Miriam E. Tucker

BALTIMORE — Rotavirus hospitalizations declined by 84% from 2006 to 2008 among children less than 3 years of age, suggesting a dramatic effect of vaccination.

That degree of decline was seen even among children 2–3 years old whose age made them ineligible to be vaccinated against rotavirus, suggesting that the vaccine's impact extends beyond direct vaccinees, Daniel C. Payne, Ph.D., said at the annual meeting of the Pediatric Academic Societies.

Dramatic decreases in rotavirus hospitalization rates were observed in 2008, compared with the pre-vaccine licensure year 2006. “Rotavirus hospitalization rate decreases were much greater than would be expected based on vaccine coverage,” said Dr. Payne of the Centers for Disease Control and Prevention, Atlanta.

The findings come from the New Vaccine Surveillance Network (NVSN), a systematic, prospective, population-based surveillance network for acute gastroenteritis in three U.S. counties with a combined catchment of approximately 85,000 children less than 3 years of age. Funded by the CDC, the NVSN allows for direct estimates of the rotavirus disease burden in each participating hospital.

Children less than 3 years of age who resided in specific counties in Tennessee, Ohio, and New York were eligible for enrollment if they had acute gastroenteritis (AGE), defined as three or more episodes of diarrhea and/or any vomiting in a 24-hour period. Surveillance was conducted during January to June of 2006, 2007, and 2008.

Stool samples were collected from 499 of 578 eligible children. The proportion of hospitalized children with AGE who tested positive for rotavirus dropped from 50% in 2006 (91 of 181) to 45% in 2007 (81 of 179) and then down to just 6% (9 of 139) in 2008. “This is a major, major decline in incidence, using the same [testing] methodology for all 3 years,” Dr. Payne commented.

At one site, Rochester, N.Y., there wasn't a single hospitalization for rotavirus gastroenteritis during 2008 in a catchment area of 28,000 children less than 3 years of age, he noted. Broken down by age, there was a 66% decline in rotavirus hospitalizations among children less than 1 year of age from 2006 to 2008, during which time vaccine coverage (defined as receipt of at least one of the three doses) increased from less than 1% to 56%. For children aged 1–2 years, there was a 95% decline over the 3 years, concurrent with a rise in vaccine coverage from 0% to 44%.

The most startling finding, however, was an 85% decline in rotavirus hospitalizations among 2- to 3-year-olds, who were age ineligible to receive the vaccine, with vaccination rates less than 1% in 2008. “It looks like a disproportionate effect,” Dr. Payne commented, adding that “this raises a previously unpredicted question: Are there indirect benefits—herd immunity—from rotavirus vaccine?”

“Clinical trials of the vaccine did not evaluate herd immunity. … This is certainly something we're looking at further,” he said.

In response to an audience member's question about cost effectiveness, Dr. Payne said that if the 84% decline in hospitalizations seen in these three surveillance sites were extrapolated to the entire country, it would mean 22,000 fewer hospitalizations and 300,000 fewer emergency department visits within a 1-year period. Cost effectiveness hasn't yet been analyzed, but “it's something that will be important to look at.”

Dr. Payne stated that he had no financial conflicts of interest to report.

There was a major decline in incidence of rotavirus causing AGE hospitalizations. ©CDC/Dr. Erskine Palmer

BALTIMORE — Rotavirus hospitalizations declined by 84% from 2006 to 2008 among children less than 3 years of age, suggesting a dramatic effect of vaccination.

That degree of decline was seen even among children 2–3 years old whose age made them ineligible to be vaccinated against rotavirus, suggesting that the vaccine's impact extends beyond direct vaccinees, Daniel C. Payne, Ph.D., said at the annual meeting of the Pediatric Academic Societies.

Dramatic decreases in rotavirus hospitalization rates were observed in 2008, compared with the pre-vaccine licensure year 2006. “Rotavirus hospitalization rate decreases were much greater than would be expected based on vaccine coverage,” said Dr. Payne of the Centers for Disease Control and Prevention, Atlanta.

The findings come from the New Vaccine Surveillance Network (NVSN), a systematic, prospective, population-based surveillance network for acute gastroenteritis in three U.S. counties with a combined catchment of approximately 85,000 children less than 3 years of age. Funded by the CDC, the NVSN allows for direct estimates of the rotavirus disease burden in each participating hospital.

Children less than 3 years of age who resided in specific counties in Tennessee, Ohio, and New York were eligible for enrollment if they had acute gastroenteritis (AGE), defined as three or more episodes of diarrhea and/or any vomiting in a 24-hour period. Surveillance was conducted during January to June of 2006, 2007, and 2008.

Stool samples were collected from 499 of 578 eligible children. The proportion of hospitalized children with AGE who tested positive for rotavirus dropped from 50% in 2006 (91 of 181) to 45% in 2007 (81 of 179) and then down to just 6% (9 of 139) in 2008. “This is a major, major decline in incidence, using the same [testing] methodology for all 3 years,” Dr. Payne commented.

At one site, Rochester, N.Y., there wasn't a single hospitalization for rotavirus gastroenteritis during 2008 in a catchment area of 28,000 children less than 3 years of age, he noted. Broken down by age, there was a 66% decline in rotavirus hospitalizations among children less than 1 year of age from 2006 to 2008, during which time vaccine coverage (defined as receipt of at least one of the three doses) increased from less than 1% to 56%. For children aged 1–2 years, there was a 95% decline over the 3 years, concurrent with a rise in vaccine coverage from 0% to 44%.

The most startling finding, however, was an 85% decline in rotavirus hospitalizations among 2- to 3-year-olds, who were age ineligible to receive the vaccine, with vaccination rates less than 1% in 2008. “It looks like a disproportionate effect,” Dr. Payne commented, adding that “this raises a previously unpredicted question: Are there indirect benefits—herd immunity—from rotavirus vaccine?”

“Clinical trials of the vaccine did not evaluate herd immunity. … This is certainly something we're looking at further,” he said.

In response to an audience member's question about cost effectiveness, Dr. Payne said that if the 84% decline in hospitalizations seen in these three surveillance sites were extrapolated to the entire country, it would mean 22,000 fewer hospitalizations and 300,000 fewer emergency department visits within a 1-year period. Cost effectiveness hasn't yet been analyzed, but “it's something that will be important to look at.”

Dr. Payne stated that he had no financial conflicts of interest to report.

There was a major decline in incidence of rotavirus causing AGE hospitalizations. ©CDC/Dr. Erskine Palmer

BALTIMORE — Rotavirus hospitalizations declined by 84% from 2006 to 2008 among children less than 3 years of age, suggesting a dramatic effect of vaccination.

That degree of decline was seen even among children 2–3 years old whose age made them ineligible to be vaccinated against rotavirus, suggesting that the vaccine's impact extends beyond direct vaccinees, Daniel C. Payne, Ph.D., said at the annual meeting of the Pediatric Academic Societies.

Dramatic decreases in rotavirus hospitalization rates were observed in 2008, compared with the pre-vaccine licensure year 2006. “Rotavirus hospitalization rate decreases were much greater than would be expected based on vaccine coverage,” said Dr. Payne of the Centers for Disease Control and Prevention, Atlanta.

The findings come from the New Vaccine Surveillance Network (NVSN), a systematic, prospective, population-based surveillance network for acute gastroenteritis in three U.S. counties with a combined catchment of approximately 85,000 children less than 3 years of age. Funded by the CDC, the NVSN allows for direct estimates of the rotavirus disease burden in each participating hospital.

Children less than 3 years of age who resided in specific counties in Tennessee, Ohio, and New York were eligible for enrollment if they had acute gastroenteritis (AGE), defined as three or more episodes of diarrhea and/or any vomiting in a 24-hour period. Surveillance was conducted during January to June of 2006, 2007, and 2008.

Stool samples were collected from 499 of 578 eligible children. The proportion of hospitalized children with AGE who tested positive for rotavirus dropped from 50% in 2006 (91 of 181) to 45% in 2007 (81 of 179) and then down to just 6% (9 of 139) in 2008. “This is a major, major decline in incidence, using the same [testing] methodology for all 3 years,” Dr. Payne commented.

At one site, Rochester, N.Y., there wasn't a single hospitalization for rotavirus gastroenteritis during 2008 in a catchment area of 28,000 children less than 3 years of age, he noted. Broken down by age, there was a 66% decline in rotavirus hospitalizations among children less than 1 year of age from 2006 to 2008, during which time vaccine coverage (defined as receipt of at least one of the three doses) increased from less than 1% to 56%. For children aged 1–2 years, there was a 95% decline over the 3 years, concurrent with a rise in vaccine coverage from 0% to 44%.

The most startling finding, however, was an 85% decline in rotavirus hospitalizations among 2- to 3-year-olds, who were age ineligible to receive the vaccine, with vaccination rates less than 1% in 2008. “It looks like a disproportionate effect,” Dr. Payne commented, adding that “this raises a previously unpredicted question: Are there indirect benefits—herd immunity—from rotavirus vaccine?”

“Clinical trials of the vaccine did not evaluate herd immunity. … This is certainly something we're looking at further,” he said.

In response to an audience member's question about cost effectiveness, Dr. Payne said that if the 84% decline in hospitalizations seen in these three surveillance sites were extrapolated to the entire country, it would mean 22,000 fewer hospitalizations and 300,000 fewer emergency department visits within a 1-year period. Cost effectiveness hasn't yet been analyzed, but “it's something that will be important to look at.”

Dr. Payne stated that he had no financial conflicts of interest to report.

There was a major decline in incidence of rotavirus causing AGE hospitalizations. ©CDC/Dr. Erskine Palmer

BALTIMORE — One in five pediatricians surveyed said that inadequate reimbursement prevents them from using combination vaccines in their practices.

The finding, from a nationwide survey of 630 pediatricians, was presented by Dr. Courtney Gidengil at the annual meeting of the Pediatric Academic Societies.

New combination vaccines reduce the number of injections required to complete the childhood immunization series, and may increase immunization coverage. However, pediatricians typically receive lower reimbursement for administering combination vaccines because fees are tied to the number of injections given, said Dr. Gidengil of Harvard Medical School, Boston.

Surveys containing 15 questions about the use of combination vaccines, benefits of combination vaccines, and vaccine reimbursement were mailed to a random sample of 1,045 pediatricians from the American Medical Association master file.

The 70% who responded did not differ from the nonresponders on any measured practice parameter: Just over half were from small practices (1–5 clinicians), a third worked in medium-sized practices (6–20 practitioners), and only 11% worked with 19 or more other clinicians. Almost half of the practices were single specialty, a third were solo or two-physician practices, and 23% were multispecialty or other types of practices. In 52%, more than 20% of patients had public health insurance.

Most of the practices (86%) participated in the Vaccines for Children (VFC) program. The vaccine financing policies of the states where the responding pediatricians practiced were 47% VFC-eligible children only, 4% with universal coverage, and 49% with coverage between those two extremes (VFC eligibles and some additional underinsured groups of children).

A majority of respondents (70%) reported currently using Pediarix, while smaller proportions used other combination vaccines including Pentacel, Comvax, TriHIBit, and Kinrix, although many said they were planning to use the two newer combinations Pentacel and Kinrix.

Less than half of the respondents agreed or strongly agreed that the practice was adequately reimbursed for the cost of vaccines in general (42%), for administration of vaccines in general (40%), or for the cost of combination vaccines (40%) or the administration of combination vaccines (39%). Inadequate reimbursement for the cost of vaccines and for the administration fees were cited by 23% and 20% of the pediatricians, respectively, as preventing them from using combination vaccines (defined as use of Pediarix or Pentacel).

Pediatricians from practices that participated in the VFC program were significantly more likely to use combination vaccines (81% vs. 61%) than were those who said they were adequately reimbursed for vaccine cost and administration (90% vs. 76%). Respondents from single-specialty, solo, or two-physician practices were somewhat more likely to use combination vaccines than were those from multispecialty or other types of practices, Dr. Gidengil said.

In a multivariate analysis, significant negative predictors of combination vaccine use were working in smaller practices, working in practices with a high proportion of privately insured patients, practicing in states with less-inclusive vaccine financing policies (ranging from VFC only to universal coverage, with intermediate levels in between), and responding “no” to being adequately reimbursed for vaccine cost and administration.

This study was funded by grants from the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality (for Dr. Gidengil's time). She stated that she had no financial disclosures regarding this study.

BALTIMORE — One in five pediatricians surveyed said that inadequate reimbursement prevents them from using combination vaccines in their practices.

The finding, from a nationwide survey of 630 pediatricians, was presented by Dr. Courtney Gidengil at the annual meeting of the Pediatric Academic Societies.

New combination vaccines reduce the number of injections required to complete the childhood immunization series, and may increase immunization coverage. However, pediatricians typically receive lower reimbursement for administering combination vaccines because fees are tied to the number of injections given, said Dr. Gidengil of Harvard Medical School, Boston.

Surveys containing 15 questions about the use of combination vaccines, benefits of combination vaccines, and vaccine reimbursement were mailed to a random sample of 1,045 pediatricians from the American Medical Association master file.

The 70% who responded did not differ from the nonresponders on any measured practice parameter: Just over half were from small practices (1–5 clinicians), a third worked in medium-sized practices (6–20 practitioners), and only 11% worked with 19 or more other clinicians. Almost half of the practices were single specialty, a third were solo or two-physician practices, and 23% were multispecialty or other types of practices. In 52%, more than 20% of patients had public health insurance.

Most of the practices (86%) participated in the Vaccines for Children (VFC) program. The vaccine financing policies of the states where the responding pediatricians practiced were 47% VFC-eligible children only, 4% with universal coverage, and 49% with coverage between those two extremes (VFC eligibles and some additional underinsured groups of children).

A majority of respondents (70%) reported currently using Pediarix, while smaller proportions used other combination vaccines including Pentacel, Comvax, TriHIBit, and Kinrix, although many said they were planning to use the two newer combinations Pentacel and Kinrix.

Less than half of the respondents agreed or strongly agreed that the practice was adequately reimbursed for the cost of vaccines in general (42%), for administration of vaccines in general (40%), or for the cost of combination vaccines (40%) or the administration of combination vaccines (39%). Inadequate reimbursement for the cost of vaccines and for the administration fees were cited by 23% and 20% of the pediatricians, respectively, as preventing them from using combination vaccines (defined as use of Pediarix or Pentacel).

Pediatricians from practices that participated in the VFC program were significantly more likely to use combination vaccines (81% vs. 61%) than were those who said they were adequately reimbursed for vaccine cost and administration (90% vs. 76%). Respondents from single-specialty, solo, or two-physician practices were somewhat more likely to use combination vaccines than were those from multispecialty or other types of practices, Dr. Gidengil said.

In a multivariate analysis, significant negative predictors of combination vaccine use were working in smaller practices, working in practices with a high proportion of privately insured patients, practicing in states with less-inclusive vaccine financing policies (ranging from VFC only to universal coverage, with intermediate levels in between), and responding “no” to being adequately reimbursed for vaccine cost and administration.

This study was funded by grants from the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality (for Dr. Gidengil's time). She stated that she had no financial disclosures regarding this study.

BALTIMORE — One in five pediatricians surveyed said that inadequate reimbursement prevents them from using combination vaccines in their practices.

The finding, from a nationwide survey of 630 pediatricians, was presented by Dr. Courtney Gidengil at the annual meeting of the Pediatric Academic Societies.

New combination vaccines reduce the number of injections required to complete the childhood immunization series, and may increase immunization coverage. However, pediatricians typically receive lower reimbursement for administering combination vaccines because fees are tied to the number of injections given, said Dr. Gidengil of Harvard Medical School, Boston.

Surveys containing 15 questions about the use of combination vaccines, benefits of combination vaccines, and vaccine reimbursement were mailed to a random sample of 1,045 pediatricians from the American Medical Association master file.

The 70% who responded did not differ from the nonresponders on any measured practice parameter: Just over half were from small practices (1–5 clinicians), a third worked in medium-sized practices (6–20 practitioners), and only 11% worked with 19 or more other clinicians. Almost half of the practices were single specialty, a third were solo or two-physician practices, and 23% were multispecialty or other types of practices. In 52%, more than 20% of patients had public health insurance.

Most of the practices (86%) participated in the Vaccines for Children (VFC) program. The vaccine financing policies of the states where the responding pediatricians practiced were 47% VFC-eligible children only, 4% with universal coverage, and 49% with coverage between those two extremes (VFC eligibles and some additional underinsured groups of children).

A majority of respondents (70%) reported currently using Pediarix, while smaller proportions used other combination vaccines including Pentacel, Comvax, TriHIBit, and Kinrix, although many said they were planning to use the two newer combinations Pentacel and Kinrix.

Less than half of the respondents agreed or strongly agreed that the practice was adequately reimbursed for the cost of vaccines in general (42%), for administration of vaccines in general (40%), or for the cost of combination vaccines (40%) or the administration of combination vaccines (39%). Inadequate reimbursement for the cost of vaccines and for the administration fees were cited by 23% and 20% of the pediatricians, respectively, as preventing them from using combination vaccines (defined as use of Pediarix or Pentacel).

Pediatricians from practices that participated in the VFC program were significantly more likely to use combination vaccines (81% vs. 61%) than were those who said they were adequately reimbursed for vaccine cost and administration (90% vs. 76%). Respondents from single-specialty, solo, or two-physician practices were somewhat more likely to use combination vaccines than were those from multispecialty or other types of practices, Dr. Gidengil said.

In a multivariate analysis, significant negative predictors of combination vaccine use were working in smaller practices, working in practices with a high proportion of privately insured patients, practicing in states with less-inclusive vaccine financing policies (ranging from VFC only to universal coverage, with intermediate levels in between), and responding “no” to being adequately reimbursed for vaccine cost and administration.

This study was funded by grants from the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality (for Dr. Gidengil's time). She stated that she had no financial disclosures regarding this study.

BALTIMORE — Rotavirus hospitalizations declined by 84% from 2006 to 2008 among children less than 3 years of age, suggesting a dramatic vaccination effect.

That degree of decline was seen even among children aged 2–3 years who were age-ineligible to be vaccinated against rotavirus, suggesting that the vaccine's impact extends beyond direct vaccinees, Daniel C. Payne, Ph.D., said at the annual meeting of the Pediatric Academic Societies.

Dramatic decreases in rotavirus hospitalization rates were observed in 2008, compared with the pre-vaccine licensure year 2006. Rotavirus hospitalization rate decreases were much greater than would be expected based on vaccine coverage,” said Dr. Payne of the Centers for Disease Control and Prevention, Atlanta.

The findings come from the New Vaccine Surveillance Network (NVSN), a systematic, prospective, population-based surveillance for acute gastroenteritis in 3 U.S. counties with a combined catchment of approximately 85,000 children less than 3 years of age. Funded by the CDC, the NVSN allows for direct estimates of the rotavirus disease burden in each participating hospital.

Children less than 3 years of age who resided in specific counties in Tennessee, Ohio, and New York were eligible for enrollment if they had acute gastroenteritis (AGE), defined as three or more episodes of diarrhea and/or any vomiting in a 24-hour period. Surveillance was conducted during January-June of 2006, 2007, and 2008.

Stool samples were collected from 499 of 578 eligible children. The proportion of hospitalized children with AGE who tested positive for rotavirus dropped from 50% in 2006 (91 of 181) to 45% in 2007 (81 of 179) and then down to just 6% (9 of 139) in 2008. “This is a major, major decline in incidence, using the same [testing] methodology for all 3 years,” Dr. Payne commented.

At one site, Rochester, N.Y., there was not a single hospitalization for rotavirus gastroenteritis during 2008 in a catchment area of 28,000 children less than 3 years of age, he noted.

Broken down by age, there was a 66% decline in rotavirus hospitalizations among children less than 1 year of age from 2006 to 2008, during which time vaccine coverage (defined as receipt of at least one of the three doses) increased from less than 1% to 56%. For children aged 1–2 years, there was a 95% decline over the 3 years, concurrent with a rise in vaccine coverage from 0% to 44%.

The most startling finding, however, was an 85% decline in rotavirus hospitalizations among 2- to 3-year-olds, who were age-ineligible to receive the vaccine, with vaccination rates less than 1% in 2008. “It looks like a disproportionate effect,” Dr. Payne commented, adding that “This raises a previously unpredicted question: Are there indirect benefits—herd immunity—from rotavirus vaccine?”

“Clinical trials of the vaccine did not evaluate herd immunity…. This is certainly something we're looking at further,” he said.

In response to an audience member's question about cost-effectiveness, Dr. Payne said that the 84% decline in hospitalizations seen in these three surveillance sites, if extrapolated to the entire country, would mean 22,000 fewer hospitalizations and 300,000 emergency department visits in a 1-year period.

Dr. Payne stated that he had no financial disclosures or conflicts of interest relevant to this study.

The decline in hospitalizations among children under 3 years of age suggests that herd immunity may be developing. ©CDC/Dr. Erskine Palmer

BALTIMORE — Rotavirus hospitalizations declined by 84% from 2006 to 2008 among children less than 3 years of age, suggesting a dramatic vaccination effect.

That degree of decline was seen even among children aged 2–3 years who were age-ineligible to be vaccinated against rotavirus, suggesting that the vaccine's impact extends beyond direct vaccinees, Daniel C. Payne, Ph.D., said at the annual meeting of the Pediatric Academic Societies.

Dramatic decreases in rotavirus hospitalization rates were observed in 2008, compared with the pre-vaccine licensure year 2006. Rotavirus hospitalization rate decreases were much greater than would be expected based on vaccine coverage,” said Dr. Payne of the Centers for Disease Control and Prevention, Atlanta.

The findings come from the New Vaccine Surveillance Network (NVSN), a systematic, prospective, population-based surveillance for acute gastroenteritis in 3 U.S. counties with a combined catchment of approximately 85,000 children less than 3 years of age. Funded by the CDC, the NVSN allows for direct estimates of the rotavirus disease burden in each participating hospital.

Children less than 3 years of age who resided in specific counties in Tennessee, Ohio, and New York were eligible for enrollment if they had acute gastroenteritis (AGE), defined as three or more episodes of diarrhea and/or any vomiting in a 24-hour period. Surveillance was conducted during January-June of 2006, 2007, and 2008.

Stool samples were collected from 499 of 578 eligible children. The proportion of hospitalized children with AGE who tested positive for rotavirus dropped from 50% in 2006 (91 of 181) to 45% in 2007 (81 of 179) and then down to just 6% (9 of 139) in 2008. “This is a major, major decline in incidence, using the same [testing] methodology for all 3 years,” Dr. Payne commented.

At one site, Rochester, N.Y., there was not a single hospitalization for rotavirus gastroenteritis during 2008 in a catchment area of 28,000 children less than 3 years of age, he noted.

Broken down by age, there was a 66% decline in rotavirus hospitalizations among children less than 1 year of age from 2006 to 2008, during which time vaccine coverage (defined as receipt of at least one of the three doses) increased from less than 1% to 56%. For children aged 1–2 years, there was a 95% decline over the 3 years, concurrent with a rise in vaccine coverage from 0% to 44%.

The most startling finding, however, was an 85% decline in rotavirus hospitalizations among 2- to 3-year-olds, who were age-ineligible to receive the vaccine, with vaccination rates less than 1% in 2008. “It looks like a disproportionate effect,” Dr. Payne commented, adding that “This raises a previously unpredicted question: Are there indirect benefits—herd immunity—from rotavirus vaccine?”

“Clinical trials of the vaccine did not evaluate herd immunity…. This is certainly something we're looking at further,” he said.

In response to an audience member's question about cost-effectiveness, Dr. Payne said that the 84% decline in hospitalizations seen in these three surveillance sites, if extrapolated to the entire country, would mean 22,000 fewer hospitalizations and 300,000 emergency department visits in a 1-year period.

Dr. Payne stated that he had no financial disclosures or conflicts of interest relevant to this study.

The decline in hospitalizations among children under 3 years of age suggests that herd immunity may be developing. ©CDC/Dr. Erskine Palmer

BALTIMORE — Rotavirus hospitalizations declined by 84% from 2006 to 2008 among children less than 3 years of age, suggesting a dramatic vaccination effect.

That degree of decline was seen even among children aged 2–3 years who were age-ineligible to be vaccinated against rotavirus, suggesting that the vaccine's impact extends beyond direct vaccinees, Daniel C. Payne, Ph.D., said at the annual meeting of the Pediatric Academic Societies.

Dramatic decreases in rotavirus hospitalization rates were observed in 2008, compared with the pre-vaccine licensure year 2006. Rotavirus hospitalization rate decreases were much greater than would be expected based on vaccine coverage,” said Dr. Payne of the Centers for Disease Control and Prevention, Atlanta.

The findings come from the New Vaccine Surveillance Network (NVSN), a systematic, prospective, population-based surveillance for acute gastroenteritis in 3 U.S. counties with a combined catchment of approximately 85,000 children less than 3 years of age. Funded by the CDC, the NVSN allows for direct estimates of the rotavirus disease burden in each participating hospital.

Children less than 3 years of age who resided in specific counties in Tennessee, Ohio, and New York were eligible for enrollment if they had acute gastroenteritis (AGE), defined as three or more episodes of diarrhea and/or any vomiting in a 24-hour period. Surveillance was conducted during January-June of 2006, 2007, and 2008.

Stool samples were collected from 499 of 578 eligible children. The proportion of hospitalized children with AGE who tested positive for rotavirus dropped from 50% in 2006 (91 of 181) to 45% in 2007 (81 of 179) and then down to just 6% (9 of 139) in 2008. “This is a major, major decline in incidence, using the same [testing] methodology for all 3 years,” Dr. Payne commented.

At one site, Rochester, N.Y., there was not a single hospitalization for rotavirus gastroenteritis during 2008 in a catchment area of 28,000 children less than 3 years of age, he noted.

Broken down by age, there was a 66% decline in rotavirus hospitalizations among children less than 1 year of age from 2006 to 2008, during which time vaccine coverage (defined as receipt of at least one of the three doses) increased from less than 1% to 56%. For children aged 1–2 years, there was a 95% decline over the 3 years, concurrent with a rise in vaccine coverage from 0% to 44%.

The most startling finding, however, was an 85% decline in rotavirus hospitalizations among 2- to 3-year-olds, who were age-ineligible to receive the vaccine, with vaccination rates less than 1% in 2008. “It looks like a disproportionate effect,” Dr. Payne commented, adding that “This raises a previously unpredicted question: Are there indirect benefits—herd immunity—from rotavirus vaccine?”

“Clinical trials of the vaccine did not evaluate herd immunity…. This is certainly something we're looking at further,” he said.

In response to an audience member's question about cost-effectiveness, Dr. Payne said that the 84% decline in hospitalizations seen in these three surveillance sites, if extrapolated to the entire country, would mean 22,000 fewer hospitalizations and 300,000 emergency department visits in a 1-year period.

Dr. Payne stated that he had no financial disclosures or conflicts of interest relevant to this study.

The decline in hospitalizations among children under 3 years of age suggests that herd immunity may be developing. ©CDC/Dr. Erskine Palmer

BALTIMORE — Antibiotic exposure within the previous 30 days increased the risk for an antimicrobial-resistant first-time urinary tract infection nearly fourfold in a retrospective cohort study of 533 healthy children aged 6 months to 6 years.

The finding suggests that clinicians should obtain a recent history of antimicrobial exposure in patients presenting with a new urinary tract infection (UTI) and select a different class of antibiotic for empiric therapy than the one the patient had previously received, Dr. Amanda A. Paschke said at the annual meeting of the Pediatric Academic Societies.

The children in the study had been diagnosed with their first UTI at one of 27 outpatient pediatric practices between July 1, 2001, and May 31, 2006. Most (92%) were female, two-thirds (60%) were white, and two-thirds (61%) were between the ages of 1 and 4 years. One-fifth (21%) had been exposed to antibiotics within the previous 120 days of the UTI, 14% within 60 days, and 8% within 30 days.

Otitis media was the most common indication for the prior antimicrobial prescriptions (51%), followed by sinusitis (11%), pharyngitis (10%), and dysuria (10%). “Many of the prescriptions were for indications that may not benefit from antibiotic treatment,” noted Dr. Paschke of Children's Hospital of Philadelphia.

The most common resistant organism was Escherichia coli (80%). Nearly half (46%) of the resistant infections were resistant to ampicillin, 17% to trimethoprim-sulfamethoxazole, and 15% to amoxicillin clavulanate, with less than 10% resistant to first- or third-generation cephalosporins.

Exposure to amoxicillin within the previous 0–30 days was associated with a nearly fourfold increased risk for an ampicillin-resistant UTI (adjusted odds ratio, 3.6), as well as for a UTI with resistance to amoxicillin clavulanate (adjusted OR, 3.9). Exposure to amoxicillin within 31–60 days increased the risk for an ampicillin-resistant UTI by 2.8-fold.

The predicted probability of an ampicillin-resistant UTI was 67% within 30 days of exposure to amoxicillin, 62% within 60 days, and 38% beyond 60 days. The predicted probability of amoxicillin clavulanate resistance was 37% within 30 days of exposure and was relatively low (13%–15%) beyond 60 days, Dr. Paschke said.

In addition to avoiding prescribing the same antimicrobial to treat a new infection that a patient recently received for a previous infection, she recommended other strategies to limit antimicrobial resistance: Use a “wait and see” prescription approach for acute otitis media, prescribe the narrowest-spectrum antimicrobials possible, use short-course antimicrobial regimens when appropriate, and avoid antimicrobials altogether for indications such as most upper respiratory infections for which antimicrobials are unlikely to be of benefit, she advised.

Dr. Paschke stated that she had no relevant conflicts of interest.

BALTIMORE — Antibiotic exposure within the previous 30 days increased the risk for an antimicrobial-resistant first-time urinary tract infection nearly fourfold in a retrospective cohort study of 533 healthy children aged 6 months to 6 years.

The finding suggests that clinicians should obtain a recent history of antimicrobial exposure in patients presenting with a new urinary tract infection (UTI) and select a different class of antibiotic for empiric therapy than the one the patient had previously received, Dr. Amanda A. Paschke said at the annual meeting of the Pediatric Academic Societies.

The children in the study had been diagnosed with their first UTI at one of 27 outpatient pediatric practices between July 1, 2001, and May 31, 2006. Most (92%) were female, two-thirds (60%) were white, and two-thirds (61%) were between the ages of 1 and 4 years. One-fifth (21%) had been exposed to antibiotics within the previous 120 days of the UTI, 14% within 60 days, and 8% within 30 days.

Otitis media was the most common indication for the prior antimicrobial prescriptions (51%), followed by sinusitis (11%), pharyngitis (10%), and dysuria (10%). “Many of the prescriptions were for indications that may not benefit from antibiotic treatment,” noted Dr. Paschke of Children's Hospital of Philadelphia.

The most common resistant organism was Escherichia coli (80%). Nearly half (46%) of the resistant infections were resistant to ampicillin, 17% to trimethoprim-sulfamethoxazole, and 15% to amoxicillin clavulanate, with less than 10% resistant to first- or third-generation cephalosporins.

Exposure to amoxicillin within the previous 0–30 days was associated with a nearly fourfold increased risk for an ampicillin-resistant UTI (adjusted odds ratio, 3.6), as well as for a UTI with resistance to amoxicillin clavulanate (adjusted OR, 3.9). Exposure to amoxicillin within 31–60 days increased the risk for an ampicillin-resistant UTI by 2.8-fold.

The predicted probability of an ampicillin-resistant UTI was 67% within 30 days of exposure to amoxicillin, 62% within 60 days, and 38% beyond 60 days. The predicted probability of amoxicillin clavulanate resistance was 37% within 30 days of exposure and was relatively low (13%–15%) beyond 60 days, Dr. Paschke said.

In addition to avoiding prescribing the same antimicrobial to treat a new infection that a patient recently received for a previous infection, she recommended other strategies to limit antimicrobial resistance: Use a “wait and see” prescription approach for acute otitis media, prescribe the narrowest-spectrum antimicrobials possible, use short-course antimicrobial regimens when appropriate, and avoid antimicrobials altogether for indications such as most upper respiratory infections for which antimicrobials are unlikely to be of benefit, she advised.

Dr. Paschke stated that she had no relevant conflicts of interest.

BALTIMORE — Antibiotic exposure within the previous 30 days increased the risk for an antimicrobial-resistant first-time urinary tract infection nearly fourfold in a retrospective cohort study of 533 healthy children aged 6 months to 6 years.

The finding suggests that clinicians should obtain a recent history of antimicrobial exposure in patients presenting with a new urinary tract infection (UTI) and select a different class of antibiotic for empiric therapy than the one the patient had previously received, Dr. Amanda A. Paschke said at the annual meeting of the Pediatric Academic Societies.

The children in the study had been diagnosed with their first UTI at one of 27 outpatient pediatric practices between July 1, 2001, and May 31, 2006. Most (92%) were female, two-thirds (60%) were white, and two-thirds (61%) were between the ages of 1 and 4 years. One-fifth (21%) had been exposed to antibiotics within the previous 120 days of the UTI, 14% within 60 days, and 8% within 30 days.

Otitis media was the most common indication for the prior antimicrobial prescriptions (51%), followed by sinusitis (11%), pharyngitis (10%), and dysuria (10%). “Many of the prescriptions were for indications that may not benefit from antibiotic treatment,” noted Dr. Paschke of Children's Hospital of Philadelphia.

The most common resistant organism was Escherichia coli (80%). Nearly half (46%) of the resistant infections were resistant to ampicillin, 17% to trimethoprim-sulfamethoxazole, and 15% to amoxicillin clavulanate, with less than 10% resistant to first- or third-generation cephalosporins.

Exposure to amoxicillin within the previous 0–30 days was associated with a nearly fourfold increased risk for an ampicillin-resistant UTI (adjusted odds ratio, 3.6), as well as for a UTI with resistance to amoxicillin clavulanate (adjusted OR, 3.9). Exposure to amoxicillin within 31–60 days increased the risk for an ampicillin-resistant UTI by 2.8-fold.

The predicted probability of an ampicillin-resistant UTI was 67% within 30 days of exposure to amoxicillin, 62% within 60 days, and 38% beyond 60 days. The predicted probability of amoxicillin clavulanate resistance was 37% within 30 days of exposure and was relatively low (13%–15%) beyond 60 days, Dr. Paschke said.

In addition to avoiding prescribing the same antimicrobial to treat a new infection that a patient recently received for a previous infection, she recommended other strategies to limit antimicrobial resistance: Use a “wait and see” prescription approach for acute otitis media, prescribe the narrowest-spectrum antimicrobials possible, use short-course antimicrobial regimens when appropriate, and avoid antimicrobials altogether for indications such as most upper respiratory infections for which antimicrobials are unlikely to be of benefit, she advised.

Dr. Paschke stated that she had no relevant conflicts of interest.

NATIONAL HARBOR, MD. — Hypertrophic scarring of the neck has been seen in five patients who underwent ablative fractional carbon dioxide laser resurfacing.

The patients, who had received the laser treatment at four different practices around the country over a 4-month period, are believed to be the first reported cases of clinically and histopathologically confirmed hypertrophic scarring following fractional CO2 laser resurfacing, although the complication has been frequently documented with traditional ablative CO2 resurfacing, often in the setting of postoperative infection.

"Our goal here is to let people know this is happening," Dr. Mathew M. Avram said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings suggest caution should be observed when treating the neck with any ablative fractional laser, Dr. Avram, of the Harvard Medical School and Massachusetts General Hospital, Boston, and his associates wrote in their report on these five patients (Lasers Surg. Med. 2009;41:185–8).

One of the five cases, a 57-year-old white woman with Fitzpatrick phototype II skin, underwent ablative fractional resurfacing (AFR) under general anesthesia, with Fraxel re:pair (Reliant Technologies Inc.) for treatment of facial acne scars and neck photodamage (rhytids and laxity). Her neck was treated using a pulse energy of 30 mJ (859 mcm depth), with treatment of 25% of exposed skin.

On postoperative day 7, three horizontal "necklacelike" lines of delayed wound healing were noted on her anterior neck. These became tender on postoperative day 11, with small papules and diffuse erythema. On postoperative day 15, the area was treated with a nonablative fractional Er:glass (1,550-nm) resurfacing laser (Fraxel re:store) in order to modify healing and flatten the thickened areas, using a 10-mJ pulse energy (555 mcm depth) applied for 14% skin coverage.

On day 20, she developed a pruritic eruption on the anterior neck consisting of macular erythema, desquamating scale, and mild induration in the horizontal arrays. She was given a diagnosis of resolved cutaneous candidiasis and treated with 0.1% triamcinolone ointment for residual inflammation. A diagnosis of resolved cutaneous candidiasis infection with residual inflammation was considered, and she was given 0.1% triamcinolone ointment twice daily for a week.

The eruption resolved 6 days later, but the area still was remarkable for multiple well-defined firm pale papules in linear arrays along skin folds of the anterior neck, with mild hypopigmentation. On examination, she had multiple, well-defined, firm patchy papules in linear arrays along skin folds of the anterior neck. A clinical diagnosis of prior candidal infection was made. Triamcinolone was stopped, and she was given clobetasol cream, applied twice daily to the papules.

A punch biopsy was obtained, and histopathologic examination showed a hypertrophic scar characterized by epidermal atrophy, follicular plugging, fibroplasia, and angioplasia with dense collagen bundles replacing the dermis and extending into the platysma muscle.

Three weeks later, the papules had completely resolved and the clobetasol cream was discontinued. Mild hypopigmentation persisted at 3 months.

The second case was a 61-year-old white woman with Fitzpatrick phototype type I skin, who was treated for acne scars on the cheeks and photodamage on the face and neck.

She had previously undergone a facelift, traditional full-face ablative CO2 resurfacing, and minimal access cranial suspension face and neck lifts. She had successfully undergone multiple treatments with an nonablative fractional Er:glass (1,550-nm) laser (Fraxel re:store) on the face, chest, and neck over 2 years with no adverse effects.

In October 2008, her face and neck were treated with CO2 AFR, with the neck treated at a pulse energy of 20 mJ (630 mcm depth), with 30% coverage of exposed skin and total treatment energy of 5.0 kJ.

Wound healing on her face was normal, but she noted "tightness" on her neck at about 2 weeks, and at 3 weeks noted firm horizontal and vertical linear bands over the treated area diagnosed as hypertrophic scars. Treatment with intralesional Kenalog injections and pulsed dye laser produced improvement but not resolution, Dr. Avram said.

While not as effective as traditional ablative resurfacing, AFR is thought to be a safer procedure because of its unique thermal damage pattern, which spares most of the treated area and significantly reduces postprocedure erythema, edema, wound care, downtime, hyper- and hypopigmentation, infection, and scarring.

However, these two cases, and three others that could not be presented because of potential litigation, highlight the fact that neck skin is more vulnerable to thermal injury than the face. This may be because the neck contains fewer pilosebaceous units, resulting in less efficient wound re-epithelialization with more limited cutaneous vasculature providing less support for wound healing, Dr. Avram said.

Use of either Er:YAG or CO2 ablative fractional laser on the neck should be performed with the least pulse energy, pulse density, and treatment fraction necessary to avoid complications and yet produce satisfactory improvement.

The presented cases provide a suggestion as to what parameters have proven excessive. Moreover, the pattern of linear scarring also suggests the possibility of excessive thermal injury via excessive overlap of energy application, he said.

As with traditional ablative resurfacing, patients undergoing fractional resurfacing need to be monitored carefully for infections. In addition, a history of plastic surgical procedures should be elicited prior to undergoing these procedures, since these may result in neck skin being placed above the jaw line.

Dr. Avram has received honoraria from Reliant Technologies.

Caution should be taken when treating the neck with any ablative procedure, as scarring (shown above)can occur. Courtesy Dr. Mathew M. Avram

NATIONAL HARBOR, MD. — Hypertrophic scarring of the neck has been seen in five patients who underwent ablative fractional carbon dioxide laser resurfacing.

The patients, who had received the laser treatment at four different practices around the country over a 4-month period, are believed to be the first reported cases of clinically and histopathologically confirmed hypertrophic scarring following fractional CO2 laser resurfacing, although the complication has been frequently documented with traditional ablative CO2 resurfacing, often in the setting of postoperative infection.

"Our goal here is to let people know this is happening," Dr. Mathew M. Avram said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings suggest caution should be observed when treating the neck with any ablative fractional laser, Dr. Avram, of the Harvard Medical School and Massachusetts General Hospital, Boston, and his associates wrote in their report on these five patients (Lasers Surg. Med. 2009;41:185–8).

One of the five cases, a 57-year-old white woman with Fitzpatrick phototype II skin, underwent ablative fractional resurfacing (AFR) under general anesthesia, with Fraxel re:pair (Reliant Technologies Inc.) for treatment of facial acne scars and neck photodamage (rhytids and laxity). Her neck was treated using a pulse energy of 30 mJ (859 mcm depth), with treatment of 25% of exposed skin.

On postoperative day 7, three horizontal "necklacelike" lines of delayed wound healing were noted on her anterior neck. These became tender on postoperative day 11, with small papules and diffuse erythema. On postoperative day 15, the area was treated with a nonablative fractional Er:glass (1,550-nm) resurfacing laser (Fraxel re:store) in order to modify healing and flatten the thickened areas, using a 10-mJ pulse energy (555 mcm depth) applied for 14% skin coverage.

On day 20, she developed a pruritic eruption on the anterior neck consisting of macular erythema, desquamating scale, and mild induration in the horizontal arrays. She was given a diagnosis of resolved cutaneous candidiasis and treated with 0.1% triamcinolone ointment for residual inflammation. A diagnosis of resolved cutaneous candidiasis infection with residual inflammation was considered, and she was given 0.1% triamcinolone ointment twice daily for a week.

The eruption resolved 6 days later, but the area still was remarkable for multiple well-defined firm pale papules in linear arrays along skin folds of the anterior neck, with mild hypopigmentation. On examination, she had multiple, well-defined, firm patchy papules in linear arrays along skin folds of the anterior neck. A clinical diagnosis of prior candidal infection was made. Triamcinolone was stopped, and she was given clobetasol cream, applied twice daily to the papules.

A punch biopsy was obtained, and histopathologic examination showed a hypertrophic scar characterized by epidermal atrophy, follicular plugging, fibroplasia, and angioplasia with dense collagen bundles replacing the dermis and extending into the platysma muscle.

Three weeks later, the papules had completely resolved and the clobetasol cream was discontinued. Mild hypopigmentation persisted at 3 months.

The second case was a 61-year-old white woman with Fitzpatrick phototype type I skin, who was treated for acne scars on the cheeks and photodamage on the face and neck.

She had previously undergone a facelift, traditional full-face ablative CO2 resurfacing, and minimal access cranial suspension face and neck lifts. She had successfully undergone multiple treatments with an nonablative fractional Er:glass (1,550-nm) laser (Fraxel re:store) on the face, chest, and neck over 2 years with no adverse effects.

In October 2008, her face and neck were treated with CO2 AFR, with the neck treated at a pulse energy of 20 mJ (630 mcm depth), with 30% coverage of exposed skin and total treatment energy of 5.0 kJ.

Wound healing on her face was normal, but she noted "tightness" on her neck at about 2 weeks, and at 3 weeks noted firm horizontal and vertical linear bands over the treated area diagnosed as hypertrophic scars. Treatment with intralesional Kenalog injections and pulsed dye laser produced improvement but not resolution, Dr. Avram said.

While not as effective as traditional ablative resurfacing, AFR is thought to be a safer procedure because of its unique thermal damage pattern, which spares most of the treated area and significantly reduces postprocedure erythema, edema, wound care, downtime, hyper- and hypopigmentation, infection, and scarring.

However, these two cases, and three others that could not be presented because of potential litigation, highlight the fact that neck skin is more vulnerable to thermal injury than the face. This may be because the neck contains fewer pilosebaceous units, resulting in less efficient wound re-epithelialization with more limited cutaneous vasculature providing less support for wound healing, Dr. Avram said.

Use of either Er:YAG or CO2 ablative fractional laser on the neck should be performed with the least pulse energy, pulse density, and treatment fraction necessary to avoid complications and yet produce satisfactory improvement.

The presented cases provide a suggestion as to what parameters have proven excessive. Moreover, the pattern of linear scarring also suggests the possibility of excessive thermal injury via excessive overlap of energy application, he said.

As with traditional ablative resurfacing, patients undergoing fractional resurfacing need to be monitored carefully for infections. In addition, a history of plastic surgical procedures should be elicited prior to undergoing these procedures, since these may result in neck skin being placed above the jaw line.

Dr. Avram has received honoraria from Reliant Technologies.

Caution should be taken when treating the neck with any ablative procedure, as scarring (shown above)can occur. Courtesy Dr. Mathew M. Avram

NATIONAL HARBOR, MD. — Hypertrophic scarring of the neck has been seen in five patients who underwent ablative fractional carbon dioxide laser resurfacing.

The patients, who had received the laser treatment at four different practices around the country over a 4-month period, are believed to be the first reported cases of clinically and histopathologically confirmed hypertrophic scarring following fractional CO2 laser resurfacing, although the complication has been frequently documented with traditional ablative CO2 resurfacing, often in the setting of postoperative infection.

"Our goal here is to let people know this is happening," Dr. Mathew M. Avram said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings suggest caution should be observed when treating the neck with any ablative fractional laser, Dr. Avram, of the Harvard Medical School and Massachusetts General Hospital, Boston, and his associates wrote in their report on these five patients (Lasers Surg. Med. 2009;41:185–8).

One of the five cases, a 57-year-old white woman with Fitzpatrick phototype II skin, underwent ablative fractional resurfacing (AFR) under general anesthesia, with Fraxel re:pair (Reliant Technologies Inc.) for treatment of facial acne scars and neck photodamage (rhytids and laxity). Her neck was treated using a pulse energy of 30 mJ (859 mcm depth), with treatment of 25% of exposed skin.

On postoperative day 7, three horizontal "necklacelike" lines of delayed wound healing were noted on her anterior neck. These became tender on postoperative day 11, with small papules and diffuse erythema. On postoperative day 15, the area was treated with a nonablative fractional Er:glass (1,550-nm) resurfacing laser (Fraxel re:store) in order to modify healing and flatten the thickened areas, using a 10-mJ pulse energy (555 mcm depth) applied for 14% skin coverage.

On day 20, she developed a pruritic eruption on the anterior neck consisting of macular erythema, desquamating scale, and mild induration in the horizontal arrays. She was given a diagnosis of resolved cutaneous candidiasis and treated with 0.1% triamcinolone ointment for residual inflammation. A diagnosis of resolved cutaneous candidiasis infection with residual inflammation was considered, and she was given 0.1% triamcinolone ointment twice daily for a week.

The eruption resolved 6 days later, but the area still was remarkable for multiple well-defined firm pale papules in linear arrays along skin folds of the anterior neck, with mild hypopigmentation. On examination, she had multiple, well-defined, firm patchy papules in linear arrays along skin folds of the anterior neck. A clinical diagnosis of prior candidal infection was made. Triamcinolone was stopped, and she was given clobetasol cream, applied twice daily to the papules.

A punch biopsy was obtained, and histopathologic examination showed a hypertrophic scar characterized by epidermal atrophy, follicular plugging, fibroplasia, and angioplasia with dense collagen bundles replacing the dermis and extending into the platysma muscle.

Three weeks later, the papules had completely resolved and the clobetasol cream was discontinued. Mild hypopigmentation persisted at 3 months.

The second case was a 61-year-old white woman with Fitzpatrick phototype type I skin, who was treated for acne scars on the cheeks and photodamage on the face and neck.

She had previously undergone a facelift, traditional full-face ablative CO2 resurfacing, and minimal access cranial suspension face and neck lifts. She had successfully undergone multiple treatments with an nonablative fractional Er:glass (1,550-nm) laser (Fraxel re:store) on the face, chest, and neck over 2 years with no adverse effects.

In October 2008, her face and neck were treated with CO2 AFR, with the neck treated at a pulse energy of 20 mJ (630 mcm depth), with 30% coverage of exposed skin and total treatment energy of 5.0 kJ.

Wound healing on her face was normal, but she noted "tightness" on her neck at about 2 weeks, and at 3 weeks noted firm horizontal and vertical linear bands over the treated area diagnosed as hypertrophic scars. Treatment with intralesional Kenalog injections and pulsed dye laser produced improvement but not resolution, Dr. Avram said.

While not as effective as traditional ablative resurfacing, AFR is thought to be a safer procedure because of its unique thermal damage pattern, which spares most of the treated area and significantly reduces postprocedure erythema, edema, wound care, downtime, hyper- and hypopigmentation, infection, and scarring.

However, these two cases, and three others that could not be presented because of potential litigation, highlight the fact that neck skin is more vulnerable to thermal injury than the face. This may be because the neck contains fewer pilosebaceous units, resulting in less efficient wound re-epithelialization with more limited cutaneous vasculature providing less support for wound healing, Dr. Avram said.

Use of either Er:YAG or CO2 ablative fractional laser on the neck should be performed with the least pulse energy, pulse density, and treatment fraction necessary to avoid complications and yet produce satisfactory improvement.

The presented cases provide a suggestion as to what parameters have proven excessive. Moreover, the pattern of linear scarring also suggests the possibility of excessive thermal injury via excessive overlap of energy application, he said.

As with traditional ablative resurfacing, patients undergoing fractional resurfacing need to be monitored carefully for infections. In addition, a history of plastic surgical procedures should be elicited prior to undergoing these procedures, since these may result in neck skin being placed above the jaw line.

Dr. Avram has received honoraria from Reliant Technologies.

Caution should be taken when treating the neck with any ablative procedure, as scarring (shown above)can occur. Courtesy Dr. Mathew M. Avram

NATIONAL HARBOR, MD. — Topical application of imiquimod for 8 weeks following pulsed dye laser photothermolysis improved the efficacy of port wine stain treatment among 13 patients in a placebo-controlled study.

Pulsed dye laser (PDL) is the preferred method for treating port wine stains (PWS), but it is limited because multiple treatments are required, and there is often incomplete resolution secondary to posttreatment vessel recurrence.

Imiquimod, a topical immune response modifier, has antiangiogenic properties that could potentially enhance the maintenance of microvascular destruction and, thus, improve the vascular lesion treatment effect in PWS patients when applied during the subsequent wound-healing phase, Dr. Anne Marie Tremaine said at the annual meeting of the American Society for Laser Medicine and Surgery.

Imiquimod (Aldara), manufactured by Graceway Pharmaceuticals LLC, is approved by the Food and Drug Administration for the treatment of genital warts and actinic keratosis. The company provided a research grant for the current PWS study, said Dr. Tremaine of the University of California, Irvine.

The 11 adults and 2 children in the study were randomized to receive either PDL plus 5% imiquimod or PDL plus placebo (vehicle cream). The patients received one PDL treatment and were then instructed to apply 250 mg of cream to an area of less than 25 cm

The treatment was well tolerated by all patients, although two required rest periods at 2 weeks post PDL because of mild crusting before they returned to imiquimod treatment. No serious adverse events were reported.

Laser speckle imaging was used to assess vascular flow. Chromameter measurements were used to quantify changes in skin color, based on the Commission Internationale d'Eclairage (CIE) L*a*b color pace with L* representing reflected light intensity; a*, the color saturation green to red scale; and b*, the color saturation blue to yellow scale.

Average a* values measured at baseline were compared with those at 8 weeks post treatment. The change in a* for PDL plus imiquimod was 0.8, compared with 0.1 for PDL plus placebo. The change in "E," the difference in color between normal and PWS skin calculated to achieve a more standardized form of measurement in seven of the subjects, was 9.1 for PDL plus imiquimod, compared with 1.4 for PDL plus placebo, Dr. Tremaine reported at the meeting.

"The addition of posttreatment imiquimod to PDL therapy may offer the next enhancement in the treatment of port wine stains," she concluded.

NATIONAL HARBOR, MD. — Topical application of imiquimod for 8 weeks following pulsed dye laser photothermolysis improved the efficacy of port wine stain treatment among 13 patients in a placebo-controlled study.

Pulsed dye laser (PDL) is the preferred method for treating port wine stains (PWS), but it is limited because multiple treatments are required, and there is often incomplete resolution secondary to posttreatment vessel recurrence.

Imiquimod, a topical immune response modifier, has antiangiogenic properties that could potentially enhance the maintenance of microvascular destruction and, thus, improve the vascular lesion treatment effect in PWS patients when applied during the subsequent wound-healing phase, Dr. Anne Marie Tremaine said at the annual meeting of the American Society for Laser Medicine and Surgery.

Imiquimod (Aldara), manufactured by Graceway Pharmaceuticals LLC, is approved by the Food and Drug Administration for the treatment of genital warts and actinic keratosis. The company provided a research grant for the current PWS study, said Dr. Tremaine of the University of California, Irvine.

The 11 adults and 2 children in the study were randomized to receive either PDL plus 5% imiquimod or PDL plus placebo (vehicle cream). The patients received one PDL treatment and were then instructed to apply 250 mg of cream to an area of less than 25 cm

The treatment was well tolerated by all patients, although two required rest periods at 2 weeks post PDL because of mild crusting before they returned to imiquimod treatment. No serious adverse events were reported.

Laser speckle imaging was used to assess vascular flow. Chromameter measurements were used to quantify changes in skin color, based on the Commission Internationale d'Eclairage (CIE) L*a*b color pace with L* representing reflected light intensity; a*, the color saturation green to red scale; and b*, the color saturation blue to yellow scale.

Average a* values measured at baseline were compared with those at 8 weeks post treatment. The change in a* for PDL plus imiquimod was 0.8, compared with 0.1 for PDL plus placebo. The change in "E," the difference in color between normal and PWS skin calculated to achieve a more standardized form of measurement in seven of the subjects, was 9.1 for PDL plus imiquimod, compared with 1.4 for PDL plus placebo, Dr. Tremaine reported at the meeting.

"The addition of posttreatment imiquimod to PDL therapy may offer the next enhancement in the treatment of port wine stains," she concluded.

NATIONAL HARBOR, MD. — Topical application of imiquimod for 8 weeks following pulsed dye laser photothermolysis improved the efficacy of port wine stain treatment among 13 patients in a placebo-controlled study.

Pulsed dye laser (PDL) is the preferred method for treating port wine stains (PWS), but it is limited because multiple treatments are required, and there is often incomplete resolution secondary to posttreatment vessel recurrence.

Imiquimod, a topical immune response modifier, has antiangiogenic properties that could potentially enhance the maintenance of microvascular destruction and, thus, improve the vascular lesion treatment effect in PWS patients when applied during the subsequent wound-healing phase, Dr. Anne Marie Tremaine said at the annual meeting of the American Society for Laser Medicine and Surgery.

Imiquimod (Aldara), manufactured by Graceway Pharmaceuticals LLC, is approved by the Food and Drug Administration for the treatment of genital warts and actinic keratosis. The company provided a research grant for the current PWS study, said Dr. Tremaine of the University of California, Irvine.

The 11 adults and 2 children in the study were randomized to receive either PDL plus 5% imiquimod or PDL plus placebo (vehicle cream). The patients received one PDL treatment and were then instructed to apply 250 mg of cream to an area of less than 25 cm

The treatment was well tolerated by all patients, although two required rest periods at 2 weeks post PDL because of mild crusting before they returned to imiquimod treatment. No serious adverse events were reported.

Laser speckle imaging was used to assess vascular flow. Chromameter measurements were used to quantify changes in skin color, based on the Commission Internationale d'Eclairage (CIE) L*a*b color pace with L* representing reflected light intensity; a*, the color saturation green to red scale; and b*, the color saturation blue to yellow scale.

Average a* values measured at baseline were compared with those at 8 weeks post treatment. The change in a* for PDL plus imiquimod was 0.8, compared with 0.1 for PDL plus placebo. The change in "E," the difference in color between normal and PWS skin calculated to achieve a more standardized form of measurement in seven of the subjects, was 9.1 for PDL plus imiquimod, compared with 1.4 for PDL plus placebo, Dr. Tremaine reported at the meeting.

"The addition of posttreatment imiquimod to PDL therapy may offer the next enhancement in the treatment of port wine stains," she concluded.

NATIONAL HARBOR, MD. — Improvement in melasma severity achieved by fractional photothermolysis lasted for a mean 13 months in five of eight patients, while the other three had recurrences in the first-ever study to follow these patients beyond 6 months.

"For refractory melasma, nonablative fractional photothermolysis is a good treatment option with long-term remission," Dr. Tracy M. Katz said at the annual meeting of the American Society for Laser Medicine and Surgery.

The device used in the study was a 1,550-nm erbium-doped Fraxel laser. Treatments were performed at 6–40 mJ (starting low in all patients and increasing in some), with eight passes per treatment at levels of 4–10; this corresponded to surface area coverage of 14%-29%. The laser settings were chosen based on the patients' skin type, with a maximum level of 7 for darker skin and up to 10 for lighter skin, said Dr. Katz of DermSurgery Associates, Houston.

A forced-air cooling device was set at low settings of 2–3 to decrease inflammation and reduce the risk of postinflammatory hyperpigmentation.

The eight women had a mean age of 44 years (range 27–57), with skin types II-IV, and they had melasma on the face that was refractory to hydroquinone and other traditional treatments. The mean duration of disease was 6 years. Each patient underwent two to seven treatments, at intervals of 4–6 weeks for lighter skin and 6–8 weeks for darker skin. Topical triple anesthetic was applied 1 hour prior to treatment.

Patients were instructed to use hydroquinone until 2–3 days prior to each treatment and then to restart it after their skin had healed and continue it for 2–6 months after the last laser treatment. They were seen for follow-up anywhere from 7 to 36 months after their last laser treatment, with a mean follow-up of 13 months.

Assessments were determined via side-by-side photo analysis by the treating physician (Dr. Paul Friedman) and a nontreating physician (Dr. Katz), based on a well-established quartile grading system of 1%-25%, 26%-50%, 51%-75%, and greater than 75%. At the last treatment session, two patients achieved more than 75% improvement, four had 51%-75% improvement, one had 26%-50%, and one had 1%-25% improvement.

During 7–36 months' follow-up, five patients had maintained their initial level of improvement and three had recurrence of their melasma. Two of those three patients had the lowest initial improvement (1%-25% and 26%-50%), Dr. Katz reported. Energy settings correlate with an increased depth of thermal injury, and pigment in dermal melasma is usually found up to the papillary/reticular dermal junction around 500 micrometers, with pigment being rare beyond 700 micrometers. Knowing this, energies up to 30 mJ should target most pigment, she noted.

Dr. Katz stated that there were no financial disclosures associated with her presentation.

NATIONAL HARBOR, MD. — Improvement in melasma severity achieved by fractional photothermolysis lasted for a mean 13 months in five of eight patients, while the other three had recurrences in the first-ever study to follow these patients beyond 6 months.

"For refractory melasma, nonablative fractional photothermolysis is a good treatment option with long-term remission," Dr. Tracy M. Katz said at the annual meeting of the American Society for Laser Medicine and Surgery.

The device used in the study was a 1,550-nm erbium-doped Fraxel laser. Treatments were performed at 6–40 mJ (starting low in all patients and increasing in some), with eight passes per treatment at levels of 4–10; this corresponded to surface area coverage of 14%-29%. The laser settings were chosen based on the patients' skin type, with a maximum level of 7 for darker skin and up to 10 for lighter skin, said Dr. Katz of DermSurgery Associates, Houston.

A forced-air cooling device was set at low settings of 2–3 to decrease inflammation and reduce the risk of postinflammatory hyperpigmentation.

The eight women had a mean age of 44 years (range 27–57), with skin types II-IV, and they had melasma on the face that was refractory to hydroquinone and other traditional treatments. The mean duration of disease was 6 years. Each patient underwent two to seven treatments, at intervals of 4–6 weeks for lighter skin and 6–8 weeks for darker skin. Topical triple anesthetic was applied 1 hour prior to treatment.

Patients were instructed to use hydroquinone until 2–3 days prior to each treatment and then to restart it after their skin had healed and continue it for 2–6 months after the last laser treatment. They were seen for follow-up anywhere from 7 to 36 months after their last laser treatment, with a mean follow-up of 13 months.

Assessments were determined via side-by-side photo analysis by the treating physician (Dr. Paul Friedman) and a nontreating physician (Dr. Katz), based on a well-established quartile grading system of 1%-25%, 26%-50%, 51%-75%, and greater than 75%. At the last treatment session, two patients achieved more than 75% improvement, four had 51%-75% improvement, one had 26%-50%, and one had 1%-25% improvement.

During 7–36 months' follow-up, five patients had maintained their initial level of improvement and three had recurrence of their melasma. Two of those three patients had the lowest initial improvement (1%-25% and 26%-50%), Dr. Katz reported. Energy settings correlate with an increased depth of thermal injury, and pigment in dermal melasma is usually found up to the papillary/reticular dermal junction around 500 micrometers, with pigment being rare beyond 700 micrometers. Knowing this, energies up to 30 mJ should target most pigment, she noted.

Dr. Katz stated that there were no financial disclosures associated with her presentation.

NATIONAL HARBOR, MD. — Improvement in melasma severity achieved by fractional photothermolysis lasted for a mean 13 months in five of eight patients, while the other three had recurrences in the first-ever study to follow these patients beyond 6 months.

"For refractory melasma, nonablative fractional photothermolysis is a good treatment option with long-term remission," Dr. Tracy M. Katz said at the annual meeting of the American Society for Laser Medicine and Surgery.

The device used in the study was a 1,550-nm erbium-doped Fraxel laser. Treatments were performed at 6–40 mJ (starting low in all patients and increasing in some), with eight passes per treatment at levels of 4–10; this corresponded to surface area coverage of 14%-29%. The laser settings were chosen based on the patients' skin type, with a maximum level of 7 for darker skin and up to 10 for lighter skin, said Dr. Katz of DermSurgery Associates, Houston.

A forced-air cooling device was set at low settings of 2–3 to decrease inflammation and reduce the risk of postinflammatory hyperpigmentation.

The eight women had a mean age of 44 years (range 27–57), with skin types II-IV, and they had melasma on the face that was refractory to hydroquinone and other traditional treatments. The mean duration of disease was 6 years. Each patient underwent two to seven treatments, at intervals of 4–6 weeks for lighter skin and 6–8 weeks for darker skin. Topical triple anesthetic was applied 1 hour prior to treatment.

Patients were instructed to use hydroquinone until 2–3 days prior to each treatment and then to restart it after their skin had healed and continue it for 2–6 months after the last laser treatment. They were seen for follow-up anywhere from 7 to 36 months after their last laser treatment, with a mean follow-up of 13 months.

Assessments were determined via side-by-side photo analysis by the treating physician (Dr. Paul Friedman) and a nontreating physician (Dr. Katz), based on a well-established quartile grading system of 1%-25%, 26%-50%, 51%-75%, and greater than 75%. At the last treatment session, two patients achieved more than 75% improvement, four had 51%-75% improvement, one had 26%-50%, and one had 1%-25% improvement.

During 7–36 months' follow-up, five patients had maintained their initial level of improvement and three had recurrence of their melasma. Two of those three patients had the lowest initial improvement (1%-25% and 26%-50%), Dr. Katz reported. Energy settings correlate with an increased depth of thermal injury, and pigment in dermal melasma is usually found up to the papillary/reticular dermal junction around 500 micrometers, with pigment being rare beyond 700 micrometers. Knowing this, energies up to 30 mJ should target most pigment, she noted.

Dr. Katz stated that there were no financial disclosures associated with her presentation.

NATIONAL HARBOR, MD. — Nonablative fractional laser resurfacing produced significant improvement in scar severity in a study of 10 patients with second- and third-degree burn scars.

A total of five treatments delivered at 4-week intervals using a 1,550-nm nonablative erbium-doped fiber laser (Fraxel re:store) resulted in objectively-assessed reductions in overall scar severity, as well as improvement in topographical and textural abnormalities, Dr. Jill Waibel reported at the annual meeting of the American Society of Laser Medicine and Surgery.

"Burn scars are a challenge because they have traditionally been difficult to treat, and they are among the worst scars seen in clinical medicine. There is compelling evidence to suggest that nonablative fractional resurfacing improves the appearance and functionality of scarred tissue following burns. I think fractional lasers are the gold standard for scars," said Dr. Waibel, who is in private practice in West Palm Beach, Fla.

Burn scars are extremely heterogeneous, often comprising areas of hypertrophy, atrophy, and hyperpigmentation. Fractional photothermolysis, which provides a greater depth of penetration than traditional CO2 laser resurfacing, appears to benefit the variety of scar types that arise from burn injury, she said.

The eight men and two women in the study ranged in age from 23 to 68 years. Nine had third-degree burns and one had second-degree burns. Treatment areas included the face, neck, chest, arms, hands, abdomen, calf, and leg. Patients were treated with energy levels ranging from 40–70 mJ/pulse, treatment level range 6–13, density 29–65 MTZ/cm

Three blinded investigators evaluated changes in overall improvement, dyschromia, degree of atrophy or hypertrophy improvement, and texture improvement graded on a quartile scale of 0–3, with 0 being none, 1 mild (1%-33%), 2 moderate (34%-66%), and 3 excellent (67%-100%). The patients also scored their own levels of self-esteem, and both the patients and the investigators independently evaluated changes in erythema, edema, hyper- and hypopigmentation, and burn scars overall at 1, 3, and 6 months after the final treatment. Photos were also taken at baseline and at 3 months post treatment.

Based on a protocol recommended by the Food and Drug Administration, the evaluators were given random before and after patient photographs. In one patient, none of the three blinded investigators identified the before and after photos correctly. All three investigators correctly identified the other 9 patient photos, so those 27 evaluations were used for the data analysis.

Overall improvement was noted in all 27 (100%), with 37% scored as excellent, 41% as moderate, and 22% as mild. Improved dyschromia was noted in 96% of the blinded evaluations, with 60% having at least moderately improved. Improvements in atrophy/hypertrophy were also noted in 96%, with 63% having at least moderately improved. Improved skin texture was seen in 100%, with 63% having at least moderately improved texture, Dr. Waibel reported.

The average of the patients' self-assessments of self-esteem at 3 months was 8.2 on a scale of 1–10 with 10 being "I feel great about myself." On a 0–3 scale of improvement in burn scar area with 0 being "no improvement" and 3 being "excellent improvement," the average of the patients' self-assessment at 3 months was 2.3. Anecdotally, patients also spoke of diminished pain, improved motion with a decrease in contractures, and better cosmesis, Dr. Waibel added.

The findings from this study will be submitted to the FDA to support a new indication for burn scars. (Fraxel re:store is currently approved for skin resurfacing.) Additional studies will be necessary to determine the optimal parameters for burn patients, Dr. Waibel said in an interview.

The next phase of studies that Dr. Waibel and her associates are studying include the use of nonablative fractional resurfacing in combination with intralesional triamcinolone (Kenalog), and also the use of ablative fractional resurfacing devices.

Dr. Waibel and her associates received a research grant from Reliant Technologies Inc. (now Solta Medical, Fraxel manufacturer) to conduct this study, and have received honoraria from the company for lectures.

The patient's hand is shown before undergoing treatment with the Fraxel re:store laser.

Three months and five laser treatments later, overall severity of the burn scar is reduced. Photos courtesy Dr. Waibel

NATIONAL HARBOR, MD. — Nonablative fractional laser resurfacing produced significant improvement in scar severity in a study of 10 patients with second- and third-degree burn scars.

A total of five treatments delivered at 4-week intervals using a 1,550-nm nonablative erbium-doped fiber laser (Fraxel re:store) resulted in objectively-assessed reductions in overall scar severity, as well as improvement in topographical and textural abnormalities, Dr. Jill Waibel reported at the annual meeting of the American Society of Laser Medicine and Surgery.

"Burn scars are a challenge because they have traditionally been difficult to treat, and they are among the worst scars seen in clinical medicine. There is compelling evidence to suggest that nonablative fractional resurfacing improves the appearance and functionality of scarred tissue following burns. I think fractional lasers are the gold standard for scars," said Dr. Waibel, who is in private practice in West Palm Beach, Fla.

Burn scars are extremely heterogeneous, often comprising areas of hypertrophy, atrophy, and hyperpigmentation. Fractional photothermolysis, which provides a greater depth of penetration than traditional CO2 laser resurfacing, appears to benefit the variety of scar types that arise from burn injury, she said.

The eight men and two women in the study ranged in age from 23 to 68 years. Nine had third-degree burns and one had second-degree burns. Treatment areas included the face, neck, chest, arms, hands, abdomen, calf, and leg. Patients were treated with energy levels ranging from 40–70 mJ/pulse, treatment level range 6–13, density 29–65 MTZ/cm

Three blinded investigators evaluated changes in overall improvement, dyschromia, degree of atrophy or hypertrophy improvement, and texture improvement graded on a quartile scale of 0–3, with 0 being none, 1 mild (1%-33%), 2 moderate (34%-66%), and 3 excellent (67%-100%). The patients also scored their own levels of self-esteem, and both the patients and the investigators independently evaluated changes in erythema, edema, hyper- and hypopigmentation, and burn scars overall at 1, 3, and 6 months after the final treatment. Photos were also taken at baseline and at 3 months post treatment.

Based on a protocol recommended by the Food and Drug Administration, the evaluators were given random before and after patient photographs. In one patient, none of the three blinded investigators identified the before and after photos correctly. All three investigators correctly identified the other 9 patient photos, so those 27 evaluations were used for the data analysis.

Overall improvement was noted in all 27 (100%), with 37% scored as excellent, 41% as moderate, and 22% as mild. Improved dyschromia was noted in 96% of the blinded evaluations, with 60% having at least moderately improved. Improvements in atrophy/hypertrophy were also noted in 96%, with 63% having at least moderately improved. Improved skin texture was seen in 100%, with 63% having at least moderately improved texture, Dr. Waibel reported.

The average of the patients' self-assessments of self-esteem at 3 months was 8.2 on a scale of 1–10 with 10 being "I feel great about myself." On a 0–3 scale of improvement in burn scar area with 0 being "no improvement" and 3 being "excellent improvement," the average of the patients' self-assessment at 3 months was 2.3. Anecdotally, patients also spoke of diminished pain, improved motion with a decrease in contractures, and better cosmesis, Dr. Waibel added.

The findings from this study will be submitted to the FDA to support a new indication for burn scars. (Fraxel re:store is currently approved for skin resurfacing.) Additional studies will be necessary to determine the optimal parameters for burn patients, Dr. Waibel said in an interview.

The next phase of studies that Dr. Waibel and her associates are studying include the use of nonablative fractional resurfacing in combination with intralesional triamcinolone (Kenalog), and also the use of ablative fractional resurfacing devices.

Dr. Waibel and her associates received a research grant from Reliant Technologies Inc. (now Solta Medical, Fraxel manufacturer) to conduct this study, and have received honoraria from the company for lectures.

The patient's hand is shown before undergoing treatment with the Fraxel re:store laser.

Three months and five laser treatments later, overall severity of the burn scar is reduced. Photos courtesy Dr. Waibel

NATIONAL HARBOR, MD. — Nonablative fractional laser resurfacing produced significant improvement in scar severity in a study of 10 patients with second- and third-degree burn scars.

A total of five treatments delivered at 4-week intervals using a 1,550-nm nonablative erbium-doped fiber laser (Fraxel re:store) resulted in objectively-assessed reductions in overall scar severity, as well as improvement in topographical and textural abnormalities, Dr. Jill Waibel reported at the annual meeting of the American Society of Laser Medicine and Surgery.

"Burn scars are a challenge because they have traditionally been difficult to treat, and they are among the worst scars seen in clinical medicine. There is compelling evidence to suggest that nonablative fractional resurfacing improves the appearance and functionality of scarred tissue following burns. I think fractional lasers are the gold standard for scars," said Dr. Waibel, who is in private practice in West Palm Beach, Fla.

Burn scars are extremely heterogeneous, often comprising areas of hypertrophy, atrophy, and hyperpigmentation. Fractional photothermolysis, which provides a greater depth of penetration than traditional CO2 laser resurfacing, appears to benefit the variety of scar types that arise from burn injury, she said.

The eight men and two women in the study ranged in age from 23 to 68 years. Nine had third-degree burns and one had second-degree burns. Treatment areas included the face, neck, chest, arms, hands, abdomen, calf, and leg. Patients were treated with energy levels ranging from 40–70 mJ/pulse, treatment level range 6–13, density 29–65 MTZ/cm

Three blinded investigators evaluated changes in overall improvement, dyschromia, degree of atrophy or hypertrophy improvement, and texture improvement graded on a quartile scale of 0–3, with 0 being none, 1 mild (1%-33%), 2 moderate (34%-66%), and 3 excellent (67%-100%). The patients also scored their own levels of self-esteem, and both the patients and the investigators independently evaluated changes in erythema, edema, hyper- and hypopigmentation, and burn scars overall at 1, 3, and 6 months after the final treatment. Photos were also taken at baseline and at 3 months post treatment.

Based on a protocol recommended by the Food and Drug Administration, the evaluators were given random before and after patient photographs. In one patient, none of the three blinded investigators identified the before and after photos correctly. All three investigators correctly identified the other 9 patient photos, so those 27 evaluations were used for the data analysis.

Overall improvement was noted in all 27 (100%), with 37% scored as excellent, 41% as moderate, and 22% as mild. Improved dyschromia was noted in 96% of the blinded evaluations, with 60% having at least moderately improved. Improvements in atrophy/hypertrophy were also noted in 96%, with 63% having at least moderately improved. Improved skin texture was seen in 100%, with 63% having at least moderately improved texture, Dr. Waibel reported.

The average of the patients' self-assessments of self-esteem at 3 months was 8.2 on a scale of 1–10 with 10 being "I feel great about myself." On a 0–3 scale of improvement in burn scar area with 0 being "no improvement" and 3 being "excellent improvement," the average of the patients' self-assessment at 3 months was 2.3. Anecdotally, patients also spoke of diminished pain, improved motion with a decrease in contractures, and better cosmesis, Dr. Waibel added.

The findings from this study will be submitted to the FDA to support a new indication for burn scars. (Fraxel re:store is currently approved for skin resurfacing.) Additional studies will be necessary to determine the optimal parameters for burn patients, Dr. Waibel said in an interview.

The next phase of studies that Dr. Waibel and her associates are studying include the use of nonablative fractional resurfacing in combination with intralesional triamcinolone (Kenalog), and also the use of ablative fractional resurfacing devices.

Dr. Waibel and her associates received a research grant from Reliant Technologies Inc. (now Solta Medical, Fraxel manufacturer) to conduct this study, and have received honoraria from the company for lectures.

The patient's hand is shown before undergoing treatment with the Fraxel re:store laser.

Three months and five laser treatments later, overall severity of the burn scar is reduced. Photos courtesy Dr. Waibel

NATIONAL HARBOR, MD. — Fractional laser resurfacing produced long-term results in a small study of patients treated for acne scarring or photodamage.

Fractional deep dermal ablation is a newer modality that produces clinical improvement in photodamaged skin and acne scarring but with reduced downtime and a lower risk of complications, compared with traditional carbon dioxide resurfacing. However, the long-term outcomes of patients treated with fractional resurfacing have not been previously reported, Dr. Arisa Ortiz said at the annual meeting of the American Society for Laser Medicine and Surgery.

In the current study, results at 1–2 years were somewhat diminished, compared with those seen at 3 months, but were still better than at baseline and patient satisfaction was maintained, said Dr. Ortiz of the University of California, Irvine.

The single-center study involved six patients with acne scarring and four with photodamage. All had been previously enrolled in studies of fractional resurfacing for those two conditions. They were aged 24–63 years, with skin types I-V. There were no serious adverse events associated with the treatment, she said.

All 10 patients returned at 3 months for assessments of improvement in skin texture, rhytids, pigmentation, skin laxity, acne scarring, and overall appearance, compared with baseline.

The patients with acne scarring were then reassessed at 1 year and the patients with photodamage, at 2 years. Three investigators clinically rated improvement on a quartile scale: 0% (no improvement), less than 25% (minor), 25%-50% (minor to moderate), 51%-75% (moderate), and greater than 75% (marked).

Among the acne scarring patients, at 1 year there was 83% maintenance of the initial overall improvement seen at 3 months. For those treated for photoaging, 50% of the 3-month improvement was maintained at 2 years. Overall, there was a 74% improvement from 3 months to the 1- or 2-year follow-up assessment. No patient returned to baseline levels, Dr. Ortiz reported.

Possible explanations for the difference in results between 3 months and the long-term visit include relaxation of tightening, progression of normal aging, or persistent inflammatory changes present at 3 months, as evidenced by heat shock protein activity and ongoing collagen remodeling seen in previous histologic studies.

These results suggest that additional treatments may be necessary to enhance long-term results. It also appeared that acne scarring requires more treatments at higher energies, compared with photodamaged skin, and that performing more frequent treatments early on may result in less bleeding and less downtime for all patients, Dr. Ortiz said.

The original study was funded by Reliant Technologies Inc., but this long-term follow-up study was departmentally funded, she said.

As demonstrated above, results at 1 year (far right) were somewhat diminished—compared with those seen at 3 months (center)—but were still better than at baseline (left), and patient satisfaction was maintained, according to Dr. Arisa Ortiz. Photos courtesy Dr. Arisa Ortiz

NATIONAL HARBOR, MD. — Fractional laser resurfacing produced long-term results in a small study of patients treated for acne scarring or photodamage.

Fractional deep dermal ablation is a newer modality that produces clinical improvement in photodamaged skin and acne scarring but with reduced downtime and a lower risk of complications, compared with traditional carbon dioxide resurfacing. However, the long-term outcomes of patients treated with fractional resurfacing have not been previously reported, Dr. Arisa Ortiz said at the annual meeting of the American Society for Laser Medicine and Surgery.

In the current study, results at 1–2 years were somewhat diminished, compared with those seen at 3 months, but were still better than at baseline and patient satisfaction was maintained, said Dr. Ortiz of the University of California, Irvine.

The single-center study involved six patients with acne scarring and four with photodamage. All had been previously enrolled in studies of fractional resurfacing for those two conditions. They were aged 24–63 years, with skin types I-V. There were no serious adverse events associated with the treatment, she said.

All 10 patients returned at 3 months for assessments of improvement in skin texture, rhytids, pigmentation, skin laxity, acne scarring, and overall appearance, compared with baseline.

The patients with acne scarring were then reassessed at 1 year and the patients with photodamage, at 2 years. Three investigators clinically rated improvement on a quartile scale: 0% (no improvement), less than 25% (minor), 25%-50% (minor to moderate), 51%-75% (moderate), and greater than 75% (marked).

Among the acne scarring patients, at 1 year there was 83% maintenance of the initial overall improvement seen at 3 months. For those treated for photoaging, 50% of the 3-month improvement was maintained at 2 years. Overall, there was a 74% improvement from 3 months to the 1- or 2-year follow-up assessment. No patient returned to baseline levels, Dr. Ortiz reported.

Possible explanations for the difference in results between 3 months and the long-term visit include relaxation of tightening, progression of normal aging, or persistent inflammatory changes present at 3 months, as evidenced by heat shock protein activity and ongoing collagen remodeling seen in previous histologic studies.

These results suggest that additional treatments may be necessary to enhance long-term results. It also appeared that acne scarring requires more treatments at higher energies, compared with photodamaged skin, and that performing more frequent treatments early on may result in less bleeding and less downtime for all patients, Dr. Ortiz said.

The original study was funded by Reliant Technologies Inc., but this long-term follow-up study was departmentally funded, she said.

As demonstrated above, results at 1 year (far right) were somewhat diminished—compared with those seen at 3 months (center)—but were still better than at baseline (left), and patient satisfaction was maintained, according to Dr. Arisa Ortiz. Photos courtesy Dr. Arisa Ortiz

NATIONAL HARBOR, MD. — Fractional laser resurfacing produced long-term results in a small study of patients treated for acne scarring or photodamage.

Fractional deep dermal ablation is a newer modality that produces clinical improvement in photodamaged skin and acne scarring but with reduced downtime and a lower risk of complications, compared with traditional carbon dioxide resurfacing. However, the long-term outcomes of patients treated with fractional resurfacing have not been previously reported, Dr. Arisa Ortiz said at the annual meeting of the American Society for Laser Medicine and Surgery.

In the current study, results at 1–2 years were somewhat diminished, compared with those seen at 3 months, but were still better than at baseline and patient satisfaction was maintained, said Dr. Ortiz of the University of California, Irvine.

The single-center study involved six patients with acne scarring and four with photodamage. All had been previously enrolled in studies of fractional resurfacing for those two conditions. They were aged 24–63 years, with skin types I-V. There were no serious adverse events associated with the treatment, she said.

All 10 patients returned at 3 months for assessments of improvement in skin texture, rhytids, pigmentation, skin laxity, acne scarring, and overall appearance, compared with baseline.

The patients with acne scarring were then reassessed at 1 year and the patients with photodamage, at 2 years. Three investigators clinically rated improvement on a quartile scale: 0% (no improvement), less than 25% (minor), 25%-50% (minor to moderate), 51%-75% (moderate), and greater than 75% (marked).

Among the acne scarring patients, at 1 year there was 83% maintenance of the initial overall improvement seen at 3 months. For those treated for photoaging, 50% of the 3-month improvement was maintained at 2 years. Overall, there was a 74% improvement from 3 months to the 1- or 2-year follow-up assessment. No patient returned to baseline levels, Dr. Ortiz reported.

Possible explanations for the difference in results between 3 months and the long-term visit include relaxation of tightening, progression of normal aging, or persistent inflammatory changes present at 3 months, as evidenced by heat shock protein activity and ongoing collagen remodeling seen in previous histologic studies.

These results suggest that additional treatments may be necessary to enhance long-term results. It also appeared that acne scarring requires more treatments at higher energies, compared with photodamaged skin, and that performing more frequent treatments early on may result in less bleeding and less downtime for all patients, Dr. Ortiz said.

The original study was funded by Reliant Technologies Inc., but this long-term follow-up study was departmentally funded, she said.

As demonstrated above, results at 1 year (far right) were somewhat diminished—compared with those seen at 3 months (center)—but were still better than at baseline (left), and patient satisfaction was maintained, according to Dr. Arisa Ortiz. Photos courtesy Dr. Arisa Ortiz

NATIONAL HARBOR, MD. — A long-pulsed 595-nm pulsed dye laser rapidly improved ecchymosis resulting from either cosmetic procedures or traumatic injury in a study of 10 patients.

Postprocedural and traumatic ecchymosis is an extremely common problem, particularly with the recent explosive growth in minimally invasive procedures that potentially induce bruising, Dr. Julie K. Karen noted at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients are often motivated to minimize or camouflage bruising to conceal the fact that they have had cosmetic intervention. Current strategies to minimize the bruising, such as discontinuation of nonessential blood thinners; meticulous intraoperative technique; and topical or oral agents such as arnica, vitamin K, and hirudin are not always effective, she said.

"Long-pulsed [pulsed dye laser] may alleviate this common stigma associated with cosmetic intervention by expediting healing," said Dr. Karen of the Laser & Skin Surgery Center of New York, N.Y.

The 10 adult patients had skin types I-IV, with one or more ecchymoses. Each subject served as his or her own control.

One ecchymosis was treated in those who had two, while those with just one ecchymosis had half of the lesion treated. None of the patients had active infections, photosensitivity/photoallergy, pregnancy/lactation, prior irradiation to the ecchymosis site, use of oral retinoids or photosensitizing drugs in the previous 2 years, or a history of keloid formation.

Each patient received a single treatment with a long-pulsed 595-nm pulsed-dye laser (Vbeam, Candela) with these parameters: spot size, 10 mm; fluence, 7.5 J/cm

Treated lesions resolved more rapidly than untreated lesions in all 10 patients. All 10 treated lesions showed improvement within 24 hours, with some improvement evident as early as 6 hours post treatment.

At 24 hours post treatment, there was an average 62% improvement from baseline in the treated lesion compared with just 13% of the untreated lesion. At 48 hours, the improvements were 76% and 37%, respectively. At 1 week post treatment, there was no longer a significant difference between the treated and untreated areas, with both lesions largely resolved (87% vs. 81%).

Side effects were minimal, including slight discomfort, erythema, and edema. Transient crusting occurred in the first two patients, in whom pulse-stacking was attempted. That was avoided in the subsequent eight patients and none had crusting, Dr. Karen said.

The precise mechanism by which laser treatment accelerates the resolution of ecchymosis is unknown. Ecchymoses result when extravasated blood accumulates in tissue. The yellow color that develops in older bruises correlates with macrophage degradation of hemoglobin to bilirubin.

The pulsed dye laser emits yellow light (595-nm) matching an absorption peak of oxyhemoglobin. Since bilirubin has a broad absorption peak of 460-nm, "we posit that laser intervention is most effective if initiated early, when hemoglobin predominates," she commented.

Dr. Karen stated that she had no relevant disclosures.

NATIONAL HARBOR, MD. — A long-pulsed 595-nm pulsed dye laser rapidly improved ecchymosis resulting from either cosmetic procedures or traumatic injury in a study of 10 patients.

Postprocedural and traumatic ecchymosis is an extremely common problem, particularly with the recent explosive growth in minimally invasive procedures that potentially induce bruising, Dr. Julie K. Karen noted at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients are often motivated to minimize or camouflage bruising to conceal the fact that they have had cosmetic intervention. Current strategies to minimize the bruising, such as discontinuation of nonessential blood thinners; meticulous intraoperative technique; and topical or oral agents such as arnica, vitamin K, and hirudin are not always effective, she said.

"Long-pulsed [pulsed dye laser] may alleviate this common stigma associated with cosmetic intervention by expediting healing," said Dr. Karen of the Laser & Skin Surgery Center of New York, N.Y.

The 10 adult patients had skin types I-IV, with one or more ecchymoses. Each subject served as his or her own control.

One ecchymosis was treated in those who had two, while those with just one ecchymosis had half of the lesion treated. None of the patients had active infections, photosensitivity/photoallergy, pregnancy/lactation, prior irradiation to the ecchymosis site, use of oral retinoids or photosensitizing drugs in the previous 2 years, or a history of keloid formation.

Each patient received a single treatment with a long-pulsed 595-nm pulsed-dye laser (Vbeam, Candela) with these parameters: spot size, 10 mm; fluence, 7.5 J/cm

Treated lesions resolved more rapidly than untreated lesions in all 10 patients. All 10 treated lesions showed improvement within 24 hours, with some improvement evident as early as 6 hours post treatment.

At 24 hours post treatment, there was an average 62% improvement from baseline in the treated lesion compared with just 13% of the untreated lesion. At 48 hours, the improvements were 76% and 37%, respectively. At 1 week post treatment, there was no longer a significant difference between the treated and untreated areas, with both lesions largely resolved (87% vs. 81%).

Side effects were minimal, including slight discomfort, erythema, and edema. Transient crusting occurred in the first two patients, in whom pulse-stacking was attempted. That was avoided in the subsequent eight patients and none had crusting, Dr. Karen said.

The precise mechanism by which laser treatment accelerates the resolution of ecchymosis is unknown. Ecchymoses result when extravasated blood accumulates in tissue. The yellow color that develops in older bruises correlates with macrophage degradation of hemoglobin to bilirubin.

The pulsed dye laser emits yellow light (595-nm) matching an absorption peak of oxyhemoglobin. Since bilirubin has a broad absorption peak of 460-nm, "we posit that laser intervention is most effective if initiated early, when hemoglobin predominates," she commented.

Dr. Karen stated that she had no relevant disclosures.

NATIONAL HARBOR, MD. — A long-pulsed 595-nm pulsed dye laser rapidly improved ecchymosis resulting from either cosmetic procedures or traumatic injury in a study of 10 patients.

Postprocedural and traumatic ecchymosis is an extremely common problem, particularly with the recent explosive growth in minimally invasive procedures that potentially induce bruising, Dr. Julie K. Karen noted at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients are often motivated to minimize or camouflage bruising to conceal the fact that they have had cosmetic intervention. Current strategies to minimize the bruising, such as discontinuation of nonessential blood thinners; meticulous intraoperative technique; and topical or oral agents such as arnica, vitamin K, and hirudin are not always effective, she said.

"Long-pulsed [pulsed dye laser] may alleviate this common stigma associated with cosmetic intervention by expediting healing," said Dr. Karen of the Laser & Skin Surgery Center of New York, N.Y.

The 10 adult patients had skin types I-IV, with one or more ecchymoses. Each subject served as his or her own control.

One ecchymosis was treated in those who had two, while those with just one ecchymosis had half of the lesion treated. None of the patients had active infections, photosensitivity/photoallergy, pregnancy/lactation, prior irradiation to the ecchymosis site, use of oral retinoids or photosensitizing drugs in the previous 2 years, or a history of keloid formation.

Each patient received a single treatment with a long-pulsed 595-nm pulsed-dye laser (Vbeam, Candela) with these parameters: spot size, 10 mm; fluence, 7.5 J/cm

Treated lesions resolved more rapidly than untreated lesions in all 10 patients. All 10 treated lesions showed improvement within 24 hours, with some improvement evident as early as 6 hours post treatment.

At 24 hours post treatment, there was an average 62% improvement from baseline in the treated lesion compared with just 13% of the untreated lesion. At 48 hours, the improvements were 76% and 37%, respectively. At 1 week post treatment, there was no longer a significant difference between the treated and untreated areas, with both lesions largely resolved (87% vs. 81%).

Side effects were minimal, including slight discomfort, erythema, and edema. Transient crusting occurred in the first two patients, in whom pulse-stacking was attempted. That was avoided in the subsequent eight patients and none had crusting, Dr. Karen said.

The precise mechanism by which laser treatment accelerates the resolution of ecchymosis is unknown. Ecchymoses result when extravasated blood accumulates in tissue. The yellow color that develops in older bruises correlates with macrophage degradation of hemoglobin to bilirubin.

The pulsed dye laser emits yellow light (595-nm) matching an absorption peak of oxyhemoglobin. Since bilirubin has a broad absorption peak of 460-nm, "we posit that laser intervention is most effective if initiated early, when hemoglobin predominates," she commented.

Dr. Karen stated that she had no relevant disclosures.