Commentary

Struan H. Coleman, MD, PhD

Associate Editor for Practice Management/Economics

Dr. Coleman is a board-certified orthopedic surgeon specializing in hip preservation and sports medicine at the Hospital for Special Surgery in New York and the Vincera Institute in Philadelphia, and currently is the Head Team Physician for the New York Mets. He earned a medical degree from Columbia College of Physicians and Surgeons and holds a D.Phil in Microbiology from Oxford University in England. He completed his residency in Orthopedic Surgery and a fellowship in Sports Medicine at the Hospital for Special Surgery. Dr. Coleman focuses on the treatment of sports-related injuries of the hip, knee, and shoulder with a particular interest in hip arthroscopy and hip preservation. He has published multiple articles and book chapters, and holds numerous patents for technologies that are utilized by sports medicine physicians and surgeons.

Jack Farr II, MD

Associate Editor for Patellofemoral

Dr. Farr is a board-certified orthopedic surgeon and has a subspecialty practice in knee and cartilage restoration. He is affiliated with the OrthoIndy Hospital and Community Hospital South. He is also the Vice President of the Patellofemoral Foundation, is on the board for the International Cartilage Repair Society, holds a board position with the Cartilage Research Foundation, and holds a voluntary clinical full professorship in Orthopedic Surgery at the Indiana University Medical Center. Dr. Farr earned his medical degree from Indiana University, and completed his Orthopedic Surgery residency at Indiana University Medical Center. He was a design surgeon for a meniscal allograft transplant system and 2 knee patellofemoral osteotomy systems. He is also a member of the American Academy of Orthopaedic Surgeons (AAOS), the Arthroscopy Association of North America (AANA), and the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA).

Kenneth Montgomery, MD

Associate Editor for Professional Sports

Dr. Montgomery is an orthopedic surgeon who is fellowship-trained in sports medicine and hand and upper extremity surgery. He is currently practicing at Tri-County Orthopedics and Sports Medicine in Morristown, New Jersey. He is also the Head Team Physician and Medical Director for the New York Jets. He served as a team orthopedist with the New York Islanders from 1997-2009, and was formerly the section chief of Sports Medicine at ProHEALTH Care Associates in Lake Success, New York. Dr. Montgomery completed his residency in Orthopedic Surgery at the Hospital for Special Surgery, and completed a Sports Medicine fellowship at Lenox Hill Hospital. He also completed a Hand and Upper Extremity fellowship at Harvard. He is one of the founders for OrthoNations, a nonprofit organization that helps educate orthopedic surgeons in developing countries. He is also one of the founding surgeons for Cayenne Medical, a medical device company specializing in sports medicine implants.

Struan H. Coleman, MD, PhD

Associate Editor for Practice Management/Economics

Dr. Coleman is a board-certified orthopedic surgeon specializing in hip preservation and sports medicine at the Hospital for Special Surgery in New York and the Vincera Institute in Philadelphia, and currently is the Head Team Physician for the New York Mets. He earned a medical degree from Columbia College of Physicians and Surgeons and holds a D.Phil in Microbiology from Oxford University in England. He completed his residency in Orthopedic Surgery and a fellowship in Sports Medicine at the Hospital for Special Surgery. Dr. Coleman focuses on the treatment of sports-related injuries of the hip, knee, and shoulder with a particular interest in hip arthroscopy and hip preservation. He has published multiple articles and book chapters, and holds numerous patents for technologies that are utilized by sports medicine physicians and surgeons.

Jack Farr II, MD

Associate Editor for Patellofemoral

Dr. Farr is a board-certified orthopedic surgeon and has a subspecialty practice in knee and cartilage restoration. He is affiliated with the OrthoIndy Hospital and Community Hospital South. He is also the Vice President of the Patellofemoral Foundation, is on the board for the International Cartilage Repair Society, holds a board position with the Cartilage Research Foundation, and holds a voluntary clinical full professorship in Orthopedic Surgery at the Indiana University Medical Center. Dr. Farr earned his medical degree from Indiana University, and completed his Orthopedic Surgery residency at Indiana University Medical Center. He was a design surgeon for a meniscal allograft transplant system and 2 knee patellofemoral osteotomy systems. He is also a member of the American Academy of Orthopaedic Surgeons (AAOS), the Arthroscopy Association of North America (AANA), and the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA).

Kenneth Montgomery, MD

Associate Editor for Professional Sports

Dr. Montgomery is an orthopedic surgeon who is fellowship-trained in sports medicine and hand and upper extremity surgery. He is currently practicing at Tri-County Orthopedics and Sports Medicine in Morristown, New Jersey. He is also the Head Team Physician and Medical Director for the New York Jets. He served as a team orthopedist with the New York Islanders from 1997-2009, and was formerly the section chief of Sports Medicine at ProHEALTH Care Associates in Lake Success, New York. Dr. Montgomery completed his residency in Orthopedic Surgery at the Hospital for Special Surgery, and completed a Sports Medicine fellowship at Lenox Hill Hospital. He also completed a Hand and Upper Extremity fellowship at Harvard. He is one of the founders for OrthoNations, a nonprofit organization that helps educate orthopedic surgeons in developing countries. He is also one of the founding surgeons for Cayenne Medical, a medical device company specializing in sports medicine implants.

Struan H. Coleman, MD, PhD

Associate Editor for Practice Management/Economics

Dr. Coleman is a board-certified orthopedic surgeon specializing in hip preservation and sports medicine at the Hospital for Special Surgery in New York and the Vincera Institute in Philadelphia, and currently is the Head Team Physician for the New York Mets. He earned a medical degree from Columbia College of Physicians and Surgeons and holds a D.Phil in Microbiology from Oxford University in England. He completed his residency in Orthopedic Surgery and a fellowship in Sports Medicine at the Hospital for Special Surgery. Dr. Coleman focuses on the treatment of sports-related injuries of the hip, knee, and shoulder with a particular interest in hip arthroscopy and hip preservation. He has published multiple articles and book chapters, and holds numerous patents for technologies that are utilized by sports medicine physicians and surgeons.

Jack Farr II, MD

Associate Editor for Patellofemoral

Dr. Farr is a board-certified orthopedic surgeon and has a subspecialty practice in knee and cartilage restoration. He is affiliated with the OrthoIndy Hospital and Community Hospital South. He is also the Vice President of the Patellofemoral Foundation, is on the board for the International Cartilage Repair Society, holds a board position with the Cartilage Research Foundation, and holds a voluntary clinical full professorship in Orthopedic Surgery at the Indiana University Medical Center. Dr. Farr earned his medical degree from Indiana University, and completed his Orthopedic Surgery residency at Indiana University Medical Center. He was a design surgeon for a meniscal allograft transplant system and 2 knee patellofemoral osteotomy systems. He is also a member of the American Academy of Orthopaedic Surgeons (AAOS), the Arthroscopy Association of North America (AANA), and the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA).

Kenneth Montgomery, MD

Associate Editor for Professional Sports

Dr. Montgomery is an orthopedic surgeon who is fellowship-trained in sports medicine and hand and upper extremity surgery. He is currently practicing at Tri-County Orthopedics and Sports Medicine in Morristown, New Jersey. He is also the Head Team Physician and Medical Director for the New York Jets. He served as a team orthopedist with the New York Islanders from 1997-2009, and was formerly the section chief of Sports Medicine at ProHEALTH Care Associates in Lake Success, New York. Dr. Montgomery completed his residency in Orthopedic Surgery at the Hospital for Special Surgery, and completed a Sports Medicine fellowship at Lenox Hill Hospital. He also completed a Hand and Upper Extremity fellowship at Harvard. He is one of the founders for OrthoNations, a nonprofit organization that helps educate orthopedic surgeons in developing countries. He is also one of the founding surgeons for Cayenne Medical, a medical device company specializing in sports medicine implants.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Dr. Emjay Tan’s case study of a 36-year-old man who became “Manic after taking a vacation” (Cases That Test Your Skills, Current Psychiatry. April 2016, p. 45-50) is off the mark by attributing the manic episode to scopolamine—theoretically possible, but statistically improbable.

Dr. Tan may be unaware of a more frequent event: vacation hypomania. About one-third of my bipolar disorder patients had their first manic episode while on an overseas vacation or upon their return. It isn’t the fun, excitement, or novelty of a vacation that triggers the episode, but sleep deprivation, which is part and parcel of such events, particularly when they involve a holiday in a substantially different time zone. 

Few people get to sleep more than a few hours the night before departing on a vacation; there’s so much to do: packing, getting to the airport hours before the flight, etc. Not many people sleep soundly on the plane, and many experience the effects of jet lag both during the first few days of vacation and when the vacationer returns home. Many vacations come with substantial and protracted sleep deprivation, and sleep deprivation is an excellent way to trigger a hypomanic episode. I suspect that is why Dr. Tan’s patient, who did not have a history of psychiatric symptoms, but who might have been genetically predisposed, became manifestly symptomatic shortly following his return from an overseas holiday.

Of course, it isn’t just first episodes of hypomania that are triggered by sleep deprivation in patients with undiagnosed bipolar disorder; the event is common in the lives of people who already receive treatment. Accordingly, my patients know that I might increase their lithium dosage for at least a few days to give them added protection as they head overseas, coupled with advice to do their best to get proper sleep.

Despite such prophylaxis, many of my bipolar disorder patients have taken a long flight overseas and, then, after half a day in the air, continued “flying.” To the best of my knowledge, none ever took scopolamine.

Martin Blinder, MD
Past Assistant Clinical Professor of Psychiatry
University of California, San Francisco
Past Adjunct Professor of Law
University of California
Hastings College of Law
San Francisco, California

Dr. Emjay Tan’s case study of a 36-year-old man who became “Manic after taking a vacation” (Cases That Test Your Skills, Current Psychiatry. April 2016, p. 45-50) is off the mark by attributing the manic episode to scopolamine—theoretically possible, but statistically improbable.

Dr. Tan may be unaware of a more frequent event: vacation hypomania. About one-third of my bipolar disorder patients had their first manic episode while on an overseas vacation or upon their return. It isn’t the fun, excitement, or novelty of a vacation that triggers the episode, but sleep deprivation, which is part and parcel of such events, particularly when they involve a holiday in a substantially different time zone. 

Few people get to sleep more than a few hours the night before departing on a vacation; there’s so much to do: packing, getting to the airport hours before the flight, etc. Not many people sleep soundly on the plane, and many experience the effects of jet lag both during the first few days of vacation and when the vacationer returns home. Many vacations come with substantial and protracted sleep deprivation, and sleep deprivation is an excellent way to trigger a hypomanic episode. I suspect that is why Dr. Tan’s patient, who did not have a history of psychiatric symptoms, but who might have been genetically predisposed, became manifestly symptomatic shortly following his return from an overseas holiday.

Of course, it isn’t just first episodes of hypomania that are triggered by sleep deprivation in patients with undiagnosed bipolar disorder; the event is common in the lives of people who already receive treatment. Accordingly, my patients know that I might increase their lithium dosage for at least a few days to give them added protection as they head overseas, coupled with advice to do their best to get proper sleep.

Despite such prophylaxis, many of my bipolar disorder patients have taken a long flight overseas and, then, after half a day in the air, continued “flying.” To the best of my knowledge, none ever took scopolamine.

Martin Blinder, MD
Past Assistant Clinical Professor of Psychiatry
University of California, San Francisco
Past Adjunct Professor of Law
University of California
Hastings College of Law
San Francisco, California

Dr. Emjay Tan’s case study of a 36-year-old man who became “Manic after taking a vacation” (Cases That Test Your Skills, Current Psychiatry. April 2016, p. 45-50) is off the mark by attributing the manic episode to scopolamine—theoretically possible, but statistically improbable.

Dr. Tan may be unaware of a more frequent event: vacation hypomania. About one-third of my bipolar disorder patients had their first manic episode while on an overseas vacation or upon their return. It isn’t the fun, excitement, or novelty of a vacation that triggers the episode, but sleep deprivation, which is part and parcel of such events, particularly when they involve a holiday in a substantially different time zone. 

Few people get to sleep more than a few hours the night before departing on a vacation; there’s so much to do: packing, getting to the airport hours before the flight, etc. Not many people sleep soundly on the plane, and many experience the effects of jet lag both during the first few days of vacation and when the vacationer returns home. Many vacations come with substantial and protracted sleep deprivation, and sleep deprivation is an excellent way to trigger a hypomanic episode. I suspect that is why Dr. Tan’s patient, who did not have a history of psychiatric symptoms, but who might have been genetically predisposed, became manifestly symptomatic shortly following his return from an overseas holiday.

Of course, it isn’t just first episodes of hypomania that are triggered by sleep deprivation in patients with undiagnosed bipolar disorder; the event is common in the lives of people who already receive treatment. Accordingly, my patients know that I might increase their lithium dosage for at least a few days to give them added protection as they head overseas, coupled with advice to do their best to get proper sleep.

Despite such prophylaxis, many of my bipolar disorder patients have taken a long flight overseas and, then, after half a day in the air, continued “flying.” To the best of my knowledge, none ever took scopolamine.

Martin Blinder, MD
Past Assistant Clinical Professor of Psychiatry
University of California, San Francisco
Past Adjunct Professor of Law
University of California
Hastings College of Law
San Francisco, California

The sun has finally set on Kobe Bryant’s magnificent career. After all the tributes and tearful goodbyes, he has finally played his last game and become a part of basketball history. Ever since his field trip to Germany for interleukin-1 receptor antagonist protein (IRAP) treatments to his knee, and his subsequent return to high-level play, I’ve been under siege in the office by patients who “want what Kobe had.” I’ve had to explain, time and time again, that IRAP treatment is not available in the United States and that platelet-rich plasma (PRP) is the closest alternative treatment, convince them that PRP may be even better, and then let them know that it’s considered experimental and not covered by insurance.

In the last issue, we discussed the future of orthopedics, which in my opinion will rely heavily on the biologic therapies now considered experimental. In this issue, we will look into our crystal balls and imagine what that future might look like. To do so, we should first consider what we hope to accomplish through the incorporation of biologic therapies.

The regeneration of articular cartilage, acceleration of fracture and tissue healing, and faster incorporation of tendon grafts to bone have long been considered the Holy Grail of Orthopedics. In his best seller, The Da Vinci Code, Dan Brown makes a compelling argument that the Holy Grail, the chalice thought to have held the blood of Christ, was in fact a mistranslated reference to his living descendants. Whenever I have a visitor or student in the operating room, I focus the scope on the synovial capillaries so they can see the individual red blood cells passing single-file through the vessels on their way to supply cells with the nutrients they need.

Perhaps, like in The Da Vinci Code, the solution to our greatest biologic challenges lies in the blood, already there, just waiting to be unlocked.

PRP has been utilized for everything from tendinopathy to arthropathy, with varied results in the literature. The lack of standardization of PRP preparations, which vary in inclusion of white cells and absolute platelet count, confounds these results even further. In this issue, we review its use in sports medicine and knee arthritis, taking a closer look at partial ulnar collateral ligament tears in baseball players.

In “Tips of the Trade,” we present a technique for “superior capsular reconstruction” that provides a novel solution for patients with pseudoparalysis from massive rotator cuff tears with little other options beside reverse total shoulder arthroplasty.

The one absolute statement I can make regarding biologics is that we currently have more questions than answers, and every hypothesis we prove simply begets more questions. More randomized controlled studies are needed in virtually every aspect of biologics, and we should all consider taking part. While the solutions our patients crave may not arrive during our careers, or even our lifetimes, the groundwork we do now will set the stage for future generations to enjoy biologically enhanced outcomes.

The sun has finally set on Kobe Bryant’s magnificent career. After all the tributes and tearful goodbyes, he has finally played his last game and become a part of basketball history. Ever since his field trip to Germany for interleukin-1 receptor antagonist protein (IRAP) treatments to his knee, and his subsequent return to high-level play, I’ve been under siege in the office by patients who “want what Kobe had.” I’ve had to explain, time and time again, that IRAP treatment is not available in the United States and that platelet-rich plasma (PRP) is the closest alternative treatment, convince them that PRP may be even better, and then let them know that it’s considered experimental and not covered by insurance.

In the last issue, we discussed the future of orthopedics, which in my opinion will rely heavily on the biologic therapies now considered experimental. In this issue, we will look into our crystal balls and imagine what that future might look like. To do so, we should first consider what we hope to accomplish through the incorporation of biologic therapies.

The regeneration of articular cartilage, acceleration of fracture and tissue healing, and faster incorporation of tendon grafts to bone have long been considered the Holy Grail of Orthopedics. In his best seller, The Da Vinci Code, Dan Brown makes a compelling argument that the Holy Grail, the chalice thought to have held the blood of Christ, was in fact a mistranslated reference to his living descendants. Whenever I have a visitor or student in the operating room, I focus the scope on the synovial capillaries so they can see the individual red blood cells passing single-file through the vessels on their way to supply cells with the nutrients they need.

Perhaps, like in The Da Vinci Code, the solution to our greatest biologic challenges lies in the blood, already there, just waiting to be unlocked.

PRP has been utilized for everything from tendinopathy to arthropathy, with varied results in the literature. The lack of standardization of PRP preparations, which vary in inclusion of white cells and absolute platelet count, confounds these results even further. In this issue, we review its use in sports medicine and knee arthritis, taking a closer look at partial ulnar collateral ligament tears in baseball players.

In “Tips of the Trade,” we present a technique for “superior capsular reconstruction” that provides a novel solution for patients with pseudoparalysis from massive rotator cuff tears with little other options beside reverse total shoulder arthroplasty.

The one absolute statement I can make regarding biologics is that we currently have more questions than answers, and every hypothesis we prove simply begets more questions. More randomized controlled studies are needed in virtually every aspect of biologics, and we should all consider taking part. While the solutions our patients crave may not arrive during our careers, or even our lifetimes, the groundwork we do now will set the stage for future generations to enjoy biologically enhanced outcomes.

The sun has finally set on Kobe Bryant’s magnificent career. After all the tributes and tearful goodbyes, he has finally played his last game and become a part of basketball history. Ever since his field trip to Germany for interleukin-1 receptor antagonist protein (IRAP) treatments to his knee, and his subsequent return to high-level play, I’ve been under siege in the office by patients who “want what Kobe had.” I’ve had to explain, time and time again, that IRAP treatment is not available in the United States and that platelet-rich plasma (PRP) is the closest alternative treatment, convince them that PRP may be even better, and then let them know that it’s considered experimental and not covered by insurance.

In the last issue, we discussed the future of orthopedics, which in my opinion will rely heavily on the biologic therapies now considered experimental. In this issue, we will look into our crystal balls and imagine what that future might look like. To do so, we should first consider what we hope to accomplish through the incorporation of biologic therapies.

The regeneration of articular cartilage, acceleration of fracture and tissue healing, and faster incorporation of tendon grafts to bone have long been considered the Holy Grail of Orthopedics. In his best seller, The Da Vinci Code, Dan Brown makes a compelling argument that the Holy Grail, the chalice thought to have held the blood of Christ, was in fact a mistranslated reference to his living descendants. Whenever I have a visitor or student in the operating room, I focus the scope on the synovial capillaries so they can see the individual red blood cells passing single-file through the vessels on their way to supply cells with the nutrients they need.

Perhaps, like in The Da Vinci Code, the solution to our greatest biologic challenges lies in the blood, already there, just waiting to be unlocked.

PRP has been utilized for everything from tendinopathy to arthropathy, with varied results in the literature. The lack of standardization of PRP preparations, which vary in inclusion of white cells and absolute platelet count, confounds these results even further. In this issue, we review its use in sports medicine and knee arthritis, taking a closer look at partial ulnar collateral ligament tears in baseball players.

In “Tips of the Trade,” we present a technique for “superior capsular reconstruction” that provides a novel solution for patients with pseudoparalysis from massive rotator cuff tears with little other options beside reverse total shoulder arthroplasty.

The one absolute statement I can make regarding biologics is that we currently have more questions than answers, and every hypothesis we prove simply begets more questions. More randomized controlled studies are needed in virtually every aspect of biologics, and we should all consider taking part. While the solutions our patients crave may not arrive during our careers, or even our lifetimes, the groundwork we do now will set the stage for future generations to enjoy biologically enhanced outcomes.

This edition of Vascular Specialist is being published early to coincide with the VAM. Since medical students will be attending the meeting I thought this would be a good opportunity to describe an often overlooked reason why, after all my years in practice, I still enjoy being a vascular surgeon. By doing so I hope to encourage these young people to consider a career in vascular surgery.

Some vascular surgeons, with the same goal, have volunteered to mentor these students at the VAM. I suspect most mentors would extoll vascular surgery as unique amongst surgical specialties. They will describe the variety of complex operations as well as advanced endovascular procedures that we perform. Proudly, some mentors will mention that other practitioners turn to us for help when they encounter uncontrollable hemorrhage. They will emphasize that we are the one specialty that covers the gamut of vascular interventions from open surgery and endovascular procedures to medical management. Perhaps some mentors will incorporate my mantra that vascular surgeons “Operate, Dilate, and Medicate.”

However, I suggest that the most satisfying aspect of our profession is not the procedures that we perform but rather the interaction we have with our patients. After all, most of us entered the medical profession to take care of patients, and vascular patients are very special indeed. However, sometimes we established vascular surgeons become too enthralled by technical advances to remember the more humanistic reasons for our being. Also, changes in medical practice and reimbursement have resulted in many being so overworked that we do not have time to enjoy relationships with our patients. Perhaps those who are so burdened should take heed from the stories mentors will relate to inspire these students.

Based on my personal experience I suspect the mentors will say something along the following lines: “Vascular conditions are chronic and are wont to afflict more than one part of the body. Accordingly, we are required to follow most patients for their whole lives (or ours!). Not only do we treat these patients but we also become intimately involved with their families, often treating them as well. Often our ‘treatment’ will not be procedural but rather will involve emotional support of these relatives as they deal with their recuperating or debilitated spouse, sibling, or parent. Those of us who have been in practice for many years will fondly recall patients who have become an integral part of our lives. The patient who undergoes a vascular procedure will return every 6 or 12 months to have their bypass checked or their other carotid assessed.

“We follow asymptomatic small abdominal aneurysms and claudicants. A venous ulcer often recurs and a dialysis patient may require a new intervention. Some patients come to the office so they can be made more secure that their condition has not deteriorated, and the lonely just because we are the only human they interact with on a regular basis. They bring with them their varied life stories and these vignettes become a part of our own fiction. Perhaps we will share with them our own life story. Contrast that to the general surgeon who repairs a hernia and after a few post op visits may never see the patient again.

“Vascular patients may be very young or more commonly very old and come from all walks of life. So the vascular surgeon will learn to calm the crying infant. She will provide careful optimism to allay the fears of a mother who brings in her daughter scarred by a cavernous hemangioma. He or she will reassure the young girl, mortified by embarrassing spider veins, that she will be able to wear a dress to her high school prom. Together with the obstetrician, the vascular surgeon will guide a pregnant woman with a DVT through her entire pregnancy assuring her that both she and her baby will be safe.”

The mentor will re-count how special it was to get a hug from an old lady who he operated on 25 years previously when he was a young surgeon. Or the gratification one gets when a father, after a successful limb revascularization, shows a video of himself walking down the aisle at his daughter’s wedding. Perhaps the mentor will confide her sense of dismay every time a young dialysis patient is admitted for revision of a fistula and the joy she feels when told that her patient has finally received a viable transplant. Year after year the vascular surgeon will follow a patient with early onset, widespread vascular disease whose parents died young from the ravages of familial hyperlipidemia.

He will provide encouragement to help the patient stop smoking and commiserate when a sibling dies from a heart attack. The mentor might relate how she felt when she saved the leg of a soldier injured by a land mine or how she was amazed by the 80-year-old ballroom dancer who danced a few weeks after a below knee amputation.

Mentors will also describe getting to know a patient’s daily routine so they can informatively advise a patient whether it is worth having a procedure to improve quality of life. Or the thrill we get when that patient thanks us for relieving the claudication that prevented gainful employment. We are relieved when a longstanding patient wakes up neurologically intact from an endarterectomy.

However, we are filled with remorse when we inform a family that they have lost their loved one who died from a ruptured aneurysm. Of course, our failures may be devastating but they reinforce our humility when we acknowledge that we have been defeated by a disease that resisted our every effort.

The mentor may also share that “Every Xmas you will collect cards thanking you for saving a life or, out of the blue, receive a carton of fruit from the orchard of a farmer who finally was able to walk amongst her crop. You will pass tissues to the sobbing husband whose wife always accompanied him to his yearly physical, but who recently passed from incurable cancer. You will listen to stories from veterans of past wars. You will see pictures of patients’ children and you will remark how they have grown through the years. A patient will make you look admiringly at their latest puppy or prize-winning pig. You will be given stock advice by a millionaire and you will pay for a taxi for the indigent to get home from your office. You may keep patients waiting while you hear intriguing gossip or wonder just how you can stop the little old lady rambling on about lost loves. You will be charmed by the 98-year-old who makes sure that she has her hair and makeup done prior to coming to see you, and how her face lights up when you pronounce her more beautiful than ever.

“Dear student, the technical aspects of vascular surgery are indeed demanding and exciting. We are invigorated by the knowledge that our expertise saved a life or limb, prevented a stroke or provided the nephrotic with a working fistula. Even the more simple cosmetic procedures give us pleasure. If you still need inspiration to embark on a vascular surgical career I encourage you to read the Presidential address Dr. Bruce J. Brener gave to the Society for Clinical Vascular Surgery in March 1996. His eloquent portrayal of the vascular surgical experience is unmatched (Amer J Surg, 1996; 172:97-9). However, it is our daily and often lifelong interaction with our wonderful patients that so intimately reinforces our humanity and makes this profession so uniquely satisfying.”

This edition of Vascular Specialist is being published early to coincide with the VAM. Since medical students will be attending the meeting I thought this would be a good opportunity to describe an often overlooked reason why, after all my years in practice, I still enjoy being a vascular surgeon. By doing so I hope to encourage these young people to consider a career in vascular surgery.

Some vascular surgeons, with the same goal, have volunteered to mentor these students at the VAM. I suspect most mentors would extoll vascular surgery as unique amongst surgical specialties. They will describe the variety of complex operations as well as advanced endovascular procedures that we perform. Proudly, some mentors will mention that other practitioners turn to us for help when they encounter uncontrollable hemorrhage. They will emphasize that we are the one specialty that covers the gamut of vascular interventions from open surgery and endovascular procedures to medical management. Perhaps some mentors will incorporate my mantra that vascular surgeons “Operate, Dilate, and Medicate.”

However, I suggest that the most satisfying aspect of our profession is not the procedures that we perform but rather the interaction we have with our patients. After all, most of us entered the medical profession to take care of patients, and vascular patients are very special indeed. However, sometimes we established vascular surgeons become too enthralled by technical advances to remember the more humanistic reasons for our being. Also, changes in medical practice and reimbursement have resulted in many being so overworked that we do not have time to enjoy relationships with our patients. Perhaps those who are so burdened should take heed from the stories mentors will relate to inspire these students.

Based on my personal experience I suspect the mentors will say something along the following lines: “Vascular conditions are chronic and are wont to afflict more than one part of the body. Accordingly, we are required to follow most patients for their whole lives (or ours!). Not only do we treat these patients but we also become intimately involved with their families, often treating them as well. Often our ‘treatment’ will not be procedural but rather will involve emotional support of these relatives as they deal with their recuperating or debilitated spouse, sibling, or parent. Those of us who have been in practice for many years will fondly recall patients who have become an integral part of our lives. The patient who undergoes a vascular procedure will return every 6 or 12 months to have their bypass checked or their other carotid assessed.

“We follow asymptomatic small abdominal aneurysms and claudicants. A venous ulcer often recurs and a dialysis patient may require a new intervention. Some patients come to the office so they can be made more secure that their condition has not deteriorated, and the lonely just because we are the only human they interact with on a regular basis. They bring with them their varied life stories and these vignettes become a part of our own fiction. Perhaps we will share with them our own life story. Contrast that to the general surgeon who repairs a hernia and after a few post op visits may never see the patient again.

“Vascular patients may be very young or more commonly very old and come from all walks of life. So the vascular surgeon will learn to calm the crying infant. She will provide careful optimism to allay the fears of a mother who brings in her daughter scarred by a cavernous hemangioma. He or she will reassure the young girl, mortified by embarrassing spider veins, that she will be able to wear a dress to her high school prom. Together with the obstetrician, the vascular surgeon will guide a pregnant woman with a DVT through her entire pregnancy assuring her that both she and her baby will be safe.”

The mentor will re-count how special it was to get a hug from an old lady who he operated on 25 years previously when he was a young surgeon. Or the gratification one gets when a father, after a successful limb revascularization, shows a video of himself walking down the aisle at his daughter’s wedding. Perhaps the mentor will confide her sense of dismay every time a young dialysis patient is admitted for revision of a fistula and the joy she feels when told that her patient has finally received a viable transplant. Year after year the vascular surgeon will follow a patient with early onset, widespread vascular disease whose parents died young from the ravages of familial hyperlipidemia.

He will provide encouragement to help the patient stop smoking and commiserate when a sibling dies from a heart attack. The mentor might relate how she felt when she saved the leg of a soldier injured by a land mine or how she was amazed by the 80-year-old ballroom dancer who danced a few weeks after a below knee amputation.

Mentors will also describe getting to know a patient’s daily routine so they can informatively advise a patient whether it is worth having a procedure to improve quality of life. Or the thrill we get when that patient thanks us for relieving the claudication that prevented gainful employment. We are relieved when a longstanding patient wakes up neurologically intact from an endarterectomy.

However, we are filled with remorse when we inform a family that they have lost their loved one who died from a ruptured aneurysm. Of course, our failures may be devastating but they reinforce our humility when we acknowledge that we have been defeated by a disease that resisted our every effort.

The mentor may also share that “Every Xmas you will collect cards thanking you for saving a life or, out of the blue, receive a carton of fruit from the orchard of a farmer who finally was able to walk amongst her crop. You will pass tissues to the sobbing husband whose wife always accompanied him to his yearly physical, but who recently passed from incurable cancer. You will listen to stories from veterans of past wars. You will see pictures of patients’ children and you will remark how they have grown through the years. A patient will make you look admiringly at their latest puppy or prize-winning pig. You will be given stock advice by a millionaire and you will pay for a taxi for the indigent to get home from your office. You may keep patients waiting while you hear intriguing gossip or wonder just how you can stop the little old lady rambling on about lost loves. You will be charmed by the 98-year-old who makes sure that she has her hair and makeup done prior to coming to see you, and how her face lights up when you pronounce her more beautiful than ever.

“Dear student, the technical aspects of vascular surgery are indeed demanding and exciting. We are invigorated by the knowledge that our expertise saved a life or limb, prevented a stroke or provided the nephrotic with a working fistula. Even the more simple cosmetic procedures give us pleasure. If you still need inspiration to embark on a vascular surgical career I encourage you to read the Presidential address Dr. Bruce J. Brener gave to the Society for Clinical Vascular Surgery in March 1996. His eloquent portrayal of the vascular surgical experience is unmatched (Amer J Surg, 1996; 172:97-9). However, it is our daily and often lifelong interaction with our wonderful patients that so intimately reinforces our humanity and makes this profession so uniquely satisfying.”

This edition of Vascular Specialist is being published early to coincide with the VAM. Since medical students will be attending the meeting I thought this would be a good opportunity to describe an often overlooked reason why, after all my years in practice, I still enjoy being a vascular surgeon. By doing so I hope to encourage these young people to consider a career in vascular surgery.

Some vascular surgeons, with the same goal, have volunteered to mentor these students at the VAM. I suspect most mentors would extoll vascular surgery as unique amongst surgical specialties. They will describe the variety of complex operations as well as advanced endovascular procedures that we perform. Proudly, some mentors will mention that other practitioners turn to us for help when they encounter uncontrollable hemorrhage. They will emphasize that we are the one specialty that covers the gamut of vascular interventions from open surgery and endovascular procedures to medical management. Perhaps some mentors will incorporate my mantra that vascular surgeons “Operate, Dilate, and Medicate.”

However, I suggest that the most satisfying aspect of our profession is not the procedures that we perform but rather the interaction we have with our patients. After all, most of us entered the medical profession to take care of patients, and vascular patients are very special indeed. However, sometimes we established vascular surgeons become too enthralled by technical advances to remember the more humanistic reasons for our being. Also, changes in medical practice and reimbursement have resulted in many being so overworked that we do not have time to enjoy relationships with our patients. Perhaps those who are so burdened should take heed from the stories mentors will relate to inspire these students.

Based on my personal experience I suspect the mentors will say something along the following lines: “Vascular conditions are chronic and are wont to afflict more than one part of the body. Accordingly, we are required to follow most patients for their whole lives (or ours!). Not only do we treat these patients but we also become intimately involved with their families, often treating them as well. Often our ‘treatment’ will not be procedural but rather will involve emotional support of these relatives as they deal with their recuperating or debilitated spouse, sibling, or parent. Those of us who have been in practice for many years will fondly recall patients who have become an integral part of our lives. The patient who undergoes a vascular procedure will return every 6 or 12 months to have their bypass checked or their other carotid assessed.

“We follow asymptomatic small abdominal aneurysms and claudicants. A venous ulcer often recurs and a dialysis patient may require a new intervention. Some patients come to the office so they can be made more secure that their condition has not deteriorated, and the lonely just because we are the only human they interact with on a regular basis. They bring with them their varied life stories and these vignettes become a part of our own fiction. Perhaps we will share with them our own life story. Contrast that to the general surgeon who repairs a hernia and after a few post op visits may never see the patient again.

“Vascular patients may be very young or more commonly very old and come from all walks of life. So the vascular surgeon will learn to calm the crying infant. She will provide careful optimism to allay the fears of a mother who brings in her daughter scarred by a cavernous hemangioma. He or she will reassure the young girl, mortified by embarrassing spider veins, that she will be able to wear a dress to her high school prom. Together with the obstetrician, the vascular surgeon will guide a pregnant woman with a DVT through her entire pregnancy assuring her that both she and her baby will be safe.”

The mentor will re-count how special it was to get a hug from an old lady who he operated on 25 years previously when he was a young surgeon. Or the gratification one gets when a father, after a successful limb revascularization, shows a video of himself walking down the aisle at his daughter’s wedding. Perhaps the mentor will confide her sense of dismay every time a young dialysis patient is admitted for revision of a fistula and the joy she feels when told that her patient has finally received a viable transplant. Year after year the vascular surgeon will follow a patient with early onset, widespread vascular disease whose parents died young from the ravages of familial hyperlipidemia.

He will provide encouragement to help the patient stop smoking and commiserate when a sibling dies from a heart attack. The mentor might relate how she felt when she saved the leg of a soldier injured by a land mine or how she was amazed by the 80-year-old ballroom dancer who danced a few weeks after a below knee amputation.

Mentors will also describe getting to know a patient’s daily routine so they can informatively advise a patient whether it is worth having a procedure to improve quality of life. Or the thrill we get when that patient thanks us for relieving the claudication that prevented gainful employment. We are relieved when a longstanding patient wakes up neurologically intact from an endarterectomy.

However, we are filled with remorse when we inform a family that they have lost their loved one who died from a ruptured aneurysm. Of course, our failures may be devastating but they reinforce our humility when we acknowledge that we have been defeated by a disease that resisted our every effort.

The mentor may also share that “Every Xmas you will collect cards thanking you for saving a life or, out of the blue, receive a carton of fruit from the orchard of a farmer who finally was able to walk amongst her crop. You will pass tissues to the sobbing husband whose wife always accompanied him to his yearly physical, but who recently passed from incurable cancer. You will listen to stories from veterans of past wars. You will see pictures of patients’ children and you will remark how they have grown through the years. A patient will make you look admiringly at their latest puppy or prize-winning pig. You will be given stock advice by a millionaire and you will pay for a taxi for the indigent to get home from your office. You may keep patients waiting while you hear intriguing gossip or wonder just how you can stop the little old lady rambling on about lost loves. You will be charmed by the 98-year-old who makes sure that she has her hair and makeup done prior to coming to see you, and how her face lights up when you pronounce her more beautiful than ever.

“Dear student, the technical aspects of vascular surgery are indeed demanding and exciting. We are invigorated by the knowledge that our expertise saved a life or limb, prevented a stroke or provided the nephrotic with a working fistula. Even the more simple cosmetic procedures give us pleasure. If you still need inspiration to embark on a vascular surgical career I encourage you to read the Presidential address Dr. Bruce J. Brener gave to the Society for Clinical Vascular Surgery in March 1996. His eloquent portrayal of the vascular surgical experience is unmatched (Amer J Surg, 1996; 172:97-9). However, it is our daily and often lifelong interaction with our wonderful patients that so intimately reinforces our humanity and makes this profession so uniquely satisfying.”

The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

What are the risks of delaying transition until adulthood?

Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.¹ This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.² This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.³ Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.

Can gender dysphoria be diagnosed at an early age?

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.^4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,^6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.³

What are the medical risks with pubertal suppression and cross-sex hormones?

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).⁷ Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,⁸ whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,^9,10 especially after resumption of puberty.

What are the medical risks of using cross-sex hormones?

Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.⁷ Additionally, use of these hormones can induce infertility, and this is not always reversible.⁶ Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.¹¹ There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.¹² Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.

Can children and adolescents make complex, life-changing decisions?

The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.

However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.¹³ However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.

One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.

The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.

References:

1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).

2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.

3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.

4. Dev Psychol. 2008 Jan;44(1):34-45.

5. J Adolesc Health. 2015 Oct;57(4):367-73.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011; 7th ed.

8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.

9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.

10. Clinics (Sao Paulo). 2012;67(6):591-6.

11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.

12. Pediatrics. 2014 Oct;134(4):696-704.

13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

What are the risks of delaying transition until adulthood?

Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.¹ This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.² This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.³ Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.

Can gender dysphoria be diagnosed at an early age?

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.^4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,^6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.³

What are the medical risks with pubertal suppression and cross-sex hormones?

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).⁷ Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,⁸ whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,^9,10 especially after resumption of puberty.

What are the medical risks of using cross-sex hormones?

Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.⁷ Additionally, use of these hormones can induce infertility, and this is not always reversible.⁶ Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.¹¹ There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.¹² Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.

Can children and adolescents make complex, life-changing decisions?

The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.

However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.¹³ However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.

One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.

The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.

References:

1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).

2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.

3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.

4. Dev Psychol. 2008 Jan;44(1):34-45.

5. J Adolesc Health. 2015 Oct;57(4):367-73.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011; 7th ed.

8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.

9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.

10. Clinics (Sao Paulo). 2012;67(6):591-6.

11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.

12. Pediatrics. 2014 Oct;134(4):696-704.

13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

What are the risks of delaying transition until adulthood?

Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.¹ This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.² This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.³ Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.

Can gender dysphoria be diagnosed at an early age?

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.^4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,^6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.³

What are the medical risks with pubertal suppression and cross-sex hormones?

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).⁷ Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,⁸ whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,^9,10 especially after resumption of puberty.

What are the medical risks of using cross-sex hormones?

Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.⁷ Additionally, use of these hormones can induce infertility, and this is not always reversible.⁶ Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.¹¹ There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.¹² Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.

Can children and adolescents make complex, life-changing decisions?

The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.

However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.¹³ However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.

One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.

The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.

References:

1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).

2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.

3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.

4. Dev Psychol. 2008 Jan;44(1):34-45.

5. J Adolesc Health. 2015 Oct;57(4):367-73.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011; 7th ed.

8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.

9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.

10. Clinics (Sao Paulo). 2012;67(6):591-6.

11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.

12. Pediatrics. 2014 Oct;134(4):696-704.

13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

In discussion of pregnancy prevention, a great deal of time is spent on female birth control, and the use of condoms is like a tag line “Oh! And, of course, use a condom.” But are we really educating our teens on condoms, their proper use, and their prevention of sexually transmitted infections (STIs). Condoms are our basic entry level birth control, but despite their relative ease of use and accessibility, their use is on the decline.

When we evaluate unintended pregnancies among teens, it is down almost 20% since 1981, according to data from the Guttmacher Institute, but compared with other developed nations, our rates are high.

In 2013, the AAP published a statement encouraging schools and pediatricians to discuss and make condoms more accessible. Fifty-four studies were done on early education of condom use, and reported a 48% increase in their use and a 42% delay in the initiation of sexual activity by 6 months.¹ Despite these positive findings , condom use is still declining.

Many factors that affect their use are lack of formal education, availability, and the perception that they decrease sexual pleasure. Condom manufacturers have started campaigns that promote the image of escalating sexual pleasure, but they are competing with the media and music industry, which inundate teens with all kinds of sexual images. In review of the media, 77% showed sexual content, compared with 14% that showed risk and responsible sexual activity.

Before educating teens about condoms, we first must educate ourselves. Condoms are available in three forms: latex (80%), lamb’s cecum (15%), and synthetic (5%). Latex is considered the most effective condom in protecting against STIs and birth control. Synthetic is a good alternative to latex when a latex allergy is present, but is more prone to breakage and slippage. Lamb’s cecum prevents spread of some STIs, but because of its porous nature it does not provide protection against viruses such as HIV, hepatitis B, and herpes simplex virus (HSV). Nonlatex has a longer shelf life and is more compatible with lubricants.

Spermicide-coated condoms have fallen out of favor because the spermicide shortens the shelf life of the condom, as well as can cause mucosal irritation. When the mucosa is irritated, there is an associated increase of contracting STIs, particularly HIV.²

Make patients are aware that condoms do expire and that it is important to check the expiration date. Educating patients on the proper technique of putting a condom on is likely an awkward conversation for most, so consider directing them to the website Bedsiders.org, which has great explanations on how to use and put condoms on, along with comparisons of all types of birth control and which one is best for them.

Making condoms easily accessible is the most-important intervention. Studies show that when condoms are readily available, their use increases. The AAP advocates for schools and primary care doctors to hand them out freely.

Education is key in increasing usage of condoms and reducing spread of STIs. Encouraging parents to talk with their teen and provide access to condoms is crucial in lowering STI statistics. Although abstinence is the only 100% proof of protection, proper use of contraception is an alternative.

References

1. “Condom Use by Adolescents,” Pediatrics. 2013 Nov. doi: 10.1542/peds.2013-2821

2. “Contraception for Adolescents,” Pediatrics. 2014 Oct 10;134:e1244-56.

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].

In discussion of pregnancy prevention, a great deal of time is spent on female birth control, and the use of condoms is like a tag line “Oh! And, of course, use a condom.” But are we really educating our teens on condoms, their proper use, and their prevention of sexually transmitted infections (STIs). Condoms are our basic entry level birth control, but despite their relative ease of use and accessibility, their use is on the decline.

When we evaluate unintended pregnancies among teens, it is down almost 20% since 1981, according to data from the Guttmacher Institute, but compared with other developed nations, our rates are high.

In 2013, the AAP published a statement encouraging schools and pediatricians to discuss and make condoms more accessible. Fifty-four studies were done on early education of condom use, and reported a 48% increase in their use and a 42% delay in the initiation of sexual activity by 6 months.¹ Despite these positive findings , condom use is still declining.

Many factors that affect their use are lack of formal education, availability, and the perception that they decrease sexual pleasure. Condom manufacturers have started campaigns that promote the image of escalating sexual pleasure, but they are competing with the media and music industry, which inundate teens with all kinds of sexual images. In review of the media, 77% showed sexual content, compared with 14% that showed risk and responsible sexual activity.

Before educating teens about condoms, we first must educate ourselves. Condoms are available in three forms: latex (80%), lamb’s cecum (15%), and synthetic (5%). Latex is considered the most effective condom in protecting against STIs and birth control. Synthetic is a good alternative to latex when a latex allergy is present, but is more prone to breakage and slippage. Lamb’s cecum prevents spread of some STIs, but because of its porous nature it does not provide protection against viruses such as HIV, hepatitis B, and herpes simplex virus (HSV). Nonlatex has a longer shelf life and is more compatible with lubricants.

Spermicide-coated condoms have fallen out of favor because the spermicide shortens the shelf life of the condom, as well as can cause mucosal irritation. When the mucosa is irritated, there is an associated increase of contracting STIs, particularly HIV.²

Make patients are aware that condoms do expire and that it is important to check the expiration date. Educating patients on the proper technique of putting a condom on is likely an awkward conversation for most, so consider directing them to the website Bedsiders.org, which has great explanations on how to use and put condoms on, along with comparisons of all types of birth control and which one is best for them.

Making condoms easily accessible is the most-important intervention. Studies show that when condoms are readily available, their use increases. The AAP advocates for schools and primary care doctors to hand them out freely.

Education is key in increasing usage of condoms and reducing spread of STIs. Encouraging parents to talk with their teen and provide access to condoms is crucial in lowering STI statistics. Although abstinence is the only 100% proof of protection, proper use of contraception is an alternative.

References

1. “Condom Use by Adolescents,” Pediatrics. 2013 Nov. doi: 10.1542/peds.2013-2821

2. “Contraception for Adolescents,” Pediatrics. 2014 Oct 10;134:e1244-56.

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].

In discussion of pregnancy prevention, a great deal of time is spent on female birth control, and the use of condoms is like a tag line “Oh! And, of course, use a condom.” But are we really educating our teens on condoms, their proper use, and their prevention of sexually transmitted infections (STIs). Condoms are our basic entry level birth control, but despite their relative ease of use and accessibility, their use is on the decline.

When we evaluate unintended pregnancies among teens, it is down almost 20% since 1981, according to data from the Guttmacher Institute, but compared with other developed nations, our rates are high.

In 2013, the AAP published a statement encouraging schools and pediatricians to discuss and make condoms more accessible. Fifty-four studies were done on early education of condom use, and reported a 48% increase in their use and a 42% delay in the initiation of sexual activity by 6 months.¹ Despite these positive findings , condom use is still declining.

Many factors that affect their use are lack of formal education, availability, and the perception that they decrease sexual pleasure. Condom manufacturers have started campaigns that promote the image of escalating sexual pleasure, but they are competing with the media and music industry, which inundate teens with all kinds of sexual images. In review of the media, 77% showed sexual content, compared with 14% that showed risk and responsible sexual activity.

Before educating teens about condoms, we first must educate ourselves. Condoms are available in three forms: latex (80%), lamb’s cecum (15%), and synthetic (5%). Latex is considered the most effective condom in protecting against STIs and birth control. Synthetic is a good alternative to latex when a latex allergy is present, but is more prone to breakage and slippage. Lamb’s cecum prevents spread of some STIs, but because of its porous nature it does not provide protection against viruses such as HIV, hepatitis B, and herpes simplex virus (HSV). Nonlatex has a longer shelf life and is more compatible with lubricants.

Spermicide-coated condoms have fallen out of favor because the spermicide shortens the shelf life of the condom, as well as can cause mucosal irritation. When the mucosa is irritated, there is an associated increase of contracting STIs, particularly HIV.²

Make patients are aware that condoms do expire and that it is important to check the expiration date. Educating patients on the proper technique of putting a condom on is likely an awkward conversation for most, so consider directing them to the website Bedsiders.org, which has great explanations on how to use and put condoms on, along with comparisons of all types of birth control and which one is best for them.

Making condoms easily accessible is the most-important intervention. Studies show that when condoms are readily available, their use increases. The AAP advocates for schools and primary care doctors to hand them out freely.

Education is key in increasing usage of condoms and reducing spread of STIs. Encouraging parents to talk with their teen and provide access to condoms is crucial in lowering STI statistics. Although abstinence is the only 100% proof of protection, proper use of contraception is an alternative.

References

1. “Condom Use by Adolescents,” Pediatrics. 2013 Nov. doi: 10.1542/peds.2013-2821

2. “Contraception for Adolescents,” Pediatrics. 2014 Oct 10;134:e1244-56.

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].