted at the American Academy of Dermatology's Academy 2009 meeting.

For example, 2008 gastroenterology guidelines advocate the prevention of colorectal cancer by using colonoscopy to detect and excise nonobligate, smaller precursor lesions (CA Cancer J. Clin. 2008;58:130–60). Likewise, more advanced imaging is being used to detect breast cancer at earlier stages. Teenage girls are recommended to receive the human papillomavirus vaccine to decrease the risk of cervical cancer. The European Society for Medical Oncology has already eliminated the diameter criterion for melanoma detection (Ann. Oncol. 2009;20 Suppl. 4:129–31).

Although the ABCDE criteria are intended to enhance the diagnosis of early melanoma, Dr. Goldsmith related that some dermatologists suggest that elimination of the diameter criterion would lead to too many biopsies. “In other words, it's become a cost issue,” he said.

“I'm not saying that saving money shouldn't be a priority. It just shouldn't be a priority of these criteria,” he said.

Dr. Goldsmith contends that the concerns about cost are unjustified. He used data from his own practice (Medicare rates for 2009, Albany, Ga.) to develop a specific cost model to assess the argument that excision and pathology for smaller suspect lesions would increase costs. He used a cost of $94 for excisions 1–5 mm in diameter and a cost of $116.54 for excisions 6–10 mm in diameter. Pathologic evaluation (at Emory University in Atlanta) cost $66, yielding a total cost of $160 for lesions 1–5 mm and $182.54 for lesions 6–10 mm. In addition, either the excision or the cost of an additional procedure would likely be reduced in many patients because of the multiple procedure cost reductions, he explained.

“Assuming our society's accepted cost of $50,000 per quality-adjusted life-year saved, and rounding up to $200 per excision, if 1 in 250 excisions saved 1 year of one person's life, the cost would be justified,” he said. Given that the average life-years lost per fatal melanoma is 18.6 (based on Surveillance, Epidemiology and End Results data), the cost would be justified if 1 in every 4,650 small-diameter lesions excised would have prevented a death from melanoma. “This cost justification is valid even if there would be no costs savings,” he said.

Models to decrease the cost of melanoma have emphasized the need to diagnose earlier invasive and in situ disease. The estimated treatment of stage III and IV disease accounted for 90% of costs from melanoma. Disease caught earlier could avoid much of this cost (J. Am. Acad. Dermatol. 1998;38:669–80).

In terms of cost alone, an increase in small-diameter biopsies would not lead to unacceptable costs and may even result in cost savings, he said.

A cost analysis must also include a discussion of the number of lesions needed to excise (NNE) or biopsy to diagnose one melanoma. NNE should only be discussed in the context of sensitivity of melanoma diagnosis.

Dr. Goldsmith highlighted two articles from 2008. In the first study, the NNE for small-diameter lesions (those 6 mm and smaller) was 1 in 24, while the NNE for larger lesions was approximately 1 in 8 (Arch. Dermatol. 2008;144:469–74). The authors concluded that the 6-mm criterion remains useful and that their biopsy rate for smaller lesions was appropriate.

In the second article, however, the study's group of expert dermoscopists would not only have misdiagnosed but would have totally missed—would not have biopsied—29% of small-diameter melanomas. Lesions were evaluated using dermoscopic images with information given about the patient's age, sex, and lesion location (Arch. Dermatol. 2008;144:476–82).

Many patients express the preference to be safe rather than sorry if there is any risk of a lesion being a melanoma.

“That desire should be considered when evaluating the results of the two studies just discussed. Would a patient who would rather be safe than sorry think that a risk of 1 in 24 for the excision of a small-diameter lesion was appropriate if he or she was also given the information that the diagnosis of more than one in four small-diameter melanomas may be missed?” he asked.

Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.

Dr. Goldsmith next addressed lesion darkness. “The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.

The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128–31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929–34; and Arch. Dermatol. 1998;134:103–4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” said Dr. Goldsmith.

In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.

Dr. Goldsmith also provided evidence that increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013–7), recognition of change in melanomas (Br. J. Dermatol. 1999;141:783–7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103–4).

“Changing the D from diameter to dark would accomplish two goals: We would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions of concern,” he said. This change would represent a true evolution of the ABCDE criteria, he added.

Changing the criteria “would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions,” Dr. Stuart Goldsmith said.

Source Courtesy Dr. Stuart Goldsmith

Lesions found by patients are likely to be deeper or more advanced than this melanoma in-situ with a mixed pattern.

Source Courtesy kimggraphics

BALTIMORE — Five percent of children in one network of private primary care pediatric practices accounted for almost a third of pediatric subspecialty visits over a 2-year period, based on a study of more than 35,000 children.

Although roughly 60% of 35,487 pediatric primary care patients had no subspecialty visits between May 2006 and April 2008, 5% of children accounted for 32% of 40,487 subspecialty visits, Dr. Louis Vernacchio and his colleagues reported in a poster at the annual meeting of the Pediatric Academic Societies. The findings may soothe concerns about the overuse of subspecialists in the management of common conditions.

The researchers analyzed data on paid claims from a single large health plan for subspecialty visits for a 2-year period for all primary care patients (aged 0-20 years) of the Pediatric Physicians' Organization at Children's, which is a network of private primary care pediatric practices affiliated with Children's Hospital Boston. The network consists of 72 practices with 182 pediatricians. All visits to subspecialty physicians were included in the analysis, except for mental health visits, wrote Dr. Vernacchio, who is a member of one of those practices.

Patients were followed for a median of 14 months and were evenly split between the sexes (49% female). The top seven subspecialties—ophthalmology, orthopedic surgery, dermatology, otolaryngology, allergy and immunology, gastroenterology, and neurology—accounted for nearly three-quarters (72%) of all visits.

“Within subspecialties, there are common diagnoses/procedures which can be targets for primary care-based quality improvement or research initiatives aimed at enhancing primary care management and reducing unnecessary referrals,” the researchers noted. These include office vision screening, scoliosis screening and nonoperative management, acne management, and otitis media management.

The study was funded by internal funds of the Pediatric Physicians' Organization at Children's. The authors reported that they have no relevant disclosures.

BALTIMORE — Five percent of children in one network of private primary care pediatric practices accounted for almost a third of pediatric subspecialty visits over a 2-year period, based on a study of more than 35,000 children.

Although roughly 60% of 35,487 pediatric primary care patients had no subspecialty visits between May 2006 and April 2008, 5% of children accounted for 32% of 40,487 subspecialty visits, Dr. Louis Vernacchio and his colleagues reported in a poster at the annual meeting of the Pediatric Academic Societies. The findings may soothe concerns about the overuse of subspecialists in the management of common conditions.

The researchers analyzed data on paid claims from a single large health plan for subspecialty visits for a 2-year period for all primary care patients (aged 0-20 years) of the Pediatric Physicians' Organization at Children's, which is a network of private primary care pediatric practices affiliated with Children's Hospital Boston. The network consists of 72 practices with 182 pediatricians. All visits to subspecialty physicians were included in the analysis, except for mental health visits, wrote Dr. Vernacchio, who is a member of one of those practices.

Patients were followed for a median of 14 months and were evenly split between the sexes (49% female). The top seven subspecialties—ophthalmology, orthopedic surgery, dermatology, otolaryngology, allergy and immunology, gastroenterology, and neurology—accounted for nearly three-quarters (72%) of all visits.

“Within subspecialties, there are common diagnoses/procedures which can be targets for primary care-based quality improvement or research initiatives aimed at enhancing primary care management and reducing unnecessary referrals,” the researchers noted. These include office vision screening, scoliosis screening and nonoperative management, acne management, and otitis media management.

The study was funded by internal funds of the Pediatric Physicians' Organization at Children's. The authors reported that they have no relevant disclosures.

BALTIMORE — Five percent of children in one network of private primary care pediatric practices accounted for almost a third of pediatric subspecialty visits over a 2-year period, based on a study of more than 35,000 children.

Although roughly 60% of 35,487 pediatric primary care patients had no subspecialty visits between May 2006 and April 2008, 5% of children accounted for 32% of 40,487 subspecialty visits, Dr. Louis Vernacchio and his colleagues reported in a poster at the annual meeting of the Pediatric Academic Societies. The findings may soothe concerns about the overuse of subspecialists in the management of common conditions.

The researchers analyzed data on paid claims from a single large health plan for subspecialty visits for a 2-year period for all primary care patients (aged 0-20 years) of the Pediatric Physicians' Organization at Children's, which is a network of private primary care pediatric practices affiliated with Children's Hospital Boston. The network consists of 72 practices with 182 pediatricians. All visits to subspecialty physicians were included in the analysis, except for mental health visits, wrote Dr. Vernacchio, who is a member of one of those practices.

Patients were followed for a median of 14 months and were evenly split between the sexes (49% female). The top seven subspecialties—ophthalmology, orthopedic surgery, dermatology, otolaryngology, allergy and immunology, gastroenterology, and neurology—accounted for nearly three-quarters (72%) of all visits.

“Within subspecialties, there are common diagnoses/procedures which can be targets for primary care-based quality improvement or research initiatives aimed at enhancing primary care management and reducing unnecessary referrals,” the researchers noted. These include office vision screening, scoliosis screening and nonoperative management, acne management, and otitis media management.

The study was funded by internal funds of the Pediatric Physicians' Organization at Children's. The authors reported that they have no relevant disclosures.

PHILADELPHIA — A quarter of pediatric dermatologists report that new patients have to wait more than 12 weeks to get an appointment, and the average overall wait time for pediatric dermatologists is 6-8 weeks, according to a survey of 243 pediatricians, general dermatologists, and pediatric dermatologists.

In comparison, the reported median wait time for a new-patient visit is less than 2 weeks to see a pediatrician and less than 5 weeks for a general/adult dermatologist, Dr. Kristen Cam said in a poster presented at the annual meeting of the Society for Pediatric Dermatology.

“A significant shortage of pediatric dermatologists is perceived by pediatricians, dermatologists, and pediatric dermatologists,” wrote Dr. Cam, a dermatology resident at the Children's Hospital of Philadelphia, and her colleagues.

They conducted the survey to assess anecdotal evidence that patients experience long wait times to see a pediatric dermatologist. The researchers asked approximately 800 physicians from the American Academy of Pediatrics, the American Academy of Dermatology, and the Society for Pediatric Dermatology to complete a 45-question online survey. In all, 243 completed the survey. Of these, 19% identified themselves as pediatricians, 28% as general or adult dermatologists, and 53% as pediatric dermatologists.

More than 90% of the survey respondents perceived a shortage of available pediatric dermatology services. Almost half of the pediatric dermatologists reported that their practices are actively recruiting additional pediatric dermatologists. A quarter of them reported actively recruiting for more than a year, the investigators said.

Almost two-thirds of pediatric dermatologists practiced in urban areas. More pediatric dermatologists practiced in academic and hybrid academic/private practice settings than in private practice.

Slightly more than half of the pediatric dermatologists had completed a categorical pediatrics residency and almost half had completed fellowship training. Median salary ranges were comparable for pediatric dermatologists and general/adult dermatologists—$200,000–$250,000—despite additional subspecialty training. In comparison, the median salary range for pediatricians was $100,000–$150,000.

“Salary was perceived to be the strongest factor deterring physicians from entering pediatric dermatology,” Dr. Cam and her associates wrote.

PHILADELPHIA — A quarter of pediatric dermatologists report that new patients have to wait more than 12 weeks to get an appointment, and the average overall wait time for pediatric dermatologists is 6-8 weeks, according to a survey of 243 pediatricians, general dermatologists, and pediatric dermatologists.

In comparison, the reported median wait time for a new-patient visit is less than 2 weeks to see a pediatrician and less than 5 weeks for a general/adult dermatologist, Dr. Kristen Cam said in a poster presented at the annual meeting of the Society for Pediatric Dermatology.

“A significant shortage of pediatric dermatologists is perceived by pediatricians, dermatologists, and pediatric dermatologists,” wrote Dr. Cam, a dermatology resident at the Children's Hospital of Philadelphia, and her colleagues.

They conducted the survey to assess anecdotal evidence that patients experience long wait times to see a pediatric dermatologist. The researchers asked approximately 800 physicians from the American Academy of Pediatrics, the American Academy of Dermatology, and the Society for Pediatric Dermatology to complete a 45-question online survey. In all, 243 completed the survey. Of these, 19% identified themselves as pediatricians, 28% as general or adult dermatologists, and 53% as pediatric dermatologists.

More than 90% of the survey respondents perceived a shortage of available pediatric dermatology services. Almost half of the pediatric dermatologists reported that their practices are actively recruiting additional pediatric dermatologists. A quarter of them reported actively recruiting for more than a year, the investigators said.

Almost two-thirds of pediatric dermatologists practiced in urban areas. More pediatric dermatologists practiced in academic and hybrid academic/private practice settings than in private practice.

Slightly more than half of the pediatric dermatologists had completed a categorical pediatrics residency and almost half had completed fellowship training. Median salary ranges were comparable for pediatric dermatologists and general/adult dermatologists—$200,000–$250,000—despite additional subspecialty training. In comparison, the median salary range for pediatricians was $100,000–$150,000.

“Salary was perceived to be the strongest factor deterring physicians from entering pediatric dermatology,” Dr. Cam and her associates wrote.

PHILADELPHIA — A quarter of pediatric dermatologists report that new patients have to wait more than 12 weeks to get an appointment, and the average overall wait time for pediatric dermatologists is 6-8 weeks, according to a survey of 243 pediatricians, general dermatologists, and pediatric dermatologists.

In comparison, the reported median wait time for a new-patient visit is less than 2 weeks to see a pediatrician and less than 5 weeks for a general/adult dermatologist, Dr. Kristen Cam said in a poster presented at the annual meeting of the Society for Pediatric Dermatology.

“A significant shortage of pediatric dermatologists is perceived by pediatricians, dermatologists, and pediatric dermatologists,” wrote Dr. Cam, a dermatology resident at the Children's Hospital of Philadelphia, and her colleagues.

They conducted the survey to assess anecdotal evidence that patients experience long wait times to see a pediatric dermatologist. The researchers asked approximately 800 physicians from the American Academy of Pediatrics, the American Academy of Dermatology, and the Society for Pediatric Dermatology to complete a 45-question online survey. In all, 243 completed the survey. Of these, 19% identified themselves as pediatricians, 28% as general or adult dermatologists, and 53% as pediatric dermatologists.

More than 90% of the survey respondents perceived a shortage of available pediatric dermatology services. Almost half of the pediatric dermatologists reported that their practices are actively recruiting additional pediatric dermatologists. A quarter of them reported actively recruiting for more than a year, the investigators said.

Almost two-thirds of pediatric dermatologists practiced in urban areas. More pediatric dermatologists practiced in academic and hybrid academic/private practice settings than in private practice.

Slightly more than half of the pediatric dermatologists had completed a categorical pediatrics residency and almost half had completed fellowship training. Median salary ranges were comparable for pediatric dermatologists and general/adult dermatologists—$200,000–$250,000—despite additional subspecialty training. In comparison, the median salary range for pediatricians was $100,000–$150,000.

“Salary was perceived to be the strongest factor deterring physicians from entering pediatric dermatology,” Dr. Cam and her associates wrote.

Genodermatoses may be rare, but it is still important to be familiar with the signs typically seen in patients, according to Dr. Kara N. Shah.

"You will see these patients in your practice. The important thing is recognizing them," said Dr. Shah, a pediatric dermatologist at the Children's Hospital of Philadelphia. She shared the following characteristics and information about causative genes for genodermatoses:

Goltz Syndrome

The characteristic features of Goltz syndrome, or focal dermal hypoplasia, include areas of focal atrophy with fat herniation, unusual pigmentary and inflammatory dermatoses, raspberry-like papillomas, scalp anomalies, a range of dental and ocular abnormalities, sparse hair, short stature, and mental retardation in some patients. The condition is known to be X-linked dominant and lethal in most males.

The genetic defect responsible for this condition has been identified as a mutation in the PORCN gene, which is a member of the porcupine gene family that encodes transmembrane endoplasmic reticulum proteins that target Wnt signaling proteins. Wnt proteins are key regulators of embryonic development.

"There are patients who have been shown to have somatic or postzygotic mosaicism. … Only a subset of cells are affected and they tend to have a milder phenotype," Dr. Shah said.

Hyper-IgE Syndrome

Hyper-IgE syndrome is characterized by chronic eczematous dermatitis, recurrent abscesses due to Staphylococcus aureus, and recurrent sinus and lung infections (with pneumatoceles). Dental abnormalities, fractures, and scoliosis are also common. Mutations in the signal transducer and activator of transcription 3 gene (STAT3) have been associated with this disorder. STAT3 is important in the JAK-STAT cytokine signaling pathway, according to Dr. Shah.

Patients who are deficient in STAT3 have deficient activation of several cytokines and reduced production of beta-defensins, leading to susceptibility to S. aureus and Candida skin infections.

NF-1-Like Syndrome

Neurofibromatosis type 1-like (NF-1-like) syndrome shares the neurofibromatosis type-1 characteristics of multiple café-au-lait spots, axillary freckling, and macrocrania. Additional features include a Noonan-like dysmorphic psychomotor development and learning difficulties. These patients, however, do not seem to develop some other NF-1 characteristics, such as Lisch nodules in the iris, neurofibromas, and central nervous system tumors.

NF-1-like syndrome is an autosomal dominant condition. Patients with NF-1-like syndrome carry mutations in the SPRED-1 gene, including nonsense frameshift, splice site, missense mutations, and in-frame deletions. The SPRED-1 protein negatively regulates Ras-mitogen-activated protein kinase (MAPK) signaling, similar to neurofibromin, the defective protein in patients with NF-1, Dr. Shah said.

Ras-MAPK Syndromes

Ras-MAPK syndromes (neuro-cardio-facial-cutaneous syndromes) include NF-1 and NF-1-like syndromes, Noonan syndrome, LEOPARD syndrome, and others. Ras is activated by cell surface receptors; activation of Ras signaling causes cell growth and differentiation, and it affects cell survival, Dr. Shah said.

The name LEOPARD highlights the main features of the disorder: lentigines, electrocardiographic conduction abnormalities, ocular hypertelorism, pulmonary stenosis, abnormalities of genitalia, retardation of growth, and deafness. "The important thing to recognize early on is the similarities with regard to some of the dysmorphic facial features … developmental issues, cardiac anomalies, or skeletal anomolies," she said.

Molecular studies have shown that LEOPARD is an allelic disorder caused by mutations in PTPN11 and RAF1.

The key features of Noonan syndrome include unusual facial features (ocular hypertelorism, down-slanting eyes, webbed neck), congenital heart disease (in 50%), short stature, and chest deformity. Mental retardation also may occur, according to Dr. Shah. Skeletal, neurologic, genitourinary, lymphatic, eye, and skin findings may be present to varying degrees. Although the pathophysiology of Noonan syndrome is not fully understood, four disease-causing genes (PTPN11, SOS1, RAF1, and KRAS) have been identified. These genes are part of the RAS transduction pathway.

Symmetric linear red macules and soft spongy plaques are among the features characteristic of Goltz syndrome, which is known to be X-linked dominant.

Source ©Dr. Albert Yan/Dr.Giuseppe Militello, DermAtlas; http://www.DermAtlas.org

Genodermatoses may be rare, but it is still important to be familiar with the signs typically seen in patients, according to Dr. Kara N. Shah.

"You will see these patients in your practice. The important thing is recognizing them," said Dr. Shah, a pediatric dermatologist at the Children's Hospital of Philadelphia. She shared the following characteristics and information about causative genes for genodermatoses:

Goltz Syndrome

The characteristic features of Goltz syndrome, or focal dermal hypoplasia, include areas of focal atrophy with fat herniation, unusual pigmentary and inflammatory dermatoses, raspberry-like papillomas, scalp anomalies, a range of dental and ocular abnormalities, sparse hair, short stature, and mental retardation in some patients. The condition is known to be X-linked dominant and lethal in most males.

The genetic defect responsible for this condition has been identified as a mutation in the PORCN gene, which is a member of the porcupine gene family that encodes transmembrane endoplasmic reticulum proteins that target Wnt signaling proteins. Wnt proteins are key regulators of embryonic development.

"There are patients who have been shown to have somatic or postzygotic mosaicism. … Only a subset of cells are affected and they tend to have a milder phenotype," Dr. Shah said.

Hyper-IgE Syndrome

Hyper-IgE syndrome is characterized by chronic eczematous dermatitis, recurrent abscesses due to Staphylococcus aureus, and recurrent sinus and lung infections (with pneumatoceles). Dental abnormalities, fractures, and scoliosis are also common. Mutations in the signal transducer and activator of transcription 3 gene (STAT3) have been associated with this disorder. STAT3 is important in the JAK-STAT cytokine signaling pathway, according to Dr. Shah.

Patients who are deficient in STAT3 have deficient activation of several cytokines and reduced production of beta-defensins, leading to susceptibility to S. aureus and Candida skin infections.

NF-1-Like Syndrome

Neurofibromatosis type 1-like (NF-1-like) syndrome shares the neurofibromatosis type-1 characteristics of multiple café-au-lait spots, axillary freckling, and macrocrania. Additional features include a Noonan-like dysmorphic psychomotor development and learning difficulties. These patients, however, do not seem to develop some other NF-1 characteristics, such as Lisch nodules in the iris, neurofibromas, and central nervous system tumors.

NF-1-like syndrome is an autosomal dominant condition. Patients with NF-1-like syndrome carry mutations in the SPRED-1 gene, including nonsense frameshift, splice site, missense mutations, and in-frame deletions. The SPRED-1 protein negatively regulates Ras-mitogen-activated protein kinase (MAPK) signaling, similar to neurofibromin, the defective protein in patients with NF-1, Dr. Shah said.

Ras-MAPK Syndromes

Ras-MAPK syndromes (neuro-cardio-facial-cutaneous syndromes) include NF-1 and NF-1-like syndromes, Noonan syndrome, LEOPARD syndrome, and others. Ras is activated by cell surface receptors; activation of Ras signaling causes cell growth and differentiation, and it affects cell survival, Dr. Shah said.

The name LEOPARD highlights the main features of the disorder: lentigines, electrocardiographic conduction abnormalities, ocular hypertelorism, pulmonary stenosis, abnormalities of genitalia, retardation of growth, and deafness. "The important thing to recognize early on is the similarities with regard to some of the dysmorphic facial features … developmental issues, cardiac anomalies, or skeletal anomolies," she said.

Molecular studies have shown that LEOPARD is an allelic disorder caused by mutations in PTPN11 and RAF1.

The key features of Noonan syndrome include unusual facial features (ocular hypertelorism, down-slanting eyes, webbed neck), congenital heart disease (in 50%), short stature, and chest deformity. Mental retardation also may occur, according to Dr. Shah. Skeletal, neurologic, genitourinary, lymphatic, eye, and skin findings may be present to varying degrees. Although the pathophysiology of Noonan syndrome is not fully understood, four disease-causing genes (PTPN11, SOS1, RAF1, and KRAS) have been identified. These genes are part of the RAS transduction pathway.

Symmetric linear red macules and soft spongy plaques are among the features characteristic of Goltz syndrome, which is known to be X-linked dominant.

Source ©Dr. Albert Yan/Dr.Giuseppe Militello, DermAtlas; http://www.DermAtlas.org

Genodermatoses may be rare, but it is still important to be familiar with the signs typically seen in patients, according to Dr. Kara N. Shah.

"You will see these patients in your practice. The important thing is recognizing them," said Dr. Shah, a pediatric dermatologist at the Children's Hospital of Philadelphia. She shared the following characteristics and information about causative genes for genodermatoses:

Goltz Syndrome

The characteristic features of Goltz syndrome, or focal dermal hypoplasia, include areas of focal atrophy with fat herniation, unusual pigmentary and inflammatory dermatoses, raspberry-like papillomas, scalp anomalies, a range of dental and ocular abnormalities, sparse hair, short stature, and mental retardation in some patients. The condition is known to be X-linked dominant and lethal in most males.

The genetic defect responsible for this condition has been identified as a mutation in the PORCN gene, which is a member of the porcupine gene family that encodes transmembrane endoplasmic reticulum proteins that target Wnt signaling proteins. Wnt proteins are key regulators of embryonic development.

"There are patients who have been shown to have somatic or postzygotic mosaicism. … Only a subset of cells are affected and they tend to have a milder phenotype," Dr. Shah said.

Hyper-IgE Syndrome

Hyper-IgE syndrome is characterized by chronic eczematous dermatitis, recurrent abscesses due to Staphylococcus aureus, and recurrent sinus and lung infections (with pneumatoceles). Dental abnormalities, fractures, and scoliosis are also common. Mutations in the signal transducer and activator of transcription 3 gene (STAT3) have been associated with this disorder. STAT3 is important in the JAK-STAT cytokine signaling pathway, according to Dr. Shah.

Patients who are deficient in STAT3 have deficient activation of several cytokines and reduced production of beta-defensins, leading to susceptibility to S. aureus and Candida skin infections.

NF-1-Like Syndrome

Neurofibromatosis type 1-like (NF-1-like) syndrome shares the neurofibromatosis type-1 characteristics of multiple café-au-lait spots, axillary freckling, and macrocrania. Additional features include a Noonan-like dysmorphic psychomotor development and learning difficulties. These patients, however, do not seem to develop some other NF-1 characteristics, such as Lisch nodules in the iris, neurofibromas, and central nervous system tumors.

NF-1-like syndrome is an autosomal dominant condition. Patients with NF-1-like syndrome carry mutations in the SPRED-1 gene, including nonsense frameshift, splice site, missense mutations, and in-frame deletions. The SPRED-1 protein negatively regulates Ras-mitogen-activated protein kinase (MAPK) signaling, similar to neurofibromin, the defective protein in patients with NF-1, Dr. Shah said.

Ras-MAPK Syndromes

Ras-MAPK syndromes (neuro-cardio-facial-cutaneous syndromes) include NF-1 and NF-1-like syndromes, Noonan syndrome, LEOPARD syndrome, and others. Ras is activated by cell surface receptors; activation of Ras signaling causes cell growth and differentiation, and it affects cell survival, Dr. Shah said.

The name LEOPARD highlights the main features of the disorder: lentigines, electrocardiographic conduction abnormalities, ocular hypertelorism, pulmonary stenosis, abnormalities of genitalia, retardation of growth, and deafness. "The important thing to recognize early on is the similarities with regard to some of the dysmorphic facial features … developmental issues, cardiac anomalies, or skeletal anomolies," she said.

Molecular studies have shown that LEOPARD is an allelic disorder caused by mutations in PTPN11 and RAF1.

The key features of Noonan syndrome include unusual facial features (ocular hypertelorism, down-slanting eyes, webbed neck), congenital heart disease (in 50%), short stature, and chest deformity. Mental retardation also may occur, according to Dr. Shah. Skeletal, neurologic, genitourinary, lymphatic, eye, and skin findings may be present to varying degrees. Although the pathophysiology of Noonan syndrome is not fully understood, four disease-causing genes (PTPN11, SOS1, RAF1, and KRAS) have been identified. These genes are part of the RAS transduction pathway.

Symmetric linear red macules and soft spongy plaques are among the features characteristic of Goltz syndrome, which is known to be X-linked dominant.

Source ©Dr. Albert Yan/Dr.Giuseppe Militello, DermAtlas; http://www.DermAtlas.org

Nonsurgical options may improve the appearance of the face for some, but patients with more skin redundancy and platysmal banding may require surgical neck or face lifts, according to Dr. Roberta D. Sengelmann.

The goal for treating the aging face is to bring back some of the attributes of the young face, Dr. Sengelmann said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). The solution is to restore the skin, contour the soft tissues, and resuspend sagging tissues.

Several nonsurgical treatments for restoring the neck—peels, intense pulsed light/broadband light, and pulsed dye laser—improve skin quality and color, said Dr. Sengelmann, a dermatologic and cosmetic surgeon in private practice.

Nonsurgical options to improve neck contour include botulinum toxin type A injections (Botox) and possibly Thermage (radiofrequency treatment).

The next option is tumescent liposculpture, which can be used to redefine the neck and jowls by removing excess adipose tissue that weighs down the skin. With this treatment, skin retraction is excellent, especially in young patients.

Dr. Sengelmann offered her approach to tumescent liposuction of the neck. She uses 100-250 cc of dilute anesthesia—0.1% lidocaine with 1:1,000,000 epinephrine—and uses a 1.5- to 2.5-mm blunt spatula cannula. She advises against over-resecting fat to avoid a crepey, unnatural appearance and to prevent complications of contour irregularities. She also suggests leaving a subdermal fat layer. In general, for each 150 cc infiltrated, 25-50 cc of fat are removed.

Some patients will also require rhytidectomy and tightening. Surgical treatment options for platysmal bands include resuspension/suture sling, resection, and corset platysmal plication.

A neck lift involves tumescent liposuction, platysmal plication, and possibly skin resection. This procedure may be indicated when there is platysmal banding and/or redundant skin and fat. Significant jowling may necessitate a face-lift.

Dr. Sengelmann also shared her technique for a neck lift. She uses tumescent anesthesia of 0.1% lidocaine with 1:1,000,000 epinephrine. First she performs liposuction of the neck and jowls. Then she creates a 2- to 3-cm submental incision that is 2-5 mm anterior to the crease. She undermines to the medial aspect of the sternocleidomastoid muscle and the base of the neck. She uses a corset suture for midline platysmal plication. Once diligent hemostatis is obtained, she closes the submental incision.

The patient will need to wear a chin strap or head wrap all day for 2 days and then for 6-8 hours a day for the balance of 1 week. Patients are advised to avoid exercise and vigorous activity. Follow-up should occur after 1-2 days and at 1 week.

Direct neck lifts tend to be more common in men. A direct neck lift involves direct anterior neck skin and subcutaneous tissue resection with plication of the platysma. The midline incision can be camouflaged using Z-plasty or jagged closure, said Dr. Sengelmann.

A face-lift is indicated when there is excessive neck skin redundancy and jowling, said Dr. Sengelmann, who offered her technique for a vertical face-lift. She uses 0.25% lidocaine with 1:250,000 epinephrine anesthesia, generally 50-80 cc per side. She makes a pre- and minimal post-auricular skin incision. She then performs subcutaneous dissection and superficial musculoaponeurotic system plication, with or without suture suspension. Finally, she redrapes and closes with 5.0 Vicryl and 6.0 epidermal suture of choice.

Dr. Sengelmann reported that she has no relevant financial disclosures.

SDEF and this news organization are owned by Elsevier.

The goal for treating the aging face is to bring back some of the attributes of the young face.

Source DR. SENGELMANN

Nonsurgical options may improve the appearance of the face for some, but patients with more skin redundancy and platysmal banding may require surgical neck or face lifts, according to Dr. Roberta D. Sengelmann.

The goal for treating the aging face is to bring back some of the attributes of the young face, Dr. Sengelmann said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). The solution is to restore the skin, contour the soft tissues, and resuspend sagging tissues.

Several nonsurgical treatments for restoring the neck—peels, intense pulsed light/broadband light, and pulsed dye laser—improve skin quality and color, said Dr. Sengelmann, a dermatologic and cosmetic surgeon in private practice.

Nonsurgical options to improve neck contour include botulinum toxin type A injections (Botox) and possibly Thermage (radiofrequency treatment).

The next option is tumescent liposculpture, which can be used to redefine the neck and jowls by removing excess adipose tissue that weighs down the skin. With this treatment, skin retraction is excellent, especially in young patients.

Dr. Sengelmann offered her approach to tumescent liposuction of the neck. She uses 100-250 cc of dilute anesthesia—0.1% lidocaine with 1:1,000,000 epinephrine—and uses a 1.5- to 2.5-mm blunt spatula cannula. She advises against over-resecting fat to avoid a crepey, unnatural appearance and to prevent complications of contour irregularities. She also suggests leaving a subdermal fat layer. In general, for each 150 cc infiltrated, 25-50 cc of fat are removed.

Some patients will also require rhytidectomy and tightening. Surgical treatment options for platysmal bands include resuspension/suture sling, resection, and corset platysmal plication.

A neck lift involves tumescent liposuction, platysmal plication, and possibly skin resection. This procedure may be indicated when there is platysmal banding and/or redundant skin and fat. Significant jowling may necessitate a face-lift.

Dr. Sengelmann also shared her technique for a neck lift. She uses tumescent anesthesia of 0.1% lidocaine with 1:1,000,000 epinephrine. First she performs liposuction of the neck and jowls. Then she creates a 2- to 3-cm submental incision that is 2-5 mm anterior to the crease. She undermines to the medial aspect of the sternocleidomastoid muscle and the base of the neck. She uses a corset suture for midline platysmal plication. Once diligent hemostatis is obtained, she closes the submental incision.

The patient will need to wear a chin strap or head wrap all day for 2 days and then for 6-8 hours a day for the balance of 1 week. Patients are advised to avoid exercise and vigorous activity. Follow-up should occur after 1-2 days and at 1 week.

Direct neck lifts tend to be more common in men. A direct neck lift involves direct anterior neck skin and subcutaneous tissue resection with plication of the platysma. The midline incision can be camouflaged using Z-plasty or jagged closure, said Dr. Sengelmann.

A face-lift is indicated when there is excessive neck skin redundancy and jowling, said Dr. Sengelmann, who offered her technique for a vertical face-lift. She uses 0.25% lidocaine with 1:250,000 epinephrine anesthesia, generally 50-80 cc per side. She makes a pre- and minimal post-auricular skin incision. She then performs subcutaneous dissection and superficial musculoaponeurotic system plication, with or without suture suspension. Finally, she redrapes and closes with 5.0 Vicryl and 6.0 epidermal suture of choice.

Dr. Sengelmann reported that she has no relevant financial disclosures.

SDEF and this news organization are owned by Elsevier.

The goal for treating the aging face is to bring back some of the attributes of the young face.

Source DR. SENGELMANN

Nonsurgical options may improve the appearance of the face for some, but patients with more skin redundancy and platysmal banding may require surgical neck or face lifts, according to Dr. Roberta D. Sengelmann.

The goal for treating the aging face is to bring back some of the attributes of the young face, Dr. Sengelmann said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). The solution is to restore the skin, contour the soft tissues, and resuspend sagging tissues.

Several nonsurgical treatments for restoring the neck—peels, intense pulsed light/broadband light, and pulsed dye laser—improve skin quality and color, said Dr. Sengelmann, a dermatologic and cosmetic surgeon in private practice.

Nonsurgical options to improve neck contour include botulinum toxin type A injections (Botox) and possibly Thermage (radiofrequency treatment).

The next option is tumescent liposculpture, which can be used to redefine the neck and jowls by removing excess adipose tissue that weighs down the skin. With this treatment, skin retraction is excellent, especially in young patients.

Dr. Sengelmann offered her approach to tumescent liposuction of the neck. She uses 100-250 cc of dilute anesthesia—0.1% lidocaine with 1:1,000,000 epinephrine—and uses a 1.5- to 2.5-mm blunt spatula cannula. She advises against over-resecting fat to avoid a crepey, unnatural appearance and to prevent complications of contour irregularities. She also suggests leaving a subdermal fat layer. In general, for each 150 cc infiltrated, 25-50 cc of fat are removed.

Some patients will also require rhytidectomy and tightening. Surgical treatment options for platysmal bands include resuspension/suture sling, resection, and corset platysmal plication.

A neck lift involves tumescent liposuction, platysmal plication, and possibly skin resection. This procedure may be indicated when there is platysmal banding and/or redundant skin and fat. Significant jowling may necessitate a face-lift.

Dr. Sengelmann also shared her technique for a neck lift. She uses tumescent anesthesia of 0.1% lidocaine with 1:1,000,000 epinephrine. First she performs liposuction of the neck and jowls. Then she creates a 2- to 3-cm submental incision that is 2-5 mm anterior to the crease. She undermines to the medial aspect of the sternocleidomastoid muscle and the base of the neck. She uses a corset suture for midline platysmal plication. Once diligent hemostatis is obtained, she closes the submental incision.

The patient will need to wear a chin strap or head wrap all day for 2 days and then for 6-8 hours a day for the balance of 1 week. Patients are advised to avoid exercise and vigorous activity. Follow-up should occur after 1-2 days and at 1 week.

Direct neck lifts tend to be more common in men. A direct neck lift involves direct anterior neck skin and subcutaneous tissue resection with plication of the platysma. The midline incision can be camouflaged using Z-plasty or jagged closure, said Dr. Sengelmann.

A face-lift is indicated when there is excessive neck skin redundancy and jowling, said Dr. Sengelmann, who offered her technique for a vertical face-lift. She uses 0.25% lidocaine with 1:250,000 epinephrine anesthesia, generally 50-80 cc per side. She makes a pre- and minimal post-auricular skin incision. She then performs subcutaneous dissection and superficial musculoaponeurotic system plication, with or without suture suspension. Finally, she redrapes and closes with 5.0 Vicryl and 6.0 epidermal suture of choice.

Dr. Sengelmann reported that she has no relevant financial disclosures.

SDEF and this news organization are owned by Elsevier.

The goal for treating the aging face is to bring back some of the attributes of the young face.

Source DR. SENGELMANN

PHILADELPHIA — Community-associated methicillin-resistant Staphylococcus aureus skin infections occur significantly less often among children with atopic dermatitis than among other outpatients with skin and soft tissue infections, based on a retrospective study of 78 children.

Children with atopic dermatitis (AD) and Staphylococcus aureus skin infections had a relatively low incidence (14%) of methicillin resistance, much lower than the rate noted (45.5%) in other outpatient services during the same period, Dr. Catalina Matiz and her colleagues wrote in a poster presented at the annual meeting of the Society for Pediatric Dermatology.

Dr. Matiz, a postdoctoral fellow at Rady Children's Hospital in San Diego, and her coinvestigators conducted a retrospective chart review of 78 children with super-infected AD seen at the Rady pediatric and adolescent dermatology clinic between June 2007 and June 2008. The children had a positive skin culture for S. aureus.

They compared these data with all skin and soft tissue infection outpatient samples sent to the hospital's microbiology lab during the same period, and also with those sent during January 2000 through January 2001 (excluding samples from the dermatology clinic).

The CA-MRSA rate for samples from outpatient services from 2000-2001 was 4% (192 S. aureus-positive cultures). The outpatient services' rates increase from 2000-2001 to 2007-2008, highlight the sharp increase in CA-MRSA over the last several years, Dr. Matiz noted.

The rate of community-associated methicillin-sensitive S. aureus among patients with AD was 86%. In comparison, the CA-MSSA rate for other outpatient services during the same period was 55%. The CA-MSSA rate for outpatient services from 2000-2001 was 96%.

Interestingly, the investigators found that prior history of hospitalization, eczema severity, age, gender and prior antibiotic treatment had no impact on risk of methicillin resistance or sensitivity in these patients.

For the patients with AD, positive S. aureus cultures were most common among patients aged 1-4 years (26%), followed by those aged 5-9 years (24%), and those less than a year (23%).

The double diffusion test (D-test)—which is used to assess inducible resistance to clindamycin—was performed for 576 of the CA-MRSA samples from the hospital's lab in 2008. In all, 2% were positive for clindamycin-inducible resistance. However, none of the D-tests performed on cultures from patients with AD were positive. D-tests were performed for six of nine cultures that showed erythromycin resistance among patients with AD.

The findings are striking. “It's absolutely counterintuitive because if you think of patients with AD as being more at risk for infection, you would think that at the very least they would have the same rate as that occurring in the regular population,” said Dr. Sheila Fallon Friedlander, a study coauthor and a professor of pediatrics and medicine at the University of California, San Diego.

Based on conversations with colleagues, other pediatric dermatologists seem to be seeing similar patterns, said Dr. Friedlander. The researchers are not sure why these children have fewer CA-MRSA infections, though they have a couple of ideas.

It may be that “because these kids are colonized already so much of the time with regular S. aureus, that it may exert sort of a protective effect against CA-MRSA,” Dr. Friedlander said.

In addition, patients with AD tend to present more often with multiple lesions. “That may also play a role in this. It may be that our atopic patients are presenting with secondarily-infected lesions that are distinct from the abscesses and the folliculitis that we are seeing in the community,” she noted.

The findings “have informed the way that I prescribe medications for my patients,” she said. The results suggest that more standard antibiotic drugs with fewer side effects—like cephalosporins—can be used first, especially while waiting for culture results. This could not only reduce costs but also save patients from more serious side effects of antibiotics used for resistant pathogens.

In addition, it would help to reduce selection of more resistant bacteria. “It [could protect] our bigger gun drugs—reserving them for when you really need them,” said Dr. Friedlander, who added that it is important to factor in local demographics about CA-MRSA infection when deciding on a treatment.

Dr. Friedlander pointed out that while the findings are very interesting, this is a small study. “I think it's an interesting first step,” she said. Further prospective studies, looking at both CA-MRSA colonization and infection rates in children with AD, will be important to confirm these results.

In a separate study also presented at the meeting, Canadian researchers found a MRSA colonization rate of 0.5% among 200 pediatric patients with AD, and a S. aureus colonization rate of 61%.

The researchers collected a total of 400 swabs from the nares and open areas/folds of ADpatients (aged 1 month-18 years) with intact skin. Severity of AD was assessed using the an AD severity score, said Dr. Alexandra Balma-Mena, a resident at the Hospital for Sick Children in Toronto. A score of 0-12 was considered mild disease, a score of 13-18 was considered moderate, and a score of 19-25 was considered severe.

More of the patients were male (57%); the average age was 5 years. Most patients had mild disease (66%), followed by moderate (30%), and severe (4%).

Dr. Sheila Fallon Friedlander (left) and Dr. Catalina Matiz found that children with atopic dermatitis and S. aureus had a relatively lower incidence of methicillin resistance.

Source Courtesy Rady Children's Hospital in San Diego

PHILADELPHIA — Community-associated methicillin-resistant Staphylococcus aureus skin infections occur significantly less often among children with atopic dermatitis than among other outpatients with skin and soft tissue infections, based on a retrospective study of 78 children.

Children with atopic dermatitis (AD) and Staphylococcus aureus skin infections had a relatively low incidence (14%) of methicillin resistance, much lower than the rate noted (45.5%) in other outpatient services during the same period, Dr. Catalina Matiz and her colleagues wrote in a poster presented at the annual meeting of the Society for Pediatric Dermatology.

Dr. Matiz, a postdoctoral fellow at Rady Children's Hospital in San Diego, and her coinvestigators conducted a retrospective chart review of 78 children with super-infected AD seen at the Rady pediatric and adolescent dermatology clinic between June 2007 and June 2008. The children had a positive skin culture for S. aureus.

They compared these data with all skin and soft tissue infection outpatient samples sent to the hospital's microbiology lab during the same period, and also with those sent during January 2000 through January 2001 (excluding samples from the dermatology clinic).

The CA-MRSA rate for samples from outpatient services from 2000-2001 was 4% (192 S. aureus-positive cultures). The outpatient services' rates increase from 2000-2001 to 2007-2008, highlight the sharp increase in CA-MRSA over the last several years, Dr. Matiz noted.

The rate of community-associated methicillin-sensitive S. aureus among patients with AD was 86%. In comparison, the CA-MSSA rate for other outpatient services during the same period was 55%. The CA-MSSA rate for outpatient services from 2000-2001 was 96%.

Interestingly, the investigators found that prior history of hospitalization, eczema severity, age, gender and prior antibiotic treatment had no impact on risk of methicillin resistance or sensitivity in these patients.

For the patients with AD, positive S. aureus cultures were most common among patients aged 1-4 years (26%), followed by those aged 5-9 years (24%), and those less than a year (23%).

The double diffusion test (D-test)—which is used to assess inducible resistance to clindamycin—was performed for 576 of the CA-MRSA samples from the hospital's lab in 2008. In all, 2% were positive for clindamycin-inducible resistance. However, none of the D-tests performed on cultures from patients with AD were positive. D-tests were performed for six of nine cultures that showed erythromycin resistance among patients with AD.

The findings are striking. “It's absolutely counterintuitive because if you think of patients with AD as being more at risk for infection, you would think that at the very least they would have the same rate as that occurring in the regular population,” said Dr. Sheila Fallon Friedlander, a study coauthor and a professor of pediatrics and medicine at the University of California, San Diego.

Based on conversations with colleagues, other pediatric dermatologists seem to be seeing similar patterns, said Dr. Friedlander. The researchers are not sure why these children have fewer CA-MRSA infections, though they have a couple of ideas.

It may be that “because these kids are colonized already so much of the time with regular S. aureus, that it may exert sort of a protective effect against CA-MRSA,” Dr. Friedlander said.

In addition, patients with AD tend to present more often with multiple lesions. “That may also play a role in this. It may be that our atopic patients are presenting with secondarily-infected lesions that are distinct from the abscesses and the folliculitis that we are seeing in the community,” she noted.

The findings “have informed the way that I prescribe medications for my patients,” she said. The results suggest that more standard antibiotic drugs with fewer side effects—like cephalosporins—can be used first, especially while waiting for culture results. This could not only reduce costs but also save patients from more serious side effects of antibiotics used for resistant pathogens.

In addition, it would help to reduce selection of more resistant bacteria. “It [could protect] our bigger gun drugs—reserving them for when you really need them,” said Dr. Friedlander, who added that it is important to factor in local demographics about CA-MRSA infection when deciding on a treatment.

Dr. Friedlander pointed out that while the findings are very interesting, this is a small study. “I think it's an interesting first step,” she said. Further prospective studies, looking at both CA-MRSA colonization and infection rates in children with AD, will be important to confirm these results.

In a separate study also presented at the meeting, Canadian researchers found a MRSA colonization rate of 0.5% among 200 pediatric patients with AD, and a S. aureus colonization rate of 61%.

The researchers collected a total of 400 swabs from the nares and open areas/folds of ADpatients (aged 1 month-18 years) with intact skin. Severity of AD was assessed using the an AD severity score, said Dr. Alexandra Balma-Mena, a resident at the Hospital for Sick Children in Toronto. A score of 0-12 was considered mild disease, a score of 13-18 was considered moderate, and a score of 19-25 was considered severe.

More of the patients were male (57%); the average age was 5 years. Most patients had mild disease (66%), followed by moderate (30%), and severe (4%).

Dr. Sheila Fallon Friedlander (left) and Dr. Catalina Matiz found that children with atopic dermatitis and S. aureus had a relatively lower incidence of methicillin resistance.

Source Courtesy Rady Children's Hospital in San Diego

PHILADELPHIA — Community-associated methicillin-resistant Staphylococcus aureus skin infections occur significantly less often among children with atopic dermatitis than among other outpatients with skin and soft tissue infections, based on a retrospective study of 78 children.

Children with atopic dermatitis (AD) and Staphylococcus aureus skin infections had a relatively low incidence (14%) of methicillin resistance, much lower than the rate noted (45.5%) in other outpatient services during the same period, Dr. Catalina Matiz and her colleagues wrote in a poster presented at the annual meeting of the Society for Pediatric Dermatology.

Dr. Matiz, a postdoctoral fellow at Rady Children's Hospital in San Diego, and her coinvestigators conducted a retrospective chart review of 78 children with super-infected AD seen at the Rady pediatric and adolescent dermatology clinic between June 2007 and June 2008. The children had a positive skin culture for S. aureus.

They compared these data with all skin and soft tissue infection outpatient samples sent to the hospital's microbiology lab during the same period, and also with those sent during January 2000 through January 2001 (excluding samples from the dermatology clinic).

The CA-MRSA rate for samples from outpatient services from 2000-2001 was 4% (192 S. aureus-positive cultures). The outpatient services' rates increase from 2000-2001 to 2007-2008, highlight the sharp increase in CA-MRSA over the last several years, Dr. Matiz noted.

The rate of community-associated methicillin-sensitive S. aureus among patients with AD was 86%. In comparison, the CA-MSSA rate for other outpatient services during the same period was 55%. The CA-MSSA rate for outpatient services from 2000-2001 was 96%.

Interestingly, the investigators found that prior history of hospitalization, eczema severity, age, gender and prior antibiotic treatment had no impact on risk of methicillin resistance or sensitivity in these patients.

For the patients with AD, positive S. aureus cultures were most common among patients aged 1-4 years (26%), followed by those aged 5-9 years (24%), and those less than a year (23%).

The double diffusion test (D-test)—which is used to assess inducible resistance to clindamycin—was performed for 576 of the CA-MRSA samples from the hospital's lab in 2008. In all, 2% were positive for clindamycin-inducible resistance. However, none of the D-tests performed on cultures from patients with AD were positive. D-tests were performed for six of nine cultures that showed erythromycin resistance among patients with AD.

The findings are striking. “It's absolutely counterintuitive because if you think of patients with AD as being more at risk for infection, you would think that at the very least they would have the same rate as that occurring in the regular population,” said Dr. Sheila Fallon Friedlander, a study coauthor and a professor of pediatrics and medicine at the University of California, San Diego.

Based on conversations with colleagues, other pediatric dermatologists seem to be seeing similar patterns, said Dr. Friedlander. The researchers are not sure why these children have fewer CA-MRSA infections, though they have a couple of ideas.

It may be that “because these kids are colonized already so much of the time with regular S. aureus, that it may exert sort of a protective effect against CA-MRSA,” Dr. Friedlander said.

In addition, patients with AD tend to present more often with multiple lesions. “That may also play a role in this. It may be that our atopic patients are presenting with secondarily-infected lesions that are distinct from the abscesses and the folliculitis that we are seeing in the community,” she noted.

The findings “have informed the way that I prescribe medications for my patients,” she said. The results suggest that more standard antibiotic drugs with fewer side effects—like cephalosporins—can be used first, especially while waiting for culture results. This could not only reduce costs but also save patients from more serious side effects of antibiotics used for resistant pathogens.

In addition, it would help to reduce selection of more resistant bacteria. “It [could protect] our bigger gun drugs—reserving them for when you really need them,” said Dr. Friedlander, who added that it is important to factor in local demographics about CA-MRSA infection when deciding on a treatment.

Dr. Friedlander pointed out that while the findings are very interesting, this is a small study. “I think it's an interesting first step,” she said. Further prospective studies, looking at both CA-MRSA colonization and infection rates in children with AD, will be important to confirm these results.

In a separate study also presented at the meeting, Canadian researchers found a MRSA colonization rate of 0.5% among 200 pediatric patients with AD, and a S. aureus colonization rate of 61%.

The researchers collected a total of 400 swabs from the nares and open areas/folds of ADpatients (aged 1 month-18 years) with intact skin. Severity of AD was assessed using the an AD severity score, said Dr. Alexandra Balma-Mena, a resident at the Hospital for Sick Children in Toronto. A score of 0-12 was considered mild disease, a score of 13-18 was considered moderate, and a score of 19-25 was considered severe.

More of the patients were male (57%); the average age was 5 years. Most patients had mild disease (66%), followed by moderate (30%), and severe (4%).

Dr. Sheila Fallon Friedlander (left) and Dr. Catalina Matiz found that children with atopic dermatitis and S. aureus had a relatively lower incidence of methicillin resistance.

Source Courtesy Rady Children's Hospital in San Diego

BALTIMORE — An intensive multidisciplinary weight-loss program can help obese adolescents lose weight and reduce lipid levels, a small study has shown.

By combining clinical care, nutrition, behavioral counseling, and exercise guidance, 28 teens in the program significantly reduced their body mass index by an average of 3 kg/m

The Michigan Pediatric Outpatient Weight Evaluation and Reduction (MPOWER) program helps obese adolescents aged 12–17 years identify causes of their weight gain as a strategy for reducing their weight. During the first visit, patients receive a complete medical evaluation including lab tests aimed at identifying possible causes for, and complications from, their weight gain. Patients with complications from their obesity may be referred to other University of Michigan subspecialty clinics.

A registered dietitian provides personalized dietary assessments and nutrition education. The program's family-focused treatment of obesity includes dietitian home visits to assess barriers to weight loss and help families improve the likelihood of success.

The program includes regular visits with pediatric therapists who specialize in weight loss. They work with families to help motivate behavioral changes and build confidence in new lifestyle habits. Each patient receives fitness evaluations and regular physical activity instruction from a physiologist. Exercise classes are tailored to adolescents, and a well-equipped exercise facility is accessible. Patients are taught new kinetic skills to help them become more active in their home environment.

The retrospective study included obese adolescents enrolled in the MPOWER program between April 2007 and July 2008 with a BMI greater than or equal to the 95th percentile for age and sex. Patients were excluded if they were taking cholesterol-lowering medications or obesogenic medications (such as steroids), or had a moderately severe mental illness.

They were weighed weekly, and their height was measured at weeks 1, 12, and 23. Lipids were measured at weeks 1 and 23. The researchers calculated mean changes in weight and BMI using measurements taken at weeks 1 and 23. Differences in fasting lipid levels at weeks 1 and 23 were calculated.

Twenty-eight patients completed 6 months in the program and their initial and final laboratory levels were available. Mean age was 15 years; 69% were female. Almost half (44%) received Medicaid. Most patients were white (64%) and 28% were black.

Final mean fasting levels of total cholesterol, LDL, and triglycerides were significantly lower than were the initial mean levels. The mean reduction in fasting total cholesterol was 7 mg/dL, with a final average level of 156.6 mg/dL. Fourteen patients had borderline or elevated initial total cholesterol levels (greater than 170 mg/dL). Eleven of these patients reduced their total cholesterol over 6 months. Eight had final levels in the normal range.

Mean reduction in fasting LDL was 2.7 mg/ dL, with a final average level of 98 mg/dL. Eleven patients had borderline or elevated initial LDL (greater than 110 mg/dL). Nine of them reduced their LDL. Six had final levels in the normal range.

The mean reduction in fasting triglycerides was 24.2 mg/dL, with a final mean level of 97.6 mg/dL. Eight patients had elevated initial triglyceride levels (greater than 150 mg/dL). Seven of these patients reduced their triglycerides levels to the normal range. Two teens with strong family histories of dyslipidemia had lipid levels that did not decrease with weight loss. Three teens who initially had normal lipid levels had elevated final levels, but all three lost weight during the program.

The study was funded by the University of Michigan Pediatric Comprehensive Weight Management Center.

BALTIMORE — An intensive multidisciplinary weight-loss program can help obese adolescents lose weight and reduce lipid levels, a small study has shown.

By combining clinical care, nutrition, behavioral counseling, and exercise guidance, 28 teens in the program significantly reduced their body mass index by an average of 3 kg/m

The Michigan Pediatric Outpatient Weight Evaluation and Reduction (MPOWER) program helps obese adolescents aged 12–17 years identify causes of their weight gain as a strategy for reducing their weight. During the first visit, patients receive a complete medical evaluation including lab tests aimed at identifying possible causes for, and complications from, their weight gain. Patients with complications from their obesity may be referred to other University of Michigan subspecialty clinics.

A registered dietitian provides personalized dietary assessments and nutrition education. The program's family-focused treatment of obesity includes dietitian home visits to assess barriers to weight loss and help families improve the likelihood of success.

The program includes regular visits with pediatric therapists who specialize in weight loss. They work with families to help motivate behavioral changes and build confidence in new lifestyle habits. Each patient receives fitness evaluations and regular physical activity instruction from a physiologist. Exercise classes are tailored to adolescents, and a well-equipped exercise facility is accessible. Patients are taught new kinetic skills to help them become more active in their home environment.

The retrospective study included obese adolescents enrolled in the MPOWER program between April 2007 and July 2008 with a BMI greater than or equal to the 95th percentile for age and sex. Patients were excluded if they were taking cholesterol-lowering medications or obesogenic medications (such as steroids), or had a moderately severe mental illness.

They were weighed weekly, and their height was measured at weeks 1, 12, and 23. Lipids were measured at weeks 1 and 23. The researchers calculated mean changes in weight and BMI using measurements taken at weeks 1 and 23. Differences in fasting lipid levels at weeks 1 and 23 were calculated.

Twenty-eight patients completed 6 months in the program and their initial and final laboratory levels were available. Mean age was 15 years; 69% were female. Almost half (44%) received Medicaid. Most patients were white (64%) and 28% were black.

Final mean fasting levels of total cholesterol, LDL, and triglycerides were significantly lower than were the initial mean levels. The mean reduction in fasting total cholesterol was 7 mg/dL, with a final average level of 156.6 mg/dL. Fourteen patients had borderline or elevated initial total cholesterol levels (greater than 170 mg/dL). Eleven of these patients reduced their total cholesterol over 6 months. Eight had final levels in the normal range.

Mean reduction in fasting LDL was 2.7 mg/ dL, with a final average level of 98 mg/dL. Eleven patients had borderline or elevated initial LDL (greater than 110 mg/dL). Nine of them reduced their LDL. Six had final levels in the normal range.

The mean reduction in fasting triglycerides was 24.2 mg/dL, with a final mean level of 97.6 mg/dL. Eight patients had elevated initial triglyceride levels (greater than 150 mg/dL). Seven of these patients reduced their triglycerides levels to the normal range. Two teens with strong family histories of dyslipidemia had lipid levels that did not decrease with weight loss. Three teens who initially had normal lipid levels had elevated final levels, but all three lost weight during the program.

The study was funded by the University of Michigan Pediatric Comprehensive Weight Management Center.

BALTIMORE — An intensive multidisciplinary weight-loss program can help obese adolescents lose weight and reduce lipid levels, a small study has shown.

By combining clinical care, nutrition, behavioral counseling, and exercise guidance, 28 teens in the program significantly reduced their body mass index by an average of 3 kg/m

The Michigan Pediatric Outpatient Weight Evaluation and Reduction (MPOWER) program helps obese adolescents aged 12–17 years identify causes of their weight gain as a strategy for reducing their weight. During the first visit, patients receive a complete medical evaluation including lab tests aimed at identifying possible causes for, and complications from, their weight gain. Patients with complications from their obesity may be referred to other University of Michigan subspecialty clinics.

A registered dietitian provides personalized dietary assessments and nutrition education. The program's family-focused treatment of obesity includes dietitian home visits to assess barriers to weight loss and help families improve the likelihood of success.

The program includes regular visits with pediatric therapists who specialize in weight loss. They work with families to help motivate behavioral changes and build confidence in new lifestyle habits. Each patient receives fitness evaluations and regular physical activity instruction from a physiologist. Exercise classes are tailored to adolescents, and a well-equipped exercise facility is accessible. Patients are taught new kinetic skills to help them become more active in their home environment.

The retrospective study included obese adolescents enrolled in the MPOWER program between April 2007 and July 2008 with a BMI greater than or equal to the 95th percentile for age and sex. Patients were excluded if they were taking cholesterol-lowering medications or obesogenic medications (such as steroids), or had a moderately severe mental illness.

They were weighed weekly, and their height was measured at weeks 1, 12, and 23. Lipids were measured at weeks 1 and 23. The researchers calculated mean changes in weight and BMI using measurements taken at weeks 1 and 23. Differences in fasting lipid levels at weeks 1 and 23 were calculated.

Twenty-eight patients completed 6 months in the program and their initial and final laboratory levels were available. Mean age was 15 years; 69% were female. Almost half (44%) received Medicaid. Most patients were white (64%) and 28% were black.

Final mean fasting levels of total cholesterol, LDL, and triglycerides were significantly lower than were the initial mean levels. The mean reduction in fasting total cholesterol was 7 mg/dL, with a final average level of 156.6 mg/dL. Fourteen patients had borderline or elevated initial total cholesterol levels (greater than 170 mg/dL). Eleven of these patients reduced their total cholesterol over 6 months. Eight had final levels in the normal range.

Mean reduction in fasting LDL was 2.7 mg/ dL, with a final average level of 98 mg/dL. Eleven patients had borderline or elevated initial LDL (greater than 110 mg/dL). Nine of them reduced their LDL. Six had final levels in the normal range.

The mean reduction in fasting triglycerides was 24.2 mg/dL, with a final mean level of 97.6 mg/dL. Eight patients had elevated initial triglyceride levels (greater than 150 mg/dL). Seven of these patients reduced their triglycerides levels to the normal range. Two teens with strong family histories of dyslipidemia had lipid levels that did not decrease with weight loss. Three teens who initially had normal lipid levels had elevated final levels, but all three lost weight during the program.

The study was funded by the University of Michigan Pediatric Comprehensive Weight Management Center.

ORLANDO — There's still no clear answer to whether CYP2D6 inhibitors—including some leading antidepressants—reduce the effectiveness of tamoxifen and increase the risk of breast cancer recurrence, based on the conflicting results of two retrospective database studies presented at the annual meeting of the American Society of Clinical Oncology.

Ronald Aubert, Ph.D., and his colleagues found that concomitant use of a CYP2D6 inhibitor increased the risk of recurrence at 2 years among 1,659 women identified through a large combined U.S. medical and pharmacy claims database. The increased risk was even greater for drugs deemed to be moderate or potent CYP2D6 inhibitors.

Dr. Vincent Dezentjé and his colleagues, however, found no increased risk in a study of 1,962 women identified through three large Dutch databases of hospital admissions, pharmacy claims, and pathologic data. Even when they looked at drugs deemed to be strong CYP2D6 inhibitors, the Dutch researchers saw no greater risk of recurrence.

“Additional studies that incorporate both genetic variants and use of inhibitors are required,” said Dr. Vered Stearns of Johns Hopkins University in Baltimore in a discussion of the studies. Until further data are available, “concomitant use of CYP2D6 inhibitors should be limited,” and noninhibitor alternative drugs should be considered.

Hepatic cytochrome P450 2D6 (CYP2D6) is key to the metabolic activation of tamoxifen to its active metabolite, endoxifen. Several previous studies have shown that women receiving tamoxifen have lower levels of endoxifen and are at greater risk of breast cancer recurrence if they have reduced-function CYP2D6 polymorphisms (poor metabolizers). Likewise, previous small studies with CYP2D6 inhibitors and tamoxifen have shown reductions in endoxifen, but have not clearly delineated their impact on breast cancer recurrence.

In their retrospective cohort analysis, Dr. Aubert and his colleagues mined medical and pharmacy claims from the 10 million member integrated database of Medco Health Solutions Inc. They used ICD-9 and CPT-4 codes to define the clinical end points. Dr. Aubert said he and several of his coinvestigators are employed by Medco Health Solutions.

The study population included women who initiated tamoxifen therapy between July 1, 2003, and Dec. 31, 2005. In all, 1,659 women met the criteria for tamoxifen adherence and breast cancer diagnosis. Of these, 945 women had no CYP2D6 inhibitor therapy, 359 women were considered to be exposed to a moderate or potent CYP2D6 inhibitor while on tamoxifen, and 355 women had either no overlap of CYP2D6 inhibitor and tamoxifen therapy or were on CYP2D6 inhibitors that were considered to be weak. Follow-up measurement started 6 months after the initiation of therapy and continued through Dec. 31, 2007.

“When we looked at the distribution of the types of CYP2D6 inhibitors, 79% were antidepressants, with the majority of those being an SSRI (52%),” said Dr. Aubert. In addition, 6% of women were on a serotonin-norepinephrine reuptake inhibitor, 34% were on some other type of antidepressant, 12% were on an antifungal, and 18% were on seven other drugs in unique classes. The mean duration of overlap with tamoxifen was 340 days; the median was 287 days.

Women on CYP2D6 inhibitors had an almost doubled incidence of breast cancer recurrence. For women not on a CYP2D6 inhibitor, the incidence was 7.5% vs. 13.9% in women on a moderate or potent CYP2D6 inhibitor (hazard ratio, 1.92; P less than .001).

“Moderate to severe CYP2D6 inhibitors used concomitantly with tamoxifen were associated with a 92% greater risk of breast cancer recurrence vs. tamoxifen alone,” said Dr. Aubert. Moderate to potent CYP2D6 inhibitor SSRIs (fluoxetine, paroxetine, and sertraline) were associated with a 120% increase in the risk of breast cancer recurrence, whereas weak CYP2D6 inhibitor SSRIs (citalopram, escitalopram, and fluvoxamine) were not associated with an increased risk.

Dr. Dezentjé of Leiden (the Netherlands) University Medical Center and his coinvestigators also performed a retrospective follow-up study. They used three large linked databases: a pharmacy database (PHARMO), a pathology database (PALGA), and a hospital admissions database (Dutch Medical Register) to look at nine CYP2D6 inhibitors: bupropion, paroxetine, fluoxetine, quinidine, duloxetine, terbinafine, amiodarone, cimetidine, and sertraline.

Patients were included if they had a pathology report of a breast cancer resection specimen between 1994 and 2006 and had used tamoxifen in the same period. In all, 3,147 patients were identified with primary breast cancer, of which 1,962 were eligible for this analysis. Most (89%) were on tamoxifen alone, leaving 213 women on tamoxifen and a CYP2D6 inhibitor. Only 150 women met the criteria (at least 60 days) for concomitant use, however, and about 70% were on either paroxetine or fluoxetine.

In a univariate Cox regression analysis, the researchers found no difference in event-free time between women who did not use CYP2D6 inhibitors and women who used concomitant tamoxifen and CYP2D6 inhibitors (HR, 0.95; P = .73). “Even if we restricted our analysis to strong inhibitors, we could not find any difference,” Dr. Dezentjé said. Dr. Dezentjé and his coauthors reported that they have no relevant financial relationships.

Dr. Stearns noted that both of the studies have several limitations. Both were retrospective studies with relatively small sample sizes and limited follow-up. “In addition, there may be incomplete accountability for recurrences, as those were determined by hospital admission. As we know, breast cancer is very much an outpatient disease.” Moreover, the reason for inhibitor use is not known in either study.

In the Medco cohort, claims data are limited, and women with early recurrences or with low medication possession rates were excluded. In the European cohort, “the magnitude of the effect may have been diluted by short concomitant medication use,” she said.

Dr. Stearns reported that she had significant financial relationships with several pharmaceutical companies.

Even concomitant use of drugs deemed to be strong inhibitors didn't increase breast cancer recurrence. DR. DEZENTJÉ

ORLANDO — There's still no clear answer to whether CYP2D6 inhibitors—including some leading antidepressants—reduce the effectiveness of tamoxifen and increase the risk of breast cancer recurrence, based on the conflicting results of two retrospective database studies presented at the annual meeting of the American Society of Clinical Oncology.

Ronald Aubert, Ph.D., and his colleagues found that concomitant use of a CYP2D6 inhibitor increased the risk of recurrence at 2 years among 1,659 women identified through a large combined U.S. medical and pharmacy claims database. The increased risk was even greater for drugs deemed to be moderate or potent CYP2D6 inhibitors.

Dr. Vincent Dezentjé and his colleagues, however, found no increased risk in a study of 1,962 women identified through three large Dutch databases of hospital admissions, pharmacy claims, and pathologic data. Even when they looked at drugs deemed to be strong CYP2D6 inhibitors, the Dutch researchers saw no greater risk of recurrence.

“Additional studies that incorporate both genetic variants and use of inhibitors are required,” said Dr. Vered Stearns of Johns Hopkins University in Baltimore in a discussion of the studies. Until further data are available, “concomitant use of CYP2D6 inhibitors should be limited,” and noninhibitor alternative drugs should be considered.

Hepatic cytochrome P450 2D6 (CYP2D6) is key to the metabolic activation of tamoxifen to its active metabolite, endoxifen. Several previous studies have shown that women receiving tamoxifen have lower levels of endoxifen and are at greater risk of breast cancer recurrence if they have reduced-function CYP2D6 polymorphisms (poor metabolizers). Likewise, previous small studies with CYP2D6 inhibitors and tamoxifen have shown reductions in endoxifen, but have not clearly delineated their impact on breast cancer recurrence.

In their retrospective cohort analysis, Dr. Aubert and his colleagues mined medical and pharmacy claims from the 10 million member integrated database of Medco Health Solutions Inc. They used ICD-9 and CPT-4 codes to define the clinical end points. Dr. Aubert said he and several of his coinvestigators are employed by Medco Health Solutions.

The study population included women who initiated tamoxifen therapy between July 1, 2003, and Dec. 31, 2005. In all, 1,659 women met the criteria for tamoxifen adherence and breast cancer diagnosis. Of these, 945 women had no CYP2D6 inhibitor therapy, 359 women were considered to be exposed to a moderate or potent CYP2D6 inhibitor while on tamoxifen, and 355 women had either no overlap of CYP2D6 inhibitor and tamoxifen therapy or were on CYP2D6 inhibitors that were considered to be weak. Follow-up measurement started 6 months after the initiation of therapy and continued through Dec. 31, 2007.

“When we looked at the distribution of the types of CYP2D6 inhibitors, 79% were antidepressants, with the majority of those being an SSRI (52%),” said Dr. Aubert. In addition, 6% of women were on a serotonin-norepinephrine reuptake inhibitor, 34% were on some other type of antidepressant, 12% were on an antifungal, and 18% were on seven other drugs in unique classes. The mean duration of overlap with tamoxifen was 340 days; the median was 287 days.

Women on CYP2D6 inhibitors had an almost doubled incidence of breast cancer recurrence. For women not on a CYP2D6 inhibitor, the incidence was 7.5% vs. 13.9% in women on a moderate or potent CYP2D6 inhibitor (hazard ratio, 1.92; P less than .001).

“Moderate to severe CYP2D6 inhibitors used concomitantly with tamoxifen were associated with a 92% greater risk of breast cancer recurrence vs. tamoxifen alone,” said Dr. Aubert. Moderate to potent CYP2D6 inhibitor SSRIs (fluoxetine, paroxetine, and sertraline) were associated with a 120% increase in the risk of breast cancer recurrence, whereas weak CYP2D6 inhibitor SSRIs (citalopram, escitalopram, and fluvoxamine) were not associated with an increased risk.

Dr. Dezentjé of Leiden (the Netherlands) University Medical Center and his coinvestigators also performed a retrospective follow-up study. They used three large linked databases: a pharmacy database (PHARMO), a pathology database (PALGA), and a hospital admissions database (Dutch Medical Register) to look at nine CYP2D6 inhibitors: bupropion, paroxetine, fluoxetine, quinidine, duloxetine, terbinafine, amiodarone, cimetidine, and sertraline.

Patients were included if they had a pathology report of a breast cancer resection specimen between 1994 and 2006 and had used tamoxifen in the same period. In all, 3,147 patients were identified with primary breast cancer, of which 1,962 were eligible for this analysis. Most (89%) were on tamoxifen alone, leaving 213 women on tamoxifen and a CYP2D6 inhibitor. Only 150 women met the criteria (at least 60 days) for concomitant use, however, and about 70% were on either paroxetine or fluoxetine.

In a univariate Cox regression analysis, the researchers found no difference in event-free time between women who did not use CYP2D6 inhibitors and women who used concomitant tamoxifen and CYP2D6 inhibitors (HR, 0.95; P = .73). “Even if we restricted our analysis to strong inhibitors, we could not find any difference,” Dr. Dezentjé said. Dr. Dezentjé and his coauthors reported that they have no relevant financial relationships.

Dr. Stearns noted that both of the studies have several limitations. Both were retrospective studies with relatively small sample sizes and limited follow-up. “In addition, there may be incomplete accountability for recurrences, as those were determined by hospital admission. As we know, breast cancer is very much an outpatient disease.” Moreover, the reason for inhibitor use is not known in either study.

In the Medco cohort, claims data are limited, and women with early recurrences or with low medication possession rates were excluded. In the European cohort, “the magnitude of the effect may have been diluted by short concomitant medication use,” she said.

Dr. Stearns reported that she had significant financial relationships with several pharmaceutical companies.

Even concomitant use of drugs deemed to be strong inhibitors didn't increase breast cancer recurrence. DR. DEZENTJÉ

ORLANDO — There's still no clear answer to whether CYP2D6 inhibitors—including some leading antidepressants—reduce the effectiveness of tamoxifen and increase the risk of breast cancer recurrence, based on the conflicting results of two retrospective database studies presented at the annual meeting of the American Society of Clinical Oncology.

Ronald Aubert, Ph.D., and his colleagues found that concomitant use of a CYP2D6 inhibitor increased the risk of recurrence at 2 years among 1,659 women identified through a large combined U.S. medical and pharmacy claims database. The increased risk was even greater for drugs deemed to be moderate or potent CYP2D6 inhibitors.

Dr. Vincent Dezentjé and his colleagues, however, found no increased risk in a study of 1,962 women identified through three large Dutch databases of hospital admissions, pharmacy claims, and pathologic data. Even when they looked at drugs deemed to be strong CYP2D6 inhibitors, the Dutch researchers saw no greater risk of recurrence.

“Additional studies that incorporate both genetic variants and use of inhibitors are required,” said Dr. Vered Stearns of Johns Hopkins University in Baltimore in a discussion of the studies. Until further data are available, “concomitant use of CYP2D6 inhibitors should be limited,” and noninhibitor alternative drugs should be considered.

Hepatic cytochrome P450 2D6 (CYP2D6) is key to the metabolic activation of tamoxifen to its active metabolite, endoxifen. Several previous studies have shown that women receiving tamoxifen have lower levels of endoxifen and are at greater risk of breast cancer recurrence if they have reduced-function CYP2D6 polymorphisms (poor metabolizers). Likewise, previous small studies with CYP2D6 inhibitors and tamoxifen have shown reductions in endoxifen, but have not clearly delineated their impact on breast cancer recurrence.

In their retrospective cohort analysis, Dr. Aubert and his colleagues mined medical and pharmacy claims from the 10 million member integrated database of Medco Health Solutions Inc. They used ICD-9 and CPT-4 codes to define the clinical end points. Dr. Aubert said he and several of his coinvestigators are employed by Medco Health Solutions.

The study population included women who initiated tamoxifen therapy between July 1, 2003, and Dec. 31, 2005. In all, 1,659 women met the criteria for tamoxifen adherence and breast cancer diagnosis. Of these, 945 women had no CYP2D6 inhibitor therapy, 359 women were considered to be exposed to a moderate or potent CYP2D6 inhibitor while on tamoxifen, and 355 women had either no overlap of CYP2D6 inhibitor and tamoxifen therapy or were on CYP2D6 inhibitors that were considered to be weak. Follow-up measurement started 6 months after the initiation of therapy and continued through Dec. 31, 2007.

“When we looked at the distribution of the types of CYP2D6 inhibitors, 79% were antidepressants, with the majority of those being an SSRI (52%),” said Dr. Aubert. In addition, 6% of women were on a serotonin-norepinephrine reuptake inhibitor, 34% were on some other type of antidepressant, 12% were on an antifungal, and 18% were on seven other drugs in unique classes. The mean duration of overlap with tamoxifen was 340 days; the median was 287 days.

Women on CYP2D6 inhibitors had an almost doubled incidence of breast cancer recurrence. For women not on a CYP2D6 inhibitor, the incidence was 7.5% vs. 13.9% in women on a moderate or potent CYP2D6 inhibitor (hazard ratio, 1.92; P less than .001).

“Moderate to severe CYP2D6 inhibitors used concomitantly with tamoxifen were associated with a 92% greater risk of breast cancer recurrence vs. tamoxifen alone,” said Dr. Aubert. Moderate to potent CYP2D6 inhibitor SSRIs (fluoxetine, paroxetine, and sertraline) were associated with a 120% increase in the risk of breast cancer recurrence, whereas weak CYP2D6 inhibitor SSRIs (citalopram, escitalopram, and fluvoxamine) were not associated with an increased risk.

Dr. Dezentjé of Leiden (the Netherlands) University Medical Center and his coinvestigators also performed a retrospective follow-up study. They used three large linked databases: a pharmacy database (PHARMO), a pathology database (PALGA), and a hospital admissions database (Dutch Medical Register) to look at nine CYP2D6 inhibitors: bupropion, paroxetine, fluoxetine, quinidine, duloxetine, terbinafine, amiodarone, cimetidine, and sertraline.

Patients were included if they had a pathology report of a breast cancer resection specimen between 1994 and 2006 and had used tamoxifen in the same period. In all, 3,147 patients were identified with primary breast cancer, of which 1,962 were eligible for this analysis. Most (89%) were on tamoxifen alone, leaving 213 women on tamoxifen and a CYP2D6 inhibitor. Only 150 women met the criteria (at least 60 days) for concomitant use, however, and about 70% were on either paroxetine or fluoxetine.

In a univariate Cox regression analysis, the researchers found no difference in event-free time between women who did not use CYP2D6 inhibitors and women who used concomitant tamoxifen and CYP2D6 inhibitors (HR, 0.95; P = .73). “Even if we restricted our analysis to strong inhibitors, we could not find any difference,” Dr. Dezentjé said. Dr. Dezentjé and his coauthors reported that they have no relevant financial relationships.

Dr. Stearns noted that both of the studies have several limitations. Both were retrospective studies with relatively small sample sizes and limited follow-up. “In addition, there may be incomplete accountability for recurrences, as those were determined by hospital admission. As we know, breast cancer is very much an outpatient disease.” Moreover, the reason for inhibitor use is not known in either study.

In the Medco cohort, claims data are limited, and women with early recurrences or with low medication possession rates were excluded. In the European cohort, “the magnitude of the effect may have been diluted by short concomitant medication use,” she said.

Dr. Stearns reported that she had significant financial relationships with several pharmaceutical companies.

Even concomitant use of drugs deemed to be strong inhibitors didn't increase breast cancer recurrence. DR. DEZENTJÉ