Hair & Nails

Cardiopulmonary resuscitation training should be a requirement for graduation from high school and should include instruction on the purpose of an automated external defibrillator and how to use one, according to an American Heart Association consensus statement released Jan. 10.

Photo credit:Flickr user John Trainor (Creative Commons)

The science advisory statement, developed in collaboration with the American Academy of Pediatrics and the American College of Emergency Physicians and published in the journal Circulation, also recommends that students have opportunities to practice and master psychomotor skills related to CPR, since trainees do not learn enough unless they get the chance to practice.

Although secondary school students most likely won’t encounter a victim of cardiac arrest at school, they may encounter one elsewhere in the community, and teaching CPR skills early can lead to more proficiency later, the AHA statement said.

"Increasing the percentage of the population trained in CPR is an integral part of an overall strategy to improve community response" to out-of-hospital cardiac arrests, the statement said. "Schools provide excellent access to a large part of the community. ... Therefore, over time, a significant percentage of the overall community will receive training."

In 2003, the International Liaison Committee on Resuscitation recommended that CPR instruction be incorporated into standard school curriculums, and the next year the AHA recommended that schools train all teachers in CPR and first aid and train all students in CPR in order to prepare for potential medical emergencies on campus.

As of the 2009-2010 school year, laws or curriculum standards in six states require CPR training as a component of mandatory health education, while 30 states encourage schools to teach CPR, according to the AHA statement. However, implementation of these laws isn’t uniform, and not all schools teach CPR, even in states that have the strongest language encouraging such training, the AHA statement said.

Therefore, requiring CPR training as a condition of high school graduation would significantly increase the level of CPR knowledge in the community over time, the statement said, adding, "the evidence shows that previous training, at any interval before there is a need to use the skills learned, will increase the likelihood that a bystander will provide appropriate care to a victim."

It’s critical to target the correct age group for training, the AHA statement said. Students younger than about 13 years old may not have the necessary physical strength to perform correct chest compressions. Therefore, "it is reasonable to limit practice of adult CPR chest compression skills to children in middle school (around 13 years old) and older," the statement said (Circulation 2011;123:[doi: 10.1161/CIR.0b013e31820b5328]).

Programs designed for schools should include the core skills of conventional CPR and hands-only CPR developed by the AHA, and should emphasize recognition of the emergency and provision of high-quality chest compressions, the statement said.

The statement does not urge mandatory automated external defibrillator (AED) skills practice, although it recommends that schools providing AED skills practice give students an opportunity to practice and master all steps of CPR and AED use, with special emphasis on minimal interruptions in performance of CPR, correct application of pads to an appropriate surrogate for the human thorax, and proper "clearing" of the patient when so instructed by the AED.

Schools have cited a lack of available class time as a barrier to implementing CPR instruction. However, it should be possible for schools to implement such training as part of health courses or as part of a "community service" requirement for high school graduation, the AHA said. In addition, schools can make use of video-based, self-directed training programs and online or other e-learning programs, the statement said.

Several members of the writing committee had relationships that the AHA deemed significant: Dr. Tom P. Aufderheide of the Medical College of Wisconsin, Milwaukee, has received research support from Zoll Medical and Advanced Circulatory Inc.; and has served as an advisor or consultant to Medtronic and JoLife Inc.; Dr. Keith Lurie of the University of Wisconsin is also founder and chief medical officer of Advanced Circulatory Systems, as well as the inventor of that company’s ResQPOD. Dr. Vincent N. Mosesso Jr. of the University of Pittsburgh has received research support from Zoll Medical.

Cardiopulmonary resuscitation training should be a requirement for graduation from high school and should include instruction on the purpose of an automated external defibrillator and how to use one, according to an American Heart Association consensus statement released Jan. 10.

Photo credit:Flickr user John Trainor (Creative Commons)

The science advisory statement, developed in collaboration with the American Academy of Pediatrics and the American College of Emergency Physicians and published in the journal Circulation, also recommends that students have opportunities to practice and master psychomotor skills related to CPR, since trainees do not learn enough unless they get the chance to practice.

Although secondary school students most likely won’t encounter a victim of cardiac arrest at school, they may encounter one elsewhere in the community, and teaching CPR skills early can lead to more proficiency later, the AHA statement said.

"Increasing the percentage of the population trained in CPR is an integral part of an overall strategy to improve community response" to out-of-hospital cardiac arrests, the statement said. "Schools provide excellent access to a large part of the community. ... Therefore, over time, a significant percentage of the overall community will receive training."

In 2003, the International Liaison Committee on Resuscitation recommended that CPR instruction be incorporated into standard school curriculums, and the next year the AHA recommended that schools train all teachers in CPR and first aid and train all students in CPR in order to prepare for potential medical emergencies on campus.

As of the 2009-2010 school year, laws or curriculum standards in six states require CPR training as a component of mandatory health education, while 30 states encourage schools to teach CPR, according to the AHA statement. However, implementation of these laws isn’t uniform, and not all schools teach CPR, even in states that have the strongest language encouraging such training, the AHA statement said.

Therefore, requiring CPR training as a condition of high school graduation would significantly increase the level of CPR knowledge in the community over time, the statement said, adding, "the evidence shows that previous training, at any interval before there is a need to use the skills learned, will increase the likelihood that a bystander will provide appropriate care to a victim."

It’s critical to target the correct age group for training, the AHA statement said. Students younger than about 13 years old may not have the necessary physical strength to perform correct chest compressions. Therefore, "it is reasonable to limit practice of adult CPR chest compression skills to children in middle school (around 13 years old) and older," the statement said (Circulation 2011;123:[doi: 10.1161/CIR.0b013e31820b5328]).

Programs designed for schools should include the core skills of conventional CPR and hands-only CPR developed by the AHA, and should emphasize recognition of the emergency and provision of high-quality chest compressions, the statement said.

The statement does not urge mandatory automated external defibrillator (AED) skills practice, although it recommends that schools providing AED skills practice give students an opportunity to practice and master all steps of CPR and AED use, with special emphasis on minimal interruptions in performance of CPR, correct application of pads to an appropriate surrogate for the human thorax, and proper "clearing" of the patient when so instructed by the AED.

Schools have cited a lack of available class time as a barrier to implementing CPR instruction. However, it should be possible for schools to implement such training as part of health courses or as part of a "community service" requirement for high school graduation, the AHA said. In addition, schools can make use of video-based, self-directed training programs and online or other e-learning programs, the statement said.

Several members of the writing committee had relationships that the AHA deemed significant: Dr. Tom P. Aufderheide of the Medical College of Wisconsin, Milwaukee, has received research support from Zoll Medical and Advanced Circulatory Inc.; and has served as an advisor or consultant to Medtronic and JoLife Inc.; Dr. Keith Lurie of the University of Wisconsin is also founder and chief medical officer of Advanced Circulatory Systems, as well as the inventor of that company’s ResQPOD. Dr. Vincent N. Mosesso Jr. of the University of Pittsburgh has received research support from Zoll Medical.

Cardiopulmonary resuscitation training should be a requirement for graduation from high school and should include instruction on the purpose of an automated external defibrillator and how to use one, according to an American Heart Association consensus statement released Jan. 10.

Photo credit:Flickr user John Trainor (Creative Commons)

The science advisory statement, developed in collaboration with the American Academy of Pediatrics and the American College of Emergency Physicians and published in the journal Circulation, also recommends that students have opportunities to practice and master psychomotor skills related to CPR, since trainees do not learn enough unless they get the chance to practice.

Although secondary school students most likely won’t encounter a victim of cardiac arrest at school, they may encounter one elsewhere in the community, and teaching CPR skills early can lead to more proficiency later, the AHA statement said.

"Increasing the percentage of the population trained in CPR is an integral part of an overall strategy to improve community response" to out-of-hospital cardiac arrests, the statement said. "Schools provide excellent access to a large part of the community. ... Therefore, over time, a significant percentage of the overall community will receive training."

In 2003, the International Liaison Committee on Resuscitation recommended that CPR instruction be incorporated into standard school curriculums, and the next year the AHA recommended that schools train all teachers in CPR and first aid and train all students in CPR in order to prepare for potential medical emergencies on campus.

As of the 2009-2010 school year, laws or curriculum standards in six states require CPR training as a component of mandatory health education, while 30 states encourage schools to teach CPR, according to the AHA statement. However, implementation of these laws isn’t uniform, and not all schools teach CPR, even in states that have the strongest language encouraging such training, the AHA statement said.

Therefore, requiring CPR training as a condition of high school graduation would significantly increase the level of CPR knowledge in the community over time, the statement said, adding, "the evidence shows that previous training, at any interval before there is a need to use the skills learned, will increase the likelihood that a bystander will provide appropriate care to a victim."

It’s critical to target the correct age group for training, the AHA statement said. Students younger than about 13 years old may not have the necessary physical strength to perform correct chest compressions. Therefore, "it is reasonable to limit practice of adult CPR chest compression skills to children in middle school (around 13 years old) and older," the statement said (Circulation 2011;123:[doi: 10.1161/CIR.0b013e31820b5328]).

Programs designed for schools should include the core skills of conventional CPR and hands-only CPR developed by the AHA, and should emphasize recognition of the emergency and provision of high-quality chest compressions, the statement said.

The statement does not urge mandatory automated external defibrillator (AED) skills practice, although it recommends that schools providing AED skills practice give students an opportunity to practice and master all steps of CPR and AED use, with special emphasis on minimal interruptions in performance of CPR, correct application of pads to an appropriate surrogate for the human thorax, and proper "clearing" of the patient when so instructed by the AED.

Schools have cited a lack of available class time as a barrier to implementing CPR instruction. However, it should be possible for schools to implement such training as part of health courses or as part of a "community service" requirement for high school graduation, the AHA said. In addition, schools can make use of video-based, self-directed training programs and online or other e-learning programs, the statement said.

Several members of the writing committee had relationships that the AHA deemed significant: Dr. Tom P. Aufderheide of the Medical College of Wisconsin, Milwaukee, has received research support from Zoll Medical and Advanced Circulatory Inc.; and has served as an advisor or consultant to Medtronic and JoLife Inc.; Dr. Keith Lurie of the University of Wisconsin is also founder and chief medical officer of Advanced Circulatory Systems, as well as the inventor of that company’s ResQPOD. Dr. Vincent N. Mosesso Jr. of the University of Pittsburgh has received research support from Zoll Medical.

LAS VEGAS - Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

"So it's worth doing a routine culture," said Dr. Eichenfield, adding that it’s fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. "Terbinafine is so cost effective," he said. "You can get it for $4-$7 per month. It used to be $1,200 for a full course."

His recommended dosages to treat onychomycosis are the following:

• For children weighing less than 20 kg: 62.5 mg/day.

• For children weighing 20-40 kg: 125 mg/day.

• For children weighing more than 40 kg: 250 mg/day.

"It's recommended that you get baseline lab work," he said. "Many of us will repeat [it] 1 month into the therapy."

In a study presented at the American Academy of Dermatology annual meeting in 2007, 39% of children treated with ciclopirox lacquer achieved a complete cure, compared with 22% of children who were treated with a placebo, suggesting that the disease can spontaneously resolve.

And what about lasers? "Whether lasers are any better than any other debridement has not been addressed," he said.

Dr. Eichenfield reported having no relevant financial disclosures.

LAS VEGAS - Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

"So it's worth doing a routine culture," said Dr. Eichenfield, adding that it’s fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. "Terbinafine is so cost effective," he said. "You can get it for $4-$7 per month. It used to be $1,200 for a full course."

His recommended dosages to treat onychomycosis are the following:

• For children weighing less than 20 kg: 62.5 mg/day.

• For children weighing 20-40 kg: 125 mg/day.

• For children weighing more than 40 kg: 250 mg/day.

"It's recommended that you get baseline lab work," he said. "Many of us will repeat [it] 1 month into the therapy."

In a study presented at the American Academy of Dermatology annual meeting in 2007, 39% of children treated with ciclopirox lacquer achieved a complete cure, compared with 22% of children who were treated with a placebo, suggesting that the disease can spontaneously resolve.

And what about lasers? "Whether lasers are any better than any other debridement has not been addressed," he said.

Dr. Eichenfield reported having no relevant financial disclosures.

LAS VEGAS - Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

"So it's worth doing a routine culture," said Dr. Eichenfield, adding that it’s fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. "Terbinafine is so cost effective," he said. "You can get it for $4-$7 per month. It used to be $1,200 for a full course."

His recommended dosages to treat onychomycosis are the following:

• For children weighing less than 20 kg: 62.5 mg/day.

• For children weighing 20-40 kg: 125 mg/day.

• For children weighing more than 40 kg: 250 mg/day.

"It's recommended that you get baseline lab work," he said. "Many of us will repeat [it] 1 month into the therapy."

In a study presented at the American Academy of Dermatology annual meeting in 2007, 39% of children treated with ciclopirox lacquer achieved a complete cure, compared with 22% of children who were treated with a placebo, suggesting that the disease can spontaneously resolve.

And what about lasers? "Whether lasers are any better than any other debridement has not been addressed," he said.

Dr. Eichenfield reported having no relevant financial disclosures.

GOTHENBURG, SWEDEN – Onychomycosis remains a difficult disorder to treat and cure, even with modern antifungal agents. But the chances of success can be greatly enhanced through application of several proven, evidence-based strategies.

A recent study identified multiple baseline factors associated with a low cure rate following a standard 3-month course of oral terbinafine for onychomycosis. One preemptive strategy in patients possessing several of these poor-prognosis factors is to consider combination therapy from the outset. Alternatively, the standard 3 months of terbinafine could be stretched for 5-6 months, Dr. Bardur Sigurgeirsson said at the annual congress of the European Academy of Dermatology and Venereology.

The host-related prognostic factors were identified in Dr. Sigurgeirsson’s recent secondary retrospective analysis of 3-year outcomes in 199 Icelandic participants in a large international randomized trial of continuous versus intermittent terbinafine (J. Eur. Acad. Dermatol. Venereol. 2010; 24:679-84).

Several of the prognostic factors were already known, but the study provided the first-ever supporting data validating their legitimacy, said Dr. Sigurgeirsson of the University of Iceland, Reykjavik. The new information is particularly useful in everyday clinical practice because no universal classification of disease severity exists.

Photo (c) 1993, Elsevier

In the multivariate, logistic, regression analysis, baseline factors associated with a negative outcome at 72 weeks of follow-up – that is, failure to achieve mycologic or clinical cure – included matrix involvement, lateral nail edge involvement, and dermatophytoma. Slow nail growth from screening to baseline was another predictor of lack of cure; this makes sense, as patients with faster-growing nails are likely to shed the infected part sooner, he noted.

Other factors enabling physicians to select good candidates for up-front combination or extended therapy were being over age 65 years, being male, having a history of prior fungal toe infection, and having a positive culture at 24 weeks’ follow-up, even if the nails look good at that point.

Several factors in popular dermatologic lore to predict poor outcome were not borne out in the study. The extent of infection involvement, the number of infected toenails, duration of infection, and presence of spikes were unrelated to the 72-week cure rate. There was a trend for patients with thicker nail plates or subungual hyperkeratosis to be less likely to reach cure, but this factor did not achieve statistical significance, he reported.

The greatest likelihood of cure at 72 weeks’ follow-up after the standard 3 months of oral terbinafine was seen in younger female patients with fast nail growth.

An earlier, randomized, multicenter study by Dr. Sigurgeirsson and coworkers made the case for up-front combination therapy with amorolfine hydrochloride 5% nail lacquer and oral terbinafine for treating onychomycosis in patients with terbinafine monotherapy lack-of-cure risk factors. The trial involved 249 patients; one of the strongest predictors of poor outcome was baseline nail matrix involvement. The success rate at 18 months was 59% for combination therapy, compared with 45% for oral terbinafine monotherapy. The cost per cure was significantly less with combination therapy (Br. J. Dermatol. 2007;157:149-57).

Onychomycosis is best viewed as a chronic relapsing condition, as evidenced by a 5-year, blinded, prospective follow-up study Dr. Sigurgeirsson and colleagues conducted in terbinafine – or itraconazole-treated patients (Arch. Dermatol. 2002;138:353-7). The mycologic relapse rates were 53% in the itraconazole arm and 48% with terbinafine.

In a subsequent study of nearly 4,000 patients, the investigators identified a number of risk factors for recurrent onychomycosis: cancer, 3.4-fold increased risk; psoriasis, 2.4-fold increased risk; tinea pedis interdigitalis, 3.9-fold increased risk; moccasin form of tinea pedis, 4.3-fold increased risk; regular swimming, 2.6-fold increased risk; and having a spouse, parents, or children with onychomycosis, 2.5- to 3.5-fold increased risk (J. Eur. Acad. Dermatol. Venereol. 2004;18:48-51).

These findings were recently confirmed and expanded upon in a Japanese survey of 30,000 dermatology patients. Dermatologists at Teikyo University in Itabashi found most of the same risk factors earlier identified by Dr. Sigurgeirsson and coworkers. In addition, the Japanese investigators identified two previously undescribed risk factors for recurrent infection: more time spent wearing shoes, and having a higher temperature in the home (J. Dermatol. 2010;37:397-406).

Prophylactic therapy is worth considering following cure of onychomycosis in patients at increased risk for relapse based upon their risk factor profile, Dr. Sigurgeirsson said. He and his coworkers recently showed that amorolfine nail lacquer applied once every 2 weeks is safe and effective for this purpose (J. Eur. Acad. Dermatol. Venereol. 2010;24:910-5).

Many of his studies of terbinafine for onychomycosis were supported by research grants from Novartis.

GOTHENBURG, SWEDEN – Onychomycosis remains a difficult disorder to treat and cure, even with modern antifungal agents. But the chances of success can be greatly enhanced through application of several proven, evidence-based strategies.

A recent study identified multiple baseline factors associated with a low cure rate following a standard 3-month course of oral terbinafine for onychomycosis. One preemptive strategy in patients possessing several of these poor-prognosis factors is to consider combination therapy from the outset. Alternatively, the standard 3 months of terbinafine could be stretched for 5-6 months, Dr. Bardur Sigurgeirsson said at the annual congress of the European Academy of Dermatology and Venereology.

The host-related prognostic factors were identified in Dr. Sigurgeirsson’s recent secondary retrospective analysis of 3-year outcomes in 199 Icelandic participants in a large international randomized trial of continuous versus intermittent terbinafine (J. Eur. Acad. Dermatol. Venereol. 2010; 24:679-84).

Several of the prognostic factors were already known, but the study provided the first-ever supporting data validating their legitimacy, said Dr. Sigurgeirsson of the University of Iceland, Reykjavik. The new information is particularly useful in everyday clinical practice because no universal classification of disease severity exists.

Photo (c) 1993, Elsevier

In the multivariate, logistic, regression analysis, baseline factors associated with a negative outcome at 72 weeks of follow-up – that is, failure to achieve mycologic or clinical cure – included matrix involvement, lateral nail edge involvement, and dermatophytoma. Slow nail growth from screening to baseline was another predictor of lack of cure; this makes sense, as patients with faster-growing nails are likely to shed the infected part sooner, he noted.

Other factors enabling physicians to select good candidates for up-front combination or extended therapy were being over age 65 years, being male, having a history of prior fungal toe infection, and having a positive culture at 24 weeks’ follow-up, even if the nails look good at that point.

Several factors in popular dermatologic lore to predict poor outcome were not borne out in the study. The extent of infection involvement, the number of infected toenails, duration of infection, and presence of spikes were unrelated to the 72-week cure rate. There was a trend for patients with thicker nail plates or subungual hyperkeratosis to be less likely to reach cure, but this factor did not achieve statistical significance, he reported.

The greatest likelihood of cure at 72 weeks’ follow-up after the standard 3 months of oral terbinafine was seen in younger female patients with fast nail growth.

An earlier, randomized, multicenter study by Dr. Sigurgeirsson and coworkers made the case for up-front combination therapy with amorolfine hydrochloride 5% nail lacquer and oral terbinafine for treating onychomycosis in patients with terbinafine monotherapy lack-of-cure risk factors. The trial involved 249 patients; one of the strongest predictors of poor outcome was baseline nail matrix involvement. The success rate at 18 months was 59% for combination therapy, compared with 45% for oral terbinafine monotherapy. The cost per cure was significantly less with combination therapy (Br. J. Dermatol. 2007;157:149-57).

Onychomycosis is best viewed as a chronic relapsing condition, as evidenced by a 5-year, blinded, prospective follow-up study Dr. Sigurgeirsson and colleagues conducted in terbinafine – or itraconazole-treated patients (Arch. Dermatol. 2002;138:353-7). The mycologic relapse rates were 53% in the itraconazole arm and 48% with terbinafine.

In a subsequent study of nearly 4,000 patients, the investigators identified a number of risk factors for recurrent onychomycosis: cancer, 3.4-fold increased risk; psoriasis, 2.4-fold increased risk; tinea pedis interdigitalis, 3.9-fold increased risk; moccasin form of tinea pedis, 4.3-fold increased risk; regular swimming, 2.6-fold increased risk; and having a spouse, parents, or children with onychomycosis, 2.5- to 3.5-fold increased risk (J. Eur. Acad. Dermatol. Venereol. 2004;18:48-51).

These findings were recently confirmed and expanded upon in a Japanese survey of 30,000 dermatology patients. Dermatologists at Teikyo University in Itabashi found most of the same risk factors earlier identified by Dr. Sigurgeirsson and coworkers. In addition, the Japanese investigators identified two previously undescribed risk factors for recurrent infection: more time spent wearing shoes, and having a higher temperature in the home (J. Dermatol. 2010;37:397-406).

Prophylactic therapy is worth considering following cure of onychomycosis in patients at increased risk for relapse based upon their risk factor profile, Dr. Sigurgeirsson said. He and his coworkers recently showed that amorolfine nail lacquer applied once every 2 weeks is safe and effective for this purpose (J. Eur. Acad. Dermatol. Venereol. 2010;24:910-5).

Many of his studies of terbinafine for onychomycosis were supported by research grants from Novartis.

GOTHENBURG, SWEDEN – Onychomycosis remains a difficult disorder to treat and cure, even with modern antifungal agents. But the chances of success can be greatly enhanced through application of several proven, evidence-based strategies.

A recent study identified multiple baseline factors associated with a low cure rate following a standard 3-month course of oral terbinafine for onychomycosis. One preemptive strategy in patients possessing several of these poor-prognosis factors is to consider combination therapy from the outset. Alternatively, the standard 3 months of terbinafine could be stretched for 5-6 months, Dr. Bardur Sigurgeirsson said at the annual congress of the European Academy of Dermatology and Venereology.

The host-related prognostic factors were identified in Dr. Sigurgeirsson’s recent secondary retrospective analysis of 3-year outcomes in 199 Icelandic participants in a large international randomized trial of continuous versus intermittent terbinafine (J. Eur. Acad. Dermatol. Venereol. 2010; 24:679-84).

Several of the prognostic factors were already known, but the study provided the first-ever supporting data validating their legitimacy, said Dr. Sigurgeirsson of the University of Iceland, Reykjavik. The new information is particularly useful in everyday clinical practice because no universal classification of disease severity exists.

Photo (c) 1993, Elsevier

In the multivariate, logistic, regression analysis, baseline factors associated with a negative outcome at 72 weeks of follow-up – that is, failure to achieve mycologic or clinical cure – included matrix involvement, lateral nail edge involvement, and dermatophytoma. Slow nail growth from screening to baseline was another predictor of lack of cure; this makes sense, as patients with faster-growing nails are likely to shed the infected part sooner, he noted.

Other factors enabling physicians to select good candidates for up-front combination or extended therapy were being over age 65 years, being male, having a history of prior fungal toe infection, and having a positive culture at 24 weeks’ follow-up, even if the nails look good at that point.

Several factors in popular dermatologic lore to predict poor outcome were not borne out in the study. The extent of infection involvement, the number of infected toenails, duration of infection, and presence of spikes were unrelated to the 72-week cure rate. There was a trend for patients with thicker nail plates or subungual hyperkeratosis to be less likely to reach cure, but this factor did not achieve statistical significance, he reported.

The greatest likelihood of cure at 72 weeks’ follow-up after the standard 3 months of oral terbinafine was seen in younger female patients with fast nail growth.

An earlier, randomized, multicenter study by Dr. Sigurgeirsson and coworkers made the case for up-front combination therapy with amorolfine hydrochloride 5% nail lacquer and oral terbinafine for treating onychomycosis in patients with terbinafine monotherapy lack-of-cure risk factors. The trial involved 249 patients; one of the strongest predictors of poor outcome was baseline nail matrix involvement. The success rate at 18 months was 59% for combination therapy, compared with 45% for oral terbinafine monotherapy. The cost per cure was significantly less with combination therapy (Br. J. Dermatol. 2007;157:149-57).

Onychomycosis is best viewed as a chronic relapsing condition, as evidenced by a 5-year, blinded, prospective follow-up study Dr. Sigurgeirsson and colleagues conducted in terbinafine – or itraconazole-treated patients (Arch. Dermatol. 2002;138:353-7). The mycologic relapse rates were 53% in the itraconazole arm and 48% with terbinafine.

In a subsequent study of nearly 4,000 patients, the investigators identified a number of risk factors for recurrent onychomycosis: cancer, 3.4-fold increased risk; psoriasis, 2.4-fold increased risk; tinea pedis interdigitalis, 3.9-fold increased risk; moccasin form of tinea pedis, 4.3-fold increased risk; regular swimming, 2.6-fold increased risk; and having a spouse, parents, or children with onychomycosis, 2.5- to 3.5-fold increased risk (J. Eur. Acad. Dermatol. Venereol. 2004;18:48-51).

These findings were recently confirmed and expanded upon in a Japanese survey of 30,000 dermatology patients. Dermatologists at Teikyo University in Itabashi found most of the same risk factors earlier identified by Dr. Sigurgeirsson and coworkers. In addition, the Japanese investigators identified two previously undescribed risk factors for recurrent infection: more time spent wearing shoes, and having a higher temperature in the home (J. Dermatol. 2010;37:397-406).

Prophylactic therapy is worth considering following cure of onychomycosis in patients at increased risk for relapse based upon their risk factor profile, Dr. Sigurgeirsson said. He and his coworkers recently showed that amorolfine nail lacquer applied once every 2 weeks is safe and effective for this purpose (J. Eur. Acad. Dermatol. Venereol. 2010;24:910-5).

Many of his studies of terbinafine for onychomycosis were supported by research grants from Novartis.

Beth S. Ruben, MD

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or “streaky” band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.

*For a PDF of the full article, click on the link to the left of this introduction.

Beth S. Ruben, MD

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or “streaky” band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.

*For a PDF of the full article, click on the link to the left of this introduction.

Beth S. Ruben, MD

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or “streaky” band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.

*For a PDF of the full article, click on the link to the left of this introduction.

NAPLES, Fla. — Many women with hirsutism have already removed their excess, unwanted hair before they present to dermatology. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, because dermatologists play an important role in identification of important medical conditions associated with excess hair growth.

"Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings." Accurate diagnosis also optimizes dermatology treatment. "Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result]," Dr. Olsen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. "You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone." In addition, she added, "I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases."

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

"One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease," Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said. To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls. These girls also will have advanced bone age but premature closure of epiphyses, "so, ultimately, they have short adult stature." In adult women, include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. "If someone is suddenly developing hirsutism, that should be in the back of your mind."

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair. "It decreases the rate of hair growth and amount of shaving a woman has to do," Dr. Olsen said. "It's a decrease in the rate of hair growth only" and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

NAPLES, Fla. — Many women with hirsutism have already removed their excess, unwanted hair before they present to dermatology. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, because dermatologists play an important role in identification of important medical conditions associated with excess hair growth.

"Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings." Accurate diagnosis also optimizes dermatology treatment. "Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result]," Dr. Olsen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. "You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone." In addition, she added, "I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases."

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

"One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease," Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said. To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls. These girls also will have advanced bone age but premature closure of epiphyses, "so, ultimately, they have short adult stature." In adult women, include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. "If someone is suddenly developing hirsutism, that should be in the back of your mind."

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair. "It decreases the rate of hair growth and amount of shaving a woman has to do," Dr. Olsen said. "It's a decrease in the rate of hair growth only" and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

NAPLES, Fla. — Many women with hirsutism have already removed their excess, unwanted hair before they present to dermatology. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, because dermatologists play an important role in identification of important medical conditions associated with excess hair growth.

"Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings." Accurate diagnosis also optimizes dermatology treatment. "Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result]," Dr. Olsen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. "You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone." In addition, she added, "I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases."

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

"One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease," Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said. To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls. These girls also will have advanced bone age but premature closure of epiphyses, "so, ultimately, they have short adult stature." In adult women, include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. "If someone is suddenly developing hirsutism, that should be in the back of your mind."

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair. "It decreases the rate of hair growth and amount of shaving a woman has to do," Dr. Olsen said. "It's a decrease in the rate of hair growth only" and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.