Hair & Nails

NEW ORLEANS - Lasers and photodynamic therapy for the treatment of fungal toenails are beginning to generate substantial buzz among patients and podiatrists, but key questions regarding these novel proposed device therapies remain to be answered before they can truly be said to be the future of onychomycosis therapy.

For laser therapy, these questions include "Does it actually work?" and if so, by what mechanism? Dr. Boni E. Elewski said at the annual meeting of the American Academy of Dermatology.

Interest in laser therapy for fungal nails took off when one device, the PinPointe FootLaser, received Food and Drug Administration clearance for onychomycosis last October. Of note, however, the FDA didn't clear the device as a curative therapy, but rather "for the temporary increase of clear nail in patients with onychomycosis." This hasn't stopped some podiatrists from offering treatment with the PinPointe or other neodymium:YAG 1,064-nm lasers at a price tag of up to $1,000 per toe, a marketing ploy that implies definitive therapy and prompted Dr. Elewski to take a closer look.

Her in vitro studies in the mycology lab have left her convinced that lasers don't eradicate fungi through heat killing; the required nail temperatures would be intolerably painful. Moreover, direct lasering of fungi on agar plates and dilute broth had absolutely no impact on fungal growth. But these negative studies don't rule out other potential mechanisms of action, including a possible immunologic effect or laser-induced denaturization of enzymes that fungi need to digest skin cells, noted Dr. Elewski, professor of dermatology at the University of Alabama at Birmingham.

She is now conducting a clinical study in which patients with onychomycosis are being treated with an Nd:YAG 1,064-nm laser – not the PinPointe FootLaser – with a 5-mm spot size, a frequency of 2 Hz, and an energy density of 16 J/cm². Patients get a total of five treatments, each consisting of more than 300 pulses administered over the nail during a couple of minutes in a predetermined pattern. Anecdotally, in individual patients she has observed instances of fungi evacuating laser-treated nails, and the nails becoming culture negative over a period of several months. The study, however, remains ongoing.

"The jury is still out. I can't say yet whether laser therapy works," Dr. Elewski commented.

Unlike laser therapy for onychomycosis, photodynamic therapy (PDT) is backed by a published rigorously conducted study. And the mechanism of action is understood: In vitro, Trichophyton rubrum absorbs 5-aminolevulinic acid and can be photo killed.

But onychomycosis is not an FDA-approved indication for PDT. Moreover, the results of the published study cited by Dr. Elewski – a 43% cure rate 12 months after PDT and 37% at 18 months of follow-up – are comparable to but not better than success rates attained in the major clinical trials of terbinafine. Plus, the PDT sessions must be preceded by a lengthy, labor-intensive chemical nail avulsion. Nonetheless, PDT may provide an alternative option for onychomycosis when terbinafine and other oral agents are contraindicated, she continued.

The PDT study involved 30 patients with onychomycosis resulting from Trichophyton rubrum who were treated at Aristotle University of Thessaloniki (Greece). Following 10 consecutive nights in which 20% urea ointment was applied under occlusion to the nail plate, dermatologists removed the nail with forceps and applied 20% 5-aminolevulinic acid for 3 hours before treatment with red light at 570-670 nm, a light density of 40 J/cm², and a fluence of 40 mW/cm². Patients got three treatment sessions, each 2 weeks apart.

The Greek investigators demanded a rigorous, FDA-style definition of cure: complete absence of clinical signs of fungal infection, or less than 10% of the nail being affected by subungual hyperkeratosis along with mycologic cure. Thirteen of 30 (43%) patients fulfilled this definition at 12 months, as did 11 (37%) at 18 months. No fungal resistance was seen (Acta Derm. Venereol. 2010;90:216-7).

Dr. Elewski said that she receives research support from Cutera.

NEW ORLEANS - Lasers and photodynamic therapy for the treatment of fungal toenails are beginning to generate substantial buzz among patients and podiatrists, but key questions regarding these novel proposed device therapies remain to be answered before they can truly be said to be the future of onychomycosis therapy.

For laser therapy, these questions include "Does it actually work?" and if so, by what mechanism? Dr. Boni E. Elewski said at the annual meeting of the American Academy of Dermatology.

Interest in laser therapy for fungal nails took off when one device, the PinPointe FootLaser, received Food and Drug Administration clearance for onychomycosis last October. Of note, however, the FDA didn't clear the device as a curative therapy, but rather "for the temporary increase of clear nail in patients with onychomycosis." This hasn't stopped some podiatrists from offering treatment with the PinPointe or other neodymium:YAG 1,064-nm lasers at a price tag of up to $1,000 per toe, a marketing ploy that implies definitive therapy and prompted Dr. Elewski to take a closer look.

Her in vitro studies in the mycology lab have left her convinced that lasers don't eradicate fungi through heat killing; the required nail temperatures would be intolerably painful. Moreover, direct lasering of fungi on agar plates and dilute broth had absolutely no impact on fungal growth. But these negative studies don't rule out other potential mechanisms of action, including a possible immunologic effect or laser-induced denaturization of enzymes that fungi need to digest skin cells, noted Dr. Elewski, professor of dermatology at the University of Alabama at Birmingham.

She is now conducting a clinical study in which patients with onychomycosis are being treated with an Nd:YAG 1,064-nm laser – not the PinPointe FootLaser – with a 5-mm spot size, a frequency of 2 Hz, and an energy density of 16 J/cm². Patients get a total of five treatments, each consisting of more than 300 pulses administered over the nail during a couple of minutes in a predetermined pattern. Anecdotally, in individual patients she has observed instances of fungi evacuating laser-treated nails, and the nails becoming culture negative over a period of several months. The study, however, remains ongoing.

"The jury is still out. I can't say yet whether laser therapy works," Dr. Elewski commented.

Unlike laser therapy for onychomycosis, photodynamic therapy (PDT) is backed by a published rigorously conducted study. And the mechanism of action is understood: In vitro, Trichophyton rubrum absorbs 5-aminolevulinic acid and can be photo killed.

But onychomycosis is not an FDA-approved indication for PDT. Moreover, the results of the published study cited by Dr. Elewski – a 43% cure rate 12 months after PDT and 37% at 18 months of follow-up – are comparable to but not better than success rates attained in the major clinical trials of terbinafine. Plus, the PDT sessions must be preceded by a lengthy, labor-intensive chemical nail avulsion. Nonetheless, PDT may provide an alternative option for onychomycosis when terbinafine and other oral agents are contraindicated, she continued.

The PDT study involved 30 patients with onychomycosis resulting from Trichophyton rubrum who were treated at Aristotle University of Thessaloniki (Greece). Following 10 consecutive nights in which 20% urea ointment was applied under occlusion to the nail plate, dermatologists removed the nail with forceps and applied 20% 5-aminolevulinic acid for 3 hours before treatment with red light at 570-670 nm, a light density of 40 J/cm², and a fluence of 40 mW/cm². Patients got three treatment sessions, each 2 weeks apart.

The Greek investigators demanded a rigorous, FDA-style definition of cure: complete absence of clinical signs of fungal infection, or less than 10% of the nail being affected by subungual hyperkeratosis along with mycologic cure. Thirteen of 30 (43%) patients fulfilled this definition at 12 months, as did 11 (37%) at 18 months. No fungal resistance was seen (Acta Derm. Venereol. 2010;90:216-7).

Dr. Elewski said that she receives research support from Cutera.

NEW ORLEANS - Lasers and photodynamic therapy for the treatment of fungal toenails are beginning to generate substantial buzz among patients and podiatrists, but key questions regarding these novel proposed device therapies remain to be answered before they can truly be said to be the future of onychomycosis therapy.

For laser therapy, these questions include "Does it actually work?" and if so, by what mechanism? Dr. Boni E. Elewski said at the annual meeting of the American Academy of Dermatology.

Interest in laser therapy for fungal nails took off when one device, the PinPointe FootLaser, received Food and Drug Administration clearance for onychomycosis last October. Of note, however, the FDA didn't clear the device as a curative therapy, but rather "for the temporary increase of clear nail in patients with onychomycosis." This hasn't stopped some podiatrists from offering treatment with the PinPointe or other neodymium:YAG 1,064-nm lasers at a price tag of up to $1,000 per toe, a marketing ploy that implies definitive therapy and prompted Dr. Elewski to take a closer look.

Her in vitro studies in the mycology lab have left her convinced that lasers don't eradicate fungi through heat killing; the required nail temperatures would be intolerably painful. Moreover, direct lasering of fungi on agar plates and dilute broth had absolutely no impact on fungal growth. But these negative studies don't rule out other potential mechanisms of action, including a possible immunologic effect or laser-induced denaturization of enzymes that fungi need to digest skin cells, noted Dr. Elewski, professor of dermatology at the University of Alabama at Birmingham.

She is now conducting a clinical study in which patients with onychomycosis are being treated with an Nd:YAG 1,064-nm laser – not the PinPointe FootLaser – with a 5-mm spot size, a frequency of 2 Hz, and an energy density of 16 J/cm². Patients get a total of five treatments, each consisting of more than 300 pulses administered over the nail during a couple of minutes in a predetermined pattern. Anecdotally, in individual patients she has observed instances of fungi evacuating laser-treated nails, and the nails becoming culture negative over a period of several months. The study, however, remains ongoing.

"The jury is still out. I can't say yet whether laser therapy works," Dr. Elewski commented.

Unlike laser therapy for onychomycosis, photodynamic therapy (PDT) is backed by a published rigorously conducted study. And the mechanism of action is understood: In vitro, Trichophyton rubrum absorbs 5-aminolevulinic acid and can be photo killed.

But onychomycosis is not an FDA-approved indication for PDT. Moreover, the results of the published study cited by Dr. Elewski – a 43% cure rate 12 months after PDT and 37% at 18 months of follow-up – are comparable to but not better than success rates attained in the major clinical trials of terbinafine. Plus, the PDT sessions must be preceded by a lengthy, labor-intensive chemical nail avulsion. Nonetheless, PDT may provide an alternative option for onychomycosis when terbinafine and other oral agents are contraindicated, she continued.

The PDT study involved 30 patients with onychomycosis resulting from Trichophyton rubrum who were treated at Aristotle University of Thessaloniki (Greece). Following 10 consecutive nights in which 20% urea ointment was applied under occlusion to the nail plate, dermatologists removed the nail with forceps and applied 20% 5-aminolevulinic acid for 3 hours before treatment with red light at 570-670 nm, a light density of 40 J/cm², and a fluence of 40 mW/cm². Patients got three treatment sessions, each 2 weeks apart.

The Greek investigators demanded a rigorous, FDA-style definition of cure: complete absence of clinical signs of fungal infection, or less than 10% of the nail being affected by subungual hyperkeratosis along with mycologic cure. Thirteen of 30 (43%) patients fulfilled this definition at 12 months, as did 11 (37%) at 18 months. No fungal resistance was seen (Acta Derm. Venereol. 2010;90:216-7).

Dr. Elewski said that she receives research support from Cutera.

Men with prostate cancer are twice as likely to have had male pattern baldness starting at age 20, according to results of a study that found no increased risk among men who began balding in their 30s or 40s.

The findings, published Feb. 16 in Annals of Oncology (doi:10.1093/annonc/mdq695), suggest that men with early baldness may benefit from routine prostate cancer screening or preventive measures that could include the systematic use of 5-alpha reductase inhibitors, the researchers wrote.

 (c) Smobserver Wikipedia/ Creative Commons  

For their research, Dr. Michael Yassa, who was a radiation oncology fellow at the Georges Pompidou European Hospital in Paris at the time of the study, and his associates studied 388 men with a diagnosis of prostate cancer, recruited from radiation oncology clinics in three French institutions. The study also included 281 matched controls with no history of cancer or hormonal pathologies, but with family histories similar to those of the cases. The mean age of the subjects was 67.2, and the controls, 66.4.

All study participants were asked to report any personal history of prostate cancer and their fathers' histories of the same, and to describe their balding pattern at ages 20, 30, and 40 along with their fathers', using a set of four images adapted from the Hamilton-Norwood scale of male pattern baldness. Case subjects' age at diagnosis, stage of disease at diagnosis, treatment, and other information were recorded.

The men with prostate cancer were twice as likely to have had male pattern baldness at age 20 (odds ratio [OR] 2.01). "This trend was lost at ages 30 or 40," the researchers wrote. No specific pattern of hair loss appeared to be a predictive factor for the development of prostate cancer.

Any balding present at age 20 was associated with an increased incidence of prostate cancer later in life. Cancer patients with early balding did not develop cancers younger – those with any pattern of balding by age 20 and 40 had a mean age of diagnosis of 64.4 and 64.5 years, respectively, compared with 64.3 years for patients with no balding by age 40. The researchers also found no associations between early balding and more aggressive types of tumors.

Dr. Yassa, now with the University of Montreal, and colleagues cited a number of earlier studies with conflicting evidence on the links between baldness and cancer. One Duke University study (Cancer Epidemiol. Biomarkers Prev. 2000;9:325-8) showed that men who developed vertex baldness by age 30 had nearly a twofold increase in risk of developing prostate cancer, but a more recent population-based study (Cancer Epidemiol. [doi:10.1016/j.canep.2010.02.003]) showed baldness at age 30 to be associated with 29% relative risk reduction for prostate cancer.

The investigators in the current study speculated that androgens might be implicated in any link between early balding and cancer. "Finasteride blocks the conversion of testosterone to dihydrotestosterone, the active metabolite of testosterone, slowing the progression of androgenic alopecia and decreasing the incidence of prostate cancer," they wrote.

They also acknowledged that their own study was limited by its small size and a case-control design involving self-reporting, that could allow for recall and selective recall bias, and a lack of controlling for factors including African heritage and dietary differences.

Neither Dr. Hassa nor his coauthors declared conflicts of interest.

Men with prostate cancer are twice as likely to have had male pattern baldness starting at age 20, according to results of a study that found no increased risk among men who began balding in their 30s or 40s.

The findings, published Feb. 16 in Annals of Oncology (doi:10.1093/annonc/mdq695), suggest that men with early baldness may benefit from routine prostate cancer screening or preventive measures that could include the systematic use of 5-alpha reductase inhibitors, the researchers wrote.

 (c) Smobserver Wikipedia/ Creative Commons  

For their research, Dr. Michael Yassa, who was a radiation oncology fellow at the Georges Pompidou European Hospital in Paris at the time of the study, and his associates studied 388 men with a diagnosis of prostate cancer, recruited from radiation oncology clinics in three French institutions. The study also included 281 matched controls with no history of cancer or hormonal pathologies, but with family histories similar to those of the cases. The mean age of the subjects was 67.2, and the controls, 66.4.

All study participants were asked to report any personal history of prostate cancer and their fathers' histories of the same, and to describe their balding pattern at ages 20, 30, and 40 along with their fathers', using a set of four images adapted from the Hamilton-Norwood scale of male pattern baldness. Case subjects' age at diagnosis, stage of disease at diagnosis, treatment, and other information were recorded.

The men with prostate cancer were twice as likely to have had male pattern baldness at age 20 (odds ratio [OR] 2.01). "This trend was lost at ages 30 or 40," the researchers wrote. No specific pattern of hair loss appeared to be a predictive factor for the development of prostate cancer.

Any balding present at age 20 was associated with an increased incidence of prostate cancer later in life. Cancer patients with early balding did not develop cancers younger – those with any pattern of balding by age 20 and 40 had a mean age of diagnosis of 64.4 and 64.5 years, respectively, compared with 64.3 years for patients with no balding by age 40. The researchers also found no associations between early balding and more aggressive types of tumors.

Dr. Yassa, now with the University of Montreal, and colleagues cited a number of earlier studies with conflicting evidence on the links between baldness and cancer. One Duke University study (Cancer Epidemiol. Biomarkers Prev. 2000;9:325-8) showed that men who developed vertex baldness by age 30 had nearly a twofold increase in risk of developing prostate cancer, but a more recent population-based study (Cancer Epidemiol. [doi:10.1016/j.canep.2010.02.003]) showed baldness at age 30 to be associated with 29% relative risk reduction for prostate cancer.

The investigators in the current study speculated that androgens might be implicated in any link between early balding and cancer. "Finasteride blocks the conversion of testosterone to dihydrotestosterone, the active metabolite of testosterone, slowing the progression of androgenic alopecia and decreasing the incidence of prostate cancer," they wrote.

They also acknowledged that their own study was limited by its small size and a case-control design involving self-reporting, that could allow for recall and selective recall bias, and a lack of controlling for factors including African heritage and dietary differences.

Neither Dr. Hassa nor his coauthors declared conflicts of interest.

Men with prostate cancer are twice as likely to have had male pattern baldness starting at age 20, according to results of a study that found no increased risk among men who began balding in their 30s or 40s.

The findings, published Feb. 16 in Annals of Oncology (doi:10.1093/annonc/mdq695), suggest that men with early baldness may benefit from routine prostate cancer screening or preventive measures that could include the systematic use of 5-alpha reductase inhibitors, the researchers wrote.

 (c) Smobserver Wikipedia/ Creative Commons  

For their research, Dr. Michael Yassa, who was a radiation oncology fellow at the Georges Pompidou European Hospital in Paris at the time of the study, and his associates studied 388 men with a diagnosis of prostate cancer, recruited from radiation oncology clinics in three French institutions. The study also included 281 matched controls with no history of cancer or hormonal pathologies, but with family histories similar to those of the cases. The mean age of the subjects was 67.2, and the controls, 66.4.

All study participants were asked to report any personal history of prostate cancer and their fathers' histories of the same, and to describe their balding pattern at ages 20, 30, and 40 along with their fathers', using a set of four images adapted from the Hamilton-Norwood scale of male pattern baldness. Case subjects' age at diagnosis, stage of disease at diagnosis, treatment, and other information were recorded.

The men with prostate cancer were twice as likely to have had male pattern baldness at age 20 (odds ratio [OR] 2.01). "This trend was lost at ages 30 or 40," the researchers wrote. No specific pattern of hair loss appeared to be a predictive factor for the development of prostate cancer.

Any balding present at age 20 was associated with an increased incidence of prostate cancer later in life. Cancer patients with early balding did not develop cancers younger – those with any pattern of balding by age 20 and 40 had a mean age of diagnosis of 64.4 and 64.5 years, respectively, compared with 64.3 years for patients with no balding by age 40. The researchers also found no associations between early balding and more aggressive types of tumors.

Dr. Yassa, now with the University of Montreal, and colleagues cited a number of earlier studies with conflicting evidence on the links between baldness and cancer. One Duke University study (Cancer Epidemiol. Biomarkers Prev. 2000;9:325-8) showed that men who developed vertex baldness by age 30 had nearly a twofold increase in risk of developing prostate cancer, but a more recent population-based study (Cancer Epidemiol. [doi:10.1016/j.canep.2010.02.003]) showed baldness at age 30 to be associated with 29% relative risk reduction for prostate cancer.

The investigators in the current study speculated that androgens might be implicated in any link between early balding and cancer. "Finasteride blocks the conversion of testosterone to dihydrotestosterone, the active metabolite of testosterone, slowing the progression of androgenic alopecia and decreasing the incidence of prostate cancer," they wrote.

They also acknowledged that their own study was limited by its small size and a case-control design involving self-reporting, that could allow for recall and selective recall bias, and a lack of controlling for factors including African heritage and dietary differences.

Neither Dr. Hassa nor his coauthors declared conflicts of interest.

NEW ORLEANS - The annual incidence of tinea capitis dropped dramatically during 1998-2007, at least in Northern California.

The incidence among children enrolled in Kaiser Permanente of Northern California was 1.3% in 1998 and again in 1999 before it began a steady decline, culminating in an incidence of 0.3% in 2007, Dr. Paradi Mirmirani reported at the annual meeting of the American Academy of Dermatology.

Her retrospective, population-based study included all Kaiser members younger than 15 years, with an average of 672,373 children per year. Some 70% of all cases of tinea capitis were diagnosed after age 5 years, noted Dr. Mirmirani of the Permanente Medical Group in Vallejo, Calif.

As in numerous other studies, the highest rates of tinea capitis in the Kaiser study occurred in black children. They were also the group with the sharpest decline during the 10-year study period. The incidence of tinea capitis in black children was 450 cases per 10,000 in 1998, plunging to about 200 per 10,000 by 2007.

The incidence declined significantly in all other ethnic groups as well, but those declines started from far lower baseline rates of 75-130 cases per 10,000 in 1998.

"That's quite a dramatic decrease. Maybe we're doing something right," commented session chair Dr. Richard L. Gallo, professor of medicine and pediatrics and chief of the division of dermatology at the University of California, San Diego.

Dr. Mirmirani said that girls had a significantly lower incidence than did boys (1.1% vs. 1.6%). Trichophyton tonsurans remained the predominant causative organism, as has been the case across the United States for decades. T. tonsurans accounted for 89% of all positive cultures at Kaiser in 1998, and 92% in 2007, Dr. Mirmirani continued.

The incidence of tinea capitis in Northern California showed no clear correlation with population density. Although the highest rate was seen in San Francisco County (the most population-dense county), the second-highest rate was in Solano County, which ranked only seventh in terms of population density.

Rates of coexisting atopic diseases in kids with tinea capitis were similar to those reported in the general population. In all, 16% of Kaiser patients with tinea capitis had a coexisting diagnosis of atopic dermatitis, 20% had asthma, and 15% had allergic rhinitis.

The big question, Dr. Mirmirani noted, is why the incidence of tinea capitis in 2007 was less than one-quarter the rate 10 years earlier. There are several possible explanations. For example, the number of new prescriptions for fluconazole and terbinafine rose significantly in the Kaiser system during the study years, while prescriptions for griseofulvin correspondingly declined. It's possible that the increased use of newer antifungal agents contributed to the fall in tinea capitis during 1998-2007.

It's also possible that since the late 1990s, dermatologists have done a better job of educating pediatricians and family physicians (the first-line physicians in dealing with dermatophyte infections) regarding recognition and treatment of cases of tinea capitis and carriers, she added.

Dr. Mirmirani observed that although T. tonsurans is the predominant pathogen today, it wasn't always so. In the 1940s and 1950s, it was Microsporum audouinii, an easier-to-diagnose organism that causes a more inflammatory infection and is visible by Wood's lamp.

"It seems like there's a constant tug of war between host and fungus, a bit of a cat-and-mouse game that causes the causative organism to evolve," the dermatologist said.

Her study was funded by the Kaiser Permanente division of research. Dr. Mirmirani declared having no relevant financial relationships with industry.

NEW ORLEANS - The annual incidence of tinea capitis dropped dramatically during 1998-2007, at least in Northern California.

The incidence among children enrolled in Kaiser Permanente of Northern California was 1.3% in 1998 and again in 1999 before it began a steady decline, culminating in an incidence of 0.3% in 2007, Dr. Paradi Mirmirani reported at the annual meeting of the American Academy of Dermatology.

Her retrospective, population-based study included all Kaiser members younger than 15 years, with an average of 672,373 children per year. Some 70% of all cases of tinea capitis were diagnosed after age 5 years, noted Dr. Mirmirani of the Permanente Medical Group in Vallejo, Calif.

As in numerous other studies, the highest rates of tinea capitis in the Kaiser study occurred in black children. They were also the group with the sharpest decline during the 10-year study period. The incidence of tinea capitis in black children was 450 cases per 10,000 in 1998, plunging to about 200 per 10,000 by 2007.

The incidence declined significantly in all other ethnic groups as well, but those declines started from far lower baseline rates of 75-130 cases per 10,000 in 1998.

"That's quite a dramatic decrease. Maybe we're doing something right," commented session chair Dr. Richard L. Gallo, professor of medicine and pediatrics and chief of the division of dermatology at the University of California, San Diego.

Dr. Mirmirani said that girls had a significantly lower incidence than did boys (1.1% vs. 1.6%). Trichophyton tonsurans remained the predominant causative organism, as has been the case across the United States for decades. T. tonsurans accounted for 89% of all positive cultures at Kaiser in 1998, and 92% in 2007, Dr. Mirmirani continued.

The incidence of tinea capitis in Northern California showed no clear correlation with population density. Although the highest rate was seen in San Francisco County (the most population-dense county), the second-highest rate was in Solano County, which ranked only seventh in terms of population density.

Rates of coexisting atopic diseases in kids with tinea capitis were similar to those reported in the general population. In all, 16% of Kaiser patients with tinea capitis had a coexisting diagnosis of atopic dermatitis, 20% had asthma, and 15% had allergic rhinitis.

The big question, Dr. Mirmirani noted, is why the incidence of tinea capitis in 2007 was less than one-quarter the rate 10 years earlier. There are several possible explanations. For example, the number of new prescriptions for fluconazole and terbinafine rose significantly in the Kaiser system during the study years, while prescriptions for griseofulvin correspondingly declined. It's possible that the increased use of newer antifungal agents contributed to the fall in tinea capitis during 1998-2007.

It's also possible that since the late 1990s, dermatologists have done a better job of educating pediatricians and family physicians (the first-line physicians in dealing with dermatophyte infections) regarding recognition and treatment of cases of tinea capitis and carriers, she added.

Dr. Mirmirani observed that although T. tonsurans is the predominant pathogen today, it wasn't always so. In the 1940s and 1950s, it was Microsporum audouinii, an easier-to-diagnose organism that causes a more inflammatory infection and is visible by Wood's lamp.

"It seems like there's a constant tug of war between host and fungus, a bit of a cat-and-mouse game that causes the causative organism to evolve," the dermatologist said.

Her study was funded by the Kaiser Permanente division of research. Dr. Mirmirani declared having no relevant financial relationships with industry.

NEW ORLEANS - The annual incidence of tinea capitis dropped dramatically during 1998-2007, at least in Northern California.

The incidence among children enrolled in Kaiser Permanente of Northern California was 1.3% in 1998 and again in 1999 before it began a steady decline, culminating in an incidence of 0.3% in 2007, Dr. Paradi Mirmirani reported at the annual meeting of the American Academy of Dermatology.

Her retrospective, population-based study included all Kaiser members younger than 15 years, with an average of 672,373 children per year. Some 70% of all cases of tinea capitis were diagnosed after age 5 years, noted Dr. Mirmirani of the Permanente Medical Group in Vallejo, Calif.

As in numerous other studies, the highest rates of tinea capitis in the Kaiser study occurred in black children. They were also the group with the sharpest decline during the 10-year study period. The incidence of tinea capitis in black children was 450 cases per 10,000 in 1998, plunging to about 200 per 10,000 by 2007.

The incidence declined significantly in all other ethnic groups as well, but those declines started from far lower baseline rates of 75-130 cases per 10,000 in 1998.

"That's quite a dramatic decrease. Maybe we're doing something right," commented session chair Dr. Richard L. Gallo, professor of medicine and pediatrics and chief of the division of dermatology at the University of California, San Diego.

Dr. Mirmirani said that girls had a significantly lower incidence than did boys (1.1% vs. 1.6%). Trichophyton tonsurans remained the predominant causative organism, as has been the case across the United States for decades. T. tonsurans accounted for 89% of all positive cultures at Kaiser in 1998, and 92% in 2007, Dr. Mirmirani continued.

The incidence of tinea capitis in Northern California showed no clear correlation with population density. Although the highest rate was seen in San Francisco County (the most population-dense county), the second-highest rate was in Solano County, which ranked only seventh in terms of population density.

Rates of coexisting atopic diseases in kids with tinea capitis were similar to those reported in the general population. In all, 16% of Kaiser patients with tinea capitis had a coexisting diagnosis of atopic dermatitis, 20% had asthma, and 15% had allergic rhinitis.

The big question, Dr. Mirmirani noted, is why the incidence of tinea capitis in 2007 was less than one-quarter the rate 10 years earlier. There are several possible explanations. For example, the number of new prescriptions for fluconazole and terbinafine rose significantly in the Kaiser system during the study years, while prescriptions for griseofulvin correspondingly declined. It's possible that the increased use of newer antifungal agents contributed to the fall in tinea capitis during 1998-2007.

It's also possible that since the late 1990s, dermatologists have done a better job of educating pediatricians and family physicians (the first-line physicians in dealing with dermatophyte infections) regarding recognition and treatment of cases of tinea capitis and carriers, she added.

Dr. Mirmirani observed that although T. tonsurans is the predominant pathogen today, it wasn't always so. In the 1940s and 1950s, it was Microsporum audouinii, an easier-to-diagnose organism that causes a more inflammatory infection and is visible by Wood's lamp.

"It seems like there's a constant tug of war between host and fungus, a bit of a cat-and-mouse game that causes the causative organism to evolve," the dermatologist said.

Her study was funded by the Kaiser Permanente division of research. Dr. Mirmirani declared having no relevant financial relationships with industry.

NEW ORLEANS - Any dermatologist who's not regularly using topical 5% 5-fluorouracil cream for treatment of warts in children is missing out on a therapy that's singularly safe, well tolerated, and effective.

That's the considered opinion of Dr. Bari B. Cunningham, who not only uses this therapy on a daily basis in her Encinitas, Calif., pediatric dermatology practice, but was also senior author of an open-label study demonstrating its benefits.

"I would strongly urge you to consider this therapy. This is a pearl that will make a major impact on the pediatric patients you see every day," she promised at the annual meeting of the American Academy of Dermatology.

From her standpoint, the most important thing about topical 5-FU cream for warts in kids is its safety, since this therapy does after all involve off-label use of a potent drug in little children. Reassuringly, in her 39-patient study there were no detectable blood levels of 5-FU during or after 6 weeks of therapy.

From the perspective of the patient and family, however, the big appeal is the therapy's ease and tolerability.

"When you're a dermatologist dealing with kids you really need to look for alternatives to the painful therapies that we currently use. If you have child with extensive warts you really can't be considering painful treatment options such as liquid nitrogen or intralesional bleomycin. That's just not going to cut it, and that family is never going to come back to you again. It’s not humane to expect a child to sit through painful treatments for something that benign," explained Dr. Cunningham.

The 39 children in her study all had at least two hand warts to which topical 5-FU cream was applied once or twice daily under occlusion for 6 weeks. Eighty-eight percent of patients were significantly improved after 6 weeks, and 41% had complete resolution of at least one wart. The treatment response didn't differ between once- and twice-daily therapy. Tolerability and patient satisfaction were excellent. At 6 months of follow-up, 87% of complete responders had no wart recurrences (Pediatr. Dermatol. 2009;26:279-85).

Since publication of her study, Dr. Cunningham has modified how she uses topical 5-FU cream for pediatric warts. The drug is applied at night under duct tape occlusion, alternating with salicylic acid under duct tape occlusion every second night because she believes the two agents are complementary. The duct tape is removed each morning and the wart is left uncovered and untreated during the day.

"I only do this for a month at a time because that's really all I ever need. If this medicine is going to work – and it usually does – it works fast," she said.

The ideal warts for this form of therapy are single and rapidly growing. "The ones that are doubling in size every couple of weeks like they've got a mind of their own, those are the perfect ones to treat with topical 5-FU because 5-FU is going to impair cell division and really shut that wart down," Dr. Cunningham continued.

She offered a few cautionary notes: Don't use this therapy on periungual warts; it will result in serious onycholysis, and the nail will fall off. Avoid treating warts on the face. In order to prevent systemic absorption, don’t use topical 5-FU cream in orally fixated thumb suckers. And make sure to keep the medication out of reach of the family dog. Dogs have a paradoxical toxic reaction to topical 5-FU. There are dozens of reports of dog fatalities in the veterinary literature, Dr. Cunningham said.

She declared having no relevant financial interests.

NEW ORLEANS - Any dermatologist who's not regularly using topical 5% 5-fluorouracil cream for treatment of warts in children is missing out on a therapy that's singularly safe, well tolerated, and effective.

That's the considered opinion of Dr. Bari B. Cunningham, who not only uses this therapy on a daily basis in her Encinitas, Calif., pediatric dermatology practice, but was also senior author of an open-label study demonstrating its benefits.

"I would strongly urge you to consider this therapy. This is a pearl that will make a major impact on the pediatric patients you see every day," she promised at the annual meeting of the American Academy of Dermatology.

From her standpoint, the most important thing about topical 5-FU cream for warts in kids is its safety, since this therapy does after all involve off-label use of a potent drug in little children. Reassuringly, in her 39-patient study there were no detectable blood levels of 5-FU during or after 6 weeks of therapy.

From the perspective of the patient and family, however, the big appeal is the therapy's ease and tolerability.

"When you're a dermatologist dealing with kids you really need to look for alternatives to the painful therapies that we currently use. If you have child with extensive warts you really can't be considering painful treatment options such as liquid nitrogen or intralesional bleomycin. That's just not going to cut it, and that family is never going to come back to you again. It’s not humane to expect a child to sit through painful treatments for something that benign," explained Dr. Cunningham.

The 39 children in her study all had at least two hand warts to which topical 5-FU cream was applied once or twice daily under occlusion for 6 weeks. Eighty-eight percent of patients were significantly improved after 6 weeks, and 41% had complete resolution of at least one wart. The treatment response didn't differ between once- and twice-daily therapy. Tolerability and patient satisfaction were excellent. At 6 months of follow-up, 87% of complete responders had no wart recurrences (Pediatr. Dermatol. 2009;26:279-85).

Since publication of her study, Dr. Cunningham has modified how she uses topical 5-FU cream for pediatric warts. The drug is applied at night under duct tape occlusion, alternating with salicylic acid under duct tape occlusion every second night because she believes the two agents are complementary. The duct tape is removed each morning and the wart is left uncovered and untreated during the day.

"I only do this for a month at a time because that's really all I ever need. If this medicine is going to work – and it usually does – it works fast," she said.

The ideal warts for this form of therapy are single and rapidly growing. "The ones that are doubling in size every couple of weeks like they've got a mind of their own, those are the perfect ones to treat with topical 5-FU because 5-FU is going to impair cell division and really shut that wart down," Dr. Cunningham continued.

She offered a few cautionary notes: Don't use this therapy on periungual warts; it will result in serious onycholysis, and the nail will fall off. Avoid treating warts on the face. In order to prevent systemic absorption, don’t use topical 5-FU cream in orally fixated thumb suckers. And make sure to keep the medication out of reach of the family dog. Dogs have a paradoxical toxic reaction to topical 5-FU. There are dozens of reports of dog fatalities in the veterinary literature, Dr. Cunningham said.

She declared having no relevant financial interests.

NEW ORLEANS - Any dermatologist who's not regularly using topical 5% 5-fluorouracil cream for treatment of warts in children is missing out on a therapy that's singularly safe, well tolerated, and effective.

That's the considered opinion of Dr. Bari B. Cunningham, who not only uses this therapy on a daily basis in her Encinitas, Calif., pediatric dermatology practice, but was also senior author of an open-label study demonstrating its benefits.

"I would strongly urge you to consider this therapy. This is a pearl that will make a major impact on the pediatric patients you see every day," she promised at the annual meeting of the American Academy of Dermatology.

From her standpoint, the most important thing about topical 5-FU cream for warts in kids is its safety, since this therapy does after all involve off-label use of a potent drug in little children. Reassuringly, in her 39-patient study there were no detectable blood levels of 5-FU during or after 6 weeks of therapy.

From the perspective of the patient and family, however, the big appeal is the therapy's ease and tolerability.

"When you're a dermatologist dealing with kids you really need to look for alternatives to the painful therapies that we currently use. If you have child with extensive warts you really can't be considering painful treatment options such as liquid nitrogen or intralesional bleomycin. That's just not going to cut it, and that family is never going to come back to you again. It’s not humane to expect a child to sit through painful treatments for something that benign," explained Dr. Cunningham.

The 39 children in her study all had at least two hand warts to which topical 5-FU cream was applied once or twice daily under occlusion for 6 weeks. Eighty-eight percent of patients were significantly improved after 6 weeks, and 41% had complete resolution of at least one wart. The treatment response didn't differ between once- and twice-daily therapy. Tolerability and patient satisfaction were excellent. At 6 months of follow-up, 87% of complete responders had no wart recurrences (Pediatr. Dermatol. 2009;26:279-85).

Since publication of her study, Dr. Cunningham has modified how she uses topical 5-FU cream for pediatric warts. The drug is applied at night under duct tape occlusion, alternating with salicylic acid under duct tape occlusion every second night because she believes the two agents are complementary. The duct tape is removed each morning and the wart is left uncovered and untreated during the day.

"I only do this for a month at a time because that's really all I ever need. If this medicine is going to work – and it usually does – it works fast," she said.

The ideal warts for this form of therapy are single and rapidly growing. "The ones that are doubling in size every couple of weeks like they've got a mind of their own, those are the perfect ones to treat with topical 5-FU because 5-FU is going to impair cell division and really shut that wart down," Dr. Cunningham continued.

She offered a few cautionary notes: Don't use this therapy on periungual warts; it will result in serious onycholysis, and the nail will fall off. Avoid treating warts on the face. In order to prevent systemic absorption, don’t use topical 5-FU cream in orally fixated thumb suckers. And make sure to keep the medication out of reach of the family dog. Dogs have a paradoxical toxic reaction to topical 5-FU. There are dozens of reports of dog fatalities in the veterinary literature, Dr. Cunningham said.

She declared having no relevant financial interests.

The Food and Drug Administration has approved a new topical treatment for head lice in children and adults.

Natroba Topical Suspension (spinosad 0.9%), proved more effective than Nix (permethrin 1%) when compared directly in clinical trials. In two trials involving a total of 1,038 children and adults, after one or two applications of spinosad, 85% and 87% of patients were lice free, compared with 45% and 43% of patients receiving permethrin (Pediatrics 2009;124:e389-95).

Photo (c) CDC/Reed & Carnrick Pharmaceuticals

Another advantage of spinosad, according to its labeling, is that it doesn’t require combing to be effective. A single, 10-minute application of spinosad is followed by a warm-water rinse. If desired, a fine-toothed comb can be used to remove dead lice and nits from the hair. A second application is permissible if the patient continues to harbor live lice 7 days later.

Investigators noted no serious adverse events in the trials, and only a small number of mild to moderate adverse events. The most common were application site erythema (seen in 6.8% of the patients given spinosad), ocular hyperemia (in 3.3% of patients), and application site irritation (in 1.5% of patients).

Spinosad works by causing neuronal excitation in insects. After a period of hyperexcitation, lice become paralyzed and die.

The FDA approval covered the use of spinosad in adults and children aged 4 years and older. The agency said that it is important not to use spinosad in infants younger than age 6 months. The product contains benzyl alcohol, which can cause serious reactions and even death in infants.

The clinical trials reported in Pediatrics were sponsored by ParaPRO, the manufacturer of Natroba. Two of the coauthors received research funding from ParaPRO, and two others served as consultants to the company.

The Food and Drug Administration has approved a new topical treatment for head lice in children and adults.

Natroba Topical Suspension (spinosad 0.9%), proved more effective than Nix (permethrin 1%) when compared directly in clinical trials. In two trials involving a total of 1,038 children and adults, after one or two applications of spinosad, 85% and 87% of patients were lice free, compared with 45% and 43% of patients receiving permethrin (Pediatrics 2009;124:e389-95).

Photo (c) CDC/Reed & Carnrick Pharmaceuticals

Another advantage of spinosad, according to its labeling, is that it doesn’t require combing to be effective. A single, 10-minute application of spinosad is followed by a warm-water rinse. If desired, a fine-toothed comb can be used to remove dead lice and nits from the hair. A second application is permissible if the patient continues to harbor live lice 7 days later.

Investigators noted no serious adverse events in the trials, and only a small number of mild to moderate adverse events. The most common were application site erythema (seen in 6.8% of the patients given spinosad), ocular hyperemia (in 3.3% of patients), and application site irritation (in 1.5% of patients).

Spinosad works by causing neuronal excitation in insects. After a period of hyperexcitation, lice become paralyzed and die.

The FDA approval covered the use of spinosad in adults and children aged 4 years and older. The agency said that it is important not to use spinosad in infants younger than age 6 months. The product contains benzyl alcohol, which can cause serious reactions and even death in infants.

The clinical trials reported in Pediatrics were sponsored by ParaPRO, the manufacturer of Natroba. Two of the coauthors received research funding from ParaPRO, and two others served as consultants to the company.

The Food and Drug Administration has approved a new topical treatment for head lice in children and adults.

Natroba Topical Suspension (spinosad 0.9%), proved more effective than Nix (permethrin 1%) when compared directly in clinical trials. In two trials involving a total of 1,038 children and adults, after one or two applications of spinosad, 85% and 87% of patients were lice free, compared with 45% and 43% of patients receiving permethrin (Pediatrics 2009;124:e389-95).

Photo (c) CDC/Reed & Carnrick Pharmaceuticals

Another advantage of spinosad, according to its labeling, is that it doesn’t require combing to be effective. A single, 10-minute application of spinosad is followed by a warm-water rinse. If desired, a fine-toothed comb can be used to remove dead lice and nits from the hair. A second application is permissible if the patient continues to harbor live lice 7 days later.

Investigators noted no serious adverse events in the trials, and only a small number of mild to moderate adverse events. The most common were application site erythema (seen in 6.8% of the patients given spinosad), ocular hyperemia (in 3.3% of patients), and application site irritation (in 1.5% of patients).

Spinosad works by causing neuronal excitation in insects. After a period of hyperexcitation, lice become paralyzed and die.

The FDA approval covered the use of spinosad in adults and children aged 4 years and older. The agency said that it is important not to use spinosad in infants younger than age 6 months. The product contains benzyl alcohol, which can cause serious reactions and even death in infants.

The clinical trials reported in Pediatrics were sponsored by ParaPRO, the manufacturer of Natroba. Two of the coauthors received research funding from ParaPRO, and two others served as consultants to the company.

ORLANDO - Expect clinical options for hair restoration to grow in the future, said Dr. Ricardo Mejia.

Robotic hair transfer, multiple technologies to optimize new growth, and even hair cloning could help overcome current limitations in hair transplantation, Dr. Mejia said. Promising technologies could someday supplant donor strip and follicular unit extraction techniques. "We are getting to the age of robotics," Dr. Mejia said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Historically, hair transplantation meant 4-mm plugs transferred at a rate of 10-200 grafts per session over a total of three to eight treatments. Because plugs were placed in a regular pattern, initial results appeared unnatural and very obvious. For some patients, a perception persists that this is still state-of-the-art for hair transplantation, Dr. Mejia said.

Photo courtesy Dr. Ricardo Mejia

A natural, irregular hairline and greater hair density in fewer treatment sessions are now commonplace. "The average session these days of 2,500 grafts is not a big deal," Dr. Mejia said at the meeting.

"Restoring youthful hairlines can be done in single sessions. ... You can get a nice, age-appropriate appearance for an individual," said Dr. Mejia, a hair transplant surgeon in private practice in Jupiter, Fla. Even with recent advances, full growth of hair grafts still takes 6 months to a year, so realistic patient expectations are important.

A new device, NeoGraft Automated Hair Transplant System (NeoGraft), was cleared for marketing by the Food and Drug Administration in March 2009. After a rotating sharp punch scores the skin, a pneumatic suction device extracts the follicles. This technique minimizes injury to the lower half of hair follicles during follicular unit extraction, Dr. Mejia said. The device also implants grafts to a uniform depth.

Researchers are working on a variety of other means to protect grafts during the transfer process. For example, some are developing solutions to protect grafts that contain allopurinol, nitric oxide inhibitors, vitamins, and other components. Also, "we are starting to look at solutions used in organ transplantation." Small studies have shown increased hair survival and growth with these solutions used to optimize protection of organs during transfer, Dr. Mejia said.

Bathing follicular units in autologous platelet-rich plasma to promote healing angiogenesis is another approach. Growth factor components also could be beneficial, Dr. Mejia said. More studies are needed to determine the efficacy of injections of autologous platelet-rich plasma into both the donor area and the recipient areas in clinical practice.

Matching the size of the incision blade to the graft size can also help improve graft survival, Dr. Mejia said. Less trauma, less ischemia, and decreased overall bleeding are associated with finer blades. Although finer blades allow higher-density graft packing, he advised caution because some studies have shown more graft death with higher densities.

Investigators also are looking at technology to optimize new hair growth once the grafts are in place.

"Low-level lasers are getting a lot of attention," Dr. Mejia said. Wavelengths are in the range of 630-670 nm, power densities are between 5-50 mW/cm², and fluences are 2-20 J/cm².

The Food and Drug Administration cleared two devices that use low-level light therapy for hair growth: HairMax LaserComb (Lexington International) for men and the MPE-90 Hair Growth Stimulation System (Salon Lasers) for women.

"How good is the HairMax comb?" a meeting attendee asked. Dr. Mejia replied that reviews are mixed: "Hair restoration surgeons are on the fence – some believe in it, some don’t. Some patients are happy with it, some are not."

A lot of research also is underway to refine auto cloning and hair multiplication technologies, Dr. Mejia said.

Dermal papilla cells or fibroblasts are the starting point, because they stimulate formation of new hairs. Multiple companies are working on proprietary processes to spur these fibroblasts to produce enough follicles in culture to replace an entire scalp. This is where they hope "to make their windfall," he said. Research includes fibroblasts grown in subatmospheric oxygen tension, addition of wound-healing factors, and injections of a "hair-stimulating complex" to promote greater hair growth.

TrichoCyte is an example of a cell-based hair regeneration technology in phase II trials based on a proprietary dermal papilla cell process (Intercytex, Manchester, England). "The technique does work but [it is] not completely satisfactory at this point," Dr. Mejia said.

More than half of participants in one protocol for another proprietary cell treatment process showed significant hair growth 1 year later, according to a release announcing phase II study results for Aderans Research Institute.

Considerable work remains to be done before regenerative medical hair cloning becomes a clinically viable option, Dr. Mejia said. "How far out are we? I say 5-10 years."

Dr. Mejia said he had no relevant disclosures.

ORLANDO - Expect clinical options for hair restoration to grow in the future, said Dr. Ricardo Mejia.

Robotic hair transfer, multiple technologies to optimize new growth, and even hair cloning could help overcome current limitations in hair transplantation, Dr. Mejia said. Promising technologies could someday supplant donor strip and follicular unit extraction techniques. "We are getting to the age of robotics," Dr. Mejia said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Historically, hair transplantation meant 4-mm plugs transferred at a rate of 10-200 grafts per session over a total of three to eight treatments. Because plugs were placed in a regular pattern, initial results appeared unnatural and very obvious. For some patients, a perception persists that this is still state-of-the-art for hair transplantation, Dr. Mejia said.

Photo courtesy Dr. Ricardo Mejia

A natural, irregular hairline and greater hair density in fewer treatment sessions are now commonplace. "The average session these days of 2,500 grafts is not a big deal," Dr. Mejia said at the meeting.

"Restoring youthful hairlines can be done in single sessions. ... You can get a nice, age-appropriate appearance for an individual," said Dr. Mejia, a hair transplant surgeon in private practice in Jupiter, Fla. Even with recent advances, full growth of hair grafts still takes 6 months to a year, so realistic patient expectations are important.

A new device, NeoGraft Automated Hair Transplant System (NeoGraft), was cleared for marketing by the Food and Drug Administration in March 2009. After a rotating sharp punch scores the skin, a pneumatic suction device extracts the follicles. This technique minimizes injury to the lower half of hair follicles during follicular unit extraction, Dr. Mejia said. The device also implants grafts to a uniform depth.

Researchers are working on a variety of other means to protect grafts during the transfer process. For example, some are developing solutions to protect grafts that contain allopurinol, nitric oxide inhibitors, vitamins, and other components. Also, "we are starting to look at solutions used in organ transplantation." Small studies have shown increased hair survival and growth with these solutions used to optimize protection of organs during transfer, Dr. Mejia said.

Bathing follicular units in autologous platelet-rich plasma to promote healing angiogenesis is another approach. Growth factor components also could be beneficial, Dr. Mejia said. More studies are needed to determine the efficacy of injections of autologous platelet-rich plasma into both the donor area and the recipient areas in clinical practice.

Matching the size of the incision blade to the graft size can also help improve graft survival, Dr. Mejia said. Less trauma, less ischemia, and decreased overall bleeding are associated with finer blades. Although finer blades allow higher-density graft packing, he advised caution because some studies have shown more graft death with higher densities.

Investigators also are looking at technology to optimize new hair growth once the grafts are in place.

"Low-level lasers are getting a lot of attention," Dr. Mejia said. Wavelengths are in the range of 630-670 nm, power densities are between 5-50 mW/cm², and fluences are 2-20 J/cm².

The Food and Drug Administration cleared two devices that use low-level light therapy for hair growth: HairMax LaserComb (Lexington International) for men and the MPE-90 Hair Growth Stimulation System (Salon Lasers) for women.

"How good is the HairMax comb?" a meeting attendee asked. Dr. Mejia replied that reviews are mixed: "Hair restoration surgeons are on the fence – some believe in it, some don’t. Some patients are happy with it, some are not."

A lot of research also is underway to refine auto cloning and hair multiplication technologies, Dr. Mejia said.

Dermal papilla cells or fibroblasts are the starting point, because they stimulate formation of new hairs. Multiple companies are working on proprietary processes to spur these fibroblasts to produce enough follicles in culture to replace an entire scalp. This is where they hope "to make their windfall," he said. Research includes fibroblasts grown in subatmospheric oxygen tension, addition of wound-healing factors, and injections of a "hair-stimulating complex" to promote greater hair growth.

TrichoCyte is an example of a cell-based hair regeneration technology in phase II trials based on a proprietary dermal papilla cell process (Intercytex, Manchester, England). "The technique does work but [it is] not completely satisfactory at this point," Dr. Mejia said.

More than half of participants in one protocol for another proprietary cell treatment process showed significant hair growth 1 year later, according to a release announcing phase II study results for Aderans Research Institute.

Considerable work remains to be done before regenerative medical hair cloning becomes a clinically viable option, Dr. Mejia said. "How far out are we? I say 5-10 years."

Dr. Mejia said he had no relevant disclosures.

ORLANDO - Expect clinical options for hair restoration to grow in the future, said Dr. Ricardo Mejia.

Robotic hair transfer, multiple technologies to optimize new growth, and even hair cloning could help overcome current limitations in hair transplantation, Dr. Mejia said. Promising technologies could someday supplant donor strip and follicular unit extraction techniques. "We are getting to the age of robotics," Dr. Mejia said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Historically, hair transplantation meant 4-mm plugs transferred at a rate of 10-200 grafts per session over a total of three to eight treatments. Because plugs were placed in a regular pattern, initial results appeared unnatural and very obvious. For some patients, a perception persists that this is still state-of-the-art for hair transplantation, Dr. Mejia said.

Photo courtesy Dr. Ricardo Mejia

A natural, irregular hairline and greater hair density in fewer treatment sessions are now commonplace. "The average session these days of 2,500 grafts is not a big deal," Dr. Mejia said at the meeting.

"Restoring youthful hairlines can be done in single sessions. ... You can get a nice, age-appropriate appearance for an individual," said Dr. Mejia, a hair transplant surgeon in private practice in Jupiter, Fla. Even with recent advances, full growth of hair grafts still takes 6 months to a year, so realistic patient expectations are important.

A new device, NeoGraft Automated Hair Transplant System (NeoGraft), was cleared for marketing by the Food and Drug Administration in March 2009. After a rotating sharp punch scores the skin, a pneumatic suction device extracts the follicles. This technique minimizes injury to the lower half of hair follicles during follicular unit extraction, Dr. Mejia said. The device also implants grafts to a uniform depth.

Researchers are working on a variety of other means to protect grafts during the transfer process. For example, some are developing solutions to protect grafts that contain allopurinol, nitric oxide inhibitors, vitamins, and other components. Also, "we are starting to look at solutions used in organ transplantation." Small studies have shown increased hair survival and growth with these solutions used to optimize protection of organs during transfer, Dr. Mejia said.

Bathing follicular units in autologous platelet-rich plasma to promote healing angiogenesis is another approach. Growth factor components also could be beneficial, Dr. Mejia said. More studies are needed to determine the efficacy of injections of autologous platelet-rich plasma into both the donor area and the recipient areas in clinical practice.

Matching the size of the incision blade to the graft size can also help improve graft survival, Dr. Mejia said. Less trauma, less ischemia, and decreased overall bleeding are associated with finer blades. Although finer blades allow higher-density graft packing, he advised caution because some studies have shown more graft death with higher densities.

Investigators also are looking at technology to optimize new hair growth once the grafts are in place.

"Low-level lasers are getting a lot of attention," Dr. Mejia said. Wavelengths are in the range of 630-670 nm, power densities are between 5-50 mW/cm², and fluences are 2-20 J/cm².

The Food and Drug Administration cleared two devices that use low-level light therapy for hair growth: HairMax LaserComb (Lexington International) for men and the MPE-90 Hair Growth Stimulation System (Salon Lasers) for women.

"How good is the HairMax comb?" a meeting attendee asked. Dr. Mejia replied that reviews are mixed: "Hair restoration surgeons are on the fence – some believe in it, some don’t. Some patients are happy with it, some are not."

A lot of research also is underway to refine auto cloning and hair multiplication technologies, Dr. Mejia said.

Dermal papilla cells or fibroblasts are the starting point, because they stimulate formation of new hairs. Multiple companies are working on proprietary processes to spur these fibroblasts to produce enough follicles in culture to replace an entire scalp. This is where they hope "to make their windfall," he said. Research includes fibroblasts grown in subatmospheric oxygen tension, addition of wound-healing factors, and injections of a "hair-stimulating complex" to promote greater hair growth.

TrichoCyte is an example of a cell-based hair regeneration technology in phase II trials based on a proprietary dermal papilla cell process (Intercytex, Manchester, England). "The technique does work but [it is] not completely satisfactory at this point," Dr. Mejia said.

More than half of participants in one protocol for another proprietary cell treatment process showed significant hair growth 1 year later, according to a release announcing phase II study results for Aderans Research Institute.

Considerable work remains to be done before regenerative medical hair cloning becomes a clinically viable option, Dr. Mejia said. "How far out are we? I say 5-10 years."

Dr. Mejia said he had no relevant disclosures.

ORLANDO - Surgical excision is the preferred approach for treating a patient who presents with a cylindroma or with the more extensive familial cylindromatosis, Dr. Leonard Slazinski said.

There are some important distinctions between the two. Cylindromas are benign skin appendage tumors that commonly present as single, slow-growing lesions on the head and neck. Lesions often appear in conjunction with spiradenomas and trichoepitheliomas, they typically are 0.5-6.0 cm in size (although some can grow larger), and they affect females more than males. They arise sporadically with no known inheritance pattern.

Photo (c)2010 Dermatopathology published by Elsevier Inc.

The tumor can be excised with careful inspection to ensure removal of all tissue, Dr. Slazinski said. "In my experience, the cylindroma often does have a pseudocapsule, which allows for blunt dissection of the tumor under direct vision."

In contrast, familial cylindromatosis is an inherited autosomal dominant condition characterized by multiple lesions located on the head and neck. Treatment is trickier, as there is no effective field or systemic therapy. Surgery should be considered most effective, but many doctors "are overwhelmed by the number of these lesions," said Dr. Slazinski, a dermatologist in private practice in Sarasota, Fla.

Familial trichoepitheliomas, Brooke-Spiegler syndrome, and familial cylindromatosis share a genetic etiology – a mutation of the CYLD gene on chromosome 16. "Great advances have been made in etiology and cellular mechanisms of familial cylindromatosis and related conditions," Dr. Slazinski said. But "treatment has not advanced to the same degree."

Removal of these lesions is often performed for aesthetic and functional reasons. "These diseases can become quite severe if untreated," Dr. Slazinski said. The psychosocial impact can be great, and patients often become social recluses.

Even with traditional excision, recurrence "is quite high" at approximately 42%, Dr. Slazinski said. Mohs micrographic surgery is used more often for solitary lesions. Other options, depending on the individual presentation, include cryotherapy, curettage, electrosurgery and radiofrequency excision, and true scalp excision with split-thickness grafting, "which is advocated in severe cases."

Cylindroma patients often present with pseudoalopecia because the tumor does not grow hair. Scalp cylindromas present a unique challenge, with limited tissue and patients’ desire to spare their hair, Dr. Slazinski said. "Hair cosmesis is often the patient’s greatest concern. Paradoxically, as hair is conserved, [the area] can become a reservoir for future tumor formation."

Some clinicians advocate topical aspirin therapy for familial cylindromatosis, Dr. Slazinski said. There may be "less than stellar results, but my patient is seeing some benefit and wants to continue on compounded, topical salicylic acid."

Dr. Slazinski described a patient with an extensive number of lesions across her face, head, and neck. "I'm blessed to be able to take care of this patient, because no one else has really offered her any possibility of improvement. I’ve taken it on myself to at least try to palliate the situation. I am under no delusion that I can cure her in any way."

Dr. Slazinski said he had no relevant financial disclosures.

ORLANDO - Surgical excision is the preferred approach for treating a patient who presents with a cylindroma or with the more extensive familial cylindromatosis, Dr. Leonard Slazinski said.

There are some important distinctions between the two. Cylindromas are benign skin appendage tumors that commonly present as single, slow-growing lesions on the head and neck. Lesions often appear in conjunction with spiradenomas and trichoepitheliomas, they typically are 0.5-6.0 cm in size (although some can grow larger), and they affect females more than males. They arise sporadically with no known inheritance pattern.

Photo (c)2010 Dermatopathology published by Elsevier Inc.

The tumor can be excised with careful inspection to ensure removal of all tissue, Dr. Slazinski said. "In my experience, the cylindroma often does have a pseudocapsule, which allows for blunt dissection of the tumor under direct vision."

In contrast, familial cylindromatosis is an inherited autosomal dominant condition characterized by multiple lesions located on the head and neck. Treatment is trickier, as there is no effective field or systemic therapy. Surgery should be considered most effective, but many doctors "are overwhelmed by the number of these lesions," said Dr. Slazinski, a dermatologist in private practice in Sarasota, Fla.

Familial trichoepitheliomas, Brooke-Spiegler syndrome, and familial cylindromatosis share a genetic etiology – a mutation of the CYLD gene on chromosome 16. "Great advances have been made in etiology and cellular mechanisms of familial cylindromatosis and related conditions," Dr. Slazinski said. But "treatment has not advanced to the same degree."

Removal of these lesions is often performed for aesthetic and functional reasons. "These diseases can become quite severe if untreated," Dr. Slazinski said. The psychosocial impact can be great, and patients often become social recluses.

Even with traditional excision, recurrence "is quite high" at approximately 42%, Dr. Slazinski said. Mohs micrographic surgery is used more often for solitary lesions. Other options, depending on the individual presentation, include cryotherapy, curettage, electrosurgery and radiofrequency excision, and true scalp excision with split-thickness grafting, "which is advocated in severe cases."

Cylindroma patients often present with pseudoalopecia because the tumor does not grow hair. Scalp cylindromas present a unique challenge, with limited tissue and patients’ desire to spare their hair, Dr. Slazinski said. "Hair cosmesis is often the patient’s greatest concern. Paradoxically, as hair is conserved, [the area] can become a reservoir for future tumor formation."

Some clinicians advocate topical aspirin therapy for familial cylindromatosis, Dr. Slazinski said. There may be "less than stellar results, but my patient is seeing some benefit and wants to continue on compounded, topical salicylic acid."

Dr. Slazinski described a patient with an extensive number of lesions across her face, head, and neck. "I'm blessed to be able to take care of this patient, because no one else has really offered her any possibility of improvement. I’ve taken it on myself to at least try to palliate the situation. I am under no delusion that I can cure her in any way."

Dr. Slazinski said he had no relevant financial disclosures.

ORLANDO - Surgical excision is the preferred approach for treating a patient who presents with a cylindroma or with the more extensive familial cylindromatosis, Dr. Leonard Slazinski said.

There are some important distinctions between the two. Cylindromas are benign skin appendage tumors that commonly present as single, slow-growing lesions on the head and neck. Lesions often appear in conjunction with spiradenomas and trichoepitheliomas, they typically are 0.5-6.0 cm in size (although some can grow larger), and they affect females more than males. They arise sporadically with no known inheritance pattern.

Photo (c)2010 Dermatopathology published by Elsevier Inc.

The tumor can be excised with careful inspection to ensure removal of all tissue, Dr. Slazinski said. "In my experience, the cylindroma often does have a pseudocapsule, which allows for blunt dissection of the tumor under direct vision."

In contrast, familial cylindromatosis is an inherited autosomal dominant condition characterized by multiple lesions located on the head and neck. Treatment is trickier, as there is no effective field or systemic therapy. Surgery should be considered most effective, but many doctors "are overwhelmed by the number of these lesions," said Dr. Slazinski, a dermatologist in private practice in Sarasota, Fla.

Familial trichoepitheliomas, Brooke-Spiegler syndrome, and familial cylindromatosis share a genetic etiology – a mutation of the CYLD gene on chromosome 16. "Great advances have been made in etiology and cellular mechanisms of familial cylindromatosis and related conditions," Dr. Slazinski said. But "treatment has not advanced to the same degree."

Removal of these lesions is often performed for aesthetic and functional reasons. "These diseases can become quite severe if untreated," Dr. Slazinski said. The psychosocial impact can be great, and patients often become social recluses.

Even with traditional excision, recurrence "is quite high" at approximately 42%, Dr. Slazinski said. Mohs micrographic surgery is used more often for solitary lesions. Other options, depending on the individual presentation, include cryotherapy, curettage, electrosurgery and radiofrequency excision, and true scalp excision with split-thickness grafting, "which is advocated in severe cases."

Cylindroma patients often present with pseudoalopecia because the tumor does not grow hair. Scalp cylindromas present a unique challenge, with limited tissue and patients’ desire to spare their hair, Dr. Slazinski said. "Hair cosmesis is often the patient’s greatest concern. Paradoxically, as hair is conserved, [the area] can become a reservoir for future tumor formation."

Some clinicians advocate topical aspirin therapy for familial cylindromatosis, Dr. Slazinski said. There may be "less than stellar results, but my patient is seeing some benefit and wants to continue on compounded, topical salicylic acid."

Dr. Slazinski described a patient with an extensive number of lesions across her face, head, and neck. "I'm blessed to be able to take care of this patient, because no one else has really offered her any possibility of improvement. I’ve taken it on myself to at least try to palliate the situation. I am under no delusion that I can cure her in any way."

Dr. Slazinski said he had no relevant financial disclosures.