Doug Brunk

SAN DIEGO — Patients with atopic dermatitis are highly colonized with Staphylococcus aureus, but do not appear to be preferentially infected with community-acquired methicillin-resistant S. aureus.

Up to 79% of patients with atopic dermatitis have S. aureus in their anterior nares, 64%-75% have it on their normal skin, and more than 90% have it on their lesional skin.

In contrast, up to 30% of atopic-free adults have S. aureus in their nasal carriage and 10% have it on their skin, Dr. Sheila Fallon Friedlander said at a conference sponsored by Rady Children's Hospital, San Diego.

A reason why patients with atopic dermatitis may have trouble with S. aureus is that they appear to lack an adequate number of cathelicidins, said Dr. Friedlander, director of pediatric dermatology at the University of California, San Francisco. “The end result clinically is that they don't have as much antimicrobial peptide helping to ward off infection. Atopics also have an impaired skin barrier, sometimes as a result of abnormal or decreased filaggrin. With increasing dryness and lack of appropriate adhesion, there is also increased skin surface area for the S. aureus to adhere to.”

In addition, she said S. aureus can elaborate superantigens, “which have the ability to stimulate the production of alternative glucocorticoid receptors. These receptors are more resistant to the effects of steroids. So often when S. aureus is present in the skin, there is elaboration of a receptor [that] makes it more difficult for the patient to respond to topical corticosteroid treatment.”

A recent study estimated that 40%-66% of patients with atopic dermatitis develop S. aureus skin infections (Pediatr. Derm. 2000;17:111-4). Another concluded that the condition is a risk factor for invasive S. aureus infection in this patient population, including bacteremia, osteomyelitis, and endocarditis (Am. J. Med. 2005;118:1048-51).

However, Dr. Friedlander described the link between atopic dermatitis and invasive disease as “a controversial issue” with data that remain unclear. “In some papers, it appears that there are lower levels of invasive disease in patients with atopic dermatitis,” she said. “Invasive disease does occur, but atopics don't seem to be at higher risk for invasive disease. Further studies are required to clarify this issue.”

The good news is that patients with atopic dermatitis do not seem to be preferentially affected with community-acquired methicillin-resistant S. aureus (CA-MRSA). An estimated 6%-19% of children with atopic dermatitis were found to have the condition (Arch. Dermatol. 2002;138:939-41). Another group of researchers concluded that the “observed incidence of cutaneous CA-MRSA lesions in patients with atopic dermatitis or other non-intact skin barrier is less than reported in other at-risk groups” (J. Clin. Dermatol. 2007;8:259-70).

Dr. Friedlander explained that, compared with the hospital-acquired form of MRSA, the community-acquired form is clonal, has many drug options, and has a predilection for skin disease. “It preferentially infects the skin; skin and soft tissue infections are what we see,” she said. “But you must remember that you can have invasive disease from this organism.”

Clinically, CA-MRSA presents as furuncles or folliculitis 65%-95% of the time. “Parents will say, 'my child keeps getting a spider bite,'” Dr. Friedlander said. Most patients look well, but 40%-50% will have fever.

Most often, CA-MRSA organisms possess Panton-Valentine leukocidin, a virulence factor that is a bicomponent cytotoxin. This virulent toxin “destroys our leukocytes by punching holes in the membrane,” she said. “This leads to capillary dilation and significant necrosis.”

CA-MRSA also may possess an aberrant fibronectin-binding protein gene, which enables the S. aureus “to adhere better to our tissue and therefore enhances invasion.”

Incision and drainage alone appears to suffice in CA-MRSA skin and soft tissue lesions smaller than 5 cm. “If a lesion is bigger than that, you need to be aggressive,” she said. “Please culture these lesions. In the old days, people used to drain these and throw the exudate away. Do not throw it away because the antibiotic susceptibility patterns differ from the hospital-acquired form, and you may need this information to determine the best therapy for your patient.”

Dr. Friedlander often starts patients on clindamycin. However, some organisms may be resistant, and therefore you need to check for inducible resistance in these patients.

“Sometimes you need to use trimethoprim/sulfamethoxazole,” she said. “In older children, you can use minocycline or doxycycline, but remember, these drugs can damage the teeth of young children, and I will not use tetracyclines in children less than 8 years of age.”

Attempts to eradicate MRSA with various combinations of antibiotics have had mixed results, but recent studies have found the use of bleach baths in combination with nasal mupirocin to be useful.

Dr. Friedlander recommends adding one-quarter of a cup of Clorox to a regular bath and repeating this treatment two times a week. In addition, some experts apply mupirocin ointment twice a day to the nares for 1 week each month.

“If you don't repeat the mupirocin treatment for a week each month, the patient appears more likely to colonize,” she said. “There is no absolutely clear superior, evidence-based regimen, but studies are ongoing and we may have some more information in the future.”

Dr. Friedlander disclosed that she has received grant and research support, honoraria, and/or consulting fees from Barrier Therapeutics Inc., Medicis Pharmaceutical Corp., Sanofi-Aventis, and Stiefel Laboratories Inc.

This MRSA infection was mistaken for spider bites. Courtesy Dr. Sheila Fallon Friedlander

SAN DIEGO — Patients with atopic dermatitis are highly colonized with Staphylococcus aureus, but do not appear to be preferentially infected with community-acquired methicillin-resistant S. aureus.

Up to 79% of patients with atopic dermatitis have S. aureus in their anterior nares, 64%-75% have it on their normal skin, and more than 90% have it on their lesional skin.

In contrast, up to 30% of atopic-free adults have S. aureus in their nasal carriage and 10% have it on their skin, Dr. Sheila Fallon Friedlander said at a conference sponsored by Rady Children's Hospital, San Diego.

A reason why patients with atopic dermatitis may have trouble with S. aureus is that they appear to lack an adequate number of cathelicidins, said Dr. Friedlander, director of pediatric dermatology at the University of California, San Francisco. “The end result clinically is that they don't have as much antimicrobial peptide helping to ward off infection. Atopics also have an impaired skin barrier, sometimes as a result of abnormal or decreased filaggrin. With increasing dryness and lack of appropriate adhesion, there is also increased skin surface area for the S. aureus to adhere to.”

In addition, she said S. aureus can elaborate superantigens, “which have the ability to stimulate the production of alternative glucocorticoid receptors. These receptors are more resistant to the effects of steroids. So often when S. aureus is present in the skin, there is elaboration of a receptor [that] makes it more difficult for the patient to respond to topical corticosteroid treatment.”

A recent study estimated that 40%-66% of patients with atopic dermatitis develop S. aureus skin infections (Pediatr. Derm. 2000;17:111-4). Another concluded that the condition is a risk factor for invasive S. aureus infection in this patient population, including bacteremia, osteomyelitis, and endocarditis (Am. J. Med. 2005;118:1048-51).

However, Dr. Friedlander described the link between atopic dermatitis and invasive disease as “a controversial issue” with data that remain unclear. “In some papers, it appears that there are lower levels of invasive disease in patients with atopic dermatitis,” she said. “Invasive disease does occur, but atopics don't seem to be at higher risk for invasive disease. Further studies are required to clarify this issue.”

The good news is that patients with atopic dermatitis do not seem to be preferentially affected with community-acquired methicillin-resistant S. aureus (CA-MRSA). An estimated 6%-19% of children with atopic dermatitis were found to have the condition (Arch. Dermatol. 2002;138:939-41). Another group of researchers concluded that the “observed incidence of cutaneous CA-MRSA lesions in patients with atopic dermatitis or other non-intact skin barrier is less than reported in other at-risk groups” (J. Clin. Dermatol. 2007;8:259-70).

Dr. Friedlander explained that, compared with the hospital-acquired form of MRSA, the community-acquired form is clonal, has many drug options, and has a predilection for skin disease. “It preferentially infects the skin; skin and soft tissue infections are what we see,” she said. “But you must remember that you can have invasive disease from this organism.”

Clinically, CA-MRSA presents as furuncles or folliculitis 65%-95% of the time. “Parents will say, 'my child keeps getting a spider bite,'” Dr. Friedlander said. Most patients look well, but 40%-50% will have fever.

Most often, CA-MRSA organisms possess Panton-Valentine leukocidin, a virulence factor that is a bicomponent cytotoxin. This virulent toxin “destroys our leukocytes by punching holes in the membrane,” she said. “This leads to capillary dilation and significant necrosis.”

CA-MRSA also may possess an aberrant fibronectin-binding protein gene, which enables the S. aureus “to adhere better to our tissue and therefore enhances invasion.”

Incision and drainage alone appears to suffice in CA-MRSA skin and soft tissue lesions smaller than 5 cm. “If a lesion is bigger than that, you need to be aggressive,” she said. “Please culture these lesions. In the old days, people used to drain these and throw the exudate away. Do not throw it away because the antibiotic susceptibility patterns differ from the hospital-acquired form, and you may need this information to determine the best therapy for your patient.”

Dr. Friedlander often starts patients on clindamycin. However, some organisms may be resistant, and therefore you need to check for inducible resistance in these patients.

“Sometimes you need to use trimethoprim/sulfamethoxazole,” she said. “In older children, you can use minocycline or doxycycline, but remember, these drugs can damage the teeth of young children, and I will not use tetracyclines in children less than 8 years of age.”

Attempts to eradicate MRSA with various combinations of antibiotics have had mixed results, but recent studies have found the use of bleach baths in combination with nasal mupirocin to be useful.

Dr. Friedlander recommends adding one-quarter of a cup of Clorox to a regular bath and repeating this treatment two times a week. In addition, some experts apply mupirocin ointment twice a day to the nares for 1 week each month.

“If you don't repeat the mupirocin treatment for a week each month, the patient appears more likely to colonize,” she said. “There is no absolutely clear superior, evidence-based regimen, but studies are ongoing and we may have some more information in the future.”

Dr. Friedlander disclosed that she has received grant and research support, honoraria, and/or consulting fees from Barrier Therapeutics Inc., Medicis Pharmaceutical Corp., Sanofi-Aventis, and Stiefel Laboratories Inc.

This MRSA infection was mistaken for spider bites. Courtesy Dr. Sheila Fallon Friedlander

SAN DIEGO — Patients with atopic dermatitis are highly colonized with Staphylococcus aureus, but do not appear to be preferentially infected with community-acquired methicillin-resistant S. aureus.

Up to 79% of patients with atopic dermatitis have S. aureus in their anterior nares, 64%-75% have it on their normal skin, and more than 90% have it on their lesional skin.

In contrast, up to 30% of atopic-free adults have S. aureus in their nasal carriage and 10% have it on their skin, Dr. Sheila Fallon Friedlander said at a conference sponsored by Rady Children's Hospital, San Diego.

A reason why patients with atopic dermatitis may have trouble with S. aureus is that they appear to lack an adequate number of cathelicidins, said Dr. Friedlander, director of pediatric dermatology at the University of California, San Francisco. “The end result clinically is that they don't have as much antimicrobial peptide helping to ward off infection. Atopics also have an impaired skin barrier, sometimes as a result of abnormal or decreased filaggrin. With increasing dryness and lack of appropriate adhesion, there is also increased skin surface area for the S. aureus to adhere to.”

In addition, she said S. aureus can elaborate superantigens, “which have the ability to stimulate the production of alternative glucocorticoid receptors. These receptors are more resistant to the effects of steroids. So often when S. aureus is present in the skin, there is elaboration of a receptor [that] makes it more difficult for the patient to respond to topical corticosteroid treatment.”

A recent study estimated that 40%-66% of patients with atopic dermatitis develop S. aureus skin infections (Pediatr. Derm. 2000;17:111-4). Another concluded that the condition is a risk factor for invasive S. aureus infection in this patient population, including bacteremia, osteomyelitis, and endocarditis (Am. J. Med. 2005;118:1048-51).

However, Dr. Friedlander described the link between atopic dermatitis and invasive disease as “a controversial issue” with data that remain unclear. “In some papers, it appears that there are lower levels of invasive disease in patients with atopic dermatitis,” she said. “Invasive disease does occur, but atopics don't seem to be at higher risk for invasive disease. Further studies are required to clarify this issue.”

The good news is that patients with atopic dermatitis do not seem to be preferentially affected with community-acquired methicillin-resistant S. aureus (CA-MRSA). An estimated 6%-19% of children with atopic dermatitis were found to have the condition (Arch. Dermatol. 2002;138:939-41). Another group of researchers concluded that the “observed incidence of cutaneous CA-MRSA lesions in patients with atopic dermatitis or other non-intact skin barrier is less than reported in other at-risk groups” (J. Clin. Dermatol. 2007;8:259-70).

Dr. Friedlander explained that, compared with the hospital-acquired form of MRSA, the community-acquired form is clonal, has many drug options, and has a predilection for skin disease. “It preferentially infects the skin; skin and soft tissue infections are what we see,” she said. “But you must remember that you can have invasive disease from this organism.”

Clinically, CA-MRSA presents as furuncles or folliculitis 65%-95% of the time. “Parents will say, 'my child keeps getting a spider bite,'” Dr. Friedlander said. Most patients look well, but 40%-50% will have fever.

Most often, CA-MRSA organisms possess Panton-Valentine leukocidin, a virulence factor that is a bicomponent cytotoxin. This virulent toxin “destroys our leukocytes by punching holes in the membrane,” she said. “This leads to capillary dilation and significant necrosis.”

CA-MRSA also may possess an aberrant fibronectin-binding protein gene, which enables the S. aureus “to adhere better to our tissue and therefore enhances invasion.”

Incision and drainage alone appears to suffice in CA-MRSA skin and soft tissue lesions smaller than 5 cm. “If a lesion is bigger than that, you need to be aggressive,” she said. “Please culture these lesions. In the old days, people used to drain these and throw the exudate away. Do not throw it away because the antibiotic susceptibility patterns differ from the hospital-acquired form, and you may need this information to determine the best therapy for your patient.”

Dr. Friedlander often starts patients on clindamycin. However, some organisms may be resistant, and therefore you need to check for inducible resistance in these patients.

“Sometimes you need to use trimethoprim/sulfamethoxazole,” she said. “In older children, you can use minocycline or doxycycline, but remember, these drugs can damage the teeth of young children, and I will not use tetracyclines in children less than 8 years of age.”

Attempts to eradicate MRSA with various combinations of antibiotics have had mixed results, but recent studies have found the use of bleach baths in combination with nasal mupirocin to be useful.

Dr. Friedlander recommends adding one-quarter of a cup of Clorox to a regular bath and repeating this treatment two times a week. In addition, some experts apply mupirocin ointment twice a day to the nares for 1 week each month.

“If you don't repeat the mupirocin treatment for a week each month, the patient appears more likely to colonize,” she said. “There is no absolutely clear superior, evidence-based regimen, but studies are ongoing and we may have some more information in the future.”

Dr. Friedlander disclosed that she has received grant and research support, honoraria, and/or consulting fees from Barrier Therapeutics Inc., Medicis Pharmaceutical Corp., Sanofi-Aventis, and Stiefel Laboratories Inc.

This MRSA infection was mistaken for spider bites. Courtesy Dr. Sheila Fallon Friedlander

CALGARY, ALTA. — As an epidemiologist whose research focuses on the prevention of cervical cancer, Dr. Eduardo L. Franco spends a lot of his time dispelling arguments and protests from other health care professionals and patients that more research is needed before universal human papillomavirus vaccination can be recommended worldwide.

“Although clinical experience has just passed 6 years, the evidence base is one of the strongest in disease prevention,” Dr. Franco said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

“The standard of proof is far more rigorous than that used in the evaluation of candidate vaccines of the past. It may be the most scrutinized vaccine by the public and the media concerning need and safety,” he said.

Prophylactic HPV vaccines include a quadrivalent form manufactured by Merck & Co. that was licensed in the United States in June 2006 and a bivalent form manufactured by GlaxoSmithKline Inc. that was submitted to the Food and Drug Administration in March 2007.

Dr. Franco, director of the division of cancer epidemiology at McGill University, Montreal, shared several examples of arguments against HPV vaccination that he encounters, followed by his counterargument for each.

One chief argument he hears is that the vaccine is too costly and unaffordable where it's most needed.

However, he said, procurement programs such as the Centers for Disease Control and Prevention's Vaccines for Children Program, the Global Alliance for Vaccines and Immunization, and the Pan American Health Organization's revolving fund should help to lower the cost.

“Historically,” he added, “prices decline with time since deployment. Competition among manufacturers should force a reduction in prices.”

In addition, ongoing studies of more simplified schedules—such as administering two doses instead of three—may affect price.

Other common arguments against HPV vaccination include the following:

▸ There are no data on long-term duration of protection. In fact, to date, studies demonstrate a sustained antibody response with no indication that humoral immunity will wane before 10 years.

“Even with lowered antibody titres, postvaccination protection has continued unabated,” said Dr. Franco, who also is a professor of epidemiology and oncology at McGill.

“We did not wait for such proof before deploying other vaccines.”

▸ Protection is limited; vaccines cover only two oncogenic types. In fact, protection is against the two most important types (HPV 16 and 18), which translates into a protective fraction of 70% of all cervical cancers. That protection “is likely to be expanded via cross-protection,” he said. “In combination with tailored screening strategies, it may achieve unprecedented lifelong protection.”

▸ Screening will continue to be needed. True, Dr. Franco said, but recent progress on new technologies such as HPV testing with Pap triage “will permit extending screening intervals safely and cost effectively. Proper integration of primary and secondary prevention strategies is likely to reduce costs and improve cervical cancer control.”

▸ There is a risk of type replacement, which occurred with the pneumococcal vaccine. In fact, Dr. Franco said, type replacement is unlikely to occur because there is no epidemiologic proof that HPV types compete for specific niches. “Several studies have tested this hypothesis,” he noted. “The fraction of the population not exposed to HPV 16 or 18 is always high; exposure to HPV 16 or 18 does not constrain the pool of susceptible individuals who could acquire other HPVs.”

▸ We should not vaccinate preteens and teens; there are no efficacy data on patients aged 9-14 years. This age group is not at risk for lesions and monitoring them “would be unethical and unproductive,” Dr. Franco said.

“Immunobridging” studies show that vaccine-induced humoral response in preteens is the highest among all groups, “which is sufficient justification for expectation of benefit,” he said.

▸ There is no proof yet that vaccination can reduce the risk of invasive cancers. Dr. Franco counters this notion by pointing out that absence of evidence is not evidence of absence. “Sensible judgment based on understanding of the natural history of HPV infection and cervical cancer indicates that prevention of precancerous lesions is an acceptable end point,” he explained.

▸ There is no cervical cancer epidemic. He responds to this argument by emphasizing that the health costs, morbidity, and mortality associated with cervical cancer are sufficiently important to justify action. Moreover, he said, the HPV vaccination is likely to exert protection against other neoplastic diseases such as malignant anogenital and oropharyngeal cancer and benign genital warts and laryngeal papillomatosis.

▸ More research is needed on safety. Dr. Franco responds to this argument by noting that the safety data on the HPV vaccine “are among the most well documented for any new vaccine. There was no waiting period for the adoption of other vaccines with lesser standards of proof. Inaction has a high cost in terms of morbidity and mortality that could have been averted.”

Dr. Franco disclosed that his entire research program has been funded by the Canadian Institutes of Health Research (CIHR), the National Cancer Institute of Canada, and the National Institutes of Health. He has received a Distinguished Scientist salary award from the CIHR and has served as an occasional adviser to several companies with products related to cervical cancer prevention.

'It may be the most scrutinized vaccine by the public and the media concerning need and safety.' DR. FRANCO

CALGARY, ALTA. — As an epidemiologist whose research focuses on the prevention of cervical cancer, Dr. Eduardo L. Franco spends a lot of his time dispelling arguments and protests from other health care professionals and patients that more research is needed before universal human papillomavirus vaccination can be recommended worldwide.

“Although clinical experience has just passed 6 years, the evidence base is one of the strongest in disease prevention,” Dr. Franco said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

“The standard of proof is far more rigorous than that used in the evaluation of candidate vaccines of the past. It may be the most scrutinized vaccine by the public and the media concerning need and safety,” he said.

Prophylactic HPV vaccines include a quadrivalent form manufactured by Merck & Co. that was licensed in the United States in June 2006 and a bivalent form manufactured by GlaxoSmithKline Inc. that was submitted to the Food and Drug Administration in March 2007.

Dr. Franco, director of the division of cancer epidemiology at McGill University, Montreal, shared several examples of arguments against HPV vaccination that he encounters, followed by his counterargument for each.

One chief argument he hears is that the vaccine is too costly and unaffordable where it's most needed.

However, he said, procurement programs such as the Centers for Disease Control and Prevention's Vaccines for Children Program, the Global Alliance for Vaccines and Immunization, and the Pan American Health Organization's revolving fund should help to lower the cost.

“Historically,” he added, “prices decline with time since deployment. Competition among manufacturers should force a reduction in prices.”

In addition, ongoing studies of more simplified schedules—such as administering two doses instead of three—may affect price.

Other common arguments against HPV vaccination include the following:

▸ There are no data on long-term duration of protection. In fact, to date, studies demonstrate a sustained antibody response with no indication that humoral immunity will wane before 10 years.

“Even with lowered antibody titres, postvaccination protection has continued unabated,” said Dr. Franco, who also is a professor of epidemiology and oncology at McGill.

“We did not wait for such proof before deploying other vaccines.”

▸ Protection is limited; vaccines cover only two oncogenic types. In fact, protection is against the two most important types (HPV 16 and 18), which translates into a protective fraction of 70% of all cervical cancers. That protection “is likely to be expanded via cross-protection,” he said. “In combination with tailored screening strategies, it may achieve unprecedented lifelong protection.”

▸ Screening will continue to be needed. True, Dr. Franco said, but recent progress on new technologies such as HPV testing with Pap triage “will permit extending screening intervals safely and cost effectively. Proper integration of primary and secondary prevention strategies is likely to reduce costs and improve cervical cancer control.”

▸ There is a risk of type replacement, which occurred with the pneumococcal vaccine. In fact, Dr. Franco said, type replacement is unlikely to occur because there is no epidemiologic proof that HPV types compete for specific niches. “Several studies have tested this hypothesis,” he noted. “The fraction of the population not exposed to HPV 16 or 18 is always high; exposure to HPV 16 or 18 does not constrain the pool of susceptible individuals who could acquire other HPVs.”

▸ We should not vaccinate preteens and teens; there are no efficacy data on patients aged 9-14 years. This age group is not at risk for lesions and monitoring them “would be unethical and unproductive,” Dr. Franco said.

“Immunobridging” studies show that vaccine-induced humoral response in preteens is the highest among all groups, “which is sufficient justification for expectation of benefit,” he said.

▸ There is no proof yet that vaccination can reduce the risk of invasive cancers. Dr. Franco counters this notion by pointing out that absence of evidence is not evidence of absence. “Sensible judgment based on understanding of the natural history of HPV infection and cervical cancer indicates that prevention of precancerous lesions is an acceptable end point,” he explained.

▸ There is no cervical cancer epidemic. He responds to this argument by emphasizing that the health costs, morbidity, and mortality associated with cervical cancer are sufficiently important to justify action. Moreover, he said, the HPV vaccination is likely to exert protection against other neoplastic diseases such as malignant anogenital and oropharyngeal cancer and benign genital warts and laryngeal papillomatosis.

▸ More research is needed on safety. Dr. Franco responds to this argument by noting that the safety data on the HPV vaccine “are among the most well documented for any new vaccine. There was no waiting period for the adoption of other vaccines with lesser standards of proof. Inaction has a high cost in terms of morbidity and mortality that could have been averted.”

Dr. Franco disclosed that his entire research program has been funded by the Canadian Institutes of Health Research (CIHR), the National Cancer Institute of Canada, and the National Institutes of Health. He has received a Distinguished Scientist salary award from the CIHR and has served as an occasional adviser to several companies with products related to cervical cancer prevention.

'It may be the most scrutinized vaccine by the public and the media concerning need and safety.' DR. FRANCO

CALGARY, ALTA. — As an epidemiologist whose research focuses on the prevention of cervical cancer, Dr. Eduardo L. Franco spends a lot of his time dispelling arguments and protests from other health care professionals and patients that more research is needed before universal human papillomavirus vaccination can be recommended worldwide.

“Although clinical experience has just passed 6 years, the evidence base is one of the strongest in disease prevention,” Dr. Franco said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

“The standard of proof is far more rigorous than that used in the evaluation of candidate vaccines of the past. It may be the most scrutinized vaccine by the public and the media concerning need and safety,” he said.

Prophylactic HPV vaccines include a quadrivalent form manufactured by Merck & Co. that was licensed in the United States in June 2006 and a bivalent form manufactured by GlaxoSmithKline Inc. that was submitted to the Food and Drug Administration in March 2007.

Dr. Franco, director of the division of cancer epidemiology at McGill University, Montreal, shared several examples of arguments against HPV vaccination that he encounters, followed by his counterargument for each.

One chief argument he hears is that the vaccine is too costly and unaffordable where it's most needed.

However, he said, procurement programs such as the Centers for Disease Control and Prevention's Vaccines for Children Program, the Global Alliance for Vaccines and Immunization, and the Pan American Health Organization's revolving fund should help to lower the cost.

“Historically,” he added, “prices decline with time since deployment. Competition among manufacturers should force a reduction in prices.”

In addition, ongoing studies of more simplified schedules—such as administering two doses instead of three—may affect price.

Other common arguments against HPV vaccination include the following:

▸ There are no data on long-term duration of protection. In fact, to date, studies demonstrate a sustained antibody response with no indication that humoral immunity will wane before 10 years.

“Even with lowered antibody titres, postvaccination protection has continued unabated,” said Dr. Franco, who also is a professor of epidemiology and oncology at McGill.

“We did not wait for such proof before deploying other vaccines.”

▸ Protection is limited; vaccines cover only two oncogenic types. In fact, protection is against the two most important types (HPV 16 and 18), which translates into a protective fraction of 70% of all cervical cancers. That protection “is likely to be expanded via cross-protection,” he said. “In combination with tailored screening strategies, it may achieve unprecedented lifelong protection.”

▸ Screening will continue to be needed. True, Dr. Franco said, but recent progress on new technologies such as HPV testing with Pap triage “will permit extending screening intervals safely and cost effectively. Proper integration of primary and secondary prevention strategies is likely to reduce costs and improve cervical cancer control.”

▸ There is a risk of type replacement, which occurred with the pneumococcal vaccine. In fact, Dr. Franco said, type replacement is unlikely to occur because there is no epidemiologic proof that HPV types compete for specific niches. “Several studies have tested this hypothesis,” he noted. “The fraction of the population not exposed to HPV 16 or 18 is always high; exposure to HPV 16 or 18 does not constrain the pool of susceptible individuals who could acquire other HPVs.”

▸ We should not vaccinate preteens and teens; there are no efficacy data on patients aged 9-14 years. This age group is not at risk for lesions and monitoring them “would be unethical and unproductive,” Dr. Franco said.

“Immunobridging” studies show that vaccine-induced humoral response in preteens is the highest among all groups, “which is sufficient justification for expectation of benefit,” he said.

▸ There is no proof yet that vaccination can reduce the risk of invasive cancers. Dr. Franco counters this notion by pointing out that absence of evidence is not evidence of absence. “Sensible judgment based on understanding of the natural history of HPV infection and cervical cancer indicates that prevention of precancerous lesions is an acceptable end point,” he explained.

▸ There is no cervical cancer epidemic. He responds to this argument by emphasizing that the health costs, morbidity, and mortality associated with cervical cancer are sufficiently important to justify action. Moreover, he said, the HPV vaccination is likely to exert protection against other neoplastic diseases such as malignant anogenital and oropharyngeal cancer and benign genital warts and laryngeal papillomatosis.

▸ More research is needed on safety. Dr. Franco responds to this argument by noting that the safety data on the HPV vaccine “are among the most well documented for any new vaccine. There was no waiting period for the adoption of other vaccines with lesser standards of proof. Inaction has a high cost in terms of morbidity and mortality that could have been averted.”

Dr. Franco disclosed that his entire research program has been funded by the Canadian Institutes of Health Research (CIHR), the National Cancer Institute of Canada, and the National Institutes of Health. He has received a Distinguished Scientist salary award from the CIHR and has served as an occasional adviser to several companies with products related to cervical cancer prevention.

'It may be the most scrutinized vaccine by the public and the media concerning need and safety.' DR. FRANCO

CALGARY, ALTA. — Physicians may have a surprising number of misconceptions about birth control, according to recent responses to a survey by 96 family physicians in Kingston, Ont.

Contrary to evidence in the medical literature, more than 60% of respondents thought pelvic inflammatory disease and ectopic pregnancy were major risks of intrauterine device use; 50% thought IUD failure was a major risk; and fewer than one-third would recommend an IUD as an option for nulliparous women, for postcoital contraception, for women with fibroids, or for women who had pelvic inflammatory disease within the last year (Can. Fam. Physician 2008;54:560-6).

“Only 41% of these physicians inserted IUDs,” Dr. Amanda Black said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada (SOGC). There may be inadequate instruction with regard to contraception in physician-training programs, she said. “Not everybody does IUD insertions, subdermal progestin implant, or vasectomy.”

Other barriers to effective contraceptive use include exaggerated concerns about potential side effects. For example, women with diabetes may use oral contraceptives if they have no end-organ damage, said Dr. Black of the division of general obstetrics and gynecology at the Ottawa Hospital. Oral contraceptives are also safe in women older than age 35 if they are healthy nonsmokers, and in women with systemic lupus erythematosus provided they have no antiphospholipid antibodies, vascular disease, or nephritis.

Another common exaggerated concern is that the use of oral and transdermal patch contraceptives cause weight gain. However, a recent Cochrane systematic review of randomized, controlled data concluded that there is no association between oral contraceptives or transdermal contraceptives and weight gain (Cochrane Database Syst. Rev. 2006 Jan. 25 [doi:10.1002/14651858.CD003987.pub2]).

Restrictive and inaccurate product labeling can also play a role in fueling misperceptions. For example, in product packaging for oral contraceptives, risks “are described for an entire class of drugs and don't reflect potential differences in products,” Dr. Black said. “They don't reflect the gradual reduction of estrogen dose since the introduction of oral contraceptives.”

And although breastfeeding is listed under precautions in oral contraceptive packaging “no high-level evidence demonstrates a harmful impact of oral contraceptives on breastfeeding.”

Compliance with contraceptive use is another matter of concern. According to the book “Contraceptive Technology” (New York: Ardent Media, 2007), 32% of women discontinue use of the birth control pill after 1 year, whereas 44% discontinue use of depot medroxyprogesterone acetate, and 20% discontinue use of intrauterine devices.

“One of the things we don't do well in is contraceptive counseling,” said Dr. Black, also of the department of obstetrics and gynecology at the University of Ottawa. “Discontinuation of all of the methods is pretty high at 1 year. But we also know that higher continuation rates are associated with good contraceptive care, the availability of a patient's method of choice, access to follow-up care to discuss ongoing concerns, and receiving information from health care providers about the noncontraceptive benefits of contraception.”

In an effort to improve professional and public education on contraception and related sexual health issues, the SOGC launched the Contraception Awareness Program in 1999, in partnership with Wyeth-Ayerst Laboratories, Janssen-Ortho Inc., Organon Canada Ltd., and Berlex (now a part of Bayer Inc.).

The “three pillars” of the program are freedom from unplanned pregnancy, freedom from sexually transmitted infections, and freedom from sexual coercion, abuse, and dysfunction. Initiatives have included school-based programs featuring visits by health professionals, and public education campaigns that include lectures, public service announcements, and brochures.

Part of the program's work involved launching a popular Web site that contains up-to-date information and education on sexual health for adults, teachers, parents, and health professionals (www.sexualityandu.ca

The presentation was part of a session sponsored by Organon Canada Ltd.

CALGARY, ALTA. — Physicians may have a surprising number of misconceptions about birth control, according to recent responses to a survey by 96 family physicians in Kingston, Ont.

Contrary to evidence in the medical literature, more than 60% of respondents thought pelvic inflammatory disease and ectopic pregnancy were major risks of intrauterine device use; 50% thought IUD failure was a major risk; and fewer than one-third would recommend an IUD as an option for nulliparous women, for postcoital contraception, for women with fibroids, or for women who had pelvic inflammatory disease within the last year (Can. Fam. Physician 2008;54:560-6).

“Only 41% of these physicians inserted IUDs,” Dr. Amanda Black said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada (SOGC). There may be inadequate instruction with regard to contraception in physician-training programs, she said. “Not everybody does IUD insertions, subdermal progestin implant, or vasectomy.”

Other barriers to effective contraceptive use include exaggerated concerns about potential side effects. For example, women with diabetes may use oral contraceptives if they have no end-organ damage, said Dr. Black of the division of general obstetrics and gynecology at the Ottawa Hospital. Oral contraceptives are also safe in women older than age 35 if they are healthy nonsmokers, and in women with systemic lupus erythematosus provided they have no antiphospholipid antibodies, vascular disease, or nephritis.

Another common exaggerated concern is that the use of oral and transdermal patch contraceptives cause weight gain. However, a recent Cochrane systematic review of randomized, controlled data concluded that there is no association between oral contraceptives or transdermal contraceptives and weight gain (Cochrane Database Syst. Rev. 2006 Jan. 25 [doi:10.1002/14651858.CD003987.pub2]).

Restrictive and inaccurate product labeling can also play a role in fueling misperceptions. For example, in product packaging for oral contraceptives, risks “are described for an entire class of drugs and don't reflect potential differences in products,” Dr. Black said. “They don't reflect the gradual reduction of estrogen dose since the introduction of oral contraceptives.”

And although breastfeeding is listed under precautions in oral contraceptive packaging “no high-level evidence demonstrates a harmful impact of oral contraceptives on breastfeeding.”

Compliance with contraceptive use is another matter of concern. According to the book “Contraceptive Technology” (New York: Ardent Media, 2007), 32% of women discontinue use of the birth control pill after 1 year, whereas 44% discontinue use of depot medroxyprogesterone acetate, and 20% discontinue use of intrauterine devices.

“One of the things we don't do well in is contraceptive counseling,” said Dr. Black, also of the department of obstetrics and gynecology at the University of Ottawa. “Discontinuation of all of the methods is pretty high at 1 year. But we also know that higher continuation rates are associated with good contraceptive care, the availability of a patient's method of choice, access to follow-up care to discuss ongoing concerns, and receiving information from health care providers about the noncontraceptive benefits of contraception.”

In an effort to improve professional and public education on contraception and related sexual health issues, the SOGC launched the Contraception Awareness Program in 1999, in partnership with Wyeth-Ayerst Laboratories, Janssen-Ortho Inc., Organon Canada Ltd., and Berlex (now a part of Bayer Inc.).

The “three pillars” of the program are freedom from unplanned pregnancy, freedom from sexually transmitted infections, and freedom from sexual coercion, abuse, and dysfunction. Initiatives have included school-based programs featuring visits by health professionals, and public education campaigns that include lectures, public service announcements, and brochures.

Part of the program's work involved launching a popular Web site that contains up-to-date information and education on sexual health for adults, teachers, parents, and health professionals (www.sexualityandu.ca

The presentation was part of a session sponsored by Organon Canada Ltd.

CALGARY, ALTA. — Physicians may have a surprising number of misconceptions about birth control, according to recent responses to a survey by 96 family physicians in Kingston, Ont.

Contrary to evidence in the medical literature, more than 60% of respondents thought pelvic inflammatory disease and ectopic pregnancy were major risks of intrauterine device use; 50% thought IUD failure was a major risk; and fewer than one-third would recommend an IUD as an option for nulliparous women, for postcoital contraception, for women with fibroids, or for women who had pelvic inflammatory disease within the last year (Can. Fam. Physician 2008;54:560-6).

“Only 41% of these physicians inserted IUDs,” Dr. Amanda Black said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada (SOGC). There may be inadequate instruction with regard to contraception in physician-training programs, she said. “Not everybody does IUD insertions, subdermal progestin implant, or vasectomy.”

Other barriers to effective contraceptive use include exaggerated concerns about potential side effects. For example, women with diabetes may use oral contraceptives if they have no end-organ damage, said Dr. Black of the division of general obstetrics and gynecology at the Ottawa Hospital. Oral contraceptives are also safe in women older than age 35 if they are healthy nonsmokers, and in women with systemic lupus erythematosus provided they have no antiphospholipid antibodies, vascular disease, or nephritis.

Another common exaggerated concern is that the use of oral and transdermal patch contraceptives cause weight gain. However, a recent Cochrane systematic review of randomized, controlled data concluded that there is no association between oral contraceptives or transdermal contraceptives and weight gain (Cochrane Database Syst. Rev. 2006 Jan. 25 [doi:10.1002/14651858.CD003987.pub2]).

Restrictive and inaccurate product labeling can also play a role in fueling misperceptions. For example, in product packaging for oral contraceptives, risks “are described for an entire class of drugs and don't reflect potential differences in products,” Dr. Black said. “They don't reflect the gradual reduction of estrogen dose since the introduction of oral contraceptives.”

And although breastfeeding is listed under precautions in oral contraceptive packaging “no high-level evidence demonstrates a harmful impact of oral contraceptives on breastfeeding.”

Compliance with contraceptive use is another matter of concern. According to the book “Contraceptive Technology” (New York: Ardent Media, 2007), 32% of women discontinue use of the birth control pill after 1 year, whereas 44% discontinue use of depot medroxyprogesterone acetate, and 20% discontinue use of intrauterine devices.

“One of the things we don't do well in is contraceptive counseling,” said Dr. Black, also of the department of obstetrics and gynecology at the University of Ottawa. “Discontinuation of all of the methods is pretty high at 1 year. But we also know that higher continuation rates are associated with good contraceptive care, the availability of a patient's method of choice, access to follow-up care to discuss ongoing concerns, and receiving information from health care providers about the noncontraceptive benefits of contraception.”

In an effort to improve professional and public education on contraception and related sexual health issues, the SOGC launched the Contraception Awareness Program in 1999, in partnership with Wyeth-Ayerst Laboratories, Janssen-Ortho Inc., Organon Canada Ltd., and Berlex (now a part of Bayer Inc.).

The “three pillars” of the program are freedom from unplanned pregnancy, freedom from sexually transmitted infections, and freedom from sexual coercion, abuse, and dysfunction. Initiatives have included school-based programs featuring visits by health professionals, and public education campaigns that include lectures, public service announcements, and brochures.

Part of the program's work involved launching a popular Web site that contains up-to-date information and education on sexual health for adults, teachers, parents, and health professionals (www.sexualityandu.ca

The presentation was part of a session sponsored by Organon Canada Ltd.

SAN DIEGO — Emerging scientific data on adults with psoriasis suggest that certain comorbidities, including metabolic syndrome and myocardial infarction, may accompany the disease.

People with psoriasis “have a tendency to be obese, have a higher rate of cardiovascular disease [and] higher rates of stroke over time; they tend to smoke more, and they have a higher prevalence of depression,” Dr. Lawrence F. Eichenfield said at a meeting on skin disorders sponsored by Rady Children's Hospital. “One [question] that needs to be addressed is, are those secondary factors because they have psoriasis and they feel depressed, and they're starting to eat and they get obese and have secondary cardiovascular effects? Or is it something about the psoriasis itself, something that is going along with inflammatory disease?”

One study found that 20- to 30-year-olds with severe psoriasis had a 310% increased risk of having a myocardial infarction, compared with age-matched controls who did not have the disease (JAMA 2006;296:1735-41).

“So in adults, the younger you are, the relatively higher risk you have,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

At present, however, the effect of psoriasis treatment on the risk of myocardial infarction or on other comorbidities is unknown.

Also unknown is how these emerging findings in adults can be translated into pediatric and adolescent patients with psoriasis. “There is a real paucity of data,” said Dr. Eichenfield, who is also a professor of pediatrics and medicine at the University of California, San Diego. “In one prospectively designed study, we tested etanercept for psoriasis in children and adolescents. Clearly, there was a higher body mass index in that population compared with controls. The real question is, how much is the inflammatory component of psoriasis contributing to this?”

In adults, the prevalence of psoriasis is estimated to be 2.2%, he said. Of those, 25% have moderate to severe disease.

Data in children and adolescents vary, but the prevalence of psoriasis in that population ranges from 0.55% to 1.0%. There are no good prospective pediatric data, he said. “If you ask adults when their psoriasis began, about one-third of them say it began during childhood or adolescence.”

Plaque psoriasis, affecting up to 84% of cases, is the most common presentation in pediatric patients. “It's certainly the type of psoriasis that causes more trouble,” Dr. Eichenfield said. “Face and intertriginous areas are commonly affected in children, so many times we'll have individuals who present with scalp psoriasis, and then over a long period of time we start seeing more typical cutaneous plaques on the elbows, knees, and buttocks.”

Two medium- and low-potency topical therapies are approved for short-term use in pediatric psoriasis: mometasone furoate and alclometasone dipropionate.

Other topical therapies that are being used include other corticosteroids; topical calcipotriol; tars and anthracyclines; tazarotene; and topical calcineurin inhibitors.

For severe psoriasis, phototherapy is Dr. Eichenfield's intervention of choice “in terms of the relative risk-benefit” ratio, he said. “It seems reasonable.”

Other unapproved treatments currently being used in pediatric psoriasis include immunosuppressive agents, systemic retinoids, and biologic agents, all of which carry a significant risk of side effects and toxicities.

Dr. Eichenfield disclosed that he has received grant and research support from Amgen Inc., Galderma Laboratories LP, Obagi Medical Products Inc., and Johnson & Johnson. He has also received honoraria from Medicis Pharmaceutical Corp. and Ranbaxy Pharmaceuticals Inc., and serves as a consultant to Amgen, Galderma, Obagi, Medicis, and Stiefel Laboratories Inc.

For severe psoriasis, phototherapy is preferred. The relative risk- benefit is reasonable. DR. EICHENFIELD

SAN DIEGO — Emerging scientific data on adults with psoriasis suggest that certain comorbidities, including metabolic syndrome and myocardial infarction, may accompany the disease.

People with psoriasis “have a tendency to be obese, have a higher rate of cardiovascular disease [and] higher rates of stroke over time; they tend to smoke more, and they have a higher prevalence of depression,” Dr. Lawrence F. Eichenfield said at a meeting on skin disorders sponsored by Rady Children's Hospital. “One [question] that needs to be addressed is, are those secondary factors because they have psoriasis and they feel depressed, and they're starting to eat and they get obese and have secondary cardiovascular effects? Or is it something about the psoriasis itself, something that is going along with inflammatory disease?”

One study found that 20- to 30-year-olds with severe psoriasis had a 310% increased risk of having a myocardial infarction, compared with age-matched controls who did not have the disease (JAMA 2006;296:1735-41).

“So in adults, the younger you are, the relatively higher risk you have,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

At present, however, the effect of psoriasis treatment on the risk of myocardial infarction or on other comorbidities is unknown.

Also unknown is how these emerging findings in adults can be translated into pediatric and adolescent patients with psoriasis. “There is a real paucity of data,” said Dr. Eichenfield, who is also a professor of pediatrics and medicine at the University of California, San Diego. “In one prospectively designed study, we tested etanercept for psoriasis in children and adolescents. Clearly, there was a higher body mass index in that population compared with controls. The real question is, how much is the inflammatory component of psoriasis contributing to this?”

In adults, the prevalence of psoriasis is estimated to be 2.2%, he said. Of those, 25% have moderate to severe disease.

Data in children and adolescents vary, but the prevalence of psoriasis in that population ranges from 0.55% to 1.0%. There are no good prospective pediatric data, he said. “If you ask adults when their psoriasis began, about one-third of them say it began during childhood or adolescence.”

Plaque psoriasis, affecting up to 84% of cases, is the most common presentation in pediatric patients. “It's certainly the type of psoriasis that causes more trouble,” Dr. Eichenfield said. “Face and intertriginous areas are commonly affected in children, so many times we'll have individuals who present with scalp psoriasis, and then over a long period of time we start seeing more typical cutaneous plaques on the elbows, knees, and buttocks.”

Two medium- and low-potency topical therapies are approved for short-term use in pediatric psoriasis: mometasone furoate and alclometasone dipropionate.

Other topical therapies that are being used include other corticosteroids; topical calcipotriol; tars and anthracyclines; tazarotene; and topical calcineurin inhibitors.

For severe psoriasis, phototherapy is Dr. Eichenfield's intervention of choice “in terms of the relative risk-benefit” ratio, he said. “It seems reasonable.”

Other unapproved treatments currently being used in pediatric psoriasis include immunosuppressive agents, systemic retinoids, and biologic agents, all of which carry a significant risk of side effects and toxicities.

Dr. Eichenfield disclosed that he has received grant and research support from Amgen Inc., Galderma Laboratories LP, Obagi Medical Products Inc., and Johnson & Johnson. He has also received honoraria from Medicis Pharmaceutical Corp. and Ranbaxy Pharmaceuticals Inc., and serves as a consultant to Amgen, Galderma, Obagi, Medicis, and Stiefel Laboratories Inc.

For severe psoriasis, phototherapy is preferred. The relative risk- benefit is reasonable. DR. EICHENFIELD

SAN DIEGO — Emerging scientific data on adults with psoriasis suggest that certain comorbidities, including metabolic syndrome and myocardial infarction, may accompany the disease.

People with psoriasis “have a tendency to be obese, have a higher rate of cardiovascular disease [and] higher rates of stroke over time; they tend to smoke more, and they have a higher prevalence of depression,” Dr. Lawrence F. Eichenfield said at a meeting on skin disorders sponsored by Rady Children's Hospital. “One [question] that needs to be addressed is, are those secondary factors because they have psoriasis and they feel depressed, and they're starting to eat and they get obese and have secondary cardiovascular effects? Or is it something about the psoriasis itself, something that is going along with inflammatory disease?”

One study found that 20- to 30-year-olds with severe psoriasis had a 310% increased risk of having a myocardial infarction, compared with age-matched controls who did not have the disease (JAMA 2006;296:1735-41).

“So in adults, the younger you are, the relatively higher risk you have,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

At present, however, the effect of psoriasis treatment on the risk of myocardial infarction or on other comorbidities is unknown.

Also unknown is how these emerging findings in adults can be translated into pediatric and adolescent patients with psoriasis. “There is a real paucity of data,” said Dr. Eichenfield, who is also a professor of pediatrics and medicine at the University of California, San Diego. “In one prospectively designed study, we tested etanercept for psoriasis in children and adolescents. Clearly, there was a higher body mass index in that population compared with controls. The real question is, how much is the inflammatory component of psoriasis contributing to this?”

In adults, the prevalence of psoriasis is estimated to be 2.2%, he said. Of those, 25% have moderate to severe disease.

Data in children and adolescents vary, but the prevalence of psoriasis in that population ranges from 0.55% to 1.0%. There are no good prospective pediatric data, he said. “If you ask adults when their psoriasis began, about one-third of them say it began during childhood or adolescence.”

Plaque psoriasis, affecting up to 84% of cases, is the most common presentation in pediatric patients. “It's certainly the type of psoriasis that causes more trouble,” Dr. Eichenfield said. “Face and intertriginous areas are commonly affected in children, so many times we'll have individuals who present with scalp psoriasis, and then over a long period of time we start seeing more typical cutaneous plaques on the elbows, knees, and buttocks.”

Two medium- and low-potency topical therapies are approved for short-term use in pediatric psoriasis: mometasone furoate and alclometasone dipropionate.

Other topical therapies that are being used include other corticosteroids; topical calcipotriol; tars and anthracyclines; tazarotene; and topical calcineurin inhibitors.

For severe psoriasis, phototherapy is Dr. Eichenfield's intervention of choice “in terms of the relative risk-benefit” ratio, he said. “It seems reasonable.”

Other unapproved treatments currently being used in pediatric psoriasis include immunosuppressive agents, systemic retinoids, and biologic agents, all of which carry a significant risk of side effects and toxicities.

Dr. Eichenfield disclosed that he has received grant and research support from Amgen Inc., Galderma Laboratories LP, Obagi Medical Products Inc., and Johnson & Johnson. He has also received honoraria from Medicis Pharmaceutical Corp. and Ranbaxy Pharmaceuticals Inc., and serves as a consultant to Amgen, Galderma, Obagi, Medicis, and Stiefel Laboratories Inc.

For severe psoriasis, phototherapy is preferred. The relative risk- benefit is reasonable. DR. EICHENFIELD

Survey results suggesting that pediatricians are more comfortable identifying–but not treating–most children's mental health problems are consistent with previous findings, a leading child and adolescent psychiatrist says.

“With the exception of attention-deficit/hyperactivity disorder, most pediatricians have limited training and experience in the diagnosis and treatment of child psychiatric disorders,” Dr. David Fassler, also a clinical professor of psychiatry at the University of Vermont, Burlington, said in an interview. “For this reason, we're seeing an increased emphasis on programs designed to enhance access to timely and appropriate consultation services.”

The results, based on a survey of Cleveland-area primary care pediatricians and child and adolescent psychiatrists, showed that ADHD was the only psychiatric condition for which most of the respondents thought pediatricians should be responsible.

“The willingness of pediatricians to accept the responsibility for identifying children's mental health problems is encouraging,” researchers led by Dr. Amy Heneghan of the department of pediatrics at Case Western Reserve University, Cleveland, reported (J. Dev. Behav. Pediatr. 2008;29:262-9). “It is an important first step toward reducing the morbidity, mortality, and costs associated with an inadequate and dysfunctional child mental health system.”

In 2005, Dr. Heneghan and her associates mailed a survey to 338 primary care pediatricians and 75 child and adolescent psychiatrists who practice in the Cleveland area.

Each respondent was asked the same three questions about ADHD, depression, behavioral problems, learning disabilities, anxiety disorders, substance abuse, and eating disorders:

▸ How strongly do you agree or disagree that pediatricians should be responsible for identifying this problem?

▸ How strongly do you agree or disagree that pediatricians should be responsible for treating or managing this problem?

▸ How strongly do you agree or disagree that pediatricians should be responsible for referring this problem?

Researchers scored each response on a 3-point Likert scale, with the choices being disagree, neutral, or agree.

Each respondent also was asked 13 questions about barriers for pediatricians in their identification, referral, and treatment of childhood mental health problems, such as lack of time for treating them and lack of training for identifying them. Researchers scored these responses on a 5-point Likert scale, with the choices being strongly disagree, disagree, neutral, agree, or strongly agree.

Another part of Dr. Heneghan's survey asked respondents to share their opinions about the availability of children's mental health services. The final analysis included responses from 132 primary care pediatricians and 31 child and adolescent psychiatrists.

Dr. Heneghan and her associates reported that with the exception of ADHD, most of the respondents in both groups agreed that pediatricians should be responsible for identifying and referring but not treating child mental health problems. For example, while less than 20% of respondents in both groups agreed that pediatricians should be responsible for treating depression, behavioral problems, learning disabilities, anxiety disorders, substance abuse, and eating disorders, 86% of primary care pediatricians and 57% of child and adolescent psychiatrists agreed that pediatricians should be responsible for treating ADHD.

More than 70% of respondents in both groups agreed that a lack of mental health services was a barrier for primary care pediatricians, but child and adolescent psychiatrists were significantly more likely than pediatricians to agree that pediatricians' lack of training in identifying childhood mental health problems was a barrier (70% vs. 47%, respectively).

Both groups strongly agreed that long waiting periods to see referred mental health providers, lack of time to treat mental health problems, and lack of qualified providers to refer to were barriers for pediatricians.

Dr. Fassler said that in his practice, child and adolescent psychiatrists are now providing on-site consultation to seven pediatric groups. He also pointed out that Massachusetts has a “well-regarded statewide initiative that includes telephone consultation with face-to-face backup, as needed.”

In addition, he said, other states have developed innovative telemedicine programs to provide such services. “I don't think pediatricians will ever be treating the full range of child psychiatric disorders,” Dr. Fassler said. “But they clearly are and should be critical members of the treatment team.”

The study was funded by the Woodruff Foundation and the Annie E. Casey Foundation.

Survey results suggesting that pediatricians are more comfortable identifying–but not treating–most children's mental health problems are consistent with previous findings, a leading child and adolescent psychiatrist says.

“With the exception of attention-deficit/hyperactivity disorder, most pediatricians have limited training and experience in the diagnosis and treatment of child psychiatric disorders,” Dr. David Fassler, also a clinical professor of psychiatry at the University of Vermont, Burlington, said in an interview. “For this reason, we're seeing an increased emphasis on programs designed to enhance access to timely and appropriate consultation services.”

The results, based on a survey of Cleveland-area primary care pediatricians and child and adolescent psychiatrists, showed that ADHD was the only psychiatric condition for which most of the respondents thought pediatricians should be responsible.

“The willingness of pediatricians to accept the responsibility for identifying children's mental health problems is encouraging,” researchers led by Dr. Amy Heneghan of the department of pediatrics at Case Western Reserve University, Cleveland, reported (J. Dev. Behav. Pediatr. 2008;29:262-9). “It is an important first step toward reducing the morbidity, mortality, and costs associated with an inadequate and dysfunctional child mental health system.”

In 2005, Dr. Heneghan and her associates mailed a survey to 338 primary care pediatricians and 75 child and adolescent psychiatrists who practice in the Cleveland area.

Each respondent was asked the same three questions about ADHD, depression, behavioral problems, learning disabilities, anxiety disorders, substance abuse, and eating disorders:

▸ How strongly do you agree or disagree that pediatricians should be responsible for identifying this problem?

▸ How strongly do you agree or disagree that pediatricians should be responsible for treating or managing this problem?

▸ How strongly do you agree or disagree that pediatricians should be responsible for referring this problem?

Researchers scored each response on a 3-point Likert scale, with the choices being disagree, neutral, or agree.

Each respondent also was asked 13 questions about barriers for pediatricians in their identification, referral, and treatment of childhood mental health problems, such as lack of time for treating them and lack of training for identifying them. Researchers scored these responses on a 5-point Likert scale, with the choices being strongly disagree, disagree, neutral, agree, or strongly agree.

Another part of Dr. Heneghan's survey asked respondents to share their opinions about the availability of children's mental health services. The final analysis included responses from 132 primary care pediatricians and 31 child and adolescent psychiatrists.

Dr. Heneghan and her associates reported that with the exception of ADHD, most of the respondents in both groups agreed that pediatricians should be responsible for identifying and referring but not treating child mental health problems. For example, while less than 20% of respondents in both groups agreed that pediatricians should be responsible for treating depression, behavioral problems, learning disabilities, anxiety disorders, substance abuse, and eating disorders, 86% of primary care pediatricians and 57% of child and adolescent psychiatrists agreed that pediatricians should be responsible for treating ADHD.

More than 70% of respondents in both groups agreed that a lack of mental health services was a barrier for primary care pediatricians, but child and adolescent psychiatrists were significantly more likely than pediatricians to agree that pediatricians' lack of training in identifying childhood mental health problems was a barrier (70% vs. 47%, respectively).

Both groups strongly agreed that long waiting periods to see referred mental health providers, lack of time to treat mental health problems, and lack of qualified providers to refer to were barriers for pediatricians.

Dr. Fassler said that in his practice, child and adolescent psychiatrists are now providing on-site consultation to seven pediatric groups. He also pointed out that Massachusetts has a “well-regarded statewide initiative that includes telephone consultation with face-to-face backup, as needed.”

In addition, he said, other states have developed innovative telemedicine programs to provide such services. “I don't think pediatricians will ever be treating the full range of child psychiatric disorders,” Dr. Fassler said. “But they clearly are and should be critical members of the treatment team.”

The study was funded by the Woodruff Foundation and the Annie E. Casey Foundation.

Survey results suggesting that pediatricians are more comfortable identifying–but not treating–most children's mental health problems are consistent with previous findings, a leading child and adolescent psychiatrist says.

“With the exception of attention-deficit/hyperactivity disorder, most pediatricians have limited training and experience in the diagnosis and treatment of child psychiatric disorders,” Dr. David Fassler, also a clinical professor of psychiatry at the University of Vermont, Burlington, said in an interview. “For this reason, we're seeing an increased emphasis on programs designed to enhance access to timely and appropriate consultation services.”

The results, based on a survey of Cleveland-area primary care pediatricians and child and adolescent psychiatrists, showed that ADHD was the only psychiatric condition for which most of the respondents thought pediatricians should be responsible.

“The willingness of pediatricians to accept the responsibility for identifying children's mental health problems is encouraging,” researchers led by Dr. Amy Heneghan of the department of pediatrics at Case Western Reserve University, Cleveland, reported (J. Dev. Behav. Pediatr. 2008;29:262-9). “It is an important first step toward reducing the morbidity, mortality, and costs associated with an inadequate and dysfunctional child mental health system.”

In 2005, Dr. Heneghan and her associates mailed a survey to 338 primary care pediatricians and 75 child and adolescent psychiatrists who practice in the Cleveland area.

Each respondent was asked the same three questions about ADHD, depression, behavioral problems, learning disabilities, anxiety disorders, substance abuse, and eating disorders:

▸ How strongly do you agree or disagree that pediatricians should be responsible for identifying this problem?

▸ How strongly do you agree or disagree that pediatricians should be responsible for treating or managing this problem?

▸ How strongly do you agree or disagree that pediatricians should be responsible for referring this problem?

Researchers scored each response on a 3-point Likert scale, with the choices being disagree, neutral, or agree.

Each respondent also was asked 13 questions about barriers for pediatricians in their identification, referral, and treatment of childhood mental health problems, such as lack of time for treating them and lack of training for identifying them. Researchers scored these responses on a 5-point Likert scale, with the choices being strongly disagree, disagree, neutral, agree, or strongly agree.

Another part of Dr. Heneghan's survey asked respondents to share their opinions about the availability of children's mental health services. The final analysis included responses from 132 primary care pediatricians and 31 child and adolescent psychiatrists.

Dr. Heneghan and her associates reported that with the exception of ADHD, most of the respondents in both groups agreed that pediatricians should be responsible for identifying and referring but not treating child mental health problems. For example, while less than 20% of respondents in both groups agreed that pediatricians should be responsible for treating depression, behavioral problems, learning disabilities, anxiety disorders, substance abuse, and eating disorders, 86% of primary care pediatricians and 57% of child and adolescent psychiatrists agreed that pediatricians should be responsible for treating ADHD.

More than 70% of respondents in both groups agreed that a lack of mental health services was a barrier for primary care pediatricians, but child and adolescent psychiatrists were significantly more likely than pediatricians to agree that pediatricians' lack of training in identifying childhood mental health problems was a barrier (70% vs. 47%, respectively).

Both groups strongly agreed that long waiting periods to see referred mental health providers, lack of time to treat mental health problems, and lack of qualified providers to refer to were barriers for pediatricians.

Dr. Fassler said that in his practice, child and adolescent psychiatrists are now providing on-site consultation to seven pediatric groups. He also pointed out that Massachusetts has a “well-regarded statewide initiative that includes telephone consultation with face-to-face backup, as needed.”

In addition, he said, other states have developed innovative telemedicine programs to provide such services. “I don't think pediatricians will ever be treating the full range of child psychiatric disorders,” Dr. Fassler said. “But they clearly are and should be critical members of the treatment team.”

The study was funded by the Woodruff Foundation and the Annie E. Casey Foundation.

SAN DIEGO — Patients with atopic dermatitis are highly colonized with Staphylococcus aureus but do not appear to be preferentially infected with community-acquired methicillin-resistant S. aureus.

Up to 79% of patients with atopic dermatitis have S. aureus in their anterior nares, 64%–75% have it on their normal skin, and more than 90% have it on their lesional skin.

In contrast, up to 30% of atopic-free adults have S. aureus in their nasal carriage and 10% have it on their skin, Dr. Sheila Fallon Friedlander said at a conference sponsored by Rady Children's Hospital, San Diego.

A reason why patients with atopic dermatitis may have trouble with S. aureus is that they appear to lack an adequate number of cathelicidins, said Dr. Friedlander, director of pediatric dermatology at the University of California, San Francisco.

"The end result clinically is that they don't have as much antimicrobial peptide helping to ward off infection. Atopics also have an impaired skin barrier, sometimes as a result of abnormal or decreased filaggrin. With increasing dryness and lack of appropriate adhesion, there is also increased skin surface area for the S. aureus to adhere to," she said.

In addition, she said S. aureus can elaborate superantigens, "which have the ability to stimulate the production of alternative glucocorticoid receptors. These receptors are more resistant to the effects of steroids. So often when S. aureus is present in the skin, there is elaboration of a receptor [that] makes it more difficult for the patient to respond to topical corticosteroid treatment."

A recent study estimated that 40%–66% of patients with atopic dermatitis develop S. aureus skin infections (Pediatr. Derm. 2000;17:111–4). Another concluded that the condition is a risk factor for invasive S. aureus infection in this patient population, including bacteremia, osteomyelitis, and endocarditis (Am. J. Med. 2005;118:1048–51).

However, Dr. Friedlander described the link between atopic dermatitis and invasive disease as "a controversial issue" with data that remain unclear.

"In some papers, it appears that there are lower levels of invasive disease in patients with atopic dermatitis," she said. "Invasive disease does occur, but atopics don't seem to be at higher risk for invasive disease. Further studies are required to clarify this issue."

The good news is that patients with atopic dermatitis do not seem to be preferentially affected with community-acquired methicillin-resistant S. aureus (CA-MRSA). An estimated 6%–19% of children with atopic dermatitis were found to have the condition (Arch. Dermatol. 2002;138:939–41).

Another group of researchers concluded that the "observed incidence of cutaneous CA-MRSA lesions in patients with atopic dermatitis or other non-intact skin barrier is less than reported in other at-risk groups" (J. Clin. Dermatol. 2007;8:259–70).

Dr. Friedlander explained that, compared with the hospital-acquired form of MRSA, the community-acquired form is clonal, has many drug options, and has a predilection for skin disease. "It preferentially infects the skin; skin and soft tissue infections are what we see," she said. "But you must remember that you can have invasive disease from this organism."

Clinically, CA-MRSA presents as furuncles or folliculitis 65%–95% of the time. "Parents will say, 'my child keeps getting a spider bite,'" Dr. Friedlander said. Most patients look well, but 40%–50% will have fever.

Most often, CA-MRSA organisms possess Panton-Valentine leukocidin, a virulence factor that is a bicomponent cytotoxin. This virulent toxin "destroys our leukocytes by punching holes in the membrane," she said. "This leads to capillary dilation and significant necrosis."

CA-MRSA also may possess an aberrant fibronectin-binding protein gene, which enables the S. aureus "to adhere better to our tissue and therefore enhances invasion."

Incision and drainage alone appears to suffice in CA-MRSA skin and soft tissue lesions smaller than 5 cm. "If a lesion is bigger than that, you need to be aggressive," she said. "Please culture these lesions. In the old days, people used to drain these and throw the exudate away. Do not throw it away because the antibiotic susceptibility patterns differ from the hospital-acquired form, and you may need this information to determine the best therapy for your patient."

Dr. Friedlander often starts patients on clindamycin. However, some organisms may be resistant, and therefore you need to check for inducible resistance in these patients. "Sometimes you need to use trimethoprim/sulfamethoxazole," she said.

"In older children, you can use minocycline or doxycycline, but remember, these drugs can damage the teeth of young children, and I will not use tetracyclines in children less than 8 years of age."

Attempts to eradicate MRSA with various combinations of antibiotics have had mixed results, but recent studies have found the use of bleach baths in combination with nasal mupirocin to be useful.

Dr. Friedlander recommends adding one-quarter of a cup of Clorox to a regular bath and repeating this treatment two times a week. In addition, some experts apply mupirocin ointment twice a day to the nares for 1 week each month.

"If you don't repeat the mupirocin treatment for a week each month, the patient appears more likely to colonize," she said. "There is no absolutely clear superior, evidence-based regimen, but studies are ongoing and we may have some more information in the future."

Control of atopic dermatitis "is the first goal in preventing infection," she pointed out. "If you control the itching and maintain the skin barrier, you are less likely to have the patient self-inoculate with staph or any other organism."

Dr. Friedlander disclosed that she has received grant and research support, honoraria, and/or consulting fees from Barrier Therapeutics Inc., Medicis Pharmaceutical Corp., Sanofi-Aventis, and Stiefel Laboratories Inc.

This patient's family mistook an MRSA infection for multiple spider bites. Courtesy Dr. Sheila Fallon Friedlander

SAN DIEGO — Patients with atopic dermatitis are highly colonized with Staphylococcus aureus but do not appear to be preferentially infected with community-acquired methicillin-resistant S. aureus.

Up to 79% of patients with atopic dermatitis have S. aureus in their anterior nares, 64%–75% have it on their normal skin, and more than 90% have it on their lesional skin.

In contrast, up to 30% of atopic-free adults have S. aureus in their nasal carriage and 10% have it on their skin, Dr. Sheila Fallon Friedlander said at a conference sponsored by Rady Children's Hospital, San Diego.

A reason why patients with atopic dermatitis may have trouble with S. aureus is that they appear to lack an adequate number of cathelicidins, said Dr. Friedlander, director of pediatric dermatology at the University of California, San Francisco.

"The end result clinically is that they don't have as much antimicrobial peptide helping to ward off infection. Atopics also have an impaired skin barrier, sometimes as a result of abnormal or decreased filaggrin. With increasing dryness and lack of appropriate adhesion, there is also increased skin surface area for the S. aureus to adhere to," she said.

In addition, she said S. aureus can elaborate superantigens, "which have the ability to stimulate the production of alternative glucocorticoid receptors. These receptors are more resistant to the effects of steroids. So often when S. aureus is present in the skin, there is elaboration of a receptor [that] makes it more difficult for the patient to respond to topical corticosteroid treatment."

A recent study estimated that 40%–66% of patients with atopic dermatitis develop S. aureus skin infections (Pediatr. Derm. 2000;17:111–4). Another concluded that the condition is a risk factor for invasive S. aureus infection in this patient population, including bacteremia, osteomyelitis, and endocarditis (Am. J. Med. 2005;118:1048–51).

However, Dr. Friedlander described the link between atopic dermatitis and invasive disease as "a controversial issue" with data that remain unclear.

"In some papers, it appears that there are lower levels of invasive disease in patients with atopic dermatitis," she said. "Invasive disease does occur, but atopics don't seem to be at higher risk for invasive disease. Further studies are required to clarify this issue."

The good news is that patients with atopic dermatitis do not seem to be preferentially affected with community-acquired methicillin-resistant S. aureus (CA-MRSA). An estimated 6%–19% of children with atopic dermatitis were found to have the condition (Arch. Dermatol. 2002;138:939–41).

Another group of researchers concluded that the "observed incidence of cutaneous CA-MRSA lesions in patients with atopic dermatitis or other non-intact skin barrier is less than reported in other at-risk groups" (J. Clin. Dermatol. 2007;8:259–70).

Dr. Friedlander explained that, compared with the hospital-acquired form of MRSA, the community-acquired form is clonal, has many drug options, and has a predilection for skin disease. "It preferentially infects the skin; skin and soft tissue infections are what we see," she said. "But you must remember that you can have invasive disease from this organism."

Clinically, CA-MRSA presents as furuncles or folliculitis 65%–95% of the time. "Parents will say, 'my child keeps getting a spider bite,'" Dr. Friedlander said. Most patients look well, but 40%–50% will have fever.

Most often, CA-MRSA organisms possess Panton-Valentine leukocidin, a virulence factor that is a bicomponent cytotoxin. This virulent toxin "destroys our leukocytes by punching holes in the membrane," she said. "This leads to capillary dilation and significant necrosis."

CA-MRSA also may possess an aberrant fibronectin-binding protein gene, which enables the S. aureus "to adhere better to our tissue and therefore enhances invasion."

Incision and drainage alone appears to suffice in CA-MRSA skin and soft tissue lesions smaller than 5 cm. "If a lesion is bigger than that, you need to be aggressive," she said. "Please culture these lesions. In the old days, people used to drain these and throw the exudate away. Do not throw it away because the antibiotic susceptibility patterns differ from the hospital-acquired form, and you may need this information to determine the best therapy for your patient."

Dr. Friedlander often starts patients on clindamycin. However, some organisms may be resistant, and therefore you need to check for inducible resistance in these patients. "Sometimes you need to use trimethoprim/sulfamethoxazole," she said.

"In older children, you can use minocycline or doxycycline, but remember, these drugs can damage the teeth of young children, and I will not use tetracyclines in children less than 8 years of age."

Attempts to eradicate MRSA with various combinations of antibiotics have had mixed results, but recent studies have found the use of bleach baths in combination with nasal mupirocin to be useful.

Dr. Friedlander recommends adding one-quarter of a cup of Clorox to a regular bath and repeating this treatment two times a week. In addition, some experts apply mupirocin ointment twice a day to the nares for 1 week each month.

"If you don't repeat the mupirocin treatment for a week each month, the patient appears more likely to colonize," she said. "There is no absolutely clear superior, evidence-based regimen, but studies are ongoing and we may have some more information in the future."

Control of atopic dermatitis "is the first goal in preventing infection," she pointed out. "If you control the itching and maintain the skin barrier, you are less likely to have the patient self-inoculate with staph or any other organism."

Dr. Friedlander disclosed that she has received grant and research support, honoraria, and/or consulting fees from Barrier Therapeutics Inc., Medicis Pharmaceutical Corp., Sanofi-Aventis, and Stiefel Laboratories Inc.

This patient's family mistook an MRSA infection for multiple spider bites. Courtesy Dr. Sheila Fallon Friedlander

SAN DIEGO — Patients with atopic dermatitis are highly colonized with Staphylococcus aureus but do not appear to be preferentially infected with community-acquired methicillin-resistant S. aureus.

Up to 79% of patients with atopic dermatitis have S. aureus in their anterior nares, 64%–75% have it on their normal skin, and more than 90% have it on their lesional skin.

In contrast, up to 30% of atopic-free adults have S. aureus in their nasal carriage and 10% have it on their skin, Dr. Sheila Fallon Friedlander said at a conference sponsored by Rady Children's Hospital, San Diego.

A reason why patients with atopic dermatitis may have trouble with S. aureus is that they appear to lack an adequate number of cathelicidins, said Dr. Friedlander, director of pediatric dermatology at the University of California, San Francisco.

"The end result clinically is that they don't have as much antimicrobial peptide helping to ward off infection. Atopics also have an impaired skin barrier, sometimes as a result of abnormal or decreased filaggrin. With increasing dryness and lack of appropriate adhesion, there is also increased skin surface area for the S. aureus to adhere to," she said.

In addition, she said S. aureus can elaborate superantigens, "which have the ability to stimulate the production of alternative glucocorticoid receptors. These receptors are more resistant to the effects of steroids. So often when S. aureus is present in the skin, there is elaboration of a receptor [that] makes it more difficult for the patient to respond to topical corticosteroid treatment."

A recent study estimated that 40%–66% of patients with atopic dermatitis develop S. aureus skin infections (Pediatr. Derm. 2000;17:111–4). Another concluded that the condition is a risk factor for invasive S. aureus infection in this patient population, including bacteremia, osteomyelitis, and endocarditis (Am. J. Med. 2005;118:1048–51).

However, Dr. Friedlander described the link between atopic dermatitis and invasive disease as "a controversial issue" with data that remain unclear.

"In some papers, it appears that there are lower levels of invasive disease in patients with atopic dermatitis," she said. "Invasive disease does occur, but atopics don't seem to be at higher risk for invasive disease. Further studies are required to clarify this issue."

The good news is that patients with atopic dermatitis do not seem to be preferentially affected with community-acquired methicillin-resistant S. aureus (CA-MRSA). An estimated 6%–19% of children with atopic dermatitis were found to have the condition (Arch. Dermatol. 2002;138:939–41).

Another group of researchers concluded that the "observed incidence of cutaneous CA-MRSA lesions in patients with atopic dermatitis or other non-intact skin barrier is less than reported in other at-risk groups" (J. Clin. Dermatol. 2007;8:259–70).

Dr. Friedlander explained that, compared with the hospital-acquired form of MRSA, the community-acquired form is clonal, has many drug options, and has a predilection for skin disease. "It preferentially infects the skin; skin and soft tissue infections are what we see," she said. "But you must remember that you can have invasive disease from this organism."

Clinically, CA-MRSA presents as furuncles or folliculitis 65%–95% of the time. "Parents will say, 'my child keeps getting a spider bite,'" Dr. Friedlander said. Most patients look well, but 40%–50% will have fever.

Most often, CA-MRSA organisms possess Panton-Valentine leukocidin, a virulence factor that is a bicomponent cytotoxin. This virulent toxin "destroys our leukocytes by punching holes in the membrane," she said. "This leads to capillary dilation and significant necrosis."

CA-MRSA also may possess an aberrant fibronectin-binding protein gene, which enables the S. aureus "to adhere better to our tissue and therefore enhances invasion."

Incision and drainage alone appears to suffice in CA-MRSA skin and soft tissue lesions smaller than 5 cm. "If a lesion is bigger than that, you need to be aggressive," she said. "Please culture these lesions. In the old days, people used to drain these and throw the exudate away. Do not throw it away because the antibiotic susceptibility patterns differ from the hospital-acquired form, and you may need this information to determine the best therapy for your patient."

Dr. Friedlander often starts patients on clindamycin. However, some organisms may be resistant, and therefore you need to check for inducible resistance in these patients. "Sometimes you need to use trimethoprim/sulfamethoxazole," she said.

"In older children, you can use minocycline or doxycycline, but remember, these drugs can damage the teeth of young children, and I will not use tetracyclines in children less than 8 years of age."

Attempts to eradicate MRSA with various combinations of antibiotics have had mixed results, but recent studies have found the use of bleach baths in combination with nasal mupirocin to be useful.

Dr. Friedlander recommends adding one-quarter of a cup of Clorox to a regular bath and repeating this treatment two times a week. In addition, some experts apply mupirocin ointment twice a day to the nares for 1 week each month.

"If you don't repeat the mupirocin treatment for a week each month, the patient appears more likely to colonize," she said. "There is no absolutely clear superior, evidence-based regimen, but studies are ongoing and we may have some more information in the future."

Control of atopic dermatitis "is the first goal in preventing infection," she pointed out. "If you control the itching and maintain the skin barrier, you are less likely to have the patient self-inoculate with staph or any other organism."

Dr. Friedlander disclosed that she has received grant and research support, honoraria, and/or consulting fees from Barrier Therapeutics Inc., Medicis Pharmaceutical Corp., Sanofi-Aventis, and Stiefel Laboratories Inc.

This patient's family mistook an MRSA infection for multiple spider bites. Courtesy Dr. Sheila Fallon Friedlander

SAN DIEGO — Barrier products may play a role as adjuvant therapy for patients with atopic dermatitis, but better studies are needed to demonstrate their efficacy.

That's the conclusion Dr. Andrew C. Krakowski made about three barrier products he discussed at a meeting on skin disorders sponsored by Rady Children's Hospital: palmitamide monoethanolamine (PEA) nonsteroidal cream (MimyX), hydrolipidic cream MAS063DP (Atopiclair), and ceramide-based emulsion (EpiCeram).

These products are 510(k) medical devices that have been cleared for marketing by the Food and Drug Administration. The manufacturers claim that they contain ingredients that might help to replace normal epidermal lipids, improve skin hydration, decrease skin barrier dysfunction, and relieve the atopic dermatitis symptoms of stinging, burning, and pruritus.

Such features are important, Dr. Krakowski said, because "we know that barrier dysfunction correlates with atopic dermatitis severity and we think there is a possible increased allergy absorption that happens through the skin of our atopic dermatitis patients. We also know that atopic dermatitis skin is a great setup for microbial colonization, and that puts you at increased risk of secondary infection. We also have good data that a disrepaired skin barrier leads to increased transepidermal water loss."

There are several barrier products currently on the market, but he limited his discussion to the three that have been studied recently:

▸ EpiCeram. Licensed by the University of California and manufactured by Ceragenix Pharmaceuticals Inc., EpiCeram is a combination of ceramides, cholesterols, and fatty acids that is expected to hit the U.S. market this fall, said Dr. Krakowski. The current cost is not known.

In a multicenter, randomized study sponsored by Ceragenix and presented as a poster at the 2008 annual meeting of the Society of Pediatric Dermatology, investigators compared 4 weeks of twice-daily ceramide-based emulsion to fluticasone propionate in children with moderate to severe atopic dermatitis. (See related story below.)

On day 14, subjects in the fluticasone group had significantly better Scoring Atopic Dermatitis (SCORAD) scores, compared with those in the ceramide-based emulsion group. By day 28, there were no significant differences in SCORAD scores between the two groups.

In a second multicenter, randomized study that included patients from Rady Children's Hospital, investigators compared 4 weeks of twice-daily ceramide-based emulsion to pimecrolimus in 38 pediatric subjects with mild to moderate atopic dermatitis. No intention-to-treat analysis was performed.

Subjects in both groups demonstrated significant improvement in Investigator Global Assessment (IGA) scores at days 14 and 28. "There was also no significant difference in pruritus between the two groups, but it wasn't clear if there was any improvement," said Dr. Krakowski, a first-year dermatology resident at the University of California, San Diego.

Subjects in the ceramide-based emulsion group had no significant improvement from baseline in Eczema Area and Severity Index (EASI) scores. By day 14, subjects in the pimecrolimus group had significantly better EASI scores, compared with their counterparts in the ceramide emulsion group. By day 28, there were no differences in median score reductions between the groups.

▸ MimyX. Manufactured by Stiefel Laboratories Inc., this water-based product is described as a fragrance-, dye-, and preservative-free emulsion to be used three times a day or as needed. According to the manufacturer's Web site, it comes as a 140-g tube, with a cost of $101, or about $22 per ounce.

The main ingredient is PEA, which is found naturally in the stratum granulosum and is thought to downregulate inflammatory response. "It's a cannabinoid agonist that is believed to modulate mast cells and immune cells, theoretically reducing histamines, cytokines, and IL-4, −6, and −8," Dr. Krakowski added. "It's also thought to bind CB2 receptors on cutaneous nerves and decrease the transmission of pruritus."

In an international open-label study, investigators assessed the effects of the PEA nonsteroidal cream applied at least twice daily for 38 days in 2,456 patients with mild to moderate atopic dermatitis (J. Eur. Acad. Dermatol. Venereol. 2008;22:73–82). Of the 2,456 patients, 923 were 12 years of age or younger.

By the end of the study, physician assessment scores demonstrated that pruritus improved by 56%, erythema by 54%, dryness by 57%, lichenification by 55%, and excoriations by 63%.

The investigators also found that by the end of the treatment period, 63% of children reduced their use of topical corticosteroids, compared with 53% of adults. In addition, 34% of subjects were able to stop using their topical corticosteroid altogether and 12% were able to switch to a lower-potency steroid.

▸ Atopiclair. Manufactured by Graceway Pharmaceuticals LLC, this product contains hyaluronic acid, Vitis vinifera (grape leaf extract), telmesteine, glycyrrhetinic acid (licorice extract), and shea butter, a derivative of shea nut oil. The product is described as dye- and fragrance-free and is used 2–3 times per day or as needed. It comes in a 100-g tube and costs about $34 per ounce.

In a multicenter, randomized, double-blind, vehicle-controlled trial, 106 infants and children with mild to moderate atopic dermatitis applied hydrolipidic cream MAS063DP or vehicle three times a day to past, current, or "reasonable future" sites as monotherapy for 43 days (J. Pediatr. 2008;152:854–9). The mean age of subjects was 5 years.

One target lesion was chosen by investigators for evaluation and photography (mostly identified on extremities). Success was defined as reaching an IGA score of 0 (clear) or 1 (almost clear).

In an intention-to-treat analysis, 53 of 69 subjects (77%) in the hydrolipidic cream group achieved a score of 0 or 1 at day 22, compared with none in the vehicle group. "The vehicle used in the study wasn't your normal petrolatum vehicle," Dr. Krakowski noted. "It was the vehicle the hydrolipidic cream came in."

Pruritus, EASI scores, subject and caregiver assessment of global response, onset and duration of itch relief, and need for rescue medication were all significantly improved in the treatment group, compared with the vehicle group.

"I think barrier products could be helpful as adjuvant treatment for atopic dermatitis," he commented. "I think the cost of these products needs to be reconciled with their cost-effectiveness; most of these products may not be covered by insurance. We also need better head-to-head, long-term, pediatric-specific trials to demonstrate efficacy of these products for treating flares directly and for maintenance therapy over the long term."

Dr. Krakowski disclosed having had no relevant conflicts of interest.

SAN DIEGO — Barrier products may play a role as adjuvant therapy for patients with atopic dermatitis, but better studies are needed to demonstrate their efficacy.

That's the conclusion Dr. Andrew C. Krakowski made about three barrier products he discussed at a meeting on skin disorders sponsored by Rady Children's Hospital: palmitamide monoethanolamine (PEA) nonsteroidal cream (MimyX), hydrolipidic cream MAS063DP (Atopiclair), and ceramide-based emulsion (EpiCeram).

These products are 510(k) medical devices that have been cleared for marketing by the Food and Drug Administration. The manufacturers claim that they contain ingredients that might help to replace normal epidermal lipids, improve skin hydration, decrease skin barrier dysfunction, and relieve the atopic dermatitis symptoms of stinging, burning, and pruritus.

Such features are important, Dr. Krakowski said, because "we know that barrier dysfunction correlates with atopic dermatitis severity and we think there is a possible increased allergy absorption that happens through the skin of our atopic dermatitis patients. We also know that atopic dermatitis skin is a great setup for microbial colonization, and that puts you at increased risk of secondary infection. We also have good data that a disrepaired skin barrier leads to increased transepidermal water loss."

There are several barrier products currently on the market, but he limited his discussion to the three that have been studied recently:

▸ EpiCeram. Licensed by the University of California and manufactured by Ceragenix Pharmaceuticals Inc., EpiCeram is a combination of ceramides, cholesterols, and fatty acids that is expected to hit the U.S. market this fall, said Dr. Krakowski. The current cost is not known.

In a multicenter, randomized study sponsored by Ceragenix and presented as a poster at the 2008 annual meeting of the Society of Pediatric Dermatology, investigators compared 4 weeks of twice-daily ceramide-based emulsion to fluticasone propionate in children with moderate to severe atopic dermatitis. (See related story below.)

On day 14, subjects in the fluticasone group had significantly better Scoring Atopic Dermatitis (SCORAD) scores, compared with those in the ceramide-based emulsion group. By day 28, there were no significant differences in SCORAD scores between the two groups.

In a second multicenter, randomized study that included patients from Rady Children's Hospital, investigators compared 4 weeks of twice-daily ceramide-based emulsion to pimecrolimus in 38 pediatric subjects with mild to moderate atopic dermatitis. No intention-to-treat analysis was performed.

Subjects in both groups demonstrated significant improvement in Investigator Global Assessment (IGA) scores at days 14 and 28. "There was also no significant difference in pruritus between the two groups, but it wasn't clear if there was any improvement," said Dr. Krakowski, a first-year dermatology resident at the University of California, San Diego.

Subjects in the ceramide-based emulsion group had no significant improvement from baseline in Eczema Area and Severity Index (EASI) scores. By day 14, subjects in the pimecrolimus group had significantly better EASI scores, compared with their counterparts in the ceramide emulsion group. By day 28, there were no differences in median score reductions between the groups.

▸ MimyX. Manufactured by Stiefel Laboratories Inc., this water-based product is described as a fragrance-, dye-, and preservative-free emulsion to be used three times a day or as needed. According to the manufacturer's Web site, it comes as a 140-g tube, with a cost of $101, or about $22 per ounce.

The main ingredient is PEA, which is found naturally in the stratum granulosum and is thought to downregulate inflammatory response. "It's a cannabinoid agonist that is believed to modulate mast cells and immune cells, theoretically reducing histamines, cytokines, and IL-4, −6, and −8," Dr. Krakowski added. "It's also thought to bind CB2 receptors on cutaneous nerves and decrease the transmission of pruritus."

In an international open-label study, investigators assessed the effects of the PEA nonsteroidal cream applied at least twice daily for 38 days in 2,456 patients with mild to moderate atopic dermatitis (J. Eur. Acad. Dermatol. Venereol. 2008;22:73–82). Of the 2,456 patients, 923 were 12 years of age or younger.

By the end of the study, physician assessment scores demonstrated that pruritus improved by 56%, erythema by 54%, dryness by 57%, lichenification by 55%, and excoriations by 63%.

The investigators also found that by the end of the treatment period, 63% of children reduced their use of topical corticosteroids, compared with 53% of adults. In addition, 34% of subjects were able to stop using their topical corticosteroid altogether and 12% were able to switch to a lower-potency steroid.

▸ Atopiclair. Manufactured by Graceway Pharmaceuticals LLC, this product contains hyaluronic acid, Vitis vinifera (grape leaf extract), telmesteine, glycyrrhetinic acid (licorice extract), and shea butter, a derivative of shea nut oil. The product is described as dye- and fragrance-free and is used 2–3 times per day or as needed. It comes in a 100-g tube and costs about $34 per ounce.

In a multicenter, randomized, double-blind, vehicle-controlled trial, 106 infants and children with mild to moderate atopic dermatitis applied hydrolipidic cream MAS063DP or vehicle three times a day to past, current, or "reasonable future" sites as monotherapy for 43 days (J. Pediatr. 2008;152:854–9). The mean age of subjects was 5 years.

One target lesion was chosen by investigators for evaluation and photography (mostly identified on extremities). Success was defined as reaching an IGA score of 0 (clear) or 1 (almost clear).

In an intention-to-treat analysis, 53 of 69 subjects (77%) in the hydrolipidic cream group achieved a score of 0 or 1 at day 22, compared with none in the vehicle group. "The vehicle used in the study wasn't your normal petrolatum vehicle," Dr. Krakowski noted. "It was the vehicle the hydrolipidic cream came in."

Pruritus, EASI scores, subject and caregiver assessment of global response, onset and duration of itch relief, and need for rescue medication were all significantly improved in the treatment group, compared with the vehicle group.

"I think barrier products could be helpful as adjuvant treatment for atopic dermatitis," he commented. "I think the cost of these products needs to be reconciled with their cost-effectiveness; most of these products may not be covered by insurance. We also need better head-to-head, long-term, pediatric-specific trials to demonstrate efficacy of these products for treating flares directly and for maintenance therapy over the long term."

Dr. Krakowski disclosed having had no relevant conflicts of interest.

SAN DIEGO — Barrier products may play a role as adjuvant therapy for patients with atopic dermatitis, but better studies are needed to demonstrate their efficacy.

That's the conclusion Dr. Andrew C. Krakowski made about three barrier products he discussed at a meeting on skin disorders sponsored by Rady Children's Hospital: palmitamide monoethanolamine (PEA) nonsteroidal cream (MimyX), hydrolipidic cream MAS063DP (Atopiclair), and ceramide-based emulsion (EpiCeram).

These products are 510(k) medical devices that have been cleared for marketing by the Food and Drug Administration. The manufacturers claim that they contain ingredients that might help to replace normal epidermal lipids, improve skin hydration, decrease skin barrier dysfunction, and relieve the atopic dermatitis symptoms of stinging, burning, and pruritus.

Such features are important, Dr. Krakowski said, because "we know that barrier dysfunction correlates with atopic dermatitis severity and we think there is a possible increased allergy absorption that happens through the skin of our atopic dermatitis patients. We also know that atopic dermatitis skin is a great setup for microbial colonization, and that puts you at increased risk of secondary infection. We also have good data that a disrepaired skin barrier leads to increased transepidermal water loss."

There are several barrier products currently on the market, but he limited his discussion to the three that have been studied recently:

▸ EpiCeram. Licensed by the University of California and manufactured by Ceragenix Pharmaceuticals Inc., EpiCeram is a combination of ceramides, cholesterols, and fatty acids that is expected to hit the U.S. market this fall, said Dr. Krakowski. The current cost is not known.

In a multicenter, randomized study sponsored by Ceragenix and presented as a poster at the 2008 annual meeting of the Society of Pediatric Dermatology, investigators compared 4 weeks of twice-daily ceramide-based emulsion to fluticasone propionate in children with moderate to severe atopic dermatitis. (See related story below.)

On day 14, subjects in the fluticasone group had significantly better Scoring Atopic Dermatitis (SCORAD) scores, compared with those in the ceramide-based emulsion group. By day 28, there were no significant differences in SCORAD scores between the two groups.

In a second multicenter, randomized study that included patients from Rady Children's Hospital, investigators compared 4 weeks of twice-daily ceramide-based emulsion to pimecrolimus in 38 pediatric subjects with mild to moderate atopic dermatitis. No intention-to-treat analysis was performed.

Subjects in both groups demonstrated significant improvement in Investigator Global Assessment (IGA) scores at days 14 and 28. "There was also no significant difference in pruritus between the two groups, but it wasn't clear if there was any improvement," said Dr. Krakowski, a first-year dermatology resident at the University of California, San Diego.

Subjects in the ceramide-based emulsion group had no significant improvement from baseline in Eczema Area and Severity Index (EASI) scores. By day 14, subjects in the pimecrolimus group had significantly better EASI scores, compared with their counterparts in the ceramide emulsion group. By day 28, there were no differences in median score reductions between the groups.

▸ MimyX. Manufactured by Stiefel Laboratories Inc., this water-based product is described as a fragrance-, dye-, and preservative-free emulsion to be used three times a day or as needed. According to the manufacturer's Web site, it comes as a 140-g tube, with a cost of $101, or about $22 per ounce.

The main ingredient is PEA, which is found naturally in the stratum granulosum and is thought to downregulate inflammatory response. "It's a cannabinoid agonist that is believed to modulate mast cells and immune cells, theoretically reducing histamines, cytokines, and IL-4, −6, and −8," Dr. Krakowski added. "It's also thought to bind CB2 receptors on cutaneous nerves and decrease the transmission of pruritus."

In an international open-label study, investigators assessed the effects of the PEA nonsteroidal cream applied at least twice daily for 38 days in 2,456 patients with mild to moderate atopic dermatitis (J. Eur. Acad. Dermatol. Venereol. 2008;22:73–82). Of the 2,456 patients, 923 were 12 years of age or younger.

By the end of the study, physician assessment scores demonstrated that pruritus improved by 56%, erythema by 54%, dryness by 57%, lichenification by 55%, and excoriations by 63%.

The investigators also found that by the end of the treatment period, 63% of children reduced their use of topical corticosteroids, compared with 53% of adults. In addition, 34% of subjects were able to stop using their topical corticosteroid altogether and 12% were able to switch to a lower-potency steroid.

▸ Atopiclair. Manufactured by Graceway Pharmaceuticals LLC, this product contains hyaluronic acid, Vitis vinifera (grape leaf extract), telmesteine, glycyrrhetinic acid (licorice extract), and shea butter, a derivative of shea nut oil. The product is described as dye- and fragrance-free and is used 2–3 times per day or as needed. It comes in a 100-g tube and costs about $34 per ounce.

In a multicenter, randomized, double-blind, vehicle-controlled trial, 106 infants and children with mild to moderate atopic dermatitis applied hydrolipidic cream MAS063DP or vehicle three times a day to past, current, or "reasonable future" sites as monotherapy for 43 days (J. Pediatr. 2008;152:854–9). The mean age of subjects was 5 years.

One target lesion was chosen by investigators for evaluation and photography (mostly identified on extremities). Success was defined as reaching an IGA score of 0 (clear) or 1 (almost clear).

In an intention-to-treat analysis, 53 of 69 subjects (77%) in the hydrolipidic cream group achieved a score of 0 or 1 at day 22, compared with none in the vehicle group. "The vehicle used in the study wasn't your normal petrolatum vehicle," Dr. Krakowski noted. "It was the vehicle the hydrolipidic cream came in."

Pruritus, EASI scores, subject and caregiver assessment of global response, onset and duration of itch relief, and need for rescue medication were all significantly improved in the treatment group, compared with the vehicle group.

"I think barrier products could be helpful as adjuvant treatment for atopic dermatitis," he commented. "I think the cost of these products needs to be reconciled with their cost-effectiveness; most of these products may not be covered by insurance. We also need better head-to-head, long-term, pediatric-specific trials to demonstrate efficacy of these products for treating flares directly and for maintenance therapy over the long term."

Dr. Krakowski disclosed having had no relevant conflicts of interest.

In the early 1990s, Dr. Shera M. Aranoff began studying the Hebrew Bible in her spare time and became struck by how often she read about the instrumental role of women in the history of the Jewish people.

“Most people think of the Bible as very patriarchal and that women didn't have much of a say or much of a place,” said Dr. Aranoff, a dermatologist who practices in New York 3 days a week. “But if you read the stories, the men were busy fighting with their neighbors and talking to God. The women really determined the course of their nation's history; they propelled the religion to the next generation.”

For example, she said, the great lawmaker and prophet Moses was constantly being saved by women—when a pharaoh demanded that all newborn Hebrew males be killed, Moses' mother, Jochebed, weaved a basket that transported him to safety down the Nile River. An Egyptian princess, Batya, rescued the infant downstream.

Later in life, God became angry at Moses for not having circumcised his youngest son. His wife, Zipporah, stepped in and performed the circumcision.

The impact of these and other women are the subject of a weekly “Women in the Bible” class that Dr. Aranoff teaches every Thursday morning during the academic school year at Kehilath Jeshurun, a synagogue in New York. Dr. Aranoff spends 10-15 hours every week preparing for each hour-long class, including reading the Bible chapter being studied and reading commentaries from ancient biblical and Talmudic texts about the relevant chapter, as well as outlining her own thoughts. She presents the information in a lecture format followed by an open discussion.

About 35-40 women from all walks of life attend the class, including physicians, psychologists, lawyers, publishers, homemakers, social workers, and real estate agents. “It's a way of looking at life and a way of living your life, because you can identify with these women in what they've gone through and what the really important things in life are,” said Dr. Aranoff, who has conducted the class free of charge for more than 15 years. “The superficial things fade away; they just seem meaningless. It helps you keep your priorities straight.”

Four years ago, her scholarship for the class resulted in “The Passions of the Matriarchs” (Jersey City, N.J.: Ktav Publishing House Inc., 2004), a book that describes the women of Genesis—Sarah, Rebecca, Rachel, and Leah—based on traditional Jewish sources. Her more recent book, “Moses' Women” (Ktav, 2008), is a commentary based on traditional sources about the women in the book of Exodus, the second book of the Hebrew Bible.

In these books and in her classes, the women of the Bible “come alive in their commentaries as we enter their private lives to understand their innermost emotions,” Dr. Aranoff explained. “Their thoughts, words, and actions are fleshed out and they become complex human beings exhibiting a full array of human passions—love, tragedy, and strength, as alongside their husbands, the Jewish patriarchs, they build the house of Israel.”

Dr. Aranoff sets the tone for a friendly atmosphere that pairs intellectual rigor with a quest for spiritual meaning. “There's a feeling there that we're all seeking together, we're all learning together and trying to understand God and religion in the world and in ourselves,” said Dr. Barbara A. Kapelman, who practices gastroenterology in New York.

She said that studying the main character in the Bible's Book of Ruth resonated with her. The story tells of Elimelech, his wife, Naomi, and their two sons, who move from Bethlehem to the nearby country of Moab to escape a famine. Once they settle in Moab, Elimelech dies, Ruth marries one of the sons, and Orpah marries the other.

The sons subsequently die and Naomi decides to return to Bethlehem. She instructs her daughters-in-law to return to their own mothers and to remarry. Orpah leaves, but Ruth remains loyal to Naomi and utters the line, “Where you go I will go, and where you stay I will stay. Your people will be my people and your God my God.”

“The eventual story is that Ruth becomes the great-grandmother of King David,” Dr. Kapelman said. “So she is blessed for her loyalty and kindness to her mother-in-law by becoming the ancestress of King David. There's a beauty and gentility about that story that I like.”

For her part, Dr. Aranoff said that all of the work she has poured into the class has led her to conclude that many things in life “are predetermined—if you're a religious person you'll say by God, if not you'll say by your DNA. [But] the only attribute that makes us truly human are the choices that we make. Those choices make us who we are, not whether you're rich or poor, or whether you're born brilliant or blind. What you get credit for are the choices that you make in your own life. Those choices determine who you are.”

Dr. Shera M. Aranoff teaches a weekly class on the role of women in the Bible. Courtesy Dr. Shera M. Aranoff

In the early 1990s, Dr. Shera M. Aranoff began studying the Hebrew Bible in her spare time and became struck by how often she read about the instrumental role of women in the history of the Jewish people.

“Most people think of the Bible as very patriarchal and that women didn't have much of a say or much of a place,” said Dr. Aranoff, a dermatologist who practices in New York 3 days a week. “But if you read the stories, the men were busy fighting with their neighbors and talking to God. The women really determined the course of their nation's history; they propelled the religion to the next generation.”

For example, she said, the great lawmaker and prophet Moses was constantly being saved by women—when a pharaoh demanded that all newborn Hebrew males be killed, Moses' mother, Jochebed, weaved a basket that transported him to safety down the Nile River. An Egyptian princess, Batya, rescued the infant downstream.

Later in life, God became angry at Moses for not having circumcised his youngest son. His wife, Zipporah, stepped in and performed the circumcision.

The impact of these and other women are the subject of a weekly “Women in the Bible” class that Dr. Aranoff teaches every Thursday morning during the academic school year at Kehilath Jeshurun, a synagogue in New York. Dr. Aranoff spends 10-15 hours every week preparing for each hour-long class, including reading the Bible chapter being studied and reading commentaries from ancient biblical and Talmudic texts about the relevant chapter, as well as outlining her own thoughts. She presents the information in a lecture format followed by an open discussion.

About 35-40 women from all walks of life attend the class, including physicians, psychologists, lawyers, publishers, homemakers, social workers, and real estate agents. “It's a way of looking at life and a way of living your life, because you can identify with these women in what they've gone through and what the really important things in life are,” said Dr. Aranoff, who has conducted the class free of charge for more than 15 years. “The superficial things fade away; they just seem meaningless. It helps you keep your priorities straight.”

Four years ago, her scholarship for the class resulted in “The Passions of the Matriarchs” (Jersey City, N.J.: Ktav Publishing House Inc., 2004), a book that describes the women of Genesis—Sarah, Rebecca, Rachel, and Leah—based on traditional Jewish sources. Her more recent book, “Moses' Women” (Ktav, 2008), is a commentary based on traditional sources about the women in the book of Exodus, the second book of the Hebrew Bible.

In these books and in her classes, the women of the Bible “come alive in their commentaries as we enter their private lives to understand their innermost emotions,” Dr. Aranoff explained. “Their thoughts, words, and actions are fleshed out and they become complex human beings exhibiting a full array of human passions—love, tragedy, and strength, as alongside their husbands, the Jewish patriarchs, they build the house of Israel.”

Dr. Aranoff sets the tone for a friendly atmosphere that pairs intellectual rigor with a quest for spiritual meaning. “There's a feeling there that we're all seeking together, we're all learning together and trying to understand God and religion in the world and in ourselves,” said Dr. Barbara A. Kapelman, who practices gastroenterology in New York.

She said that studying the main character in the Bible's Book of Ruth resonated with her. The story tells of Elimelech, his wife, Naomi, and their two sons, who move from Bethlehem to the nearby country of Moab to escape a famine. Once they settle in Moab, Elimelech dies, Ruth marries one of the sons, and Orpah marries the other.

The sons subsequently die and Naomi decides to return to Bethlehem. She instructs her daughters-in-law to return to their own mothers and to remarry. Orpah leaves, but Ruth remains loyal to Naomi and utters the line, “Where you go I will go, and where you stay I will stay. Your people will be my people and your God my God.”

“The eventual story is that Ruth becomes the great-grandmother of King David,” Dr. Kapelman said. “So she is blessed for her loyalty and kindness to her mother-in-law by becoming the ancestress of King David. There's a beauty and gentility about that story that I like.”

For her part, Dr. Aranoff said that all of the work she has poured into the class has led her to conclude that many things in life “are predetermined—if you're a religious person you'll say by God, if not you'll say by your DNA. [But] the only attribute that makes us truly human are the choices that we make. Those choices make us who we are, not whether you're rich or poor, or whether you're born brilliant or blind. What you get credit for are the choices that you make in your own life. Those choices determine who you are.”

Dr. Shera M. Aranoff teaches a weekly class on the role of women in the Bible. Courtesy Dr. Shera M. Aranoff

In the early 1990s, Dr. Shera M. Aranoff began studying the Hebrew Bible in her spare time and became struck by how often she read about the instrumental role of women in the history of the Jewish people.

“Most people think of the Bible as very patriarchal and that women didn't have much of a say or much of a place,” said Dr. Aranoff, a dermatologist who practices in New York 3 days a week. “But if you read the stories, the men were busy fighting with their neighbors and talking to God. The women really determined the course of their nation's history; they propelled the religion to the next generation.”

For example, she said, the great lawmaker and prophet Moses was constantly being saved by women—when a pharaoh demanded that all newborn Hebrew males be killed, Moses' mother, Jochebed, weaved a basket that transported him to safety down the Nile River. An Egyptian princess, Batya, rescued the infant downstream.

Later in life, God became angry at Moses for not having circumcised his youngest son. His wife, Zipporah, stepped in and performed the circumcision.

The impact of these and other women are the subject of a weekly “Women in the Bible” class that Dr. Aranoff teaches every Thursday morning during the academic school year at Kehilath Jeshurun, a synagogue in New York. Dr. Aranoff spends 10-15 hours every week preparing for each hour-long class, including reading the Bible chapter being studied and reading commentaries from ancient biblical and Talmudic texts about the relevant chapter, as well as outlining her own thoughts. She presents the information in a lecture format followed by an open discussion.

About 35-40 women from all walks of life attend the class, including physicians, psychologists, lawyers, publishers, homemakers, social workers, and real estate agents. “It's a way of looking at life and a way of living your life, because you can identify with these women in what they've gone through and what the really important things in life are,” said Dr. Aranoff, who has conducted the class free of charge for more than 15 years. “The superficial things fade away; they just seem meaningless. It helps you keep your priorities straight.”

Four years ago, her scholarship for the class resulted in “The Passions of the Matriarchs” (Jersey City, N.J.: Ktav Publishing House Inc., 2004), a book that describes the women of Genesis—Sarah, Rebecca, Rachel, and Leah—based on traditional Jewish sources. Her more recent book, “Moses' Women” (Ktav, 2008), is a commentary based on traditional sources about the women in the book of Exodus, the second book of the Hebrew Bible.

In these books and in her classes, the women of the Bible “come alive in their commentaries as we enter their private lives to understand their innermost emotions,” Dr. Aranoff explained. “Their thoughts, words, and actions are fleshed out and they become complex human beings exhibiting a full array of human passions—love, tragedy, and strength, as alongside their husbands, the Jewish patriarchs, they build the house of Israel.”

Dr. Aranoff sets the tone for a friendly atmosphere that pairs intellectual rigor with a quest for spiritual meaning. “There's a feeling there that we're all seeking together, we're all learning together and trying to understand God and religion in the world and in ourselves,” said Dr. Barbara A. Kapelman, who practices gastroenterology in New York.

She said that studying the main character in the Bible's Book of Ruth resonated with her. The story tells of Elimelech, his wife, Naomi, and their two sons, who move from Bethlehem to the nearby country of Moab to escape a famine. Once they settle in Moab, Elimelech dies, Ruth marries one of the sons, and Orpah marries the other.

The sons subsequently die and Naomi decides to return to Bethlehem. She instructs her daughters-in-law to return to their own mothers and to remarry. Orpah leaves, but Ruth remains loyal to Naomi and utters the line, “Where you go I will go, and where you stay I will stay. Your people will be my people and your God my God.”

“The eventual story is that Ruth becomes the great-grandmother of King David,” Dr. Kapelman said. “So she is blessed for her loyalty and kindness to her mother-in-law by becoming the ancestress of King David. There's a beauty and gentility about that story that I like.”

For her part, Dr. Aranoff said that all of the work she has poured into the class has led her to conclude that many things in life “are predetermined—if you're a religious person you'll say by God, if not you'll say by your DNA. [But] the only attribute that makes us truly human are the choices that we make. Those choices make us who we are, not whether you're rich or poor, or whether you're born brilliant or blind. What you get credit for are the choices that you make in your own life. Those choices determine who you are.”

Dr. Shera M. Aranoff teaches a weekly class on the role of women in the Bible. Courtesy Dr. Shera M. Aranoff

CALGARY, ALTA. — As an epidemiologist whose research focuses on the prevention of cervical cancer, Dr. Eduardo L. Franco spends a lot of his time dispelling baseless arguments and protests from other health care professionals and patients that more research is needed before universal human papillomavirus vaccination can be recommended worldwide.

“Although clinical experience has just passed 6 years, the evidence base is one of the strongest in disease prevention,” Dr. Franco said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “The standard of proof is far more rigorous than that used in the evaluation of candidate vaccines of the past. It may be the most scrutinized vaccine by the public and the media concerning need and safety.”

Prophylactic HPV vaccines include a quadrivalent form manufactured by Merck & Co. that was licensed in the United States in June of 2006 and a bivalent form manufactured by GlaxoSmithKline Inc. that was submitted to the Food and Drug Administration in March 2007.

Dr. Franco, director of the division of cancer epidemiology at McGill University, Montreal, shared several examples of arguments against HPV vaccination that he encounters, followed by his counterargument for each.

One chief argument he hears is that the vaccine is too costly and unaffordable where it's most needed. However, he said, procurement programs such as the Centers for Disease Control and Prevention's Vaccines for Children Program, the Global Alliance for Vaccines and Immunization, and the Pan American Health Organization's revolving fund should help to lower the cost. “Historically,” he added, “prices decline with time since deployment. Competition among manufacturers should force a reduction in prices.”

In addition, ongoing studies of more simplified schedules—such as administering two doses instead of three—also may affect price.

Other common arguments against HPV vaccination include the following:

▸ There are no data on long-term duration of protection. In fact, to date, studies demonstrate a sustained antibody response with no indication that humoral immunity will wane before 10 years. “Even with lowered antibody titres, postvaccination protection has continued unabated,” said Dr. Franco, who also is a professor of epidemiology and oncology at McGill. “We did not wait for such proof before deploying other vaccines.”

▸ Protection is limited; vaccines cover only two oncogenic types. In fact, protection is against the two most important types (HPV 16 and 18), which translates into a protective fraction of 70% of all cervical cancers. That protection “is likely to be expanded via cross-protection,” he said. “In combination with tailored screening strategies, it may achieve unprecedented lifelong protection.”

▸ Screening will continue to be needed. True, Dr. Franco said, but recent progress on new technologies such as HPV testing with Pap triage “will permit extending screening intervals safely and cost effectively. Proper integration of primary and secondary prevention strategies is likely to reduce costs and improve cervical cancer control.”

▸ There is a risk of type replacement, which occurred with the pneumococcal vaccine. In fact, Dr. Franco said, type replacement is unlikely to occur because there is no epidemiologic proof that HPV types compete for specific niches. “Several studies have tested this hypothesis,” he noted. “The fraction of the population not exposed to HPV 16 or 18 is always high; exposure to HPV 16 or 18 does not constrain the pool of susceptible individuals who could acquire other HPVs.”

▸ We should not vaccinate preteens and teens; there are no efficacy data on patients aged 9-14 years. This age group is not at risk for lesions and monitoring them “would be unethical and unproductive,” Dr. Franco said. “Immunobridging” studies show that vaccine-induced humoral response in preteens is the highest among all groups, “which is sufficient justification for expectation of benefit,” he said.

▸ There is no proof yet that vaccination can reduce the risk of invasive cancers. Dr. Franco counters this notion by pointing out that absence of evidence is not evidence of absence. “Sensible judgment based on understanding of the natural history of HPV infection and cervical cancer indicates that prevention of precancerous lesions is an acceptable end point,” he explained.

▸ There is no cervical cancer epidemic. He responds to this argument by emphasizing that the health costs, morbidity, and mortality associated with cervical cancer are sufficiently important to justify action. Moreover, he said, the HPV vaccination is likely to exert protection against other neoplastic diseases such as malignant anogenital and oropharyngeal cancer and benign genital warts and laryngeal papillomatosis.

▸ More research is needed on safety. Dr. Franco responds to this argument by noting that the safety data on the HPV vaccine “are among the most well documented for any new vaccine. There was no waiting period for the adoption of other vaccines with lesser standards of proof. Inaction has a high cost in terms of morbidity and mortality that could have been averted.”

Dr. Franco disclosed that his entire research program has been funded by the Canadian Institutes of Health Research (CIHR), the National Cancer Institute of Canada, and the National Institutes of Health. He has received a Distinguished Scientist salary award from the CIHR and has served as an occasional adviser to several companies with products related to cervical cancer prevention.

The evidencebase in favor of vaccination isone of the strongest in disease prevention. DR. FRANCO

CALGARY, ALTA. — As an epidemiologist whose research focuses on the prevention of cervical cancer, Dr. Eduardo L. Franco spends a lot of his time dispelling baseless arguments and protests from other health care professionals and patients that more research is needed before universal human papillomavirus vaccination can be recommended worldwide.

“Although clinical experience has just passed 6 years, the evidence base is one of the strongest in disease prevention,” Dr. Franco said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “The standard of proof is far more rigorous than that used in the evaluation of candidate vaccines of the past. It may be the most scrutinized vaccine by the public and the media concerning need and safety.”

Prophylactic HPV vaccines include a quadrivalent form manufactured by Merck & Co. that was licensed in the United States in June of 2006 and a bivalent form manufactured by GlaxoSmithKline Inc. that was submitted to the Food and Drug Administration in March 2007.

Dr. Franco, director of the division of cancer epidemiology at McGill University, Montreal, shared several examples of arguments against HPV vaccination that he encounters, followed by his counterargument for each.

One chief argument he hears is that the vaccine is too costly and unaffordable where it's most needed. However, he said, procurement programs such as the Centers for Disease Control and Prevention's Vaccines for Children Program, the Global Alliance for Vaccines and Immunization, and the Pan American Health Organization's revolving fund should help to lower the cost. “Historically,” he added, “prices decline with time since deployment. Competition among manufacturers should force a reduction in prices.”

In addition, ongoing studies of more simplified schedules—such as administering two doses instead of three—also may affect price.

Other common arguments against HPV vaccination include the following:

▸ There are no data on long-term duration of protection. In fact, to date, studies demonstrate a sustained antibody response with no indication that humoral immunity will wane before 10 years. “Even with lowered antibody titres, postvaccination protection has continued unabated,” said Dr. Franco, who also is a professor of epidemiology and oncology at McGill. “We did not wait for such proof before deploying other vaccines.”

▸ Protection is limited; vaccines cover only two oncogenic types. In fact, protection is against the two most important types (HPV 16 and 18), which translates into a protective fraction of 70% of all cervical cancers. That protection “is likely to be expanded via cross-protection,” he said. “In combination with tailored screening strategies, it may achieve unprecedented lifelong protection.”

▸ Screening will continue to be needed. True, Dr. Franco said, but recent progress on new technologies such as HPV testing with Pap triage “will permit extending screening intervals safely and cost effectively. Proper integration of primary and secondary prevention strategies is likely to reduce costs and improve cervical cancer control.”

▸ There is a risk of type replacement, which occurred with the pneumococcal vaccine. In fact, Dr. Franco said, type replacement is unlikely to occur because there is no epidemiologic proof that HPV types compete for specific niches. “Several studies have tested this hypothesis,” he noted. “The fraction of the population not exposed to HPV 16 or 18 is always high; exposure to HPV 16 or 18 does not constrain the pool of susceptible individuals who could acquire other HPVs.”

▸ We should not vaccinate preteens and teens; there are no efficacy data on patients aged 9-14 years. This age group is not at risk for lesions and monitoring them “would be unethical and unproductive,” Dr. Franco said. “Immunobridging” studies show that vaccine-induced humoral response in preteens is the highest among all groups, “which is sufficient justification for expectation of benefit,” he said.

▸ There is no proof yet that vaccination can reduce the risk of invasive cancers. Dr. Franco counters this notion by pointing out that absence of evidence is not evidence of absence. “Sensible judgment based on understanding of the natural history of HPV infection and cervical cancer indicates that prevention of precancerous lesions is an acceptable end point,” he explained.

▸ There is no cervical cancer epidemic. He responds to this argument by emphasizing that the health costs, morbidity, and mortality associated with cervical cancer are sufficiently important to justify action. Moreover, he said, the HPV vaccination is likely to exert protection against other neoplastic diseases such as malignant anogenital and oropharyngeal cancer and benign genital warts and laryngeal papillomatosis.

▸ More research is needed on safety. Dr. Franco responds to this argument by noting that the safety data on the HPV vaccine “are among the most well documented for any new vaccine. There was no waiting period for the adoption of other vaccines with lesser standards of proof. Inaction has a high cost in terms of morbidity and mortality that could have been averted.”

Dr. Franco disclosed that his entire research program has been funded by the Canadian Institutes of Health Research (CIHR), the National Cancer Institute of Canada, and the National Institutes of Health. He has received a Distinguished Scientist salary award from the CIHR and has served as an occasional adviser to several companies with products related to cervical cancer prevention.

The evidencebase in favor of vaccination isone of the strongest in disease prevention. DR. FRANCO

CALGARY, ALTA. — As an epidemiologist whose research focuses on the prevention of cervical cancer, Dr. Eduardo L. Franco spends a lot of his time dispelling baseless arguments and protests from other health care professionals and patients that more research is needed before universal human papillomavirus vaccination can be recommended worldwide.

“Although clinical experience has just passed 6 years, the evidence base is one of the strongest in disease prevention,” Dr. Franco said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “The standard of proof is far more rigorous than that used in the evaluation of candidate vaccines of the past. It may be the most scrutinized vaccine by the public and the media concerning need and safety.”

Prophylactic HPV vaccines include a quadrivalent form manufactured by Merck & Co. that was licensed in the United States in June of 2006 and a bivalent form manufactured by GlaxoSmithKline Inc. that was submitted to the Food and Drug Administration in March 2007.

Dr. Franco, director of the division of cancer epidemiology at McGill University, Montreal, shared several examples of arguments against HPV vaccination that he encounters, followed by his counterargument for each.

One chief argument he hears is that the vaccine is too costly and unaffordable where it's most needed. However, he said, procurement programs such as the Centers for Disease Control and Prevention's Vaccines for Children Program, the Global Alliance for Vaccines and Immunization, and the Pan American Health Organization's revolving fund should help to lower the cost. “Historically,” he added, “prices decline with time since deployment. Competition among manufacturers should force a reduction in prices.”

In addition, ongoing studies of more simplified schedules—such as administering two doses instead of three—also may affect price.

Other common arguments against HPV vaccination include the following:

▸ There are no data on long-term duration of protection. In fact, to date, studies demonstrate a sustained antibody response with no indication that humoral immunity will wane before 10 years. “Even with lowered antibody titres, postvaccination protection has continued unabated,” said Dr. Franco, who also is a professor of epidemiology and oncology at McGill. “We did not wait for such proof before deploying other vaccines.”

▸ Protection is limited; vaccines cover only two oncogenic types. In fact, protection is against the two most important types (HPV 16 and 18), which translates into a protective fraction of 70% of all cervical cancers. That protection “is likely to be expanded via cross-protection,” he said. “In combination with tailored screening strategies, it may achieve unprecedented lifelong protection.”

▸ Screening will continue to be needed. True, Dr. Franco said, but recent progress on new technologies such as HPV testing with Pap triage “will permit extending screening intervals safely and cost effectively. Proper integration of primary and secondary prevention strategies is likely to reduce costs and improve cervical cancer control.”

▸ There is a risk of type replacement, which occurred with the pneumococcal vaccine. In fact, Dr. Franco said, type replacement is unlikely to occur because there is no epidemiologic proof that HPV types compete for specific niches. “Several studies have tested this hypothesis,” he noted. “The fraction of the population not exposed to HPV 16 or 18 is always high; exposure to HPV 16 or 18 does not constrain the pool of susceptible individuals who could acquire other HPVs.”

▸ We should not vaccinate preteens and teens; there are no efficacy data on patients aged 9-14 years. This age group is not at risk for lesions and monitoring them “would be unethical and unproductive,” Dr. Franco said. “Immunobridging” studies show that vaccine-induced humoral response in preteens is the highest among all groups, “which is sufficient justification for expectation of benefit,” he said.

▸ There is no proof yet that vaccination can reduce the risk of invasive cancers. Dr. Franco counters this notion by pointing out that absence of evidence is not evidence of absence. “Sensible judgment based on understanding of the natural history of HPV infection and cervical cancer indicates that prevention of precancerous lesions is an acceptable end point,” he explained.

▸ There is no cervical cancer epidemic. He responds to this argument by emphasizing that the health costs, morbidity, and mortality associated with cervical cancer are sufficiently important to justify action. Moreover, he said, the HPV vaccination is likely to exert protection against other neoplastic diseases such as malignant anogenital and oropharyngeal cancer and benign genital warts and laryngeal papillomatosis.

▸ More research is needed on safety. Dr. Franco responds to this argument by noting that the safety data on the HPV vaccine “are among the most well documented for any new vaccine. There was no waiting period for the adoption of other vaccines with lesser standards of proof. Inaction has a high cost in terms of morbidity and mortality that could have been averted.”

Dr. Franco disclosed that his entire research program has been funded by the Canadian Institutes of Health Research (CIHR), the National Cancer Institute of Canada, and the National Institutes of Health. He has received a Distinguished Scientist salary award from the CIHR and has served as an occasional adviser to several companies with products related to cervical cancer prevention.

The evidencebase in favor of vaccination isone of the strongest in disease prevention. DR. FRANCO

In the early 1990s, Dr. Shera M. Aranoff began studying the Hebrew Bible in her spare time and became struck by how often she read about the instrumental role of women in the history of the Jewish people.

“Most people think of the Bible as very patriarchal and that women didn't have much of a say or much of a place,” said Dr. Aranoff, a dermatologist who practices in New York 3 days a week. “But if you read the stories, the men were busy fighting with their neighbors and talking to God. The women really determined the course of their nation's history; they propelled the religion to the next generation.”

For example, she said, the great lawmaker and prophet Moses was constantly being saved by women—when a pharaoh demanded that all newborn Hebrew males be killed, Moses' mother, Jochebed, weaved a basket that transported him to safety down the Nile River. An Egyptian princess, Batya, rescued the infant downstream.

Later in life, God became angry at Moses for not having circumcised his youngest son. His wife, Zipporah, stepped in and performed the circumcision.

The impact of these and other women are the subject of a weekly “Women in the Bible” class that Dr. Aranoff teaches every Thursday morning during the academic school year at Kehilath Jeshurun, a synagogue in New York. Dr. Aranoff spends 10-15 hours every week preparing for each hour-long class, including reading the Bible chapter being studied and reading commentaries from ancient biblical and Talmudic texts about the relevant chapter, as well as outlining her own thoughts. She presents the information in a lecture format followed by an open discussion.

About 35-40 women from all walks of life attend the class, including physicians, psychologists, lawyers, publishers, homemakers, social workers, and real estate agents. “It's a way of looking at life and a way of living your life, because you can identify with these women in what they've gone through and what the really important things in life are,” said Dr. Aranoff, who has conducted the class free of charge for more than 15 years. “The superficial things fade away; they just seem meaningless. It helps you keep your priorities straight.”

Four years ago, her scholarship for the class resulted in “The Passions of the Matriarchs” (Jersey City, N.J.: Ktav Publishing House Inc., 2004), a book that describes the women of Genesis—Sarah, Rebecca, Rachel, and Leah—based on traditional Jewish sources. Her more recent book, “Moses' Women” (Ktav, 2008), is a commentary based on traditional sources about the women in the book of Exodus, the second book of the Hebrew Bible.

In these books and in her classes, the women of the Bible “come alive in their commentaries as we enter their private lives to understand their innermost emotions,” Dr. Aranoff explained. “Their thoughts, words, and actions are fleshed out and they become complex human beings exhibiting a full array of human passions—love, tragedy, and strength, as alongside their husbands, the Jewish patriarchs, they build the house of Israel.”

Dr. Aranoff sets the tone for a friendly atmosphere that pairs intellectual rigor with a quest for spiritual meaning. “There's a feeling there that we're all seeking together, we're all learning together and trying to understand God and religion in the world and in ourselves,” said Dr. Barbara A. Kapelman, who practices gastroenterology in New York.

She said that studying the main character in the Bible's Book of Ruth resonated with her. The story tells of Elimelech, his wife, Naomi, and their two sons, who move from Bethlehem to the nearby country of Moab to escape a famine. Once they settle in Moab, Elimelech dies, Ruth marries one of the sons, and Orpah marries the other.

The sons subsequently die and Naomi decides to return to Bethlehem. She instructs her daughters-in-law to return to their own mothers and to remarry. Orpah leaves, but Ruth remains loyal to Naomi and utters the line, “Where you go I will go, and where you stay I will stay. Your people will be my people and your God my God.”

“The eventual story is that Ruth becomes the great-grandmother of King David,” Dr. Kapelman said. “So she is blessed for her loyalty and kindness to her mother-in-law by becoming the ancestress of King David. There's a beauty and gentility about that story that I like.”

For her part, Dr. Aranoff said that all of the work she has poured into the class has led her to conclude that many things in life “are predetermined—if you're a religious person you'll say by God, if not you'll say by your DNA. [But] the only attribute that makes us truly human are the choices that we make. Those choices make us who we are, not whether you're rich or poor, or whether you're born brilliant or blind. What you get credit for are the choices that you make in your own life. Those choices determine who you are. That comes out over and over again.”

Dr. Shera M. Aranoff teaches a weekly “Women in the Bible” class. Courtesy Dr. Shera M. Aranoff

In the early 1990s, Dr. Shera M. Aranoff began studying the Hebrew Bible in her spare time and became struck by how often she read about the instrumental role of women in the history of the Jewish people.

“Most people think of the Bible as very patriarchal and that women didn't have much of a say or much of a place,” said Dr. Aranoff, a dermatologist who practices in New York 3 days a week. “But if you read the stories, the men were busy fighting with their neighbors and talking to God. The women really determined the course of their nation's history; they propelled the religion to the next generation.”

For example, she said, the great lawmaker and prophet Moses was constantly being saved by women—when a pharaoh demanded that all newborn Hebrew males be killed, Moses' mother, Jochebed, weaved a basket that transported him to safety down the Nile River. An Egyptian princess, Batya, rescued the infant downstream.

Later in life, God became angry at Moses for not having circumcised his youngest son. His wife, Zipporah, stepped in and performed the circumcision.

The impact of these and other women are the subject of a weekly “Women in the Bible” class that Dr. Aranoff teaches every Thursday morning during the academic school year at Kehilath Jeshurun, a synagogue in New York. Dr. Aranoff spends 10-15 hours every week preparing for each hour-long class, including reading the Bible chapter being studied and reading commentaries from ancient biblical and Talmudic texts about the relevant chapter, as well as outlining her own thoughts. She presents the information in a lecture format followed by an open discussion.

About 35-40 women from all walks of life attend the class, including physicians, psychologists, lawyers, publishers, homemakers, social workers, and real estate agents. “It's a way of looking at life and a way of living your life, because you can identify with these women in what they've gone through and what the really important things in life are,” said Dr. Aranoff, who has conducted the class free of charge for more than 15 years. “The superficial things fade away; they just seem meaningless. It helps you keep your priorities straight.”

Four years ago, her scholarship for the class resulted in “The Passions of the Matriarchs” (Jersey City, N.J.: Ktav Publishing House Inc., 2004), a book that describes the women of Genesis—Sarah, Rebecca, Rachel, and Leah—based on traditional Jewish sources. Her more recent book, “Moses' Women” (Ktav, 2008), is a commentary based on traditional sources about the women in the book of Exodus, the second book of the Hebrew Bible.

In these books and in her classes, the women of the Bible “come alive in their commentaries as we enter their private lives to understand their innermost emotions,” Dr. Aranoff explained. “Their thoughts, words, and actions are fleshed out and they become complex human beings exhibiting a full array of human passions—love, tragedy, and strength, as alongside their husbands, the Jewish patriarchs, they build the house of Israel.”

Dr. Aranoff sets the tone for a friendly atmosphere that pairs intellectual rigor with a quest for spiritual meaning. “There's a feeling there that we're all seeking together, we're all learning together and trying to understand God and religion in the world and in ourselves,” said Dr. Barbara A. Kapelman, who practices gastroenterology in New York.

She said that studying the main character in the Bible's Book of Ruth resonated with her. The story tells of Elimelech, his wife, Naomi, and their two sons, who move from Bethlehem to the nearby country of Moab to escape a famine. Once they settle in Moab, Elimelech dies, Ruth marries one of the sons, and Orpah marries the other.

The sons subsequently die and Naomi decides to return to Bethlehem. She instructs her daughters-in-law to return to their own mothers and to remarry. Orpah leaves, but Ruth remains loyal to Naomi and utters the line, “Where you go I will go, and where you stay I will stay. Your people will be my people and your God my God.”

“The eventual story is that Ruth becomes the great-grandmother of King David,” Dr. Kapelman said. “So she is blessed for her loyalty and kindness to her mother-in-law by becoming the ancestress of King David. There's a beauty and gentility about that story that I like.”

For her part, Dr. Aranoff said that all of the work she has poured into the class has led her to conclude that many things in life “are predetermined—if you're a religious person you'll say by God, if not you'll say by your DNA. [But] the only attribute that makes us truly human are the choices that we make. Those choices make us who we are, not whether you're rich or poor, or whether you're born brilliant or blind. What you get credit for are the choices that you make in your own life. Those choices determine who you are. That comes out over and over again.”

Dr. Shera M. Aranoff teaches a weekly “Women in the Bible” class. Courtesy Dr. Shera M. Aranoff

In the early 1990s, Dr. Shera M. Aranoff began studying the Hebrew Bible in her spare time and became struck by how often she read about the instrumental role of women in the history of the Jewish people.

“Most people think of the Bible as very patriarchal and that women didn't have much of a say or much of a place,” said Dr. Aranoff, a dermatologist who practices in New York 3 days a week. “But if you read the stories, the men were busy fighting with their neighbors and talking to God. The women really determined the course of their nation's history; they propelled the religion to the next generation.”

For example, she said, the great lawmaker and prophet Moses was constantly being saved by women—when a pharaoh demanded that all newborn Hebrew males be killed, Moses' mother, Jochebed, weaved a basket that transported him to safety down the Nile River. An Egyptian princess, Batya, rescued the infant downstream.

Later in life, God became angry at Moses for not having circumcised his youngest son. His wife, Zipporah, stepped in and performed the circumcision.

The impact of these and other women are the subject of a weekly “Women in the Bible” class that Dr. Aranoff teaches every Thursday morning during the academic school year at Kehilath Jeshurun, a synagogue in New York. Dr. Aranoff spends 10-15 hours every week preparing for each hour-long class, including reading the Bible chapter being studied and reading commentaries from ancient biblical and Talmudic texts about the relevant chapter, as well as outlining her own thoughts. She presents the information in a lecture format followed by an open discussion.

About 35-40 women from all walks of life attend the class, including physicians, psychologists, lawyers, publishers, homemakers, social workers, and real estate agents. “It's a way of looking at life and a way of living your life, because you can identify with these women in what they've gone through and what the really important things in life are,” said Dr. Aranoff, who has conducted the class free of charge for more than 15 years. “The superficial things fade away; they just seem meaningless. It helps you keep your priorities straight.”

Four years ago, her scholarship for the class resulted in “The Passions of the Matriarchs” (Jersey City, N.J.: Ktav Publishing House Inc., 2004), a book that describes the women of Genesis—Sarah, Rebecca, Rachel, and Leah—based on traditional Jewish sources. Her more recent book, “Moses' Women” (Ktav, 2008), is a commentary based on traditional sources about the women in the book of Exodus, the second book of the Hebrew Bible.

In these books and in her classes, the women of the Bible “come alive in their commentaries as we enter their private lives to understand their innermost emotions,” Dr. Aranoff explained. “Their thoughts, words, and actions are fleshed out and they become complex human beings exhibiting a full array of human passions—love, tragedy, and strength, as alongside their husbands, the Jewish patriarchs, they build the house of Israel.”

Dr. Aranoff sets the tone for a friendly atmosphere that pairs intellectual rigor with a quest for spiritual meaning. “There's a feeling there that we're all seeking together, we're all learning together and trying to understand God and religion in the world and in ourselves,” said Dr. Barbara A. Kapelman, who practices gastroenterology in New York.

She said that studying the main character in the Bible's Book of Ruth resonated with her. The story tells of Elimelech, his wife, Naomi, and their two sons, who move from Bethlehem to the nearby country of Moab to escape a famine. Once they settle in Moab, Elimelech dies, Ruth marries one of the sons, and Orpah marries the other.

The sons subsequently die and Naomi decides to return to Bethlehem. She instructs her daughters-in-law to return to their own mothers and to remarry. Orpah leaves, but Ruth remains loyal to Naomi and utters the line, “Where you go I will go, and where you stay I will stay. Your people will be my people and your God my God.”

“The eventual story is that Ruth becomes the great-grandmother of King David,” Dr. Kapelman said. “So she is blessed for her loyalty and kindness to her mother-in-law by becoming the ancestress of King David. There's a beauty and gentility about that story that I like.”

For her part, Dr. Aranoff said that all of the work she has poured into the class has led her to conclude that many things in life “are predetermined—if you're a religious person you'll say by God, if not you'll say by your DNA. [But] the only attribute that makes us truly human are the choices that we make. Those choices make us who we are, not whether you're rich or poor, or whether you're born brilliant or blind. What you get credit for are the choices that you make in your own life. Those choices determine who you are. That comes out over and over again.”

Dr. Shera M. Aranoff teaches a weekly “Women in the Bible” class. Courtesy Dr. Shera M. Aranoff