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The leading independent newspaper covering dermatology news and commentary.
Prioritize oral health in children with DEB
LONDON – , pediatric dentist Susanne Krämer told attendees at the first EB World Congress.
While it may not be the first thing on the minds of families coming to terms with their children having a chronic and potentially debilitating skin disease, it is important to consider oral health early to ensure healthy dentition and mouth function, both of which will affect the ability to eat and thus nutrition.
When there are a lot of other health issues, “dentistry is not a priority,” Dr. Krämer acknowledged in an interview at the meeting, organized by the Dystrophic Epidermolysis Bullosa Association (DEBRA).
Something as simple as brushing teeth can be very distressing for parents of a child with EB, she observed, especially if there is dysphagia and toothpaste may be getting into the airways accidentally.
Oral health was one of the topics that patients with EB and their families said would be good to have some guidance on when they were surveyed by DEBRA International. This led the charity to develop its first clinical practice guideline in 2012. Dr. Krämer was the lead author of the guidelines, which are about to be updated and republished.
The “Oral Health for Patients with Epidermolysis Bullosa – Best Clinical Practice Guidelines” (Int J Paediatr Dent. 2012;22 Suppl 1:1-35) are in the final stages of being revised, said Dr. Krämer, who is head of the department of pediatric dentistry at the University of Chile in Santiago. Although there is not much new evidence since the guidelines were first published, “we do have a lot of new technologies within dentistry that can aid the care of EB,” she said.
An important addition to the upcoming 2020 guidelines is a chapter on the patient-clinician partnership. This was added because “you can have fantastic technologies, but if you don’t have a confident relationship with the family and the patient, you won’t be able to proceed.” Dr. Krämer explained: “Patients with EB are so fragile and so afraid of being hurt that they won’t open their mouth unless there is a confidence with the clinician and they trust [him or her]; once they trust, they [will] open the mouth and you can work.”
Dr. Krämer noted that timing of the first dental appointment will depend on the referral pathway for every country and then every service. In her specialist practice the aim is to see newly diagnosed babies before the age of 3 months. “Lots of people would argue they don’t have teeth, but I need to educate the families on several aspects of oral health from early on.”
Older patients with EB may be more aware of the importance of a healthy mouth from a functional point of view and the need to eat and swallow normally, Dr. Krämer said, adding that the “social aspects of having a healthy smile are very important as well.”
Oral care in EB has come a long way since the 1970s when teeth extraction was recommended as the primary dental treatment option. “If you refer to literature in the 90s, that said we can actually restore the teeth in the patients with EB, and what we are now saying is that we have to prevent oral disease,” Dr. Krämer said.
Can oral disease be prevented completely? Yes, she said, but only in a few patients. “We still have decay in a lot of our patients, but far less than what we have had before. It will depend on the compliance of the family and the patient,” Dr. Krämer noted.
Compliance also is a factor in improving mouth function after surgery, which may be done to prevent the tongue from fusing to the bottom of the mouth and to relieve or prevent microstomia, which limits mouth opening.
“We are doing a lot of surgeries to release the fibrotic scars ... we have done it in both children and adults, but there have been better results in adults, because they are able to comply with the course of exercises” after surgery, Dr. Krämer said.
Results of an as-yet unpublished randomized controlled trial of postoperative mouth exercises demonstrate that patients who did the exercises, which involved using a device to stretch the mouth three times a day for 3 months, saw improvements in mouth opening. Once they stopped doing the exercises, however, these improvements faded. Considering the time spent on dressing changes and other exercises, this is perhaps understandable, she acknowledged.
Prevention, education, continual follow-up, and early referral are key to good oral health, Dr. Krämer emphasized. “If there is patient-clinician partnership confidence, they can have regular checkups with dental cleaning, with a fluoride varnish, different preventive strategies so they do not need to get to the point where they need general anesthesia or extractions.” Extractions still will be done, she added, but more for orthodontic reasons, because the teeth do not fit in the mouth. “That is our ideal world, that is where we want to go.”
LONDON – , pediatric dentist Susanne Krämer told attendees at the first EB World Congress.
While it may not be the first thing on the minds of families coming to terms with their children having a chronic and potentially debilitating skin disease, it is important to consider oral health early to ensure healthy dentition and mouth function, both of which will affect the ability to eat and thus nutrition.
When there are a lot of other health issues, “dentistry is not a priority,” Dr. Krämer acknowledged in an interview at the meeting, organized by the Dystrophic Epidermolysis Bullosa Association (DEBRA).
Something as simple as brushing teeth can be very distressing for parents of a child with EB, she observed, especially if there is dysphagia and toothpaste may be getting into the airways accidentally.
Oral health was one of the topics that patients with EB and their families said would be good to have some guidance on when they were surveyed by DEBRA International. This led the charity to develop its first clinical practice guideline in 2012. Dr. Krämer was the lead author of the guidelines, which are about to be updated and republished.
The “Oral Health for Patients with Epidermolysis Bullosa – Best Clinical Practice Guidelines” (Int J Paediatr Dent. 2012;22 Suppl 1:1-35) are in the final stages of being revised, said Dr. Krämer, who is head of the department of pediatric dentistry at the University of Chile in Santiago. Although there is not much new evidence since the guidelines were first published, “we do have a lot of new technologies within dentistry that can aid the care of EB,” she said.
An important addition to the upcoming 2020 guidelines is a chapter on the patient-clinician partnership. This was added because “you can have fantastic technologies, but if you don’t have a confident relationship with the family and the patient, you won’t be able to proceed.” Dr. Krämer explained: “Patients with EB are so fragile and so afraid of being hurt that they won’t open their mouth unless there is a confidence with the clinician and they trust [him or her]; once they trust, they [will] open the mouth and you can work.”
Dr. Krämer noted that timing of the first dental appointment will depend on the referral pathway for every country and then every service. In her specialist practice the aim is to see newly diagnosed babies before the age of 3 months. “Lots of people would argue they don’t have teeth, but I need to educate the families on several aspects of oral health from early on.”
Older patients with EB may be more aware of the importance of a healthy mouth from a functional point of view and the need to eat and swallow normally, Dr. Krämer said, adding that the “social aspects of having a healthy smile are very important as well.”
Oral care in EB has come a long way since the 1970s when teeth extraction was recommended as the primary dental treatment option. “If you refer to literature in the 90s, that said we can actually restore the teeth in the patients with EB, and what we are now saying is that we have to prevent oral disease,” Dr. Krämer said.
Can oral disease be prevented completely? Yes, she said, but only in a few patients. “We still have decay in a lot of our patients, but far less than what we have had before. It will depend on the compliance of the family and the patient,” Dr. Krämer noted.
Compliance also is a factor in improving mouth function after surgery, which may be done to prevent the tongue from fusing to the bottom of the mouth and to relieve or prevent microstomia, which limits mouth opening.
“We are doing a lot of surgeries to release the fibrotic scars ... we have done it in both children and adults, but there have been better results in adults, because they are able to comply with the course of exercises” after surgery, Dr. Krämer said.
Results of an as-yet unpublished randomized controlled trial of postoperative mouth exercises demonstrate that patients who did the exercises, which involved using a device to stretch the mouth three times a day for 3 months, saw improvements in mouth opening. Once they stopped doing the exercises, however, these improvements faded. Considering the time spent on dressing changes and other exercises, this is perhaps understandable, she acknowledged.
Prevention, education, continual follow-up, and early referral are key to good oral health, Dr. Krämer emphasized. “If there is patient-clinician partnership confidence, they can have regular checkups with dental cleaning, with a fluoride varnish, different preventive strategies so they do not need to get to the point where they need general anesthesia or extractions.” Extractions still will be done, she added, but more for orthodontic reasons, because the teeth do not fit in the mouth. “That is our ideal world, that is where we want to go.”
LONDON – , pediatric dentist Susanne Krämer told attendees at the first EB World Congress.
While it may not be the first thing on the minds of families coming to terms with their children having a chronic and potentially debilitating skin disease, it is important to consider oral health early to ensure healthy dentition and mouth function, both of which will affect the ability to eat and thus nutrition.
When there are a lot of other health issues, “dentistry is not a priority,” Dr. Krämer acknowledged in an interview at the meeting, organized by the Dystrophic Epidermolysis Bullosa Association (DEBRA).
Something as simple as brushing teeth can be very distressing for parents of a child with EB, she observed, especially if there is dysphagia and toothpaste may be getting into the airways accidentally.
Oral health was one of the topics that patients with EB and their families said would be good to have some guidance on when they were surveyed by DEBRA International. This led the charity to develop its first clinical practice guideline in 2012. Dr. Krämer was the lead author of the guidelines, which are about to be updated and republished.
The “Oral Health for Patients with Epidermolysis Bullosa – Best Clinical Practice Guidelines” (Int J Paediatr Dent. 2012;22 Suppl 1:1-35) are in the final stages of being revised, said Dr. Krämer, who is head of the department of pediatric dentistry at the University of Chile in Santiago. Although there is not much new evidence since the guidelines were first published, “we do have a lot of new technologies within dentistry that can aid the care of EB,” she said.
An important addition to the upcoming 2020 guidelines is a chapter on the patient-clinician partnership. This was added because “you can have fantastic technologies, but if you don’t have a confident relationship with the family and the patient, you won’t be able to proceed.” Dr. Krämer explained: “Patients with EB are so fragile and so afraid of being hurt that they won’t open their mouth unless there is a confidence with the clinician and they trust [him or her]; once they trust, they [will] open the mouth and you can work.”
Dr. Krämer noted that timing of the first dental appointment will depend on the referral pathway for every country and then every service. In her specialist practice the aim is to see newly diagnosed babies before the age of 3 months. “Lots of people would argue they don’t have teeth, but I need to educate the families on several aspects of oral health from early on.”
Older patients with EB may be more aware of the importance of a healthy mouth from a functional point of view and the need to eat and swallow normally, Dr. Krämer said, adding that the “social aspects of having a healthy smile are very important as well.”
Oral care in EB has come a long way since the 1970s when teeth extraction was recommended as the primary dental treatment option. “If you refer to literature in the 90s, that said we can actually restore the teeth in the patients with EB, and what we are now saying is that we have to prevent oral disease,” Dr. Krämer said.
Can oral disease be prevented completely? Yes, she said, but only in a few patients. “We still have decay in a lot of our patients, but far less than what we have had before. It will depend on the compliance of the family and the patient,” Dr. Krämer noted.
Compliance also is a factor in improving mouth function after surgery, which may be done to prevent the tongue from fusing to the bottom of the mouth and to relieve or prevent microstomia, which limits mouth opening.
“We are doing a lot of surgeries to release the fibrotic scars ... we have done it in both children and adults, but there have been better results in adults, because they are able to comply with the course of exercises” after surgery, Dr. Krämer said.
Results of an as-yet unpublished randomized controlled trial of postoperative mouth exercises demonstrate that patients who did the exercises, which involved using a device to stretch the mouth three times a day for 3 months, saw improvements in mouth opening. Once they stopped doing the exercises, however, these improvements faded. Considering the time spent on dressing changes and other exercises, this is perhaps understandable, she acknowledged.
Prevention, education, continual follow-up, and early referral are key to good oral health, Dr. Krämer emphasized. “If there is patient-clinician partnership confidence, they can have regular checkups with dental cleaning, with a fluoride varnish, different preventive strategies so they do not need to get to the point where they need general anesthesia or extractions.” Extractions still will be done, she added, but more for orthodontic reasons, because the teeth do not fit in the mouth. “That is our ideal world, that is where we want to go.”
REPORTING FROM EB 2020
Target plantar keratoderma when managing ‘mild’ EBS
LONDON – Hardened feet are a major determinant of the clinical course of epidermolysis bullosa simplex (EBS), according to research presented by a German team of investigators at the EB World Congress.
In a study of 157 individuals with EBS, 75.8% had plantar keratoderma, a condition associated with a vicious circle of pain, reduced mobility, subsequent weight gain, and further foot problems.
“EBS has severe impacts on various aspects of everyday life,” Antonia Reimer, MD, and associates at the University of Freiburg, Germany, reported in a poster presentation. “Plantar involvement and [plantar keratoderma] are serious complications of all EBS subtypes, correlating with excessive weight gain, pain, local infections, and limited mobility.”
The researchers suggested that “targeting [plantar keratoderma] should be a priority in EBS therapy and research.”
In their retrospective cohort study, clinical and molecular data were retrieved from patient records, and major determinants of the clinical course of EBS investigated. As such, the researchers looked at how weight changes affected EBS, the effect of hardening skin on the feet, pain, mobility, and working life.
“EB simplex is generally regarded as the ‘mildest’ EB type,” Dr. Reimer and colleagues wrote, “however, individuals with EBS report a high disease burden and frequent pain.” The team found that just under 30% of patients (n = 46) experienced frequent pain, particularly those with localized and severe EBS. Of the patients experiencing pain, the majority (75.2%) had plantar keratoderma. Furthermore, those with blisters underneath the hardened skin reported having the most painful lesions.
Palmoplantar hyperhidrosis was present in slightly more than 40% of cases, and was especially common in individuals with localized EBS, Dr. Reimer and colleagues found. They also found that bacterial and fungal infections occurred in 14% and 7% of patients, respectively, and this correlated significantly with diffuse plantar keratoderma.
A third of patients experience mobility problems, and 8.2% required a wheelchair; 16.4% “were in occupational disability,” the team reported.
“Hyperkeratosis is important because it isn’t just about treating the hyperkeratosis, it’s also looking at the mechanical balance of the foot,” Tariq Khan, PhD, said during an unrelated oral presentation. Dr. Khan, a consultant podiatrist specializing in EB at Great Ormond Street Hospital NHS Foundation Trust in London, discussed how to best manage the feet of people with EB.
“Podiatry technology and how we treat can often be detrimental to an EB patient,” Dr. Khan cautioned at the meeting, which was organized by the Dystrophic Epidermolysis Bullosa Association (DEBRA).
For example, “certain devices, certain types of material, will add more friction and pressure and cause more blistering,” he added, making treatment challenging.
Having worked with the EB community for the past 22 years, he noted that he had seen how podiatry practices had been refined to deal with this patient population. Dr. Khan is one of several experts behind EB podiatry guidelines issued by DEBRA International last year (Br J Dermatol. 2019 Aug 9. doi: 10.1111/bjd.18381) and has run the charity’s first practical EB podiatry skills course to educate more podiatrists on the intricacies of managing EB feet.
During his talk, Dr. Kahn mentioned several innovations that came about by working with external companies, such as the production of special cotton socks containing silver fibers to help reduce the symptom of hot feet, and development of a cooling insole that helped draw moisture and odor away from the foot while providing comfort to the wearer.
One of the main problems for those with EB is finding comfortable footwear that doesn’t aggravate their symptoms, Dr. Khan emphasized.
According to the EB podiatry guidelines, footwear needs to be supportive, and “its primary focus should be aimed at minimizing blistering by reducing friction.” If blisters are already present, the guidelines note that dressings and topical antiseptics or antibiotics might be used until the blisters heal. “Therefore, suitable shoes or footwear are essential to accommodate dressings and not lead to further trauma to the damaged area. Footwear that is adjustable may be beneficial in these circumstances.”
What constitutes appropriate footwear is open to debate and was the topic of a separate poster presentation at meeting. Mark O’Sullivan, EB team podiatrist at Solihull and Birmingham Women’s and Children’s NHS Foundation Trust, and associates looked at whether wearing rocker bottom footwear could ease the formation of blisters in patients with EBS.
The team studied nine patients who reported regular plantar blistering. An in-shoe measurement system was devised to measure patients’ plantar pressure while they were wearing their existing footwear and then again when they were wearing new footwear with a rocker bottom. Participants completed questionnaires about the development of blisters on their feet, their activity levels, and pain.
The rocker bottom footwear reduced the peak plantar pressure by 30.5% and the total plantar pressure by 31.8%, compared with regular footwear. A shift in the average pressure under the foot was seen, moving from the heels of the feet to the midfoot area, while remaining similar in the front foot area.
“Patient feedback has been mixed,” Mr. O’Sullivan said when presenting the poster. “Patients state that blisters have often reduced in the heels and forefoot, but new blisters have developed in the midfoot.” As a result, some study participants chose to alternate wearing the rocker bottom footwear with their normal shoes, to even out the places where blisters might form.
Although the jury is still out on the benefit of rocker bottom footwear, one thing that might help those with EBS who develop regular foot blisters may be to keep their weight in check. In a separate poster presentation given by Lynn Hubbard, a specialist EB dietitian in the department of nutrition and dietetics at St. Thomas’ Hospital in London, it was shown that almost a third of patients with EB simplex were obese, compared with 26% of adults in the general U.K. population.
“People with EBS are known to have hyperkeratosis and foot-blistering,” Ms. Hubbard observed in the poster. This can lead to reduce mobility and pain, which “may in turn have an impact on body weight, and an increased BMI [body mass index] may further affect mobility.”
Data were collected on 90 patients who attended a U.K. EBS clinic over an 11-month period. While 45.5% of patients had a normal weight, the majority was overweight (21.1%), obese (21.1%), or morbidly obese (10%).
Fifteen patients completed questionnaires about their mobility, and almost all felt that their weight had an adverse effect on their feet, as did EBS. Several also noted problems with their EBS, in the skin folds around the bra, waist, and sock lines.
“We now plan to begin a pilot study to establish a supportive weight management program for people with EBS and evaluate both weight loss and impact on mobility,” Ms. Hubbard reported.
No conflicts of interest were declared by any of the speakers.
SOURCES: EB 2020. Reimer A et al. Poster 26; Khan T. oral presentation; O’Sullivan M et al. Poster 93; Hubbard L. Poster 19.
LONDON – Hardened feet are a major determinant of the clinical course of epidermolysis bullosa simplex (EBS), according to research presented by a German team of investigators at the EB World Congress.
In a study of 157 individuals with EBS, 75.8% had plantar keratoderma, a condition associated with a vicious circle of pain, reduced mobility, subsequent weight gain, and further foot problems.
“EBS has severe impacts on various aspects of everyday life,” Antonia Reimer, MD, and associates at the University of Freiburg, Germany, reported in a poster presentation. “Plantar involvement and [plantar keratoderma] are serious complications of all EBS subtypes, correlating with excessive weight gain, pain, local infections, and limited mobility.”
The researchers suggested that “targeting [plantar keratoderma] should be a priority in EBS therapy and research.”
In their retrospective cohort study, clinical and molecular data were retrieved from patient records, and major determinants of the clinical course of EBS investigated. As such, the researchers looked at how weight changes affected EBS, the effect of hardening skin on the feet, pain, mobility, and working life.
“EB simplex is generally regarded as the ‘mildest’ EB type,” Dr. Reimer and colleagues wrote, “however, individuals with EBS report a high disease burden and frequent pain.” The team found that just under 30% of patients (n = 46) experienced frequent pain, particularly those with localized and severe EBS. Of the patients experiencing pain, the majority (75.2%) had plantar keratoderma. Furthermore, those with blisters underneath the hardened skin reported having the most painful lesions.
Palmoplantar hyperhidrosis was present in slightly more than 40% of cases, and was especially common in individuals with localized EBS, Dr. Reimer and colleagues found. They also found that bacterial and fungal infections occurred in 14% and 7% of patients, respectively, and this correlated significantly with diffuse plantar keratoderma.
A third of patients experience mobility problems, and 8.2% required a wheelchair; 16.4% “were in occupational disability,” the team reported.
“Hyperkeratosis is important because it isn’t just about treating the hyperkeratosis, it’s also looking at the mechanical balance of the foot,” Tariq Khan, PhD, said during an unrelated oral presentation. Dr. Khan, a consultant podiatrist specializing in EB at Great Ormond Street Hospital NHS Foundation Trust in London, discussed how to best manage the feet of people with EB.
“Podiatry technology and how we treat can often be detrimental to an EB patient,” Dr. Khan cautioned at the meeting, which was organized by the Dystrophic Epidermolysis Bullosa Association (DEBRA).
For example, “certain devices, certain types of material, will add more friction and pressure and cause more blistering,” he added, making treatment challenging.
Having worked with the EB community for the past 22 years, he noted that he had seen how podiatry practices had been refined to deal with this patient population. Dr. Khan is one of several experts behind EB podiatry guidelines issued by DEBRA International last year (Br J Dermatol. 2019 Aug 9. doi: 10.1111/bjd.18381) and has run the charity’s first practical EB podiatry skills course to educate more podiatrists on the intricacies of managing EB feet.
During his talk, Dr. Kahn mentioned several innovations that came about by working with external companies, such as the production of special cotton socks containing silver fibers to help reduce the symptom of hot feet, and development of a cooling insole that helped draw moisture and odor away from the foot while providing comfort to the wearer.
One of the main problems for those with EB is finding comfortable footwear that doesn’t aggravate their symptoms, Dr. Khan emphasized.
According to the EB podiatry guidelines, footwear needs to be supportive, and “its primary focus should be aimed at minimizing blistering by reducing friction.” If blisters are already present, the guidelines note that dressings and topical antiseptics or antibiotics might be used until the blisters heal. “Therefore, suitable shoes or footwear are essential to accommodate dressings and not lead to further trauma to the damaged area. Footwear that is adjustable may be beneficial in these circumstances.”
What constitutes appropriate footwear is open to debate and was the topic of a separate poster presentation at meeting. Mark O’Sullivan, EB team podiatrist at Solihull and Birmingham Women’s and Children’s NHS Foundation Trust, and associates looked at whether wearing rocker bottom footwear could ease the formation of blisters in patients with EBS.
The team studied nine patients who reported regular plantar blistering. An in-shoe measurement system was devised to measure patients’ plantar pressure while they were wearing their existing footwear and then again when they were wearing new footwear with a rocker bottom. Participants completed questionnaires about the development of blisters on their feet, their activity levels, and pain.
The rocker bottom footwear reduced the peak plantar pressure by 30.5% and the total plantar pressure by 31.8%, compared with regular footwear. A shift in the average pressure under the foot was seen, moving from the heels of the feet to the midfoot area, while remaining similar in the front foot area.
“Patient feedback has been mixed,” Mr. O’Sullivan said when presenting the poster. “Patients state that blisters have often reduced in the heels and forefoot, but new blisters have developed in the midfoot.” As a result, some study participants chose to alternate wearing the rocker bottom footwear with their normal shoes, to even out the places where blisters might form.
Although the jury is still out on the benefit of rocker bottom footwear, one thing that might help those with EBS who develop regular foot blisters may be to keep their weight in check. In a separate poster presentation given by Lynn Hubbard, a specialist EB dietitian in the department of nutrition and dietetics at St. Thomas’ Hospital in London, it was shown that almost a third of patients with EB simplex were obese, compared with 26% of adults in the general U.K. population.
“People with EBS are known to have hyperkeratosis and foot-blistering,” Ms. Hubbard observed in the poster. This can lead to reduce mobility and pain, which “may in turn have an impact on body weight, and an increased BMI [body mass index] may further affect mobility.”
Data were collected on 90 patients who attended a U.K. EBS clinic over an 11-month period. While 45.5% of patients had a normal weight, the majority was overweight (21.1%), obese (21.1%), or morbidly obese (10%).
Fifteen patients completed questionnaires about their mobility, and almost all felt that their weight had an adverse effect on their feet, as did EBS. Several also noted problems with their EBS, in the skin folds around the bra, waist, and sock lines.
“We now plan to begin a pilot study to establish a supportive weight management program for people with EBS and evaluate both weight loss and impact on mobility,” Ms. Hubbard reported.
No conflicts of interest were declared by any of the speakers.
SOURCES: EB 2020. Reimer A et al. Poster 26; Khan T. oral presentation; O’Sullivan M et al. Poster 93; Hubbard L. Poster 19.
LONDON – Hardened feet are a major determinant of the clinical course of epidermolysis bullosa simplex (EBS), according to research presented by a German team of investigators at the EB World Congress.
In a study of 157 individuals with EBS, 75.8% had plantar keratoderma, a condition associated with a vicious circle of pain, reduced mobility, subsequent weight gain, and further foot problems.
“EBS has severe impacts on various aspects of everyday life,” Antonia Reimer, MD, and associates at the University of Freiburg, Germany, reported in a poster presentation. “Plantar involvement and [plantar keratoderma] are serious complications of all EBS subtypes, correlating with excessive weight gain, pain, local infections, and limited mobility.”
The researchers suggested that “targeting [plantar keratoderma] should be a priority in EBS therapy and research.”
In their retrospective cohort study, clinical and molecular data were retrieved from patient records, and major determinants of the clinical course of EBS investigated. As such, the researchers looked at how weight changes affected EBS, the effect of hardening skin on the feet, pain, mobility, and working life.
“EB simplex is generally regarded as the ‘mildest’ EB type,” Dr. Reimer and colleagues wrote, “however, individuals with EBS report a high disease burden and frequent pain.” The team found that just under 30% of patients (n = 46) experienced frequent pain, particularly those with localized and severe EBS. Of the patients experiencing pain, the majority (75.2%) had plantar keratoderma. Furthermore, those with blisters underneath the hardened skin reported having the most painful lesions.
Palmoplantar hyperhidrosis was present in slightly more than 40% of cases, and was especially common in individuals with localized EBS, Dr. Reimer and colleagues found. They also found that bacterial and fungal infections occurred in 14% and 7% of patients, respectively, and this correlated significantly with diffuse plantar keratoderma.
A third of patients experience mobility problems, and 8.2% required a wheelchair; 16.4% “were in occupational disability,” the team reported.
“Hyperkeratosis is important because it isn’t just about treating the hyperkeratosis, it’s also looking at the mechanical balance of the foot,” Tariq Khan, PhD, said during an unrelated oral presentation. Dr. Khan, a consultant podiatrist specializing in EB at Great Ormond Street Hospital NHS Foundation Trust in London, discussed how to best manage the feet of people with EB.
“Podiatry technology and how we treat can often be detrimental to an EB patient,” Dr. Khan cautioned at the meeting, which was organized by the Dystrophic Epidermolysis Bullosa Association (DEBRA).
For example, “certain devices, certain types of material, will add more friction and pressure and cause more blistering,” he added, making treatment challenging.
Having worked with the EB community for the past 22 years, he noted that he had seen how podiatry practices had been refined to deal with this patient population. Dr. Khan is one of several experts behind EB podiatry guidelines issued by DEBRA International last year (Br J Dermatol. 2019 Aug 9. doi: 10.1111/bjd.18381) and has run the charity’s first practical EB podiatry skills course to educate more podiatrists on the intricacies of managing EB feet.
During his talk, Dr. Kahn mentioned several innovations that came about by working with external companies, such as the production of special cotton socks containing silver fibers to help reduce the symptom of hot feet, and development of a cooling insole that helped draw moisture and odor away from the foot while providing comfort to the wearer.
One of the main problems for those with EB is finding comfortable footwear that doesn’t aggravate their symptoms, Dr. Khan emphasized.
According to the EB podiatry guidelines, footwear needs to be supportive, and “its primary focus should be aimed at minimizing blistering by reducing friction.” If blisters are already present, the guidelines note that dressings and topical antiseptics or antibiotics might be used until the blisters heal. “Therefore, suitable shoes or footwear are essential to accommodate dressings and not lead to further trauma to the damaged area. Footwear that is adjustable may be beneficial in these circumstances.”
What constitutes appropriate footwear is open to debate and was the topic of a separate poster presentation at meeting. Mark O’Sullivan, EB team podiatrist at Solihull and Birmingham Women’s and Children’s NHS Foundation Trust, and associates looked at whether wearing rocker bottom footwear could ease the formation of blisters in patients with EBS.
The team studied nine patients who reported regular plantar blistering. An in-shoe measurement system was devised to measure patients’ plantar pressure while they were wearing their existing footwear and then again when they were wearing new footwear with a rocker bottom. Participants completed questionnaires about the development of blisters on their feet, their activity levels, and pain.
The rocker bottom footwear reduced the peak plantar pressure by 30.5% and the total plantar pressure by 31.8%, compared with regular footwear. A shift in the average pressure under the foot was seen, moving from the heels of the feet to the midfoot area, while remaining similar in the front foot area.
“Patient feedback has been mixed,” Mr. O’Sullivan said when presenting the poster. “Patients state that blisters have often reduced in the heels and forefoot, but new blisters have developed in the midfoot.” As a result, some study participants chose to alternate wearing the rocker bottom footwear with their normal shoes, to even out the places where blisters might form.
Although the jury is still out on the benefit of rocker bottom footwear, one thing that might help those with EBS who develop regular foot blisters may be to keep their weight in check. In a separate poster presentation given by Lynn Hubbard, a specialist EB dietitian in the department of nutrition and dietetics at St. Thomas’ Hospital in London, it was shown that almost a third of patients with EB simplex were obese, compared with 26% of adults in the general U.K. population.
“People with EBS are known to have hyperkeratosis and foot-blistering,” Ms. Hubbard observed in the poster. This can lead to reduce mobility and pain, which “may in turn have an impact on body weight, and an increased BMI [body mass index] may further affect mobility.”
Data were collected on 90 patients who attended a U.K. EBS clinic over an 11-month period. While 45.5% of patients had a normal weight, the majority was overweight (21.1%), obese (21.1%), or morbidly obese (10%).
Fifteen patients completed questionnaires about their mobility, and almost all felt that their weight had an adverse effect on their feet, as did EBS. Several also noted problems with their EBS, in the skin folds around the bra, waist, and sock lines.
“We now plan to begin a pilot study to establish a supportive weight management program for people with EBS and evaluate both weight loss and impact on mobility,” Ms. Hubbard reported.
No conflicts of interest were declared by any of the speakers.
SOURCES: EB 2020. Reimer A et al. Poster 26; Khan T. oral presentation; O’Sullivan M et al. Poster 93; Hubbard L. Poster 19.
REPORTING FROM EB 2020
Hand deformity happens early in children with dystrophic epidermolysis bullosa
London – A predictable course of hand contracture was seen in a U.K. study of children with recessive dystrophic epidermolysis bullosa (RDEB), with all children experiencing moderate or severe hand deformity by the age of 12 years.
This stark finding, reported at the EB World Congress, organized by the Dystrophic Epidermolysis Bullosa Association (DEBRA), highlighted the importance of intervening early with surgical methods that aim to prevent the pseudosyndactyly, or “mitten” hand deformity, which is an unfortunate characteristic of the genetic skin condition.
The investigative team, from the plastic and reconstructive surgery department at Great Ormond Street Hospital for Children NHS Trust, London, presented data from a retrospective case review of 24 children who attended their specialist pediatric EB center between 2010 and 2019. Of these, seven children had surgery to release hand contractures.
A total of 250 hand assessments were made via the novel Assessment of the Component Hand Contractures in Epidermolysis Bullosa (ACE). The assessment provides a hand deformity grade (HDG) – none, mild, moderate, and severe –based on the typical contractures that are seen in RDEB, such as between the fingers (web space contractures), finger flexion contractures, and thumb adduction contractures.
Using the ACE tool, “we found four significant time points regarding hand contracture development,” Catherine Miller, one of the team’s occupational therapists, said during a poster presentation. At birth, none of the children had any signs of hand deformity, but by 2 years of age half had mild hand contracture. By age 6, all children had some form of hand deformity, Ms. Miller said, and by age 12 all had moderate to severe hand deformity, “so adding to the data that hand deformities really are inevitable.”
Other findings were that the thumb and finger web spaces were the first to contract, Ms. Miller said. “So they tend to develop earlier and progress relatively slowly.” By contrast the finger flexion contractures occurred later on, “but progress more relatively rapidly,” she observed.
“Our data are limited as not every child is included at every age, and out tool has not yet been validated,” Ms. Miller and team acknowledged in the poster. “We assume that hand contractures do not improve, and therefore have included operated hands (mean age 6 years) at their last preoperative HDG in order to represent older children and more advanced hand deformities.”
In an interview, Ms. Miller noted that families have a lot going on when their newborn is diagnosed with RDEB, so introducing the idea that there will be substantial hand deformities in the future “is a difficult conversation. We have to take that gently.”
There are nonsurgical approaches to keeping the hands open, such as “encouraging them to open their hands in play, daily stretches; we can make splints with a silicon substance and other thermoplastic materials,” Ms. Miller said.
Hand surgery is a ‘blunt tool’
“The primary problem, of course, is the dermal fibrosis that we see that creates scarring and secondary problems,” said Gill Smith, a plastic surgery consultant who works with Ms. Miller at the hospital.
“In an ideal world, you would bandage up [the children] so that they could never injure their hands, but then they couldn’t use them, they couldn’t grow properly, and they could not develop,” Ms. Smith said in an oral presentation about hand surgery in children with RDEB. “You do not want them to get to the secondary stage, because the secondary stage is a real problem – you get all these impairments of hand function – pseudosyndactyly, finger contraction, and first web contracture, and ending up in a ‘mitten’ hand.”
Surgery is a very “crude” and “blunt tool,” Ms. Smith emphasized. Prevention is key, and perhaps in the future gene therapy, mesenchymal stem cells, and the like will mean that there is less need for hand surgery, she intimated. Until then, there are some things that can be done surgically – such as wrapping the hands, using gloves to protect the skin, stretching out the web spaces of the palm, and using splints. “All of these things we are trying to improve all the time, and come up with new ideas.”
The question is when to intervene? Ms. Smith said that in any other type of hand surgery, particularly in children where growth and function might be affected, the aim would be to “go in early.” In children with RDEB, however, the timing is not so clear: “Should we be going in early, before secondary joint changes, before we get secondary tendon shortening?” Perhaps this would result in less complex surgery, she suggested, but “it is a really huge deal for families and for children. For the moment we are still only really doing it when there [are] quite significant functional difficulties.”
When it comes to the type of surgery done to release the hands, “everyone has variants on the release technique,” but none are known to be better than any other, Ms. Smith said. Surgical release deals with consequences of dermal fibrosis but also creates more fibrosis, she cautioned.
Effects of hand surgery do not last long
How long the surgery’s effect will last is “what everyone wants to know, and I don’t think anyone has found a really good answer. It is variable, but unfortunately it’s a lot shorter than we’d like,” said Ms. Smith.
Indeed, data in another poster presentation by Ms. Smith and colleagues showed that the situation can be ‘back to square one’ within just a couple of years. Of the seven patients who had surgery at a mean 7 years of age (range 6-10 years), “most had returned to their original total score by 2 years post surgery,” the team wrote. All children “were initially happy with both appearance and function after surgery” they added; however, “happiness gradually decreased with time as they lost function and their scores increased with recurrence of contracture.”
The team noted that “sometimes after surgery a different component of the hand contracture worsened but function was preserved.”
While the ACE tool used by the team has not yet been validated, they believe it to be “a systematic tool with a structured method of administration.” As such it can help with informed decision making, they believe, and it could be used with functional measures to see how hand contractures might be impacting hand function and quality of life.
The ACE tool can be downloaded for free from the GOSH website.
SOURCE: Jessop N et al. EB 2020. Posters 42 and 43; Smith G et al. Poster 63.
London – A predictable course of hand contracture was seen in a U.K. study of children with recessive dystrophic epidermolysis bullosa (RDEB), with all children experiencing moderate or severe hand deformity by the age of 12 years.
This stark finding, reported at the EB World Congress, organized by the Dystrophic Epidermolysis Bullosa Association (DEBRA), highlighted the importance of intervening early with surgical methods that aim to prevent the pseudosyndactyly, or “mitten” hand deformity, which is an unfortunate characteristic of the genetic skin condition.
The investigative team, from the plastic and reconstructive surgery department at Great Ormond Street Hospital for Children NHS Trust, London, presented data from a retrospective case review of 24 children who attended their specialist pediatric EB center between 2010 and 2019. Of these, seven children had surgery to release hand contractures.
A total of 250 hand assessments were made via the novel Assessment of the Component Hand Contractures in Epidermolysis Bullosa (ACE). The assessment provides a hand deformity grade (HDG) – none, mild, moderate, and severe –based on the typical contractures that are seen in RDEB, such as between the fingers (web space contractures), finger flexion contractures, and thumb adduction contractures.
Using the ACE tool, “we found four significant time points regarding hand contracture development,” Catherine Miller, one of the team’s occupational therapists, said during a poster presentation. At birth, none of the children had any signs of hand deformity, but by 2 years of age half had mild hand contracture. By age 6, all children had some form of hand deformity, Ms. Miller said, and by age 12 all had moderate to severe hand deformity, “so adding to the data that hand deformities really are inevitable.”
Other findings were that the thumb and finger web spaces were the first to contract, Ms. Miller said. “So they tend to develop earlier and progress relatively slowly.” By contrast the finger flexion contractures occurred later on, “but progress more relatively rapidly,” she observed.
“Our data are limited as not every child is included at every age, and out tool has not yet been validated,” Ms. Miller and team acknowledged in the poster. “We assume that hand contractures do not improve, and therefore have included operated hands (mean age 6 years) at their last preoperative HDG in order to represent older children and more advanced hand deformities.”
In an interview, Ms. Miller noted that families have a lot going on when their newborn is diagnosed with RDEB, so introducing the idea that there will be substantial hand deformities in the future “is a difficult conversation. We have to take that gently.”
There are nonsurgical approaches to keeping the hands open, such as “encouraging them to open their hands in play, daily stretches; we can make splints with a silicon substance and other thermoplastic materials,” Ms. Miller said.
Hand surgery is a ‘blunt tool’
“The primary problem, of course, is the dermal fibrosis that we see that creates scarring and secondary problems,” said Gill Smith, a plastic surgery consultant who works with Ms. Miller at the hospital.
“In an ideal world, you would bandage up [the children] so that they could never injure their hands, but then they couldn’t use them, they couldn’t grow properly, and they could not develop,” Ms. Smith said in an oral presentation about hand surgery in children with RDEB. “You do not want them to get to the secondary stage, because the secondary stage is a real problem – you get all these impairments of hand function – pseudosyndactyly, finger contraction, and first web contracture, and ending up in a ‘mitten’ hand.”
Surgery is a very “crude” and “blunt tool,” Ms. Smith emphasized. Prevention is key, and perhaps in the future gene therapy, mesenchymal stem cells, and the like will mean that there is less need for hand surgery, she intimated. Until then, there are some things that can be done surgically – such as wrapping the hands, using gloves to protect the skin, stretching out the web spaces of the palm, and using splints. “All of these things we are trying to improve all the time, and come up with new ideas.”
The question is when to intervene? Ms. Smith said that in any other type of hand surgery, particularly in children where growth and function might be affected, the aim would be to “go in early.” In children with RDEB, however, the timing is not so clear: “Should we be going in early, before secondary joint changes, before we get secondary tendon shortening?” Perhaps this would result in less complex surgery, she suggested, but “it is a really huge deal for families and for children. For the moment we are still only really doing it when there [are] quite significant functional difficulties.”
When it comes to the type of surgery done to release the hands, “everyone has variants on the release technique,” but none are known to be better than any other, Ms. Smith said. Surgical release deals with consequences of dermal fibrosis but also creates more fibrosis, she cautioned.
Effects of hand surgery do not last long
How long the surgery’s effect will last is “what everyone wants to know, and I don’t think anyone has found a really good answer. It is variable, but unfortunately it’s a lot shorter than we’d like,” said Ms. Smith.
Indeed, data in another poster presentation by Ms. Smith and colleagues showed that the situation can be ‘back to square one’ within just a couple of years. Of the seven patients who had surgery at a mean 7 years of age (range 6-10 years), “most had returned to their original total score by 2 years post surgery,” the team wrote. All children “were initially happy with both appearance and function after surgery” they added; however, “happiness gradually decreased with time as they lost function and their scores increased with recurrence of contracture.”
The team noted that “sometimes after surgery a different component of the hand contracture worsened but function was preserved.”
While the ACE tool used by the team has not yet been validated, they believe it to be “a systematic tool with a structured method of administration.” As such it can help with informed decision making, they believe, and it could be used with functional measures to see how hand contractures might be impacting hand function and quality of life.
The ACE tool can be downloaded for free from the GOSH website.
SOURCE: Jessop N et al. EB 2020. Posters 42 and 43; Smith G et al. Poster 63.
London – A predictable course of hand contracture was seen in a U.K. study of children with recessive dystrophic epidermolysis bullosa (RDEB), with all children experiencing moderate or severe hand deformity by the age of 12 years.
This stark finding, reported at the EB World Congress, organized by the Dystrophic Epidermolysis Bullosa Association (DEBRA), highlighted the importance of intervening early with surgical methods that aim to prevent the pseudosyndactyly, or “mitten” hand deformity, which is an unfortunate characteristic of the genetic skin condition.
The investigative team, from the plastic and reconstructive surgery department at Great Ormond Street Hospital for Children NHS Trust, London, presented data from a retrospective case review of 24 children who attended their specialist pediatric EB center between 2010 and 2019. Of these, seven children had surgery to release hand contractures.
A total of 250 hand assessments were made via the novel Assessment of the Component Hand Contractures in Epidermolysis Bullosa (ACE). The assessment provides a hand deformity grade (HDG) – none, mild, moderate, and severe –based on the typical contractures that are seen in RDEB, such as between the fingers (web space contractures), finger flexion contractures, and thumb adduction contractures.
Using the ACE tool, “we found four significant time points regarding hand contracture development,” Catherine Miller, one of the team’s occupational therapists, said during a poster presentation. At birth, none of the children had any signs of hand deformity, but by 2 years of age half had mild hand contracture. By age 6, all children had some form of hand deformity, Ms. Miller said, and by age 12 all had moderate to severe hand deformity, “so adding to the data that hand deformities really are inevitable.”
Other findings were that the thumb and finger web spaces were the first to contract, Ms. Miller said. “So they tend to develop earlier and progress relatively slowly.” By contrast the finger flexion contractures occurred later on, “but progress more relatively rapidly,” she observed.
“Our data are limited as not every child is included at every age, and out tool has not yet been validated,” Ms. Miller and team acknowledged in the poster. “We assume that hand contractures do not improve, and therefore have included operated hands (mean age 6 years) at their last preoperative HDG in order to represent older children and more advanced hand deformities.”
In an interview, Ms. Miller noted that families have a lot going on when their newborn is diagnosed with RDEB, so introducing the idea that there will be substantial hand deformities in the future “is a difficult conversation. We have to take that gently.”
There are nonsurgical approaches to keeping the hands open, such as “encouraging them to open their hands in play, daily stretches; we can make splints with a silicon substance and other thermoplastic materials,” Ms. Miller said.
Hand surgery is a ‘blunt tool’
“The primary problem, of course, is the dermal fibrosis that we see that creates scarring and secondary problems,” said Gill Smith, a plastic surgery consultant who works with Ms. Miller at the hospital.
“In an ideal world, you would bandage up [the children] so that they could never injure their hands, but then they couldn’t use them, they couldn’t grow properly, and they could not develop,” Ms. Smith said in an oral presentation about hand surgery in children with RDEB. “You do not want them to get to the secondary stage, because the secondary stage is a real problem – you get all these impairments of hand function – pseudosyndactyly, finger contraction, and first web contracture, and ending up in a ‘mitten’ hand.”
Surgery is a very “crude” and “blunt tool,” Ms. Smith emphasized. Prevention is key, and perhaps in the future gene therapy, mesenchymal stem cells, and the like will mean that there is less need for hand surgery, she intimated. Until then, there are some things that can be done surgically – such as wrapping the hands, using gloves to protect the skin, stretching out the web spaces of the palm, and using splints. “All of these things we are trying to improve all the time, and come up with new ideas.”
The question is when to intervene? Ms. Smith said that in any other type of hand surgery, particularly in children where growth and function might be affected, the aim would be to “go in early.” In children with RDEB, however, the timing is not so clear: “Should we be going in early, before secondary joint changes, before we get secondary tendon shortening?” Perhaps this would result in less complex surgery, she suggested, but “it is a really huge deal for families and for children. For the moment we are still only really doing it when there [are] quite significant functional difficulties.”
When it comes to the type of surgery done to release the hands, “everyone has variants on the release technique,” but none are known to be better than any other, Ms. Smith said. Surgical release deals with consequences of dermal fibrosis but also creates more fibrosis, she cautioned.
Effects of hand surgery do not last long
How long the surgery’s effect will last is “what everyone wants to know, and I don’t think anyone has found a really good answer. It is variable, but unfortunately it’s a lot shorter than we’d like,” said Ms. Smith.
Indeed, data in another poster presentation by Ms. Smith and colleagues showed that the situation can be ‘back to square one’ within just a couple of years. Of the seven patients who had surgery at a mean 7 years of age (range 6-10 years), “most had returned to their original total score by 2 years post surgery,” the team wrote. All children “were initially happy with both appearance and function after surgery” they added; however, “happiness gradually decreased with time as they lost function and their scores increased with recurrence of contracture.”
The team noted that “sometimes after surgery a different component of the hand contracture worsened but function was preserved.”
While the ACE tool used by the team has not yet been validated, they believe it to be “a systematic tool with a structured method of administration.” As such it can help with informed decision making, they believe, and it could be used with functional measures to see how hand contractures might be impacting hand function and quality of life.
The ACE tool can be downloaded for free from the GOSH website.
SOURCE: Jessop N et al. EB 2020. Posters 42 and 43; Smith G et al. Poster 63.
REPORTING FROM EB 2020
Patient counseling about what to expect with noninvasive skin tightening is key
LAHAINA, HAWAII – It’s important to counsel patients about the degree of improvement to expect with noninvasive skin tightening procedures, Nazanin Saedi, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
Many and we really need to educate our patients about what we can do so that they have realistic expectations,” said Dr. Saedi, director of laser surgery and cosmetic dermatology at Sidney Kimmel Medical College, Philadelphia.
Treatment with these devices improve skin laxity, and some improve skin texture as well, she said. These devices are not an option for patients who want to have several inches of excess skin removed.
“You have to tell patients that this isn’t a replacement for a face-lift or a mini face-lift,” but patients can expect to see mild and modest improvement, and they’ll continue to see improvement for 3-6 months.
Patient selection is also important. Patients with mild to moderate laxity who do not want to undergo surgery and anesthesia are good candidates, as opposed to those who are older and have thin, sagging skin, Dr. Saedi said, noting that there still is no standard method of defining laxity.
She referred to a recent study illustrating the importance of counseling patients about what to expect. Of the 83 patients in a practice who had undergone microfocused ultrasound treatments and responded to an anonymous survey about the results of treatment, almost 80% reported at least mild improvement (14.5% said the improvement was significant, almost 28% said it was moderate, 37.3% said it was mild, and 20.5% said there was no improvement).
However, although about half (53.1%) reported being satisfied with their results, almost 45% said that the results did not meet their expectations (Lasers Surg Med. 2019;51[6]:495-9).
In an interview at the meeting, Dr. Saedi commented on these results and the importance of counseling.
Listen to the interview by clicking the play button at the end of this story.
During the presentation, Dr. Saedi, who is also codirector of cutaneous surgery in the department of dermatology and cutaneous biology at Sidney Kimmel Medical College, reviewed different technologies used for noninvasive skin tightening, including ablative and fractional laser resurfacing, radiofrequency, and microfocused ultrasound with visualization.
She disclosed serving on the advisory board and/or as a consultant for Aerolase, Alastin, Alma, Cartessa Aesthetics, Cynosure, and Vivo Capital, and that she has equipment from these companies, except for Vivo Capital and Alastin.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
To listen to the interview, click the play button below.
LAHAINA, HAWAII – It’s important to counsel patients about the degree of improvement to expect with noninvasive skin tightening procedures, Nazanin Saedi, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
Many and we really need to educate our patients about what we can do so that they have realistic expectations,” said Dr. Saedi, director of laser surgery and cosmetic dermatology at Sidney Kimmel Medical College, Philadelphia.
Treatment with these devices improve skin laxity, and some improve skin texture as well, she said. These devices are not an option for patients who want to have several inches of excess skin removed.
“You have to tell patients that this isn’t a replacement for a face-lift or a mini face-lift,” but patients can expect to see mild and modest improvement, and they’ll continue to see improvement for 3-6 months.
Patient selection is also important. Patients with mild to moderate laxity who do not want to undergo surgery and anesthesia are good candidates, as opposed to those who are older and have thin, sagging skin, Dr. Saedi said, noting that there still is no standard method of defining laxity.
She referred to a recent study illustrating the importance of counseling patients about what to expect. Of the 83 patients in a practice who had undergone microfocused ultrasound treatments and responded to an anonymous survey about the results of treatment, almost 80% reported at least mild improvement (14.5% said the improvement was significant, almost 28% said it was moderate, 37.3% said it was mild, and 20.5% said there was no improvement).
However, although about half (53.1%) reported being satisfied with their results, almost 45% said that the results did not meet their expectations (Lasers Surg Med. 2019;51[6]:495-9).
In an interview at the meeting, Dr. Saedi commented on these results and the importance of counseling.
Listen to the interview by clicking the play button at the end of this story.
During the presentation, Dr. Saedi, who is also codirector of cutaneous surgery in the department of dermatology and cutaneous biology at Sidney Kimmel Medical College, reviewed different technologies used for noninvasive skin tightening, including ablative and fractional laser resurfacing, radiofrequency, and microfocused ultrasound with visualization.
She disclosed serving on the advisory board and/or as a consultant for Aerolase, Alastin, Alma, Cartessa Aesthetics, Cynosure, and Vivo Capital, and that she has equipment from these companies, except for Vivo Capital and Alastin.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
To listen to the interview, click the play button below.
LAHAINA, HAWAII – It’s important to counsel patients about the degree of improvement to expect with noninvasive skin tightening procedures, Nazanin Saedi, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
Many and we really need to educate our patients about what we can do so that they have realistic expectations,” said Dr. Saedi, director of laser surgery and cosmetic dermatology at Sidney Kimmel Medical College, Philadelphia.
Treatment with these devices improve skin laxity, and some improve skin texture as well, she said. These devices are not an option for patients who want to have several inches of excess skin removed.
“You have to tell patients that this isn’t a replacement for a face-lift or a mini face-lift,” but patients can expect to see mild and modest improvement, and they’ll continue to see improvement for 3-6 months.
Patient selection is also important. Patients with mild to moderate laxity who do not want to undergo surgery and anesthesia are good candidates, as opposed to those who are older and have thin, sagging skin, Dr. Saedi said, noting that there still is no standard method of defining laxity.
She referred to a recent study illustrating the importance of counseling patients about what to expect. Of the 83 patients in a practice who had undergone microfocused ultrasound treatments and responded to an anonymous survey about the results of treatment, almost 80% reported at least mild improvement (14.5% said the improvement was significant, almost 28% said it was moderate, 37.3% said it was mild, and 20.5% said there was no improvement).
However, although about half (53.1%) reported being satisfied with their results, almost 45% said that the results did not meet their expectations (Lasers Surg Med. 2019;51[6]:495-9).
In an interview at the meeting, Dr. Saedi commented on these results and the importance of counseling.
Listen to the interview by clicking the play button at the end of this story.
During the presentation, Dr. Saedi, who is also codirector of cutaneous surgery in the department of dermatology and cutaneous biology at Sidney Kimmel Medical College, reviewed different technologies used for noninvasive skin tightening, including ablative and fractional laser resurfacing, radiofrequency, and microfocused ultrasound with visualization.
She disclosed serving on the advisory board and/or as a consultant for Aerolase, Alastin, Alma, Cartessa Aesthetics, Cynosure, and Vivo Capital, and that she has equipment from these companies, except for Vivo Capital and Alastin.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
To listen to the interview, click the play button below.
REPORTING FROM SDEF HAWAII DERMATOLOGY SEMINAR
Reassurance on general anesthesia in young kids
LAHAINA, HAWAII – Two recent large, well-conducted, and persuasive Jessica Sprague, MD, said at the SDEF Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“These two studies can be cited in conversation with parents and are very reassuring for a single episode of general anesthesia,” observed Dr. Sprague, a dermatologist at Rady Children’s Hospital and the University of California, both in San Diego.
“As a take home, I think we can feel pretty confident that single exposure to short-duration general anesthesia does not have any adverse neurocognitive effects,” she added.
In 2016, the Food and Drug Administration issued a drug safety communication that general anesthesia lasting for more than 3 hours in children aged less than 3 years, or repeated shorter-duration general anesthesia, may affect the development of children’s brains. This edict caused considerable turmoil among both physicians and parents. The warning was based upon animal studies suggesting adverse effects, including abnormal axon formation and other structural changes, impaired learning and memory, and heightened emotional reactivity to threats. Preliminary human cohort studies generated conflicting results, but were tough to interpret because of potential confounding issues, most prominently the distinct possibility that the very reason the child was undergoing general anesthesia might inherently predispose to neurodevelopmental problems, the dermatologist explained.
Enter the GAS trial, a multinational, assessor-blinded study in which 722 generally healthy infants undergoing hernia repair at 28 centers in the United States and six other countries were randomized to general anesthesia for a median of 54 minutes or awake regional anesthesia. Assessment via a detailed neuropsychological test battery and parent questionnaires at age 2 and 5 years showed no between-group differences at all. Of note, the GAS trial was funded by the FDA, the National Institutes of Health, and similar national health care agencies in the other participating countries (Lancet. 2019 Feb 16;393[10172]:664-77).
The other major recent research contribution was a province-wide Ontario study led by investigators at the Hospital for Sick Children in Toronto. This retrospective study included 2,346 sibling pairs aged 4-5 years in which one child in each pair received general anesthesia as a preschooler. All participants underwent testing using the comprehensive Early Development Instrument. Reassuringly, no between-group differences were found in any of the five domains assessed by the testing: language and cognitive development, physical health and well-being, emotional health and maturity, social knowledge and competence, and communication skills and general knowledge (JAMA Pediatr. 2019 Jan 1;173[1]:29-36).
These two studies address a pressing issue, since 10% of children in the United States and other developed countries receive general anesthesia within their first 3 years of life. Common indications in dermatology include excisional surgery, laser therapy for extensive port wine birthmarks, and diagnostic MRIs.
Dr. Sprague advised that, based upon the new data, “you definitely do not want to delay necessary imaging studies or surgeries, but MRIs can often be done without general anesthesia in infants less than 2 months old. If you have an infant who needs an MRI for something like PHACE syndrome [posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities], if you can get them in before 2 months of age sometimes you can avoid the general anesthesia if you wrap them tight enough. But once they get over 2 months ,there’s too much wiggle and it’s pretty impossible.”
Her other suggestions:
- Consider delaying nonurgent surgeries and imaging until at least age 6 months and ideally 3 years. “Parents will eventually want surgery to be done for a benign-appearing congenital nevus on the cheek, but it doesn’t necessarily need to be done before 6 months. The same with a residual hemangioma. I would recommend doing it before they go to kindergarten and before they get a sort of sense of what their self looks like, but you have some time between ages 3 and 5 to do that,” Dr. Sprague said.
- Seek out an anesthesiologist who has extensive experience with infants and young children, as is common at a dedicated children’s hospital. “If you live somewhere where the anesthesiologists are primarily seeing adult patients, they’re just not as good,” according to the pediatric dermatologist.
- Definitely consider a topical anesthesia strategy in infants who require multiple procedures, because there remains some unresolved concern about the potential neurodevelopmental impact of multiple bouts of general anesthesia.
Dr. Sprague reported having no financial conflicts regarding her presentation.
The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
LAHAINA, HAWAII – Two recent large, well-conducted, and persuasive Jessica Sprague, MD, said at the SDEF Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“These two studies can be cited in conversation with parents and are very reassuring for a single episode of general anesthesia,” observed Dr. Sprague, a dermatologist at Rady Children’s Hospital and the University of California, both in San Diego.
“As a take home, I think we can feel pretty confident that single exposure to short-duration general anesthesia does not have any adverse neurocognitive effects,” she added.
In 2016, the Food and Drug Administration issued a drug safety communication that general anesthesia lasting for more than 3 hours in children aged less than 3 years, or repeated shorter-duration general anesthesia, may affect the development of children’s brains. This edict caused considerable turmoil among both physicians and parents. The warning was based upon animal studies suggesting adverse effects, including abnormal axon formation and other structural changes, impaired learning and memory, and heightened emotional reactivity to threats. Preliminary human cohort studies generated conflicting results, but were tough to interpret because of potential confounding issues, most prominently the distinct possibility that the very reason the child was undergoing general anesthesia might inherently predispose to neurodevelopmental problems, the dermatologist explained.
Enter the GAS trial, a multinational, assessor-blinded study in which 722 generally healthy infants undergoing hernia repair at 28 centers in the United States and six other countries were randomized to general anesthesia for a median of 54 minutes or awake regional anesthesia. Assessment via a detailed neuropsychological test battery and parent questionnaires at age 2 and 5 years showed no between-group differences at all. Of note, the GAS trial was funded by the FDA, the National Institutes of Health, and similar national health care agencies in the other participating countries (Lancet. 2019 Feb 16;393[10172]:664-77).
The other major recent research contribution was a province-wide Ontario study led by investigators at the Hospital for Sick Children in Toronto. This retrospective study included 2,346 sibling pairs aged 4-5 years in which one child in each pair received general anesthesia as a preschooler. All participants underwent testing using the comprehensive Early Development Instrument. Reassuringly, no between-group differences were found in any of the five domains assessed by the testing: language and cognitive development, physical health and well-being, emotional health and maturity, social knowledge and competence, and communication skills and general knowledge (JAMA Pediatr. 2019 Jan 1;173[1]:29-36).
These two studies address a pressing issue, since 10% of children in the United States and other developed countries receive general anesthesia within their first 3 years of life. Common indications in dermatology include excisional surgery, laser therapy for extensive port wine birthmarks, and diagnostic MRIs.
Dr. Sprague advised that, based upon the new data, “you definitely do not want to delay necessary imaging studies or surgeries, but MRIs can often be done without general anesthesia in infants less than 2 months old. If you have an infant who needs an MRI for something like PHACE syndrome [posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities], if you can get them in before 2 months of age sometimes you can avoid the general anesthesia if you wrap them tight enough. But once they get over 2 months ,there’s too much wiggle and it’s pretty impossible.”
Her other suggestions:
- Consider delaying nonurgent surgeries and imaging until at least age 6 months and ideally 3 years. “Parents will eventually want surgery to be done for a benign-appearing congenital nevus on the cheek, but it doesn’t necessarily need to be done before 6 months. The same with a residual hemangioma. I would recommend doing it before they go to kindergarten and before they get a sort of sense of what their self looks like, but you have some time between ages 3 and 5 to do that,” Dr. Sprague said.
- Seek out an anesthesiologist who has extensive experience with infants and young children, as is common at a dedicated children’s hospital. “If you live somewhere where the anesthesiologists are primarily seeing adult patients, they’re just not as good,” according to the pediatric dermatologist.
- Definitely consider a topical anesthesia strategy in infants who require multiple procedures, because there remains some unresolved concern about the potential neurodevelopmental impact of multiple bouts of general anesthesia.
Dr. Sprague reported having no financial conflicts regarding her presentation.
The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
LAHAINA, HAWAII – Two recent large, well-conducted, and persuasive Jessica Sprague, MD, said at the SDEF Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“These two studies can be cited in conversation with parents and are very reassuring for a single episode of general anesthesia,” observed Dr. Sprague, a dermatologist at Rady Children’s Hospital and the University of California, both in San Diego.
“As a take home, I think we can feel pretty confident that single exposure to short-duration general anesthesia does not have any adverse neurocognitive effects,” she added.
In 2016, the Food and Drug Administration issued a drug safety communication that general anesthesia lasting for more than 3 hours in children aged less than 3 years, or repeated shorter-duration general anesthesia, may affect the development of children’s brains. This edict caused considerable turmoil among both physicians and parents. The warning was based upon animal studies suggesting adverse effects, including abnormal axon formation and other structural changes, impaired learning and memory, and heightened emotional reactivity to threats. Preliminary human cohort studies generated conflicting results, but were tough to interpret because of potential confounding issues, most prominently the distinct possibility that the very reason the child was undergoing general anesthesia might inherently predispose to neurodevelopmental problems, the dermatologist explained.
Enter the GAS trial, a multinational, assessor-blinded study in which 722 generally healthy infants undergoing hernia repair at 28 centers in the United States and six other countries were randomized to general anesthesia for a median of 54 minutes or awake regional anesthesia. Assessment via a detailed neuropsychological test battery and parent questionnaires at age 2 and 5 years showed no between-group differences at all. Of note, the GAS trial was funded by the FDA, the National Institutes of Health, and similar national health care agencies in the other participating countries (Lancet. 2019 Feb 16;393[10172]:664-77).
The other major recent research contribution was a province-wide Ontario study led by investigators at the Hospital for Sick Children in Toronto. This retrospective study included 2,346 sibling pairs aged 4-5 years in which one child in each pair received general anesthesia as a preschooler. All participants underwent testing using the comprehensive Early Development Instrument. Reassuringly, no between-group differences were found in any of the five domains assessed by the testing: language and cognitive development, physical health and well-being, emotional health and maturity, social knowledge and competence, and communication skills and general knowledge (JAMA Pediatr. 2019 Jan 1;173[1]:29-36).
These two studies address a pressing issue, since 10% of children in the United States and other developed countries receive general anesthesia within their first 3 years of life. Common indications in dermatology include excisional surgery, laser therapy for extensive port wine birthmarks, and diagnostic MRIs.
Dr. Sprague advised that, based upon the new data, “you definitely do not want to delay necessary imaging studies or surgeries, but MRIs can often be done without general anesthesia in infants less than 2 months old. If you have an infant who needs an MRI for something like PHACE syndrome [posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities], if you can get them in before 2 months of age sometimes you can avoid the general anesthesia if you wrap them tight enough. But once they get over 2 months ,there’s too much wiggle and it’s pretty impossible.”
Her other suggestions:
- Consider delaying nonurgent surgeries and imaging until at least age 6 months and ideally 3 years. “Parents will eventually want surgery to be done for a benign-appearing congenital nevus on the cheek, but it doesn’t necessarily need to be done before 6 months. The same with a residual hemangioma. I would recommend doing it before they go to kindergarten and before they get a sort of sense of what their self looks like, but you have some time between ages 3 and 5 to do that,” Dr. Sprague said.
- Seek out an anesthesiologist who has extensive experience with infants and young children, as is common at a dedicated children’s hospital. “If you live somewhere where the anesthesiologists are primarily seeing adult patients, they’re just not as good,” according to the pediatric dermatologist.
- Definitely consider a topical anesthesia strategy in infants who require multiple procedures, because there remains some unresolved concern about the potential neurodevelopmental impact of multiple bouts of general anesthesia.
Dr. Sprague reported having no financial conflicts regarding her presentation.
The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
Banning indoor tanning devices could save lives and money
according to a study published in JAMA Dermatology.
The study also suggests a ban would result in a collective cost savings of $5.7 billion and productivity gains of $41.3 billion.
Compared with a ban on indoor tanning for minors, the benefits of a full ban on devices were 3.7-fold higher in the United States/Canada and 2.6-fold higher in Europe, according to study author Louisa G. Gordon, PhD, of the QIMR Berghofer Medical Research Institute in Brisbane, Australia, and colleagues.
The researchers noted that indoor tanning is regulated in more than 20 countries. Australia has instituted a ban on commercial indoor tanning devices, and Brazil has banned both commercial and private tanning devices.
In the United States, 19 states have banned the use of indoor tanning beds for minors, and 44 states as well as the District of Columbia have some regulation of tanning facilities for minors, according to the National Conference of State Legislatures.
With this study, Dr. Gordon and colleagues sought to explore what effect an outright ban on indoor tanning devices, a prohibition for minors only, or continuing current levels of indoor tanning would have on the health and economy of the United States, Canada, and Europe.
The researchers created a Markov cohort model of 110,932,523 individuals in the United States/Canada and 141,970,492 individuals in Europe, all aged 12-35 years.
The team used data from epidemiologic studies, cost reports, and official cancer registries to estimate the prevalence of indoor tanning, risk of developing melanoma, and mortality rates from skin cancer and other causes. The researchers also estimated health care costs of melanoma treatment in each region as well as the societal cost of dying prematurely from melanoma, adjusted to 2018 dollars.
Results
The model suggested a ban on indoor tanning in the United States and Canada would result in 244,347 fewer melanomas (–8.7%), 89,193 fewer deaths from melanoma (–6.9%), and 7.3 million fewer keratinocyte carcinomas (–7.8%) than continuing at the current levels of use. The ban would also save 428,781 life-years, have a cost savings of $3.5 billion, and confer productivity gains of $27.5 billion, the researchers said.
When applying the ban in Europe, the model estimated 203,736 fewer melanomas (–4.9%), 98,288 fewer deaths from melanoma (–4.4%), and 2.4 million fewer keratinocyte carcinomas (–4.4%). The researchers also noted that Europe would see a gain of 459,669 life-years, a cost savings of $2.1 billion, and a productivity gain of $13.7 billion.
Dr. Gordon and colleagues acknowledged that their model had some limitations, such as in estimating the prevalence of certain skin cancers across Europe, which can range from 10% to 56% depending on the country. In addition, the model did not account for the money spent in implementing a ban, which could include costs associated with regulation, compliance, and buy-back schemes for tanning devices.
Implications
In an interview, Dr. Gordon said the researchers conducted this study to stress the health benefits and cost savings of regulating indoor tanning devices in North America and Europe. She noted that she had previously published a report in 2009 that helped Australia make the decision to ban such devices there, but she said the tanning industry was in its infancy during that time, which factored into the decision to ban indoor tanning (Health Policy. 2009 Mar;89[3]:303-11).
Any ban by a regulatory agency “should include everyone,” Dr. Gordon said, because “banning minors is a halfway attempt to prevent skin cancers.” The danger isn’t just present in children. “People in their 20s and 30s are still very image conscious,” she said. “The pressure is enormous.”
Anyone interested in tanning should use tanning creams or sprays instead of using indoor tanning devices, Dr. Gordon said. “Consumers can control their UV exposure,” she noted. “Prevention is incredibly important, and skin cancer is one of a few cancers we can almost entirely prevent via protecting our skin. The same can’t be said for other horrible cancers.”
Adam Friedman, MD, a professor at George Washington University, Washington, who was not involved in this study, said it should come as no surprise to dermatologists that preventing artificial UVA heavy exposure reduces the incidence of skin cancer, but the “more compelling component of this study is cost.”
“The lay public is extremely health care cost conscientious,” he said. “This is a commonly debated topic for emerging politicians at every level; not to mention, no one enjoys bleeding money. Dermatologists can use the angle of, ‘save skin now, save money later,’ to target the financial burden of accelerated skin aging and skin cancer as a mechanism for persuading patients not to ‘shake and bake.’ ”
While the Food and Drug Administration has proposed restricting the use of indoor tanning devices for minors nationwide, it has not issued a final rule on the matter, and the prospect of an outright ban in the United States for the general population is less feasible, noted Dr. Friedman.
“I think it would be difficult to expand this [proposed] ban given the financial impact on numerous businesses,” he said. “It would likely take more evidence and support beyond the medical community to make this happen, but here’s hoping,”
This study was funded by the World Health Organization UV Radiation Programme and Cancer Council Victoria. One author disclosed personal fees from Cancer Council Victoria, and one disclosed grants from TrygFonden. The other authors and Dr. Friedman reported no relevant conflicts of interest.
SOURCE: Gordon L et al. JAMA Dermatol. 2020 Feb 19. doi: 10.1001/jamadermatol.2020.0001.
according to a study published in JAMA Dermatology.
The study also suggests a ban would result in a collective cost savings of $5.7 billion and productivity gains of $41.3 billion.
Compared with a ban on indoor tanning for minors, the benefits of a full ban on devices were 3.7-fold higher in the United States/Canada and 2.6-fold higher in Europe, according to study author Louisa G. Gordon, PhD, of the QIMR Berghofer Medical Research Institute in Brisbane, Australia, and colleagues.
The researchers noted that indoor tanning is regulated in more than 20 countries. Australia has instituted a ban on commercial indoor tanning devices, and Brazil has banned both commercial and private tanning devices.
In the United States, 19 states have banned the use of indoor tanning beds for minors, and 44 states as well as the District of Columbia have some regulation of tanning facilities for minors, according to the National Conference of State Legislatures.
With this study, Dr. Gordon and colleagues sought to explore what effect an outright ban on indoor tanning devices, a prohibition for minors only, or continuing current levels of indoor tanning would have on the health and economy of the United States, Canada, and Europe.
The researchers created a Markov cohort model of 110,932,523 individuals in the United States/Canada and 141,970,492 individuals in Europe, all aged 12-35 years.
The team used data from epidemiologic studies, cost reports, and official cancer registries to estimate the prevalence of indoor tanning, risk of developing melanoma, and mortality rates from skin cancer and other causes. The researchers also estimated health care costs of melanoma treatment in each region as well as the societal cost of dying prematurely from melanoma, adjusted to 2018 dollars.
Results
The model suggested a ban on indoor tanning in the United States and Canada would result in 244,347 fewer melanomas (–8.7%), 89,193 fewer deaths from melanoma (–6.9%), and 7.3 million fewer keratinocyte carcinomas (–7.8%) than continuing at the current levels of use. The ban would also save 428,781 life-years, have a cost savings of $3.5 billion, and confer productivity gains of $27.5 billion, the researchers said.
When applying the ban in Europe, the model estimated 203,736 fewer melanomas (–4.9%), 98,288 fewer deaths from melanoma (–4.4%), and 2.4 million fewer keratinocyte carcinomas (–4.4%). The researchers also noted that Europe would see a gain of 459,669 life-years, a cost savings of $2.1 billion, and a productivity gain of $13.7 billion.
Dr. Gordon and colleagues acknowledged that their model had some limitations, such as in estimating the prevalence of certain skin cancers across Europe, which can range from 10% to 56% depending on the country. In addition, the model did not account for the money spent in implementing a ban, which could include costs associated with regulation, compliance, and buy-back schemes for tanning devices.
Implications
In an interview, Dr. Gordon said the researchers conducted this study to stress the health benefits and cost savings of regulating indoor tanning devices in North America and Europe. She noted that she had previously published a report in 2009 that helped Australia make the decision to ban such devices there, but she said the tanning industry was in its infancy during that time, which factored into the decision to ban indoor tanning (Health Policy. 2009 Mar;89[3]:303-11).
Any ban by a regulatory agency “should include everyone,” Dr. Gordon said, because “banning minors is a halfway attempt to prevent skin cancers.” The danger isn’t just present in children. “People in their 20s and 30s are still very image conscious,” she said. “The pressure is enormous.”
Anyone interested in tanning should use tanning creams or sprays instead of using indoor tanning devices, Dr. Gordon said. “Consumers can control their UV exposure,” she noted. “Prevention is incredibly important, and skin cancer is one of a few cancers we can almost entirely prevent via protecting our skin. The same can’t be said for other horrible cancers.”
Adam Friedman, MD, a professor at George Washington University, Washington, who was not involved in this study, said it should come as no surprise to dermatologists that preventing artificial UVA heavy exposure reduces the incidence of skin cancer, but the “more compelling component of this study is cost.”
“The lay public is extremely health care cost conscientious,” he said. “This is a commonly debated topic for emerging politicians at every level; not to mention, no one enjoys bleeding money. Dermatologists can use the angle of, ‘save skin now, save money later,’ to target the financial burden of accelerated skin aging and skin cancer as a mechanism for persuading patients not to ‘shake and bake.’ ”
While the Food and Drug Administration has proposed restricting the use of indoor tanning devices for minors nationwide, it has not issued a final rule on the matter, and the prospect of an outright ban in the United States for the general population is less feasible, noted Dr. Friedman.
“I think it would be difficult to expand this [proposed] ban given the financial impact on numerous businesses,” he said. “It would likely take more evidence and support beyond the medical community to make this happen, but here’s hoping,”
This study was funded by the World Health Organization UV Radiation Programme and Cancer Council Victoria. One author disclosed personal fees from Cancer Council Victoria, and one disclosed grants from TrygFonden. The other authors and Dr. Friedman reported no relevant conflicts of interest.
SOURCE: Gordon L et al. JAMA Dermatol. 2020 Feb 19. doi: 10.1001/jamadermatol.2020.0001.
according to a study published in JAMA Dermatology.
The study also suggests a ban would result in a collective cost savings of $5.7 billion and productivity gains of $41.3 billion.
Compared with a ban on indoor tanning for minors, the benefits of a full ban on devices were 3.7-fold higher in the United States/Canada and 2.6-fold higher in Europe, according to study author Louisa G. Gordon, PhD, of the QIMR Berghofer Medical Research Institute in Brisbane, Australia, and colleagues.
The researchers noted that indoor tanning is regulated in more than 20 countries. Australia has instituted a ban on commercial indoor tanning devices, and Brazil has banned both commercial and private tanning devices.
In the United States, 19 states have banned the use of indoor tanning beds for minors, and 44 states as well as the District of Columbia have some regulation of tanning facilities for minors, according to the National Conference of State Legislatures.
With this study, Dr. Gordon and colleagues sought to explore what effect an outright ban on indoor tanning devices, a prohibition for minors only, or continuing current levels of indoor tanning would have on the health and economy of the United States, Canada, and Europe.
The researchers created a Markov cohort model of 110,932,523 individuals in the United States/Canada and 141,970,492 individuals in Europe, all aged 12-35 years.
The team used data from epidemiologic studies, cost reports, and official cancer registries to estimate the prevalence of indoor tanning, risk of developing melanoma, and mortality rates from skin cancer and other causes. The researchers also estimated health care costs of melanoma treatment in each region as well as the societal cost of dying prematurely from melanoma, adjusted to 2018 dollars.
Results
The model suggested a ban on indoor tanning in the United States and Canada would result in 244,347 fewer melanomas (–8.7%), 89,193 fewer deaths from melanoma (–6.9%), and 7.3 million fewer keratinocyte carcinomas (–7.8%) than continuing at the current levels of use. The ban would also save 428,781 life-years, have a cost savings of $3.5 billion, and confer productivity gains of $27.5 billion, the researchers said.
When applying the ban in Europe, the model estimated 203,736 fewer melanomas (–4.9%), 98,288 fewer deaths from melanoma (–4.4%), and 2.4 million fewer keratinocyte carcinomas (–4.4%). The researchers also noted that Europe would see a gain of 459,669 life-years, a cost savings of $2.1 billion, and a productivity gain of $13.7 billion.
Dr. Gordon and colleagues acknowledged that their model had some limitations, such as in estimating the prevalence of certain skin cancers across Europe, which can range from 10% to 56% depending on the country. In addition, the model did not account for the money spent in implementing a ban, which could include costs associated with regulation, compliance, and buy-back schemes for tanning devices.
Implications
In an interview, Dr. Gordon said the researchers conducted this study to stress the health benefits and cost savings of regulating indoor tanning devices in North America and Europe. She noted that she had previously published a report in 2009 that helped Australia make the decision to ban such devices there, but she said the tanning industry was in its infancy during that time, which factored into the decision to ban indoor tanning (Health Policy. 2009 Mar;89[3]:303-11).
Any ban by a regulatory agency “should include everyone,” Dr. Gordon said, because “banning minors is a halfway attempt to prevent skin cancers.” The danger isn’t just present in children. “People in their 20s and 30s are still very image conscious,” she said. “The pressure is enormous.”
Anyone interested in tanning should use tanning creams or sprays instead of using indoor tanning devices, Dr. Gordon said. “Consumers can control their UV exposure,” she noted. “Prevention is incredibly important, and skin cancer is one of a few cancers we can almost entirely prevent via protecting our skin. The same can’t be said for other horrible cancers.”
Adam Friedman, MD, a professor at George Washington University, Washington, who was not involved in this study, said it should come as no surprise to dermatologists that preventing artificial UVA heavy exposure reduces the incidence of skin cancer, but the “more compelling component of this study is cost.”
“The lay public is extremely health care cost conscientious,” he said. “This is a commonly debated topic for emerging politicians at every level; not to mention, no one enjoys bleeding money. Dermatologists can use the angle of, ‘save skin now, save money later,’ to target the financial burden of accelerated skin aging and skin cancer as a mechanism for persuading patients not to ‘shake and bake.’ ”
While the Food and Drug Administration has proposed restricting the use of indoor tanning devices for minors nationwide, it has not issued a final rule on the matter, and the prospect of an outright ban in the United States for the general population is less feasible, noted Dr. Friedman.
“I think it would be difficult to expand this [proposed] ban given the financial impact on numerous businesses,” he said. “It would likely take more evidence and support beyond the medical community to make this happen, but here’s hoping,”
This study was funded by the World Health Organization UV Radiation Programme and Cancer Council Victoria. One author disclosed personal fees from Cancer Council Victoria, and one disclosed grants from TrygFonden. The other authors and Dr. Friedman reported no relevant conflicts of interest.
SOURCE: Gordon L et al. JAMA Dermatol. 2020 Feb 19. doi: 10.1001/jamadermatol.2020.0001.
FROM JAMA DERMATOLOGY
Data back botulinum toxin for facial flushing, androgenetic alopecia
LAHAINA, HAWAII – The list of Mark Rubin, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
There are data to support these uses, and there are data associating botulinum toxin treatment with improvement in depression, which suggest the effect may not be necessarily be related to improvement in appearance, said Dr. Rubin, who is in private practice in Beverly Hills, Calif., and is associate professor of dermatology at the University of California, San Diego.
Facial flushing: Very few people use botulinum toxin for facial flushing, but Dr. Rubin, who is among those who do not, described the data as “impressive.” Several trials, he noted, have found that very small doses can significantly reduce the amount of facial erythema, including an average 45% reduction after 60 days in one trial of 24 women (Acta Med Iran. 2016 Jul;54[7]:454-7).
In another study of 25 patients with facial erythema related to rosacea who were treated with 14-45 units intradermally to the nasal tip, bridge, and alae, there were statistically significant improvements in erythema 1, 2, and 3 months after treatment among the 15 with complete data (Dermatol Surg. 2015 Jan;41 Suppl 1:S9-16).
“If you’re using very small doses and they’re intradermal, there really is minimal risk you’re going to have a problem by inadvertently affecting musculature” in these patients, Dr. Rubin commented.
In another study of 9 patients with rosacea, treatment with incobotulinumtoxinA was associated with a significant reduction in erythema, papules, pustules, and telangiectasias, up to 15 weeks, compared with saline. The treatment patients also experienced less burning and stinging that did those who received saline (J Drugs Dermatol. 2017 Jun 1;16[6]:549-54.)
Menopausal hot flashes: Dr. Rubin described one study of 60 patients with severe hot flashes that compared saline with botulinum toxin, injected in 40 sites (2 units per site), including the neck, hairline, scalp, and chest. At 60 days’ follow-up, those treated with botulinum toxin had a significant reduction in sweating and in the number and severity of hot flashes; these women also had improved mood in terms of depression and irritability (Dermatol Surg. 2011 Nov;37[11]:1579-83).
Androgenetic alopecia: In a 60-week study of 50 men with androgenetic alopecia (Hamilton ratings of II-IV), 150 units of botulinum toxin A was injected into the scalp muscles (temporalis, frontalis, periauricular, and occipital), and repeated 6 months later (Plast Reconstr Surg. 2010 Nov;126[5]:246e-8e). Among the 40 patients who completed the trial, 75% had a response, and from baseline to 48 weeks, there was an 18% increase in mean hair counts in a 2 cm area, and a“profound” 39% reduction in hair loss (as measured by hair counts on the pillow in the morning), Dr. Rubin noted.
“Presumably, this is because if you’re relaxing the scalp muscles you’re getting increased blood flow into the scalp,” including increased oxygenation, which decreases the conversion of testosterone to dihydrotestosterone and increases the conversion of testosterone to estradiol, he said.
In another study, 8 of 10 patients with androgenic alopecia has “good to excellent” results 24 weeks after botulinum toxin injections with 5 units per site at 30 sites. Referring to the increasing popularity of platelet-rich plasma (PRP) injections for male pattern alopecia, Dr. Rubin said that in his opinion “PRP certainly doesn’t do any better” than botulinum toxin for male pattern alopecia and is a much more involved injection, “so this is definitely something worth considering if you have more people coming into your practice thinking about injections for male pattern alopecia.”
Pore size and sebum production: A 2019 review of published studies of botulinum toxin A looking at the effect on sebum and pore size, Dr. Rubin said, found that most studies “suggest it does actually reduce pore size and sebum production” (J Cosmet Dermatol. 2019 Apr;18[2]:451-7).
This can be considered an option for those patients concerned about pore size, who are not satisfied with results of retinoid or laser treatment, he commented. This approach may not have an effect in all patients, so he advised first treating a small trial area, and photographing patients to record their level of improvement. “It’s rarely profound, but it’s additive, it’s one more thing you can do.”
Depression: These data include a study of 30 patients with major depression, half who received one onabotulinumtoxinA injection in the glabellar area as adjunctive treatment of depression. After 6 weeks, those who were treated had an average of 47% reduction in depression scores on the Hamilton Depression Rating Scale, compared with an average 9% reduction among those on placebo (J Psychiatr Res. 2012 May;46[5]:574-81). Two recent studies have had similar results, according to Dr. Rubin.
Results of another study, he said, raise the question of whether patients are less depressed because they are pleased with the cosmetic effects or if there is another explanation (J Am Acad Dermatol. 2016 Jan;74[1]:171-3.e1). The study, which included 59 patients with depression treated in the glabellar areas with botulinum toxin injections, found no association between severity of the furrows and degree of depression or between the degree of furrow correction and degree of relief from depression after treatment. “So the patients who had the most improvement were not necessarily the ones who were the least depressed afterwards,” he said.
These data imply that something else may be occurring that is not necessarily muscle related, he said.
Dr. Rubin said he had no relevant disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
LAHAINA, HAWAII – The list of Mark Rubin, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
There are data to support these uses, and there are data associating botulinum toxin treatment with improvement in depression, which suggest the effect may not be necessarily be related to improvement in appearance, said Dr. Rubin, who is in private practice in Beverly Hills, Calif., and is associate professor of dermatology at the University of California, San Diego.
Facial flushing: Very few people use botulinum toxin for facial flushing, but Dr. Rubin, who is among those who do not, described the data as “impressive.” Several trials, he noted, have found that very small doses can significantly reduce the amount of facial erythema, including an average 45% reduction after 60 days in one trial of 24 women (Acta Med Iran. 2016 Jul;54[7]:454-7).
In another study of 25 patients with facial erythema related to rosacea who were treated with 14-45 units intradermally to the nasal tip, bridge, and alae, there were statistically significant improvements in erythema 1, 2, and 3 months after treatment among the 15 with complete data (Dermatol Surg. 2015 Jan;41 Suppl 1:S9-16).
“If you’re using very small doses and they’re intradermal, there really is minimal risk you’re going to have a problem by inadvertently affecting musculature” in these patients, Dr. Rubin commented.
In another study of 9 patients with rosacea, treatment with incobotulinumtoxinA was associated with a significant reduction in erythema, papules, pustules, and telangiectasias, up to 15 weeks, compared with saline. The treatment patients also experienced less burning and stinging that did those who received saline (J Drugs Dermatol. 2017 Jun 1;16[6]:549-54.)
Menopausal hot flashes: Dr. Rubin described one study of 60 patients with severe hot flashes that compared saline with botulinum toxin, injected in 40 sites (2 units per site), including the neck, hairline, scalp, and chest. At 60 days’ follow-up, those treated with botulinum toxin had a significant reduction in sweating and in the number and severity of hot flashes; these women also had improved mood in terms of depression and irritability (Dermatol Surg. 2011 Nov;37[11]:1579-83).
Androgenetic alopecia: In a 60-week study of 50 men with androgenetic alopecia (Hamilton ratings of II-IV), 150 units of botulinum toxin A was injected into the scalp muscles (temporalis, frontalis, periauricular, and occipital), and repeated 6 months later (Plast Reconstr Surg. 2010 Nov;126[5]:246e-8e). Among the 40 patients who completed the trial, 75% had a response, and from baseline to 48 weeks, there was an 18% increase in mean hair counts in a 2 cm area, and a“profound” 39% reduction in hair loss (as measured by hair counts on the pillow in the morning), Dr. Rubin noted.
“Presumably, this is because if you’re relaxing the scalp muscles you’re getting increased blood flow into the scalp,” including increased oxygenation, which decreases the conversion of testosterone to dihydrotestosterone and increases the conversion of testosterone to estradiol, he said.
In another study, 8 of 10 patients with androgenic alopecia has “good to excellent” results 24 weeks after botulinum toxin injections with 5 units per site at 30 sites. Referring to the increasing popularity of platelet-rich plasma (PRP) injections for male pattern alopecia, Dr. Rubin said that in his opinion “PRP certainly doesn’t do any better” than botulinum toxin for male pattern alopecia and is a much more involved injection, “so this is definitely something worth considering if you have more people coming into your practice thinking about injections for male pattern alopecia.”
Pore size and sebum production: A 2019 review of published studies of botulinum toxin A looking at the effect on sebum and pore size, Dr. Rubin said, found that most studies “suggest it does actually reduce pore size and sebum production” (J Cosmet Dermatol. 2019 Apr;18[2]:451-7).
This can be considered an option for those patients concerned about pore size, who are not satisfied with results of retinoid or laser treatment, he commented. This approach may not have an effect in all patients, so he advised first treating a small trial area, and photographing patients to record their level of improvement. “It’s rarely profound, but it’s additive, it’s one more thing you can do.”
Depression: These data include a study of 30 patients with major depression, half who received one onabotulinumtoxinA injection in the glabellar area as adjunctive treatment of depression. After 6 weeks, those who were treated had an average of 47% reduction in depression scores on the Hamilton Depression Rating Scale, compared with an average 9% reduction among those on placebo (J Psychiatr Res. 2012 May;46[5]:574-81). Two recent studies have had similar results, according to Dr. Rubin.
Results of another study, he said, raise the question of whether patients are less depressed because they are pleased with the cosmetic effects or if there is another explanation (J Am Acad Dermatol. 2016 Jan;74[1]:171-3.e1). The study, which included 59 patients with depression treated in the glabellar areas with botulinum toxin injections, found no association between severity of the furrows and degree of depression or between the degree of furrow correction and degree of relief from depression after treatment. “So the patients who had the most improvement were not necessarily the ones who were the least depressed afterwards,” he said.
These data imply that something else may be occurring that is not necessarily muscle related, he said.
Dr. Rubin said he had no relevant disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
LAHAINA, HAWAII – The list of Mark Rubin, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
There are data to support these uses, and there are data associating botulinum toxin treatment with improvement in depression, which suggest the effect may not be necessarily be related to improvement in appearance, said Dr. Rubin, who is in private practice in Beverly Hills, Calif., and is associate professor of dermatology at the University of California, San Diego.
Facial flushing: Very few people use botulinum toxin for facial flushing, but Dr. Rubin, who is among those who do not, described the data as “impressive.” Several trials, he noted, have found that very small doses can significantly reduce the amount of facial erythema, including an average 45% reduction after 60 days in one trial of 24 women (Acta Med Iran. 2016 Jul;54[7]:454-7).
In another study of 25 patients with facial erythema related to rosacea who were treated with 14-45 units intradermally to the nasal tip, bridge, and alae, there were statistically significant improvements in erythema 1, 2, and 3 months after treatment among the 15 with complete data (Dermatol Surg. 2015 Jan;41 Suppl 1:S9-16).
“If you’re using very small doses and they’re intradermal, there really is minimal risk you’re going to have a problem by inadvertently affecting musculature” in these patients, Dr. Rubin commented.
In another study of 9 patients with rosacea, treatment with incobotulinumtoxinA was associated with a significant reduction in erythema, papules, pustules, and telangiectasias, up to 15 weeks, compared with saline. The treatment patients also experienced less burning and stinging that did those who received saline (J Drugs Dermatol. 2017 Jun 1;16[6]:549-54.)
Menopausal hot flashes: Dr. Rubin described one study of 60 patients with severe hot flashes that compared saline with botulinum toxin, injected in 40 sites (2 units per site), including the neck, hairline, scalp, and chest. At 60 days’ follow-up, those treated with botulinum toxin had a significant reduction in sweating and in the number and severity of hot flashes; these women also had improved mood in terms of depression and irritability (Dermatol Surg. 2011 Nov;37[11]:1579-83).
Androgenetic alopecia: In a 60-week study of 50 men with androgenetic alopecia (Hamilton ratings of II-IV), 150 units of botulinum toxin A was injected into the scalp muscles (temporalis, frontalis, periauricular, and occipital), and repeated 6 months later (Plast Reconstr Surg. 2010 Nov;126[5]:246e-8e). Among the 40 patients who completed the trial, 75% had a response, and from baseline to 48 weeks, there was an 18% increase in mean hair counts in a 2 cm area, and a“profound” 39% reduction in hair loss (as measured by hair counts on the pillow in the morning), Dr. Rubin noted.
“Presumably, this is because if you’re relaxing the scalp muscles you’re getting increased blood flow into the scalp,” including increased oxygenation, which decreases the conversion of testosterone to dihydrotestosterone and increases the conversion of testosterone to estradiol, he said.
In another study, 8 of 10 patients with androgenic alopecia has “good to excellent” results 24 weeks after botulinum toxin injections with 5 units per site at 30 sites. Referring to the increasing popularity of platelet-rich plasma (PRP) injections for male pattern alopecia, Dr. Rubin said that in his opinion “PRP certainly doesn’t do any better” than botulinum toxin for male pattern alopecia and is a much more involved injection, “so this is definitely something worth considering if you have more people coming into your practice thinking about injections for male pattern alopecia.”
Pore size and sebum production: A 2019 review of published studies of botulinum toxin A looking at the effect on sebum and pore size, Dr. Rubin said, found that most studies “suggest it does actually reduce pore size and sebum production” (J Cosmet Dermatol. 2019 Apr;18[2]:451-7).
This can be considered an option for those patients concerned about pore size, who are not satisfied with results of retinoid or laser treatment, he commented. This approach may not have an effect in all patients, so he advised first treating a small trial area, and photographing patients to record their level of improvement. “It’s rarely profound, but it’s additive, it’s one more thing you can do.”
Depression: These data include a study of 30 patients with major depression, half who received one onabotulinumtoxinA injection in the glabellar area as adjunctive treatment of depression. After 6 weeks, those who were treated had an average of 47% reduction in depression scores on the Hamilton Depression Rating Scale, compared with an average 9% reduction among those on placebo (J Psychiatr Res. 2012 May;46[5]:574-81). Two recent studies have had similar results, according to Dr. Rubin.
Results of another study, he said, raise the question of whether patients are less depressed because they are pleased with the cosmetic effects or if there is another explanation (J Am Acad Dermatol. 2016 Jan;74[1]:171-3.e1). The study, which included 59 patients with depression treated in the glabellar areas with botulinum toxin injections, found no association between severity of the furrows and degree of depression or between the degree of furrow correction and degree of relief from depression after treatment. “So the patients who had the most improvement were not necessarily the ones who were the least depressed afterwards,” he said.
These data imply that something else may be occurring that is not necessarily muscle related, he said.
Dr. Rubin said he had no relevant disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
Nail dystrophy and nail plate thinning
At a follow-up visit, a biopsy of the skin on the fingertips was performed, which showed lichenoid lymphocytic inflammatory infiltrate with associated hyperkeratosis, hypergranulosis, and acanthosis.
No fungal elements were seen. The findings were consistent with lichen planus.
The patient was started on hydroxychloroquine. It was recommended she start a 6-week course of oral prednisone, but the mother was opposed to systemic treatment because of potential side effects.
She continued topical betamethasone without much change. Topical tacrolimus later was recommended to use on off days of betamethasone, which led to no improvement. Narrow-band UVB also was started with minimal improvement. Unfortunately,
Nail lichen planus (NLP) in children is not a common condition.1 In a recent series from Chiheb et al., NLP was reported in 90 patients, of which 40% were children; a quarter of the patients reported having extracutaneous involvement as well.2 In another childhood LP series,14 % of the children presented with nail disease.3 It can be a severe disease that, if not treated aggressively, may lead to destruction of the nail bed. This condition seems to be more prevalent in boys than girls and more prevalent in African American children.3 Unfortunately, in this patient’s case, the mother was hesitant to use systemic therapy and aggressive treatment was delayed.
Possible but not clear associations with autoimmune conditions such as vitiligo, autoimmune thyroiditis, myasthenia gravis, alopecia areata, thymoma, autoimmune polyendocrinopathy, atopic dermatitis, and lichen nitidus have been described in children with LP.
The clinical characteristics of NLP include nail plate thinning with longitudinal ridging and fissuring, with or without pterygium; trachyonychia; and erythema of the lunula when the nail matrix is involved. When the nail bed is affected, the patient can present with onycholysis with or without subungual hyperkeratosis and violaceous hue of the nail bed.4 NLP can have three different clinical presentations described by Tosti et al., which include typical NLP, 20‐nail dystrophy (trachyonychia), and idiopathic nail atrophy. Idiopathic nail atrophy is described solely in children as an acute and rapid progression that leads to destruction of the nail within months, which appears to be the clinical presentation in our patient.
The differential diagnosis of nail dystrophy in children includes infectious processes such as onychomycosis, especially when children present with onycholysis and subungual hyperkeratosis. Because of this, it is recommended to perform a nail culture or submit a sample of nail clippings for microscopic evaluation to confirm the diagnosis of onychomycosis prior to starting systemic therapy in children. Fingernail involvement without toenail involvement is an unusual presentation of onychomycosis.
Twenty-nail dystrophy – also known as trachyonychia – can be caused by several inflammatory skin conditions such as lichen planus, psoriasis, eczema, pemphigus vulgaris, and alopecia areata. Clinically, there is uniformly monomorphic thinning of the nail plate with longitudinal ridging without splitting or pterygium.1 This is a benign condition and should not cause scarring. About 10% of the cases of 20-nail dystrophy are caused by lichen planus.
Nail psoriasis is characterized by nail pitting, oil spots on the nail plate, leukonychia, subungual hyperkeratosis, and onycholysis, as well as nail crumbling, which were not seen in our patient. Although her initial presentation was of 20-nail dystrophy, which also can be a presentation of nail psoriasis, its rapid evolution with associated nail atrophy and pterygium make it unlikely to be psoriasis in this particular patient.
Patients with pachyonychia congenita – which is a genetic disorder or keratinization caused by mutations on several genes encoding keratin such as K6a, K16, K17, K6b, and possibly K6c – present with nail thickening (pachyonychia) and discoloration of the nails, as well as pincer nails. These patients also present with oral leukokeratosis and focal palmoplantar keratoderma.
The main treatment of lichen planus is potent topical corticosteroids.
For nail disease, topical treatment may not be effective and systemic treatment may be necessary. Systemic corticosteroids have been used in several pediatric series varying from a short course given at a dose of 1- 2 mg/kg per day for 2 weeks to a longer 3-month course followed by tapering.3 There are several protocols of intramuscular triamcinolone at a dose of 0.5 mg/kg in children in once a month injections for about 3 months that have been reported successful with minimal side effects.1 Other medications reported useful in patients with NLP include dapsone and acitretin. Other treatment options include narrow-band UVB and PUVA.3
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Email her at [email protected].
References
1. Arch Dermatol. 2001 Aug;137(8):1027-32.
2. Ann Dermatol Venereol. 2015 Jan;142(1):21-5.
3. Pediatr Dermatol. 2014 Jan-Feb;31(1):59-67.
4. Dermatological diseases, in “Nails: Diagnosis, Therapy, and Surgery,” 3rd ed. (Oxford: Elsevier Saunders, 2005, p. 105).
At a follow-up visit, a biopsy of the skin on the fingertips was performed, which showed lichenoid lymphocytic inflammatory infiltrate with associated hyperkeratosis, hypergranulosis, and acanthosis.
No fungal elements were seen. The findings were consistent with lichen planus.
The patient was started on hydroxychloroquine. It was recommended she start a 6-week course of oral prednisone, but the mother was opposed to systemic treatment because of potential side effects.
She continued topical betamethasone without much change. Topical tacrolimus later was recommended to use on off days of betamethasone, which led to no improvement. Narrow-band UVB also was started with minimal improvement. Unfortunately,
Nail lichen planus (NLP) in children is not a common condition.1 In a recent series from Chiheb et al., NLP was reported in 90 patients, of which 40% were children; a quarter of the patients reported having extracutaneous involvement as well.2 In another childhood LP series,14 % of the children presented with nail disease.3 It can be a severe disease that, if not treated aggressively, may lead to destruction of the nail bed. This condition seems to be more prevalent in boys than girls and more prevalent in African American children.3 Unfortunately, in this patient’s case, the mother was hesitant to use systemic therapy and aggressive treatment was delayed.
Possible but not clear associations with autoimmune conditions such as vitiligo, autoimmune thyroiditis, myasthenia gravis, alopecia areata, thymoma, autoimmune polyendocrinopathy, atopic dermatitis, and lichen nitidus have been described in children with LP.
The clinical characteristics of NLP include nail plate thinning with longitudinal ridging and fissuring, with or without pterygium; trachyonychia; and erythema of the lunula when the nail matrix is involved. When the nail bed is affected, the patient can present with onycholysis with or without subungual hyperkeratosis and violaceous hue of the nail bed.4 NLP can have three different clinical presentations described by Tosti et al., which include typical NLP, 20‐nail dystrophy (trachyonychia), and idiopathic nail atrophy. Idiopathic nail atrophy is described solely in children as an acute and rapid progression that leads to destruction of the nail within months, which appears to be the clinical presentation in our patient.
The differential diagnosis of nail dystrophy in children includes infectious processes such as onychomycosis, especially when children present with onycholysis and subungual hyperkeratosis. Because of this, it is recommended to perform a nail culture or submit a sample of nail clippings for microscopic evaluation to confirm the diagnosis of onychomycosis prior to starting systemic therapy in children. Fingernail involvement without toenail involvement is an unusual presentation of onychomycosis.
Twenty-nail dystrophy – also known as trachyonychia – can be caused by several inflammatory skin conditions such as lichen planus, psoriasis, eczema, pemphigus vulgaris, and alopecia areata. Clinically, there is uniformly monomorphic thinning of the nail plate with longitudinal ridging without splitting or pterygium.1 This is a benign condition and should not cause scarring. About 10% of the cases of 20-nail dystrophy are caused by lichen planus.
Nail psoriasis is characterized by nail pitting, oil spots on the nail plate, leukonychia, subungual hyperkeratosis, and onycholysis, as well as nail crumbling, which were not seen in our patient. Although her initial presentation was of 20-nail dystrophy, which also can be a presentation of nail psoriasis, its rapid evolution with associated nail atrophy and pterygium make it unlikely to be psoriasis in this particular patient.
Patients with pachyonychia congenita – which is a genetic disorder or keratinization caused by mutations on several genes encoding keratin such as K6a, K16, K17, K6b, and possibly K6c – present with nail thickening (pachyonychia) and discoloration of the nails, as well as pincer nails. These patients also present with oral leukokeratosis and focal palmoplantar keratoderma.
The main treatment of lichen planus is potent topical corticosteroids.
For nail disease, topical treatment may not be effective and systemic treatment may be necessary. Systemic corticosteroids have been used in several pediatric series varying from a short course given at a dose of 1- 2 mg/kg per day for 2 weeks to a longer 3-month course followed by tapering.3 There are several protocols of intramuscular triamcinolone at a dose of 0.5 mg/kg in children in once a month injections for about 3 months that have been reported successful with minimal side effects.1 Other medications reported useful in patients with NLP include dapsone and acitretin. Other treatment options include narrow-band UVB and PUVA.3
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Email her at [email protected].
References
1. Arch Dermatol. 2001 Aug;137(8):1027-32.
2. Ann Dermatol Venereol. 2015 Jan;142(1):21-5.
3. Pediatr Dermatol. 2014 Jan-Feb;31(1):59-67.
4. Dermatological diseases, in “Nails: Diagnosis, Therapy, and Surgery,” 3rd ed. (Oxford: Elsevier Saunders, 2005, p. 105).
At a follow-up visit, a biopsy of the skin on the fingertips was performed, which showed lichenoid lymphocytic inflammatory infiltrate with associated hyperkeratosis, hypergranulosis, and acanthosis.
No fungal elements were seen. The findings were consistent with lichen planus.
The patient was started on hydroxychloroquine. It was recommended she start a 6-week course of oral prednisone, but the mother was opposed to systemic treatment because of potential side effects.
She continued topical betamethasone without much change. Topical tacrolimus later was recommended to use on off days of betamethasone, which led to no improvement. Narrow-band UVB also was started with minimal improvement. Unfortunately,
Nail lichen planus (NLP) in children is not a common condition.1 In a recent series from Chiheb et al., NLP was reported in 90 patients, of which 40% were children; a quarter of the patients reported having extracutaneous involvement as well.2 In another childhood LP series,14 % of the children presented with nail disease.3 It can be a severe disease that, if not treated aggressively, may lead to destruction of the nail bed. This condition seems to be more prevalent in boys than girls and more prevalent in African American children.3 Unfortunately, in this patient’s case, the mother was hesitant to use systemic therapy and aggressive treatment was delayed.
Possible but not clear associations with autoimmune conditions such as vitiligo, autoimmune thyroiditis, myasthenia gravis, alopecia areata, thymoma, autoimmune polyendocrinopathy, atopic dermatitis, and lichen nitidus have been described in children with LP.
The clinical characteristics of NLP include nail plate thinning with longitudinal ridging and fissuring, with or without pterygium; trachyonychia; and erythema of the lunula when the nail matrix is involved. When the nail bed is affected, the patient can present with onycholysis with or without subungual hyperkeratosis and violaceous hue of the nail bed.4 NLP can have three different clinical presentations described by Tosti et al., which include typical NLP, 20‐nail dystrophy (trachyonychia), and idiopathic nail atrophy. Idiopathic nail atrophy is described solely in children as an acute and rapid progression that leads to destruction of the nail within months, which appears to be the clinical presentation in our patient.
The differential diagnosis of nail dystrophy in children includes infectious processes such as onychomycosis, especially when children present with onycholysis and subungual hyperkeratosis. Because of this, it is recommended to perform a nail culture or submit a sample of nail clippings for microscopic evaluation to confirm the diagnosis of onychomycosis prior to starting systemic therapy in children. Fingernail involvement without toenail involvement is an unusual presentation of onychomycosis.
Twenty-nail dystrophy – also known as trachyonychia – can be caused by several inflammatory skin conditions such as lichen planus, psoriasis, eczema, pemphigus vulgaris, and alopecia areata. Clinically, there is uniformly monomorphic thinning of the nail plate with longitudinal ridging without splitting or pterygium.1 This is a benign condition and should not cause scarring. About 10% of the cases of 20-nail dystrophy are caused by lichen planus.
Nail psoriasis is characterized by nail pitting, oil spots on the nail plate, leukonychia, subungual hyperkeratosis, and onycholysis, as well as nail crumbling, which were not seen in our patient. Although her initial presentation was of 20-nail dystrophy, which also can be a presentation of nail psoriasis, its rapid evolution with associated nail atrophy and pterygium make it unlikely to be psoriasis in this particular patient.
Patients with pachyonychia congenita – which is a genetic disorder or keratinization caused by mutations on several genes encoding keratin such as K6a, K16, K17, K6b, and possibly K6c – present with nail thickening (pachyonychia) and discoloration of the nails, as well as pincer nails. These patients also present with oral leukokeratosis and focal palmoplantar keratoderma.
The main treatment of lichen planus is potent topical corticosteroids.
For nail disease, topical treatment may not be effective and systemic treatment may be necessary. Systemic corticosteroids have been used in several pediatric series varying from a short course given at a dose of 1- 2 mg/kg per day for 2 weeks to a longer 3-month course followed by tapering.3 There are several protocols of intramuscular triamcinolone at a dose of 0.5 mg/kg in children in once a month injections for about 3 months that have been reported successful with minimal side effects.1 Other medications reported useful in patients with NLP include dapsone and acitretin. Other treatment options include narrow-band UVB and PUVA.3
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Email her at [email protected].
References
1. Arch Dermatol. 2001 Aug;137(8):1027-32.
2. Ann Dermatol Venereol. 2015 Jan;142(1):21-5.
3. Pediatr Dermatol. 2014 Jan-Feb;31(1):59-67.
4. Dermatological diseases, in “Nails: Diagnosis, Therapy, and Surgery,” 3rd ed. (Oxford: Elsevier Saunders, 2005, p. 105).
An 8-year-old female child comes to our pediatric dermatology clinic for evaluation of onychomycosis on her fingernails. The mother stated the child started developing funny-looking nails 1 year prior to the visit. It started with only two fingernails affected and now has spread to all her fingernails. Her toenails are not involved.
She denied any pain or itching. She initially was treated with topical antifungal medications as well as tea tree oil, apple cider vinegar, and a 6-week course of oral griseofulvin without any improvement. Her nails progressively have gotten much worse. She has no history of atopic dermatitis or any other skin conditions. She denied any joint pain, sun sensitivity, hair loss, or any other symptoms. The mother denied any family history of nail fungus, ringworm, psoriasis, or eczema.
She likes to play basketball and enjoys arts and crafts. She has a cat and a dog; neither of them have any skin problems.
On physical examination, there is nail dystrophy with nail plate thinning and longitudinal fissuring of all fingernails but not of the toenails. She also has hyperpigmented violaceous plaques on the surrounding periungual skin. There are no other skin lesions, and there are no oral or genital lesions. There is no scalp involvement or hair loss. At follow-up several months later, she had complete destruction of the nail plate with scar formation.
A fungal culture was performed, as well as microscopic analysis of the nail with periodic acid fast and giemsa stains, which showed no fungal organisms.
She initially was treated with topical betamethasone twice a day for 6 weeks and then 2 weeks on and 2 weeks off without much change.
Psoriasis elevates cancer risk
Psoriasis patients are at increased risk for several types of cancer, notably lymphoma and keratinocyte cancer, based on data from a systematic review and meta-analysis of more than 2 million patients.
Previous studies have identified an increased overall cancer risk in psoriasis patients, compared with the general population or controls without psoriasis, and both lymphomas and keratinocyte cancers occur more often in psoriasis patients, compared with controls, but additional larger studies have been conducted since the last meta-analysis was published in 2013, wrote Sofie Vaengebjerg, MD, of the University of Copenhagen and colleagues.
To better identify the risk of cancer in psoriasis and psoriatic arthritis patients and to explore the impact of biologics, the researchers reviewed data from 112 studies totaling 2,053,932 patients in a study published in JAMA Dermatology.
Overall, the risk of any cancer was slightly higher in psoriasis patients (risk ratio, 1.21; 95% confidence interval, 1.11-1.33), compared with controls, with a prevalence of 4.78% and an incidence rate of 11.75 per 1,000 person-years. The most common cancer among psoriasis patients was keratinocyte cancer, with a risk ratio of 2.28 (95% CI, 1.73-3.01), a prevalence of 2.55%, and an incidence rate of 4.35 per 1,000 person-years.
Other cancers with significantly elevated risk among psoriasis patients were lymphomas (RR, 1.56; 95% CI, 1.37-1.78), lung cancer (RR, 1.26; 95% CI, 1.13-1.40), and bladder cancer (RR, 1.12; 95% CI, 1.04-1.19).
No increased risk of cancer was noted among psoriasis patients who were treated with biologics. “However, patients receiving biologic agents are selected and the results might be reliant on selection bias, and studies investigating long-term safety of these drugs are still limited,” the researchers wrote.
In addition, psoriatic arthritis was not associated with any overall increase in cancer risk, with the exception of three studies showing an increased risk for breast cancer, the researchers noted. The overall cancer prevalence for psoriatic arthritis patients was 5.74%, with an incidence rate of 6.44 per 1,000 person-years.
The study findings were limited by several factors, including the inconsistencies in study design and characteristics and the small amount of data on biologic agents and psoriatic arthritis, the researchers noted. However, the results were strengthened by the large number of patients, real-world study settings, inclusion of biologics, and analysis of cancer in psoriatic arthritis patients.
“Clinicians treating patients with psoriasis should be aware of this increased risk, especially for lymphomas, as immunogenic treatment might be associated with exacerbations,” and should be aware that more research is needed to assess cancer risk associated with biologics, they concluded.
The study received no outside funding. Lead author Dr. Vaengebjerg had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple companies, including AbbVie, Janssen, Novartis, Eli Lilly, LEO Pharma, UCB, Almirall, and Sanofi.
SOURCE: Vaengebjerg S et al. JAMA Dermatol. 2020 Feb 19. doi:10.1001/jamadermatol.2020.0024.
Psoriasis patients are at increased risk for several types of cancer, notably lymphoma and keratinocyte cancer, based on data from a systematic review and meta-analysis of more than 2 million patients.
Previous studies have identified an increased overall cancer risk in psoriasis patients, compared with the general population or controls without psoriasis, and both lymphomas and keratinocyte cancers occur more often in psoriasis patients, compared with controls, but additional larger studies have been conducted since the last meta-analysis was published in 2013, wrote Sofie Vaengebjerg, MD, of the University of Copenhagen and colleagues.
To better identify the risk of cancer in psoriasis and psoriatic arthritis patients and to explore the impact of biologics, the researchers reviewed data from 112 studies totaling 2,053,932 patients in a study published in JAMA Dermatology.
Overall, the risk of any cancer was slightly higher in psoriasis patients (risk ratio, 1.21; 95% confidence interval, 1.11-1.33), compared with controls, with a prevalence of 4.78% and an incidence rate of 11.75 per 1,000 person-years. The most common cancer among psoriasis patients was keratinocyte cancer, with a risk ratio of 2.28 (95% CI, 1.73-3.01), a prevalence of 2.55%, and an incidence rate of 4.35 per 1,000 person-years.
Other cancers with significantly elevated risk among psoriasis patients were lymphomas (RR, 1.56; 95% CI, 1.37-1.78), lung cancer (RR, 1.26; 95% CI, 1.13-1.40), and bladder cancer (RR, 1.12; 95% CI, 1.04-1.19).
No increased risk of cancer was noted among psoriasis patients who were treated with biologics. “However, patients receiving biologic agents are selected and the results might be reliant on selection bias, and studies investigating long-term safety of these drugs are still limited,” the researchers wrote.
In addition, psoriatic arthritis was not associated with any overall increase in cancer risk, with the exception of three studies showing an increased risk for breast cancer, the researchers noted. The overall cancer prevalence for psoriatic arthritis patients was 5.74%, with an incidence rate of 6.44 per 1,000 person-years.
The study findings were limited by several factors, including the inconsistencies in study design and characteristics and the small amount of data on biologic agents and psoriatic arthritis, the researchers noted. However, the results were strengthened by the large number of patients, real-world study settings, inclusion of biologics, and analysis of cancer in psoriatic arthritis patients.
“Clinicians treating patients with psoriasis should be aware of this increased risk, especially for lymphomas, as immunogenic treatment might be associated with exacerbations,” and should be aware that more research is needed to assess cancer risk associated with biologics, they concluded.
The study received no outside funding. Lead author Dr. Vaengebjerg had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple companies, including AbbVie, Janssen, Novartis, Eli Lilly, LEO Pharma, UCB, Almirall, and Sanofi.
SOURCE: Vaengebjerg S et al. JAMA Dermatol. 2020 Feb 19. doi:10.1001/jamadermatol.2020.0024.
Psoriasis patients are at increased risk for several types of cancer, notably lymphoma and keratinocyte cancer, based on data from a systematic review and meta-analysis of more than 2 million patients.
Previous studies have identified an increased overall cancer risk in psoriasis patients, compared with the general population or controls without psoriasis, and both lymphomas and keratinocyte cancers occur more often in psoriasis patients, compared with controls, but additional larger studies have been conducted since the last meta-analysis was published in 2013, wrote Sofie Vaengebjerg, MD, of the University of Copenhagen and colleagues.
To better identify the risk of cancer in psoriasis and psoriatic arthritis patients and to explore the impact of biologics, the researchers reviewed data from 112 studies totaling 2,053,932 patients in a study published in JAMA Dermatology.
Overall, the risk of any cancer was slightly higher in psoriasis patients (risk ratio, 1.21; 95% confidence interval, 1.11-1.33), compared with controls, with a prevalence of 4.78% and an incidence rate of 11.75 per 1,000 person-years. The most common cancer among psoriasis patients was keratinocyte cancer, with a risk ratio of 2.28 (95% CI, 1.73-3.01), a prevalence of 2.55%, and an incidence rate of 4.35 per 1,000 person-years.
Other cancers with significantly elevated risk among psoriasis patients were lymphomas (RR, 1.56; 95% CI, 1.37-1.78), lung cancer (RR, 1.26; 95% CI, 1.13-1.40), and bladder cancer (RR, 1.12; 95% CI, 1.04-1.19).
No increased risk of cancer was noted among psoriasis patients who were treated with biologics. “However, patients receiving biologic agents are selected and the results might be reliant on selection bias, and studies investigating long-term safety of these drugs are still limited,” the researchers wrote.
In addition, psoriatic arthritis was not associated with any overall increase in cancer risk, with the exception of three studies showing an increased risk for breast cancer, the researchers noted. The overall cancer prevalence for psoriatic arthritis patients was 5.74%, with an incidence rate of 6.44 per 1,000 person-years.
The study findings were limited by several factors, including the inconsistencies in study design and characteristics and the small amount of data on biologic agents and psoriatic arthritis, the researchers noted. However, the results were strengthened by the large number of patients, real-world study settings, inclusion of biologics, and analysis of cancer in psoriatic arthritis patients.
“Clinicians treating patients with psoriasis should be aware of this increased risk, especially for lymphomas, as immunogenic treatment might be associated with exacerbations,” and should be aware that more research is needed to assess cancer risk associated with biologics, they concluded.
The study received no outside funding. Lead author Dr. Vaengebjerg had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple companies, including AbbVie, Janssen, Novartis, Eli Lilly, LEO Pharma, UCB, Almirall, and Sanofi.
SOURCE: Vaengebjerg S et al. JAMA Dermatol. 2020 Feb 19. doi:10.1001/jamadermatol.2020.0024.
FROM JAMA DERMATOLOGY
‘Momentous’ USMLE change: New pass/fail format stuns medicine
News that the United States Medical Licensing Examination (USMLE) program will change its Step 1 scoring from a 3-digit number to pass/fail starting Jan. 1, 2022, has set off a flurry of shocked responses from students and physicians.
J. Bryan Carmody, MD, MPH, an assistant professor at Eastern Virginia Medical School in Norfolk, said in an interview that he was “stunned” when he heard the news on Wednesday and said the switch presents “the single biggest opportunity for medical school education reform since the Flexner Report,” which in 1910 established standards for modern medical education.
Numbers will continue for some tests
The USMLE cosponsors – the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) – said that the Step 2 Clinical Knowledge (CK) exam and Step 3 will continue to be scored numerically. Step 2 Clinical Skills (CS) will continue its pass/fail system.
The change was made after Step 1 had been roundly criticized as playing too big a role in the process of becoming a physician and for causing students to study for the test instead of engaging fully in their medical education.
Ramie Fathy, a third-year medical student at the University of Pennsylvania, Philadelphia, currently studying for Step 1, said in an interview that it would have been nice personally to have the pass/fail choice, but he predicts both good and unintended consequences in the change.
The positive news, Mr. Fathy said, is that less emphasis will be put on the Step 1 test, which includes memorizing basic science details that may or not be relevant depending on later specialty choice.
“It’s not necessarily measuring what the test makers intended, which was whether or not a student can understand and apply basic science concepts to the practice of medicine,” he said.
“The current system encourages students to get as high a score as possible, which – after a certain point – translates to memorizing many little details that become increasingly less practically relevant,” Mr. Fathy said.
Pressure may move elsewhere?
However, Mr. Fathy worries that, without a scoring system to help decide who stands out in Step 1, residency program directors will depend more on the reputation of candidates’ medical school and the clout of the person writing a letter of recommendation – factors that are often influenced by family resources and social standing. That could wedge a further economic divide into the path to becoming a physician.
Mr. Fathy said he and fellow students are watching for information on what the passing bar will be and what happens with Step 2 Clinical Knowledge exam. USMLE has promised more information as soon as it is available.
“The question is whether that test will replace Step 1 as the standardized metric of student competency,” Mr. Fathy said, which would put more pressure on students further down the medical path.
Will Step 2 anxiety increase?
Dr. Carmody agreed that there is the danger that students now will spend their time studying for Step 2 CK at the expense of other parts of their education.
Meaningful reform will depend on the pass/fail move being coupled with other reforms, most importantly application caps, said Dr. Carmody, who teaches preclinical medical students and works with the residency program.
He has been blogging about Step 1 pass/fail for the past year.
Currently students can apply for as many residencies as they can pay for and Carmody said the number of applications per student has been rising over the past decade.
“That puts program directors under an impossible burden,” he said. “With our Step 1-based system, there’s significant inequality in the number of interviews people get. Programs end up overinviting the same group of people who look good on paper.”
People outside that group respond by sending more applications than they need to just to get a few interviews, Dr. Carmody added.
With caps, students would have an incentive to apply to only those programs in which they had a sincere interest, he said. Program directors also would then be better able to evaluate each application.
Switching Step 1 to pass/fail may have some effect on medical school burnout, Dr. Carmody said.
“It’s one thing to work hard when you’re on call and your patients depend on it,” he said. “But I would have a hard time staying up late every night studying something that I know in my heart is not going to help my patients, but I have to do it because I have to do better than the person who’s studying in the apartment next to me.”
Test has strayed from original purpose
Joseph Safdieh, MD, an assistant dean for clinical curriculum and director of the medical student neurology clerkship for the Weill Cornell Medicine, New York, sees the move as positive overall.
“We should not be using any single metric to define or describe our students’ overall profile,” he said in an interview.
“This has been a very significant anxiety point for our medical students for quite a number of years,” Dr. Safdieh said. “They were frustrated that their entire 4 years of medical school seemingly came down to one number.”
The test was created originally as one of three parts of licensure, he pointed out.
“Over the past 10 or 15 years, the exam has morphed to become a litmus test for very specific residency programs,” he said.
However, Dr. Safdieh has concerns that Step 2 will cultivate the same anxiety and may get too big a spotlight without the Step 1 metric, “although one could argue that test does more accurately reflect clinical material,” he said.
He also worries that students who have selected a specialty by the time they take Step 2 may find late in the game that they are less competitive in their field than they thought they were and may have to make a last-minute switch.
Dr. Safdieh said he thinks Step 2 will be next to go the pass/fail route. In reading between the lines of the announcement, he believes the test cosponsors didn’t make both pass/fail at once because it would have been “a nuclear bomb to the system.”
He credited the cosponsors with making what he called a “bold and momentous decision to initiate radical change in the overall transition between undergraduate and graduate medical education.”
Dr. Safdieh added that few in medicine were expecting Wednesday’s announcement.
“I think many of us were expecting them to go to quartile grading, not to go this far,” he said.
Dr. Safdieh suggested that, among those who may see downstream effects from the pass/fail move are offshore schools, such as those in the Caribbean. “Those schools rely on Step 1 to demonstrate that their students are meeting the rigor,” he said. But he hopes that this will lead to more holistic review.
“We’re hoping that this will force change in the system so that residency directors will look at more than just test-taking ability. They’ll look at publications and scholarship, community service and advocacy and performance in medical school,” Dr. Safdieh said.
Alison J. Whelan, MD, chief medical education officer of the Association of American Medical Colleges said in a statement, “The transition from medical school to residency training is a matter of great concern throughout academic medicine.
“The decision by the NBME and FSMB to change USMLE Step 1 score reporting to pass/fail was very carefully considered to balance student learning and student well-being,” she said. “The medical education community must now work together to identify and implement additional changes to improve the overall UME-GME [undergraduate and graduate medical education] transition system for all stakeholders and the AAMC is committed to helping lead this work.”
Dr. Fathy, Dr. Carmody, and Dr. Safdieh have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
News that the United States Medical Licensing Examination (USMLE) program will change its Step 1 scoring from a 3-digit number to pass/fail starting Jan. 1, 2022, has set off a flurry of shocked responses from students and physicians.
J. Bryan Carmody, MD, MPH, an assistant professor at Eastern Virginia Medical School in Norfolk, said in an interview that he was “stunned” when he heard the news on Wednesday and said the switch presents “the single biggest opportunity for medical school education reform since the Flexner Report,” which in 1910 established standards for modern medical education.
Numbers will continue for some tests
The USMLE cosponsors – the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) – said that the Step 2 Clinical Knowledge (CK) exam and Step 3 will continue to be scored numerically. Step 2 Clinical Skills (CS) will continue its pass/fail system.
The change was made after Step 1 had been roundly criticized as playing too big a role in the process of becoming a physician and for causing students to study for the test instead of engaging fully in their medical education.
Ramie Fathy, a third-year medical student at the University of Pennsylvania, Philadelphia, currently studying for Step 1, said in an interview that it would have been nice personally to have the pass/fail choice, but he predicts both good and unintended consequences in the change.
The positive news, Mr. Fathy said, is that less emphasis will be put on the Step 1 test, which includes memorizing basic science details that may or not be relevant depending on later specialty choice.
“It’s not necessarily measuring what the test makers intended, which was whether or not a student can understand and apply basic science concepts to the practice of medicine,” he said.
“The current system encourages students to get as high a score as possible, which – after a certain point – translates to memorizing many little details that become increasingly less practically relevant,” Mr. Fathy said.
Pressure may move elsewhere?
However, Mr. Fathy worries that, without a scoring system to help decide who stands out in Step 1, residency program directors will depend more on the reputation of candidates’ medical school and the clout of the person writing a letter of recommendation – factors that are often influenced by family resources and social standing. That could wedge a further economic divide into the path to becoming a physician.
Mr. Fathy said he and fellow students are watching for information on what the passing bar will be and what happens with Step 2 Clinical Knowledge exam. USMLE has promised more information as soon as it is available.
“The question is whether that test will replace Step 1 as the standardized metric of student competency,” Mr. Fathy said, which would put more pressure on students further down the medical path.
Will Step 2 anxiety increase?
Dr. Carmody agreed that there is the danger that students now will spend their time studying for Step 2 CK at the expense of other parts of their education.
Meaningful reform will depend on the pass/fail move being coupled with other reforms, most importantly application caps, said Dr. Carmody, who teaches preclinical medical students and works with the residency program.
He has been blogging about Step 1 pass/fail for the past year.
Currently students can apply for as many residencies as they can pay for and Carmody said the number of applications per student has been rising over the past decade.
“That puts program directors under an impossible burden,” he said. “With our Step 1-based system, there’s significant inequality in the number of interviews people get. Programs end up overinviting the same group of people who look good on paper.”
People outside that group respond by sending more applications than they need to just to get a few interviews, Dr. Carmody added.
With caps, students would have an incentive to apply to only those programs in which they had a sincere interest, he said. Program directors also would then be better able to evaluate each application.
Switching Step 1 to pass/fail may have some effect on medical school burnout, Dr. Carmody said.
“It’s one thing to work hard when you’re on call and your patients depend on it,” he said. “But I would have a hard time staying up late every night studying something that I know in my heart is not going to help my patients, but I have to do it because I have to do better than the person who’s studying in the apartment next to me.”
Test has strayed from original purpose
Joseph Safdieh, MD, an assistant dean for clinical curriculum and director of the medical student neurology clerkship for the Weill Cornell Medicine, New York, sees the move as positive overall.
“We should not be using any single metric to define or describe our students’ overall profile,” he said in an interview.
“This has been a very significant anxiety point for our medical students for quite a number of years,” Dr. Safdieh said. “They were frustrated that their entire 4 years of medical school seemingly came down to one number.”
The test was created originally as one of three parts of licensure, he pointed out.
“Over the past 10 or 15 years, the exam has morphed to become a litmus test for very specific residency programs,” he said.
However, Dr. Safdieh has concerns that Step 2 will cultivate the same anxiety and may get too big a spotlight without the Step 1 metric, “although one could argue that test does more accurately reflect clinical material,” he said.
He also worries that students who have selected a specialty by the time they take Step 2 may find late in the game that they are less competitive in their field than they thought they were and may have to make a last-minute switch.
Dr. Safdieh said he thinks Step 2 will be next to go the pass/fail route. In reading between the lines of the announcement, he believes the test cosponsors didn’t make both pass/fail at once because it would have been “a nuclear bomb to the system.”
He credited the cosponsors with making what he called a “bold and momentous decision to initiate radical change in the overall transition between undergraduate and graduate medical education.”
Dr. Safdieh added that few in medicine were expecting Wednesday’s announcement.
“I think many of us were expecting them to go to quartile grading, not to go this far,” he said.
Dr. Safdieh suggested that, among those who may see downstream effects from the pass/fail move are offshore schools, such as those in the Caribbean. “Those schools rely on Step 1 to demonstrate that their students are meeting the rigor,” he said. But he hopes that this will lead to more holistic review.
“We’re hoping that this will force change in the system so that residency directors will look at more than just test-taking ability. They’ll look at publications and scholarship, community service and advocacy and performance in medical school,” Dr. Safdieh said.
Alison J. Whelan, MD, chief medical education officer of the Association of American Medical Colleges said in a statement, “The transition from medical school to residency training is a matter of great concern throughout academic medicine.
“The decision by the NBME and FSMB to change USMLE Step 1 score reporting to pass/fail was very carefully considered to balance student learning and student well-being,” she said. “The medical education community must now work together to identify and implement additional changes to improve the overall UME-GME [undergraduate and graduate medical education] transition system for all stakeholders and the AAMC is committed to helping lead this work.”
Dr. Fathy, Dr. Carmody, and Dr. Safdieh have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
News that the United States Medical Licensing Examination (USMLE) program will change its Step 1 scoring from a 3-digit number to pass/fail starting Jan. 1, 2022, has set off a flurry of shocked responses from students and physicians.
J. Bryan Carmody, MD, MPH, an assistant professor at Eastern Virginia Medical School in Norfolk, said in an interview that he was “stunned” when he heard the news on Wednesday and said the switch presents “the single biggest opportunity for medical school education reform since the Flexner Report,” which in 1910 established standards for modern medical education.
Numbers will continue for some tests
The USMLE cosponsors – the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) – said that the Step 2 Clinical Knowledge (CK) exam and Step 3 will continue to be scored numerically. Step 2 Clinical Skills (CS) will continue its pass/fail system.
The change was made after Step 1 had been roundly criticized as playing too big a role in the process of becoming a physician and for causing students to study for the test instead of engaging fully in their medical education.
Ramie Fathy, a third-year medical student at the University of Pennsylvania, Philadelphia, currently studying for Step 1, said in an interview that it would have been nice personally to have the pass/fail choice, but he predicts both good and unintended consequences in the change.
The positive news, Mr. Fathy said, is that less emphasis will be put on the Step 1 test, which includes memorizing basic science details that may or not be relevant depending on later specialty choice.
“It’s not necessarily measuring what the test makers intended, which was whether or not a student can understand and apply basic science concepts to the practice of medicine,” he said.
“The current system encourages students to get as high a score as possible, which – after a certain point – translates to memorizing many little details that become increasingly less practically relevant,” Mr. Fathy said.
Pressure may move elsewhere?
However, Mr. Fathy worries that, without a scoring system to help decide who stands out in Step 1, residency program directors will depend more on the reputation of candidates’ medical school and the clout of the person writing a letter of recommendation – factors that are often influenced by family resources and social standing. That could wedge a further economic divide into the path to becoming a physician.
Mr. Fathy said he and fellow students are watching for information on what the passing bar will be and what happens with Step 2 Clinical Knowledge exam. USMLE has promised more information as soon as it is available.
“The question is whether that test will replace Step 1 as the standardized metric of student competency,” Mr. Fathy said, which would put more pressure on students further down the medical path.
Will Step 2 anxiety increase?
Dr. Carmody agreed that there is the danger that students now will spend their time studying for Step 2 CK at the expense of other parts of their education.
Meaningful reform will depend on the pass/fail move being coupled with other reforms, most importantly application caps, said Dr. Carmody, who teaches preclinical medical students and works with the residency program.
He has been blogging about Step 1 pass/fail for the past year.
Currently students can apply for as many residencies as they can pay for and Carmody said the number of applications per student has been rising over the past decade.
“That puts program directors under an impossible burden,” he said. “With our Step 1-based system, there’s significant inequality in the number of interviews people get. Programs end up overinviting the same group of people who look good on paper.”
People outside that group respond by sending more applications than they need to just to get a few interviews, Dr. Carmody added.
With caps, students would have an incentive to apply to only those programs in which they had a sincere interest, he said. Program directors also would then be better able to evaluate each application.
Switching Step 1 to pass/fail may have some effect on medical school burnout, Dr. Carmody said.
“It’s one thing to work hard when you’re on call and your patients depend on it,” he said. “But I would have a hard time staying up late every night studying something that I know in my heart is not going to help my patients, but I have to do it because I have to do better than the person who’s studying in the apartment next to me.”
Test has strayed from original purpose
Joseph Safdieh, MD, an assistant dean for clinical curriculum and director of the medical student neurology clerkship for the Weill Cornell Medicine, New York, sees the move as positive overall.
“We should not be using any single metric to define or describe our students’ overall profile,” he said in an interview.
“This has been a very significant anxiety point for our medical students for quite a number of years,” Dr. Safdieh said. “They were frustrated that their entire 4 years of medical school seemingly came down to one number.”
The test was created originally as one of three parts of licensure, he pointed out.
“Over the past 10 or 15 years, the exam has morphed to become a litmus test for very specific residency programs,” he said.
However, Dr. Safdieh has concerns that Step 2 will cultivate the same anxiety and may get too big a spotlight without the Step 1 metric, “although one could argue that test does more accurately reflect clinical material,” he said.
He also worries that students who have selected a specialty by the time they take Step 2 may find late in the game that they are less competitive in their field than they thought they were and may have to make a last-minute switch.
Dr. Safdieh said he thinks Step 2 will be next to go the pass/fail route. In reading between the lines of the announcement, he believes the test cosponsors didn’t make both pass/fail at once because it would have been “a nuclear bomb to the system.”
He credited the cosponsors with making what he called a “bold and momentous decision to initiate radical change in the overall transition between undergraduate and graduate medical education.”
Dr. Safdieh added that few in medicine were expecting Wednesday’s announcement.
“I think many of us were expecting them to go to quartile grading, not to go this far,” he said.
Dr. Safdieh suggested that, among those who may see downstream effects from the pass/fail move are offshore schools, such as those in the Caribbean. “Those schools rely on Step 1 to demonstrate that their students are meeting the rigor,” he said. But he hopes that this will lead to more holistic review.
“We’re hoping that this will force change in the system so that residency directors will look at more than just test-taking ability. They’ll look at publications and scholarship, community service and advocacy and performance in medical school,” Dr. Safdieh said.
Alison J. Whelan, MD, chief medical education officer of the Association of American Medical Colleges said in a statement, “The transition from medical school to residency training is a matter of great concern throughout academic medicine.
“The decision by the NBME and FSMB to change USMLE Step 1 score reporting to pass/fail was very carefully considered to balance student learning and student well-being,” she said. “The medical education community must now work together to identify and implement additional changes to improve the overall UME-GME [undergraduate and graduate medical education] transition system for all stakeholders and the AAMC is committed to helping lead this work.”
Dr. Fathy, Dr. Carmody, and Dr. Safdieh have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.