Damian McNamara

SAN ANTONIO — A high level of clinical acumen is crucial to the early diagnosis of serious hypersensitivity reactions to antiepileptic drugs, Dr. Adelaide A. Hebert said at a meeting sponsored by Skin Disease Education Foundation.

Erythema multiforme is a major concern for patients with anticonvulsant hypersensitivity, said Dr. Hebert, professor of dermatology and pediatrics at the University of Texas, Houston.

If a patient presents with anticonvulsant hypersensitivity syndrome, as it is often called in the literature, check the medication's chemical structure before switching him or her to a different agent. “Cross-reactivity among aromatic anticonvulsant medications may be as high as 75%,” Dr. Hebert said at the meeting.

There are no reports of drug hypersensitivity with levetiracetam, so it is a notable exception among antiepileptic drugs. “I have asked my neurology colleagues why everyone is not put on Keppra [levetiracetam]. They tell me it does not work well for all patients and it's a third-tier, more expensive agent.”

Although the rest of the anticonvulsants carry some risk, the aromatic anticonvulsants are most often involved in hypersensitivity syndromes, especially phenobarbital, phenytoin, and carbamazepine.

Phenobarbital can cause morbilliform reactions, urticaria, erythema multiforme, photosensitivity, and purpura.

Up to 10% of patients taking phenytoin will have a cutaneous reaction. A lupuslike reaction can occur or it may exacerbate preexisting lupus, Dr. Hebert said.

Some atypical cutaneous effects are reported with carbamazepine hypersensitivity, such as unusual bruising and oral ulceration. Photosensitivity, urticaria and Stevens-Johnson syndrome are other risks.

In one recent study, investigators assessed genetic susceptibility to carbamazepine hypersensitivity (Pharmacogenet. Genomics 2006;16:297–306).

Another high-risk anticonvulsant is lamotrigine (Lamictal). Although it has no aromatic ring, “this does not mean lamotrigine does not carry its own risks,” Dr. Hebert said. Serious cutaneous eruptions, which may be life threatening, occur more often in children than in adults (1 in 100 pediatric patients versus 1 in 333 adult patients). “Not many medications cause such a high frequency,” she said.

About 10% of patients will develop erythema and a maculopapular eruption, usually within the first 2–8 weeks of lamotrigine use. A history of rash related to another antiepileptic and age younger than 13 years were predictors in one study (Epilepsia 2006;47:318–22).

Initiate lamotrigine at the lowest possible dose and increase slowly. Caution is advised when it is combined with valproic acid since this triples lamotrigine's half-life. A lamotrigine-associated eruption is more likely with this combination, especially as the lamotrigine dose increases over time.

Valproic acid on its own can cause erythema multiforme and Stevens-Johnson syndrome. Alopecia, petechiae, photosensitivity, and pruritus are other possibilities. It can also cause diaphoresis.

With any hypersensitivity reaction, discontinue the drug, get liver function tests and a complete blood count with differential, measure creatine levels, and do a urinalysis. Administer corticosteroids if the reaction is severe, Dr. Hebert advised.

Management of anticonvulsant hypersensitivity syndrome includes avoidance of all aromatic anticonvulsants or other causative medications. Aromatic anticonvulsants include felbamate (Felbatol), fosphenytoin (Cerebyx), and primidone. Cross-reactivity can be avoided by choosing a nonaromatic agent such as ethosuximide (Zarontin), gabapentin (Neurontin), tiagabine (Gabitril), or topiramate (Topamax). “It is a very good idea to also talk to a family member about this [cross-reactivity] and the risk of future hypersensitivity reactions,” Dr. Hebert said. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

'Cross-reactivity among aromatic anticonvulsant medications may be as high as 75%.' DR. HEBERT

SAN ANTONIO — A high level of clinical acumen is crucial to the early diagnosis of serious hypersensitivity reactions to antiepileptic drugs, Dr. Adelaide A. Hebert said at a meeting sponsored by Skin Disease Education Foundation.

Erythema multiforme is a major concern for patients with anticonvulsant hypersensitivity, said Dr. Hebert, professor of dermatology and pediatrics at the University of Texas, Houston.

If a patient presents with anticonvulsant hypersensitivity syndrome, as it is often called in the literature, check the medication's chemical structure before switching him or her to a different agent. “Cross-reactivity among aromatic anticonvulsant medications may be as high as 75%,” Dr. Hebert said at the meeting.

There are no reports of drug hypersensitivity with levetiracetam, so it is a notable exception among antiepileptic drugs. “I have asked my neurology colleagues why everyone is not put on Keppra [levetiracetam]. They tell me it does not work well for all patients and it's a third-tier, more expensive agent.”

Although the rest of the anticonvulsants carry some risk, the aromatic anticonvulsants are most often involved in hypersensitivity syndromes, especially phenobarbital, phenytoin, and carbamazepine.

Phenobarbital can cause morbilliform reactions, urticaria, erythema multiforme, photosensitivity, and purpura.

Up to 10% of patients taking phenytoin will have a cutaneous reaction. A lupuslike reaction can occur or it may exacerbate preexisting lupus, Dr. Hebert said.

Some atypical cutaneous effects are reported with carbamazepine hypersensitivity, such as unusual bruising and oral ulceration. Photosensitivity, urticaria and Stevens-Johnson syndrome are other risks.

In one recent study, investigators assessed genetic susceptibility to carbamazepine hypersensitivity (Pharmacogenet. Genomics 2006;16:297–306).

Another high-risk anticonvulsant is lamotrigine (Lamictal). Although it has no aromatic ring, “this does not mean lamotrigine does not carry its own risks,” Dr. Hebert said. Serious cutaneous eruptions, which may be life threatening, occur more often in children than in adults (1 in 100 pediatric patients versus 1 in 333 adult patients). “Not many medications cause such a high frequency,” she said.

About 10% of patients will develop erythema and a maculopapular eruption, usually within the first 2–8 weeks of lamotrigine use. A history of rash related to another antiepileptic and age younger than 13 years were predictors in one study (Epilepsia 2006;47:318–22).

Initiate lamotrigine at the lowest possible dose and increase slowly. Caution is advised when it is combined with valproic acid since this triples lamotrigine's half-life. A lamotrigine-associated eruption is more likely with this combination, especially as the lamotrigine dose increases over time.

Valproic acid on its own can cause erythema multiforme and Stevens-Johnson syndrome. Alopecia, petechiae, photosensitivity, and pruritus are other possibilities. It can also cause diaphoresis.

With any hypersensitivity reaction, discontinue the drug, get liver function tests and a complete blood count with differential, measure creatine levels, and do a urinalysis. Administer corticosteroids if the reaction is severe, Dr. Hebert advised.

Management of anticonvulsant hypersensitivity syndrome includes avoidance of all aromatic anticonvulsants or other causative medications. Aromatic anticonvulsants include felbamate (Felbatol), fosphenytoin (Cerebyx), and primidone. Cross-reactivity can be avoided by choosing a nonaromatic agent such as ethosuximide (Zarontin), gabapentin (Neurontin), tiagabine (Gabitril), or topiramate (Topamax). “It is a very good idea to also talk to a family member about this [cross-reactivity] and the risk of future hypersensitivity reactions,” Dr. Hebert said. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

'Cross-reactivity among aromatic anticonvulsant medications may be as high as 75%.' DR. HEBERT

SAN ANTONIO — A high level of clinical acumen is crucial to the early diagnosis of serious hypersensitivity reactions to antiepileptic drugs, Dr. Adelaide A. Hebert said at a meeting sponsored by Skin Disease Education Foundation.

Erythema multiforme is a major concern for patients with anticonvulsant hypersensitivity, said Dr. Hebert, professor of dermatology and pediatrics at the University of Texas, Houston.

If a patient presents with anticonvulsant hypersensitivity syndrome, as it is often called in the literature, check the medication's chemical structure before switching him or her to a different agent. “Cross-reactivity among aromatic anticonvulsant medications may be as high as 75%,” Dr. Hebert said at the meeting.

There are no reports of drug hypersensitivity with levetiracetam, so it is a notable exception among antiepileptic drugs. “I have asked my neurology colleagues why everyone is not put on Keppra [levetiracetam]. They tell me it does not work well for all patients and it's a third-tier, more expensive agent.”

Although the rest of the anticonvulsants carry some risk, the aromatic anticonvulsants are most often involved in hypersensitivity syndromes, especially phenobarbital, phenytoin, and carbamazepine.

Phenobarbital can cause morbilliform reactions, urticaria, erythema multiforme, photosensitivity, and purpura.

Up to 10% of patients taking phenytoin will have a cutaneous reaction. A lupuslike reaction can occur or it may exacerbate preexisting lupus, Dr. Hebert said.

Some atypical cutaneous effects are reported with carbamazepine hypersensitivity, such as unusual bruising and oral ulceration. Photosensitivity, urticaria and Stevens-Johnson syndrome are other risks.

In one recent study, investigators assessed genetic susceptibility to carbamazepine hypersensitivity (Pharmacogenet. Genomics 2006;16:297–306).

Another high-risk anticonvulsant is lamotrigine (Lamictal). Although it has no aromatic ring, “this does not mean lamotrigine does not carry its own risks,” Dr. Hebert said. Serious cutaneous eruptions, which may be life threatening, occur more often in children than in adults (1 in 100 pediatric patients versus 1 in 333 adult patients). “Not many medications cause such a high frequency,” she said.

About 10% of patients will develop erythema and a maculopapular eruption, usually within the first 2–8 weeks of lamotrigine use. A history of rash related to another antiepileptic and age younger than 13 years were predictors in one study (Epilepsia 2006;47:318–22).

Initiate lamotrigine at the lowest possible dose and increase slowly. Caution is advised when it is combined with valproic acid since this triples lamotrigine's half-life. A lamotrigine-associated eruption is more likely with this combination, especially as the lamotrigine dose increases over time.

Valproic acid on its own can cause erythema multiforme and Stevens-Johnson syndrome. Alopecia, petechiae, photosensitivity, and pruritus are other possibilities. It can also cause diaphoresis.

With any hypersensitivity reaction, discontinue the drug, get liver function tests and a complete blood count with differential, measure creatine levels, and do a urinalysis. Administer corticosteroids if the reaction is severe, Dr. Hebert advised.

Management of anticonvulsant hypersensitivity syndrome includes avoidance of all aromatic anticonvulsants or other causative medications. Aromatic anticonvulsants include felbamate (Felbatol), fosphenytoin (Cerebyx), and primidone. Cross-reactivity can be avoided by choosing a nonaromatic agent such as ethosuximide (Zarontin), gabapentin (Neurontin), tiagabine (Gabitril), or topiramate (Topamax). “It is a very good idea to also talk to a family member about this [cross-reactivity] and the risk of future hypersensitivity reactions,” Dr. Hebert said. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

'Cross-reactivity among aromatic anticonvulsant medications may be as high as 75%.' DR. HEBERT

ORLANDO — Ramelteon is effective for a subset of patients with insomnia, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute. In addition, because the agent works on melatonin receptors, a potential off-label use is for patients with shift-work disorder.

Ramelteon (Rozerem, Takeda Pharmaceuticals) targets the melatonin receptors MT1 and MT2. The agent is approximately 10 times more potent than melatonin. Other approved drugs promote sleep by increasing γ-aminobutyric acid (GABA), which is normally released by the suprachiasmatic nucleus in the brain.

“Ramelteon is a very interesting drug. It is the first on the market for sleep that does not work on the GABA system,” Dr. Wallace B. Mendelson said. The melatonin receptor agonist is a very short acting drug with a half-life of 1–2 hours. “It is very potent for helping people fall asleep but not as effective for those who wake up early. So it's for a subset of patients.”

The Food and Drug Administration approved ramelteon for treatment of insomnia characterized by difficulty with sleep onset. “It is not a DEA-classified substance, only a hypnotic without potential for dependence,” said Dr. Mendelson, psychopharmacology consultant for many pharmaceutical companies, including Takeda Pharmaceuticals North America Inc.

A delay to peak therapeutic effect is another distinction of ramelteon, compared with benzodiazepines and newer, nonbenzodiazepine GABA agonists such as zolpidem (Ambien, Sanofi-Aventis) or eszopiclone (Lunesta, Sepracor). Dr. Mendelson said, “It can take up to a week for full effect, so caution patients that they may not feel tired right away.” Dr. Mendelson is also a consultant, an advisor, and on the speakers' bureau for Sanofi-Aventis and Sepracor Inc.

People with shift-work sleep disorder can experience excessive daytime sleepiness because their body rhythm stays the same but the world changes around them, Dr. Mendelson said. “No one knows why some people are more susceptible to this, except it is harder to adapt to nighttime shift work as you get older.”

Pharmacotherapy with a sleep aid might be sufficient for a shift worker who complains only of sleepiness or trouble going off to sleep, Dr. Mendelson said. However, “if they are having trouble with both sleep and waking, it might make sense to try to help them shift to the new time. One way is to use melatonin.”

Exogenous melatonin can shift circadian rhythms. Melatonin taken in the evening can shift a person's circadian rhythm earlier while melatonin in the morning can shift it later, he said.

“I have a real issue with the quality and standardization of melatonin. It's not consistent, which is why I prefer a drug like Rozerem,” Dr. Mendelson said. “Rozerem is not indicated for this, but some research indicates it can shift circadian rhythm with off-label use similar to melatonin.”

Another option for circadian rhythm adjustment is bright light therapy. “I like bright light therapy because it's more benign—but it works the opposite.” In the morning, the therapy pushes circadian rhythm phase earlier, and at night, it pushes it later.

Insomnia rarely occurs alone, Dr. Mendelson said. “About 80% of insomnia patients you see have some other disorder. The old name was secondary insomnia. Us sleep guys are now calling this comorbid insomnia.”

Ramelteon might be an appropriate choice for patients with sleep apnea, Dr. Mendelson said. A significant minority of sleep apnea will present with insomnia as the primary complaint. “We need to carefully diagnose because most of the agents we prescribe for insomnia can make sleep apnea worse, except ramelteon or the tricyclic antidepressants.”

The probability of diagnosing a psychiatric disorder increases among patients who complain of insomnia (Sleep Med. 2005;6:549–53). In this study, a survey of 200 general hospital patients indicated 57% reported insomnia and 50% reported at least one psychiatric disorder.

Insomnia can play a major role in several psychiatric illnesses, especially depression, Dr. Mendelson said. “Targeting insomnia with sleep aids and behavioral therapy can improve outcomes.” Insomnia may also signal depression onset. “On average, 41% of people will have insomnia preceding depression.”

ORLANDO — Ramelteon is effective for a subset of patients with insomnia, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute. In addition, because the agent works on melatonin receptors, a potential off-label use is for patients with shift-work disorder.

Ramelteon (Rozerem, Takeda Pharmaceuticals) targets the melatonin receptors MT1 and MT2. The agent is approximately 10 times more potent than melatonin. Other approved drugs promote sleep by increasing γ-aminobutyric acid (GABA), which is normally released by the suprachiasmatic nucleus in the brain.

“Ramelteon is a very interesting drug. It is the first on the market for sleep that does not work on the GABA system,” Dr. Wallace B. Mendelson said. The melatonin receptor agonist is a very short acting drug with a half-life of 1–2 hours. “It is very potent for helping people fall asleep but not as effective for those who wake up early. So it's for a subset of patients.”

The Food and Drug Administration approved ramelteon for treatment of insomnia characterized by difficulty with sleep onset. “It is not a DEA-classified substance, only a hypnotic without potential for dependence,” said Dr. Mendelson, psychopharmacology consultant for many pharmaceutical companies, including Takeda Pharmaceuticals North America Inc.

A delay to peak therapeutic effect is another distinction of ramelteon, compared with benzodiazepines and newer, nonbenzodiazepine GABA agonists such as zolpidem (Ambien, Sanofi-Aventis) or eszopiclone (Lunesta, Sepracor). Dr. Mendelson said, “It can take up to a week for full effect, so caution patients that they may not feel tired right away.” Dr. Mendelson is also a consultant, an advisor, and on the speakers' bureau for Sanofi-Aventis and Sepracor Inc.

People with shift-work sleep disorder can experience excessive daytime sleepiness because their body rhythm stays the same but the world changes around them, Dr. Mendelson said. “No one knows why some people are more susceptible to this, except it is harder to adapt to nighttime shift work as you get older.”

Pharmacotherapy with a sleep aid might be sufficient for a shift worker who complains only of sleepiness or trouble going off to sleep, Dr. Mendelson said. However, “if they are having trouble with both sleep and waking, it might make sense to try to help them shift to the new time. One way is to use melatonin.”

Exogenous melatonin can shift circadian rhythms. Melatonin taken in the evening can shift a person's circadian rhythm earlier while melatonin in the morning can shift it later, he said.

“I have a real issue with the quality and standardization of melatonin. It's not consistent, which is why I prefer a drug like Rozerem,” Dr. Mendelson said. “Rozerem is not indicated for this, but some research indicates it can shift circadian rhythm with off-label use similar to melatonin.”

Another option for circadian rhythm adjustment is bright light therapy. “I like bright light therapy because it's more benign—but it works the opposite.” In the morning, the therapy pushes circadian rhythm phase earlier, and at night, it pushes it later.

Insomnia rarely occurs alone, Dr. Mendelson said. “About 80% of insomnia patients you see have some other disorder. The old name was secondary insomnia. Us sleep guys are now calling this comorbid insomnia.”

Ramelteon might be an appropriate choice for patients with sleep apnea, Dr. Mendelson said. A significant minority of sleep apnea will present with insomnia as the primary complaint. “We need to carefully diagnose because most of the agents we prescribe for insomnia can make sleep apnea worse, except ramelteon or the tricyclic antidepressants.”

The probability of diagnosing a psychiatric disorder increases among patients who complain of insomnia (Sleep Med. 2005;6:549–53). In this study, a survey of 200 general hospital patients indicated 57% reported insomnia and 50% reported at least one psychiatric disorder.

Insomnia can play a major role in several psychiatric illnesses, especially depression, Dr. Mendelson said. “Targeting insomnia with sleep aids and behavioral therapy can improve outcomes.” Insomnia may also signal depression onset. “On average, 41% of people will have insomnia preceding depression.”

ORLANDO — Ramelteon is effective for a subset of patients with insomnia, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute. In addition, because the agent works on melatonin receptors, a potential off-label use is for patients with shift-work disorder.

Ramelteon (Rozerem, Takeda Pharmaceuticals) targets the melatonin receptors MT1 and MT2. The agent is approximately 10 times more potent than melatonin. Other approved drugs promote sleep by increasing γ-aminobutyric acid (GABA), which is normally released by the suprachiasmatic nucleus in the brain.

“Ramelteon is a very interesting drug. It is the first on the market for sleep that does not work on the GABA system,” Dr. Wallace B. Mendelson said. The melatonin receptor agonist is a very short acting drug with a half-life of 1–2 hours. “It is very potent for helping people fall asleep but not as effective for those who wake up early. So it's for a subset of patients.”

The Food and Drug Administration approved ramelteon for treatment of insomnia characterized by difficulty with sleep onset. “It is not a DEA-classified substance, only a hypnotic without potential for dependence,” said Dr. Mendelson, psychopharmacology consultant for many pharmaceutical companies, including Takeda Pharmaceuticals North America Inc.

A delay to peak therapeutic effect is another distinction of ramelteon, compared with benzodiazepines and newer, nonbenzodiazepine GABA agonists such as zolpidem (Ambien, Sanofi-Aventis) or eszopiclone (Lunesta, Sepracor). Dr. Mendelson said, “It can take up to a week for full effect, so caution patients that they may not feel tired right away.” Dr. Mendelson is also a consultant, an advisor, and on the speakers' bureau for Sanofi-Aventis and Sepracor Inc.

People with shift-work sleep disorder can experience excessive daytime sleepiness because their body rhythm stays the same but the world changes around them, Dr. Mendelson said. “No one knows why some people are more susceptible to this, except it is harder to adapt to nighttime shift work as you get older.”

Pharmacotherapy with a sleep aid might be sufficient for a shift worker who complains only of sleepiness or trouble going off to sleep, Dr. Mendelson said. However, “if they are having trouble with both sleep and waking, it might make sense to try to help them shift to the new time. One way is to use melatonin.”

Exogenous melatonin can shift circadian rhythms. Melatonin taken in the evening can shift a person's circadian rhythm earlier while melatonin in the morning can shift it later, he said.

“I have a real issue with the quality and standardization of melatonin. It's not consistent, which is why I prefer a drug like Rozerem,” Dr. Mendelson said. “Rozerem is not indicated for this, but some research indicates it can shift circadian rhythm with off-label use similar to melatonin.”

Another option for circadian rhythm adjustment is bright light therapy. “I like bright light therapy because it's more benign—but it works the opposite.” In the morning, the therapy pushes circadian rhythm phase earlier, and at night, it pushes it later.

Insomnia rarely occurs alone, Dr. Mendelson said. “About 80% of insomnia patients you see have some other disorder. The old name was secondary insomnia. Us sleep guys are now calling this comorbid insomnia.”

Ramelteon might be an appropriate choice for patients with sleep apnea, Dr. Mendelson said. A significant minority of sleep apnea will present with insomnia as the primary complaint. “We need to carefully diagnose because most of the agents we prescribe for insomnia can make sleep apnea worse, except ramelteon or the tricyclic antidepressants.”

The probability of diagnosing a psychiatric disorder increases among patients who complain of insomnia (Sleep Med. 2005;6:549–53). In this study, a survey of 200 general hospital patients indicated 57% reported insomnia and 50% reported at least one psychiatric disorder.

Insomnia can play a major role in several psychiatric illnesses, especially depression, Dr. Mendelson said. “Targeting insomnia with sleep aids and behavioral therapy can improve outcomes.” Insomnia may also signal depression onset. “On average, 41% of people will have insomnia preceding depression.”

SAN ANTONIO — The diuretic spironolactone is inexpensive, well tolerated, and effective for most women with acne vulgaris, Dr. Steven A. Davis said at a meeting of Skin Disease Education Foundation.

“This is one of the better products” for treating acne, Dr. Davis said. “It really gets to the heart of the acne problem, at least as well as or better than antibiotics.”

Hormones can play a major role in manifesting acne, as evidenced by premenstrual flare in women, acne changes with oral contraceptive and pregnancy, and exercise- and stress-induced acne flares in women and men. Spironolactone can clear acne in these patients by blunting the androgen response, he said.

“All of my patients are women—spironolactone can cause gynecomastia in men,” said Dr. Davis of the University of Texas, San Antonio. “We ask them if their acne occurs right before their period and clears up after. We noticed that a lot of adolescent girls will get acne during a sport season and clear up afterward, pointing to a testosterone effect of heavy exercise.”

This off-label use of spironolactone, however, is primarily indicated for women over 18 years and up to 70 years old, he said. “One of the great things is that the response is usually very fast. If someone is given 75 mg/day and there is no response in 7–10 days, it's unlikely to work.” In a study at the university, treatment for a median of 15 months was considered effective for 79% of 53 consecutive female patients.

Dr. Davis' standard dosing protocol is 75 mg/day taken as two 25-mg pills in the morning and one 25-mg pill in the evening. Diuretic side effects vary widely from patient to patient and tend to occur at daily doses of 100 mg/day or greater. With this in mind, he doses higher in the morning. “I would rather they urinate frequently during the day if it occurs,” he said. SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

The dose can be increased to 100 mg/day, given as two 25-mg pills in the morning and two 25-mg pills in the evening if there is no response within a week, but the doses should not exceed 200 mg/day in divided doses, Dr. Davis said.

Spironolactone is available as a generic and costs $10–$20 for a bottle of 100 pills. Dr. Davis has no financial relationship with any manufacturer of spironolactone.

“It's a very safe and very clean product. I feel very comfortable giving it to a woman taking oral contraceptives,” he said. “I've probably treated at least 1,000 patients with spironolactone, and it requires little or no blood testing. I don't think it's necessary to follow potassium levels in most healthy adults.”

The most common side effects are menstrual irregularities, which occurred in 5 participants in the 53-patient series, “but I tend not to see this at 75 mg. As you start going up the line to 100 mg and 125 mg, the menstrual irregularities start to kick in.”

In response to a question from the audience, Dr. Davis said lithium and digoxin can interact with spironolactone, so if patients taking a psychoactive drug should check with their psychiatrist about potential interactions.

“The patient satisfaction rate is very, very high. Some patients are treated for 10 or more years without side effects.”

SAN ANTONIO — The diuretic spironolactone is inexpensive, well tolerated, and effective for most women with acne vulgaris, Dr. Steven A. Davis said at a meeting of Skin Disease Education Foundation.

“This is one of the better products” for treating acne, Dr. Davis said. “It really gets to the heart of the acne problem, at least as well as or better than antibiotics.”

Hormones can play a major role in manifesting acne, as evidenced by premenstrual flare in women, acne changes with oral contraceptive and pregnancy, and exercise- and stress-induced acne flares in women and men. Spironolactone can clear acne in these patients by blunting the androgen response, he said.

“All of my patients are women—spironolactone can cause gynecomastia in men,” said Dr. Davis of the University of Texas, San Antonio. “We ask them if their acne occurs right before their period and clears up after. We noticed that a lot of adolescent girls will get acne during a sport season and clear up afterward, pointing to a testosterone effect of heavy exercise.”

This off-label use of spironolactone, however, is primarily indicated for women over 18 years and up to 70 years old, he said. “One of the great things is that the response is usually very fast. If someone is given 75 mg/day and there is no response in 7–10 days, it's unlikely to work.” In a study at the university, treatment for a median of 15 months was considered effective for 79% of 53 consecutive female patients.

Dr. Davis' standard dosing protocol is 75 mg/day taken as two 25-mg pills in the morning and one 25-mg pill in the evening. Diuretic side effects vary widely from patient to patient and tend to occur at daily doses of 100 mg/day or greater. With this in mind, he doses higher in the morning. “I would rather they urinate frequently during the day if it occurs,” he said. SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

The dose can be increased to 100 mg/day, given as two 25-mg pills in the morning and two 25-mg pills in the evening if there is no response within a week, but the doses should not exceed 200 mg/day in divided doses, Dr. Davis said.

Spironolactone is available as a generic and costs $10–$20 for a bottle of 100 pills. Dr. Davis has no financial relationship with any manufacturer of spironolactone.

“It's a very safe and very clean product. I feel very comfortable giving it to a woman taking oral contraceptives,” he said. “I've probably treated at least 1,000 patients with spironolactone, and it requires little or no blood testing. I don't think it's necessary to follow potassium levels in most healthy adults.”

The most common side effects are menstrual irregularities, which occurred in 5 participants in the 53-patient series, “but I tend not to see this at 75 mg. As you start going up the line to 100 mg and 125 mg, the menstrual irregularities start to kick in.”

In response to a question from the audience, Dr. Davis said lithium and digoxin can interact with spironolactone, so if patients taking a psychoactive drug should check with their psychiatrist about potential interactions.

“The patient satisfaction rate is very, very high. Some patients are treated for 10 or more years without side effects.”

SAN ANTONIO — The diuretic spironolactone is inexpensive, well tolerated, and effective for most women with acne vulgaris, Dr. Steven A. Davis said at a meeting of Skin Disease Education Foundation.

“This is one of the better products” for treating acne, Dr. Davis said. “It really gets to the heart of the acne problem, at least as well as or better than antibiotics.”

Hormones can play a major role in manifesting acne, as evidenced by premenstrual flare in women, acne changes with oral contraceptive and pregnancy, and exercise- and stress-induced acne flares in women and men. Spironolactone can clear acne in these patients by blunting the androgen response, he said.

“All of my patients are women—spironolactone can cause gynecomastia in men,” said Dr. Davis of the University of Texas, San Antonio. “We ask them if their acne occurs right before their period and clears up after. We noticed that a lot of adolescent girls will get acne during a sport season and clear up afterward, pointing to a testosterone effect of heavy exercise.”

This off-label use of spironolactone, however, is primarily indicated for women over 18 years and up to 70 years old, he said. “One of the great things is that the response is usually very fast. If someone is given 75 mg/day and there is no response in 7–10 days, it's unlikely to work.” In a study at the university, treatment for a median of 15 months was considered effective for 79% of 53 consecutive female patients.

Dr. Davis' standard dosing protocol is 75 mg/day taken as two 25-mg pills in the morning and one 25-mg pill in the evening. Diuretic side effects vary widely from patient to patient and tend to occur at daily doses of 100 mg/day or greater. With this in mind, he doses higher in the morning. “I would rather they urinate frequently during the day if it occurs,” he said. SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

The dose can be increased to 100 mg/day, given as two 25-mg pills in the morning and two 25-mg pills in the evening if there is no response within a week, but the doses should not exceed 200 mg/day in divided doses, Dr. Davis said.

Spironolactone is available as a generic and costs $10–$20 for a bottle of 100 pills. Dr. Davis has no financial relationship with any manufacturer of spironolactone.

“It's a very safe and very clean product. I feel very comfortable giving it to a woman taking oral contraceptives,” he said. “I've probably treated at least 1,000 patients with spironolactone, and it requires little or no blood testing. I don't think it's necessary to follow potassium levels in most healthy adults.”

The most common side effects are menstrual irregularities, which occurred in 5 participants in the 53-patient series, “but I tend not to see this at 75 mg. As you start going up the line to 100 mg and 125 mg, the menstrual irregularities start to kick in.”

In response to a question from the audience, Dr. Davis said lithium and digoxin can interact with spironolactone, so if patients taking a psychoactive drug should check with their psychiatrist about potential interactions.

“The patient satisfaction rate is very, very high. Some patients are treated for 10 or more years without side effects.”

LAS VEGAS — There are not enough data to recommend mesotherapy to patients, although some evidence supports a specific form—injected lipolysis—for localized fat reduction, according to two presentations at an international symposium on cosmetic and laser surgery.

Mesotherapy is touted for many indications worldwide, including cellulite reduction and pain management. Confusion abounds, however, because people often refer to mesotherapy and injected lipolysis interchangeably, said Dr. Paul T. Rose of Tampa.

"Oftentimes I am asked: Does mesotherapy work?" said Dr. Adam M. Rotunda of the division of dermatology at the University of California, Los Angeles. "We cannot say it works or does not work—it is such a general term."

An injected combination of the soy-derived phospholipid phosphatidylcholine (PC) and the solvent sodium deoxycholate (DC) "is well proven" for localized fat lysis, Dr. Rose said. He and colleague Dr. Michael Morgan assessed punch biopsies from a patient after PC/DC injections, and histology showed destruction of fat (J. Cosmet. Laser Ther. 2005;7:17–9). "There is a profound inflammatory response with neutrophils, plasma cells, and hopefully, macrophages to eat up the fat," he said.

Another study of 30 patients demonstrated some benefit of this combination for correction of lower eyelid bulging (Dermatol. Surg. 2001;27:391–2), Dr. Rotunda said. An open-label study of 43 patients who received a "pretty aggressive" regimen of up to 100 mL PC/DC per treatment session demonstrated some improvements in abdominal fat, he said.

"I'm not impressed with the abdomen—you need a significant amount. I am impressed with jowl-area results," Dr. Rotunda said. Other commonly treated areas include inferior orbital fat, chins, arms, flanks, lateral and medial thighs, and knees.

Even with this evidence, more research is needed. "Most of these studies are unblinded, open case series. But we are moving in the direction of having peer review literature," Dr. Rotunda said. For example, Dr. David Goldberg and his associates conducted a study in 10 patients who received four monthly injections of multivitamin and conjugated hyaluronic acid for facial rejuvenation (Dermatol. Surg., in press). Although thickened collagen fibers were noted, "no clinical benefits were seen," Dr. Rotunda said.

Intravenous PC can lower blood lipids, and a similar mechanism of action might lyse subcutaneous fat. "In our lab, however, phosphatidylcholine has not demonstrated any antifat property. Sodium deoxycholate, however, is a detergent known to lyse fat [Dermatol. Surg. 2004;30:1001–8]. So could this solvent actually be the active ingredient?" Dr. Rotunda asked.

"We are working on a double-blind study of PC vs. DC [for submental fat] to see if you need PC at all," Dr. Rotunda said. He disclosed a relationship with Kythera Biopharmaceuticals Inc., codeveloper of a patent-pending process owned by the University of California, Los Angeles, for the use of detergent in treating fat. Dr. Rose had no relevant disclosure.

Injected lipolysis is contraindicated in patients on blood thinners or those with severe hypertension or cardiac disease, HIV, severe renal disease, allergies to medication, or unrealistic expectations, Dr. Rose said. "This is not a procedure for profound weight loss. If I have a patient come in and they are markedly obese, I tell them mesotherapy is not an option." The therapy can be an adjunct to liposuction or other procedures, he added.

Patients can receive the treatment every 2- 4 weeks at up to four areas at a time. "It is not magic. It can be four or five treatments," Dr. Rose noted. It is important to inform patients that they can get significant swelling and that bruising almost always occurs, he said.

Other effects, such as erythema, burning, tenderness, a jelly-like edema post injection, and nodularity, will go away within weeks, Dr. Rotunda said.

Mesotherapy Is a No Go for Cellulite

Not enough evidence of efficacy exists to recommend mesotherapy for treatment of cellulite.

Although some evidence supports a form of mesotherapy for local fat lysis, "I am far more skeptical about this area, it's more sketchy. Objective data are lacking for cellulite," said Dr. Rose.

Proponents of mesotherapy for cellulite say connective tissue dissolution can degrade and smooth out skin, Dr. Rotunda said, "but there are no published data that demonstrate improvements of 'skin dimpling.'"

"There is a lack of controlled studies or histologic studies [but] there are people doing this," Dr. Rose said.

"Unscrupulous individuals are administering this," agreed Dr. Rotunda.

"Until further studies are performed, patients considering mesotherapy for cellulite must be aware that the substances currently being injected to treat this cosmetically disturbing, but medically benign, condition have not been thoroughly evaluated for safety or efficacy," Dr. Rotunda and his colleagues said in a review article on injectables used for cellulite (J. Cosmet. Laser Ther. 2005;7:147–54).

LAS VEGAS — There are not enough data to recommend mesotherapy to patients, although some evidence supports a specific form—injected lipolysis—for localized fat reduction, according to two presentations at an international symposium on cosmetic and laser surgery.

Mesotherapy is touted for many indications worldwide, including cellulite reduction and pain management. Confusion abounds, however, because people often refer to mesotherapy and injected lipolysis interchangeably, said Dr. Paul T. Rose of Tampa.

"Oftentimes I am asked: Does mesotherapy work?" said Dr. Adam M. Rotunda of the division of dermatology at the University of California, Los Angeles. "We cannot say it works or does not work—it is such a general term."

An injected combination of the soy-derived phospholipid phosphatidylcholine (PC) and the solvent sodium deoxycholate (DC) "is well proven" for localized fat lysis, Dr. Rose said. He and colleague Dr. Michael Morgan assessed punch biopsies from a patient after PC/DC injections, and histology showed destruction of fat (J. Cosmet. Laser Ther. 2005;7:17–9). "There is a profound inflammatory response with neutrophils, plasma cells, and hopefully, macrophages to eat up the fat," he said.

Another study of 30 patients demonstrated some benefit of this combination for correction of lower eyelid bulging (Dermatol. Surg. 2001;27:391–2), Dr. Rotunda said. An open-label study of 43 patients who received a "pretty aggressive" regimen of up to 100 mL PC/DC per treatment session demonstrated some improvements in abdominal fat, he said.

"I'm not impressed with the abdomen—you need a significant amount. I am impressed with jowl-area results," Dr. Rotunda said. Other commonly treated areas include inferior orbital fat, chins, arms, flanks, lateral and medial thighs, and knees.

Even with this evidence, more research is needed. "Most of these studies are unblinded, open case series. But we are moving in the direction of having peer review literature," Dr. Rotunda said. For example, Dr. David Goldberg and his associates conducted a study in 10 patients who received four monthly injections of multivitamin and conjugated hyaluronic acid for facial rejuvenation (Dermatol. Surg., in press). Although thickened collagen fibers were noted, "no clinical benefits were seen," Dr. Rotunda said.

Intravenous PC can lower blood lipids, and a similar mechanism of action might lyse subcutaneous fat. "In our lab, however, phosphatidylcholine has not demonstrated any antifat property. Sodium deoxycholate, however, is a detergent known to lyse fat [Dermatol. Surg. 2004;30:1001–8]. So could this solvent actually be the active ingredient?" Dr. Rotunda asked.

"We are working on a double-blind study of PC vs. DC [for submental fat] to see if you need PC at all," Dr. Rotunda said. He disclosed a relationship with Kythera Biopharmaceuticals Inc., codeveloper of a patent-pending process owned by the University of California, Los Angeles, for the use of detergent in treating fat. Dr. Rose had no relevant disclosure.

Injected lipolysis is contraindicated in patients on blood thinners or those with severe hypertension or cardiac disease, HIV, severe renal disease, allergies to medication, or unrealistic expectations, Dr. Rose said. "This is not a procedure for profound weight loss. If I have a patient come in and they are markedly obese, I tell them mesotherapy is not an option." The therapy can be an adjunct to liposuction or other procedures, he added.

Patients can receive the treatment every 2- 4 weeks at up to four areas at a time. "It is not magic. It can be four or five treatments," Dr. Rose noted. It is important to inform patients that they can get significant swelling and that bruising almost always occurs, he said.

Other effects, such as erythema, burning, tenderness, a jelly-like edema post injection, and nodularity, will go away within weeks, Dr. Rotunda said.

Mesotherapy Is a No Go for Cellulite

Not enough evidence of efficacy exists to recommend mesotherapy for treatment of cellulite.

Although some evidence supports a form of mesotherapy for local fat lysis, "I am far more skeptical about this area, it's more sketchy. Objective data are lacking for cellulite," said Dr. Rose.

Proponents of mesotherapy for cellulite say connective tissue dissolution can degrade and smooth out skin, Dr. Rotunda said, "but there are no published data that demonstrate improvements of 'skin dimpling.'"

"There is a lack of controlled studies or histologic studies [but] there are people doing this," Dr. Rose said.

"Unscrupulous individuals are administering this," agreed Dr. Rotunda.

"Until further studies are performed, patients considering mesotherapy for cellulite must be aware that the substances currently being injected to treat this cosmetically disturbing, but medically benign, condition have not been thoroughly evaluated for safety or efficacy," Dr. Rotunda and his colleagues said in a review article on injectables used for cellulite (J. Cosmet. Laser Ther. 2005;7:147–54).

LAS VEGAS — There are not enough data to recommend mesotherapy to patients, although some evidence supports a specific form—injected lipolysis—for localized fat reduction, according to two presentations at an international symposium on cosmetic and laser surgery.

Mesotherapy is touted for many indications worldwide, including cellulite reduction and pain management. Confusion abounds, however, because people often refer to mesotherapy and injected lipolysis interchangeably, said Dr. Paul T. Rose of Tampa.

"Oftentimes I am asked: Does mesotherapy work?" said Dr. Adam M. Rotunda of the division of dermatology at the University of California, Los Angeles. "We cannot say it works or does not work—it is such a general term."

An injected combination of the soy-derived phospholipid phosphatidylcholine (PC) and the solvent sodium deoxycholate (DC) "is well proven" for localized fat lysis, Dr. Rose said. He and colleague Dr. Michael Morgan assessed punch biopsies from a patient after PC/DC injections, and histology showed destruction of fat (J. Cosmet. Laser Ther. 2005;7:17–9). "There is a profound inflammatory response with neutrophils, plasma cells, and hopefully, macrophages to eat up the fat," he said.

Another study of 30 patients demonstrated some benefit of this combination for correction of lower eyelid bulging (Dermatol. Surg. 2001;27:391–2), Dr. Rotunda said. An open-label study of 43 patients who received a "pretty aggressive" regimen of up to 100 mL PC/DC per treatment session demonstrated some improvements in abdominal fat, he said.

"I'm not impressed with the abdomen—you need a significant amount. I am impressed with jowl-area results," Dr. Rotunda said. Other commonly treated areas include inferior orbital fat, chins, arms, flanks, lateral and medial thighs, and knees.

Even with this evidence, more research is needed. "Most of these studies are unblinded, open case series. But we are moving in the direction of having peer review literature," Dr. Rotunda said. For example, Dr. David Goldberg and his associates conducted a study in 10 patients who received four monthly injections of multivitamin and conjugated hyaluronic acid for facial rejuvenation (Dermatol. Surg., in press). Although thickened collagen fibers were noted, "no clinical benefits were seen," Dr. Rotunda said.

Intravenous PC can lower blood lipids, and a similar mechanism of action might lyse subcutaneous fat. "In our lab, however, phosphatidylcholine has not demonstrated any antifat property. Sodium deoxycholate, however, is a detergent known to lyse fat [Dermatol. Surg. 2004;30:1001–8]. So could this solvent actually be the active ingredient?" Dr. Rotunda asked.

"We are working on a double-blind study of PC vs. DC [for submental fat] to see if you need PC at all," Dr. Rotunda said. He disclosed a relationship with Kythera Biopharmaceuticals Inc., codeveloper of a patent-pending process owned by the University of California, Los Angeles, for the use of detergent in treating fat. Dr. Rose had no relevant disclosure.

Injected lipolysis is contraindicated in patients on blood thinners or those with severe hypertension or cardiac disease, HIV, severe renal disease, allergies to medication, or unrealistic expectations, Dr. Rose said. "This is not a procedure for profound weight loss. If I have a patient come in and they are markedly obese, I tell them mesotherapy is not an option." The therapy can be an adjunct to liposuction or other procedures, he added.

Patients can receive the treatment every 2- 4 weeks at up to four areas at a time. "It is not magic. It can be four or five treatments," Dr. Rose noted. It is important to inform patients that they can get significant swelling and that bruising almost always occurs, he said.

Other effects, such as erythema, burning, tenderness, a jelly-like edema post injection, and nodularity, will go away within weeks, Dr. Rotunda said.

Mesotherapy Is a No Go for Cellulite

Not enough evidence of efficacy exists to recommend mesotherapy for treatment of cellulite.

Although some evidence supports a form of mesotherapy for local fat lysis, "I am far more skeptical about this area, it's more sketchy. Objective data are lacking for cellulite," said Dr. Rose.

Proponents of mesotherapy for cellulite say connective tissue dissolution can degrade and smooth out skin, Dr. Rotunda said, "but there are no published data that demonstrate improvements of 'skin dimpling.'"

"There is a lack of controlled studies or histologic studies [but] there are people doing this," Dr. Rose said.

"Unscrupulous individuals are administering this," agreed Dr. Rotunda.

"Until further studies are performed, patients considering mesotherapy for cellulite must be aware that the substances currently being injected to treat this cosmetically disturbing, but medically benign, condition have not been thoroughly evaluated for safety or efficacy," Dr. Rotunda and his colleagues said in a review article on injectables used for cellulite (J. Cosmet. Laser Ther. 2005;7:147–54).

LAS VEGAS — Chemoprevention with photodynamic therapy is encouraging—the therapy increases the time it takes actinic keratoses to develop into skin cancer, according to anecdotal data and preliminary results of larger trials.

Chemoprevention is the most important indication for photodynamic therapy (PDT), Dr. Michael H. Gold said at an international symposium on cosmetic and laser surgery.

Initial reports indicate efficacy for basal cell carcinoma, especially superficial lesions, and researchers have reported improvements to nodular basal cell and ulcerative basal cell lesions.

"PDT is wonderful for basal cell carcinoma on the ear. Mohs surgeons don't want to touch it, and my only other option is radiation," said Dr. Gold, who is in private practice in Nashville, Tenn., and is also with Vanderbilt University, Nashville.

Methyl-aminolevulinic HCl (Metvixia/PhotoCure, Galderma) and 5-aminolevulinic acid (ALA) (Levulan Kerastick, Dusa Pharmaceuticals) are the two photosensitizers generally studied for use with photodynamic therapy. Dr. Gold is a researcher, speaker, and consultant for Dusa.

ALA is approved for the treatment of precancerous actinic keratoses on the face and scalp. The product is being developed for the treatment of acne and photodamage, according to the manufacturer's Web site. Methyl-aminolevulinic HCl (methyl-ALA) is approved in the United States for treatment of nonhyperkeratotic actinic keratoses. The product is marketed in Europe as Metvix and carries an additional indication for basal cell carcinoma unsuitable for conventional therapy.

"What is interesting is what has been done with Metvix," Dr. Gold said. There has been a great deal of "very good work done in Europe with Metvix for actinic keratoses and Bowen's disease. It is now the treatment of choice in Europe for Bowen's disease."

There are two very interesting studies in Europe looking at immunosuppressed organ transplant patients treated with methyl-ALA, Dr. Gold said.

In one study, a single treatment with methyl-ALA/PDT delayed development of actinic keratoses for 9.6 months, versus 6.8 months in untreated patients (Acta. Derm. Venereol. 2006;86:25–8). The second study is an ongoing multicenter trial with 81 transplant patients enrolled to date who were treated with either methyl-ALA/PDT or cryotherapy. There was a significantly lower number of actinic keratoses in the areas treated with methyl-ALA/PDT, according to preliminary findings presented at the 10th World Congress on Cancers of the Skin in Vienna in 2005.

European research includes reports of two patients who had an allergic contact dermatitis reaction to methyl-ALA but not ALA (Br. J. Dermatol. 2004;150:143–5). "So keep this in mind in the United States," Dr. Gold said.

In a study of 69 patients with multiple actinic keratoses on their faces, patients receiving PDT with methyl-ALA reported less pain on a 0–10 scale compared with a PDT/ALA combination (J. Drugs Dermatol. 2006;5:353–6).

A second investigation compared PDT with ALA or methyl-ALA for inflammatory acne vulgaris (J. Am. Acad. Dermatol. 2006;54:647–51). This split-face study with 15 participants found no differences in response rates but more prolonged and severe adverse effects on the ALA-treated side. The treatment protocol was not a fair comparison, Dr. Gold said, which "is important to understand. The authors stated the ALA side will give you as much, if not more, adverse events than the methyl-ALA. But you cannot compare apples to oranges as they did this in the study.

"My response to both of these articles is, basically, you cannot compare short-term application of ALA, where we have no problems, to long-term methyl-ALA under occlusion, where we have problems," Dr. Gold said.

LAS VEGAS — Chemoprevention with photodynamic therapy is encouraging—the therapy increases the time it takes actinic keratoses to develop into skin cancer, according to anecdotal data and preliminary results of larger trials.

Chemoprevention is the most important indication for photodynamic therapy (PDT), Dr. Michael H. Gold said at an international symposium on cosmetic and laser surgery.

Initial reports indicate efficacy for basal cell carcinoma, especially superficial lesions, and researchers have reported improvements to nodular basal cell and ulcerative basal cell lesions.

"PDT is wonderful for basal cell carcinoma on the ear. Mohs surgeons don't want to touch it, and my only other option is radiation," said Dr. Gold, who is in private practice in Nashville, Tenn., and is also with Vanderbilt University, Nashville.

Methyl-aminolevulinic HCl (Metvixia/PhotoCure, Galderma) and 5-aminolevulinic acid (ALA) (Levulan Kerastick, Dusa Pharmaceuticals) are the two photosensitizers generally studied for use with photodynamic therapy. Dr. Gold is a researcher, speaker, and consultant for Dusa.

ALA is approved for the treatment of precancerous actinic keratoses on the face and scalp. The product is being developed for the treatment of acne and photodamage, according to the manufacturer's Web site. Methyl-aminolevulinic HCl (methyl-ALA) is approved in the United States for treatment of nonhyperkeratotic actinic keratoses. The product is marketed in Europe as Metvix and carries an additional indication for basal cell carcinoma unsuitable for conventional therapy.

"What is interesting is what has been done with Metvix," Dr. Gold said. There has been a great deal of "very good work done in Europe with Metvix for actinic keratoses and Bowen's disease. It is now the treatment of choice in Europe for Bowen's disease."

There are two very interesting studies in Europe looking at immunosuppressed organ transplant patients treated with methyl-ALA, Dr. Gold said.

In one study, a single treatment with methyl-ALA/PDT delayed development of actinic keratoses for 9.6 months, versus 6.8 months in untreated patients (Acta. Derm. Venereol. 2006;86:25–8). The second study is an ongoing multicenter trial with 81 transplant patients enrolled to date who were treated with either methyl-ALA/PDT or cryotherapy. There was a significantly lower number of actinic keratoses in the areas treated with methyl-ALA/PDT, according to preliminary findings presented at the 10th World Congress on Cancers of the Skin in Vienna in 2005.

European research includes reports of two patients who had an allergic contact dermatitis reaction to methyl-ALA but not ALA (Br. J. Dermatol. 2004;150:143–5). "So keep this in mind in the United States," Dr. Gold said.

In a study of 69 patients with multiple actinic keratoses on their faces, patients receiving PDT with methyl-ALA reported less pain on a 0–10 scale compared with a PDT/ALA combination (J. Drugs Dermatol. 2006;5:353–6).

A second investigation compared PDT with ALA or methyl-ALA for inflammatory acne vulgaris (J. Am. Acad. Dermatol. 2006;54:647–51). This split-face study with 15 participants found no differences in response rates but more prolonged and severe adverse effects on the ALA-treated side. The treatment protocol was not a fair comparison, Dr. Gold said, which "is important to understand. The authors stated the ALA side will give you as much, if not more, adverse events than the methyl-ALA. But you cannot compare apples to oranges as they did this in the study.

"My response to both of these articles is, basically, you cannot compare short-term application of ALA, where we have no problems, to long-term methyl-ALA under occlusion, where we have problems," Dr. Gold said.

LAS VEGAS — Chemoprevention with photodynamic therapy is encouraging—the therapy increases the time it takes actinic keratoses to develop into skin cancer, according to anecdotal data and preliminary results of larger trials.

Chemoprevention is the most important indication for photodynamic therapy (PDT), Dr. Michael H. Gold said at an international symposium on cosmetic and laser surgery.

Initial reports indicate efficacy for basal cell carcinoma, especially superficial lesions, and researchers have reported improvements to nodular basal cell and ulcerative basal cell lesions.

"PDT is wonderful for basal cell carcinoma on the ear. Mohs surgeons don't want to touch it, and my only other option is radiation," said Dr. Gold, who is in private practice in Nashville, Tenn., and is also with Vanderbilt University, Nashville.

Methyl-aminolevulinic HCl (Metvixia/PhotoCure, Galderma) and 5-aminolevulinic acid (ALA) (Levulan Kerastick, Dusa Pharmaceuticals) are the two photosensitizers generally studied for use with photodynamic therapy. Dr. Gold is a researcher, speaker, and consultant for Dusa.

ALA is approved for the treatment of precancerous actinic keratoses on the face and scalp. The product is being developed for the treatment of acne and photodamage, according to the manufacturer's Web site. Methyl-aminolevulinic HCl (methyl-ALA) is approved in the United States for treatment of nonhyperkeratotic actinic keratoses. The product is marketed in Europe as Metvix and carries an additional indication for basal cell carcinoma unsuitable for conventional therapy.

"What is interesting is what has been done with Metvix," Dr. Gold said. There has been a great deal of "very good work done in Europe with Metvix for actinic keratoses and Bowen's disease. It is now the treatment of choice in Europe for Bowen's disease."

There are two very interesting studies in Europe looking at immunosuppressed organ transplant patients treated with methyl-ALA, Dr. Gold said.

In one study, a single treatment with methyl-ALA/PDT delayed development of actinic keratoses for 9.6 months, versus 6.8 months in untreated patients (Acta. Derm. Venereol. 2006;86:25–8). The second study is an ongoing multicenter trial with 81 transplant patients enrolled to date who were treated with either methyl-ALA/PDT or cryotherapy. There was a significantly lower number of actinic keratoses in the areas treated with methyl-ALA/PDT, according to preliminary findings presented at the 10th World Congress on Cancers of the Skin in Vienna in 2005.

European research includes reports of two patients who had an allergic contact dermatitis reaction to methyl-ALA but not ALA (Br. J. Dermatol. 2004;150:143–5). "So keep this in mind in the United States," Dr. Gold said.

In a study of 69 patients with multiple actinic keratoses on their faces, patients receiving PDT with methyl-ALA reported less pain on a 0–10 scale compared with a PDT/ALA combination (J. Drugs Dermatol. 2006;5:353–6).

A second investigation compared PDT with ALA or methyl-ALA for inflammatory acne vulgaris (J. Am. Acad. Dermatol. 2006;54:647–51). This split-face study with 15 participants found no differences in response rates but more prolonged and severe adverse effects on the ALA-treated side. The treatment protocol was not a fair comparison, Dr. Gold said, which "is important to understand. The authors stated the ALA side will give you as much, if not more, adverse events than the methyl-ALA. But you cannot compare apples to oranges as they did this in the study.

"My response to both of these articles is, basically, you cannot compare short-term application of ALA, where we have no problems, to long-term methyl-ALA under occlusion, where we have problems," Dr. Gold said.

SAN ANTONIO — Treatment of atopic dermatitis in pediatric patients is shifting from symptom control to repair of the skin barrier function, Dr. Rebecca Lynn Smith said at a meeting of Skin Disease Education Foundation.

“It used to be we treated flare-ups. Now we aim to repair the skin barrier with integration of physiologic moisturizers,” she said. Physiologic moisturizers replace lost lipids, reduce transepidermal water loss, and calm inflammation, according to Dr. Smith, a dermatologist in private practice in Fort Mill, S.C.

A reliance on nonphysiologic moisturizers, such as petrolatum, eased when the physiologic moisturizers MimyX (Stiefel Laboratories), Atopiclair (Chester Valley Pharmaceuticals), and EpiCeram (Ceragenix Pharmaceuticals) became available. Nonphysiologic products “sit on the skin like icing on a cake and prevent water loss. Physiologic moisturizers are incorporated into the skin,” said Dr. Smith, who has a consulting agreement with Stiefel Laboratories.

Skin barrier defects in atopic dermatitis include increased stratum corneum chymotryptic enzyme, increased proteases, decreased maturation of lamellar bodies, and decreased filaggrin.

Palmitamide MEA (PEA) is an important component of MimyX nonsteroidal cream, Dr. Smith said. PEA is an essential fatty acid with anti-inflammatory properties.

Researchers conducted a PEA study in which atopic patients applied PEA and Eucerin cream to their left wrist and forearm, and Eucerin cream only to their right wrist and arm. “After 2 weeks you can see the difference,” Dr. Smith said.

An open-label, international study assessed 2,456 people aged 2–70 years with mild to moderate atopy treated with adjunctive PEA cream. Results were presented as a poster by Dr. B. Eberien-Koeing and associates at the 2006 annual meeting of the American Academy of Dermatology. They assessed itching, erythema, scaling, dryness, lichenification, and excoriation. “With PEA cream everything significantly improved or was eliminated,” Dr. Smith said.

Atopiclair cream contains the anti-inflammatory, antipruritic glycyrrhetinic acid, as well as sodium hyaluronate, a powerful hydrating agent.

Physiologic moisturizers combined with common sense tips for management of atopic dermatitis can make a big difference in quality of life for affected children, Dr. Smith said. “If we can stop these kids from itching and scratching, we can get their skin to heal. An important issue is sleep quality—they are up at night itching and scratching.”

A daily bath for children in lukewarm water is recommended, Dr. Smith said. Apply medications and moisturizers immediately afterward, and limit contact with suspected allergens or irritants. Antihistamines are a treatment option. Instruct the parent or guardian keep the child cool and avoid excessive perspiration, dress them in cotton clothes, and file their fingernails, she suggested.

Once atopic flare is under control, consider dilute bleach baths to prevent or treat infections. Add 1/8 cup of bleach to a half-full bathtub for a 5- to 15-minute soak twice a week. “I describe this as a clean, chlorinated pool to moms who are alarmed when I mention a bleach bath,” Dr. Smith said. “Make sure they rinse the [bleach] bath off when they are done.”

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO — Treatment of atopic dermatitis in pediatric patients is shifting from symptom control to repair of the skin barrier function, Dr. Rebecca Lynn Smith said at a meeting of Skin Disease Education Foundation.

“It used to be we treated flare-ups. Now we aim to repair the skin barrier with integration of physiologic moisturizers,” she said. Physiologic moisturizers replace lost lipids, reduce transepidermal water loss, and calm inflammation, according to Dr. Smith, a dermatologist in private practice in Fort Mill, S.C.

A reliance on nonphysiologic moisturizers, such as petrolatum, eased when the physiologic moisturizers MimyX (Stiefel Laboratories), Atopiclair (Chester Valley Pharmaceuticals), and EpiCeram (Ceragenix Pharmaceuticals) became available. Nonphysiologic products “sit on the skin like icing on a cake and prevent water loss. Physiologic moisturizers are incorporated into the skin,” said Dr. Smith, who has a consulting agreement with Stiefel Laboratories.

Skin barrier defects in atopic dermatitis include increased stratum corneum chymotryptic enzyme, increased proteases, decreased maturation of lamellar bodies, and decreased filaggrin.

Palmitamide MEA (PEA) is an important component of MimyX nonsteroidal cream, Dr. Smith said. PEA is an essential fatty acid with anti-inflammatory properties.

Researchers conducted a PEA study in which atopic patients applied PEA and Eucerin cream to their left wrist and forearm, and Eucerin cream only to their right wrist and arm. “After 2 weeks you can see the difference,” Dr. Smith said.

An open-label, international study assessed 2,456 people aged 2–70 years with mild to moderate atopy treated with adjunctive PEA cream. Results were presented as a poster by Dr. B. Eberien-Koeing and associates at the 2006 annual meeting of the American Academy of Dermatology. They assessed itching, erythema, scaling, dryness, lichenification, and excoriation. “With PEA cream everything significantly improved or was eliminated,” Dr. Smith said.

Atopiclair cream contains the anti-inflammatory, antipruritic glycyrrhetinic acid, as well as sodium hyaluronate, a powerful hydrating agent.

Physiologic moisturizers combined with common sense tips for management of atopic dermatitis can make a big difference in quality of life for affected children, Dr. Smith said. “If we can stop these kids from itching and scratching, we can get their skin to heal. An important issue is sleep quality—they are up at night itching and scratching.”

A daily bath for children in lukewarm water is recommended, Dr. Smith said. Apply medications and moisturizers immediately afterward, and limit contact with suspected allergens or irritants. Antihistamines are a treatment option. Instruct the parent or guardian keep the child cool and avoid excessive perspiration, dress them in cotton clothes, and file their fingernails, she suggested.

Once atopic flare is under control, consider dilute bleach baths to prevent or treat infections. Add 1/8 cup of bleach to a half-full bathtub for a 5- to 15-minute soak twice a week. “I describe this as a clean, chlorinated pool to moms who are alarmed when I mention a bleach bath,” Dr. Smith said. “Make sure they rinse the [bleach] bath off when they are done.”

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO — Treatment of atopic dermatitis in pediatric patients is shifting from symptom control to repair of the skin barrier function, Dr. Rebecca Lynn Smith said at a meeting of Skin Disease Education Foundation.

“It used to be we treated flare-ups. Now we aim to repair the skin barrier with integration of physiologic moisturizers,” she said. Physiologic moisturizers replace lost lipids, reduce transepidermal water loss, and calm inflammation, according to Dr. Smith, a dermatologist in private practice in Fort Mill, S.C.

A reliance on nonphysiologic moisturizers, such as petrolatum, eased when the physiologic moisturizers MimyX (Stiefel Laboratories), Atopiclair (Chester Valley Pharmaceuticals), and EpiCeram (Ceragenix Pharmaceuticals) became available. Nonphysiologic products “sit on the skin like icing on a cake and prevent water loss. Physiologic moisturizers are incorporated into the skin,” said Dr. Smith, who has a consulting agreement with Stiefel Laboratories.

Skin barrier defects in atopic dermatitis include increased stratum corneum chymotryptic enzyme, increased proteases, decreased maturation of lamellar bodies, and decreased filaggrin.

Palmitamide MEA (PEA) is an important component of MimyX nonsteroidal cream, Dr. Smith said. PEA is an essential fatty acid with anti-inflammatory properties.

Researchers conducted a PEA study in which atopic patients applied PEA and Eucerin cream to their left wrist and forearm, and Eucerin cream only to their right wrist and arm. “After 2 weeks you can see the difference,” Dr. Smith said.

An open-label, international study assessed 2,456 people aged 2–70 years with mild to moderate atopy treated with adjunctive PEA cream. Results were presented as a poster by Dr. B. Eberien-Koeing and associates at the 2006 annual meeting of the American Academy of Dermatology. They assessed itching, erythema, scaling, dryness, lichenification, and excoriation. “With PEA cream everything significantly improved or was eliminated,” Dr. Smith said.

Atopiclair cream contains the anti-inflammatory, antipruritic glycyrrhetinic acid, as well as sodium hyaluronate, a powerful hydrating agent.

Physiologic moisturizers combined with common sense tips for management of atopic dermatitis can make a big difference in quality of life for affected children, Dr. Smith said. “If we can stop these kids from itching and scratching, we can get their skin to heal. An important issue is sleep quality—they are up at night itching and scratching.”

A daily bath for children in lukewarm water is recommended, Dr. Smith said. Apply medications and moisturizers immediately afterward, and limit contact with suspected allergens or irritants. Antihistamines are a treatment option. Instruct the parent or guardian keep the child cool and avoid excessive perspiration, dress them in cotton clothes, and file their fingernails, she suggested.

Once atopic flare is under control, consider dilute bleach baths to prevent or treat infections. Add 1/8 cup of bleach to a half-full bathtub for a 5- to 15-minute soak twice a week. “I describe this as a clean, chlorinated pool to moms who are alarmed when I mention a bleach bath,” Dr. Smith said. “Make sure they rinse the [bleach] bath off when they are done.”

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO, TEXAS — Drug rash with eosinophilia and systemic symptoms syndrome is a severe drug hypersensitivity reaction syndrome that can manifest weeks after initiation of therapy, so detective work may be needed to identify and quickly stop the culprit, Dr. Asra Ali said at a meeting sponsored by Skin Disease Education Foundation.

“Hypersensitivity reactions tend to cause severe effects in our patients,” she said. Patients who have the drug rash with eosinophilia and systemic symptoms (DRESS) syndrome often present with a triad of fever, dermatitis, and internal organ involvement. An estimated 10% do not recover.

“DRESS syndrome is a delayed reaction … so we look at a drug calendar to identify which medications might be causing the hypersensitivity. Unfortunately, at M.D. Anderson [Cancer Center in Houston] they are often put on 10 different medications at admission, so it's sometimes difficult to determine which drug is causing the hypersensitivity,” said Dr. Ali of the center's department of dermatology.

DRESS syndrome can affect almost any organ system but most often attacks the skin (84%–100% of patients). Cutaneous symptoms include morbilliform eruptions, blisters, exfoliative dermatitis, erythroderma, and facial edema. “Drug-induced maculopapular exanthems account for about 95% of all drug-induced cutaneous eruptions we see,” Dr. Ali said.

Systemic symptoms include renal dysfunction, which affects fewer than 30% of patients. Proteinuria is the most frequently reported renal abnormality. Lung involvement is not very common, thyroiditis affects only a small subset of patients, and cardiac abnormalities are very rare, Dr. Ali said. Pericarditis and tachycardia have been reported with minocycline use.

Minocycline triggered DRESS syndrome in 18 patients in a French database study from 1985 to 2000 (Br. J. Dermatol. 2006;155:422–8). Other drugs implicated for inducing cutaneous injury included abacavir (68 cases), carbamazepine (63), nevirapine (22), allopurinol (21), lamotrigine (7), and phenytoin (7).

Unlike the more common type A drug reactions that can be predicted from the pharmacology of a drug, such as sedation from antihistamines, DRESS syndrome is a type B reaction. “These are called the bizarre reactions—we cannot predict them. We worry about these the most,” she said.

If DRESS syndrome is suspected, one should first rule out a mimicking infection such as staph toxic shock syndrome. Other conditions in a differential diagnosis include viral eruption, angio-immunoblastic lymphadenopathy, vasculitis, Kawasaki disease, serum sickness, and exfoliative dermatitis (from psoriasis, dermatitis, or lymphoma, for example). “HIV patients are more susceptible to developing DRESS, as are patients with autoimmune diseases,” Dr. Ali noted.

Although drug hypersensitivity reactions feature a wide range of presentations, treatment for all is similar. Prompt withdrawal of the offending drug is critical, but a rash and hepatitis can persist for weeks afterward. Antipyretics, supportive care, high-dose intravenous N-acetylcysteine, and topical steroids are treatment options. “We typically do give systemic steroids, although it may promote viral activation if the patient has” human herpes virus 6, she cautioned.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO, TEXAS — Drug rash with eosinophilia and systemic symptoms syndrome is a severe drug hypersensitivity reaction syndrome that can manifest weeks after initiation of therapy, so detective work may be needed to identify and quickly stop the culprit, Dr. Asra Ali said at a meeting sponsored by Skin Disease Education Foundation.

“Hypersensitivity reactions tend to cause severe effects in our patients,” she said. Patients who have the drug rash with eosinophilia and systemic symptoms (DRESS) syndrome often present with a triad of fever, dermatitis, and internal organ involvement. An estimated 10% do not recover.

“DRESS syndrome is a delayed reaction … so we look at a drug calendar to identify which medications might be causing the hypersensitivity. Unfortunately, at M.D. Anderson [Cancer Center in Houston] they are often put on 10 different medications at admission, so it's sometimes difficult to determine which drug is causing the hypersensitivity,” said Dr. Ali of the center's department of dermatology.

DRESS syndrome can affect almost any organ system but most often attacks the skin (84%–100% of patients). Cutaneous symptoms include morbilliform eruptions, blisters, exfoliative dermatitis, erythroderma, and facial edema. “Drug-induced maculopapular exanthems account for about 95% of all drug-induced cutaneous eruptions we see,” Dr. Ali said.

Systemic symptoms include renal dysfunction, which affects fewer than 30% of patients. Proteinuria is the most frequently reported renal abnormality. Lung involvement is not very common, thyroiditis affects only a small subset of patients, and cardiac abnormalities are very rare, Dr. Ali said. Pericarditis and tachycardia have been reported with minocycline use.

Minocycline triggered DRESS syndrome in 18 patients in a French database study from 1985 to 2000 (Br. J. Dermatol. 2006;155:422–8). Other drugs implicated for inducing cutaneous injury included abacavir (68 cases), carbamazepine (63), nevirapine (22), allopurinol (21), lamotrigine (7), and phenytoin (7).

Unlike the more common type A drug reactions that can be predicted from the pharmacology of a drug, such as sedation from antihistamines, DRESS syndrome is a type B reaction. “These are called the bizarre reactions—we cannot predict them. We worry about these the most,” she said.

If DRESS syndrome is suspected, one should first rule out a mimicking infection such as staph toxic shock syndrome. Other conditions in a differential diagnosis include viral eruption, angio-immunoblastic lymphadenopathy, vasculitis, Kawasaki disease, serum sickness, and exfoliative dermatitis (from psoriasis, dermatitis, or lymphoma, for example). “HIV patients are more susceptible to developing DRESS, as are patients with autoimmune diseases,” Dr. Ali noted.

Although drug hypersensitivity reactions feature a wide range of presentations, treatment for all is similar. Prompt withdrawal of the offending drug is critical, but a rash and hepatitis can persist for weeks afterward. Antipyretics, supportive care, high-dose intravenous N-acetylcysteine, and topical steroids are treatment options. “We typically do give systemic steroids, although it may promote viral activation if the patient has” human herpes virus 6, she cautioned.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO, TEXAS — Drug rash with eosinophilia and systemic symptoms syndrome is a severe drug hypersensitivity reaction syndrome that can manifest weeks after initiation of therapy, so detective work may be needed to identify and quickly stop the culprit, Dr. Asra Ali said at a meeting sponsored by Skin Disease Education Foundation.

“Hypersensitivity reactions tend to cause severe effects in our patients,” she said. Patients who have the drug rash with eosinophilia and systemic symptoms (DRESS) syndrome often present with a triad of fever, dermatitis, and internal organ involvement. An estimated 10% do not recover.

“DRESS syndrome is a delayed reaction … so we look at a drug calendar to identify which medications might be causing the hypersensitivity. Unfortunately, at M.D. Anderson [Cancer Center in Houston] they are often put on 10 different medications at admission, so it's sometimes difficult to determine which drug is causing the hypersensitivity,” said Dr. Ali of the center's department of dermatology.

DRESS syndrome can affect almost any organ system but most often attacks the skin (84%–100% of patients). Cutaneous symptoms include morbilliform eruptions, blisters, exfoliative dermatitis, erythroderma, and facial edema. “Drug-induced maculopapular exanthems account for about 95% of all drug-induced cutaneous eruptions we see,” Dr. Ali said.

Systemic symptoms include renal dysfunction, which affects fewer than 30% of patients. Proteinuria is the most frequently reported renal abnormality. Lung involvement is not very common, thyroiditis affects only a small subset of patients, and cardiac abnormalities are very rare, Dr. Ali said. Pericarditis and tachycardia have been reported with minocycline use.

Minocycline triggered DRESS syndrome in 18 patients in a French database study from 1985 to 2000 (Br. J. Dermatol. 2006;155:422–8). Other drugs implicated for inducing cutaneous injury included abacavir (68 cases), carbamazepine (63), nevirapine (22), allopurinol (21), lamotrigine (7), and phenytoin (7).

Unlike the more common type A drug reactions that can be predicted from the pharmacology of a drug, such as sedation from antihistamines, DRESS syndrome is a type B reaction. “These are called the bizarre reactions—we cannot predict them. We worry about these the most,” she said.

If DRESS syndrome is suspected, one should first rule out a mimicking infection such as staph toxic shock syndrome. Other conditions in a differential diagnosis include viral eruption, angio-immunoblastic lymphadenopathy, vasculitis, Kawasaki disease, serum sickness, and exfoliative dermatitis (from psoriasis, dermatitis, or lymphoma, for example). “HIV patients are more susceptible to developing DRESS, as are patients with autoimmune diseases,” Dr. Ali noted.

Although drug hypersensitivity reactions feature a wide range of presentations, treatment for all is similar. Prompt withdrawal of the offending drug is critical, but a rash and hepatitis can persist for weeks afterward. Antipyretics, supportive care, high-dose intravenous N-acetylcysteine, and topical steroids are treatment options. “We typically do give systemic steroids, although it may promote viral activation if the patient has” human herpes virus 6, she cautioned.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO — Address the underlying androgen excess when a woman presents for correction of cutaneous effects of hyperandrogenism, Dr. Ellen E. Wilson said at a meeting of Skin Disease Education Foundation.

Polycystic ovarian syndrome (PCOS) is the most common etiology of hyperandrogenism. “Dermatologic manifestations include hirsutism, acne, acanthosis nigricans, and androgenetic alopecia—in that order,” said Dr. Wilson, a reproductive endocrinologist at the University of Texas Southwestern Medical Center in Dallas.

A contraceptive pill, patch, or ring regimen can regularize periods and treat the effects of hyperandrogenism. Low-dose oral contraceptives decrease free testosterone levels, with the progestins desogestrel, gestodene, and norgestimate being associated with greater reductions. “The bottom line is probably any low-dose formulation produces an overall similar clinical response,” she said.

Treatment with hormonal suppression will be needed for at least 6 months before there is an observable difference. “I counsel patients that it takes time,” Dr. Wilson said. “For hirsutism, often I recommend they go to a dermatologist for hair removal, and I tell them there should be no new growth.” Patients with PCOS may remain on oral contraceptives through their 40s, often until they are menopausal.

If oral contraceptives are not enough, “we will supplement with spironolactone,” Dr. Wilson said. “Spironolactone is a potential teratogen, so we feel more comfortable if they are already on an oral contraceptive.” Spironolactone is effective in doses of 100–200 mg/day.

Vaniqa (eflornithine) is approved for hirsutism as a twice-a-day local treatment. “It is expensive and works in one-third to two-thirds of women,” she said. “It is something they can try.”

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO — Address the underlying androgen excess when a woman presents for correction of cutaneous effects of hyperandrogenism, Dr. Ellen E. Wilson said at a meeting of Skin Disease Education Foundation.

Polycystic ovarian syndrome (PCOS) is the most common etiology of hyperandrogenism. “Dermatologic manifestations include hirsutism, acne, acanthosis nigricans, and androgenetic alopecia—in that order,” said Dr. Wilson, a reproductive endocrinologist at the University of Texas Southwestern Medical Center in Dallas.

A contraceptive pill, patch, or ring regimen can regularize periods and treat the effects of hyperandrogenism. Low-dose oral contraceptives decrease free testosterone levels, with the progestins desogestrel, gestodene, and norgestimate being associated with greater reductions. “The bottom line is probably any low-dose formulation produces an overall similar clinical response,” she said.

Treatment with hormonal suppression will be needed for at least 6 months before there is an observable difference. “I counsel patients that it takes time,” Dr. Wilson said. “For hirsutism, often I recommend they go to a dermatologist for hair removal, and I tell them there should be no new growth.” Patients with PCOS may remain on oral contraceptives through their 40s, often until they are menopausal.

If oral contraceptives are not enough, “we will supplement with spironolactone,” Dr. Wilson said. “Spironolactone is a potential teratogen, so we feel more comfortable if they are already on an oral contraceptive.” Spironolactone is effective in doses of 100–200 mg/day.

Vaniqa (eflornithine) is approved for hirsutism as a twice-a-day local treatment. “It is expensive and works in one-third to two-thirds of women,” she said. “It is something they can try.”

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO — Address the underlying androgen excess when a woman presents for correction of cutaneous effects of hyperandrogenism, Dr. Ellen E. Wilson said at a meeting of Skin Disease Education Foundation.

Polycystic ovarian syndrome (PCOS) is the most common etiology of hyperandrogenism. “Dermatologic manifestations include hirsutism, acne, acanthosis nigricans, and androgenetic alopecia—in that order,” said Dr. Wilson, a reproductive endocrinologist at the University of Texas Southwestern Medical Center in Dallas.

A contraceptive pill, patch, or ring regimen can regularize periods and treat the effects of hyperandrogenism. Low-dose oral contraceptives decrease free testosterone levels, with the progestins desogestrel, gestodene, and norgestimate being associated with greater reductions. “The bottom line is probably any low-dose formulation produces an overall similar clinical response,” she said.

Treatment with hormonal suppression will be needed for at least 6 months before there is an observable difference. “I counsel patients that it takes time,” Dr. Wilson said. “For hirsutism, often I recommend they go to a dermatologist for hair removal, and I tell them there should be no new growth.” Patients with PCOS may remain on oral contraceptives through their 40s, often until they are menopausal.

If oral contraceptives are not enough, “we will supplement with spironolactone,” Dr. Wilson said. “Spironolactone is a potential teratogen, so we feel more comfortable if they are already on an oral contraceptive.” Spironolactone is effective in doses of 100–200 mg/day.

Vaniqa (eflornithine) is approved for hirsutism as a twice-a-day local treatment. “It is expensive and works in one-third to two-thirds of women,” she said. “It is something they can try.”

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO — All cases of congenital heart block are caused by neonatal lupus, Dr. Bernice Krafchik said at a meeting sponsored by Skin Disease Education Foundation.

About half of neonatal lupus babies will have congenital heart block. Part of the challenge in diagnosis is that most often the mothers are asymptomatic, added Dr. Krafchik, professor emeritus of pediatrics and medicine, the Hospital for Sick Children, University of Toronto.

The heart block is usually complete heart block. “These patients often require a pacemaker—you have to really watch these kids closely; the pacemaker itself can have adverse events and cause death.”

In general, babies with just cutaneous lesions from neonatal lupus erythematosus respond well to therapy, according to Dr. Krafchik.

“Skin patients really do very well and the lesions disappear. But they may develop systemic lupus erythematosus [SLE] later.” Babies with neonatal lupus skin lesions usually are born to mothers with SLE, which she said is one of the new facts emerging about neonatal lupus.

About 50% of babies born with neonatal lupus have skin lesions. There are four presentations: periorbital lesions that produce a “raccoon” face, annular erythema with atrophy, central erythema with an edge, and telangiectasias.

The telangiectasias are less common but might persist into adulthood. Some telangiectasias respond to laser treatment, although scarring can be problematic, said Dr. Krafchik.

Neonatal lupus can cause thrombocytopenia and hepatitis as well. Hepatitis occurs in approximately 10% of affected neonates and is usually mild with “excellent recovery,” she said at the meeting.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO — All cases of congenital heart block are caused by neonatal lupus, Dr. Bernice Krafchik said at a meeting sponsored by Skin Disease Education Foundation.

About half of neonatal lupus babies will have congenital heart block. Part of the challenge in diagnosis is that most often the mothers are asymptomatic, added Dr. Krafchik, professor emeritus of pediatrics and medicine, the Hospital for Sick Children, University of Toronto.

The heart block is usually complete heart block. “These patients often require a pacemaker—you have to really watch these kids closely; the pacemaker itself can have adverse events and cause death.”

In general, babies with just cutaneous lesions from neonatal lupus erythematosus respond well to therapy, according to Dr. Krafchik.

“Skin patients really do very well and the lesions disappear. But they may develop systemic lupus erythematosus [SLE] later.” Babies with neonatal lupus skin lesions usually are born to mothers with SLE, which she said is one of the new facts emerging about neonatal lupus.

About 50% of babies born with neonatal lupus have skin lesions. There are four presentations: periorbital lesions that produce a “raccoon” face, annular erythema with atrophy, central erythema with an edge, and telangiectasias.

The telangiectasias are less common but might persist into adulthood. Some telangiectasias respond to laser treatment, although scarring can be problematic, said Dr. Krafchik.

Neonatal lupus can cause thrombocytopenia and hepatitis as well. Hepatitis occurs in approximately 10% of affected neonates and is usually mild with “excellent recovery,” she said at the meeting.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN ANTONIO — All cases of congenital heart block are caused by neonatal lupus, Dr. Bernice Krafchik said at a meeting sponsored by Skin Disease Education Foundation.

About half of neonatal lupus babies will have congenital heart block. Part of the challenge in diagnosis is that most often the mothers are asymptomatic, added Dr. Krafchik, professor emeritus of pediatrics and medicine, the Hospital for Sick Children, University of Toronto.

The heart block is usually complete heart block. “These patients often require a pacemaker—you have to really watch these kids closely; the pacemaker itself can have adverse events and cause death.”

In general, babies with just cutaneous lesions from neonatal lupus erythematosus respond well to therapy, according to Dr. Krafchik.

“Skin patients really do very well and the lesions disappear. But they may develop systemic lupus erythematosus [SLE] later.” Babies with neonatal lupus skin lesions usually are born to mothers with SLE, which she said is one of the new facts emerging about neonatal lupus.

About 50% of babies born with neonatal lupus have skin lesions. There are four presentations: periorbital lesions that produce a “raccoon” face, annular erythema with atrophy, central erythema with an edge, and telangiectasias.

The telangiectasias are less common but might persist into adulthood. Some telangiectasias respond to laser treatment, although scarring can be problematic, said Dr. Krafchik.

Neonatal lupus can cause thrombocytopenia and hepatitis as well. Hepatitis occurs in approximately 10% of affected neonates and is usually mild with “excellent recovery,” she said at the meeting.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

MIAMI — Snapping hip syndrome, labral tears, and tibial and metatarsal fractures are injuries unique to dancers, Dr. Craig C. Young said at the annual meeting of the American Medical Society for Sports Medicine.

Most research focuses on ballet, given its relatively high risk of injuries from dancing en pointe and from landing jumps in an external hip rotation. However, jazz dancing also is associated with injuries from internal hip rotations; modern dancing injuries are caused by knee flexion, dancing barefoot, and women doing lifts; and injuries associated with ballroom dancing are often associated with high heel throws.

“One myth is that dancers aren't athletes. Some are in better shape than my ballplayers,” said Dr. Young of the Medical College of Wisconsin in Milwaukee. Dancers also are extremely competitive and may not be forthcoming about their injuries because of this competitiveness.

Choreographers don't necessarily look at dance from a biomechanical perspective, so their pieces often include repetitive hyperextension and flexion, incorrect lifting techniques, and snapping motions, he said.

About 90% of the dancers treated in Dr. Young's practice do ballet. “We see a lot of external snapping hips.” Internal snapping hip injuries are less common, but can occur when the dancer is in a non-weight bearing position. Hip labral tears occur quite often, too. Patients present with sharp pain in the groin. An MRI arthrogram can aid diagnosis.

Stress fractures of the tibia and metatarsal shaft are quite common. Spiral fracture of the fifth metatarsal shaft is unique to dance and, in fact, is commonly referred to as a “dancer fracture.” This inversion injury occurs while en pointe. Patients do well after casting, he said.

Injuries in the upper extremities occur when dancers hold their arms in unusual positions for prolonged periods; they also frequently lift and carry weight away from the body. Adverse outcomes include rotator cuff tendinitis, thoracic outlet syndrome, and effort thrombosis.

Ankle impingement, bunions, hammertoes, and nail problems also occur. Dancers can present with subungual hematomas, paronychia, and ingrown nails. “They shouldn't clip their toenails, but use an emery board every day or every other day to keep their nails the same length.”

Unusual forms of tendinitis common in dancers include sartorius tendinitis from overuse of the hip external rotator. Dancers experience pain with external rotation, full flexion, and hip abduction. Rectus femoris tendinitis occurs from repetitive forward extensions of the leg. Groin pain occurs, especially when the knee is extended. Extensor hallucis longus tendinitis causes pain when a ballet dancer is in demi-pointe. Achilles tendinitis also occurs from overuse or ribbon friction. “Make sure they bring their pointe shoes. Have them show you how they tie their ribbons. Often, we can treat it without any other changes.”

The sole of pointe shoes is a piece of cardboard with no protection at the toe, so the dancer's muscles and the floor act as shock absorbers. “Ask what kind of floor they are dancing on. A dancer at a small studio may be dancing on concrete.”

Physicians who treat dancers must learn the French ballet terms because dancers often use them. Ask them to explain the move or have another dancer demonstrate it, he said.

MIAMI — Snapping hip syndrome, labral tears, and tibial and metatarsal fractures are injuries unique to dancers, Dr. Craig C. Young said at the annual meeting of the American Medical Society for Sports Medicine.

Most research focuses on ballet, given its relatively high risk of injuries from dancing en pointe and from landing jumps in an external hip rotation. However, jazz dancing also is associated with injuries from internal hip rotations; modern dancing injuries are caused by knee flexion, dancing barefoot, and women doing lifts; and injuries associated with ballroom dancing are often associated with high heel throws.

“One myth is that dancers aren't athletes. Some are in better shape than my ballplayers,” said Dr. Young of the Medical College of Wisconsin in Milwaukee. Dancers also are extremely competitive and may not be forthcoming about their injuries because of this competitiveness.

Choreographers don't necessarily look at dance from a biomechanical perspective, so their pieces often include repetitive hyperextension and flexion, incorrect lifting techniques, and snapping motions, he said.

About 90% of the dancers treated in Dr. Young's practice do ballet. “We see a lot of external snapping hips.” Internal snapping hip injuries are less common, but can occur when the dancer is in a non-weight bearing position. Hip labral tears occur quite often, too. Patients present with sharp pain in the groin. An MRI arthrogram can aid diagnosis.

Stress fractures of the tibia and metatarsal shaft are quite common. Spiral fracture of the fifth metatarsal shaft is unique to dance and, in fact, is commonly referred to as a “dancer fracture.” This inversion injury occurs while en pointe. Patients do well after casting, he said.

Injuries in the upper extremities occur when dancers hold their arms in unusual positions for prolonged periods; they also frequently lift and carry weight away from the body. Adverse outcomes include rotator cuff tendinitis, thoracic outlet syndrome, and effort thrombosis.

Ankle impingement, bunions, hammertoes, and nail problems also occur. Dancers can present with subungual hematomas, paronychia, and ingrown nails. “They shouldn't clip their toenails, but use an emery board every day or every other day to keep their nails the same length.”

Unusual forms of tendinitis common in dancers include sartorius tendinitis from overuse of the hip external rotator. Dancers experience pain with external rotation, full flexion, and hip abduction. Rectus femoris tendinitis occurs from repetitive forward extensions of the leg. Groin pain occurs, especially when the knee is extended. Extensor hallucis longus tendinitis causes pain when a ballet dancer is in demi-pointe. Achilles tendinitis also occurs from overuse or ribbon friction. “Make sure they bring their pointe shoes. Have them show you how they tie their ribbons. Often, we can treat it without any other changes.”

The sole of pointe shoes is a piece of cardboard with no protection at the toe, so the dancer's muscles and the floor act as shock absorbers. “Ask what kind of floor they are dancing on. A dancer at a small studio may be dancing on concrete.”

Physicians who treat dancers must learn the French ballet terms because dancers often use them. Ask them to explain the move or have another dancer demonstrate it, he said.

MIAMI — Snapping hip syndrome, labral tears, and tibial and metatarsal fractures are injuries unique to dancers, Dr. Craig C. Young said at the annual meeting of the American Medical Society for Sports Medicine.

Most research focuses on ballet, given its relatively high risk of injuries from dancing en pointe and from landing jumps in an external hip rotation. However, jazz dancing also is associated with injuries from internal hip rotations; modern dancing injuries are caused by knee flexion, dancing barefoot, and women doing lifts; and injuries associated with ballroom dancing are often associated with high heel throws.

“One myth is that dancers aren't athletes. Some are in better shape than my ballplayers,” said Dr. Young of the Medical College of Wisconsin in Milwaukee. Dancers also are extremely competitive and may not be forthcoming about their injuries because of this competitiveness.

Choreographers don't necessarily look at dance from a biomechanical perspective, so their pieces often include repetitive hyperextension and flexion, incorrect lifting techniques, and snapping motions, he said.

About 90% of the dancers treated in Dr. Young's practice do ballet. “We see a lot of external snapping hips.” Internal snapping hip injuries are less common, but can occur when the dancer is in a non-weight bearing position. Hip labral tears occur quite often, too. Patients present with sharp pain in the groin. An MRI arthrogram can aid diagnosis.

Stress fractures of the tibia and metatarsal shaft are quite common. Spiral fracture of the fifth metatarsal shaft is unique to dance and, in fact, is commonly referred to as a “dancer fracture.” This inversion injury occurs while en pointe. Patients do well after casting, he said.

Injuries in the upper extremities occur when dancers hold their arms in unusual positions for prolonged periods; they also frequently lift and carry weight away from the body. Adverse outcomes include rotator cuff tendinitis, thoracic outlet syndrome, and effort thrombosis.

Ankle impingement, bunions, hammertoes, and nail problems also occur. Dancers can present with subungual hematomas, paronychia, and ingrown nails. “They shouldn't clip their toenails, but use an emery board every day or every other day to keep their nails the same length.”

Unusual forms of tendinitis common in dancers include sartorius tendinitis from overuse of the hip external rotator. Dancers experience pain with external rotation, full flexion, and hip abduction. Rectus femoris tendinitis occurs from repetitive forward extensions of the leg. Groin pain occurs, especially when the knee is extended. Extensor hallucis longus tendinitis causes pain when a ballet dancer is in demi-pointe. Achilles tendinitis also occurs from overuse or ribbon friction. “Make sure they bring their pointe shoes. Have them show you how they tie their ribbons. Often, we can treat it without any other changes.”

The sole of pointe shoes is a piece of cardboard with no protection at the toe, so the dancer's muscles and the floor act as shock absorbers. “Ask what kind of floor they are dancing on. A dancer at a small studio may be dancing on concrete.”

Physicians who treat dancers must learn the French ballet terms because dancers often use them. Ask them to explain the move or have another dancer demonstrate it, he said.