2012 South Beach Symposium

MIAMI BEACH – A diagnosis of pediatric psoriasis is a major event for a child and their family – especially given the long-term medical and psychosocial implications – so proceed cautiously, said Dr. Ronald C. Hansen.

"I am never in a big hurry to make the diagnosis of psoriasis if I am not sure. When you make the diagnosis, you are pretty much saying: ‘You are going to have some degree of psoriasis the rest of your life," Dr. Hansen said at the South Beach Symposium.

And, "I never ever underestimate the impact of psoriasis on the child’s life," he said. "I’ve had 5-year-olds already psychologically stricken."

Affected children – particularly those with more severe disease – will be self-conscious and avoid undressing before gym class or joining others to swim at a pool, said Dr. Hansen, chief of pediatric dermatology at Phoenix Children’s Hospital. "These kids end up loathing their bodies." Psoriasis often has long-term impacts on relationships and intimacy as well.

"The psychosocial impacts ... are immense," agreed session moderator Dr. Lawrence A. Schachner. Because of this, consider whether your patient needs psychosocial counseling when you diagnose psoriasis, added Dr. Schachner, who is director of pediatric dermatology at the University of Miami.

Pediatric psoriasis impacts the whole family. Counsel parents that psoriasis will require a long-term commitment to provide care for their child.

The onset of childhood psoriasis can occur at any age, even at birth. "It is genetically loaded," Dr. Hansen said.

For example, a child born to unaffected parents has about a 4% chance of developing psoriasis, he said. In contrast, a child born to one parent with psoriasis has a 28% likelihood of also developing psoriasis, and if both parents are affected, it jumps to 65%. The chances are even greater if the child has a sibling with psoriasis.

A clinical tip is to ask parents about a history of diaper dermatitis. In his experience, when Dr. Hansen suspects childhood psoriasis, he asks families about whether the child has had difficult diaper rashes. "The parents roll their eyes and say, ‘Yes, diaper rashes from hell.’ This is one of the things I hear routinely when I make the diagnosis in a 4-year-old."

Umbilical and scalp involvement often suggest psoriasis. Severe seborrheic dermatitis, for example, is another diagnostic clue. "We all know about the flaky, persistent scalp dermatitis, sometimes misdiagnosed as seborrheic dermatitis, but again it’s the seborrheic dermatitis from hell. It doesn’t respond to usual treatments," he said.

Even with a rash that looks like psoriasis, most children will have something else: seborrheic dermatitis, atopic dermatitis, or a candidal infection. "If it’s the first time I see this rash, I don’t make the diagnosis of psoriasis. ... Maybe about 20% of them will end up with psoriasis," Dr. Hansen said.

In contrast to adults with psoriasis, pediatric patients can present with prominent, full facial involvement. Flexural involvement is common in all ages, and the lesions can be thick and white or erythematous.

Be particularly thorough with your differential diagnosis of annular psoriasis. "The annular form can fool us. There are a lot of things that cause rings," Dr. Hansen said. A misdiagnosis of extensive tinea can occur, for example.

Some children with psoriasis can have extensive nail involvement. But "nail pits typify psoriasis. ... You can only use nail pits as a diagnostic [criterion] for psoriasis if the cuticle and proximal nail fold are intact," he said.

Pustular psoriasis is rare but important to diagnose in children, Dr. Hansen said. "These patients can be physically quite ill, and treatment has to be instituted right away."

Acute generalized pustular psoriasis is a severe form. Patients can present with fevers, polyarthritis, alopecia, cholestatic jaundice, acute respiratory distress syndrome, eye complications, conjunctivitis, and other adverse signs and comorbidities. "These kids tend to be medical emergencies," Dr. Hansen said. "Consider hospitalization if they have fever."

Many potential factors can elicit this condition. Acute generalized pustular psoriasis can be triggered by an upper respiratory infection or urinary tract infection. "Infections can open the door to anyone already predisposed to get psoriasis," Dr. Hansen said. Withdrawal from systemic or topical steroids and sunburn are other triggers. "Interestingly enough, the [tumor necrosis factor] antagonists which we use to treat psoriasis can also precipitate generalized pustular psoriasis. This confuses most people," he said.

Dr. Hansen disclosed that is a researcher for Novartis. Dr. Schachner disclosed that he is a consultant for Beiersdorf and a researcher/investigator for Astellas, Ferndale, Novartis, Organogenesis, and Stiefel. Both receive royalties from Elsevier, which also owns this news organization.

MIAMI BEACH – A diagnosis of pediatric psoriasis is a major event for a child and their family – especially given the long-term medical and psychosocial implications – so proceed cautiously, said Dr. Ronald C. Hansen.

"I am never in a big hurry to make the diagnosis of psoriasis if I am not sure. When you make the diagnosis, you are pretty much saying: ‘You are going to have some degree of psoriasis the rest of your life," Dr. Hansen said at the South Beach Symposium.

And, "I never ever underestimate the impact of psoriasis on the child’s life," he said. "I’ve had 5-year-olds already psychologically stricken."

Affected children – particularly those with more severe disease – will be self-conscious and avoid undressing before gym class or joining others to swim at a pool, said Dr. Hansen, chief of pediatric dermatology at Phoenix Children’s Hospital. "These kids end up loathing their bodies." Psoriasis often has long-term impacts on relationships and intimacy as well.

"The psychosocial impacts ... are immense," agreed session moderator Dr. Lawrence A. Schachner. Because of this, consider whether your patient needs psychosocial counseling when you diagnose psoriasis, added Dr. Schachner, who is director of pediatric dermatology at the University of Miami.

Pediatric psoriasis impacts the whole family. Counsel parents that psoriasis will require a long-term commitment to provide care for their child.

The onset of childhood psoriasis can occur at any age, even at birth. "It is genetically loaded," Dr. Hansen said.

For example, a child born to unaffected parents has about a 4% chance of developing psoriasis, he said. In contrast, a child born to one parent with psoriasis has a 28% likelihood of also developing psoriasis, and if both parents are affected, it jumps to 65%. The chances are even greater if the child has a sibling with psoriasis.

A clinical tip is to ask parents about a history of diaper dermatitis. In his experience, when Dr. Hansen suspects childhood psoriasis, he asks families about whether the child has had difficult diaper rashes. "The parents roll their eyes and say, ‘Yes, diaper rashes from hell.’ This is one of the things I hear routinely when I make the diagnosis in a 4-year-old."

Umbilical and scalp involvement often suggest psoriasis. Severe seborrheic dermatitis, for example, is another diagnostic clue. "We all know about the flaky, persistent scalp dermatitis, sometimes misdiagnosed as seborrheic dermatitis, but again it’s the seborrheic dermatitis from hell. It doesn’t respond to usual treatments," he said.

Even with a rash that looks like psoriasis, most children will have something else: seborrheic dermatitis, atopic dermatitis, or a candidal infection. "If it’s the first time I see this rash, I don’t make the diagnosis of psoriasis. ... Maybe about 20% of them will end up with psoriasis," Dr. Hansen said.

In contrast to adults with psoriasis, pediatric patients can present with prominent, full facial involvement. Flexural involvement is common in all ages, and the lesions can be thick and white or erythematous.

Be particularly thorough with your differential diagnosis of annular psoriasis. "The annular form can fool us. There are a lot of things that cause rings," Dr. Hansen said. A misdiagnosis of extensive tinea can occur, for example.

Some children with psoriasis can have extensive nail involvement. But "nail pits typify psoriasis. ... You can only use nail pits as a diagnostic [criterion] for psoriasis if the cuticle and proximal nail fold are intact," he said.

Pustular psoriasis is rare but important to diagnose in children, Dr. Hansen said. "These patients can be physically quite ill, and treatment has to be instituted right away."

Acute generalized pustular psoriasis is a severe form. Patients can present with fevers, polyarthritis, alopecia, cholestatic jaundice, acute respiratory distress syndrome, eye complications, conjunctivitis, and other adverse signs and comorbidities. "These kids tend to be medical emergencies," Dr. Hansen said. "Consider hospitalization if they have fever."

Many potential factors can elicit this condition. Acute generalized pustular psoriasis can be triggered by an upper respiratory infection or urinary tract infection. "Infections can open the door to anyone already predisposed to get psoriasis," Dr. Hansen said. Withdrawal from systemic or topical steroids and sunburn are other triggers. "Interestingly enough, the [tumor necrosis factor] antagonists which we use to treat psoriasis can also precipitate generalized pustular psoriasis. This confuses most people," he said.

Dr. Hansen disclosed that is a researcher for Novartis. Dr. Schachner disclosed that he is a consultant for Beiersdorf and a researcher/investigator for Astellas, Ferndale, Novartis, Organogenesis, and Stiefel. Both receive royalties from Elsevier, which also owns this news organization.

MIAMI BEACH – A diagnosis of pediatric psoriasis is a major event for a child and their family – especially given the long-term medical and psychosocial implications – so proceed cautiously, said Dr. Ronald C. Hansen.

"I am never in a big hurry to make the diagnosis of psoriasis if I am not sure. When you make the diagnosis, you are pretty much saying: ‘You are going to have some degree of psoriasis the rest of your life," Dr. Hansen said at the South Beach Symposium.

And, "I never ever underestimate the impact of psoriasis on the child’s life," he said. "I’ve had 5-year-olds already psychologically stricken."

Affected children – particularly those with more severe disease – will be self-conscious and avoid undressing before gym class or joining others to swim at a pool, said Dr. Hansen, chief of pediatric dermatology at Phoenix Children’s Hospital. "These kids end up loathing their bodies." Psoriasis often has long-term impacts on relationships and intimacy as well.

"The psychosocial impacts ... are immense," agreed session moderator Dr. Lawrence A. Schachner. Because of this, consider whether your patient needs psychosocial counseling when you diagnose psoriasis, added Dr. Schachner, who is director of pediatric dermatology at the University of Miami.

Pediatric psoriasis impacts the whole family. Counsel parents that psoriasis will require a long-term commitment to provide care for their child.

The onset of childhood psoriasis can occur at any age, even at birth. "It is genetically loaded," Dr. Hansen said.

For example, a child born to unaffected parents has about a 4% chance of developing psoriasis, he said. In contrast, a child born to one parent with psoriasis has a 28% likelihood of also developing psoriasis, and if both parents are affected, it jumps to 65%. The chances are even greater if the child has a sibling with psoriasis.

A clinical tip is to ask parents about a history of diaper dermatitis. In his experience, when Dr. Hansen suspects childhood psoriasis, he asks families about whether the child has had difficult diaper rashes. "The parents roll their eyes and say, ‘Yes, diaper rashes from hell.’ This is one of the things I hear routinely when I make the diagnosis in a 4-year-old."

Umbilical and scalp involvement often suggest psoriasis. Severe seborrheic dermatitis, for example, is another diagnostic clue. "We all know about the flaky, persistent scalp dermatitis, sometimes misdiagnosed as seborrheic dermatitis, but again it’s the seborrheic dermatitis from hell. It doesn’t respond to usual treatments," he said.

Even with a rash that looks like psoriasis, most children will have something else: seborrheic dermatitis, atopic dermatitis, or a candidal infection. "If it’s the first time I see this rash, I don’t make the diagnosis of psoriasis. ... Maybe about 20% of them will end up with psoriasis," Dr. Hansen said.

In contrast to adults with psoriasis, pediatric patients can present with prominent, full facial involvement. Flexural involvement is common in all ages, and the lesions can be thick and white or erythematous.

Be particularly thorough with your differential diagnosis of annular psoriasis. "The annular form can fool us. There are a lot of things that cause rings," Dr. Hansen said. A misdiagnosis of extensive tinea can occur, for example.

Some children with psoriasis can have extensive nail involvement. But "nail pits typify psoriasis. ... You can only use nail pits as a diagnostic [criterion] for psoriasis if the cuticle and proximal nail fold are intact," he said.

Pustular psoriasis is rare but important to diagnose in children, Dr. Hansen said. "These patients can be physically quite ill, and treatment has to be instituted right away."

Acute generalized pustular psoriasis is a severe form. Patients can present with fevers, polyarthritis, alopecia, cholestatic jaundice, acute respiratory distress syndrome, eye complications, conjunctivitis, and other adverse signs and comorbidities. "These kids tend to be medical emergencies," Dr. Hansen said. "Consider hospitalization if they have fever."

Many potential factors can elicit this condition. Acute generalized pustular psoriasis can be triggered by an upper respiratory infection or urinary tract infection. "Infections can open the door to anyone already predisposed to get psoriasis," Dr. Hansen said. Withdrawal from systemic or topical steroids and sunburn are other triggers. "Interestingly enough, the [tumor necrosis factor] antagonists which we use to treat psoriasis can also precipitate generalized pustular psoriasis. This confuses most people," he said.

Dr. Hansen disclosed that is a researcher for Novartis. Dr. Schachner disclosed that he is a consultant for Beiersdorf and a researcher/investigator for Astellas, Ferndale, Novartis, Organogenesis, and Stiefel. Both receive royalties from Elsevier, which also owns this news organization.

MIAMI BEACH – Remain skeptical about new devices or drugs that claim the ability to target fungal infections, recommended Dr. Alan B. Fleischer Jr.

"You are probably going to be barraged by devices that do something for nail fungus," Dr. Fleischer said. "As a physician, try to focus on curing the fungus and not just making them [patients] look better," he said at the South Beach Symposium.

For example, enrollment is underway for a study to assess a 1320-nm Nd:YAG device to fight onychomycosis. However, the primary outcome in the trial is "improved appearance," not fungal cure, he said. "It is confusing ... to a consumer. Improving the appearance sounds similar, but it is not the same."

Photo (c) 1993, Elsevier

When it comes to topical treatments for onychomycosis, efinaconazole is in development for treating mild to moderate forms of toenail infection, noted Dr. Fleischer. The manufacturer, Valeant Pharmaceuticals, reported promising results in two international phase III studies in December 2011. However, Valeant has not released mycology results.

"Pay attention to the cure rate when it is approved, probably sometime in the next year," said Dr. Fleischer, professor of dermatology at Wake Forest University in Winston-Salem, N.C.

Patients may ask about natural cures for fungal infections, but the data are generally unconvincing or lacking, Dr. Fleischer said. For example, some people advocate melaleuca oil from the tea tree to clear tinea pedis. However, when 104 patients were randomized to creams containing 10% melaleuca oil, 1% tolnaftate, or placebo, "melaleuca oil cleared 30% of subjects of tinea pedis. That is very low," he said (Australas. J. Dermatol. 1992;33:145-9). Of the tolnaftate-treated patients, 85% had a negative culture at the end of therapy, and 21% of placebo patients were considered cleared.

Other patients might ask about using vinegar to cure foot fungus. They may have read about this natural remedy on the Internet, where a Google search for the keywords "vinegar" and "foot fungus" yields about 116,000 results. "Although there are no data, topical vinegar immersion probably does something," Dr. Fleischer said.

"Fungal infections are still out there, but new drugs and modalities are continually evolving," he added.

Dr. Fleischer disclosed that he is a consultant for Intendis and Upsher-Smith Laboratories. He is also a researcher for Abbott, Amgen, Astellas, Galderma, GlaxoSmithKline, Intendis, and Pfizer. He receives a salary from Merz Pharma.

MIAMI BEACH – Remain skeptical about new devices or drugs that claim the ability to target fungal infections, recommended Dr. Alan B. Fleischer Jr.

"You are probably going to be barraged by devices that do something for nail fungus," Dr. Fleischer said. "As a physician, try to focus on curing the fungus and not just making them [patients] look better," he said at the South Beach Symposium.

For example, enrollment is underway for a study to assess a 1320-nm Nd:YAG device to fight onychomycosis. However, the primary outcome in the trial is "improved appearance," not fungal cure, he said. "It is confusing ... to a consumer. Improving the appearance sounds similar, but it is not the same."

Photo (c) 1993, Elsevier

When it comes to topical treatments for onychomycosis, efinaconazole is in development for treating mild to moderate forms of toenail infection, noted Dr. Fleischer. The manufacturer, Valeant Pharmaceuticals, reported promising results in two international phase III studies in December 2011. However, Valeant has not released mycology results.

"Pay attention to the cure rate when it is approved, probably sometime in the next year," said Dr. Fleischer, professor of dermatology at Wake Forest University in Winston-Salem, N.C.

Patients may ask about natural cures for fungal infections, but the data are generally unconvincing or lacking, Dr. Fleischer said. For example, some people advocate melaleuca oil from the tea tree to clear tinea pedis. However, when 104 patients were randomized to creams containing 10% melaleuca oil, 1% tolnaftate, or placebo, "melaleuca oil cleared 30% of subjects of tinea pedis. That is very low," he said (Australas. J. Dermatol. 1992;33:145-9). Of the tolnaftate-treated patients, 85% had a negative culture at the end of therapy, and 21% of placebo patients were considered cleared.

Other patients might ask about using vinegar to cure foot fungus. They may have read about this natural remedy on the Internet, where a Google search for the keywords "vinegar" and "foot fungus" yields about 116,000 results. "Although there are no data, topical vinegar immersion probably does something," Dr. Fleischer said.

"Fungal infections are still out there, but new drugs and modalities are continually evolving," he added.

Dr. Fleischer disclosed that he is a consultant for Intendis and Upsher-Smith Laboratories. He is also a researcher for Abbott, Amgen, Astellas, Galderma, GlaxoSmithKline, Intendis, and Pfizer. He receives a salary from Merz Pharma.

MIAMI BEACH – Remain skeptical about new devices or drugs that claim the ability to target fungal infections, recommended Dr. Alan B. Fleischer Jr.

"You are probably going to be barraged by devices that do something for nail fungus," Dr. Fleischer said. "As a physician, try to focus on curing the fungus and not just making them [patients] look better," he said at the South Beach Symposium.

For example, enrollment is underway for a study to assess a 1320-nm Nd:YAG device to fight onychomycosis. However, the primary outcome in the trial is "improved appearance," not fungal cure, he said. "It is confusing ... to a consumer. Improving the appearance sounds similar, but it is not the same."

Photo (c) 1993, Elsevier

When it comes to topical treatments for onychomycosis, efinaconazole is in development for treating mild to moderate forms of toenail infection, noted Dr. Fleischer. The manufacturer, Valeant Pharmaceuticals, reported promising results in two international phase III studies in December 2011. However, Valeant has not released mycology results.

"Pay attention to the cure rate when it is approved, probably sometime in the next year," said Dr. Fleischer, professor of dermatology at Wake Forest University in Winston-Salem, N.C.

Patients may ask about natural cures for fungal infections, but the data are generally unconvincing or lacking, Dr. Fleischer said. For example, some people advocate melaleuca oil from the tea tree to clear tinea pedis. However, when 104 patients were randomized to creams containing 10% melaleuca oil, 1% tolnaftate, or placebo, "melaleuca oil cleared 30% of subjects of tinea pedis. That is very low," he said (Australas. J. Dermatol. 1992;33:145-9). Of the tolnaftate-treated patients, 85% had a negative culture at the end of therapy, and 21% of placebo patients were considered cleared.

Other patients might ask about using vinegar to cure foot fungus. They may have read about this natural remedy on the Internet, where a Google search for the keywords "vinegar" and "foot fungus" yields about 116,000 results. "Although there are no data, topical vinegar immersion probably does something," Dr. Fleischer said.

"Fungal infections are still out there, but new drugs and modalities are continually evolving," he added.

Dr. Fleischer disclosed that he is a consultant for Intendis and Upsher-Smith Laboratories. He is also a researcher for Abbott, Amgen, Astellas, Galderma, GlaxoSmithKline, Intendis, and Pfizer. He receives a salary from Merz Pharma.

MIAMI BEACH – Rather than working to identify a particular rosacea subtype in your patient, adopt a simpler strategy and treat based on presenting signs, Dr. James Q. Del Rosso said at the South Beach Symposium.

"Why not evaluate and treat a patient with rosacea based on the clinical features they present with?" Dr. Del Rosso asked. For example, the common feature in the vast majority of patients is central facial diffuse erythema. "We are talking about 80% or 90% of the patients we see."

Rosacea is an umbrella term. "We talk a lot about subtypes, but that doesn’t necessarily answer all the questions," Dr. Del Rosso said. "I want to suggest we narrow the definition a bit so we focus on the more common clinical situations in practice."

In other words, rather than distinguishing papulopustular rosacea from erythematotelangiectatic or phymatous subtypes, consider whether a patient has intermittent or persistent rosacea. Intermittent rosacea features inflammatory lesions, perilesional erythema, and background erythema. In contrast, persistent rosacea will present as background erythema (more prominently), as well as telangiectasias and phymatous changes to the skin.

This classification reflects more "real world" presentations of rosacea, said Dr. Del Rosso, a dermatologist in group practice in Las Vegas.

Treatment

The clinical features of rosacea go beyond diagnosis classification and can guide selection of therapy as well. In terms of topical therapies, metronidazole 1% and 0.75% and azelaic acid 15% gel are approved by the Food and Drug Administration to treat papulopustular rosacea, which is characterized by inflammatory lesions, erythema, and telangiectasias.

"There is a mechanism supporting why topical or oral metronidazole is effective," Dr. Del Rosso said. Metronidazole modifies the augmented, innate immune response implicated early in the development of rosacea. In terms of azelaic acid, data about mechanism of action are only available in mice.

This immune response occurs very early in the pathogenesis of rosacea and during flares, Dr. Del Rosso said. Researchers have identified another important pathway, a neurogenic vascular dysregulation that could explain the vasodilation and diffuse erythema commonly seen in many patients. Although it is unclear which mechanism arises first, Dr. Del Rosso said, "I’m going to roll the dice and I will [guess that] innate immunity happens first."

Conventional oral agents can treat rosacea effectively as well. Tetracyclines, for example, work through a variety of anti-inflammatory effects. "Current evidence does not support the need to eradicate or suppress a bacterium," Dr. Del Rosso said. For this reason, multiple studies support the efficacy of subantimicrobial doxycycline for its anti-inflammatory actions (Am. J. Clin. Dermatol. 2010;11:217-22; Cutis 2010;86:16-25).

Recent evidence suggests lower-dose doxycycline (40-mg extended-release doxycycline, for example) is sufficient to inhibit matrix metalloproteinase (MMP) enzymes that break down connective tissue proteins (Pharmacol. Res. 2011;63:130-45). MMPs are upregulated in rosacea and other conditions that feature dermal destruction.

"All of the tetracyclines seem to work on blocking MMP activity, but doxycycline works the best," Dr. David E. Cohen said in a separate presentation at the meeting. Doxycycline can inhibit multiple pathways involved in rosacea, he said. Recent findings "suggest a previously unknown mechanism of action of subantimicrobial doxycycline."

Cathelicidin Pathways

Another new finding is that the MMP pathway and the cathelicidin pathways are no longer thought to be distinct, said Dr. Cohen of the department of dermatology at New York University Langone Medical Center in New York City.

"Last year I said these two things were independently elevated [in rosacea]," Dr. Cohen said. "Now we know they can trigger each other. It’s a vicious cycle, a vortex."

Cathelicidins are protective peptides in the skin. These endogenous players cleave and kill virus and fungi and recruit a host immune response, Dr. Cohen said. "They are inactive normally. So the cathelicidins are there for a good reason, but they are always ‘on’ in rosacea." When these peptides are overexpressed, as they are in rosacea, they can trigger inflammation and angiogenesis.

A specific cathelicidin garnering a lot of attention is LL-37, a vasoactive and inflammatory host-defense peptide also overexpressed in rosacea. "This is very important," Dr. Del Rosso said. "LL-37 just keeps popping up in the pathogenesis of skin disorders." Various levels of LL-37 are implicated in atopic dermatitis and cutaneous lupus, for example. In healthy skin, LL-37 helps to maintain homeostatic immunity and fights bacteria and viruses in the skin.

Dr. Del Rosso disclosed that he is a consultant, researcher, and member of the speakers bureaus for Allergan and Galderma. Dr. Cohen disclosed that he is a consultant for, receives honoraria from, and is on the advisory board for Galderma.

MIAMI BEACH – Rather than working to identify a particular rosacea subtype in your patient, adopt a simpler strategy and treat based on presenting signs, Dr. James Q. Del Rosso said at the South Beach Symposium.

"Why not evaluate and treat a patient with rosacea based on the clinical features they present with?" Dr. Del Rosso asked. For example, the common feature in the vast majority of patients is central facial diffuse erythema. "We are talking about 80% or 90% of the patients we see."

Rosacea is an umbrella term. "We talk a lot about subtypes, but that doesn’t necessarily answer all the questions," Dr. Del Rosso said. "I want to suggest we narrow the definition a bit so we focus on the more common clinical situations in practice."

In other words, rather than distinguishing papulopustular rosacea from erythematotelangiectatic or phymatous subtypes, consider whether a patient has intermittent or persistent rosacea. Intermittent rosacea features inflammatory lesions, perilesional erythema, and background erythema. In contrast, persistent rosacea will present as background erythema (more prominently), as well as telangiectasias and phymatous changes to the skin.

This classification reflects more "real world" presentations of rosacea, said Dr. Del Rosso, a dermatologist in group practice in Las Vegas.

Treatment

The clinical features of rosacea go beyond diagnosis classification and can guide selection of therapy as well. In terms of topical therapies, metronidazole 1% and 0.75% and azelaic acid 15% gel are approved by the Food and Drug Administration to treat papulopustular rosacea, which is characterized by inflammatory lesions, erythema, and telangiectasias.

"There is a mechanism supporting why topical or oral metronidazole is effective," Dr. Del Rosso said. Metronidazole modifies the augmented, innate immune response implicated early in the development of rosacea. In terms of azelaic acid, data about mechanism of action are only available in mice.

This immune response occurs very early in the pathogenesis of rosacea and during flares, Dr. Del Rosso said. Researchers have identified another important pathway, a neurogenic vascular dysregulation that could explain the vasodilation and diffuse erythema commonly seen in many patients. Although it is unclear which mechanism arises first, Dr. Del Rosso said, "I’m going to roll the dice and I will [guess that] innate immunity happens first."

Conventional oral agents can treat rosacea effectively as well. Tetracyclines, for example, work through a variety of anti-inflammatory effects. "Current evidence does not support the need to eradicate or suppress a bacterium," Dr. Del Rosso said. For this reason, multiple studies support the efficacy of subantimicrobial doxycycline for its anti-inflammatory actions (Am. J. Clin. Dermatol. 2010;11:217-22; Cutis 2010;86:16-25).

Recent evidence suggests lower-dose doxycycline (40-mg extended-release doxycycline, for example) is sufficient to inhibit matrix metalloproteinase (MMP) enzymes that break down connective tissue proteins (Pharmacol. Res. 2011;63:130-45). MMPs are upregulated in rosacea and other conditions that feature dermal destruction.

"All of the tetracyclines seem to work on blocking MMP activity, but doxycycline works the best," Dr. David E. Cohen said in a separate presentation at the meeting. Doxycycline can inhibit multiple pathways involved in rosacea, he said. Recent findings "suggest a previously unknown mechanism of action of subantimicrobial doxycycline."

Cathelicidin Pathways

Another new finding is that the MMP pathway and the cathelicidin pathways are no longer thought to be distinct, said Dr. Cohen of the department of dermatology at New York University Langone Medical Center in New York City.

"Last year I said these two things were independently elevated [in rosacea]," Dr. Cohen said. "Now we know they can trigger each other. It’s a vicious cycle, a vortex."

Cathelicidins are protective peptides in the skin. These endogenous players cleave and kill virus and fungi and recruit a host immune response, Dr. Cohen said. "They are inactive normally. So the cathelicidins are there for a good reason, but they are always ‘on’ in rosacea." When these peptides are overexpressed, as they are in rosacea, they can trigger inflammation and angiogenesis.

A specific cathelicidin garnering a lot of attention is LL-37, a vasoactive and inflammatory host-defense peptide also overexpressed in rosacea. "This is very important," Dr. Del Rosso said. "LL-37 just keeps popping up in the pathogenesis of skin disorders." Various levels of LL-37 are implicated in atopic dermatitis and cutaneous lupus, for example. In healthy skin, LL-37 helps to maintain homeostatic immunity and fights bacteria and viruses in the skin.

Dr. Del Rosso disclosed that he is a consultant, researcher, and member of the speakers bureaus for Allergan and Galderma. Dr. Cohen disclosed that he is a consultant for, receives honoraria from, and is on the advisory board for Galderma.

MIAMI BEACH – Rather than working to identify a particular rosacea subtype in your patient, adopt a simpler strategy and treat based on presenting signs, Dr. James Q. Del Rosso said at the South Beach Symposium.

"Why not evaluate and treat a patient with rosacea based on the clinical features they present with?" Dr. Del Rosso asked. For example, the common feature in the vast majority of patients is central facial diffuse erythema. "We are talking about 80% or 90% of the patients we see."

Rosacea is an umbrella term. "We talk a lot about subtypes, but that doesn’t necessarily answer all the questions," Dr. Del Rosso said. "I want to suggest we narrow the definition a bit so we focus on the more common clinical situations in practice."

In other words, rather than distinguishing papulopustular rosacea from erythematotelangiectatic or phymatous subtypes, consider whether a patient has intermittent or persistent rosacea. Intermittent rosacea features inflammatory lesions, perilesional erythema, and background erythema. In contrast, persistent rosacea will present as background erythema (more prominently), as well as telangiectasias and phymatous changes to the skin.

This classification reflects more "real world" presentations of rosacea, said Dr. Del Rosso, a dermatologist in group practice in Las Vegas.

Treatment

The clinical features of rosacea go beyond diagnosis classification and can guide selection of therapy as well. In terms of topical therapies, metronidazole 1% and 0.75% and azelaic acid 15% gel are approved by the Food and Drug Administration to treat papulopustular rosacea, which is characterized by inflammatory lesions, erythema, and telangiectasias.

"There is a mechanism supporting why topical or oral metronidazole is effective," Dr. Del Rosso said. Metronidazole modifies the augmented, innate immune response implicated early in the development of rosacea. In terms of azelaic acid, data about mechanism of action are only available in mice.

This immune response occurs very early in the pathogenesis of rosacea and during flares, Dr. Del Rosso said. Researchers have identified another important pathway, a neurogenic vascular dysregulation that could explain the vasodilation and diffuse erythema commonly seen in many patients. Although it is unclear which mechanism arises first, Dr. Del Rosso said, "I’m going to roll the dice and I will [guess that] innate immunity happens first."

Conventional oral agents can treat rosacea effectively as well. Tetracyclines, for example, work through a variety of anti-inflammatory effects. "Current evidence does not support the need to eradicate or suppress a bacterium," Dr. Del Rosso said. For this reason, multiple studies support the efficacy of subantimicrobial doxycycline for its anti-inflammatory actions (Am. J. Clin. Dermatol. 2010;11:217-22; Cutis 2010;86:16-25).

Recent evidence suggests lower-dose doxycycline (40-mg extended-release doxycycline, for example) is sufficient to inhibit matrix metalloproteinase (MMP) enzymes that break down connective tissue proteins (Pharmacol. Res. 2011;63:130-45). MMPs are upregulated in rosacea and other conditions that feature dermal destruction.

"All of the tetracyclines seem to work on blocking MMP activity, but doxycycline works the best," Dr. David E. Cohen said in a separate presentation at the meeting. Doxycycline can inhibit multiple pathways involved in rosacea, he said. Recent findings "suggest a previously unknown mechanism of action of subantimicrobial doxycycline."

Cathelicidin Pathways

Another new finding is that the MMP pathway and the cathelicidin pathways are no longer thought to be distinct, said Dr. Cohen of the department of dermatology at New York University Langone Medical Center in New York City.

"Last year I said these two things were independently elevated [in rosacea]," Dr. Cohen said. "Now we know they can trigger each other. It’s a vicious cycle, a vortex."

Cathelicidins are protective peptides in the skin. These endogenous players cleave and kill virus and fungi and recruit a host immune response, Dr. Cohen said. "They are inactive normally. So the cathelicidins are there for a good reason, but they are always ‘on’ in rosacea." When these peptides are overexpressed, as they are in rosacea, they can trigger inflammation and angiogenesis.

A specific cathelicidin garnering a lot of attention is LL-37, a vasoactive and inflammatory host-defense peptide also overexpressed in rosacea. "This is very important," Dr. Del Rosso said. "LL-37 just keeps popping up in the pathogenesis of skin disorders." Various levels of LL-37 are implicated in atopic dermatitis and cutaneous lupus, for example. In healthy skin, LL-37 helps to maintain homeostatic immunity and fights bacteria and viruses in the skin.

Dr. Del Rosso disclosed that he is a consultant, researcher, and member of the speakers bureaus for Allergan and Galderma. Dr. Cohen disclosed that he is a consultant for, receives honoraria from, and is on the advisory board for Galderma.

MIAMI BEACH – It may now be possible for patients to experience the benefits of hyaluronic acid fillers without a needle, according to investigators.

In a double-blind, controlled study of 100 women with moderate to severe photo-damaged skin, a novel nanotechnology was used to shepherd topical hyaluronic acid through the dermis, essentially overcoming the large particle size hurdle of years past.

Significant improvements in overall efficacy, skin roughness, and "smoothing effect" were observed after 90 days. Blinded observers reported the benefits in 40 women who applied topical cross-linked hyaluronic acid (Restylane) twice a day to their full face, compared with 20 women who applied the nanotechnology vehicle only. Additional significant improvements were seen among another 40 women who applied non-cross linked topical hyaluronic acid using the same regimen.

"We know the skin is a barrier. It acts as a barrier for things getting in, but it can also prevent topical compounds from getting in," said Dr. Glynis R. Ablon, who is on the dermatology faculty at the University of California, Los Angeles.

"Topical hyaluronic acid does appear to be penetrating the skin with this unique Ionic Nano Particle Technology [INParT] delivery system," she said.

The potential for Transdermal Corp’s INParT extends beyond patients with photo-damaged skin and could provide additional therapeutic options for acne, rosacea, psoriasis, and melasma, said Dr. Ablon, at the South Beach Symposium.

Dr. Ablon and her colleague Dr. Mark S. Nestor conducted the study at two U.S. sites. Participants were 35 to 65 years old and evaluated at days 15, 45, 90, and 120 (following a 4-week washout period).

They assessed six parameters. For example, at 120 days, the percentage of patients with skin roughness rated as "smooth" or "very smooth" was 100% of the cross linked group, 88% of the non-cross linked group, and 55% of controls. Similarly, at 20 weeks skin ratings of "hydrated" or "very hydrated" were reported for 100% of the cross-linked group, 87% of the non-cross linked group, and 52% of controls.

Similar improvements in skin elasticity, skin radiance, and "smoothing effect" were also observed.

The raters also measured overall efficacy at the same time point. The percentage of patients who reported good or excellent overall efficacy was 93% in the cross-linked group, 35% in the non-cross linked group, and 0% in the control group.

Topical hyaluronic acid "appears to have a significant aesthetic enhancement effect," Dr. Ablon said.

Interestingly, skin roughness, hydration, and elasticity ratings continued to improve even after 90 days in the cross-linked hyaluronic acid group, Dr. Ablon said. This finding suggests collagen remodeling took place.

The researchers also assessed how well participants accepted the therapy at 12 weeks. "Tolerance was 100% across the board," Dr. Ablon said.

Transdermal Corp funded this study through an unrestricted educational grant. Dr. Ablon and Dr. Nestor are consultants and investigators for Transdermal Corp. Dr. Ablon also is an investigator and advisory board member for Medicis, which markets Restylane. Dr. Nestor is an investigator, consultant, speaker, and advisory board member for Medicis.

MIAMI BEACH – It may now be possible for patients to experience the benefits of hyaluronic acid fillers without a needle, according to investigators.

In a double-blind, controlled study of 100 women with moderate to severe photo-damaged skin, a novel nanotechnology was used to shepherd topical hyaluronic acid through the dermis, essentially overcoming the large particle size hurdle of years past.

Significant improvements in overall efficacy, skin roughness, and "smoothing effect" were observed after 90 days. Blinded observers reported the benefits in 40 women who applied topical cross-linked hyaluronic acid (Restylane) twice a day to their full face, compared with 20 women who applied the nanotechnology vehicle only. Additional significant improvements were seen among another 40 women who applied non-cross linked topical hyaluronic acid using the same regimen.

"We know the skin is a barrier. It acts as a barrier for things getting in, but it can also prevent topical compounds from getting in," said Dr. Glynis R. Ablon, who is on the dermatology faculty at the University of California, Los Angeles.

"Topical hyaluronic acid does appear to be penetrating the skin with this unique Ionic Nano Particle Technology [INParT] delivery system," she said.

The potential for Transdermal Corp’s INParT extends beyond patients with photo-damaged skin and could provide additional therapeutic options for acne, rosacea, psoriasis, and melasma, said Dr. Ablon, at the South Beach Symposium.

Dr. Ablon and her colleague Dr. Mark S. Nestor conducted the study at two U.S. sites. Participants were 35 to 65 years old and evaluated at days 15, 45, 90, and 120 (following a 4-week washout period).

They assessed six parameters. For example, at 120 days, the percentage of patients with skin roughness rated as "smooth" or "very smooth" was 100% of the cross linked group, 88% of the non-cross linked group, and 55% of controls. Similarly, at 20 weeks skin ratings of "hydrated" or "very hydrated" were reported for 100% of the cross-linked group, 87% of the non-cross linked group, and 52% of controls.

Similar improvements in skin elasticity, skin radiance, and "smoothing effect" were also observed.

The raters also measured overall efficacy at the same time point. The percentage of patients who reported good or excellent overall efficacy was 93% in the cross-linked group, 35% in the non-cross linked group, and 0% in the control group.

Topical hyaluronic acid "appears to have a significant aesthetic enhancement effect," Dr. Ablon said.

Interestingly, skin roughness, hydration, and elasticity ratings continued to improve even after 90 days in the cross-linked hyaluronic acid group, Dr. Ablon said. This finding suggests collagen remodeling took place.

The researchers also assessed how well participants accepted the therapy at 12 weeks. "Tolerance was 100% across the board," Dr. Ablon said.

Transdermal Corp funded this study through an unrestricted educational grant. Dr. Ablon and Dr. Nestor are consultants and investigators for Transdermal Corp. Dr. Ablon also is an investigator and advisory board member for Medicis, which markets Restylane. Dr. Nestor is an investigator, consultant, speaker, and advisory board member for Medicis.

MIAMI BEACH – It may now be possible for patients to experience the benefits of hyaluronic acid fillers without a needle, according to investigators.

In a double-blind, controlled study of 100 women with moderate to severe photo-damaged skin, a novel nanotechnology was used to shepherd topical hyaluronic acid through the dermis, essentially overcoming the large particle size hurdle of years past.

Significant improvements in overall efficacy, skin roughness, and "smoothing effect" were observed after 90 days. Blinded observers reported the benefits in 40 women who applied topical cross-linked hyaluronic acid (Restylane) twice a day to their full face, compared with 20 women who applied the nanotechnology vehicle only. Additional significant improvements were seen among another 40 women who applied non-cross linked topical hyaluronic acid using the same regimen.

"We know the skin is a barrier. It acts as a barrier for things getting in, but it can also prevent topical compounds from getting in," said Dr. Glynis R. Ablon, who is on the dermatology faculty at the University of California, Los Angeles.

"Topical hyaluronic acid does appear to be penetrating the skin with this unique Ionic Nano Particle Technology [INParT] delivery system," she said.

The potential for Transdermal Corp’s INParT extends beyond patients with photo-damaged skin and could provide additional therapeutic options for acne, rosacea, psoriasis, and melasma, said Dr. Ablon, at the South Beach Symposium.

Dr. Ablon and her colleague Dr. Mark S. Nestor conducted the study at two U.S. sites. Participants were 35 to 65 years old and evaluated at days 15, 45, 90, and 120 (following a 4-week washout period).

They assessed six parameters. For example, at 120 days, the percentage of patients with skin roughness rated as "smooth" or "very smooth" was 100% of the cross linked group, 88% of the non-cross linked group, and 55% of controls. Similarly, at 20 weeks skin ratings of "hydrated" or "very hydrated" were reported for 100% of the cross-linked group, 87% of the non-cross linked group, and 52% of controls.

Similar improvements in skin elasticity, skin radiance, and "smoothing effect" were also observed.

The raters also measured overall efficacy at the same time point. The percentage of patients who reported good or excellent overall efficacy was 93% in the cross-linked group, 35% in the non-cross linked group, and 0% in the control group.

Topical hyaluronic acid "appears to have a significant aesthetic enhancement effect," Dr. Ablon said.

Interestingly, skin roughness, hydration, and elasticity ratings continued to improve even after 90 days in the cross-linked hyaluronic acid group, Dr. Ablon said. This finding suggests collagen remodeling took place.

The researchers also assessed how well participants accepted the therapy at 12 weeks. "Tolerance was 100% across the board," Dr. Ablon said.

Transdermal Corp funded this study through an unrestricted educational grant. Dr. Ablon and Dr. Nestor are consultants and investigators for Transdermal Corp. Dr. Ablon also is an investigator and advisory board member for Medicis, which markets Restylane. Dr. Nestor is an investigator, consultant, speaker, and advisory board member for Medicis.

MIAMI BEACH – A new therapy to combat advanced basal cell carcinoma is generating excitement in the few months since its Food and Drug Administration approval.

"Vismodegib provides substantial clinical benefit for patients with advanced basal cell carcinoma [BCC]," Dr. Scott M. Dinehart said at the South Beach Symposium. "For dermatology, this is a very important pathway." Through its novel ability to block a signaling pathway implicated in the development BCC, it can help treat "the kinds of terrible skin cancers where maybe you can operate on them or maybe not," said Dr. Dinehart, a dermatologist in private practice in Little Rock, Ark.

The FDA approved the oral, once-daily medication in January 2012 to treat adults with metastatic BCC or locally advanced, recurrent BCC after surgery. It is also indicated for patients with locally advanced BCC who are not candidates for surgery or radiation treatment.

Most side effects are mild to moderate, Dr. Dinehart said. "Muscle spasms are the one I am most worried about," he added, saying that such events might cause patients to discontinue use of the agent. Patients might also experience hair loss and taste changes because the hedgehog pathway is active in differentiation and proliferation of hair follicles and taste buds. "The side effects are the kind we can work around," Dr. Dinehart said.

Weight loss, fatigue, nausea, diarrhea, decreased appetite, constipation, arthralgias, and vomiting were other adverse events reported by 10% or more of participants in preclinical trials, according to the medication guide. Because of its teratogenicity, vismodegib carries a black box warning about embryo-fetal death and severe birth defects.

The hedgehog pathway inhibitor, vismodegib (Erivedge, Genentech), not only offers promise for patients with advanced BCC, but its approval also culminates a fascinating story of scientific discovery.

Five and half decades ago, in 1957, a herd of sheep in Idaho gave birth to one-eyed lambs. U.S. Department of Agriculture investigators determined that the "cyclops" lambs were born after dry weather drove the sheep to higher ground, where they ate corn lilies that contained a teratogenic toxin. They dubbed the toxin "cyclopamine."

The toxin blocks the segmentation of the brain and the two halves of the brain don’t separate during embryonic development, Dr. Brian Berman said in a separate presentation at the meeting. "Humans are also susceptible," added Dr. Berman, a professor of dermatology and cutaneous surgery at the University of Miami.

The toxin discovery probably would have remained a footnote in history, Dr. Dinehart said, except for scientists who looked at oncologic properties of this teratogenic compound. For example, Philip A. Beachy, Ph.D., while at Johns Hopkins in the early 1990s, cloned a hedgehog pathway gene in fruit flies that regulates embryonic cell differentiation. He observed that fruit fly embryos born with a faulty copy of the gene had a spiky or pointy appearance.

Dr. Berman said the most important of the hedgehog pathways in humans is called sonic hedgehog, which was named "after the Nintendo character with the spiky hair."

Dr. Dinehart said he is a consultant for Genentech. Dr. Berman is a consultant and a member of the speakers bureau for Genentech.

MIAMI BEACH – A new therapy to combat advanced basal cell carcinoma is generating excitement in the few months since its Food and Drug Administration approval.

"Vismodegib provides substantial clinical benefit for patients with advanced basal cell carcinoma [BCC]," Dr. Scott M. Dinehart said at the South Beach Symposium. "For dermatology, this is a very important pathway." Through its novel ability to block a signaling pathway implicated in the development BCC, it can help treat "the kinds of terrible skin cancers where maybe you can operate on them or maybe not," said Dr. Dinehart, a dermatologist in private practice in Little Rock, Ark.

The FDA approved the oral, once-daily medication in January 2012 to treat adults with metastatic BCC or locally advanced, recurrent BCC after surgery. It is also indicated for patients with locally advanced BCC who are not candidates for surgery or radiation treatment.

Most side effects are mild to moderate, Dr. Dinehart said. "Muscle spasms are the one I am most worried about," he added, saying that such events might cause patients to discontinue use of the agent. Patients might also experience hair loss and taste changes because the hedgehog pathway is active in differentiation and proliferation of hair follicles and taste buds. "The side effects are the kind we can work around," Dr. Dinehart said.

Weight loss, fatigue, nausea, diarrhea, decreased appetite, constipation, arthralgias, and vomiting were other adverse events reported by 10% or more of participants in preclinical trials, according to the medication guide. Because of its teratogenicity, vismodegib carries a black box warning about embryo-fetal death and severe birth defects.

The hedgehog pathway inhibitor, vismodegib (Erivedge, Genentech), not only offers promise for patients with advanced BCC, but its approval also culminates a fascinating story of scientific discovery.

Five and half decades ago, in 1957, a herd of sheep in Idaho gave birth to one-eyed lambs. U.S. Department of Agriculture investigators determined that the "cyclops" lambs were born after dry weather drove the sheep to higher ground, where they ate corn lilies that contained a teratogenic toxin. They dubbed the toxin "cyclopamine."

The toxin blocks the segmentation of the brain and the two halves of the brain don’t separate during embryonic development, Dr. Brian Berman said in a separate presentation at the meeting. "Humans are also susceptible," added Dr. Berman, a professor of dermatology and cutaneous surgery at the University of Miami.

The toxin discovery probably would have remained a footnote in history, Dr. Dinehart said, except for scientists who looked at oncologic properties of this teratogenic compound. For example, Philip A. Beachy, Ph.D., while at Johns Hopkins in the early 1990s, cloned a hedgehog pathway gene in fruit flies that regulates embryonic cell differentiation. He observed that fruit fly embryos born with a faulty copy of the gene had a spiky or pointy appearance.

Dr. Berman said the most important of the hedgehog pathways in humans is called sonic hedgehog, which was named "after the Nintendo character with the spiky hair."

Dr. Dinehart said he is a consultant for Genentech. Dr. Berman is a consultant and a member of the speakers bureau for Genentech.

MIAMI BEACH – A new therapy to combat advanced basal cell carcinoma is generating excitement in the few months since its Food and Drug Administration approval.

"Vismodegib provides substantial clinical benefit for patients with advanced basal cell carcinoma [BCC]," Dr. Scott M. Dinehart said at the South Beach Symposium. "For dermatology, this is a very important pathway." Through its novel ability to block a signaling pathway implicated in the development BCC, it can help treat "the kinds of terrible skin cancers where maybe you can operate on them or maybe not," said Dr. Dinehart, a dermatologist in private practice in Little Rock, Ark.

The FDA approved the oral, once-daily medication in January 2012 to treat adults with metastatic BCC or locally advanced, recurrent BCC after surgery. It is also indicated for patients with locally advanced BCC who are not candidates for surgery or radiation treatment.

Most side effects are mild to moderate, Dr. Dinehart said. "Muscle spasms are the one I am most worried about," he added, saying that such events might cause patients to discontinue use of the agent. Patients might also experience hair loss and taste changes because the hedgehog pathway is active in differentiation and proliferation of hair follicles and taste buds. "The side effects are the kind we can work around," Dr. Dinehart said.

Weight loss, fatigue, nausea, diarrhea, decreased appetite, constipation, arthralgias, and vomiting were other adverse events reported by 10% or more of participants in preclinical trials, according to the medication guide. Because of its teratogenicity, vismodegib carries a black box warning about embryo-fetal death and severe birth defects.

The hedgehog pathway inhibitor, vismodegib (Erivedge, Genentech), not only offers promise for patients with advanced BCC, but its approval also culminates a fascinating story of scientific discovery.

Five and half decades ago, in 1957, a herd of sheep in Idaho gave birth to one-eyed lambs. U.S. Department of Agriculture investigators determined that the "cyclops" lambs were born after dry weather drove the sheep to higher ground, where they ate corn lilies that contained a teratogenic toxin. They dubbed the toxin "cyclopamine."

The toxin blocks the segmentation of the brain and the two halves of the brain don’t separate during embryonic development, Dr. Brian Berman said in a separate presentation at the meeting. "Humans are also susceptible," added Dr. Berman, a professor of dermatology and cutaneous surgery at the University of Miami.

The toxin discovery probably would have remained a footnote in history, Dr. Dinehart said, except for scientists who looked at oncologic properties of this teratogenic compound. For example, Philip A. Beachy, Ph.D., while at Johns Hopkins in the early 1990s, cloned a hedgehog pathway gene in fruit flies that regulates embryonic cell differentiation. He observed that fruit fly embryos born with a faulty copy of the gene had a spiky or pointy appearance.

Dr. Berman said the most important of the hedgehog pathways in humans is called sonic hedgehog, which was named "after the Nintendo character with the spiky hair."

Dr. Dinehart said he is a consultant for Genentech. Dr. Berman is a consultant and a member of the speakers bureau for Genentech.

MIAMI BEACH – As more U.S. dermatologists are using cannulas to deliver soft tissue fillers for rejuvenation, tips to refine the technique and optimize patient outcomes are emerging.

Cannula use "seems to be gaining a lot of momentum in this country, and some of that really stems from the European experience," Dr. Joel L. Cohen said in an interview.

The size of the cannula, as well as the gauge of the needle that creates the entry point, can determine outcomes in different anatomic areas, Dr. Cohen said at the South Beach Symposium. "Cannulas have very specific roles in very specific areas. Personally, I have found them useful in the cheek, the infraorbital area, in the décolleté, and the dorsal hands."

He also shared a practical tip that eases cannula insertion. To deliver filler product using a 27 G cannula, for example, Dr. Cohen first nicks the skin with a slightly larger 25 G needle where he wants his entry point. Then, he pinches and holds the skin around the needle while his assistant removes it. That way, he knows the precise point to insert the cannula "rather than [later] fumbling around in a little bit of bleeding to find it. It’s really a helpful trick we’ve incorporated into our office."

A 25 G cannula can also be used to deliver fillers to the décolleté or dorsal side of the hands, said Dr. Cohen, who is in private practice in Englewood, Colo. In contrast, a smaller 30 G cannula may be more appropriate for rejuvenation of the infraorbital area, he said. "Using a 30 G cannula below the eyes, I feel that I am seeing less bruising and less swelling in this area, but at the same time, I am able to precisely deliver the filler product deep into the muscle along the periosteum."

An ability to fan product out in multiple directions from one entry point is an advantage of the cannula. "It’s a useful technique, and cannulas have helped me get better results with less bruising in my practice," Dr. Cohen said. The lower bruising potential seems to come from the cannula’s blunt tip, which can tuck under, above, or around a blood vessel. In contrast, a sharp needle is more likely to puncture the same vessel and cause postprocedure bruising, he said. And, fanning a needle around under the skin can increase the risk of bruising even further (Derm. Surg. 2008;34:S105-9).

"Some physicians, including me, actually have found patients experience less pain" with a cannula than with a needle, he added.

Although dermatologic use of cannulas has grown over the past year, "I don’t think it’s going to completely take over. You definitely still need needles for many different areas. I continue top use needles in the nasolabial folds [and] the oral commissure. For fine lines and wrinkles and more shallow rhytids, you definitely still need needles," he said

More information on cannulas can be found in an article published by Dr. Cohen and his colleague Dr. Joshua A. Zeichner (J. Drugs. Dermatol. 2012;11:70-2).

Dr. Cohen reported that he had no relevant disclosures.

MIAMI BEACH – As more U.S. dermatologists are using cannulas to deliver soft tissue fillers for rejuvenation, tips to refine the technique and optimize patient outcomes are emerging.

Cannula use "seems to be gaining a lot of momentum in this country, and some of that really stems from the European experience," Dr. Joel L. Cohen said in an interview.

The size of the cannula, as well as the gauge of the needle that creates the entry point, can determine outcomes in different anatomic areas, Dr. Cohen said at the South Beach Symposium. "Cannulas have very specific roles in very specific areas. Personally, I have found them useful in the cheek, the infraorbital area, in the décolleté, and the dorsal hands."

He also shared a practical tip that eases cannula insertion. To deliver filler product using a 27 G cannula, for example, Dr. Cohen first nicks the skin with a slightly larger 25 G needle where he wants his entry point. Then, he pinches and holds the skin around the needle while his assistant removes it. That way, he knows the precise point to insert the cannula "rather than [later] fumbling around in a little bit of bleeding to find it. It’s really a helpful trick we’ve incorporated into our office."

A 25 G cannula can also be used to deliver fillers to the décolleté or dorsal side of the hands, said Dr. Cohen, who is in private practice in Englewood, Colo. In contrast, a smaller 30 G cannula may be more appropriate for rejuvenation of the infraorbital area, he said. "Using a 30 G cannula below the eyes, I feel that I am seeing less bruising and less swelling in this area, but at the same time, I am able to precisely deliver the filler product deep into the muscle along the periosteum."

An ability to fan product out in multiple directions from one entry point is an advantage of the cannula. "It’s a useful technique, and cannulas have helped me get better results with less bruising in my practice," Dr. Cohen said. The lower bruising potential seems to come from the cannula’s blunt tip, which can tuck under, above, or around a blood vessel. In contrast, a sharp needle is more likely to puncture the same vessel and cause postprocedure bruising, he said. And, fanning a needle around under the skin can increase the risk of bruising even further (Derm. Surg. 2008;34:S105-9).

"Some physicians, including me, actually have found patients experience less pain" with a cannula than with a needle, he added.

Although dermatologic use of cannulas has grown over the past year, "I don’t think it’s going to completely take over. You definitely still need needles for many different areas. I continue top use needles in the nasolabial folds [and] the oral commissure. For fine lines and wrinkles and more shallow rhytids, you definitely still need needles," he said

More information on cannulas can be found in an article published by Dr. Cohen and his colleague Dr. Joshua A. Zeichner (J. Drugs. Dermatol. 2012;11:70-2).

Dr. Cohen reported that he had no relevant disclosures.

MIAMI BEACH – As more U.S. dermatologists are using cannulas to deliver soft tissue fillers for rejuvenation, tips to refine the technique and optimize patient outcomes are emerging.

Cannula use "seems to be gaining a lot of momentum in this country, and some of that really stems from the European experience," Dr. Joel L. Cohen said in an interview.

The size of the cannula, as well as the gauge of the needle that creates the entry point, can determine outcomes in different anatomic areas, Dr. Cohen said at the South Beach Symposium. "Cannulas have very specific roles in very specific areas. Personally, I have found them useful in the cheek, the infraorbital area, in the décolleté, and the dorsal hands."

He also shared a practical tip that eases cannula insertion. To deliver filler product using a 27 G cannula, for example, Dr. Cohen first nicks the skin with a slightly larger 25 G needle where he wants his entry point. Then, he pinches and holds the skin around the needle while his assistant removes it. That way, he knows the precise point to insert the cannula "rather than [later] fumbling around in a little bit of bleeding to find it. It’s really a helpful trick we’ve incorporated into our office."

A 25 G cannula can also be used to deliver fillers to the décolleté or dorsal side of the hands, said Dr. Cohen, who is in private practice in Englewood, Colo. In contrast, a smaller 30 G cannula may be more appropriate for rejuvenation of the infraorbital area, he said. "Using a 30 G cannula below the eyes, I feel that I am seeing less bruising and less swelling in this area, but at the same time, I am able to precisely deliver the filler product deep into the muscle along the periosteum."

An ability to fan product out in multiple directions from one entry point is an advantage of the cannula. "It’s a useful technique, and cannulas have helped me get better results with less bruising in my practice," Dr. Cohen said. The lower bruising potential seems to come from the cannula’s blunt tip, which can tuck under, above, or around a blood vessel. In contrast, a sharp needle is more likely to puncture the same vessel and cause postprocedure bruising, he said. And, fanning a needle around under the skin can increase the risk of bruising even further (Derm. Surg. 2008;34:S105-9).

"Some physicians, including me, actually have found patients experience less pain" with a cannula than with a needle, he added.

Although dermatologic use of cannulas has grown over the past year, "I don’t think it’s going to completely take over. You definitely still need needles for many different areas. I continue top use needles in the nasolabial folds [and] the oral commissure. For fine lines and wrinkles and more shallow rhytids, you definitely still need needles," he said

More information on cannulas can be found in an article published by Dr. Cohen and his colleague Dr. Joshua A. Zeichner (J. Drugs. Dermatol. 2012;11:70-2).

Dr. Cohen reported that he had no relevant disclosures.

MIAMI BEACH – Early and aggressive anti-inflammatory therapy – preferably combination – is the key to treating acne and postinflammatory hyperpigmentation in patients with skin of color.

Acne prevalence is about the same in black and white patients, said Dr. Valerie D. Callender. The same mechanisms cause acne and the same treatments, in general, are used regardless of skin type, she said. "What is important is ... there are sequelae of acne that make it a little different, and there are certain, special considerations we have to keep in mind when treating patients with darker skin types."

Prevention of keloids, hypertrophic scars, and postinflammatory hyperpigmentation are among the special considerations in this patient population, Dr. Callender said at the South Beach Symposium.

Keloids and hypertrophic scars usually result from inflammatory acne papules, nodules, and cysts, and can be challenging to treat. The keloids and scarring commonly arise along the jawline and on the chest, shoulder, and back. "It’s important to be very aggressive to resolve the inflammation, to treat them effectively. A lot of these patients do very well with isotretinoin and oral antibiotics," said Dr. Callender of the dermatology department at Howard University in Washington, D.C.

In patients with keloids, consider injection of 20 mg/cc intralesional triamcinolone every 4 weeks, sometimes every 2 weeks, to get these lesions to go down, she said. "Remember that is part of their acne regimen."

Postinflammatory hyperpigmentation (PIH) is a common presenting complaint among skin of color patients with acne or another inflammatory skin condition.

PIH is "psychologically devastating for these patients. We have to treat the PIH just as aggressively as we treat the acne," Dr. Callender said. In some cases, the disfigurement is severe and the hyperpigmented patches and macules can persist for months or even years.

In a study of 2,895 females aged 10-70, prevalence of PIH varied by ethnicity (J. Eur. Acad. Dermatol. Venereol. 2011;25:1054-60). The researchers at Massachusetts General Hospital in Boston found that PIH affected 65% of 384 black study patients and 48% of 258 Hispanic patients. "The other racial groups were less than 20% for PIH; this goes along with what we do in our practices," Dr. Callender said.

There are multiple options for prevention and treatment of PIH. Sunscreen, sun avoidance, and early diagnosis can prevent or minimize adverse effects. Hydroquinone, retinoids, azelaic acid, and/or kojic acid are recommended treatments.

"I love my hydroquinone, I use it a lot," Dr. Callender said. Hydroquinone lightens areas of hyperpigmentation through inhibition of tyrosine conversion to melanin, reduces the number of melanosomes, and inhibits DNA and RNA synthesis of melanocytes.

Topical retinoid agents are useful because they not only treat acne, but also address the hyperpigmentation, she said. Also, once the hyperpigmentation is under control, the topical retinoids help to exfoliate the skin and keep PIH from recurring. "We love to keep these patients on long-term topical retinoid therapy."

Tolerability is very important when prescribing topical retinoids and other agents. Carefully consider each patient’s potential risk for cutaneous irritation, including erythema, peeling, burning, and dryness. Be sure to inform nurses and office staff that when a patient calls about tolerability, "you have to inquire about any changes in pigmentation [as well], especially in skin of color patients," Dr. Callender said. Moisturizers, cleansers, and less irritating vehicles can improve tolerability.

"We also use adjunctive therapies and sunscreen protection [for PIH]. Remember combination therapy is the way to go," she said.

She and her associates conducted a meta-analysis looking at the tolerability of a fixed combination adapalene 0.1% and benzoyl peroxide 2.5% gel product (Epiduo) for acne in patients by Fitzpatrick skin type (J. Clin. Aesthet. Dermatol. 2010;3:15-9). They found erythema, scaling, and dryness scores higher for white patients in all three studies. Burning and stinging scores were not significantly different. "Tolerability is good for your skin of color patients. You don’t need to be overly concerned about a lot of irritation just because their skin is dark."

Chemical peels, lasers, and light-based therapies are additional treatment options for acne. Peels made with glycolic acid, salicylic acid, Jessner’s solution, or a combination is acceptable in skin of color patients. However, "be very, very careful with peels in skin of color patients. Make sure [to] use superficial peeling agents," Dr. Callender said.

More clinical studies of lasers and light-based therapies to treat acne are including the darker skin types, Dr. Callender said. Blue light, diode laser, intense pulse light, and photodynamic therapy are examples. "As we learn how to adjust the settings, they will be safer for skin of color patients," she said.

Dr. Callender disclosed that she is a consultant for Allergan and Galderma, which markets Epiduo; a researcher for Allergan, Galderma, and Intendis; and a member of the speakers’ bureau for Galderma.

MIAMI BEACH – Early and aggressive anti-inflammatory therapy – preferably combination – is the key to treating acne and postinflammatory hyperpigmentation in patients with skin of color.

Acne prevalence is about the same in black and white patients, said Dr. Valerie D. Callender. The same mechanisms cause acne and the same treatments, in general, are used regardless of skin type, she said. "What is important is ... there are sequelae of acne that make it a little different, and there are certain, special considerations we have to keep in mind when treating patients with darker skin types."

Prevention of keloids, hypertrophic scars, and postinflammatory hyperpigmentation are among the special considerations in this patient population, Dr. Callender said at the South Beach Symposium.

Keloids and hypertrophic scars usually result from inflammatory acne papules, nodules, and cysts, and can be challenging to treat. The keloids and scarring commonly arise along the jawline and on the chest, shoulder, and back. "It’s important to be very aggressive to resolve the inflammation, to treat them effectively. A lot of these patients do very well with isotretinoin and oral antibiotics," said Dr. Callender of the dermatology department at Howard University in Washington, D.C.

In patients with keloids, consider injection of 20 mg/cc intralesional triamcinolone every 4 weeks, sometimes every 2 weeks, to get these lesions to go down, she said. "Remember that is part of their acne regimen."

Postinflammatory hyperpigmentation (PIH) is a common presenting complaint among skin of color patients with acne or another inflammatory skin condition.

PIH is "psychologically devastating for these patients. We have to treat the PIH just as aggressively as we treat the acne," Dr. Callender said. In some cases, the disfigurement is severe and the hyperpigmented patches and macules can persist for months or even years.

In a study of 2,895 females aged 10-70, prevalence of PIH varied by ethnicity (J. Eur. Acad. Dermatol. Venereol. 2011;25:1054-60). The researchers at Massachusetts General Hospital in Boston found that PIH affected 65% of 384 black study patients and 48% of 258 Hispanic patients. "The other racial groups were less than 20% for PIH; this goes along with what we do in our practices," Dr. Callender said.

There are multiple options for prevention and treatment of PIH. Sunscreen, sun avoidance, and early diagnosis can prevent or minimize adverse effects. Hydroquinone, retinoids, azelaic acid, and/or kojic acid are recommended treatments.

"I love my hydroquinone, I use it a lot," Dr. Callender said. Hydroquinone lightens areas of hyperpigmentation through inhibition of tyrosine conversion to melanin, reduces the number of melanosomes, and inhibits DNA and RNA synthesis of melanocytes.

Topical retinoid agents are useful because they not only treat acne, but also address the hyperpigmentation, she said. Also, once the hyperpigmentation is under control, the topical retinoids help to exfoliate the skin and keep PIH from recurring. "We love to keep these patients on long-term topical retinoid therapy."

Tolerability is very important when prescribing topical retinoids and other agents. Carefully consider each patient’s potential risk for cutaneous irritation, including erythema, peeling, burning, and dryness. Be sure to inform nurses and office staff that when a patient calls about tolerability, "you have to inquire about any changes in pigmentation [as well], especially in skin of color patients," Dr. Callender said. Moisturizers, cleansers, and less irritating vehicles can improve tolerability.

"We also use adjunctive therapies and sunscreen protection [for PIH]. Remember combination therapy is the way to go," she said.

She and her associates conducted a meta-analysis looking at the tolerability of a fixed combination adapalene 0.1% and benzoyl peroxide 2.5% gel product (Epiduo) for acne in patients by Fitzpatrick skin type (J. Clin. Aesthet. Dermatol. 2010;3:15-9). They found erythema, scaling, and dryness scores higher for white patients in all three studies. Burning and stinging scores were not significantly different. "Tolerability is good for your skin of color patients. You don’t need to be overly concerned about a lot of irritation just because their skin is dark."

Chemical peels, lasers, and light-based therapies are additional treatment options for acne. Peels made with glycolic acid, salicylic acid, Jessner’s solution, or a combination is acceptable in skin of color patients. However, "be very, very careful with peels in skin of color patients. Make sure [to] use superficial peeling agents," Dr. Callender said.

More clinical studies of lasers and light-based therapies to treat acne are including the darker skin types, Dr. Callender said. Blue light, diode laser, intense pulse light, and photodynamic therapy are examples. "As we learn how to adjust the settings, they will be safer for skin of color patients," she said.

Dr. Callender disclosed that she is a consultant for Allergan and Galderma, which markets Epiduo; a researcher for Allergan, Galderma, and Intendis; and a member of the speakers’ bureau for Galderma.

MIAMI BEACH – Early and aggressive anti-inflammatory therapy – preferably combination – is the key to treating acne and postinflammatory hyperpigmentation in patients with skin of color.

Acne prevalence is about the same in black and white patients, said Dr. Valerie D. Callender. The same mechanisms cause acne and the same treatments, in general, are used regardless of skin type, she said. "What is important is ... there are sequelae of acne that make it a little different, and there are certain, special considerations we have to keep in mind when treating patients with darker skin types."

Prevention of keloids, hypertrophic scars, and postinflammatory hyperpigmentation are among the special considerations in this patient population, Dr. Callender said at the South Beach Symposium.

Keloids and hypertrophic scars usually result from inflammatory acne papules, nodules, and cysts, and can be challenging to treat. The keloids and scarring commonly arise along the jawline and on the chest, shoulder, and back. "It’s important to be very aggressive to resolve the inflammation, to treat them effectively. A lot of these patients do very well with isotretinoin and oral antibiotics," said Dr. Callender of the dermatology department at Howard University in Washington, D.C.

In patients with keloids, consider injection of 20 mg/cc intralesional triamcinolone every 4 weeks, sometimes every 2 weeks, to get these lesions to go down, she said. "Remember that is part of their acne regimen."

Postinflammatory hyperpigmentation (PIH) is a common presenting complaint among skin of color patients with acne or another inflammatory skin condition.

PIH is "psychologically devastating for these patients. We have to treat the PIH just as aggressively as we treat the acne," Dr. Callender said. In some cases, the disfigurement is severe and the hyperpigmented patches and macules can persist for months or even years.

In a study of 2,895 females aged 10-70, prevalence of PIH varied by ethnicity (J. Eur. Acad. Dermatol. Venereol. 2011;25:1054-60). The researchers at Massachusetts General Hospital in Boston found that PIH affected 65% of 384 black study patients and 48% of 258 Hispanic patients. "The other racial groups were less than 20% for PIH; this goes along with what we do in our practices," Dr. Callender said.

There are multiple options for prevention and treatment of PIH. Sunscreen, sun avoidance, and early diagnosis can prevent or minimize adverse effects. Hydroquinone, retinoids, azelaic acid, and/or kojic acid are recommended treatments.

"I love my hydroquinone, I use it a lot," Dr. Callender said. Hydroquinone lightens areas of hyperpigmentation through inhibition of tyrosine conversion to melanin, reduces the number of melanosomes, and inhibits DNA and RNA synthesis of melanocytes.

Topical retinoid agents are useful because they not only treat acne, but also address the hyperpigmentation, she said. Also, once the hyperpigmentation is under control, the topical retinoids help to exfoliate the skin and keep PIH from recurring. "We love to keep these patients on long-term topical retinoid therapy."

Tolerability is very important when prescribing topical retinoids and other agents. Carefully consider each patient’s potential risk for cutaneous irritation, including erythema, peeling, burning, and dryness. Be sure to inform nurses and office staff that when a patient calls about tolerability, "you have to inquire about any changes in pigmentation [as well], especially in skin of color patients," Dr. Callender said. Moisturizers, cleansers, and less irritating vehicles can improve tolerability.

"We also use adjunctive therapies and sunscreen protection [for PIH]. Remember combination therapy is the way to go," she said.

She and her associates conducted a meta-analysis looking at the tolerability of a fixed combination adapalene 0.1% and benzoyl peroxide 2.5% gel product (Epiduo) for acne in patients by Fitzpatrick skin type (J. Clin. Aesthet. Dermatol. 2010;3:15-9). They found erythema, scaling, and dryness scores higher for white patients in all three studies. Burning and stinging scores were not significantly different. "Tolerability is good for your skin of color patients. You don’t need to be overly concerned about a lot of irritation just because their skin is dark."

Chemical peels, lasers, and light-based therapies are additional treatment options for acne. Peels made with glycolic acid, salicylic acid, Jessner’s solution, or a combination is acceptable in skin of color patients. However, "be very, very careful with peels in skin of color patients. Make sure [to] use superficial peeling agents," Dr. Callender said.

More clinical studies of lasers and light-based therapies to treat acne are including the darker skin types, Dr. Callender said. Blue light, diode laser, intense pulse light, and photodynamic therapy are examples. "As we learn how to adjust the settings, they will be safer for skin of color patients," she said.

Dr. Callender disclosed that she is a consultant for Allergan and Galderma, which markets Epiduo; a researcher for Allergan, Galderma, and Intendis; and a member of the speakers’ bureau for Galderma.

MIAMI BEACH – Acne presentation, treatment, and counseling will vary according to whether your patient is a neonate, infant, child, preadolescent, or teenager, according to Dr. Jonette E. Keri.

Courtesy Dr. Lawrence F. Eichenfield

• Neonatal acne. These small, erythematous papules that arise before 6 weeks of life probably represent a heterogenous set of conditions. Ketoconazole cream 2% twice per day is a treatment option.

However, "a lot of doctors choose not to treat because it’s not a scarring process," Dr. Keri said. You can reassure parents that most neonatal acne improves relatively quickly, usually within a few months. If true comedones are present, consider treatment with the same acne mediations indicated for infantile acne.

• Infantile acne. Infantile acne appears in children up to 1 year, usually at 3-6 months of age. Male infants are more prone to acne than female infants, and lesions tend to appear on the cheeks and chin and have the appearance of classic adolescent acne. Increased sebum production and some comedones are often present.

"You should treat because it can cause scarring," Dr. Keri said. Also, "this acne may predispose [children] to worse acne in teenage years – that is shown to be true for any form of infantile acne. It doesn’t have to be severe," said Dr. Keri of the University of Miami and chief of dermatology services at the Miami VA Hospital.

She offered the following clinical tips for treating and managing acne based on developmental age:

Combine treatments and use products appropriate for a baby, Dr. Keri advised at the South Beach Symposium. Although some experts recommend benzoyl peroxide, proceed with caution. The concern is getting any benzoyl peroxide near a baby’s eyes, "so you probably want to stay away from the washes."

Treatment options include topical antibiotics, adapalene, or a retinoid like tretinoin. Oral erythromycin is another acceptable option, she said.

"Isotretinoin is actually indicated if a severe, scarring process is going on," said Dr. Keri. She said that she searched the literature and found that some clinicians prescribe isotretinoin in children as young as 5 months.

• Midchildhood acne. "It is a newer concept, but a very important concept," Dr. Keri said. Acne is relatively rare between the ages of 1 and 8 years. During this time androgens in the body should be low and stable.

If acne does arise, it could point to an underlying hormonal abnormality. Evaluate three things: bone age, the growth chart, and hormone levels. "That may be a bit much for a dermatologist, but a pediatrician does these evaluations often," she said.

Accelerated bone age on a wrist radiograph can point to androgen excess, whereas delayed bone age suggests Cushing’s disease. A growth chart that shows a child’s height crossing percentiles upward or increasing faster than would be expected can also suggest androgen excess.

"Hormone levels can be tricky," Dr. Keri said. High levels of androgens, free testosterone, or dehydroepiandrosterone also can occur with tumors or polycystic ovarian syndrome (PCOS). "Another reason they can be tricky is because the child is developing into an adult, so you may need a pediatric endocrinologist to tease this out."

• Preadolescent acne. Treatments for children aged 9-12 years are essentially the same as for infants and midchildhood patients. However, patient counseling plays a bigger role. "Adherence is a big issue with these kids, so try to give them a once-a-day regimen," Dr. Keri said. Isotretinoin is rarely prescribed in this age group, but if severity dictates the need, it is likely the child will need retreatment (two or three courses) over time.

Comedones, seborrhea, and even PCOS are associated with preteen acne. Rule out precocious puberty and distinguish abnormal hormonal changes from normal signs of puberty, Dr. Keri recommended.

"PCOS is very complicated; you are going to need some help, a multispecialty approach," Dr. Keri said. Early diagnosis is worthwhile, she added. "If you identify PCOS when these young ladies are younger, you can prevent infertility, diabetes, [and] coronary artery disease, because they get these things more often than a woman who doesn’t have PCOS."

• Adolescent acne. Speaking directly and appropriately with teenagers about their acne can facilitate better outcomes, Dr. Keri said. For example, instead of asking, "How many days a week do you use your medicines?" ask, "How do you use your acne medicines?" Also determine their expectations before prescribing, and find out if they have a prom or other major social event coming up.

It is also important to evaluate their previous acne-fighting strategies. "It can be painfully tiring to go through all they have done and used, but if you don’t do that, you’re not going to have a good starting point," she said. Find out what they like and dislike, and really listen to their answers. "They will be honest if you listen to them."

Also, adolescents like to use pads to apply their acne medicine, so keep those formulations in mind for this age group, she said.

Dr. Keri said she had no relevant financial disclosures.

MIAMI BEACH – Acne presentation, treatment, and counseling will vary according to whether your patient is a neonate, infant, child, preadolescent, or teenager, according to Dr. Jonette E. Keri.

Courtesy Dr. Lawrence F. Eichenfield

• Neonatal acne. These small, erythematous papules that arise before 6 weeks of life probably represent a heterogenous set of conditions. Ketoconazole cream 2% twice per day is a treatment option.

However, "a lot of doctors choose not to treat because it’s not a scarring process," Dr. Keri said. You can reassure parents that most neonatal acne improves relatively quickly, usually within a few months. If true comedones are present, consider treatment with the same acne mediations indicated for infantile acne.

• Infantile acne. Infantile acne appears in children up to 1 year, usually at 3-6 months of age. Male infants are more prone to acne than female infants, and lesions tend to appear on the cheeks and chin and have the appearance of classic adolescent acne. Increased sebum production and some comedones are often present.

"You should treat because it can cause scarring," Dr. Keri said. Also, "this acne may predispose [children] to worse acne in teenage years – that is shown to be true for any form of infantile acne. It doesn’t have to be severe," said Dr. Keri of the University of Miami and chief of dermatology services at the Miami VA Hospital.

She offered the following clinical tips for treating and managing acne based on developmental age:

Combine treatments and use products appropriate for a baby, Dr. Keri advised at the South Beach Symposium. Although some experts recommend benzoyl peroxide, proceed with caution. The concern is getting any benzoyl peroxide near a baby’s eyes, "so you probably want to stay away from the washes."

Treatment options include topical antibiotics, adapalene, or a retinoid like tretinoin. Oral erythromycin is another acceptable option, she said.

"Isotretinoin is actually indicated if a severe, scarring process is going on," said Dr. Keri. She said that she searched the literature and found that some clinicians prescribe isotretinoin in children as young as 5 months.

• Midchildhood acne. "It is a newer concept, but a very important concept," Dr. Keri said. Acne is relatively rare between the ages of 1 and 8 years. During this time androgens in the body should be low and stable.

If acne does arise, it could point to an underlying hormonal abnormality. Evaluate three things: bone age, the growth chart, and hormone levels. "That may be a bit much for a dermatologist, but a pediatrician does these evaluations often," she said.

Accelerated bone age on a wrist radiograph can point to androgen excess, whereas delayed bone age suggests Cushing’s disease. A growth chart that shows a child’s height crossing percentiles upward or increasing faster than would be expected can also suggest androgen excess.

"Hormone levels can be tricky," Dr. Keri said. High levels of androgens, free testosterone, or dehydroepiandrosterone also can occur with tumors or polycystic ovarian syndrome (PCOS). "Another reason they can be tricky is because the child is developing into an adult, so you may need a pediatric endocrinologist to tease this out."

• Preadolescent acne. Treatments for children aged 9-12 years are essentially the same as for infants and midchildhood patients. However, patient counseling plays a bigger role. "Adherence is a big issue with these kids, so try to give them a once-a-day regimen," Dr. Keri said. Isotretinoin is rarely prescribed in this age group, but if severity dictates the need, it is likely the child will need retreatment (two or three courses) over time.

Comedones, seborrhea, and even PCOS are associated with preteen acne. Rule out precocious puberty and distinguish abnormal hormonal changes from normal signs of puberty, Dr. Keri recommended.

"PCOS is very complicated; you are going to need some help, a multispecialty approach," Dr. Keri said. Early diagnosis is worthwhile, she added. "If you identify PCOS when these young ladies are younger, you can prevent infertility, diabetes, [and] coronary artery disease, because they get these things more often than a woman who doesn’t have PCOS."

• Adolescent acne. Speaking directly and appropriately with teenagers about their acne can facilitate better outcomes, Dr. Keri said. For example, instead of asking, "How many days a week do you use your medicines?" ask, "How do you use your acne medicines?" Also determine their expectations before prescribing, and find out if they have a prom or other major social event coming up.

It is also important to evaluate their previous acne-fighting strategies. "It can be painfully tiring to go through all they have done and used, but if you don’t do that, you’re not going to have a good starting point," she said. Find out what they like and dislike, and really listen to their answers. "They will be honest if you listen to them."

Also, adolescents like to use pads to apply their acne medicine, so keep those formulations in mind for this age group, she said.

Dr. Keri said she had no relevant financial disclosures.

MIAMI BEACH – Acne presentation, treatment, and counseling will vary according to whether your patient is a neonate, infant, child, preadolescent, or teenager, according to Dr. Jonette E. Keri.

Courtesy Dr. Lawrence F. Eichenfield

• Neonatal acne. These small, erythematous papules that arise before 6 weeks of life probably represent a heterogenous set of conditions. Ketoconazole cream 2% twice per day is a treatment option.

However, "a lot of doctors choose not to treat because it’s not a scarring process," Dr. Keri said. You can reassure parents that most neonatal acne improves relatively quickly, usually within a few months. If true comedones are present, consider treatment with the same acne mediations indicated for infantile acne.

• Infantile acne. Infantile acne appears in children up to 1 year, usually at 3-6 months of age. Male infants are more prone to acne than female infants, and lesions tend to appear on the cheeks and chin and have the appearance of classic adolescent acne. Increased sebum production and some comedones are often present.

"You should treat because it can cause scarring," Dr. Keri said. Also, "this acne may predispose [children] to worse acne in teenage years – that is shown to be true for any form of infantile acne. It doesn’t have to be severe," said Dr. Keri of the University of Miami and chief of dermatology services at the Miami VA Hospital.

She offered the following clinical tips for treating and managing acne based on developmental age:

Combine treatments and use products appropriate for a baby, Dr. Keri advised at the South Beach Symposium. Although some experts recommend benzoyl peroxide, proceed with caution. The concern is getting any benzoyl peroxide near a baby’s eyes, "so you probably want to stay away from the washes."

Treatment options include topical antibiotics, adapalene, or a retinoid like tretinoin. Oral erythromycin is another acceptable option, she said.

"Isotretinoin is actually indicated if a severe, scarring process is going on," said Dr. Keri. She said that she searched the literature and found that some clinicians prescribe isotretinoin in children as young as 5 months.

• Midchildhood acne. "It is a newer concept, but a very important concept," Dr. Keri said. Acne is relatively rare between the ages of 1 and 8 years. During this time androgens in the body should be low and stable.

If acne does arise, it could point to an underlying hormonal abnormality. Evaluate three things: bone age, the growth chart, and hormone levels. "That may be a bit much for a dermatologist, but a pediatrician does these evaluations often," she said.

Accelerated bone age on a wrist radiograph can point to androgen excess, whereas delayed bone age suggests Cushing’s disease. A growth chart that shows a child’s height crossing percentiles upward or increasing faster than would be expected can also suggest androgen excess.

"Hormone levels can be tricky," Dr. Keri said. High levels of androgens, free testosterone, or dehydroepiandrosterone also can occur with tumors or polycystic ovarian syndrome (PCOS). "Another reason they can be tricky is because the child is developing into an adult, so you may need a pediatric endocrinologist to tease this out."

• Preadolescent acne. Treatments for children aged 9-12 years are essentially the same as for infants and midchildhood patients. However, patient counseling plays a bigger role. "Adherence is a big issue with these kids, so try to give them a once-a-day regimen," Dr. Keri said. Isotretinoin is rarely prescribed in this age group, but if severity dictates the need, it is likely the child will need retreatment (two or three courses) over time.

Comedones, seborrhea, and even PCOS are associated with preteen acne. Rule out precocious puberty and distinguish abnormal hormonal changes from normal signs of puberty, Dr. Keri recommended.

"PCOS is very complicated; you are going to need some help, a multispecialty approach," Dr. Keri said. Early diagnosis is worthwhile, she added. "If you identify PCOS when these young ladies are younger, you can prevent infertility, diabetes, [and] coronary artery disease, because they get these things more often than a woman who doesn’t have PCOS."

• Adolescent acne. Speaking directly and appropriately with teenagers about their acne can facilitate better outcomes, Dr. Keri said. For example, instead of asking, "How many days a week do you use your medicines?" ask, "How do you use your acne medicines?" Also determine their expectations before prescribing, and find out if they have a prom or other major social event coming up.

It is also important to evaluate their previous acne-fighting strategies. "It can be painfully tiring to go through all they have done and used, but if you don’t do that, you’re not going to have a good starting point," she said. Find out what they like and dislike, and really listen to their answers. "They will be honest if you listen to them."

Also, adolescents like to use pads to apply their acne medicine, so keep those formulations in mind for this age group, she said.

Dr. Keri said she had no relevant financial disclosures.