SPD Annual Meeting

COEUR D’ALENE, IDAHO – Switching to a referral-only policy in one pediatric dermatology clinic in a children’s hospital reduced the average wait for an initial appointment by 10%.

"A referral-only system may be an effective method for other pediatric dermatology clinics, as well as other pediatric subspecialties, to decrease patient wait time to see a subspecialist," Dr. Tiffany J. Herd concluded at the annual meeting of the Society for Pediatric Dermatology.

Nationally, pediatric dermatology is very close to the top of the list of pediatric subspecialties in terms of patient wait time. Strategies to reduce wait time for pediatric dermatology are urgently needed, noted Dr. Herd of Children’s Mercy Hospitals and Clinics in Kansas City, Mo.

She presented a retrospective study analyzing the impact of implementing a referral-only policy for new outpatient pediatric dermatology appointments at the medical center. The study entailed reviewing the medical records of 6,316 pediatric dermatology clinic patients seen initially either during January-August of 2012–before the switch to a referral-only policy–or in January-August of 2013, after the policy was in place.

Self-referrals accounted for 24% of all initial appointments in 2012, but only 4% a year later. Mean patient wait time fell from 36.4 days in 2012 to 32.9 in 2013, a 9.6% decrease. The median wait time dropped from 34 to 24 days.

The 15 most common diagnoses were the same before and after the policy shift. The top three in both time periods were benign neoplasms of the skin, atopic dermatitis, and acne. Their proportion of total new clinic visits was the same in 2012 and 2013. Indeed, the proportion changed for only one of the top 15 diagnoses: warts, which accounted for 9.2% of initial appointments in 2012, but only 7.4% a year later, according to Dr. Herd.

Of note, however, the complexity of the cases seen in the pediatric dermatology clinic rose substantially following the shift to a referral-only policy. In 2012, 40% of initially referred patients were billed as Level 3 complexity, compared with 68% in 2013.

Patient demographics didn’t change, nor did the type of insurance coverage. These findings suggest that access to pediatric dermatology services remained equitable following implementation of the referral-only policy, she continued.

Primary care physicians are probably capable of handling many of the pediatric dermatologic conditions which they now commonly refer to the subspecialty clinic. An interesting topic for future study will be to see if targeted education of primary care clinicians and pediatric residents regarding the top 15 diagnoses seen in the referral-only pediatric dermatology clinic allows the nondermatologists to reduce their referral rate, Dr. Herd said.

She reported having no financial conflicts regarding this study, which was conducted with institutional funds.

[email protected]

COEUR D’ALENE, IDAHO – Switching to a referral-only policy in one pediatric dermatology clinic in a children’s hospital reduced the average wait for an initial appointment by 10%.

"A referral-only system may be an effective method for other pediatric dermatology clinics, as well as other pediatric subspecialties, to decrease patient wait time to see a subspecialist," Dr. Tiffany J. Herd concluded at the annual meeting of the Society for Pediatric Dermatology.

Nationally, pediatric dermatology is very close to the top of the list of pediatric subspecialties in terms of patient wait time. Strategies to reduce wait time for pediatric dermatology are urgently needed, noted Dr. Herd of Children’s Mercy Hospitals and Clinics in Kansas City, Mo.

She presented a retrospective study analyzing the impact of implementing a referral-only policy for new outpatient pediatric dermatology appointments at the medical center. The study entailed reviewing the medical records of 6,316 pediatric dermatology clinic patients seen initially either during January-August of 2012–before the switch to a referral-only policy–or in January-August of 2013, after the policy was in place.

Self-referrals accounted for 24% of all initial appointments in 2012, but only 4% a year later. Mean patient wait time fell from 36.4 days in 2012 to 32.9 in 2013, a 9.6% decrease. The median wait time dropped from 34 to 24 days.

The 15 most common diagnoses were the same before and after the policy shift. The top three in both time periods were benign neoplasms of the skin, atopic dermatitis, and acne. Their proportion of total new clinic visits was the same in 2012 and 2013. Indeed, the proportion changed for only one of the top 15 diagnoses: warts, which accounted for 9.2% of initial appointments in 2012, but only 7.4% a year later, according to Dr. Herd.

Of note, however, the complexity of the cases seen in the pediatric dermatology clinic rose substantially following the shift to a referral-only policy. In 2012, 40% of initially referred patients were billed as Level 3 complexity, compared with 68% in 2013.

Patient demographics didn’t change, nor did the type of insurance coverage. These findings suggest that access to pediatric dermatology services remained equitable following implementation of the referral-only policy, she continued.

Primary care physicians are probably capable of handling many of the pediatric dermatologic conditions which they now commonly refer to the subspecialty clinic. An interesting topic for future study will be to see if targeted education of primary care clinicians and pediatric residents regarding the top 15 diagnoses seen in the referral-only pediatric dermatology clinic allows the nondermatologists to reduce their referral rate, Dr. Herd said.

She reported having no financial conflicts regarding this study, which was conducted with institutional funds.

[email protected]

COEUR D’ALENE, IDAHO – Switching to a referral-only policy in one pediatric dermatology clinic in a children’s hospital reduced the average wait for an initial appointment by 10%.

"A referral-only system may be an effective method for other pediatric dermatology clinics, as well as other pediatric subspecialties, to decrease patient wait time to see a subspecialist," Dr. Tiffany J. Herd concluded at the annual meeting of the Society for Pediatric Dermatology.

Nationally, pediatric dermatology is very close to the top of the list of pediatric subspecialties in terms of patient wait time. Strategies to reduce wait time for pediatric dermatology are urgently needed, noted Dr. Herd of Children’s Mercy Hospitals and Clinics in Kansas City, Mo.

She presented a retrospective study analyzing the impact of implementing a referral-only policy for new outpatient pediatric dermatology appointments at the medical center. The study entailed reviewing the medical records of 6,316 pediatric dermatology clinic patients seen initially either during January-August of 2012–before the switch to a referral-only policy–or in January-August of 2013, after the policy was in place.

Self-referrals accounted for 24% of all initial appointments in 2012, but only 4% a year later. Mean patient wait time fell from 36.4 days in 2012 to 32.9 in 2013, a 9.6% decrease. The median wait time dropped from 34 to 24 days.

The 15 most common diagnoses were the same before and after the policy shift. The top three in both time periods were benign neoplasms of the skin, atopic dermatitis, and acne. Their proportion of total new clinic visits was the same in 2012 and 2013. Indeed, the proportion changed for only one of the top 15 diagnoses: warts, which accounted for 9.2% of initial appointments in 2012, but only 7.4% a year later, according to Dr. Herd.

Of note, however, the complexity of the cases seen in the pediatric dermatology clinic rose substantially following the shift to a referral-only policy. In 2012, 40% of initially referred patients were billed as Level 3 complexity, compared with 68% in 2013.

Patient demographics didn’t change, nor did the type of insurance coverage. These findings suggest that access to pediatric dermatology services remained equitable following implementation of the referral-only policy, she continued.

Primary care physicians are probably capable of handling many of the pediatric dermatologic conditions which they now commonly refer to the subspecialty clinic. An interesting topic for future study will be to see if targeted education of primary care clinicians and pediatric residents regarding the top 15 diagnoses seen in the referral-only pediatric dermatology clinic allows the nondermatologists to reduce their referral rate, Dr. Herd said.

She reported having no financial conflicts regarding this study, which was conducted with institutional funds.

[email protected]

COEUR D’ALENE, IDAHO – Early therapeutic intervention in children with lymphatic malformations appears to reduce the risk of lesion progression and symptomatic complications, according to a large retrospective study.

"Lymphatic malformations are progressive, but early intervention makes a difference in terms of volume increase and the complication rate. Early intervention should definitely be considered when functional impairment due to local extension is a concern," Dr. Joyce Teng said at the annual meeting of the Society for Pediatric Dermatology.

Lymphatic malformations (LMs) are benign, low-flow congenital vascular anomalies due to abnormal formation of lymphatic vessels in utero. The lesions consist of sequestered lymphatic cysts lined with lymphatic epithelium surrounded by connective tissue stroma. These cysts don’t drain. The result is soft, doughy masses underlying normal-looking epidermis.

Close to two-thirds of LMs occur on the head and neck. They commonly cause pain and swelling, especially during an upper respiratory infection. These head and neck lesions not only cause unsightly facial asymmetry, but as they progress they can press on the airway. Truncal lesions not infrequently send affected patients to the emergency department with acute abdominal pain, explained Dr. Teng, director of pediatric dermatology at Stanford (Calif.) University.

There is no ideal therapy for LMs. Management options include conservative observation, surgical excision, sclerotherapy, and potentially disease-modifying medications, with sildenafil and sirolimus among the agents under study.

In children, sclerotherapy is a particularly attractive alternative to surgical excision. The Stanford experience as described by Dr. Teng indicates that doxycycline and ethanolamine are equally safe and effective sclerosants for this purpose, as is the Japanese agent OK-432, unavailable in North America or Europe.

Dr. Teng presented a retrospective chart review of 336 patients under age 20 years with LMs in Stanford’s large clinical database. Half were female. The LMs were first noted at a mean age of 2.1 years and a median of 2 months. Forty-three percent were macrocystic as defined by septated cystic spaces in excess of 2 cc, while another 35% of patients had a mix of macro- and microcysts.

Disease progression was defined as lesion enlargement at a rate greater than the patient’s growth rate or worsening signs and symptoms. The LM progression rate was 47% in childhood.

The median age at the time of progression was 4.9 years. Consistent with the findings of an earlier study by investigators at Harvard University, Boston, the rate of rapid progression in the Stanford study was greater among 15- to 20-year-olds than in children, probably due to the influence of pubertal hormonal changes. In the retrospective 441-patient Harvard study, the LM progression rate was 40% in childhood, 64% in adolescence, and 95% lifetime (J. Craniofac. Surg. 2012;23:149-52).

Dr. Teng and coworkers found that observation without active treatment was associated with a 2.1-fold increased risk of progression. Also, older age at the time of diagnosis was associated with a higher risk of complications. Indeed, the odds of progression rose by 17% per year of age at diagnosis of LM.

In contrast, factors not associated with progression risk in the Stanford study were gender, lesion location or subtype, or having LMs at multiple sites.

Forty-one children with LMs on the head and neck underwent sclerotherapy at a median age of 1-2 years.

Among 19 patients treated with doxycycline, there were two recurrences. Outcomes were rated as excellent in 53% of cases, meaning two investigators agreed that the two sides of the face looked nearly the same post treatment. Outcomes of doxycycline sclerotherapy were rated good in another 26%. Among 12 ethanolamine-treated patients, outcomes were rated excellent in 42% and good in 25%. One of the 12 patients experienced an LM recurrence, as did 3 of 10 treated with OK-432. No procedural complications occurred in the ethanolamine group. One doxycycline-treated patient experienced a treatment-related hemorrhage.

In a multivariate analysis, doxycycline and ethanolamine didn’t differ in effectiveness. Both performed best in treating macrocystic lesions, where 90% of patients experienced marked LM volume reduction, as did 73% of patients with mixed lesions. The success rate was lowest when treating purely microcystic lesions.

"I’ve talked to lots of interventional radiologists. These cases aren’t all that common, and their choice of sclerosant seems to really depend upon their training and comfort level," Dr. Teng said.

She advised getting a baseline magnetic resonance image (MRI) to confirm the diagnosis of LM and to determine the baseline extent of disease in order to guide future decisions about intervention. In addition, a post-treatment MRI showing LM volume reduction provides objective evidence of therapeutic success.

One audience member, citing the high cost of MRIs, asked if there are less expensive ways to measure the magnitude of treatment response. Dr. Teng replied that imaging is best. She added, however, that the cost of an MRI is reduced by about $800 when sedation isn’t required. And a Stanford study has shown that the use of a child-friendly teaching kit enables most children to undergo an MRI without sedation.

"It’s like a video game they take home and play for a month. When they come back for their MRI more than 80% of kids don’t need sedation anymore. It really cuts down the cost," she said.

Dr. Teng credited University of California, Irvine, medical student Viraat Patel as deserving primary authorship status for this study, conducted under her supervision. The study was supported by the Society for Pediatric Dermatology. Dr. Teng had no financial conflicts.

[email protected]

COEUR D’ALENE, IDAHO – Early therapeutic intervention in children with lymphatic malformations appears to reduce the risk of lesion progression and symptomatic complications, according to a large retrospective study.

"Lymphatic malformations are progressive, but early intervention makes a difference in terms of volume increase and the complication rate. Early intervention should definitely be considered when functional impairment due to local extension is a concern," Dr. Joyce Teng said at the annual meeting of the Society for Pediatric Dermatology.

Lymphatic malformations (LMs) are benign, low-flow congenital vascular anomalies due to abnormal formation of lymphatic vessels in utero. The lesions consist of sequestered lymphatic cysts lined with lymphatic epithelium surrounded by connective tissue stroma. These cysts don’t drain. The result is soft, doughy masses underlying normal-looking epidermis.

Close to two-thirds of LMs occur on the head and neck. They commonly cause pain and swelling, especially during an upper respiratory infection. These head and neck lesions not only cause unsightly facial asymmetry, but as they progress they can press on the airway. Truncal lesions not infrequently send affected patients to the emergency department with acute abdominal pain, explained Dr. Teng, director of pediatric dermatology at Stanford (Calif.) University.

There is no ideal therapy for LMs. Management options include conservative observation, surgical excision, sclerotherapy, and potentially disease-modifying medications, with sildenafil and sirolimus among the agents under study.

In children, sclerotherapy is a particularly attractive alternative to surgical excision. The Stanford experience as described by Dr. Teng indicates that doxycycline and ethanolamine are equally safe and effective sclerosants for this purpose, as is the Japanese agent OK-432, unavailable in North America or Europe.

Dr. Teng presented a retrospective chart review of 336 patients under age 20 years with LMs in Stanford’s large clinical database. Half were female. The LMs were first noted at a mean age of 2.1 years and a median of 2 months. Forty-three percent were macrocystic as defined by septated cystic spaces in excess of 2 cc, while another 35% of patients had a mix of macro- and microcysts.

Disease progression was defined as lesion enlargement at a rate greater than the patient’s growth rate or worsening signs and symptoms. The LM progression rate was 47% in childhood.

The median age at the time of progression was 4.9 years. Consistent with the findings of an earlier study by investigators at Harvard University, Boston, the rate of rapid progression in the Stanford study was greater among 15- to 20-year-olds than in children, probably due to the influence of pubertal hormonal changes. In the retrospective 441-patient Harvard study, the LM progression rate was 40% in childhood, 64% in adolescence, and 95% lifetime (J. Craniofac. Surg. 2012;23:149-52).

Dr. Teng and coworkers found that observation without active treatment was associated with a 2.1-fold increased risk of progression. Also, older age at the time of diagnosis was associated with a higher risk of complications. Indeed, the odds of progression rose by 17% per year of age at diagnosis of LM.

In contrast, factors not associated with progression risk in the Stanford study were gender, lesion location or subtype, or having LMs at multiple sites.

Forty-one children with LMs on the head and neck underwent sclerotherapy at a median age of 1-2 years.

Among 19 patients treated with doxycycline, there were two recurrences. Outcomes were rated as excellent in 53% of cases, meaning two investigators agreed that the two sides of the face looked nearly the same post treatment. Outcomes of doxycycline sclerotherapy were rated good in another 26%. Among 12 ethanolamine-treated patients, outcomes were rated excellent in 42% and good in 25%. One of the 12 patients experienced an LM recurrence, as did 3 of 10 treated with OK-432. No procedural complications occurred in the ethanolamine group. One doxycycline-treated patient experienced a treatment-related hemorrhage.

In a multivariate analysis, doxycycline and ethanolamine didn’t differ in effectiveness. Both performed best in treating macrocystic lesions, where 90% of patients experienced marked LM volume reduction, as did 73% of patients with mixed lesions. The success rate was lowest when treating purely microcystic lesions.

"I’ve talked to lots of interventional radiologists. These cases aren’t all that common, and their choice of sclerosant seems to really depend upon their training and comfort level," Dr. Teng said.

She advised getting a baseline magnetic resonance image (MRI) to confirm the diagnosis of LM and to determine the baseline extent of disease in order to guide future decisions about intervention. In addition, a post-treatment MRI showing LM volume reduction provides objective evidence of therapeutic success.

One audience member, citing the high cost of MRIs, asked if there are less expensive ways to measure the magnitude of treatment response. Dr. Teng replied that imaging is best. She added, however, that the cost of an MRI is reduced by about $800 when sedation isn’t required. And a Stanford study has shown that the use of a child-friendly teaching kit enables most children to undergo an MRI without sedation.

"It’s like a video game they take home and play for a month. When they come back for their MRI more than 80% of kids don’t need sedation anymore. It really cuts down the cost," she said.

Dr. Teng credited University of California, Irvine, medical student Viraat Patel as deserving primary authorship status for this study, conducted under her supervision. The study was supported by the Society for Pediatric Dermatology. Dr. Teng had no financial conflicts.

[email protected]

COEUR D’ALENE, IDAHO – Early therapeutic intervention in children with lymphatic malformations appears to reduce the risk of lesion progression and symptomatic complications, according to a large retrospective study.

"Lymphatic malformations are progressive, but early intervention makes a difference in terms of volume increase and the complication rate. Early intervention should definitely be considered when functional impairment due to local extension is a concern," Dr. Joyce Teng said at the annual meeting of the Society for Pediatric Dermatology.

Lymphatic malformations (LMs) are benign, low-flow congenital vascular anomalies due to abnormal formation of lymphatic vessels in utero. The lesions consist of sequestered lymphatic cysts lined with lymphatic epithelium surrounded by connective tissue stroma. These cysts don’t drain. The result is soft, doughy masses underlying normal-looking epidermis.

Close to two-thirds of LMs occur on the head and neck. They commonly cause pain and swelling, especially during an upper respiratory infection. These head and neck lesions not only cause unsightly facial asymmetry, but as they progress they can press on the airway. Truncal lesions not infrequently send affected patients to the emergency department with acute abdominal pain, explained Dr. Teng, director of pediatric dermatology at Stanford (Calif.) University.

There is no ideal therapy for LMs. Management options include conservative observation, surgical excision, sclerotherapy, and potentially disease-modifying medications, with sildenafil and sirolimus among the agents under study.

In children, sclerotherapy is a particularly attractive alternative to surgical excision. The Stanford experience as described by Dr. Teng indicates that doxycycline and ethanolamine are equally safe and effective sclerosants for this purpose, as is the Japanese agent OK-432, unavailable in North America or Europe.

Dr. Teng presented a retrospective chart review of 336 patients under age 20 years with LMs in Stanford’s large clinical database. Half were female. The LMs were first noted at a mean age of 2.1 years and a median of 2 months. Forty-three percent were macrocystic as defined by septated cystic spaces in excess of 2 cc, while another 35% of patients had a mix of macro- and microcysts.

Disease progression was defined as lesion enlargement at a rate greater than the patient’s growth rate or worsening signs and symptoms. The LM progression rate was 47% in childhood.

The median age at the time of progression was 4.9 years. Consistent with the findings of an earlier study by investigators at Harvard University, Boston, the rate of rapid progression in the Stanford study was greater among 15- to 20-year-olds than in children, probably due to the influence of pubertal hormonal changes. In the retrospective 441-patient Harvard study, the LM progression rate was 40% in childhood, 64% in adolescence, and 95% lifetime (J. Craniofac. Surg. 2012;23:149-52).

Dr. Teng and coworkers found that observation without active treatment was associated with a 2.1-fold increased risk of progression. Also, older age at the time of diagnosis was associated with a higher risk of complications. Indeed, the odds of progression rose by 17% per year of age at diagnosis of LM.

In contrast, factors not associated with progression risk in the Stanford study were gender, lesion location or subtype, or having LMs at multiple sites.

Forty-one children with LMs on the head and neck underwent sclerotherapy at a median age of 1-2 years.

Among 19 patients treated with doxycycline, there were two recurrences. Outcomes were rated as excellent in 53% of cases, meaning two investigators agreed that the two sides of the face looked nearly the same post treatment. Outcomes of doxycycline sclerotherapy were rated good in another 26%. Among 12 ethanolamine-treated patients, outcomes were rated excellent in 42% and good in 25%. One of the 12 patients experienced an LM recurrence, as did 3 of 10 treated with OK-432. No procedural complications occurred in the ethanolamine group. One doxycycline-treated patient experienced a treatment-related hemorrhage.

In a multivariate analysis, doxycycline and ethanolamine didn’t differ in effectiveness. Both performed best in treating macrocystic lesions, where 90% of patients experienced marked LM volume reduction, as did 73% of patients with mixed lesions. The success rate was lowest when treating purely microcystic lesions.

"I’ve talked to lots of interventional radiologists. These cases aren’t all that common, and their choice of sclerosant seems to really depend upon their training and comfort level," Dr. Teng said.

She advised getting a baseline magnetic resonance image (MRI) to confirm the diagnosis of LM and to determine the baseline extent of disease in order to guide future decisions about intervention. In addition, a post-treatment MRI showing LM volume reduction provides objective evidence of therapeutic success.

One audience member, citing the high cost of MRIs, asked if there are less expensive ways to measure the magnitude of treatment response. Dr. Teng replied that imaging is best. She added, however, that the cost of an MRI is reduced by about $800 when sedation isn’t required. And a Stanford study has shown that the use of a child-friendly teaching kit enables most children to undergo an MRI without sedation.

"It’s like a video game they take home and play for a month. When they come back for their MRI more than 80% of kids don’t need sedation anymore. It really cuts down the cost," she said.

Dr. Teng credited University of California, Irvine, medical student Viraat Patel as deserving primary authorship status for this study, conducted under her supervision. The study was supported by the Society for Pediatric Dermatology. Dr. Teng had no financial conflicts.

[email protected]

COEUR D’ALENE, IDAHO – Teledermatology is gathering steam – and supportive data – as a potentially invaluable way to address the overlapping problems of a dermatology workforce shortage, gruelingly long wait times for appointments, limited dermatologic skills on the part of busy primary care physicians, and the anticipated sharply increased demand for dermatologic services as the Affordable Care Act brings many millions of new patients into the ranks of the insured.

But, in the main, it won’t be telemedicine in the familiar form that physicians have come to think of: that is, as remote, face-to-face, real-time video conferencing. The future lies in mobile teledermatology, also known as store and forward, Dr. Carrie L. Kovarik asserted at the annual meeting of the Society for Pediatric Dermatology.

Store-and-forward teledermatology takes advantage of the ubiquity of smart phones and the dazzlingly high quality of their photographic capability. Here’s how it works under AccessDerm, a mobile store-and-forward teledermatology platform developed by the American Academy of Dermatology. Dr. Kovarik, a University of Pennsylvania, Philadelphia, dermatologist and a pioneer of teledermatology in Africa, heads the AAD AccessDerm initiative.

Mobile teledermatology is conducted between a primary care provider and a remote consulting dermatologist. Using the AccessDerm app, the primary care physician submits a case, providing clinical images, and filling out a standardized template to provide mandatory information regarding clinical history.

At present, AccessDerm is connected in 19 states and the District of Columbia. Any AAD member in those locales can serve as a voluntary teledermatology consultant. At the University of Pennsylvania, the dermatology department faculty and residents serve as a pool as the cases come in, picking them up as their workflow permits.

The program operates in 14 Philadelphia health clinics, including all 10 city public health clinics. It has been a hit with patients, many of whom are immigrants who are reluctant to go to the university dermatology clinic and who are far more comfortable in their local clinic, where translators are available. The city council loves the program as well.

In an as-yet unpublished prospective study involving 202 AccessDerm consultations in which the primary care provider was asked in submitting the case to provide their thoughts regarding diagnosis and management, the Penn dermatology consultants overturned the primary care providers’ opinions in the majority of instances. Indeed, the diagnostic concordance rate was just 22%, and the concordance rate regarding management was 23%.

A total of 77% of the cases were managed via teledermatology alone. In the other 23%, an in-person dermatology consultation was recommended; this rate was higher than when primary care providers are taught to do careful skin biopsies and submit them as part of the teledermatology consult.

"Typically, if you teach primary care providers to do biopsies, you need to see patients only 5%-10% of the time as a safety net for those complex cases in a teledermatology program," according to Dr. Kovarik.

The primary care providers stated that, in the absence of teledermatology, 61% of the patients would have not had any access to dermatologic care.

"We’re providing a lot of access where there was no access," Dr. Kovarik observed.

An added benefit of the Philadelphia mobile teledermatology experience is that the primary care clinicians are getting better and better at dermatology.

"They’re asking us harder questions now," she said. "They’re not asking us about eczema anymore."

In another recent study, Dr. Kovarik and her Penn coworkers demonstrated that mobile teledermatology is a reliable and efficient way to triage inpatient dermatology consultations. This is an issue of practical importance to office-based dermatologists. Most of the time, if they get asked to consult on a hospital inpatient, they feel obligated to go to the hospital that day because they can’t tell from the phone conversation how urgent the situation really is.

In this prospective study of 50 adult inpatients for whom a dermatology consultation was requested, all participants were evaluated separately by an in-person dermatologist and two independent teledermatologists. At least 90% of the time, the on-site dermatologist recommended the patient be seen that day, so did the teledermatologists. When the in-person dermatologist recommended a biopsy, 95% of the time the teledermatologists did, too. The teledermatologists were able to triage 60% of the consultations to be seen the next day or later, enabling office-based teledermatologists to bunch some of their inpatient consultations (JAMA Dermatology 2014;150:419-24).

"At Penn, we’re big advocates of teletriage. We’re setting up a system where we have all the consults come to us as teledermatology. We’ll look at the case and say we can help the primary care provider treat that problem, we can triage it to a certain clinic, or the patient could go see the next available dermatologist. But everyone is going to be seen by teledermatology first so we can put [the patients] in the right place to get the care they need. Otherwise, the consults come in with a note saying ‘rash on the right leg’ and who knows how bad it is," Dr. Kovarik said.

Right now only 9 states provide reimbursement for telemedicine services, although another 30 states are considering it. Proposed federal legislation would provide national coverage; Dr. Kovarik sees passage of such a law as an essential major step forward in gaining widespread acceptance of mobile teledermatology.

Asked about billing, she replied that she is aware of one major health insurer interested in providing coverage for teledermatology, in part so they can promote it in consumer advertising as an example of their high-quality care.

"I don’t see teledermatology as part of direct fee for service in the next decade. I see it more as part of a value-based health care plan. I think patients like it, and it adds value. So I think it will be part of the new health care landscape before too long," Dr. Kovarik predicted.

She reported having no financial conflicts of interest.

[email protected]

COEUR D’ALENE, IDAHO – Teledermatology is gathering steam – and supportive data – as a potentially invaluable way to address the overlapping problems of a dermatology workforce shortage, gruelingly long wait times for appointments, limited dermatologic skills on the part of busy primary care physicians, and the anticipated sharply increased demand for dermatologic services as the Affordable Care Act brings many millions of new patients into the ranks of the insured.

But, in the main, it won’t be telemedicine in the familiar form that physicians have come to think of: that is, as remote, face-to-face, real-time video conferencing. The future lies in mobile teledermatology, also known as store and forward, Dr. Carrie L. Kovarik asserted at the annual meeting of the Society for Pediatric Dermatology.

Store-and-forward teledermatology takes advantage of the ubiquity of smart phones and the dazzlingly high quality of their photographic capability. Here’s how it works under AccessDerm, a mobile store-and-forward teledermatology platform developed by the American Academy of Dermatology. Dr. Kovarik, a University of Pennsylvania, Philadelphia, dermatologist and a pioneer of teledermatology in Africa, heads the AAD AccessDerm initiative.

Mobile teledermatology is conducted between a primary care provider and a remote consulting dermatologist. Using the AccessDerm app, the primary care physician submits a case, providing clinical images, and filling out a standardized template to provide mandatory information regarding clinical history.

At present, AccessDerm is connected in 19 states and the District of Columbia. Any AAD member in those locales can serve as a voluntary teledermatology consultant. At the University of Pennsylvania, the dermatology department faculty and residents serve as a pool as the cases come in, picking them up as their workflow permits.

The program operates in 14 Philadelphia health clinics, including all 10 city public health clinics. It has been a hit with patients, many of whom are immigrants who are reluctant to go to the university dermatology clinic and who are far more comfortable in their local clinic, where translators are available. The city council loves the program as well.

In an as-yet unpublished prospective study involving 202 AccessDerm consultations in which the primary care provider was asked in submitting the case to provide their thoughts regarding diagnosis and management, the Penn dermatology consultants overturned the primary care providers’ opinions in the majority of instances. Indeed, the diagnostic concordance rate was just 22%, and the concordance rate regarding management was 23%.

A total of 77% of the cases were managed via teledermatology alone. In the other 23%, an in-person dermatology consultation was recommended; this rate was higher than when primary care providers are taught to do careful skin biopsies and submit them as part of the teledermatology consult.

"Typically, if you teach primary care providers to do biopsies, you need to see patients only 5%-10% of the time as a safety net for those complex cases in a teledermatology program," according to Dr. Kovarik.

The primary care providers stated that, in the absence of teledermatology, 61% of the patients would have not had any access to dermatologic care.

"We’re providing a lot of access where there was no access," Dr. Kovarik observed.

An added benefit of the Philadelphia mobile teledermatology experience is that the primary care clinicians are getting better and better at dermatology.

"They’re asking us harder questions now," she said. "They’re not asking us about eczema anymore."

In another recent study, Dr. Kovarik and her Penn coworkers demonstrated that mobile teledermatology is a reliable and efficient way to triage inpatient dermatology consultations. This is an issue of practical importance to office-based dermatologists. Most of the time, if they get asked to consult on a hospital inpatient, they feel obligated to go to the hospital that day because they can’t tell from the phone conversation how urgent the situation really is.

In this prospective study of 50 adult inpatients for whom a dermatology consultation was requested, all participants were evaluated separately by an in-person dermatologist and two independent teledermatologists. At least 90% of the time, the on-site dermatologist recommended the patient be seen that day, so did the teledermatologists. When the in-person dermatologist recommended a biopsy, 95% of the time the teledermatologists did, too. The teledermatologists were able to triage 60% of the consultations to be seen the next day or later, enabling office-based teledermatologists to bunch some of their inpatient consultations (JAMA Dermatology 2014;150:419-24).

"At Penn, we’re big advocates of teletriage. We’re setting up a system where we have all the consults come to us as teledermatology. We’ll look at the case and say we can help the primary care provider treat that problem, we can triage it to a certain clinic, or the patient could go see the next available dermatologist. But everyone is going to be seen by teledermatology first so we can put [the patients] in the right place to get the care they need. Otherwise, the consults come in with a note saying ‘rash on the right leg’ and who knows how bad it is," Dr. Kovarik said.

Right now only 9 states provide reimbursement for telemedicine services, although another 30 states are considering it. Proposed federal legislation would provide national coverage; Dr. Kovarik sees passage of such a law as an essential major step forward in gaining widespread acceptance of mobile teledermatology.

Asked about billing, she replied that she is aware of one major health insurer interested in providing coverage for teledermatology, in part so they can promote it in consumer advertising as an example of their high-quality care.

"I don’t see teledermatology as part of direct fee for service in the next decade. I see it more as part of a value-based health care plan. I think patients like it, and it adds value. So I think it will be part of the new health care landscape before too long," Dr. Kovarik predicted.

She reported having no financial conflicts of interest.

[email protected]

COEUR D’ALENE, IDAHO – Teledermatology is gathering steam – and supportive data – as a potentially invaluable way to address the overlapping problems of a dermatology workforce shortage, gruelingly long wait times for appointments, limited dermatologic skills on the part of busy primary care physicians, and the anticipated sharply increased demand for dermatologic services as the Affordable Care Act brings many millions of new patients into the ranks of the insured.

But, in the main, it won’t be telemedicine in the familiar form that physicians have come to think of: that is, as remote, face-to-face, real-time video conferencing. The future lies in mobile teledermatology, also known as store and forward, Dr. Carrie L. Kovarik asserted at the annual meeting of the Society for Pediatric Dermatology.

Store-and-forward teledermatology takes advantage of the ubiquity of smart phones and the dazzlingly high quality of their photographic capability. Here’s how it works under AccessDerm, a mobile store-and-forward teledermatology platform developed by the American Academy of Dermatology. Dr. Kovarik, a University of Pennsylvania, Philadelphia, dermatologist and a pioneer of teledermatology in Africa, heads the AAD AccessDerm initiative.

Mobile teledermatology is conducted between a primary care provider and a remote consulting dermatologist. Using the AccessDerm app, the primary care physician submits a case, providing clinical images, and filling out a standardized template to provide mandatory information regarding clinical history.

At present, AccessDerm is connected in 19 states and the District of Columbia. Any AAD member in those locales can serve as a voluntary teledermatology consultant. At the University of Pennsylvania, the dermatology department faculty and residents serve as a pool as the cases come in, picking them up as their workflow permits.

The program operates in 14 Philadelphia health clinics, including all 10 city public health clinics. It has been a hit with patients, many of whom are immigrants who are reluctant to go to the university dermatology clinic and who are far more comfortable in their local clinic, where translators are available. The city council loves the program as well.

In an as-yet unpublished prospective study involving 202 AccessDerm consultations in which the primary care provider was asked in submitting the case to provide their thoughts regarding diagnosis and management, the Penn dermatology consultants overturned the primary care providers’ opinions in the majority of instances. Indeed, the diagnostic concordance rate was just 22%, and the concordance rate regarding management was 23%.

A total of 77% of the cases were managed via teledermatology alone. In the other 23%, an in-person dermatology consultation was recommended; this rate was higher than when primary care providers are taught to do careful skin biopsies and submit them as part of the teledermatology consult.

"Typically, if you teach primary care providers to do biopsies, you need to see patients only 5%-10% of the time as a safety net for those complex cases in a teledermatology program," according to Dr. Kovarik.

The primary care providers stated that, in the absence of teledermatology, 61% of the patients would have not had any access to dermatologic care.

"We’re providing a lot of access where there was no access," Dr. Kovarik observed.

An added benefit of the Philadelphia mobile teledermatology experience is that the primary care clinicians are getting better and better at dermatology.

"They’re asking us harder questions now," she said. "They’re not asking us about eczema anymore."

In another recent study, Dr. Kovarik and her Penn coworkers demonstrated that mobile teledermatology is a reliable and efficient way to triage inpatient dermatology consultations. This is an issue of practical importance to office-based dermatologists. Most of the time, if they get asked to consult on a hospital inpatient, they feel obligated to go to the hospital that day because they can’t tell from the phone conversation how urgent the situation really is.

In this prospective study of 50 adult inpatients for whom a dermatology consultation was requested, all participants were evaluated separately by an in-person dermatologist and two independent teledermatologists. At least 90% of the time, the on-site dermatologist recommended the patient be seen that day, so did the teledermatologists. When the in-person dermatologist recommended a biopsy, 95% of the time the teledermatologists did, too. The teledermatologists were able to triage 60% of the consultations to be seen the next day or later, enabling office-based teledermatologists to bunch some of their inpatient consultations (JAMA Dermatology 2014;150:419-24).

"At Penn, we’re big advocates of teletriage. We’re setting up a system where we have all the consults come to us as teledermatology. We’ll look at the case and say we can help the primary care provider treat that problem, we can triage it to a certain clinic, or the patient could go see the next available dermatologist. But everyone is going to be seen by teledermatology first so we can put [the patients] in the right place to get the care they need. Otherwise, the consults come in with a note saying ‘rash on the right leg’ and who knows how bad it is," Dr. Kovarik said.

Right now only 9 states provide reimbursement for telemedicine services, although another 30 states are considering it. Proposed federal legislation would provide national coverage; Dr. Kovarik sees passage of such a law as an essential major step forward in gaining widespread acceptance of mobile teledermatology.

Asked about billing, she replied that she is aware of one major health insurer interested in providing coverage for teledermatology, in part so they can promote it in consumer advertising as an example of their high-quality care.

"I don’t see teledermatology as part of direct fee for service in the next decade. I see it more as part of a value-based health care plan. I think patients like it, and it adds value. So I think it will be part of the new health care landscape before too long," Dr. Kovarik predicted.

She reported having no financial conflicts of interest.

[email protected]

COEUR D’ALENE, IDAHO – Teledermatology is gathering steam – and supportive data – as a potentially invaluable way to address the overlapping problems of a dermatology workforce shortage, gruelingly long wait times for appointments, limited dermatologic skills on the part of busy primary care physicians, and the anticipated sharply increased demand for dermatologic services as the Affordable Care Act brings many millions of new patients into the ranks of the insured.

But, in the main, it won’t be telemedicine in the familiar form that physicians have come to think of: that is, as remote, face-to-face, real-time video conferencing. The future lies in mobile teledermatology, also known as store and forward, Dr. Carrie L. Kovarik asserted at the annual meeting of the Society for Pediatric Dermatology.

Store-and-forward teledermatology takes advantage of the ubiquity of smart phones and the dazzlingly high quality of their photographic capability. Here’s how it works under AccessDerm, a mobile store-and-forward teledermatology platform developed by the American Academy of Dermatology. Dr. Kovarik, a University of Pennsylvania, Philadelphia, dermatologist and a pioneer of teledermatology in Africa, heads the AAD AccessDerm initiative.

Mobile teledermatology is conducted between a primary care provider and a remote consulting dermatologist. Using the AccessDerm app, the primary care physician submits a case, providing clinical images, and filling out a standardized template to provide mandatory information regarding clinical history.

At present, AccessDerm is connected in 19 states and the District of Columbia. Any AAD member in those locales can serve as a voluntary teledermatology consultant. At the University of Pennsylvania, the dermatology department faculty and residents serve as a pool as the cases come in, picking them up as their workflow permits.

The program operates in 14 Philadelphia health clinics, including all 10 city public health clinics. It has been a hit with patients, many of whom are immigrants who are reluctant to go to the university dermatology clinic and who are far more comfortable in their local clinic, where translators are available. The city council loves the program as well.

In an as-yet unpublished prospective study involving 202 AccessDerm consultations in which the primary care provider was asked in submitting the case to provide their thoughts regarding diagnosis and management, the Penn dermatology consultants overturned the primary care providers’ opinions in the majority of instances. Indeed, the diagnostic concordance rate was just 22%, and the concordance rate regarding management was 23%.

A total of 77% of the cases were managed via teledermatology alone. In the other 23%, an in-person dermatology consultation was recommended; this rate was higher than when primary care providers are taught to do careful skin biopsies and submit them as part of the teledermatology consult.

"Typically, if you teach primary care providers to do biopsies, you need to see patients only 5%-10% of the time as a safety net for those complex cases in a teledermatology program," according to Dr. Kovarik.

The primary care providers stated that, in the absence of teledermatology, 61% of the patients would have not had any access to dermatologic care.

"We’re providing a lot of access where there was no access," Dr. Kovarik observed.

An added benefit of the Philadelphia mobile teledermatology experience is that the primary care clinicians are getting better and better at dermatology.

"They’re asking us harder questions now," she said. "They’re not asking us about eczema anymore."

In another recent study, Dr. Kovarik and her Penn coworkers demonstrated that mobile teledermatology is a reliable and efficient way to triage inpatient dermatology consultations. This is an issue of practical importance to office-based dermatologists. Most of the time, if they get asked to consult on a hospital inpatient, they feel obligated to go to the hospital that day because they can’t tell from the phone conversation how urgent the situation really is.

In this prospective study of 50 adult inpatients for whom a dermatology consultation was requested, all participants were evaluated separately by an in-person dermatologist and two independent teledermatologists. At least 90% of the time, the on-site dermatologist recommended the patient be seen that day, so did the teledermatologists. When the in-person dermatologist recommended a biopsy, 95% of the time the teledermatologists did, too. The teledermatologists were able to triage 60% of the consultations to be seen the next day or later, enabling office-based teledermatologists to bunch some of their inpatient consultations (JAMA Dermatology 2014;150:419-24).

"At Penn, we’re big advocates of teletriage. We’re setting up a system where we have all the consults come to us as teledermatology. We’ll look at the case and say we can help the primary care provider treat that problem, we can triage it to a certain clinic, or the patient could go see the next available dermatologist. But everyone is going to be seen by teledermatology first so we can put [the patients] in the right place to get the care they need. Otherwise, the consults come in with a note saying ‘rash on the right leg’ and who knows how bad it is," Dr. Kovarik said.

Right now only 9 states provide reimbursement for telemedicine services, although another 30 states are considering it. Proposed federal legislation would provide national coverage; Dr. Kovarik sees passage of such a law as an essential major step forward in gaining widespread acceptance of mobile teledermatology.

Asked about billing, she replied that she is aware of one major health insurer interested in providing coverage for teledermatology, in part so they can promote it in consumer advertising as an example of their high-quality care.

"I don’t see teledermatology as part of direct fee for service in the next decade. I see it more as part of a value-based health care plan. I think patients like it, and it adds value. So I think it will be part of the new health care landscape before too long," Dr. Kovarik predicted.

She reported having no financial conflicts of interest.

[email protected]

COEUR D’ALENE, IDAHO – Teledermatology is gathering steam – and supportive data – as a potentially invaluable way to address the overlapping problems of a dermatology workforce shortage, gruelingly long wait times for appointments, limited dermatologic skills on the part of busy primary care physicians, and the anticipated sharply increased demand for dermatologic services as the Affordable Care Act brings many millions of new patients into the ranks of the insured.

But, in the main, it won’t be telemedicine in the familiar form that physicians have come to think of: that is, as remote, face-to-face, real-time video conferencing. The future lies in mobile teledermatology, also known as store and forward, Dr. Carrie L. Kovarik asserted at the annual meeting of the Society for Pediatric Dermatology.

Store-and-forward teledermatology takes advantage of the ubiquity of smart phones and the dazzlingly high quality of their photographic capability. Here’s how it works under AccessDerm, a mobile store-and-forward teledermatology platform developed by the American Academy of Dermatology. Dr. Kovarik, a University of Pennsylvania, Philadelphia, dermatologist and a pioneer of teledermatology in Africa, heads the AAD AccessDerm initiative.

Mobile teledermatology is conducted between a primary care provider and a remote consulting dermatologist. Using the AccessDerm app, the primary care physician submits a case, providing clinical images, and filling out a standardized template to provide mandatory information regarding clinical history.

At present, AccessDerm is connected in 19 states and the District of Columbia. Any AAD member in those locales can serve as a voluntary teledermatology consultant. At the University of Pennsylvania, the dermatology department faculty and residents serve as a pool as the cases come in, picking them up as their workflow permits.

The program operates in 14 Philadelphia health clinics, including all 10 city public health clinics. It has been a hit with patients, many of whom are immigrants who are reluctant to go to the university dermatology clinic and who are far more comfortable in their local clinic, where translators are available. The city council loves the program as well.

In an as-yet unpublished prospective study involving 202 AccessDerm consultations in which the primary care provider was asked in submitting the case to provide their thoughts regarding diagnosis and management, the Penn dermatology consultants overturned the primary care providers’ opinions in the majority of instances. Indeed, the diagnostic concordance rate was just 22%, and the concordance rate regarding management was 23%.

A total of 77% of the cases were managed via teledermatology alone. In the other 23%, an in-person dermatology consultation was recommended; this rate was higher than when primary care providers are taught to do careful skin biopsies and submit them as part of the teledermatology consult.

"Typically, if you teach primary care providers to do biopsies, you need to see patients only 5%-10% of the time as a safety net for those complex cases in a teledermatology program," according to Dr. Kovarik.

The primary care providers stated that, in the absence of teledermatology, 61% of the patients would have not had any access to dermatologic care.

"We’re providing a lot of access where there was no access," Dr. Kovarik observed.

An added benefit of the Philadelphia mobile teledermatology experience is that the primary care clinicians are getting better and better at dermatology.

"They’re asking us harder questions now," she said. "They’re not asking us about eczema anymore."

In another recent study, Dr. Kovarik and her Penn coworkers demonstrated that mobile teledermatology is a reliable and efficient way to triage inpatient dermatology consultations. This is an issue of practical importance to office-based dermatologists. Most of the time, if they get asked to consult on a hospital inpatient, they feel obligated to go to the hospital that day because they can’t tell from the phone conversation how urgent the situation really is.

In this prospective study of 50 adult inpatients for whom a dermatology consultation was requested, all participants were evaluated separately by an in-person dermatologist and two independent teledermatologists. At least 90% of the time, the on-site dermatologist recommended the patient be seen that day, so did the teledermatologists. When the in-person dermatologist recommended a biopsy, 95% of the time the teledermatologists did, too. The teledermatologists were able to triage 60% of the consultations to be seen the next day or later, enabling office-based teledermatologists to bunch some of their inpatient consultations (JAMA Dermatology 2014;150:419-24).

"At Penn, we’re big advocates of teletriage. We’re setting up a system where we have all the consults come to us as teledermatology. We’ll look at the case and say we can help the primary care provider treat that problem, we can triage it to a certain clinic, or the patient could go see the next available dermatologist. But everyone is going to be seen by teledermatology first so we can put [the patients] in the right place to get the care they need. Otherwise, the consults come in with a note saying ‘rash on the right leg’ and who knows how bad it is," Dr. Kovarik said.

Right now only 9 states provide reimbursement for telemedicine services, although another 30 states are considering it. Proposed federal legislation would provide national coverage; Dr. Kovarik sees passage of such a law as an essential major step forward in gaining widespread acceptance of mobile teledermatology.

Asked about billing, she replied that she is aware of one major health insurer interested in providing coverage for teledermatology, in part so they can promote it in consumer advertising as an example of their high-quality care.

"I don’t see teledermatology as part of direct fee for service in the next decade. I see it more as part of a value-based health care plan. I think patients like it, and it adds value. So I think it will be part of the new health care landscape before too long," Dr. Kovarik predicted.

She reported having no financial conflicts of interest.

[email protected]

COEUR D’ALENE, IDAHO – Teledermatology is gathering steam – and supportive data – as a potentially invaluable way to address the overlapping problems of a dermatology workforce shortage, gruelingly long wait times for appointments, limited dermatologic skills on the part of busy primary care physicians, and the anticipated sharply increased demand for dermatologic services as the Affordable Care Act brings many millions of new patients into the ranks of the insured.

But, in the main, it won’t be telemedicine in the familiar form that physicians have come to think of: that is, as remote, face-to-face, real-time video conferencing. The future lies in mobile teledermatology, also known as store and forward, Dr. Carrie L. Kovarik asserted at the annual meeting of the Society for Pediatric Dermatology.

Store-and-forward teledermatology takes advantage of the ubiquity of smart phones and the dazzlingly high quality of their photographic capability. Here’s how it works under AccessDerm, a mobile store-and-forward teledermatology platform developed by the American Academy of Dermatology. Dr. Kovarik, a University of Pennsylvania, Philadelphia, dermatologist and a pioneer of teledermatology in Africa, heads the AAD AccessDerm initiative.

Mobile teledermatology is conducted between a primary care provider and a remote consulting dermatologist. Using the AccessDerm app, the primary care physician submits a case, providing clinical images, and filling out a standardized template to provide mandatory information regarding clinical history.

At present, AccessDerm is connected in 19 states and the District of Columbia. Any AAD member in those locales can serve as a voluntary teledermatology consultant. At the University of Pennsylvania, the dermatology department faculty and residents serve as a pool as the cases come in, picking them up as their workflow permits.

The program operates in 14 Philadelphia health clinics, including all 10 city public health clinics. It has been a hit with patients, many of whom are immigrants who are reluctant to go to the university dermatology clinic and who are far more comfortable in their local clinic, where translators are available. The city council loves the program as well.

In an as-yet unpublished prospective study involving 202 AccessDerm consultations in which the primary care provider was asked in submitting the case to provide their thoughts regarding diagnosis and management, the Penn dermatology consultants overturned the primary care providers’ opinions in the majority of instances. Indeed, the diagnostic concordance rate was just 22%, and the concordance rate regarding management was 23%.

A total of 77% of the cases were managed via teledermatology alone. In the other 23%, an in-person dermatology consultation was recommended; this rate was higher than when primary care providers are taught to do careful skin biopsies and submit them as part of the teledermatology consult.

"Typically, if you teach primary care providers to do biopsies, you need to see patients only 5%-10% of the time as a safety net for those complex cases in a teledermatology program," according to Dr. Kovarik.

The primary care providers stated that, in the absence of teledermatology, 61% of the patients would have not had any access to dermatologic care.

"We’re providing a lot of access where there was no access," Dr. Kovarik observed.

An added benefit of the Philadelphia mobile teledermatology experience is that the primary care clinicians are getting better and better at dermatology.

"They’re asking us harder questions now," she said. "They’re not asking us about eczema anymore."

In another recent study, Dr. Kovarik and her Penn coworkers demonstrated that mobile teledermatology is a reliable and efficient way to triage inpatient dermatology consultations. This is an issue of practical importance to office-based dermatologists. Most of the time, if they get asked to consult on a hospital inpatient, they feel obligated to go to the hospital that day because they can’t tell from the phone conversation how urgent the situation really is.

In this prospective study of 50 adult inpatients for whom a dermatology consultation was requested, all participants were evaluated separately by an in-person dermatologist and two independent teledermatologists. At least 90% of the time, the on-site dermatologist recommended the patient be seen that day, so did the teledermatologists. When the in-person dermatologist recommended a biopsy, 95% of the time the teledermatologists did, too. The teledermatologists were able to triage 60% of the consultations to be seen the next day or later, enabling office-based teledermatologists to bunch some of their inpatient consultations (JAMA Dermatology 2014;150:419-24).

"At Penn, we’re big advocates of teletriage. We’re setting up a system where we have all the consults come to us as teledermatology. We’ll look at the case and say we can help the primary care provider treat that problem, we can triage it to a certain clinic, or the patient could go see the next available dermatologist. But everyone is going to be seen by teledermatology first so we can put [the patients] in the right place to get the care they need. Otherwise, the consults come in with a note saying ‘rash on the right leg’ and who knows how bad it is," Dr. Kovarik said.

Right now only 9 states provide reimbursement for telemedicine services, although another 30 states are considering it. Proposed federal legislation would provide national coverage; Dr. Kovarik sees passage of such a law as an essential major step forward in gaining widespread acceptance of mobile teledermatology.

Asked about billing, she replied that she is aware of one major health insurer interested in providing coverage for teledermatology, in part so they can promote it in consumer advertising as an example of their high-quality care.

"I don’t see teledermatology as part of direct fee for service in the next decade. I see it more as part of a value-based health care plan. I think patients like it, and it adds value. So I think it will be part of the new health care landscape before too long," Dr. Kovarik predicted.

She reported having no financial conflicts of interest.

[email protected]

COEUR D’ALENE, IDAHO – The psoriasiform eruptions that occur in a subgroup of patients with Kawasaki disease during the acute or subacute phase may be a red flag for more severe coronary artery involvement, according to a retrospective, case-control study.

Another striking feature of these psoriasiform lesions is that they go into remission. No recurrences were seen in the study population during up to 13 years of follow-up, in marked contrast to classic psoriasis, a chronic disease, Dr. Wynnis L. Tom observed at the annual meeting of the Society for Pediatric Dermatology.

She presented what she believes to be the first study to formally compare the psoriasiform lesions arising in a minority of Kawasaki disease (KD) patients with the lesions of classic psoriasis. The study population consisted of 11 KD patients with psoriasiform eruptions whose median age was 1.9 years, 22 matched controls with KD and no psoriasiform lesions, and another 22 matched controls with psoriasis but not KD.

Kawasaki disease patients who developed psoriasiform eruptions had significantly more dilated coronary arteries than did those who did not, as reflected in their median maximal echocardiographic z-score of 2.7, compared with 1.8 in controls. A z-score greater than 2.5 is deemed to indicate clinically significant coronary artery dilation, noted Dr. Tom, a pediatric dermatologist at Rady Children’s Hospital and the University of California, San Diego.

The psoriasiform eruptions resolved within 13 months in all 11 affected KD patients, with no recurrences. In contrast, only 5 of 22 controls with classic psoriasis experienced remission during follow-up of up to 6 years.

The cutaneous distribution of the psoriasiform lesions in patients with KD was also distinctive. The eruptions were significantly less common in the head, neck, and diaper area than is the case in classic psoriasis. In addition, patients with KD and psoriasiform eruptions were significantly less likely to be overweight or obese than were controls with classic psoriasis.

Skin biopsies read by a blinded dermatopathologist showed that the psoriasiform lesions that arose during KD demonstrated suprabasilar staining of keratin 16 and increased expression of Ki-67 antigen. They differed from classic psoriasis lesions in that they displayed more crusting, serum, and an increased prevalence of bacteria at the epidermis.

There was no significant difference between KD patients with and without psoriasiform eruptions in terms of maximum levels of C-reactive protein, erythrocyte sedimentation rate, and other inflammatory markers. However, patients with psoriasiform lesions required significantly more time for their gamma-glutamyl transferase level and platelet count to return to normal.

One possible explanation for the distinct phenotype of these psoriasiform eruptions is that KD brings forth the skin lesions in patients who are predisposed to psoriasis, but without causing typical chronic psoriasis because the underlying KD is self-limited. But further study with larger numbers of patients is required for clarification, according to Dr. Tom.

Her work is supported by a career development award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. She reported having no financial conflicts regarding this study.

[email protected]

COEUR D’ALENE, IDAHO – The psoriasiform eruptions that occur in a subgroup of patients with Kawasaki disease during the acute or subacute phase may be a red flag for more severe coronary artery involvement, according to a retrospective, case-control study.

Another striking feature of these psoriasiform lesions is that they go into remission. No recurrences were seen in the study population during up to 13 years of follow-up, in marked contrast to classic psoriasis, a chronic disease, Dr. Wynnis L. Tom observed at the annual meeting of the Society for Pediatric Dermatology.

She presented what she believes to be the first study to formally compare the psoriasiform lesions arising in a minority of Kawasaki disease (KD) patients with the lesions of classic psoriasis. The study population consisted of 11 KD patients with psoriasiform eruptions whose median age was 1.9 years, 22 matched controls with KD and no psoriasiform lesions, and another 22 matched controls with psoriasis but not KD.

Kawasaki disease patients who developed psoriasiform eruptions had significantly more dilated coronary arteries than did those who did not, as reflected in their median maximal echocardiographic z-score of 2.7, compared with 1.8 in controls. A z-score greater than 2.5 is deemed to indicate clinically significant coronary artery dilation, noted Dr. Tom, a pediatric dermatologist at Rady Children’s Hospital and the University of California, San Diego.

The psoriasiform eruptions resolved within 13 months in all 11 affected KD patients, with no recurrences. In contrast, only 5 of 22 controls with classic psoriasis experienced remission during follow-up of up to 6 years.

The cutaneous distribution of the psoriasiform lesions in patients with KD was also distinctive. The eruptions were significantly less common in the head, neck, and diaper area than is the case in classic psoriasis. In addition, patients with KD and psoriasiform eruptions were significantly less likely to be overweight or obese than were controls with classic psoriasis.

Skin biopsies read by a blinded dermatopathologist showed that the psoriasiform lesions that arose during KD demonstrated suprabasilar staining of keratin 16 and increased expression of Ki-67 antigen. They differed from classic psoriasis lesions in that they displayed more crusting, serum, and an increased prevalence of bacteria at the epidermis.

There was no significant difference between KD patients with and without psoriasiform eruptions in terms of maximum levels of C-reactive protein, erythrocyte sedimentation rate, and other inflammatory markers. However, patients with psoriasiform lesions required significantly more time for their gamma-glutamyl transferase level and platelet count to return to normal.

One possible explanation for the distinct phenotype of these psoriasiform eruptions is that KD brings forth the skin lesions in patients who are predisposed to psoriasis, but without causing typical chronic psoriasis because the underlying KD is self-limited. But further study with larger numbers of patients is required for clarification, according to Dr. Tom.

Her work is supported by a career development award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. She reported having no financial conflicts regarding this study.

[email protected]

COEUR D’ALENE, IDAHO – The psoriasiform eruptions that occur in a subgroup of patients with Kawasaki disease during the acute or subacute phase may be a red flag for more severe coronary artery involvement, according to a retrospective, case-control study.

Another striking feature of these psoriasiform lesions is that they go into remission. No recurrences were seen in the study population during up to 13 years of follow-up, in marked contrast to classic psoriasis, a chronic disease, Dr. Wynnis L. Tom observed at the annual meeting of the Society for Pediatric Dermatology.

She presented what she believes to be the first study to formally compare the psoriasiform lesions arising in a minority of Kawasaki disease (KD) patients with the lesions of classic psoriasis. The study population consisted of 11 KD patients with psoriasiform eruptions whose median age was 1.9 years, 22 matched controls with KD and no psoriasiform lesions, and another 22 matched controls with psoriasis but not KD.

Kawasaki disease patients who developed psoriasiform eruptions had significantly more dilated coronary arteries than did those who did not, as reflected in their median maximal echocardiographic z-score of 2.7, compared with 1.8 in controls. A z-score greater than 2.5 is deemed to indicate clinically significant coronary artery dilation, noted Dr. Tom, a pediatric dermatologist at Rady Children’s Hospital and the University of California, San Diego.

The psoriasiform eruptions resolved within 13 months in all 11 affected KD patients, with no recurrences. In contrast, only 5 of 22 controls with classic psoriasis experienced remission during follow-up of up to 6 years.

The cutaneous distribution of the psoriasiform lesions in patients with KD was also distinctive. The eruptions were significantly less common in the head, neck, and diaper area than is the case in classic psoriasis. In addition, patients with KD and psoriasiform eruptions were significantly less likely to be overweight or obese than were controls with classic psoriasis.

Skin biopsies read by a blinded dermatopathologist showed that the psoriasiform lesions that arose during KD demonstrated suprabasilar staining of keratin 16 and increased expression of Ki-67 antigen. They differed from classic psoriasis lesions in that they displayed more crusting, serum, and an increased prevalence of bacteria at the epidermis.

There was no significant difference between KD patients with and without psoriasiform eruptions in terms of maximum levels of C-reactive protein, erythrocyte sedimentation rate, and other inflammatory markers. However, patients with psoriasiform lesions required significantly more time for their gamma-glutamyl transferase level and platelet count to return to normal.

One possible explanation for the distinct phenotype of these psoriasiform eruptions is that KD brings forth the skin lesions in patients who are predisposed to psoriasis, but without causing typical chronic psoriasis because the underlying KD is self-limited. But further study with larger numbers of patients is required for clarification, according to Dr. Tom.

Her work is supported by a career development award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. She reported having no financial conflicts regarding this study.

[email protected]

COEUR D’ALENE, IDAHO – The most important test in determining the cause of diffuse hair loss in children and adolescents is a gentle hair pull, Dr. Elise A. Olsen said at the annual meeting of the Society for Pediatric Dermatology.

"This is something you should do in all patients with alopecia, accompanied by looking under the microscope at the hair you’ve pulled. Grasp a small clump of hair close to the scalp and gently pull through to the ends. It’s important that you do it not just in one area but all over, in various places on the scalp. Coming away with three or four hairs per pull is abnormal. Be especially gentle in young children because you can actually induce what looks like a loose anagen syndrome, confusing the picture," explained Dr. Olsen, professor of dermatology and medicine and director of the hair disorders research and treatment center at Duke University in Durham, N.C.

She described how to use the hair pull and other tools to differentiate between telogen effluvium, alopecia areata, androgenetic alopecia, loose anagen syndrome, and short anagen syndrome.

Telogen effluvium: This condition is characterized by a global decrease in hair density. This global reduction can be confirmed by performing a midline part on the back and top of the scalp, which should show a similarly widened, thinned part.

Microscopic examination of the proximal end of all hairs that come off with hair pulls in an adolescent with telogen effluvium should show them to be telogen hairs.

"If you see any anagen hairs, that’s abnormal, and I would urge you to think about another condition, like loose anagen syndrome or alopecia areata," Dr. Olsen said.

Potential etiologies of telogen effluvium include stress, thyroid disease, medication side effects, vitamin A intake in excess of 15,000 IU/day, and numerous diet or nutritional deficits.

"Diet is incredibly important in figuring out the cause of telogen effluvium, particularly in children and adolescents, where you might be dealing with bulimia, anorexia nervosa, or another abnormal diet," according to the dermatologist.

The relationship between hair loss and iron deficiency is a matter of long-standing controversy. Low iron levels have often been linked to hair loss. As yet, however, there is no well-controlled clinical trial showing that iron replacement improves telogen effluvium in an iron-deficient patient.

Isotretinoin tops the list of medications that can cause telogen effluvium in pediatric patients. Other drugs that need to be considered include sodium valproate, antidepressants, lithium, and medications for attention-deficit/hyperactivity disorder.

Vitamin supplements should be stopped for at least 24 hours before conducting screening laboratory testing in a patient with telogen effluvium. Dr. Olsen recommended ordering a CBC with differential; thyroid-stimulating hormone and free thyroxine; serum ferritin; total iron binding capacity; and an erythrocyte sedimentation rate to screen for occult inflammatory conditions, which would skew the ferritin results. While a serum ferritin less than 40 ng/mL ordinarily has 98% sensitivity and specificity for iron deficiency, the bar rises to less than 70 ng/mL in patients with any kind of underlying systemic inflammation.

Alopecia areata: This form of diffuse hair loss can look clinically just like telogen effluvium. The key distinguishing feature is a positive hair pull showing not only telogen hairs but dystrophic, "exclamation point" anagen hairs as well.

"These anagen hairs are broken off or bayonet-like in appearance, and there’s usually a distortion of the hair shaft diameter as well," she explained.

Scalp dermoscopy will show yellow dots of keratinaceous debris in the empty follicles of patients with alopecia areata, an uncommon condition in children.

Androgenetic alopecia: The most useful clue in differentiating this condition from telogen effluvium is that a midline part will be widened on the central scalp but never over the occiput. The gentle hair pull typically doesn’t yield any hairs except in affected areas on the top portion of the scalp. Any hairs produced via the hair pull will be telogen hairs, and they will typically vary in diameter. Dermoscopy may show perifollicular pigmentation in areas of hair loss.

"If you diagnose alopecia areata in an adolescent, there are some key things you need to discuss with the parents," Dr. Olsen stressed.

For example, their child is likely to have a more rapidly progressive course of hair loss. And affected girls are at increased risk for underlying hyperandrogenemia-related symptoms, including hirsutism, insulin resistance, polycystic ovarian syndrome, and metabolic syndrome. A finding of acanthosis nigricans in a nonobese teen is a very good indicator that they may have underlying insulin resistance.

Loose anagen syndrome: This condition, whose onset is usually before 8 years of age, is characterized by short, very slow-growing hair. The hair pull yields anagen hairs, which under the microscope have a distinctive appearance marked by a rolled-up proximal tip.

Short anagen syndrome: The hallmarks here are decreased hair density, increased shedding, and an inability to grow hair long. On the hair pull, affected patients have an increased number of telogen hairs. The telogen hairs, which are newly regrowing in response to the truncated anagen cycle, will have a tapered tip at the distal end.

Scalp biopsy is of variable utility in diagnosing the cause of diffuse hair loss in young patients. It can be used to make the diagnosis of certain conditions, including acute alopecia areata, trichotillomania, connective tissue disease, infection, tumor, and scarring disorders. However, scalp biopsy can’t be used to make a definitive diagnosis of telogen effluvium, androgenetic alopecia, or long-standing alopecia areata – it can only be suggestive.

Pathologic standards dictate that the scalp biopsy should always be 4 mm. Normal white adults have roughly 36 follicles per 4-mm biopsy. African American adults have about 22. While no standard numbers have been established for children, the number of follicles per biopsy is higher than in adults because of the child’s smaller head size. After all, the number of follicles present at birth is what an individual will carry throughout life, Dr. Olsen explained.

It’s important that patients and parents understand the need for patience regarding hair regrowth, which takes 6-12 months after the cause of alopecia has been identified and eliminated. That means, for example, that in a patient with thyroid disease the clock for regrowth starts ticking not at the time treatment begins, but when the patient becomes euthyroid.

Dr. Olsen reported serving as a consultant to Canfield Scientific and Allergan.

[email protected]

COEUR D’ALENE, IDAHO – The most important test in determining the cause of diffuse hair loss in children and adolescents is a gentle hair pull, Dr. Elise A. Olsen said at the annual meeting of the Society for Pediatric Dermatology.

"This is something you should do in all patients with alopecia, accompanied by looking under the microscope at the hair you’ve pulled. Grasp a small clump of hair close to the scalp and gently pull through to the ends. It’s important that you do it not just in one area but all over, in various places on the scalp. Coming away with three or four hairs per pull is abnormal. Be especially gentle in young children because you can actually induce what looks like a loose anagen syndrome, confusing the picture," explained Dr. Olsen, professor of dermatology and medicine and director of the hair disorders research and treatment center at Duke University in Durham, N.C.

She described how to use the hair pull and other tools to differentiate between telogen effluvium, alopecia areata, androgenetic alopecia, loose anagen syndrome, and short anagen syndrome.

Telogen effluvium: This condition is characterized by a global decrease in hair density. This global reduction can be confirmed by performing a midline part on the back and top of the scalp, which should show a similarly widened, thinned part.

Microscopic examination of the proximal end of all hairs that come off with hair pulls in an adolescent with telogen effluvium should show them to be telogen hairs.

"If you see any anagen hairs, that’s abnormal, and I would urge you to think about another condition, like loose anagen syndrome or alopecia areata," Dr. Olsen said.

Potential etiologies of telogen effluvium include stress, thyroid disease, medication side effects, vitamin A intake in excess of 15,000 IU/day, and numerous diet or nutritional deficits.

"Diet is incredibly important in figuring out the cause of telogen effluvium, particularly in children and adolescents, where you might be dealing with bulimia, anorexia nervosa, or another abnormal diet," according to the dermatologist.

The relationship between hair loss and iron deficiency is a matter of long-standing controversy. Low iron levels have often been linked to hair loss. As yet, however, there is no well-controlled clinical trial showing that iron replacement improves telogen effluvium in an iron-deficient patient.

Isotretinoin tops the list of medications that can cause telogen effluvium in pediatric patients. Other drugs that need to be considered include sodium valproate, antidepressants, lithium, and medications for attention-deficit/hyperactivity disorder.

Vitamin supplements should be stopped for at least 24 hours before conducting screening laboratory testing in a patient with telogen effluvium. Dr. Olsen recommended ordering a CBC with differential; thyroid-stimulating hormone and free thyroxine; serum ferritin; total iron binding capacity; and an erythrocyte sedimentation rate to screen for occult inflammatory conditions, which would skew the ferritin results. While a serum ferritin less than 40 ng/mL ordinarily has 98% sensitivity and specificity for iron deficiency, the bar rises to less than 70 ng/mL in patients with any kind of underlying systemic inflammation.

Alopecia areata: This form of diffuse hair loss can look clinically just like telogen effluvium. The key distinguishing feature is a positive hair pull showing not only telogen hairs but dystrophic, "exclamation point" anagen hairs as well.

"These anagen hairs are broken off or bayonet-like in appearance, and there’s usually a distortion of the hair shaft diameter as well," she explained.

Scalp dermoscopy will show yellow dots of keratinaceous debris in the empty follicles of patients with alopecia areata, an uncommon condition in children.

Androgenetic alopecia: The most useful clue in differentiating this condition from telogen effluvium is that a midline part will be widened on the central scalp but never over the occiput. The gentle hair pull typically doesn’t yield any hairs except in affected areas on the top portion of the scalp. Any hairs produced via the hair pull will be telogen hairs, and they will typically vary in diameter. Dermoscopy may show perifollicular pigmentation in areas of hair loss.

"If you diagnose alopecia areata in an adolescent, there are some key things you need to discuss with the parents," Dr. Olsen stressed.

For example, their child is likely to have a more rapidly progressive course of hair loss. And affected girls are at increased risk for underlying hyperandrogenemia-related symptoms, including hirsutism, insulin resistance, polycystic ovarian syndrome, and metabolic syndrome. A finding of acanthosis nigricans in a nonobese teen is a very good indicator that they may have underlying insulin resistance.

Loose anagen syndrome: This condition, whose onset is usually before 8 years of age, is characterized by short, very slow-growing hair. The hair pull yields anagen hairs, which under the microscope have a distinctive appearance marked by a rolled-up proximal tip.

Short anagen syndrome: The hallmarks here are decreased hair density, increased shedding, and an inability to grow hair long. On the hair pull, affected patients have an increased number of telogen hairs. The telogen hairs, which are newly regrowing in response to the truncated anagen cycle, will have a tapered tip at the distal end.

Scalp biopsy is of variable utility in diagnosing the cause of diffuse hair loss in young patients. It can be used to make the diagnosis of certain conditions, including acute alopecia areata, trichotillomania, connective tissue disease, infection, tumor, and scarring disorders. However, scalp biopsy can’t be used to make a definitive diagnosis of telogen effluvium, androgenetic alopecia, or long-standing alopecia areata – it can only be suggestive.

Pathologic standards dictate that the scalp biopsy should always be 4 mm. Normal white adults have roughly 36 follicles per 4-mm biopsy. African American adults have about 22. While no standard numbers have been established for children, the number of follicles per biopsy is higher than in adults because of the child’s smaller head size. After all, the number of follicles present at birth is what an individual will carry throughout life, Dr. Olsen explained.

It’s important that patients and parents understand the need for patience regarding hair regrowth, which takes 6-12 months after the cause of alopecia has been identified and eliminated. That means, for example, that in a patient with thyroid disease the clock for regrowth starts ticking not at the time treatment begins, but when the patient becomes euthyroid.

Dr. Olsen reported serving as a consultant to Canfield Scientific and Allergan.

[email protected]

COEUR D’ALENE, IDAHO – The most important test in determining the cause of diffuse hair loss in children and adolescents is a gentle hair pull, Dr. Elise A. Olsen said at the annual meeting of the Society for Pediatric Dermatology.

"This is something you should do in all patients with alopecia, accompanied by looking under the microscope at the hair you’ve pulled. Grasp a small clump of hair close to the scalp and gently pull through to the ends. It’s important that you do it not just in one area but all over, in various places on the scalp. Coming away with three or four hairs per pull is abnormal. Be especially gentle in young children because you can actually induce what looks like a loose anagen syndrome, confusing the picture," explained Dr. Olsen, professor of dermatology and medicine and director of the hair disorders research and treatment center at Duke University in Durham, N.C.

She described how to use the hair pull and other tools to differentiate between telogen effluvium, alopecia areata, androgenetic alopecia, loose anagen syndrome, and short anagen syndrome.

Telogen effluvium: This condition is characterized by a global decrease in hair density. This global reduction can be confirmed by performing a midline part on the back and top of the scalp, which should show a similarly widened, thinned part.

Microscopic examination of the proximal end of all hairs that come off with hair pulls in an adolescent with telogen effluvium should show them to be telogen hairs.

"If you see any anagen hairs, that’s abnormal, and I would urge you to think about another condition, like loose anagen syndrome or alopecia areata," Dr. Olsen said.

Potential etiologies of telogen effluvium include stress, thyroid disease, medication side effects, vitamin A intake in excess of 15,000 IU/day, and numerous diet or nutritional deficits.

"Diet is incredibly important in figuring out the cause of telogen effluvium, particularly in children and adolescents, where you might be dealing with bulimia, anorexia nervosa, or another abnormal diet," according to the dermatologist.

The relationship between hair loss and iron deficiency is a matter of long-standing controversy. Low iron levels have often been linked to hair loss. As yet, however, there is no well-controlled clinical trial showing that iron replacement improves telogen effluvium in an iron-deficient patient.

Isotretinoin tops the list of medications that can cause telogen effluvium in pediatric patients. Other drugs that need to be considered include sodium valproate, antidepressants, lithium, and medications for attention-deficit/hyperactivity disorder.

Vitamin supplements should be stopped for at least 24 hours before conducting screening laboratory testing in a patient with telogen effluvium. Dr. Olsen recommended ordering a CBC with differential; thyroid-stimulating hormone and free thyroxine; serum ferritin; total iron binding capacity; and an erythrocyte sedimentation rate to screen for occult inflammatory conditions, which would skew the ferritin results. While a serum ferritin less than 40 ng/mL ordinarily has 98% sensitivity and specificity for iron deficiency, the bar rises to less than 70 ng/mL in patients with any kind of underlying systemic inflammation.

Alopecia areata: This form of diffuse hair loss can look clinically just like telogen effluvium. The key distinguishing feature is a positive hair pull showing not only telogen hairs but dystrophic, "exclamation point" anagen hairs as well.

"These anagen hairs are broken off or bayonet-like in appearance, and there’s usually a distortion of the hair shaft diameter as well," she explained.

Scalp dermoscopy will show yellow dots of keratinaceous debris in the empty follicles of patients with alopecia areata, an uncommon condition in children.

Androgenetic alopecia: The most useful clue in differentiating this condition from telogen effluvium is that a midline part will be widened on the central scalp but never over the occiput. The gentle hair pull typically doesn’t yield any hairs except in affected areas on the top portion of the scalp. Any hairs produced via the hair pull will be telogen hairs, and they will typically vary in diameter. Dermoscopy may show perifollicular pigmentation in areas of hair loss.

"If you diagnose alopecia areata in an adolescent, there are some key things you need to discuss with the parents," Dr. Olsen stressed.

For example, their child is likely to have a more rapidly progressive course of hair loss. And affected girls are at increased risk for underlying hyperandrogenemia-related symptoms, including hirsutism, insulin resistance, polycystic ovarian syndrome, and metabolic syndrome. A finding of acanthosis nigricans in a nonobese teen is a very good indicator that they may have underlying insulin resistance.

Loose anagen syndrome: This condition, whose onset is usually before 8 years of age, is characterized by short, very slow-growing hair. The hair pull yields anagen hairs, which under the microscope have a distinctive appearance marked by a rolled-up proximal tip.

Short anagen syndrome: The hallmarks here are decreased hair density, increased shedding, and an inability to grow hair long. On the hair pull, affected patients have an increased number of telogen hairs. The telogen hairs, which are newly regrowing in response to the truncated anagen cycle, will have a tapered tip at the distal end.

Scalp biopsy is of variable utility in diagnosing the cause of diffuse hair loss in young patients. It can be used to make the diagnosis of certain conditions, including acute alopecia areata, trichotillomania, connective tissue disease, infection, tumor, and scarring disorders. However, scalp biopsy can’t be used to make a definitive diagnosis of telogen effluvium, androgenetic alopecia, or long-standing alopecia areata – it can only be suggestive.

Pathologic standards dictate that the scalp biopsy should always be 4 mm. Normal white adults have roughly 36 follicles per 4-mm biopsy. African American adults have about 22. While no standard numbers have been established for children, the number of follicles per biopsy is higher than in adults because of the child’s smaller head size. After all, the number of follicles present at birth is what an individual will carry throughout life, Dr. Olsen explained.

It’s important that patients and parents understand the need for patience regarding hair regrowth, which takes 6-12 months after the cause of alopecia has been identified and eliminated. That means, for example, that in a patient with thyroid disease the clock for regrowth starts ticking not at the time treatment begins, but when the patient becomes euthyroid.

Dr. Olsen reported serving as a consultant to Canfield Scientific and Allergan.

[email protected]

COEUR D’ALENE, ID. – A new study puts a price on the financial and emotional costs of childhood atopic dermatitis – and concludes both are much steeper than generally recognized.

Moreover, among low-income families, a significant correlation was documented between the monthly financial cost of atopic dermatitis care and the emotional burden imposed by the disease as reflected in higher CADIS (Childhood Atopic Dermatitis Impact Scale) scores, Ms. Michelle G. Filanovsky reported at the annual meeting of the Society for Pediatric Dermatology.

© -aniaostudio- / ThinkStock

"Our study is the first to correlate financial burden with emotional impact of atopic dermatitis for patients of lower socioeconomic status. This has great implications for how practitioners can help lessen the burden of the disease: Perhaps by helping families lower the cost of disease, we can help lower the emotional burden," observed Ms. Filanovsky, a medical student at Case Western Reserve University, Cleveland.

She and her coinvestigators surveyed parents or other caretakers of 79 children aged 6 months to 12 years with moderate to severe atopic dermatitis who presented to Cleveland dermatology clinics, typically because of a disease flare. Forty-five of the children were covered by Medicaid.

Subjects were queried regarding their total direct and indirect costs for atopic dermatitis care during the past 4 weeks. Direct costs include physician office and emergency department visits, prescription medications, complementary and alternative medicine, and – most importantly – over-the-counter (OTC) products, which are used extensively in atopic dermatitis care. Indirect costs included time missed from work or school and additional child-care expenses.

The disease’s emotional impact was assessed by CADIS on a 1-10 scale. CADIS addresses issues including caregiver sleep disruption and other caregiver concerns, as well as any difficulties the child is experiencing with sleep, school, socialization and conduct, self-esteem, and activity limitations.

The mean personal cost of atopic dermatitis in the month prior to the office visit was $273.78, representing on average more than one-third of a family’s available monthly money, Ms. Filanovsky said. The breakdown was $75.12 in direct costs and $198.66 for indirect costs. Families with commercial health care insurance averaged $130.58 in direct and $436.16 in indirect costs, with much lower costs in the Medicaid group.

OTC products made up the largest portion of direct costs. An average of $15.28 was spent on moisturizers, $9.42 on OTC topical steroids, $8.46 on bath products, and $4.66 on antihistamines. Time missed from work accounted for the bulk of the indirect costs.

Medicaid patients showed a significant linear correlation between CADIS scores and both total monthly costs of atopic dermatitis care and monthly costs adjusted by family size and income. However, commercially insured families did not.

Ms. Filanovsky proposed several measures as worthy of further study to help reduce the financial and emotional burden of atopic dermatitis, including insurance coverage of moisturizers, physician guidance regarding the most cost-effective OTC products, and implementation of afterwork office hours or nurse on-call visits during flares to minimize the indirect cost of care.

Survey respondents received $25 for their participation, with the funds provided by Nestle. Ms. Filanovsky reported no financial conflicts regarding this study.

[email protected]

COEUR D’ALENE, ID. – A new study puts a price on the financial and emotional costs of childhood atopic dermatitis – and concludes both are much steeper than generally recognized.

Moreover, among low-income families, a significant correlation was documented between the monthly financial cost of atopic dermatitis care and the emotional burden imposed by the disease as reflected in higher CADIS (Childhood Atopic Dermatitis Impact Scale) scores, Ms. Michelle G. Filanovsky reported at the annual meeting of the Society for Pediatric Dermatology.

© -aniaostudio- / ThinkStock

"Our study is the first to correlate financial burden with emotional impact of atopic dermatitis for patients of lower socioeconomic status. This has great implications for how practitioners can help lessen the burden of the disease: Perhaps by helping families lower the cost of disease, we can help lower the emotional burden," observed Ms. Filanovsky, a medical student at Case Western Reserve University, Cleveland.

She and her coinvestigators surveyed parents or other caretakers of 79 children aged 6 months to 12 years with moderate to severe atopic dermatitis who presented to Cleveland dermatology clinics, typically because of a disease flare. Forty-five of the children were covered by Medicaid.

Subjects were queried regarding their total direct and indirect costs for atopic dermatitis care during the past 4 weeks. Direct costs include physician office and emergency department visits, prescription medications, complementary and alternative medicine, and – most importantly – over-the-counter (OTC) products, which are used extensively in atopic dermatitis care. Indirect costs included time missed from work or school and additional child-care expenses.

The disease’s emotional impact was assessed by CADIS on a 1-10 scale. CADIS addresses issues including caregiver sleep disruption and other caregiver concerns, as well as any difficulties the child is experiencing with sleep, school, socialization and conduct, self-esteem, and activity limitations.

The mean personal cost of atopic dermatitis in the month prior to the office visit was $273.78, representing on average more than one-third of a family’s available monthly money, Ms. Filanovsky said. The breakdown was $75.12 in direct costs and $198.66 for indirect costs. Families with commercial health care insurance averaged $130.58 in direct and $436.16 in indirect costs, with much lower costs in the Medicaid group.

OTC products made up the largest portion of direct costs. An average of $15.28 was spent on moisturizers, $9.42 on OTC topical steroids, $8.46 on bath products, and $4.66 on antihistamines. Time missed from work accounted for the bulk of the indirect costs.

Medicaid patients showed a significant linear correlation between CADIS scores and both total monthly costs of atopic dermatitis care and monthly costs adjusted by family size and income. However, commercially insured families did not.

Ms. Filanovsky proposed several measures as worthy of further study to help reduce the financial and emotional burden of atopic dermatitis, including insurance coverage of moisturizers, physician guidance regarding the most cost-effective OTC products, and implementation of afterwork office hours or nurse on-call visits during flares to minimize the indirect cost of care.

Survey respondents received $25 for their participation, with the funds provided by Nestle. Ms. Filanovsky reported no financial conflicts regarding this study.

[email protected]

COEUR D’ALENE, ID. – A new study puts a price on the financial and emotional costs of childhood atopic dermatitis – and concludes both are much steeper than generally recognized.

Moreover, among low-income families, a significant correlation was documented between the monthly financial cost of atopic dermatitis care and the emotional burden imposed by the disease as reflected in higher CADIS (Childhood Atopic Dermatitis Impact Scale) scores, Ms. Michelle G. Filanovsky reported at the annual meeting of the Society for Pediatric Dermatology.

© -aniaostudio- / ThinkStock

"Our study is the first to correlate financial burden with emotional impact of atopic dermatitis for patients of lower socioeconomic status. This has great implications for how practitioners can help lessen the burden of the disease: Perhaps by helping families lower the cost of disease, we can help lower the emotional burden," observed Ms. Filanovsky, a medical student at Case Western Reserve University, Cleveland.

She and her coinvestigators surveyed parents or other caretakers of 79 children aged 6 months to 12 years with moderate to severe atopic dermatitis who presented to Cleveland dermatology clinics, typically because of a disease flare. Forty-five of the children were covered by Medicaid.

Subjects were queried regarding their total direct and indirect costs for atopic dermatitis care during the past 4 weeks. Direct costs include physician office and emergency department visits, prescription medications, complementary and alternative medicine, and – most importantly – over-the-counter (OTC) products, which are used extensively in atopic dermatitis care. Indirect costs included time missed from work or school and additional child-care expenses.

The disease’s emotional impact was assessed by CADIS on a 1-10 scale. CADIS addresses issues including caregiver sleep disruption and other caregiver concerns, as well as any difficulties the child is experiencing with sleep, school, socialization and conduct, self-esteem, and activity limitations.

The mean personal cost of atopic dermatitis in the month prior to the office visit was $273.78, representing on average more than one-third of a family’s available monthly money, Ms. Filanovsky said. The breakdown was $75.12 in direct costs and $198.66 for indirect costs. Families with commercial health care insurance averaged $130.58 in direct and $436.16 in indirect costs, with much lower costs in the Medicaid group.

OTC products made up the largest portion of direct costs. An average of $15.28 was spent on moisturizers, $9.42 on OTC topical steroids, $8.46 on bath products, and $4.66 on antihistamines. Time missed from work accounted for the bulk of the indirect costs.

Medicaid patients showed a significant linear correlation between CADIS scores and both total monthly costs of atopic dermatitis care and monthly costs adjusted by family size and income. However, commercially insured families did not.

Ms. Filanovsky proposed several measures as worthy of further study to help reduce the financial and emotional burden of atopic dermatitis, including insurance coverage of moisturizers, physician guidance regarding the most cost-effective OTC products, and implementation of afterwork office hours or nurse on-call visits during flares to minimize the indirect cost of care.

Survey respondents received $25 for their participation, with the funds provided by Nestle. Ms. Filanovsky reported no financial conflicts regarding this study.

[email protected]

COEUR D’ALENE, IDAHO – Topical corticosteroids applied to the dry skin of children with atopic dermatitis proved as effective for clinical improvement as the soak and smear technique favored by many physicians, according to a randomized, investigator-blinded clinical trial.

"The use of corticosteroid application to prehydrated, wet skin is not more efficacious than corticosteroid application to dry skin in pediatric patients with atopic dermatitis," Dr. Richard J. Antaya reported at the annual meeting of the Society for Pediatric Dermatology. "This study suggests that 2 weeks of using either soak and smear or standard topical corticosteroid application techniques results in considerable improvement in atopic dermatitis severity," he said.

Eczema Area and Severity Index (EASI) scores improved to a similarly impressive extent – close to 85% after 2 weeks – regardless of which application method was used, added Dr. Antaya, professor of dermatology, pediatrics, and nursing and director of pediatric dermatology at Yale University in New Haven, Conn.

The study included 47 patients aged 4 months to 16 years with atopic dermatitis and a mean baseline EASI score of 15.5. All were assigned to 2 weeks of twice-daily topical steroid therapy. Those younger than age 2 years received a prescription for a 1-lb jar of hydrocortisone 2.5% ointment; older patients received 1-lb jars of triamcinolone 0.1% ointment, and, for the more sensitive face and intertriginous areas, hydrocortisone 2.5% ointment. Patients were randomized to twice-daily application of their medication to affected dry skin or to a single daily soak and smear session and one application of the medication to dry skin.

Soak and smear entails a 10-minute soak in lukewarm plain water to boost skin hydration, followed by steroid application to the wet skin. Data from several studies conducted in adults concluded that soak and smear is more effective than was conventional steroid application to dry skin. For example, a retrospective study of 28 adults referred to a tertiary dermatologic center for highly refractory atopic dermatitis or other eczematous dermatoses showed 26 of the 28 were clear or at least 90% improved after several days to 2 weeks of soak and smear sessions (Arch. Dermatol. 2005;141:1556-9).

In Dr. Antaya’s pediatric atopic dermatitis study, assessment of EASI scores was performed by a dermatologist blinded to the treatment arm. The profound and similar improvement in EASI scores in the two treatment groups was accompanied by essentially equal improvements in measures of sleep quality, itch, and overall disease impact.

Also, there was no difference in EASI score improvement between the two groups when patients were stratified according to baseline atopic dermatitis severity.

No differences between the groups were noted in treatment days missed or development of folliculitis. Neither group showed any evidence of hypothalamic-pituitary-adrenal axis suppression, he added.

Dr. Antaya attributed the marked improvement in atopic dermatitis seen in both study groups to the fact that, at the study outset, caregivers received education aimed at alleviating steroid phobia. Also, the 1-lb jars of medication encouraged treatment compliance, he noted.

Dr. Antaya reported having no financial conflicts with regard to this study.

[email protected]

COEUR D’ALENE, IDAHO – Topical corticosteroids applied to the dry skin of children with atopic dermatitis proved as effective for clinical improvement as the soak and smear technique favored by many physicians, according to a randomized, investigator-blinded clinical trial.

"The use of corticosteroid application to prehydrated, wet skin is not more efficacious than corticosteroid application to dry skin in pediatric patients with atopic dermatitis," Dr. Richard J. Antaya reported at the annual meeting of the Society for Pediatric Dermatology. "This study suggests that 2 weeks of using either soak and smear or standard topical corticosteroid application techniques results in considerable improvement in atopic dermatitis severity," he said.

Eczema Area and Severity Index (EASI) scores improved to a similarly impressive extent – close to 85% after 2 weeks – regardless of which application method was used, added Dr. Antaya, professor of dermatology, pediatrics, and nursing and director of pediatric dermatology at Yale University in New Haven, Conn.

The study included 47 patients aged 4 months to 16 years with atopic dermatitis and a mean baseline EASI score of 15.5. All were assigned to 2 weeks of twice-daily topical steroid therapy. Those younger than age 2 years received a prescription for a 1-lb jar of hydrocortisone 2.5% ointment; older patients received 1-lb jars of triamcinolone 0.1% ointment, and, for the more sensitive face and intertriginous areas, hydrocortisone 2.5% ointment. Patients were randomized to twice-daily application of their medication to affected dry skin or to a single daily soak and smear session and one application of the medication to dry skin.

Soak and smear entails a 10-minute soak in lukewarm plain water to boost skin hydration, followed by steroid application to the wet skin. Data from several studies conducted in adults concluded that soak and smear is more effective than was conventional steroid application to dry skin. For example, a retrospective study of 28 adults referred to a tertiary dermatologic center for highly refractory atopic dermatitis or other eczematous dermatoses showed 26 of the 28 were clear or at least 90% improved after several days to 2 weeks of soak and smear sessions (Arch. Dermatol. 2005;141:1556-9).

In Dr. Antaya’s pediatric atopic dermatitis study, assessment of EASI scores was performed by a dermatologist blinded to the treatment arm. The profound and similar improvement in EASI scores in the two treatment groups was accompanied by essentially equal improvements in measures of sleep quality, itch, and overall disease impact.

Also, there was no difference in EASI score improvement between the two groups when patients were stratified according to baseline atopic dermatitis severity.

No differences between the groups were noted in treatment days missed or development of folliculitis. Neither group showed any evidence of hypothalamic-pituitary-adrenal axis suppression, he added.

Dr. Antaya attributed the marked improvement in atopic dermatitis seen in both study groups to the fact that, at the study outset, caregivers received education aimed at alleviating steroid phobia. Also, the 1-lb jars of medication encouraged treatment compliance, he noted.

Dr. Antaya reported having no financial conflicts with regard to this study.

[email protected]

COEUR D’ALENE, IDAHO – Topical corticosteroids applied to the dry skin of children with atopic dermatitis proved as effective for clinical improvement as the soak and smear technique favored by many physicians, according to a randomized, investigator-blinded clinical trial.

"The use of corticosteroid application to prehydrated, wet skin is not more efficacious than corticosteroid application to dry skin in pediatric patients with atopic dermatitis," Dr. Richard J. Antaya reported at the annual meeting of the Society for Pediatric Dermatology. "This study suggests that 2 weeks of using either soak and smear or standard topical corticosteroid application techniques results in considerable improvement in atopic dermatitis severity," he said.

Eczema Area and Severity Index (EASI) scores improved to a similarly impressive extent – close to 85% after 2 weeks – regardless of which application method was used, added Dr. Antaya, professor of dermatology, pediatrics, and nursing and director of pediatric dermatology at Yale University in New Haven, Conn.

The study included 47 patients aged 4 months to 16 years with atopic dermatitis and a mean baseline EASI score of 15.5. All were assigned to 2 weeks of twice-daily topical steroid therapy. Those younger than age 2 years received a prescription for a 1-lb jar of hydrocortisone 2.5% ointment; older patients received 1-lb jars of triamcinolone 0.1% ointment, and, for the more sensitive face and intertriginous areas, hydrocortisone 2.5% ointment. Patients were randomized to twice-daily application of their medication to affected dry skin or to a single daily soak and smear session and one application of the medication to dry skin.

Soak and smear entails a 10-minute soak in lukewarm plain water to boost skin hydration, followed by steroid application to the wet skin. Data from several studies conducted in adults concluded that soak and smear is more effective than was conventional steroid application to dry skin. For example, a retrospective study of 28 adults referred to a tertiary dermatologic center for highly refractory atopic dermatitis or other eczematous dermatoses showed 26 of the 28 were clear or at least 90% improved after several days to 2 weeks of soak and smear sessions (Arch. Dermatol. 2005;141:1556-9).

In Dr. Antaya’s pediatric atopic dermatitis study, assessment of EASI scores was performed by a dermatologist blinded to the treatment arm. The profound and similar improvement in EASI scores in the two treatment groups was accompanied by essentially equal improvements in measures of sleep quality, itch, and overall disease impact.

Also, there was no difference in EASI score improvement between the two groups when patients were stratified according to baseline atopic dermatitis severity.

No differences between the groups were noted in treatment days missed or development of folliculitis. Neither group showed any evidence of hypothalamic-pituitary-adrenal axis suppression, he added.

Dr. Antaya attributed the marked improvement in atopic dermatitis seen in both study groups to the fact that, at the study outset, caregivers received education aimed at alleviating steroid phobia. Also, the 1-lb jars of medication encouraged treatment compliance, he noted.

Dr. Antaya reported having no financial conflicts with regard to this study.

[email protected]

COEUR D’ALENE, ID. – Pediatric chronic cutaneous lupus erythematosus transforms into systemic disease in one-quarter of cases, and if it’s going to do so, it’ll typically be within the first year after diagnosis, according to a retrospective study.

"Importantly, no one developed end-organ damage through the end of follow-up, perhaps suggesting that SLE arising in pediatric patients with CCLE follows a more indolent, benign course, just as we’ve seen in previous studies in adults with CCLE with transformation to SLE," Dr. Lisa Arkin observed at the annual meeting of the Society for Pediatric Dermatology.

If that is indeed true, it’s good news for pediatric CCLE patients and their families because it sets them apart from the others who develop SLE prior to adulthood. Twenty percent of all cases of SLE present before age 20, and in general they tend to follow a more aggressive course than adult-onset SLE, with a higher frequency of end-organ involvement necessitating sustained immunosuppression, as well as higher mortality, noted Dr. Arkin, recently appointed as head of pediatric dermatology at Rush University Medical Center, Chicago.

Pediatric CCLE is a rare and little-studied disease. Its most common form is discoid LE, characterized by scaling, telangiectasias, atrophy, follicular plugging, and scarring.

Much more is known about adult discoid LE, a far more common condition. Less than 5%-10% of adults with discoid LE develop SLE, and when they do, the systemic manifestations are more likely to be benign than is typical in adult SLE patients whose systemic disease was not preceded by discoid LE, the pediatric dermatologist explained.

Because so little is known about pediatric CCLE, she conducted a retrospective study including 45 affected patients seen at Lurie Children’s Hospital of Chicago. Seven of the 45 presented initially with concurrent CCLE and SLE. The remaining 38 were followed for a median of 4.4 years, during which 9 patients (24%) transitioned to SLE. Of note, that 1-in-4 risk of transformation from skin to systemic disease is spot-on with the results of the three previous small retrospective studies of pediatric CCLE, the most recent of which was reported 6 years ago from Brazil (Pediatr. Dermatol. 2008;25:163-7).

Of the 7 patients in Dr. Arkin’s study with concurrent CCLE and SLE at presentation, 6 had discoid LE, as did 34 of the 38 with only CCLE at presentation who were followed for development of SLE.

Of the 38 patients with only CCLE at presentation, 12 (32%) had disease limited to the skin throughout follow-up.

Another 17 (45%) with only CCLE at presentation developed laboratory abnormalities during follow-up without transitioning to SLE, including 14 with antinuclear antibodies. Nine of these patients developed more than two laboratory abnormalities. Notably, all had been on hydroxychloroquine ever since the onset of their CCLE. This suggests the intriguing possibility that hydroxychloroquine – an immunomodulatory agent rather than an immunosuppressant – may favorably alter the natural history of disease progression in this young population, according to Dr. Arkin. That’s been shown to be the case in studies conducted in adult military personnel, where long-term follow-up of troops randomized to hydroxychloroquine for antimalarial prophylaxis delayed the diagnosis of SLE, lowered the rate of autoantibody accumulation, retarded renal damage, reduced the risk of infection, and improved overall survival (Lupus 2007;16:401-9).

Patients with concurrent CCLE and SLE presented at a considerably younger age: a mean of 8.7 years old, compared with 13.3 years of age for those with only CCLE.

No formal guidelines exist for monitoring patients with CCLE. Based upon her study findings, Dr. Arkin recommended that "it seems reasonable" to perform a meticulous physical exam and review of systems and obtain laboratory tests on a quarterly basis, particularly in the first year following diagnosis, when the risk of transformation to SLE is highest. The quarterly lab workup should include a complete blood count and complete metabolic panel, urinalysis, complement, antiphospholipid antibodies, and antinuclear antibodies with titer.

"I think one of the big questions which has not been answered is, should all kids with CCLE get oral hydroxychloroquine? There are no studies in children. The only FDA-approved indication is for antimalarial prophylaxis, although it’s certainly used commonly off-label for pediatric CCLE and also for SLE," she said.

The major side effects of oral hydroxychloroquine in children include retinal toxicity, which is dose-dependent, along with GI upset, headaches, and vivid dreams.

Dr. Arkin observed that while a randomized trial of hydroxychloroquine to delay or prevent SLE in high-risk individuals is warranted, she was unable to identify any predictors of transformation from CCLE to SLE in her study, despite an extensive search.

"I love this study," commented SPD President Dr. Beth A. Drolet, professor of dermatology at the Medical College of Wisconsin, Milwaukee. "Your point that if transformation to SLE happens, it’s going to happen quickly – that’s enormously helpful to me clinically."

The study was funded by the SPD. Dr. Arkin reported having no financial conflicts.

[email protected]

COEUR D’ALENE, ID. – Pediatric chronic cutaneous lupus erythematosus transforms into systemic disease in one-quarter of cases, and if it’s going to do so, it’ll typically be within the first year after diagnosis, according to a retrospective study.

"Importantly, no one developed end-organ damage through the end of follow-up, perhaps suggesting that SLE arising in pediatric patients with CCLE follows a more indolent, benign course, just as we’ve seen in previous studies in adults with CCLE with transformation to SLE," Dr. Lisa Arkin observed at the annual meeting of the Society for Pediatric Dermatology.

If that is indeed true, it’s good news for pediatric CCLE patients and their families because it sets them apart from the others who develop SLE prior to adulthood. Twenty percent of all cases of SLE present before age 20, and in general they tend to follow a more aggressive course than adult-onset SLE, with a higher frequency of end-organ involvement necessitating sustained immunosuppression, as well as higher mortality, noted Dr. Arkin, recently appointed as head of pediatric dermatology at Rush University Medical Center, Chicago.

Pediatric CCLE is a rare and little-studied disease. Its most common form is discoid LE, characterized by scaling, telangiectasias, atrophy, follicular plugging, and scarring.

Much more is known about adult discoid LE, a far more common condition. Less than 5%-10% of adults with discoid LE develop SLE, and when they do, the systemic manifestations are more likely to be benign than is typical in adult SLE patients whose systemic disease was not preceded by discoid LE, the pediatric dermatologist explained.

Because so little is known about pediatric CCLE, she conducted a retrospective study including 45 affected patients seen at Lurie Children’s Hospital of Chicago. Seven of the 45 presented initially with concurrent CCLE and SLE. The remaining 38 were followed for a median of 4.4 years, during which 9 patients (24%) transitioned to SLE. Of note, that 1-in-4 risk of transformation from skin to systemic disease is spot-on with the results of the three previous small retrospective studies of pediatric CCLE, the most recent of which was reported 6 years ago from Brazil (Pediatr. Dermatol. 2008;25:163-7).

Of the 7 patients in Dr. Arkin’s study with concurrent CCLE and SLE at presentation, 6 had discoid LE, as did 34 of the 38 with only CCLE at presentation who were followed for development of SLE.

Of the 38 patients with only CCLE at presentation, 12 (32%) had disease limited to the skin throughout follow-up.

Another 17 (45%) with only CCLE at presentation developed laboratory abnormalities during follow-up without transitioning to SLE, including 14 with antinuclear antibodies. Nine of these patients developed more than two laboratory abnormalities. Notably, all had been on hydroxychloroquine ever since the onset of their CCLE. This suggests the intriguing possibility that hydroxychloroquine – an immunomodulatory agent rather than an immunosuppressant – may favorably alter the natural history of disease progression in this young population, according to Dr. Arkin. That’s been shown to be the case in studies conducted in adult military personnel, where long-term follow-up of troops randomized to hydroxychloroquine for antimalarial prophylaxis delayed the diagnosis of SLE, lowered the rate of autoantibody accumulation, retarded renal damage, reduced the risk of infection, and improved overall survival (Lupus 2007;16:401-9).

Patients with concurrent CCLE and SLE presented at a considerably younger age: a mean of 8.7 years old, compared with 13.3 years of age for those with only CCLE.

No formal guidelines exist for monitoring patients with CCLE. Based upon her study findings, Dr. Arkin recommended that "it seems reasonable" to perform a meticulous physical exam and review of systems and obtain laboratory tests on a quarterly basis, particularly in the first year following diagnosis, when the risk of transformation to SLE is highest. The quarterly lab workup should include a complete blood count and complete metabolic panel, urinalysis, complement, antiphospholipid antibodies, and antinuclear antibodies with titer.

"I think one of the big questions which has not been answered is, should all kids with CCLE get oral hydroxychloroquine? There are no studies in children. The only FDA-approved indication is for antimalarial prophylaxis, although it’s certainly used commonly off-label for pediatric CCLE and also for SLE," she said.

The major side effects of oral hydroxychloroquine in children include retinal toxicity, which is dose-dependent, along with GI upset, headaches, and vivid dreams.

Dr. Arkin observed that while a randomized trial of hydroxychloroquine to delay or prevent SLE in high-risk individuals is warranted, she was unable to identify any predictors of transformation from CCLE to SLE in her study, despite an extensive search.

"I love this study," commented SPD President Dr. Beth A. Drolet, professor of dermatology at the Medical College of Wisconsin, Milwaukee. "Your point that if transformation to SLE happens, it’s going to happen quickly – that’s enormously helpful to me clinically."

The study was funded by the SPD. Dr. Arkin reported having no financial conflicts.

[email protected]

COEUR D’ALENE, ID. – Pediatric chronic cutaneous lupus erythematosus transforms into systemic disease in one-quarter of cases, and if it’s going to do so, it’ll typically be within the first year after diagnosis, according to a retrospective study.

"Importantly, no one developed end-organ damage through the end of follow-up, perhaps suggesting that SLE arising in pediatric patients with CCLE follows a more indolent, benign course, just as we’ve seen in previous studies in adults with CCLE with transformation to SLE," Dr. Lisa Arkin observed at the annual meeting of the Society for Pediatric Dermatology.

If that is indeed true, it’s good news for pediatric CCLE patients and their families because it sets them apart from the others who develop SLE prior to adulthood. Twenty percent of all cases of SLE present before age 20, and in general they tend to follow a more aggressive course than adult-onset SLE, with a higher frequency of end-organ involvement necessitating sustained immunosuppression, as well as higher mortality, noted Dr. Arkin, recently appointed as head of pediatric dermatology at Rush University Medical Center, Chicago.

Pediatric CCLE is a rare and little-studied disease. Its most common form is discoid LE, characterized by scaling, telangiectasias, atrophy, follicular plugging, and scarring.

Much more is known about adult discoid LE, a far more common condition. Less than 5%-10% of adults with discoid LE develop SLE, and when they do, the systemic manifestations are more likely to be benign than is typical in adult SLE patients whose systemic disease was not preceded by discoid LE, the pediatric dermatologist explained.

Because so little is known about pediatric CCLE, she conducted a retrospective study including 45 affected patients seen at Lurie Children’s Hospital of Chicago. Seven of the 45 presented initially with concurrent CCLE and SLE. The remaining 38 were followed for a median of 4.4 years, during which 9 patients (24%) transitioned to SLE. Of note, that 1-in-4 risk of transformation from skin to systemic disease is spot-on with the results of the three previous small retrospective studies of pediatric CCLE, the most recent of which was reported 6 years ago from Brazil (Pediatr. Dermatol. 2008;25:163-7).

Of the 7 patients in Dr. Arkin’s study with concurrent CCLE and SLE at presentation, 6 had discoid LE, as did 34 of the 38 with only CCLE at presentation who were followed for development of SLE.

Of the 38 patients with only CCLE at presentation, 12 (32%) had disease limited to the skin throughout follow-up.

Another 17 (45%) with only CCLE at presentation developed laboratory abnormalities during follow-up without transitioning to SLE, including 14 with antinuclear antibodies. Nine of these patients developed more than two laboratory abnormalities. Notably, all had been on hydroxychloroquine ever since the onset of their CCLE. This suggests the intriguing possibility that hydroxychloroquine – an immunomodulatory agent rather than an immunosuppressant – may favorably alter the natural history of disease progression in this young population, according to Dr. Arkin. That’s been shown to be the case in studies conducted in adult military personnel, where long-term follow-up of troops randomized to hydroxychloroquine for antimalarial prophylaxis delayed the diagnosis of SLE, lowered the rate of autoantibody accumulation, retarded renal damage, reduced the risk of infection, and improved overall survival (Lupus 2007;16:401-9).

Patients with concurrent CCLE and SLE presented at a considerably younger age: a mean of 8.7 years old, compared with 13.3 years of age for those with only CCLE.

No formal guidelines exist for monitoring patients with CCLE. Based upon her study findings, Dr. Arkin recommended that "it seems reasonable" to perform a meticulous physical exam and review of systems and obtain laboratory tests on a quarterly basis, particularly in the first year following diagnosis, when the risk of transformation to SLE is highest. The quarterly lab workup should include a complete blood count and complete metabolic panel, urinalysis, complement, antiphospholipid antibodies, and antinuclear antibodies with titer.

"I think one of the big questions which has not been answered is, should all kids with CCLE get oral hydroxychloroquine? There are no studies in children. The only FDA-approved indication is for antimalarial prophylaxis, although it’s certainly used commonly off-label for pediatric CCLE and also for SLE," she said.

The major side effects of oral hydroxychloroquine in children include retinal toxicity, which is dose-dependent, along with GI upset, headaches, and vivid dreams.

Dr. Arkin observed that while a randomized trial of hydroxychloroquine to delay or prevent SLE in high-risk individuals is warranted, she was unable to identify any predictors of transformation from CCLE to SLE in her study, despite an extensive search.

"I love this study," commented SPD President Dr. Beth A. Drolet, professor of dermatology at the Medical College of Wisconsin, Milwaukee. "Your point that if transformation to SLE happens, it’s going to happen quickly – that’s enormously helpful to me clinically."

The study was funded by the SPD. Dr. Arkin reported having no financial conflicts.

[email protected]