Nancy A. Melville

ANAHEIM, CALIF. — An in-office camouflage makeup expert can help mask postoperative bruising, swelling, or redness, which can make the difference to patients who feel injured or disfigured, said Howard Steinman, M.D., at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

It's not uncommon for dermatologists to simply give patients a list of a few paramedical products and send them on their way, without considering that most patients will not want to be seen in public, even by strangers, immediately after the procedure. "You may see a normal postop result—bruising, redness, or asymmetry—and you think it looks like a normal, great result, but the patient probably doesn't see it that way," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif.

The last thing a patient likely wants to do is go to a cosmetic counter with an unsightly face when the salespeople look like models, he added. "Having to buy the products outside the office is simply not a viable option for cosmetic patients."

The difficulties of using past-generation paramedical products turned many practitioners away from offering in-house camouflage makeup services.

But mineral makeup has changed all that. Newer products are much easier for staff people to use and for patients to learn to apply themselves. The products can be highly effective in normalizing or almost normalizing regular bruising, covering redness, and masking pigmentary changes.

The makeup helps cover expected discoloration caused by everything from ablative procedures, deeper peels, and S-lifts to blepharoplasty, Mohs surgery, and even botulinum type A injections.

The products are formulated for postsurgical use, are waterproof, have an SPF, and are easy to apply and remove, Dr. Steinman said. The paramedical products he uses include Youngblood Mineral Makeup, DermaColor Camouflage, and Lycogel. He said he does not have financial ties to any of the manufacturers.

There are some limitations—the makeup usually won't cover three-dimensional conditions, for instance. And it often can't cover very dark bruising or a lack of texture, he noted.

The staff person in charge of applying the camouflage makeup can offer an added level of care and understanding that boosts patient satisfaction.

"If you use someone who's experienced in paramedical camouflage makeup, they understand the psyche of the postop patient, the procedures, and they have great credibility in your office." In Dr. Steinman's practice, the makeup expert is his wife, Diedre, but estheticians or other staff members with experience in paramedical camouflage makeup can take on the role.

To allow adequate time and planning for makeup application and training, the service is best offered as a postsurgical session, arranged along with the other procedures, Dr. Steinman recommended.

Makeup should be matched to patients' facial skin prior to laser or chemical peels to ensure the appropriate color will be available postoperatively, and patients should be told to bring in their own makeup to help them feel as "normal" as possible when they leave.

Considering the low cost and risk of camouflage makeup, the minimal office space required, and the high level of patient satisfaction, the inclusion of such services is very worthwhile, Dr. Steinman said.

"When this is incorporated in your office, the fear we all have of doing procedures that have downtime can be ameliorated," he said. "With something like CO₂ laser resurfacing, for instance, I have no concerns about downtime."

"If you're not offering camouflage makeup, then you're missing the boat, because this really completes the whole package for the patient and makes you, the physician, feel much more secure," he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — An in-office camouflage makeup expert can help mask postoperative bruising, swelling, or redness, which can make the difference to patients who feel injured or disfigured, said Howard Steinman, M.D., at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

It's not uncommon for dermatologists to simply give patients a list of a few paramedical products and send them on their way, without considering that most patients will not want to be seen in public, even by strangers, immediately after the procedure. "You may see a normal postop result—bruising, redness, or asymmetry—and you think it looks like a normal, great result, but the patient probably doesn't see it that way," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif.

The last thing a patient likely wants to do is go to a cosmetic counter with an unsightly face when the salespeople look like models, he added. "Having to buy the products outside the office is simply not a viable option for cosmetic patients."

The difficulties of using past-generation paramedical products turned many practitioners away from offering in-house camouflage makeup services.

But mineral makeup has changed all that. Newer products are much easier for staff people to use and for patients to learn to apply themselves. The products can be highly effective in normalizing or almost normalizing regular bruising, covering redness, and masking pigmentary changes.

The makeup helps cover expected discoloration caused by everything from ablative procedures, deeper peels, and S-lifts to blepharoplasty, Mohs surgery, and even botulinum type A injections.

The products are formulated for postsurgical use, are waterproof, have an SPF, and are easy to apply and remove, Dr. Steinman said. The paramedical products he uses include Youngblood Mineral Makeup, DermaColor Camouflage, and Lycogel. He said he does not have financial ties to any of the manufacturers.

There are some limitations—the makeup usually won't cover three-dimensional conditions, for instance. And it often can't cover very dark bruising or a lack of texture, he noted.

The staff person in charge of applying the camouflage makeup can offer an added level of care and understanding that boosts patient satisfaction.

"If you use someone who's experienced in paramedical camouflage makeup, they understand the psyche of the postop patient, the procedures, and they have great credibility in your office." In Dr. Steinman's practice, the makeup expert is his wife, Diedre, but estheticians or other staff members with experience in paramedical camouflage makeup can take on the role.

To allow adequate time and planning for makeup application and training, the service is best offered as a postsurgical session, arranged along with the other procedures, Dr. Steinman recommended.

Makeup should be matched to patients' facial skin prior to laser or chemical peels to ensure the appropriate color will be available postoperatively, and patients should be told to bring in their own makeup to help them feel as "normal" as possible when they leave.

Considering the low cost and risk of camouflage makeup, the minimal office space required, and the high level of patient satisfaction, the inclusion of such services is very worthwhile, Dr. Steinman said.

"When this is incorporated in your office, the fear we all have of doing procedures that have downtime can be ameliorated," he said. "With something like CO₂ laser resurfacing, for instance, I have no concerns about downtime."

"If you're not offering camouflage makeup, then you're missing the boat, because this really completes the whole package for the patient and makes you, the physician, feel much more secure," he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — An in-office camouflage makeup expert can help mask postoperative bruising, swelling, or redness, which can make the difference to patients who feel injured or disfigured, said Howard Steinman, M.D., at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

It's not uncommon for dermatologists to simply give patients a list of a few paramedical products and send them on their way, without considering that most patients will not want to be seen in public, even by strangers, immediately after the procedure. "You may see a normal postop result—bruising, redness, or asymmetry—and you think it looks like a normal, great result, but the patient probably doesn't see it that way," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif.

The last thing a patient likely wants to do is go to a cosmetic counter with an unsightly face when the salespeople look like models, he added. "Having to buy the products outside the office is simply not a viable option for cosmetic patients."

The difficulties of using past-generation paramedical products turned many practitioners away from offering in-house camouflage makeup services.

But mineral makeup has changed all that. Newer products are much easier for staff people to use and for patients to learn to apply themselves. The products can be highly effective in normalizing or almost normalizing regular bruising, covering redness, and masking pigmentary changes.

The makeup helps cover expected discoloration caused by everything from ablative procedures, deeper peels, and S-lifts to blepharoplasty, Mohs surgery, and even botulinum type A injections.

The products are formulated for postsurgical use, are waterproof, have an SPF, and are easy to apply and remove, Dr. Steinman said. The paramedical products he uses include Youngblood Mineral Makeup, DermaColor Camouflage, and Lycogel. He said he does not have financial ties to any of the manufacturers.

There are some limitations—the makeup usually won't cover three-dimensional conditions, for instance. And it often can't cover very dark bruising or a lack of texture, he noted.

The staff person in charge of applying the camouflage makeup can offer an added level of care and understanding that boosts patient satisfaction.

"If you use someone who's experienced in paramedical camouflage makeup, they understand the psyche of the postop patient, the procedures, and they have great credibility in your office." In Dr. Steinman's practice, the makeup expert is his wife, Diedre, but estheticians or other staff members with experience in paramedical camouflage makeup can take on the role.

To allow adequate time and planning for makeup application and training, the service is best offered as a postsurgical session, arranged along with the other procedures, Dr. Steinman recommended.

Makeup should be matched to patients' facial skin prior to laser or chemical peels to ensure the appropriate color will be available postoperatively, and patients should be told to bring in their own makeup to help them feel as "normal" as possible when they leave.

Considering the low cost and risk of camouflage makeup, the minimal office space required, and the high level of patient satisfaction, the inclusion of such services is very worthwhile, Dr. Steinman said.

"When this is incorporated in your office, the fear we all have of doing procedures that have downtime can be ameliorated," he said. "With something like CO₂ laser resurfacing, for instance, I have no concerns about downtime."

"If you're not offering camouflage makeup, then you're missing the boat, because this really completes the whole package for the patient and makes you, the physician, feel much more secure," he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — With growing concerns about treatment of depression in pregnancy, omega-3 fatty acids are gaining attention as a possible treatment that might be without risk and exceptionally healthful for mother and child, Marlene Freeman, M.D., said at a psychopharmacology conference sponsored by the University of Arizona.

Omega-3 fatty acids, best known for their cardiovascular benefits (including reduction of triglyceride levels and thrombosis risk) gained even more attention when epidemiologic studies showed lower rates of depression in countries with high consumption of omega-3-rich seafood and higher depression rates in countries where fish consumption is lowest (Lancet 1998;351:1213 and J. Affect. Disord. 2002;69:15–29).

Omega-3 fatty acids can become depleted during pregnancy and lactation anyway, so the suggestion that they might play a role preventing depression in pregnancy is even more intriguing—especially with recent research raising concerns of a possible neonatal withdrawal syndrome associated with use of selective serotonin reuptake inhibitors during pregnancy, said Dr. Freeman, director of the university's women's mental health program in Tucson.

In addition to the epidemiologic research, studies looking at omega-3s and depression have included four double-blind, placebo-controlled trials. In three of the studies, involving treatment-resistant patients, a significant response was seen in the omega-3 groups, who received widely varying doses of marine sources of omega-3 fatty acids, including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

Dosages in the three positive studies ranged from 1 g of EPA all the way up to 9.6 g of EPA and DHA.

In a fourth study involving 35 subjects, however, there was no separation seen between the treatment group receiving 2 g of DHA and placebo (Am. J. Psychiatry 2003;160:996–8).

A non-peer reviewed study looking specifically at the role of omega-3 fatty acids in depression among pregnant women and involving nearly 14,000 pregnant British women showed higher depression scores correlating with lower seafood intake. The study indicated a protective effect of omega-3 acids not only at 18 weeks' gestation but also at 8 weeks and 32 weeks post partum.

The most recent findings out of Dr. Freeman's lab shed more light on issues such as palatability and efficacy. In a small, open-label, flexible-dose study of 15 patients using doses up to 2.8 g/day of EPA and DHA, patients showed a mean decrease on the Edinburgh Postnatal Depression Scale (EPDS) of 39% and a mean decrease of 34% on the Hamilton Rating Scale for Depression.

The longer patients stayed in the study, the better they did, with a 40% EPDS decrease at 4 weeks and a 49% decrease at 8 weeks; however, Dr. Freeman said the figures were very biased, and she emphasized that more follow-up is necessary.

“We do think omega-3s look like an acceptable potential treatment option, but more research is needed,” Dr. Freeman said.

The study also indicated that the dosage of omega-3 tablets, which included up to six large capsules a day, was surprisingly well tolerated.

“We were concerned about giving pregnant women these big capsules because of problems like morning sickness, heartburn, and other gastrointestinal symptoms that can go along with pregnancy,” she said. “Overall, the doses were amazingly well tolerated.”

The highest levels of omega-3 fatty acids are found in fatty fish. In addition to their known cardiovascular benefits, the compounds have been associated with benefits ranging from brain and retinal development to prevention of breast and lung cancer.

The news gets even better, she said, in terms of their possible benefits for infants, with reports linking omega-3 intake in pregnant mothers to better sleep patterns in infants and higher IQs.

In terms of the role of omega-3 fatty acids in depression, theories on the possible mechanisms of action vary widely and include increased serotonergic activity, inhibition of protein kinase C, anti-inflammatory properties, suppression of phosphatidylinositol-associated second messenger activity, and increases in heart-rate variability.

Plant sources such as flaxseed offer some omega-3s, but seafood has far richer concentrations. Supplements such as fish oil tablets are also beneficial.

SCOTTSDALE, ARIZ. — With growing concerns about treatment of depression in pregnancy, omega-3 fatty acids are gaining attention as a possible treatment that might be without risk and exceptionally healthful for mother and child, Marlene Freeman, M.D., said at a psychopharmacology conference sponsored by the University of Arizona.

Omega-3 fatty acids, best known for their cardiovascular benefits (including reduction of triglyceride levels and thrombosis risk) gained even more attention when epidemiologic studies showed lower rates of depression in countries with high consumption of omega-3-rich seafood and higher depression rates in countries where fish consumption is lowest (Lancet 1998;351:1213 and J. Affect. Disord. 2002;69:15–29).

Omega-3 fatty acids can become depleted during pregnancy and lactation anyway, so the suggestion that they might play a role preventing depression in pregnancy is even more intriguing—especially with recent research raising concerns of a possible neonatal withdrawal syndrome associated with use of selective serotonin reuptake inhibitors during pregnancy, said Dr. Freeman, director of the university's women's mental health program in Tucson.

In addition to the epidemiologic research, studies looking at omega-3s and depression have included four double-blind, placebo-controlled trials. In three of the studies, involving treatment-resistant patients, a significant response was seen in the omega-3 groups, who received widely varying doses of marine sources of omega-3 fatty acids, including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

Dosages in the three positive studies ranged from 1 g of EPA all the way up to 9.6 g of EPA and DHA.

In a fourth study involving 35 subjects, however, there was no separation seen between the treatment group receiving 2 g of DHA and placebo (Am. J. Psychiatry 2003;160:996–8).

A non-peer reviewed study looking specifically at the role of omega-3 fatty acids in depression among pregnant women and involving nearly 14,000 pregnant British women showed higher depression scores correlating with lower seafood intake. The study indicated a protective effect of omega-3 acids not only at 18 weeks' gestation but also at 8 weeks and 32 weeks post partum.

The most recent findings out of Dr. Freeman's lab shed more light on issues such as palatability and efficacy. In a small, open-label, flexible-dose study of 15 patients using doses up to 2.8 g/day of EPA and DHA, patients showed a mean decrease on the Edinburgh Postnatal Depression Scale (EPDS) of 39% and a mean decrease of 34% on the Hamilton Rating Scale for Depression.

The longer patients stayed in the study, the better they did, with a 40% EPDS decrease at 4 weeks and a 49% decrease at 8 weeks; however, Dr. Freeman said the figures were very biased, and she emphasized that more follow-up is necessary.

“We do think omega-3s look like an acceptable potential treatment option, but more research is needed,” Dr. Freeman said.

The study also indicated that the dosage of omega-3 tablets, which included up to six large capsules a day, was surprisingly well tolerated.

“We were concerned about giving pregnant women these big capsules because of problems like morning sickness, heartburn, and other gastrointestinal symptoms that can go along with pregnancy,” she said. “Overall, the doses were amazingly well tolerated.”

The highest levels of omega-3 fatty acids are found in fatty fish. In addition to their known cardiovascular benefits, the compounds have been associated with benefits ranging from brain and retinal development to prevention of breast and lung cancer.

The news gets even better, she said, in terms of their possible benefits for infants, with reports linking omega-3 intake in pregnant mothers to better sleep patterns in infants and higher IQs.

In terms of the role of omega-3 fatty acids in depression, theories on the possible mechanisms of action vary widely and include increased serotonergic activity, inhibition of protein kinase C, anti-inflammatory properties, suppression of phosphatidylinositol-associated second messenger activity, and increases in heart-rate variability.

Plant sources such as flaxseed offer some omega-3s, but seafood has far richer concentrations. Supplements such as fish oil tablets are also beneficial.

SCOTTSDALE, ARIZ. — With growing concerns about treatment of depression in pregnancy, omega-3 fatty acids are gaining attention as a possible treatment that might be without risk and exceptionally healthful for mother and child, Marlene Freeman, M.D., said at a psychopharmacology conference sponsored by the University of Arizona.

Omega-3 fatty acids, best known for their cardiovascular benefits (including reduction of triglyceride levels and thrombosis risk) gained even more attention when epidemiologic studies showed lower rates of depression in countries with high consumption of omega-3-rich seafood and higher depression rates in countries where fish consumption is lowest (Lancet 1998;351:1213 and J. Affect. Disord. 2002;69:15–29).

Omega-3 fatty acids can become depleted during pregnancy and lactation anyway, so the suggestion that they might play a role preventing depression in pregnancy is even more intriguing—especially with recent research raising concerns of a possible neonatal withdrawal syndrome associated with use of selective serotonin reuptake inhibitors during pregnancy, said Dr. Freeman, director of the university's women's mental health program in Tucson.

In addition to the epidemiologic research, studies looking at omega-3s and depression have included four double-blind, placebo-controlled trials. In three of the studies, involving treatment-resistant patients, a significant response was seen in the omega-3 groups, who received widely varying doses of marine sources of omega-3 fatty acids, including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

Dosages in the three positive studies ranged from 1 g of EPA all the way up to 9.6 g of EPA and DHA.

In a fourth study involving 35 subjects, however, there was no separation seen between the treatment group receiving 2 g of DHA and placebo (Am. J. Psychiatry 2003;160:996–8).

A non-peer reviewed study looking specifically at the role of omega-3 fatty acids in depression among pregnant women and involving nearly 14,000 pregnant British women showed higher depression scores correlating with lower seafood intake. The study indicated a protective effect of omega-3 acids not only at 18 weeks' gestation but also at 8 weeks and 32 weeks post partum.

The most recent findings out of Dr. Freeman's lab shed more light on issues such as palatability and efficacy. In a small, open-label, flexible-dose study of 15 patients using doses up to 2.8 g/day of EPA and DHA, patients showed a mean decrease on the Edinburgh Postnatal Depression Scale (EPDS) of 39% and a mean decrease of 34% on the Hamilton Rating Scale for Depression.

The longer patients stayed in the study, the better they did, with a 40% EPDS decrease at 4 weeks and a 49% decrease at 8 weeks; however, Dr. Freeman said the figures were very biased, and she emphasized that more follow-up is necessary.

“We do think omega-3s look like an acceptable potential treatment option, but more research is needed,” Dr. Freeman said.

The study also indicated that the dosage of omega-3 tablets, which included up to six large capsules a day, was surprisingly well tolerated.

“We were concerned about giving pregnant women these big capsules because of problems like morning sickness, heartburn, and other gastrointestinal symptoms that can go along with pregnancy,” she said. “Overall, the doses were amazingly well tolerated.”

The highest levels of omega-3 fatty acids are found in fatty fish. In addition to their known cardiovascular benefits, the compounds have been associated with benefits ranging from brain and retinal development to prevention of breast and lung cancer.

The news gets even better, she said, in terms of their possible benefits for infants, with reports linking omega-3 intake in pregnant mothers to better sleep patterns in infants and higher IQs.

In terms of the role of omega-3 fatty acids in depression, theories on the possible mechanisms of action vary widely and include increased serotonergic activity, inhibition of protein kinase C, anti-inflammatory properties, suppression of phosphatidylinositol-associated second messenger activity, and increases in heart-rate variability.

Plant sources such as flaxseed offer some omega-3s, but seafood has far richer concentrations. Supplements such as fish oil tablets are also beneficial.

SCOTTSDALE, ARIZ. — Although 5% 5-fluorouracil cream received Food and Drug Administration approval for treatment of superficial basal cell carcinoma nearly 4 decades ago, the cream is underused for that indication today, even though it is very well tolerated and is particularly beneficial as an alternative to surgery for many patients, Leon H. Kircik, M.D., said at a meeting sponsored by the Skin Disease Education Foundation.

The cream was first approved by the FDA based on a study showing a 93% cure rate among 54 patients with 113 superficial basal cell carcinoma lesions after an average treatment period of about 6 weeks.

To take a fresh look at the treatment, Dr. Kircik, a dermatologist in Louisville, Ky., conducted a study treating 25 patients with 27 lesions with the 5-FU brand Efudex and found remarkably similar results.

The study showed a cure rate that was just the same—93%, with the average cure time in Dr. Kircik's study of about 10 weeks. Four lesions were cured by week 6, 5 lesions were cured by week 9, and 16 were cured by week 12.

Just as remarkable, however, were findings on patient-reported tolerability, pain, and satisfaction. On a tolerability scale of 1-4, with 1 being “very painful” and 4 being “not painful” at all, the ratings were consistently between 3.5 and 3.8 over the 15-week course.

“Most patients did not complain, and this is unusual,” Dr. Kircik said. “With 5-FU cream use on actinic keratosis patients, there are often many more complaints of pain and discomfort.”

Inclusion criteria in Dr. Kircik's study included lesion diameter greater than 0.5 cm and less than 2.0 cm. Criteria for exclusion included treatment for skin cancer within the last month, pregnancy, or a known sensitivity to the treatment.

Scarring was minimal, with scarring levels between 0.22 and 0.38 on a scale of 0 (no scarring) to 3 (severe scarring) And, in what Dr. Kircik said was the most telling reading, most patients indicated they would be willing to repeat the therapy.

“If you ask this of an actinic keratosis patient, their response is often 'no way,' but there was a very different profile with these patients,” Dr. Kircik said. “There were no serious adverse events, the medication was well tolerated, and there was little to no pain during the course of the treatment.”

Dr. Kircik said he believes that in addition to a relatively high cost, some physicians may shy away from 5-FU cream for superficial BCC treatment because of the higher pain problems they've heard reported by actinic keratosis patients.

The treatment, however, is particularly beneficial for patients such as the elderly, whose overall health could make them poor candidates for surgery, and younger patients with cosmetic concerns, since the treatment has an excellent cosmetic outcome.

Studies furthermore show that 5-FU cream's 93% cure rate is similar to that of other treatments including excision (about 90%) and curettage (93%), Dr. Kircik said.

“Considering that these therapies all have similar cure rates, [you] should consider patient tolerability and the excellent cosmetic outcome factors when considering 5-FU cream,” he said.

Dr. Kircik disclosed that he has received funding either as a consultant or as an investigator from Valeant Pharmaceuticals International, the maker of Efudex, and other pharmaceutical companies.

The Skin Disease Education Foundation and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — Although 5% 5-fluorouracil cream received Food and Drug Administration approval for treatment of superficial basal cell carcinoma nearly 4 decades ago, the cream is underused for that indication today, even though it is very well tolerated and is particularly beneficial as an alternative to surgery for many patients, Leon H. Kircik, M.D., said at a meeting sponsored by the Skin Disease Education Foundation.

The cream was first approved by the FDA based on a study showing a 93% cure rate among 54 patients with 113 superficial basal cell carcinoma lesions after an average treatment period of about 6 weeks.

To take a fresh look at the treatment, Dr. Kircik, a dermatologist in Louisville, Ky., conducted a study treating 25 patients with 27 lesions with the 5-FU brand Efudex and found remarkably similar results.

The study showed a cure rate that was just the same—93%, with the average cure time in Dr. Kircik's study of about 10 weeks. Four lesions were cured by week 6, 5 lesions were cured by week 9, and 16 were cured by week 12.

Just as remarkable, however, were findings on patient-reported tolerability, pain, and satisfaction. On a tolerability scale of 1-4, with 1 being “very painful” and 4 being “not painful” at all, the ratings were consistently between 3.5 and 3.8 over the 15-week course.

“Most patients did not complain, and this is unusual,” Dr. Kircik said. “With 5-FU cream use on actinic keratosis patients, there are often many more complaints of pain and discomfort.”

Inclusion criteria in Dr. Kircik's study included lesion diameter greater than 0.5 cm and less than 2.0 cm. Criteria for exclusion included treatment for skin cancer within the last month, pregnancy, or a known sensitivity to the treatment.

Scarring was minimal, with scarring levels between 0.22 and 0.38 on a scale of 0 (no scarring) to 3 (severe scarring) And, in what Dr. Kircik said was the most telling reading, most patients indicated they would be willing to repeat the therapy.

“If you ask this of an actinic keratosis patient, their response is often 'no way,' but there was a very different profile with these patients,” Dr. Kircik said. “There were no serious adverse events, the medication was well tolerated, and there was little to no pain during the course of the treatment.”

Dr. Kircik said he believes that in addition to a relatively high cost, some physicians may shy away from 5-FU cream for superficial BCC treatment because of the higher pain problems they've heard reported by actinic keratosis patients.

The treatment, however, is particularly beneficial for patients such as the elderly, whose overall health could make them poor candidates for surgery, and younger patients with cosmetic concerns, since the treatment has an excellent cosmetic outcome.

Studies furthermore show that 5-FU cream's 93% cure rate is similar to that of other treatments including excision (about 90%) and curettage (93%), Dr. Kircik said.

“Considering that these therapies all have similar cure rates, [you] should consider patient tolerability and the excellent cosmetic outcome factors when considering 5-FU cream,” he said.

Dr. Kircik disclosed that he has received funding either as a consultant or as an investigator from Valeant Pharmaceuticals International, the maker of Efudex, and other pharmaceutical companies.

The Skin Disease Education Foundation and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — Although 5% 5-fluorouracil cream received Food and Drug Administration approval for treatment of superficial basal cell carcinoma nearly 4 decades ago, the cream is underused for that indication today, even though it is very well tolerated and is particularly beneficial as an alternative to surgery for many patients, Leon H. Kircik, M.D., said at a meeting sponsored by the Skin Disease Education Foundation.

The cream was first approved by the FDA based on a study showing a 93% cure rate among 54 patients with 113 superficial basal cell carcinoma lesions after an average treatment period of about 6 weeks.

To take a fresh look at the treatment, Dr. Kircik, a dermatologist in Louisville, Ky., conducted a study treating 25 patients with 27 lesions with the 5-FU brand Efudex and found remarkably similar results.

The study showed a cure rate that was just the same—93%, with the average cure time in Dr. Kircik's study of about 10 weeks. Four lesions were cured by week 6, 5 lesions were cured by week 9, and 16 were cured by week 12.

Just as remarkable, however, were findings on patient-reported tolerability, pain, and satisfaction. On a tolerability scale of 1-4, with 1 being “very painful” and 4 being “not painful” at all, the ratings were consistently between 3.5 and 3.8 over the 15-week course.

“Most patients did not complain, and this is unusual,” Dr. Kircik said. “With 5-FU cream use on actinic keratosis patients, there are often many more complaints of pain and discomfort.”

Inclusion criteria in Dr. Kircik's study included lesion diameter greater than 0.5 cm and less than 2.0 cm. Criteria for exclusion included treatment for skin cancer within the last month, pregnancy, or a known sensitivity to the treatment.

Scarring was minimal, with scarring levels between 0.22 and 0.38 on a scale of 0 (no scarring) to 3 (severe scarring) And, in what Dr. Kircik said was the most telling reading, most patients indicated they would be willing to repeat the therapy.

“If you ask this of an actinic keratosis patient, their response is often 'no way,' but there was a very different profile with these patients,” Dr. Kircik said. “There were no serious adverse events, the medication was well tolerated, and there was little to no pain during the course of the treatment.”

Dr. Kircik said he believes that in addition to a relatively high cost, some physicians may shy away from 5-FU cream for superficial BCC treatment because of the higher pain problems they've heard reported by actinic keratosis patients.

The treatment, however, is particularly beneficial for patients such as the elderly, whose overall health could make them poor candidates for surgery, and younger patients with cosmetic concerns, since the treatment has an excellent cosmetic outcome.

Studies furthermore show that 5-FU cream's 93% cure rate is similar to that of other treatments including excision (about 90%) and curettage (93%), Dr. Kircik said.

“Considering that these therapies all have similar cure rates, [you] should consider patient tolerability and the excellent cosmetic outcome factors when considering 5-FU cream,” he said.

Dr. Kircik disclosed that he has received funding either as a consultant or as an investigator from Valeant Pharmaceuticals International, the maker of Efudex, and other pharmaceutical companies.

The Skin Disease Education Foundation and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. – Medications have their rightful place in headache treatment, but a strong dose of some key coping and behavioral tools can go a long way toward helping patients manage their own headaches, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

The placebo effect has long shown how powerful an influence perception can be in how patients experience pain, and research shows that effect to be particularly important in headaches, he said.

In fact, nearly every published headache study comparing drugs alone with a combination of drugs and behavior therapy has shown the combined treatment to be superior, said Dr. Lake, who is director of the division of behavioral medicine at the Michigan Head-Pain & Neurological Institute in Ann Arbor, Mich.

“We can emphasize the power of drugs in our interventions, or we can emphasize the coping skills, but it doesn't have to be either/or because there are ways to think of them together,” he said.

An important starting point in teaching patients self-efficacy in headache control is to convey the sense of confidence that they can indeed prevent and control headaches, and that they can remain calm and continue to function, Dr. Lake said.

Establishing those core beliefs gives patients a critical sense of control over pain; research has shown that people's beliefs that they can accomplish something are better predictors of their actually accomplishing it than are most other factors, including past performance, he said.

Clinicians can help build up those beliefs by presenting examples of people who had similar obstacles and overcame them. “What often inspires us the most and changes our behavior is seeing someone else who overcame it,” Dr. Lake said.

In addition to noting others' experiences, clinicians can suggest that patients look to their own experiences and think of an obstacle that they overcame. “Urge patients to consider how they overcame it and think about how they could use those same skills in managing or preventing their pain,” Dr. Lake said.

Patients should, however, also work to try to raise their level of pain tolerance. This effort is especially important among patients who are trying to decrease excessive use of analgesics and who will likely have to deal with some pain in the process. “These patients need to learn to tolerate some level of pain without reaching for a painkiller,” Dr. Lake said.

Deep breathing skills and other relaxation methods can be useful tools in pain tolerance, and optimal health behavior, including nutrition and sleep regulation, should be encouraged to further control headaches.

Finally, Dr. Lake emphasized that a clinician's enthusiastic reinforcement of adaptive behavior can make a bigger difference to patients than some doctors may realize. “Reinforcement is a huge factor in our relationships with patients,” he said. “I think we sometimes don't recognize how important our relationship is with patients.”

SCOTTSDALE, ARIZ. – Medications have their rightful place in headache treatment, but a strong dose of some key coping and behavioral tools can go a long way toward helping patients manage their own headaches, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

The placebo effect has long shown how powerful an influence perception can be in how patients experience pain, and research shows that effect to be particularly important in headaches, he said.

In fact, nearly every published headache study comparing drugs alone with a combination of drugs and behavior therapy has shown the combined treatment to be superior, said Dr. Lake, who is director of the division of behavioral medicine at the Michigan Head-Pain & Neurological Institute in Ann Arbor, Mich.

“We can emphasize the power of drugs in our interventions, or we can emphasize the coping skills, but it doesn't have to be either/or because there are ways to think of them together,” he said.

An important starting point in teaching patients self-efficacy in headache control is to convey the sense of confidence that they can indeed prevent and control headaches, and that they can remain calm and continue to function, Dr. Lake said.

Establishing those core beliefs gives patients a critical sense of control over pain; research has shown that people's beliefs that they can accomplish something are better predictors of their actually accomplishing it than are most other factors, including past performance, he said.

Clinicians can help build up those beliefs by presenting examples of people who had similar obstacles and overcame them. “What often inspires us the most and changes our behavior is seeing someone else who overcame it,” Dr. Lake said.

In addition to noting others' experiences, clinicians can suggest that patients look to their own experiences and think of an obstacle that they overcame. “Urge patients to consider how they overcame it and think about how they could use those same skills in managing or preventing their pain,” Dr. Lake said.

Patients should, however, also work to try to raise their level of pain tolerance. This effort is especially important among patients who are trying to decrease excessive use of analgesics and who will likely have to deal with some pain in the process. “These patients need to learn to tolerate some level of pain without reaching for a painkiller,” Dr. Lake said.

Deep breathing skills and other relaxation methods can be useful tools in pain tolerance, and optimal health behavior, including nutrition and sleep regulation, should be encouraged to further control headaches.

Finally, Dr. Lake emphasized that a clinician's enthusiastic reinforcement of adaptive behavior can make a bigger difference to patients than some doctors may realize. “Reinforcement is a huge factor in our relationships with patients,” he said. “I think we sometimes don't recognize how important our relationship is with patients.”

SCOTTSDALE, ARIZ. – Medications have their rightful place in headache treatment, but a strong dose of some key coping and behavioral tools can go a long way toward helping patients manage their own headaches, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

The placebo effect has long shown how powerful an influence perception can be in how patients experience pain, and research shows that effect to be particularly important in headaches, he said.

In fact, nearly every published headache study comparing drugs alone with a combination of drugs and behavior therapy has shown the combined treatment to be superior, said Dr. Lake, who is director of the division of behavioral medicine at the Michigan Head-Pain & Neurological Institute in Ann Arbor, Mich.

“We can emphasize the power of drugs in our interventions, or we can emphasize the coping skills, but it doesn't have to be either/or because there are ways to think of them together,” he said.

An important starting point in teaching patients self-efficacy in headache control is to convey the sense of confidence that they can indeed prevent and control headaches, and that they can remain calm and continue to function, Dr. Lake said.

Establishing those core beliefs gives patients a critical sense of control over pain; research has shown that people's beliefs that they can accomplish something are better predictors of their actually accomplishing it than are most other factors, including past performance, he said.

Clinicians can help build up those beliefs by presenting examples of people who had similar obstacles and overcame them. “What often inspires us the most and changes our behavior is seeing someone else who overcame it,” Dr. Lake said.

In addition to noting others' experiences, clinicians can suggest that patients look to their own experiences and think of an obstacle that they overcame. “Urge patients to consider how they overcame it and think about how they could use those same skills in managing or preventing their pain,” Dr. Lake said.

Patients should, however, also work to try to raise their level of pain tolerance. This effort is especially important among patients who are trying to decrease excessive use of analgesics and who will likely have to deal with some pain in the process. “These patients need to learn to tolerate some level of pain without reaching for a painkiller,” Dr. Lake said.

Deep breathing skills and other relaxation methods can be useful tools in pain tolerance, and optimal health behavior, including nutrition and sleep regulation, should be encouraged to further control headaches.

Finally, Dr. Lake emphasized that a clinician's enthusiastic reinforcement of adaptive behavior can make a bigger difference to patients than some doctors may realize. “Reinforcement is a huge factor in our relationships with patients,” he said. “I think we sometimes don't recognize how important our relationship is with patients.”

SCOTTSDALE, ARIZ. – The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20-44, the rate is about 25 per 100,000. Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (N.Y.).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture. “You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having an LP.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment. But with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, she said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care, Dr. Friedman noted.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” she said. “It's crucial to have an ophthalmologist and a neurologist who are both following the patient and talking to each other about how to manage the patient.”

SCOTTSDALE, ARIZ. – The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20-44, the rate is about 25 per 100,000. Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (N.Y.).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture. “You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having an LP.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment. But with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, she said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care, Dr. Friedman noted.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” she said. “It's crucial to have an ophthalmologist and a neurologist who are both following the patient and talking to each other about how to manage the patient.”

SCOTTSDALE, ARIZ. – The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20-44, the rate is about 25 per 100,000. Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (N.Y.).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture. “You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having an LP.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment. But with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, she said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care, Dr. Friedman noted.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” she said. “It's crucial to have an ophthalmologist and a neurologist who are both following the patient and talking to each other about how to manage the patient.”

SCOTTSDALE, ARIZ. – Headache management in the elderly involves consideration of factors not often seen in younger patients, Jerry W. Swanson, M.D., said at a symposium sponsored by the American Headache Society.

The possibility of secondary headache is greater in older patients, who often experience polypharmacy and drug interactions, said Dr. Swanson, professor and chair of the division of neurology at the Mayo Clinic Medical School in Rochester, Minn.

Headache ranks as the 10th most common symptom among elderly women and the 14th among elderly men.

Secondary headaches represent one-third of headaches in the elderly, compared with 10% in the general population (Headache 1990;30:273-6).

Typical causes of secondary headaches in the elderly include lesional headaches or cerebrovascular disease–both of which are more common in the elderly–as well as medication-induced headaches.

Giant cell arteritis, a necrotizing, granulomatous arteritis rarely seen before age 50, also should be considered. “New-onset headache is the key with giant cell arteritis,” Dr. Swanson said. Other common symptoms of giant cell arteritis include jaw claudication (which occurs in about 40% of cases), fatigue, and fever.

When elderly patients present with a headache, it is important to obtain a detailed history. It's especially important to get a detailed medication history. Why? “Because patients have more medical conditions as they age, you're much more likely to encounter polypharmacy, which increases the risk of drug interactions and side effects,” Dr. Swanson said.

Elderly patients are also prone to have a reduced tolerance to those side effects, he pointed out.

Headaches that are associated with medication are often generalized and of mild to moderate severity, and they may be throbbing.

The list of drugs that could be etiologic includes antibiotics, such as tetracycline; bronchodilators; cardiovascular drugs, such as vasodilators and antihypertensives; sedatives and stimulants; antidepressants, such as selective serotonin reuptake inhibitors; and reproductive drugs, such as estrogen.

With secondary headache ruled out, diagnosing and managing primary headaches in the elderly can pose unique challenges and atypical twists. Migraine headaches, for instance, peak in prevalence at about age 40 and are thus less common in the elderly.

That means migraines make up about 8% of headaches in women over age 60 and 3% in men. However, the literature indicates that migraines develop in about 2% of patients over age 50.

In the elderly, migraine headaches can present with reduced severity and frequency than in younger patients. But there can also be what neurologist C. Miller Fisher, M.D., described as “late-life migraine accompaniments”–including new onset of focal neurologic symptoms, positive visual displays, gradual buildup of visual and sensory symptoms, and serial progression.

Tension-type headaches, though also less common in older age, are more prevalent than migraines, with rates beyond age 65 varying between 27% and 44.5% and higher rates reported among women.

Treatment of migraine or tension-type headaches in older patients can be difficult. It is important to keep in mind that if a prophylactic approach is used with elderly patients, the starting dose should be low and with slow increases, Dr. Swanson said.

Cluster headaches, though also infrequent, are more common among men.

“Virtually all patients for whom a [cluster headache] diagnosis is being entertained should undergo MRI and [magnetic resonance angiography],” he said.

Another type of primary headache, the hypnic headache, has been reported specifically in the elderly and not in younger age groups, he said.

First described in 1988 and still rare, the hypnic headache is a dull one that develops only during sleep, yet with “clocklike regularity.” In addition, the hypnic headache is not attributed to any other disorder.

Treatments for the hypnic headache include sleep rationing, lithium, caffeine, or indomethacin, Dr. Swanson noted.

SCOTTSDALE, ARIZ. – Headache management in the elderly involves consideration of factors not often seen in younger patients, Jerry W. Swanson, M.D., said at a symposium sponsored by the American Headache Society.

The possibility of secondary headache is greater in older patients, who often experience polypharmacy and drug interactions, said Dr. Swanson, professor and chair of the division of neurology at the Mayo Clinic Medical School in Rochester, Minn.

Headache ranks as the 10th most common symptom among elderly women and the 14th among elderly men.

Secondary headaches represent one-third of headaches in the elderly, compared with 10% in the general population (Headache 1990;30:273-6).

Typical causes of secondary headaches in the elderly include lesional headaches or cerebrovascular disease–both of which are more common in the elderly–as well as medication-induced headaches.

Giant cell arteritis, a necrotizing, granulomatous arteritis rarely seen before age 50, also should be considered. “New-onset headache is the key with giant cell arteritis,” Dr. Swanson said. Other common symptoms of giant cell arteritis include jaw claudication (which occurs in about 40% of cases), fatigue, and fever.

When elderly patients present with a headache, it is important to obtain a detailed history. It's especially important to get a detailed medication history. Why? “Because patients have more medical conditions as they age, you're much more likely to encounter polypharmacy, which increases the risk of drug interactions and side effects,” Dr. Swanson said.

Elderly patients are also prone to have a reduced tolerance to those side effects, he pointed out.

Headaches that are associated with medication are often generalized and of mild to moderate severity, and they may be throbbing.

The list of drugs that could be etiologic includes antibiotics, such as tetracycline; bronchodilators; cardiovascular drugs, such as vasodilators and antihypertensives; sedatives and stimulants; antidepressants, such as selective serotonin reuptake inhibitors; and reproductive drugs, such as estrogen.

With secondary headache ruled out, diagnosing and managing primary headaches in the elderly can pose unique challenges and atypical twists. Migraine headaches, for instance, peak in prevalence at about age 40 and are thus less common in the elderly.

That means migraines make up about 8% of headaches in women over age 60 and 3% in men. However, the literature indicates that migraines develop in about 2% of patients over age 50.

In the elderly, migraine headaches can present with reduced severity and frequency than in younger patients. But there can also be what neurologist C. Miller Fisher, M.D., described as “late-life migraine accompaniments”–including new onset of focal neurologic symptoms, positive visual displays, gradual buildup of visual and sensory symptoms, and serial progression.

Tension-type headaches, though also less common in older age, are more prevalent than migraines, with rates beyond age 65 varying between 27% and 44.5% and higher rates reported among women.

Treatment of migraine or tension-type headaches in older patients can be difficult. It is important to keep in mind that if a prophylactic approach is used with elderly patients, the starting dose should be low and with slow increases, Dr. Swanson said.

Cluster headaches, though also infrequent, are more common among men.

“Virtually all patients for whom a [cluster headache] diagnosis is being entertained should undergo MRI and [magnetic resonance angiography],” he said.

Another type of primary headache, the hypnic headache, has been reported specifically in the elderly and not in younger age groups, he said.

First described in 1988 and still rare, the hypnic headache is a dull one that develops only during sleep, yet with “clocklike regularity.” In addition, the hypnic headache is not attributed to any other disorder.

Treatments for the hypnic headache include sleep rationing, lithium, caffeine, or indomethacin, Dr. Swanson noted.

SCOTTSDALE, ARIZ. – Headache management in the elderly involves consideration of factors not often seen in younger patients, Jerry W. Swanson, M.D., said at a symposium sponsored by the American Headache Society.

The possibility of secondary headache is greater in older patients, who often experience polypharmacy and drug interactions, said Dr. Swanson, professor and chair of the division of neurology at the Mayo Clinic Medical School in Rochester, Minn.

Headache ranks as the 10th most common symptom among elderly women and the 14th among elderly men.

Secondary headaches represent one-third of headaches in the elderly, compared with 10% in the general population (Headache 1990;30:273-6).

Typical causes of secondary headaches in the elderly include lesional headaches or cerebrovascular disease–both of which are more common in the elderly–as well as medication-induced headaches.

Giant cell arteritis, a necrotizing, granulomatous arteritis rarely seen before age 50, also should be considered. “New-onset headache is the key with giant cell arteritis,” Dr. Swanson said. Other common symptoms of giant cell arteritis include jaw claudication (which occurs in about 40% of cases), fatigue, and fever.

When elderly patients present with a headache, it is important to obtain a detailed history. It's especially important to get a detailed medication history. Why? “Because patients have more medical conditions as they age, you're much more likely to encounter polypharmacy, which increases the risk of drug interactions and side effects,” Dr. Swanson said.

Elderly patients are also prone to have a reduced tolerance to those side effects, he pointed out.

Headaches that are associated with medication are often generalized and of mild to moderate severity, and they may be throbbing.

The list of drugs that could be etiologic includes antibiotics, such as tetracycline; bronchodilators; cardiovascular drugs, such as vasodilators and antihypertensives; sedatives and stimulants; antidepressants, such as selective serotonin reuptake inhibitors; and reproductive drugs, such as estrogen.

With secondary headache ruled out, diagnosing and managing primary headaches in the elderly can pose unique challenges and atypical twists. Migraine headaches, for instance, peak in prevalence at about age 40 and are thus less common in the elderly.

That means migraines make up about 8% of headaches in women over age 60 and 3% in men. However, the literature indicates that migraines develop in about 2% of patients over age 50.

In the elderly, migraine headaches can present with reduced severity and frequency than in younger patients. But there can also be what neurologist C. Miller Fisher, M.D., described as “late-life migraine accompaniments”–including new onset of focal neurologic symptoms, positive visual displays, gradual buildup of visual and sensory symptoms, and serial progression.

Tension-type headaches, though also less common in older age, are more prevalent than migraines, with rates beyond age 65 varying between 27% and 44.5% and higher rates reported among women.

Treatment of migraine or tension-type headaches in older patients can be difficult. It is important to keep in mind that if a prophylactic approach is used with elderly patients, the starting dose should be low and with slow increases, Dr. Swanson said.

Cluster headaches, though also infrequent, are more common among men.

“Virtually all patients for whom a [cluster headache] diagnosis is being entertained should undergo MRI and [magnetic resonance angiography],” he said.

Another type of primary headache, the hypnic headache, has been reported specifically in the elderly and not in younger age groups, he said.

First described in 1988 and still rare, the hypnic headache is a dull one that develops only during sleep, yet with “clocklike regularity.” In addition, the hypnic headache is not attributed to any other disorder.

Treatments for the hypnic headache include sleep rationing, lithium, caffeine, or indomethacin, Dr. Swanson noted.

SCOTTSDALE, ARIZ. — Radiofrequency tissue tightening using Thermage's ThermaCool TC system has gained favor for wrinkle reduction with the standard use of a single pass of the device, but better results and greater tolerance are seen with a multiple-passes approach using reduced treatment-level settings, said Bill H. Halmi, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

The ThermaCool system, which has received Food and Drug Administration approval for smoothing wrinkles and sagging skin around the face, has yielded only modest results, and subtle changes were often not even noticeable, said Dr. Halmi, a dermatologist and owner of Arizona Advanced Dermatology in Phoenix.

Furthermore, the treatment was not without some discomfort, and early safety observations showed a 6% rate of scarring or texture change 6 months post treatment.

In a new technique introduced last year by Brian Zelickson, M.D., however, use of multiple passes in a single treatment with lower frequency showed the achievement of greater deep-collagen denaturation. In addition, the already rare risk of surface tissue damage was further decreased, as was patient discomfort.

Dermatologists including Dr. Halmi have picked up on the multiple-passes approach and report much improved results. "The newer treatment paradigm is much better tolerated, reduces the risks, and appears so far to offer better results," Dr. Halmi said.

With the multiple-passes approach, frequency should be reduced and as many as four or five passes can be used. "One pass is made over the entire surface area, then on the second pass you concentrate on the areas of interest, and you can go on to four or five passes on the face to reach a clinical point of physical tightening," Dr. Halmi said.

Since there is immediate collagen contraction, visible results are seen right away, but this response usually lasts only a matter of hours or days. It typically takes about 2 months, however, to see the maximum results of the more important secondary response showing collagen remodeling and tightening.

While radiofrequency (RF) waves have long been used in dermatology for purposes such as electrocoagulation and skin resurfacing, the ThermaCool system is unique in that it uses a patented capacitive coupling to give greater uniformity in heating and tightening deeper tissue, Dr. Halmi explained.

The device also uses cooling before, during, and after the delivery of the RF energy to protect the epidermis.

Slides presented from Dr. Halmi's practice showed dramatic improvement in areas including the nasolabial fold, the jowls, and especially the neck.

"It turns out neck tightening is probably the area this [treatment] does the best in," Dr. Halmi said. "Using the 'traditional' protocol of one pass usually achieves at least subtle results, but multiple passes appear to be yielding much better results."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — Radiofrequency tissue tightening using Thermage's ThermaCool TC system has gained favor for wrinkle reduction with the standard use of a single pass of the device, but better results and greater tolerance are seen with a multiple-passes approach using reduced treatment-level settings, said Bill H. Halmi, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

The ThermaCool system, which has received Food and Drug Administration approval for smoothing wrinkles and sagging skin around the face, has yielded only modest results, and subtle changes were often not even noticeable, said Dr. Halmi, a dermatologist and owner of Arizona Advanced Dermatology in Phoenix.

Furthermore, the treatment was not without some discomfort, and early safety observations showed a 6% rate of scarring or texture change 6 months post treatment.

In a new technique introduced last year by Brian Zelickson, M.D., however, use of multiple passes in a single treatment with lower frequency showed the achievement of greater deep-collagen denaturation. In addition, the already rare risk of surface tissue damage was further decreased, as was patient discomfort.

Dermatologists including Dr. Halmi have picked up on the multiple-passes approach and report much improved results. "The newer treatment paradigm is much better tolerated, reduces the risks, and appears so far to offer better results," Dr. Halmi said.

With the multiple-passes approach, frequency should be reduced and as many as four or five passes can be used. "One pass is made over the entire surface area, then on the second pass you concentrate on the areas of interest, and you can go on to four or five passes on the face to reach a clinical point of physical tightening," Dr. Halmi said.

Since there is immediate collagen contraction, visible results are seen right away, but this response usually lasts only a matter of hours or days. It typically takes about 2 months, however, to see the maximum results of the more important secondary response showing collagen remodeling and tightening.

While radiofrequency (RF) waves have long been used in dermatology for purposes such as electrocoagulation and skin resurfacing, the ThermaCool system is unique in that it uses a patented capacitive coupling to give greater uniformity in heating and tightening deeper tissue, Dr. Halmi explained.

The device also uses cooling before, during, and after the delivery of the RF energy to protect the epidermis.

Slides presented from Dr. Halmi's practice showed dramatic improvement in areas including the nasolabial fold, the jowls, and especially the neck.

"It turns out neck tightening is probably the area this [treatment] does the best in," Dr. Halmi said. "Using the 'traditional' protocol of one pass usually achieves at least subtle results, but multiple passes appear to be yielding much better results."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — Radiofrequency tissue tightening using Thermage's ThermaCool TC system has gained favor for wrinkle reduction with the standard use of a single pass of the device, but better results and greater tolerance are seen with a multiple-passes approach using reduced treatment-level settings, said Bill H. Halmi, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

The ThermaCool system, which has received Food and Drug Administration approval for smoothing wrinkles and sagging skin around the face, has yielded only modest results, and subtle changes were often not even noticeable, said Dr. Halmi, a dermatologist and owner of Arizona Advanced Dermatology in Phoenix.

Furthermore, the treatment was not without some discomfort, and early safety observations showed a 6% rate of scarring or texture change 6 months post treatment.

In a new technique introduced last year by Brian Zelickson, M.D., however, use of multiple passes in a single treatment with lower frequency showed the achievement of greater deep-collagen denaturation. In addition, the already rare risk of surface tissue damage was further decreased, as was patient discomfort.

Dermatologists including Dr. Halmi have picked up on the multiple-passes approach and report much improved results. "The newer treatment paradigm is much better tolerated, reduces the risks, and appears so far to offer better results," Dr. Halmi said.

With the multiple-passes approach, frequency should be reduced and as many as four or five passes can be used. "One pass is made over the entire surface area, then on the second pass you concentrate on the areas of interest, and you can go on to four or five passes on the face to reach a clinical point of physical tightening," Dr. Halmi said.

Since there is immediate collagen contraction, visible results are seen right away, but this response usually lasts only a matter of hours or days. It typically takes about 2 months, however, to see the maximum results of the more important secondary response showing collagen remodeling and tightening.

While radiofrequency (RF) waves have long been used in dermatology for purposes such as electrocoagulation and skin resurfacing, the ThermaCool system is unique in that it uses a patented capacitive coupling to give greater uniformity in heating and tightening deeper tissue, Dr. Halmi explained.

The device also uses cooling before, during, and after the delivery of the RF energy to protect the epidermis.

Slides presented from Dr. Halmi's practice showed dramatic improvement in areas including the nasolabial fold, the jowls, and especially the neck.

"It turns out neck tightening is probably the area this [treatment] does the best in," Dr. Halmi said. "Using the 'traditional' protocol of one pass usually achieves at least subtle results, but multiple passes appear to be yielding much better results."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially for use in children and emergent situations, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product can be ideal for many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

“It's a few seconds versus the time it takes for stitches, which with children can take upward of half an hour. So the benefit is obvious,” said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

The product also is especially beneficial for the commonly problematic diaper region.

“Usually, when you stitch the diaper region, you worry about postop infection, but this is far superior,” Dr. Cunningham said.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli species. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use. The old adhesives also tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to physicians' preferences, with newer formulations being more viscous and featuring better applicator tips.

Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas, Dr. Cunningham said.

She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

For the same reason, doctors should avoid placing Neosporin (neomycin) ointment or other petrolatum-based products on an incision that needs to be closed, because such products can cause the Dermabond to dissolve.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. Dr. Cunningham argued that the savings in time make up for the cost. “If you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond,” she said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially for use in children and emergent situations, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product can be ideal for many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

“It's a few seconds versus the time it takes for stitches, which with children can take upward of half an hour. So the benefit is obvious,” said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

The product also is especially beneficial for the commonly problematic diaper region.

“Usually, when you stitch the diaper region, you worry about postop infection, but this is far superior,” Dr. Cunningham said.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli species. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use. The old adhesives also tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to physicians' preferences, with newer formulations being more viscous and featuring better applicator tips.

Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas, Dr. Cunningham said.

She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

For the same reason, doctors should avoid placing Neosporin (neomycin) ointment or other petrolatum-based products on an incision that needs to be closed, because such products can cause the Dermabond to dissolve.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. Dr. Cunningham argued that the savings in time make up for the cost. “If you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond,” she said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially for use in children and emergent situations, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product can be ideal for many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

“It's a few seconds versus the time it takes for stitches, which with children can take upward of half an hour. So the benefit is obvious,” said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

The product also is especially beneficial for the commonly problematic diaper region.

“Usually, when you stitch the diaper region, you worry about postop infection, but this is far superior,” Dr. Cunningham said.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli species. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use. The old adhesives also tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to physicians' preferences, with newer formulations being more viscous and featuring better applicator tips.

Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas, Dr. Cunningham said.

She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

For the same reason, doctors should avoid placing Neosporin (neomycin) ointment or other petrolatum-based products on an incision that needs to be closed, because such products can cause the Dermabond to dissolve.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. Dr. Cunningham argued that the savings in time make up for the cost. “If you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond,” she said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.