Sherry Boschert

SAN FRANCISCO — Complications from a prolactinoma during pregnancy are best avoided by treating the adenoma before conception.

But with many women delaying pregnancy, it's not uncommon to see a woman in her late 30s with a macroadenoma who says she wants to get pregnant soon and doesn't have the luxury of suppressing the tumor for a year or two on medical therapy before conception, Dr. J. Blake Tyrrell said at a conference on diabetes and advances in endocrinology and metabolism sponsored by the University of California, San Francisco.

The sparse data available to help guide the management of these patients suggest that suppressing prolactin-secreting adenomas with dopamine agonists reduces the effects of the tumor and allows the patient to get pregnant without increasing the risk of fetal loss or fetal abnormalities.

There is less experience with cabergoline, today's treatment of choice, than with the former first-line agent bromocriptine.

Whether the patient has a microadenoma or macroadenoma, Dr. Tyrrell prefers to treat with cabergoline to allow menstrual cycles to normalize. If the patient misses a period, test for pregnancy, and if she is pregnant discontinue cabergoline, advised Dr. Tyrrell, director of the endocrinology clinic at the university. With this method, fetal exposure to the drug should be no more than a couple of weeks, he said.

Once off of therapy, fewer than 2% of microadenomas will enlarge during pregnancy. Given this low risk, many providers choose to leave them alone during pregnancy. Dr. Tyrrell suggested following prolactin levels every 6 weeks, and if they get as high as 500 ng/mL, “I might get a bit concerned and ask the patient how she's doing,” he said.

Macroadenomas that are left untreated during pregnancy will enlarge in about 23% of cases and cause headache and visual field defects. “That's not a situation you want to get into,” he said. Only 3% of macroadenomas that were surgically debulked prior to conception enlarged during pregnancy, but medical therapy has largely replaced surgical treatment for prolactinomas.

In the management of macroadenomas during pregnancy, “We're on very thin ice” due to very limited data on the risks from taking dopamine agonists before or during pregnancy, he said.

One study reported on 86 women with macroadenomas who conceived after bromocriptine treatment, which was then stopped. Twenty women (23%) developed visual field defects during pregnancy. Four patients then underwent surgical treatment and 15 received bromocriptine therapy, and all 20 had successful pregnancy outcomes (Endocrinol. Metab. Clin. North Am. 2006;35:99–116).

Data from the early 1980s described 29 women with macroadenomas who were managed with continuous bromocriptine throughout pregnancy. Two developed visual field defects. All had successful pregnancy outcomes. Dr. Tyrrell noted that 7 of these 29 women probably had nonfunctional tumors because their serum prolactin levels were less than 200 ng/mL, which suggests that continuous drug therapy was associated with an even higher rate of visual field defects in women with functioning tumors (in 2 of 22) patients.

That's about the extent of the world literature on managing macroadenomas during pregnancy, which is “not very good considering that these drugs have been around for more than 30 years,” he said.

There are no data on continuous cabergoline therapy during pregnancy.

In the worst-case scenario, a macroadenoma may enlarge, usually during the second or third trimester, causing headache and visual field defects. A noncontrast MRI can be done safely during pregnancy to define the size.

If the tumor is enlarging, try medical therapy, and deliver the fetus early if it's viable. Surgery is a last resort, Dr. Tyrrell said.

“Think about this if you can ahead of time to deal with the tumor before conception, before getting into trouble during pregnancy,” he concluded.

SAN FRANCISCO — Complications from a prolactinoma during pregnancy are best avoided by treating the adenoma before conception.

But with many women delaying pregnancy, it's not uncommon to see a woman in her late 30s with a macroadenoma who says she wants to get pregnant soon and doesn't have the luxury of suppressing the tumor for a year or two on medical therapy before conception, Dr. J. Blake Tyrrell said at a conference on diabetes and advances in endocrinology and metabolism sponsored by the University of California, San Francisco.

The sparse data available to help guide the management of these patients suggest that suppressing prolactin-secreting adenomas with dopamine agonists reduces the effects of the tumor and allows the patient to get pregnant without increasing the risk of fetal loss or fetal abnormalities.

There is less experience with cabergoline, today's treatment of choice, than with the former first-line agent bromocriptine.

Whether the patient has a microadenoma or macroadenoma, Dr. Tyrrell prefers to treat with cabergoline to allow menstrual cycles to normalize. If the patient misses a period, test for pregnancy, and if she is pregnant discontinue cabergoline, advised Dr. Tyrrell, director of the endocrinology clinic at the university. With this method, fetal exposure to the drug should be no more than a couple of weeks, he said.

Once off of therapy, fewer than 2% of microadenomas will enlarge during pregnancy. Given this low risk, many providers choose to leave them alone during pregnancy. Dr. Tyrrell suggested following prolactin levels every 6 weeks, and if they get as high as 500 ng/mL, “I might get a bit concerned and ask the patient how she's doing,” he said.

Macroadenomas that are left untreated during pregnancy will enlarge in about 23% of cases and cause headache and visual field defects. “That's not a situation you want to get into,” he said. Only 3% of macroadenomas that were surgically debulked prior to conception enlarged during pregnancy, but medical therapy has largely replaced surgical treatment for prolactinomas.

In the management of macroadenomas during pregnancy, “We're on very thin ice” due to very limited data on the risks from taking dopamine agonists before or during pregnancy, he said.

One study reported on 86 women with macroadenomas who conceived after bromocriptine treatment, which was then stopped. Twenty women (23%) developed visual field defects during pregnancy. Four patients then underwent surgical treatment and 15 received bromocriptine therapy, and all 20 had successful pregnancy outcomes (Endocrinol. Metab. Clin. North Am. 2006;35:99–116).

Data from the early 1980s described 29 women with macroadenomas who were managed with continuous bromocriptine throughout pregnancy. Two developed visual field defects. All had successful pregnancy outcomes. Dr. Tyrrell noted that 7 of these 29 women probably had nonfunctional tumors because their serum prolactin levels were less than 200 ng/mL, which suggests that continuous drug therapy was associated with an even higher rate of visual field defects in women with functioning tumors (in 2 of 22) patients.

That's about the extent of the world literature on managing macroadenomas during pregnancy, which is “not very good considering that these drugs have been around for more than 30 years,” he said.

There are no data on continuous cabergoline therapy during pregnancy.

In the worst-case scenario, a macroadenoma may enlarge, usually during the second or third trimester, causing headache and visual field defects. A noncontrast MRI can be done safely during pregnancy to define the size.

If the tumor is enlarging, try medical therapy, and deliver the fetus early if it's viable. Surgery is a last resort, Dr. Tyrrell said.

“Think about this if you can ahead of time to deal with the tumor before conception, before getting into trouble during pregnancy,” he concluded.

SAN FRANCISCO — Complications from a prolactinoma during pregnancy are best avoided by treating the adenoma before conception.

But with many women delaying pregnancy, it's not uncommon to see a woman in her late 30s with a macroadenoma who says she wants to get pregnant soon and doesn't have the luxury of suppressing the tumor for a year or two on medical therapy before conception, Dr. J. Blake Tyrrell said at a conference on diabetes and advances in endocrinology and metabolism sponsored by the University of California, San Francisco.

The sparse data available to help guide the management of these patients suggest that suppressing prolactin-secreting adenomas with dopamine agonists reduces the effects of the tumor and allows the patient to get pregnant without increasing the risk of fetal loss or fetal abnormalities.

There is less experience with cabergoline, today's treatment of choice, than with the former first-line agent bromocriptine.

Whether the patient has a microadenoma or macroadenoma, Dr. Tyrrell prefers to treat with cabergoline to allow menstrual cycles to normalize. If the patient misses a period, test for pregnancy, and if she is pregnant discontinue cabergoline, advised Dr. Tyrrell, director of the endocrinology clinic at the university. With this method, fetal exposure to the drug should be no more than a couple of weeks, he said.

Once off of therapy, fewer than 2% of microadenomas will enlarge during pregnancy. Given this low risk, many providers choose to leave them alone during pregnancy. Dr. Tyrrell suggested following prolactin levels every 6 weeks, and if they get as high as 500 ng/mL, “I might get a bit concerned and ask the patient how she's doing,” he said.

Macroadenomas that are left untreated during pregnancy will enlarge in about 23% of cases and cause headache and visual field defects. “That's not a situation you want to get into,” he said. Only 3% of macroadenomas that were surgically debulked prior to conception enlarged during pregnancy, but medical therapy has largely replaced surgical treatment for prolactinomas.

In the management of macroadenomas during pregnancy, “We're on very thin ice” due to very limited data on the risks from taking dopamine agonists before or during pregnancy, he said.

One study reported on 86 women with macroadenomas who conceived after bromocriptine treatment, which was then stopped. Twenty women (23%) developed visual field defects during pregnancy. Four patients then underwent surgical treatment and 15 received bromocriptine therapy, and all 20 had successful pregnancy outcomes (Endocrinol. Metab. Clin. North Am. 2006;35:99–116).

Data from the early 1980s described 29 women with macroadenomas who were managed with continuous bromocriptine throughout pregnancy. Two developed visual field defects. All had successful pregnancy outcomes. Dr. Tyrrell noted that 7 of these 29 women probably had nonfunctional tumors because their serum prolactin levels were less than 200 ng/mL, which suggests that continuous drug therapy was associated with an even higher rate of visual field defects in women with functioning tumors (in 2 of 22) patients.

That's about the extent of the world literature on managing macroadenomas during pregnancy, which is “not very good considering that these drugs have been around for more than 30 years,” he said.

There are no data on continuous cabergoline therapy during pregnancy.

In the worst-case scenario, a macroadenoma may enlarge, usually during the second or third trimester, causing headache and visual field defects. A noncontrast MRI can be done safely during pregnancy to define the size.

If the tumor is enlarging, try medical therapy, and deliver the fetus early if it's viable. Surgery is a last resort, Dr. Tyrrell said.

“Think about this if you can ahead of time to deal with the tumor before conception, before getting into trouble during pregnancy,” he concluded.

Adolescents with dyslipidemia—especially those who were overweight or obese—were more likely than were adolescents with normal lipid levels to have increased carotid artery intima-media thickness by young adulthood, a study of 1,711 people found.

Also, the single set of cut points used in the National Cholesterol Education Program (NCEP) guidelines worked as well as the age- and sex-specific cut points derived from growth curve data in National Health and Nutrition Examination Surveys (NHANES) for predicting increased carotid intima-media thickness in young adults (J. Am. Coll. Cardiol. 2009;53:860–9 [doi:10.1016/j.jacc.2008.09.061]). The finding argues for using the simpler, fixed NCEP approach rather than the percentile-based NHANES approach, reported Costan G. Magnussen of the University of Tasmania (Australia).

Mr. Magnussen and his associates analyzed data from three large population-based, prospective cohort studies: the Finnish Cardiovascular Risk in Young Finns Study, the U.S.-based Bogalusa Heart Study, and the Australian Childhood Determination of Adult Health Study. Lipid and lipoprotein levels were measured in adolescents between the ages of 12 and 18 years and again when they were between the ages of 29 and 30 years, at which time they also had an ultrasound to measure carotid intima-media thickness, a surrogate for the risk of developing atherosclerosis.

In a previous analysis of this same data set, Mr. Magnussen and his associates found that adolescents with borderline or high-risk dyslipidemia were significantly more likely than were those with normal lipid levels to have dyslipidemia as adults after a mean follow-up of 20 years (Circulation 2008;117:32–42).

In the current study, adolescent dyslipidemia increased the relative risk for high intima-media thickness in adulthood by 60%–250%, and the higher risk was seen regardless of adult lipid and lipoprotein levels.

Adult carotid intima-media thickness was substantially higher in those who had been overweight or obese adolescents with dyslipidemia. The investigators estimated that overweight or obese 15-year-olds with dyslipidemia would show a difference in intima-media thickness of 0.11 mm in males or 0.08 mm in females by age 35 years, compared with normal-weight 15-year-olds with normal cholesterol levels.

Increased intima-media thickness in young adulthood provides “a more solid end point than we've had before,” said Dr. Roberta Williams, who was not involved in the study.

“If you are overweight/obese and have abnormal lipid levels, it is highly likely that you are headed for real changes in your vascular bed as an adult,” said Dr. Williams, chair of pediatrics at the University of Southern California, Los Angeles. She said she has no conflicts of interest related to this topic.

The positive predictive value of adolescent dyslipidemia was low (ranging from 11% to 37% depending on weight and type of dyslipidemia), a fact that may be explained in part by normal adolescent fluctuations in levels of lipoproteins, which are “building blocks'” for some hormones, she said. As a result, it's hard to tell which adolescents with dyslipidemia will go on to have increased intima-media thickness.

But the study found a high negative predictive value (ranging from 81% to 90%), meaning that adolescents without dyslipidemia are unlikely to develop cardiovascular disease as young adults.

In an editorial commenting on the study, Dr. Stephen R. Daniels noted that the findings do not settle the question of whether all adolescents or targeted populations should be screened for dyslipidemia. Current guidelines recommend screening based on family history or the presence of other risk factors such as obesity, diabetes, or hypertension.

The study addresses neither the morbidity and mortality outcomes after adolescent dyslipidemia is identified, nor the costs or acceptability of screening, noted Dr. Daniels, professor and chairman of pediatrics at the University of Colorado at Denver (J. Am. Coll. Cardiol. 2009;53:870–1 [doi:10.1016/j.jacc.2008.11.037]).

Dr. Magnussen reported no conflicts of interest related to this study. Dr. Daniels has been a consultant for Abbott Laboratories and Merck/Schering-Plough Pharmaceuticals, which market anticholesterol medications.

Obese teens with abnormal lipid levels are likely headed for real changes in their vascular beds as adults. DR. WILLIAMS

Adolescents with dyslipidemia—especially those who were overweight or obese—were more likely than were adolescents with normal lipid levels to have increased carotid artery intima-media thickness by young adulthood, a study of 1,711 people found.

Also, the single set of cut points used in the National Cholesterol Education Program (NCEP) guidelines worked as well as the age- and sex-specific cut points derived from growth curve data in National Health and Nutrition Examination Surveys (NHANES) for predicting increased carotid intima-media thickness in young adults (J. Am. Coll. Cardiol. 2009;53:860–9 [doi:10.1016/j.jacc.2008.09.061]). The finding argues for using the simpler, fixed NCEP approach rather than the percentile-based NHANES approach, reported Costan G. Magnussen of the University of Tasmania (Australia).

Mr. Magnussen and his associates analyzed data from three large population-based, prospective cohort studies: the Finnish Cardiovascular Risk in Young Finns Study, the U.S.-based Bogalusa Heart Study, and the Australian Childhood Determination of Adult Health Study. Lipid and lipoprotein levels were measured in adolescents between the ages of 12 and 18 years and again when they were between the ages of 29 and 30 years, at which time they also had an ultrasound to measure carotid intima-media thickness, a surrogate for the risk of developing atherosclerosis.

In a previous analysis of this same data set, Mr. Magnussen and his associates found that adolescents with borderline or high-risk dyslipidemia were significantly more likely than were those with normal lipid levels to have dyslipidemia as adults after a mean follow-up of 20 years (Circulation 2008;117:32–42).

In the current study, adolescent dyslipidemia increased the relative risk for high intima-media thickness in adulthood by 60%–250%, and the higher risk was seen regardless of adult lipid and lipoprotein levels.

Adult carotid intima-media thickness was substantially higher in those who had been overweight or obese adolescents with dyslipidemia. The investigators estimated that overweight or obese 15-year-olds with dyslipidemia would show a difference in intima-media thickness of 0.11 mm in males or 0.08 mm in females by age 35 years, compared with normal-weight 15-year-olds with normal cholesterol levels.

Increased intima-media thickness in young adulthood provides “a more solid end point than we've had before,” said Dr. Roberta Williams, who was not involved in the study.

“If you are overweight/obese and have abnormal lipid levels, it is highly likely that you are headed for real changes in your vascular bed as an adult,” said Dr. Williams, chair of pediatrics at the University of Southern California, Los Angeles. She said she has no conflicts of interest related to this topic.

The positive predictive value of adolescent dyslipidemia was low (ranging from 11% to 37% depending on weight and type of dyslipidemia), a fact that may be explained in part by normal adolescent fluctuations in levels of lipoproteins, which are “building blocks'” for some hormones, she said. As a result, it's hard to tell which adolescents with dyslipidemia will go on to have increased intima-media thickness.

But the study found a high negative predictive value (ranging from 81% to 90%), meaning that adolescents without dyslipidemia are unlikely to develop cardiovascular disease as young adults.

In an editorial commenting on the study, Dr. Stephen R. Daniels noted that the findings do not settle the question of whether all adolescents or targeted populations should be screened for dyslipidemia. Current guidelines recommend screening based on family history or the presence of other risk factors such as obesity, diabetes, or hypertension.

The study addresses neither the morbidity and mortality outcomes after adolescent dyslipidemia is identified, nor the costs or acceptability of screening, noted Dr. Daniels, professor and chairman of pediatrics at the University of Colorado at Denver (J. Am. Coll. Cardiol. 2009;53:870–1 [doi:10.1016/j.jacc.2008.11.037]).

Dr. Magnussen reported no conflicts of interest related to this study. Dr. Daniels has been a consultant for Abbott Laboratories and Merck/Schering-Plough Pharmaceuticals, which market anticholesterol medications.

Obese teens with abnormal lipid levels are likely headed for real changes in their vascular beds as adults. DR. WILLIAMS

Adolescents with dyslipidemia—especially those who were overweight or obese—were more likely than were adolescents with normal lipid levels to have increased carotid artery intima-media thickness by young adulthood, a study of 1,711 people found.

Also, the single set of cut points used in the National Cholesterol Education Program (NCEP) guidelines worked as well as the age- and sex-specific cut points derived from growth curve data in National Health and Nutrition Examination Surveys (NHANES) for predicting increased carotid intima-media thickness in young adults (J. Am. Coll. Cardiol. 2009;53:860–9 [doi:10.1016/j.jacc.2008.09.061]). The finding argues for using the simpler, fixed NCEP approach rather than the percentile-based NHANES approach, reported Costan G. Magnussen of the University of Tasmania (Australia).

Mr. Magnussen and his associates analyzed data from three large population-based, prospective cohort studies: the Finnish Cardiovascular Risk in Young Finns Study, the U.S.-based Bogalusa Heart Study, and the Australian Childhood Determination of Adult Health Study. Lipid and lipoprotein levels were measured in adolescents between the ages of 12 and 18 years and again when they were between the ages of 29 and 30 years, at which time they also had an ultrasound to measure carotid intima-media thickness, a surrogate for the risk of developing atherosclerosis.

In a previous analysis of this same data set, Mr. Magnussen and his associates found that adolescents with borderline or high-risk dyslipidemia were significantly more likely than were those with normal lipid levels to have dyslipidemia as adults after a mean follow-up of 20 years (Circulation 2008;117:32–42).

In the current study, adolescent dyslipidemia increased the relative risk for high intima-media thickness in adulthood by 60%–250%, and the higher risk was seen regardless of adult lipid and lipoprotein levels.

Adult carotid intima-media thickness was substantially higher in those who had been overweight or obese adolescents with dyslipidemia. The investigators estimated that overweight or obese 15-year-olds with dyslipidemia would show a difference in intima-media thickness of 0.11 mm in males or 0.08 mm in females by age 35 years, compared with normal-weight 15-year-olds with normal cholesterol levels.

Increased intima-media thickness in young adulthood provides “a more solid end point than we've had before,” said Dr. Roberta Williams, who was not involved in the study.

“If you are overweight/obese and have abnormal lipid levels, it is highly likely that you are headed for real changes in your vascular bed as an adult,” said Dr. Williams, chair of pediatrics at the University of Southern California, Los Angeles. She said she has no conflicts of interest related to this topic.

The positive predictive value of adolescent dyslipidemia was low (ranging from 11% to 37% depending on weight and type of dyslipidemia), a fact that may be explained in part by normal adolescent fluctuations in levels of lipoproteins, which are “building blocks'” for some hormones, she said. As a result, it's hard to tell which adolescents with dyslipidemia will go on to have increased intima-media thickness.

But the study found a high negative predictive value (ranging from 81% to 90%), meaning that adolescents without dyslipidemia are unlikely to develop cardiovascular disease as young adults.

In an editorial commenting on the study, Dr. Stephen R. Daniels noted that the findings do not settle the question of whether all adolescents or targeted populations should be screened for dyslipidemia. Current guidelines recommend screening based on family history or the presence of other risk factors such as obesity, diabetes, or hypertension.

The study addresses neither the morbidity and mortality outcomes after adolescent dyslipidemia is identified, nor the costs or acceptability of screening, noted Dr. Daniels, professor and chairman of pediatrics at the University of Colorado at Denver (J. Am. Coll. Cardiol. 2009;53:870–1 [doi:10.1016/j.jacc.2008.11.037]).

Dr. Magnussen reported no conflicts of interest related to this study. Dr. Daniels has been a consultant for Abbott Laboratories and Merck/Schering-Plough Pharmaceuticals, which market anticholesterol medications.

Obese teens with abnormal lipid levels are likely headed for real changes in their vascular beds as adults. DR. WILLIAMS

SAN FRANCISCO — Advances in imaging techniques are providing new insights into trabecular and cortical bone structure and may help assess bone quality, a key component of bone strength identified by a 2001 National Institutes of Health consensus panel.

Recent studies suggest that high-resolution MRI (hrMRI), multidetector CT, and high-resolution peripheral quantitative CT (hr-pQCT) each may be useful in assessing bone quality. But each brings different advantages and disadvantages, and it's unclear which imaging modality will be best for identifying osteoporotic fractures and monitoring treatment-related changes in bone structure.

The three imaging modalities can produce significantly different absolute numbers compared with each other when assessing trabecular or cortical bone structure, yet all correlate reasonably well with micro-CT as a standard of reference, Dr. Thomas M. Link said at a conference sponsored by the International Society for Magnetic Resonance in Medicine. Because of differences in acquisition and analysis of the images, bone structure data from the three imaging modalities are not directly comparable.

Trabecular and cortical bone structure are key components of bone quality, which was deemed to be an important component of bone strength, according to NIH (JAMA 2001;285:785–95).

In one randomized, double-blind study, for example, 51 postmenopausal women with osteopenia were treated with alendronate or placebo and followed over a 2-year period by 3T MRI of the radius, tibia, and femur, hr-pQCT of the radius and tibia, and dual x-ray absorptiometry measures of bone mineral density. Both hrMRI and hr-pQCT results for trabecular bone showed moderate but significant correlation with bone density as a reference, even though there was a twofold to fourfold difference between hrMRI and hr-pQCT in parameter values such as trabecular number, thickness, or separation (J. Bone Miner. Res. 2008;23:463–74).

In earlier studies, hrMRI showed that salmon-calcitonin nasal spray helped maintain trabecular microarchitecture, compared with placebo (J. Bone Miner. Res. 2005;20:1548–61) and that testosterone replacement may improve trabecular architecture in hypogonadal men (J. Clin. Endocrinol. Metab. 2003;88:1497–502).

Another study of 106 postmenopausal women found no difference in conventional bone mineral density measurements between the 35 women with a history of fractures and the fracture-free women in the rest of the cohort, but hr-pQCT imaging showed significant differences in trabecular structure (J. Clin. Endocrinol. Metab. 2005;90:6508–15).

Multidetector CT was used in a separate study showing significant increases in trabecular microstructure in 65 postmenopausal women who were treated for 12 months with teriparatide for osteoporosis (J. Bone Miner. Res. 2007;22:1426–33).

For corticol bone imaging, a newer area of research, two 2008 studies using hr-pQCT showed substantial differences between postmenopausal women with hip or wrist fractures, compared with fracture-free women, said Dr. Link, professor of radiology at the University of California, San Francisco.

Both hrMRI and hr-pQCT are being used experimentally to assess cortical bone porosity, which affects bone stability. One recent study using hr-pQCT found significant differences between normal premenopausal women, normal postmenopausal women, and postmenopausal women with renal osteodystrophy.

“This is quite exciting to see these changes in cortical bone porosity. We don't really know what they mean yet, but they're clearly associated with fracture risk,” Dr. Link said.

MRI or hr-pQCT provide high spatial resolution and produce no or relatively little radiation, compared with high-radiation exposure from multidetector CT. Multidector CT has the advantage of allowing imaging of more central skeletal sites such as the spine or proximal femur, he said. The hr-pQCT scanners image only peripheral sites such as small areas of the radius and tibia and possibly the calcaneus, while hrMRI covers larger areas of the radius, tibia, and possibly the femur.

The CT techniques provide measures of bone densitometry. Although hrMRI gives no densitometric data, some studies suggest it may be used to analyze bone marrow composition through spectroscopy in order to assess bone stability. The three techniques appear to have similar rates of reproducibility.

MRI is expensive, and the time needed for imaging results in motion artifacts. In comparison, hr-pQCT requires a dedicated scanner. Although the exam time is shorter with hr-pQCT, motion artifacts remain a problem. Multidetector CT is widely available and requires less time for a scan. Postimage processing requires very sophisticated techniques with MRI, but also is technically challenging with hr-pQCT.

Trabecular and cortical bone architecture of the distal tibia is seen here with hr-pQCT.

High-resolution 3T MRI of the distal tibia visualizes trabecular and cortical bone architecture. Images courtesy Dr. Thomas M. Link

SAN FRANCISCO — Advances in imaging techniques are providing new insights into trabecular and cortical bone structure and may help assess bone quality, a key component of bone strength identified by a 2001 National Institutes of Health consensus panel.

Recent studies suggest that high-resolution MRI (hrMRI), multidetector CT, and high-resolution peripheral quantitative CT (hr-pQCT) each may be useful in assessing bone quality. But each brings different advantages and disadvantages, and it's unclear which imaging modality will be best for identifying osteoporotic fractures and monitoring treatment-related changes in bone structure.

The three imaging modalities can produce significantly different absolute numbers compared with each other when assessing trabecular or cortical bone structure, yet all correlate reasonably well with micro-CT as a standard of reference, Dr. Thomas M. Link said at a conference sponsored by the International Society for Magnetic Resonance in Medicine. Because of differences in acquisition and analysis of the images, bone structure data from the three imaging modalities are not directly comparable.

Trabecular and cortical bone structure are key components of bone quality, which was deemed to be an important component of bone strength, according to NIH (JAMA 2001;285:785–95).

In one randomized, double-blind study, for example, 51 postmenopausal women with osteopenia were treated with alendronate or placebo and followed over a 2-year period by 3T MRI of the radius, tibia, and femur, hr-pQCT of the radius and tibia, and dual x-ray absorptiometry measures of bone mineral density. Both hrMRI and hr-pQCT results for trabecular bone showed moderate but significant correlation with bone density as a reference, even though there was a twofold to fourfold difference between hrMRI and hr-pQCT in parameter values such as trabecular number, thickness, or separation (J. Bone Miner. Res. 2008;23:463–74).

In earlier studies, hrMRI showed that salmon-calcitonin nasal spray helped maintain trabecular microarchitecture, compared with placebo (J. Bone Miner. Res. 2005;20:1548–61) and that testosterone replacement may improve trabecular architecture in hypogonadal men (J. Clin. Endocrinol. Metab. 2003;88:1497–502).

Another study of 106 postmenopausal women found no difference in conventional bone mineral density measurements between the 35 women with a history of fractures and the fracture-free women in the rest of the cohort, but hr-pQCT imaging showed significant differences in trabecular structure (J. Clin. Endocrinol. Metab. 2005;90:6508–15).

Multidetector CT was used in a separate study showing significant increases in trabecular microstructure in 65 postmenopausal women who were treated for 12 months with teriparatide for osteoporosis (J. Bone Miner. Res. 2007;22:1426–33).

For corticol bone imaging, a newer area of research, two 2008 studies using hr-pQCT showed substantial differences between postmenopausal women with hip or wrist fractures, compared with fracture-free women, said Dr. Link, professor of radiology at the University of California, San Francisco.

Both hrMRI and hr-pQCT are being used experimentally to assess cortical bone porosity, which affects bone stability. One recent study using hr-pQCT found significant differences between normal premenopausal women, normal postmenopausal women, and postmenopausal women with renal osteodystrophy.

“This is quite exciting to see these changes in cortical bone porosity. We don't really know what they mean yet, but they're clearly associated with fracture risk,” Dr. Link said.

MRI or hr-pQCT provide high spatial resolution and produce no or relatively little radiation, compared with high-radiation exposure from multidetector CT. Multidector CT has the advantage of allowing imaging of more central skeletal sites such as the spine or proximal femur, he said. The hr-pQCT scanners image only peripheral sites such as small areas of the radius and tibia and possibly the calcaneus, while hrMRI covers larger areas of the radius, tibia, and possibly the femur.

The CT techniques provide measures of bone densitometry. Although hrMRI gives no densitometric data, some studies suggest it may be used to analyze bone marrow composition through spectroscopy in order to assess bone stability. The three techniques appear to have similar rates of reproducibility.

MRI is expensive, and the time needed for imaging results in motion artifacts. In comparison, hr-pQCT requires a dedicated scanner. Although the exam time is shorter with hr-pQCT, motion artifacts remain a problem. Multidetector CT is widely available and requires less time for a scan. Postimage processing requires very sophisticated techniques with MRI, but also is technically challenging with hr-pQCT.

Trabecular and cortical bone architecture of the distal tibia is seen here with hr-pQCT.

High-resolution 3T MRI of the distal tibia visualizes trabecular and cortical bone architecture. Images courtesy Dr. Thomas M. Link

SAN FRANCISCO — Advances in imaging techniques are providing new insights into trabecular and cortical bone structure and may help assess bone quality, a key component of bone strength identified by a 2001 National Institutes of Health consensus panel.

Recent studies suggest that high-resolution MRI (hrMRI), multidetector CT, and high-resolution peripheral quantitative CT (hr-pQCT) each may be useful in assessing bone quality. But each brings different advantages and disadvantages, and it's unclear which imaging modality will be best for identifying osteoporotic fractures and monitoring treatment-related changes in bone structure.

The three imaging modalities can produce significantly different absolute numbers compared with each other when assessing trabecular or cortical bone structure, yet all correlate reasonably well with micro-CT as a standard of reference, Dr. Thomas M. Link said at a conference sponsored by the International Society for Magnetic Resonance in Medicine. Because of differences in acquisition and analysis of the images, bone structure data from the three imaging modalities are not directly comparable.

Trabecular and cortical bone structure are key components of bone quality, which was deemed to be an important component of bone strength, according to NIH (JAMA 2001;285:785–95).

In one randomized, double-blind study, for example, 51 postmenopausal women with osteopenia were treated with alendronate or placebo and followed over a 2-year period by 3T MRI of the radius, tibia, and femur, hr-pQCT of the radius and tibia, and dual x-ray absorptiometry measures of bone mineral density. Both hrMRI and hr-pQCT results for trabecular bone showed moderate but significant correlation with bone density as a reference, even though there was a twofold to fourfold difference between hrMRI and hr-pQCT in parameter values such as trabecular number, thickness, or separation (J. Bone Miner. Res. 2008;23:463–74).

In earlier studies, hrMRI showed that salmon-calcitonin nasal spray helped maintain trabecular microarchitecture, compared with placebo (J. Bone Miner. Res. 2005;20:1548–61) and that testosterone replacement may improve trabecular architecture in hypogonadal men (J. Clin. Endocrinol. Metab. 2003;88:1497–502).

Another study of 106 postmenopausal women found no difference in conventional bone mineral density measurements between the 35 women with a history of fractures and the fracture-free women in the rest of the cohort, but hr-pQCT imaging showed significant differences in trabecular structure (J. Clin. Endocrinol. Metab. 2005;90:6508–15).

Multidetector CT was used in a separate study showing significant increases in trabecular microstructure in 65 postmenopausal women who were treated for 12 months with teriparatide for osteoporosis (J. Bone Miner. Res. 2007;22:1426–33).

For corticol bone imaging, a newer area of research, two 2008 studies using hr-pQCT showed substantial differences between postmenopausal women with hip or wrist fractures, compared with fracture-free women, said Dr. Link, professor of radiology at the University of California, San Francisco.

Both hrMRI and hr-pQCT are being used experimentally to assess cortical bone porosity, which affects bone stability. One recent study using hr-pQCT found significant differences between normal premenopausal women, normal postmenopausal women, and postmenopausal women with renal osteodystrophy.

“This is quite exciting to see these changes in cortical bone porosity. We don't really know what they mean yet, but they're clearly associated with fracture risk,” Dr. Link said.

MRI or hr-pQCT provide high spatial resolution and produce no or relatively little radiation, compared with high-radiation exposure from multidetector CT. Multidector CT has the advantage of allowing imaging of more central skeletal sites such as the spine or proximal femur, he said. The hr-pQCT scanners image only peripheral sites such as small areas of the radius and tibia and possibly the calcaneus, while hrMRI covers larger areas of the radius, tibia, and possibly the femur.

The CT techniques provide measures of bone densitometry. Although hrMRI gives no densitometric data, some studies suggest it may be used to analyze bone marrow composition through spectroscopy in order to assess bone stability. The three techniques appear to have similar rates of reproducibility.

MRI is expensive, and the time needed for imaging results in motion artifacts. In comparison, hr-pQCT requires a dedicated scanner. Although the exam time is shorter with hr-pQCT, motion artifacts remain a problem. Multidetector CT is widely available and requires less time for a scan. Postimage processing requires very sophisticated techniques with MRI, but also is technically challenging with hr-pQCT.

Trabecular and cortical bone architecture of the distal tibia is seen here with hr-pQCT.

High-resolution 3T MRI of the distal tibia visualizes trabecular and cortical bone architecture. Images courtesy Dr. Thomas M. Link

SAN FRANCISCO — Advances in imaging techniques are providing new insights into trabecular and cortical bone structure and may help assess bone quality, a key component of bone strength identified by a 2001 National Institutes of Health consensus panel.

Recent studies suggest that high-resolution MRI (hrMRI), multidetector CT, and high-resolution peripheral quantitative CT (hr-pQCT) each may be useful in assessing bone quality. But each brings different advantages and disadvantages, and it's unclear which imaging modality will be best for identifying osteoporotic fractures and monitoring treatment-related changes in bone structure.

The three imaging modalities can produce significantly different absolute numbers compared with each other when assessing trabecular or cortical bone structure, yet all correlate reasonably well with micro-CT as a standard of reference, Dr. Thomas M. Link said at a conference sponsored by the International Society for Magnetic Resonance in Medicine. Because of differences in acquisition and analysis of the images, bone structure data from the three imaging modalities are not directly comparable.

Trabecular and cortical bone structure are key components of bone quality, which was deemed to be an important component of bone strength, according to NIH (JAMA 2001;285:785–95).

In one randomized, double-blind study, for example, 51 postmenopausal women with osteopenia were treated with alendronate or placebo and followed over a 2-year period by 3T MRI of the radius, tibia and femur, hr-pQCT of the radius and tibia, and dual x-ray absorptiometry measures of bone mineral density. Both 3T MRI and hr-pQCT results for trabecular bone showed moderate but significant correlation with bone density as a reference, even though there was a twofold to fourfold difference between 3T MRI and hr-pQCT in parameter values such as trabecular number, thickness, or separation (J. Bone Miner. Res. 2008;23:463–74).

In earlier studies, hrMRI showed that salmon-calcitonin nasal spray helped maintain trabecular microarchitecture, compared with placebo (J. Bone Miner. Res. 2005;20:1548–61) and that testosterone replacement may improve trabecular architecture in hypogonadal men (J. Clin. Endocrinol. Metab. 2003;88:1497–502).

Another study of 106 postmenopausal women found no difference in conventional bone mineral density measurements between the 35 women with a history of fractures and the fracture-free women in the rest of the cohort, but hr-pQCT imaging showed significant differences in trabecular structure (J. Clin. Endocrinol. Metab. 2005;90:6508–15).

Multidetector CT was used in a separate study showing significant increases in trabecular microstructure in 65 postmenopausal women who were treated for 12 months with teriparatide for osteoporosis (J. Bone Miner. Res. 2007;22:1426–33).

For corticol bone imaging, a newer area of research, two 2008 studies using hr-pQCT showed substantial differences between postmenopausal women with hip or wrist fractures, compared with fracture-free women, said Dr. Link, professor of radiology at the University of California, San Francisco.

Both hrMRI and hr-pQCT are being used experimentally to assess cortical bone porosity, which affects bone stability. One recent study using hr-pQCT found significant differences between normal premenopausal women, normal postmenopausal women, and postmenopausal women with renal osteodystrophy. “This is quite exciting to see these changes in cortical bone porosity. We don't really know what they mean yet, but they're clearly associated with fracture risk,” said Dr. Link, who has has received research funding and support from Merck, which markets medication to treat osteoporosis.

MRI or hr-pQCT provide high spatial resolution and produce no or relatively little radiation, compared with high-radiation exposure from multidetector CT. Multidector CT has the advantage of allowing imaging of more central skeletal sites such as the spine or proximal femur, he said. The hr-pQCT scanners image only peripheral sites such as small areas of the radius and tibia and possibly the calcaneus, while hrMRI covers larger areas of the radius, tibia, and possibly the femur.

The CT techniques provide measures of bone densitometry. Although hrMRI gives no densitometric data, some studies suggest it may be used to analyze bone marrow composition through spectroscopy in order to assess bone stability. The three techniques appear to have similar rates of reproducibility.

MRI is expensive, and the time needed for imaging results in motion artifacts. In comparison, hr-pQCT requires a dedicated scanner. Although the exam time is shorter with hr-pQCT, motion artifacts remain a problem. Multidetector CT is widely available and requires less time for a scan. Postimage processing requires very sophisticated techniques with MRI, but also is technically challenging with hr-pQCT.

Trabecular and cortical bone architecture of the distal tibia is seen here with hr-pQCT.

High-resolution 3T MRI of the distal tibia shows trabecular and cortical bone architecture. IMAGES COURTESY DR. THOMAS M. LINK

SAN FRANCISCO — Advances in imaging techniques are providing new insights into trabecular and cortical bone structure and may help assess bone quality, a key component of bone strength identified by a 2001 National Institutes of Health consensus panel.

Recent studies suggest that high-resolution MRI (hrMRI), multidetector CT, and high-resolution peripheral quantitative CT (hr-pQCT) each may be useful in assessing bone quality. But each brings different advantages and disadvantages, and it's unclear which imaging modality will be best for identifying osteoporotic fractures and monitoring treatment-related changes in bone structure.

The three imaging modalities can produce significantly different absolute numbers compared with each other when assessing trabecular or cortical bone structure, yet all correlate reasonably well with micro-CT as a standard of reference, Dr. Thomas M. Link said at a conference sponsored by the International Society for Magnetic Resonance in Medicine. Because of differences in acquisition and analysis of the images, bone structure data from the three imaging modalities are not directly comparable.

Trabecular and cortical bone structure are key components of bone quality, which was deemed to be an important component of bone strength, according to NIH (JAMA 2001;285:785–95).

In one randomized, double-blind study, for example, 51 postmenopausal women with osteopenia were treated with alendronate or placebo and followed over a 2-year period by 3T MRI of the radius, tibia and femur, hr-pQCT of the radius and tibia, and dual x-ray absorptiometry measures of bone mineral density. Both 3T MRI and hr-pQCT results for trabecular bone showed moderate but significant correlation with bone density as a reference, even though there was a twofold to fourfold difference between 3T MRI and hr-pQCT in parameter values such as trabecular number, thickness, or separation (J. Bone Miner. Res. 2008;23:463–74).

In earlier studies, hrMRI showed that salmon-calcitonin nasal spray helped maintain trabecular microarchitecture, compared with placebo (J. Bone Miner. Res. 2005;20:1548–61) and that testosterone replacement may improve trabecular architecture in hypogonadal men (J. Clin. Endocrinol. Metab. 2003;88:1497–502).

Another study of 106 postmenopausal women found no difference in conventional bone mineral density measurements between the 35 women with a history of fractures and the fracture-free women in the rest of the cohort, but hr-pQCT imaging showed significant differences in trabecular structure (J. Clin. Endocrinol. Metab. 2005;90:6508–15).

Multidetector CT was used in a separate study showing significant increases in trabecular microstructure in 65 postmenopausal women who were treated for 12 months with teriparatide for osteoporosis (J. Bone Miner. Res. 2007;22:1426–33).

For corticol bone imaging, a newer area of research, two 2008 studies using hr-pQCT showed substantial differences between postmenopausal women with hip or wrist fractures, compared with fracture-free women, said Dr. Link, professor of radiology at the University of California, San Francisco.

Both hrMRI and hr-pQCT are being used experimentally to assess cortical bone porosity, which affects bone stability. One recent study using hr-pQCT found significant differences between normal premenopausal women, normal postmenopausal women, and postmenopausal women with renal osteodystrophy. “This is quite exciting to see these changes in cortical bone porosity. We don't really know what they mean yet, but they're clearly associated with fracture risk,” said Dr. Link, who has has received research funding and support from Merck, which markets medication to treat osteoporosis.

MRI or hr-pQCT provide high spatial resolution and produce no or relatively little radiation, compared with high-radiation exposure from multidetector CT. Multidector CT has the advantage of allowing imaging of more central skeletal sites such as the spine or proximal femur, he said. The hr-pQCT scanners image only peripheral sites such as small areas of the radius and tibia and possibly the calcaneus, while hrMRI covers larger areas of the radius, tibia, and possibly the femur.

The CT techniques provide measures of bone densitometry. Although hrMRI gives no densitometric data, some studies suggest it may be used to analyze bone marrow composition through spectroscopy in order to assess bone stability. The three techniques appear to have similar rates of reproducibility.

MRI is expensive, and the time needed for imaging results in motion artifacts. In comparison, hr-pQCT requires a dedicated scanner. Although the exam time is shorter with hr-pQCT, motion artifacts remain a problem. Multidetector CT is widely available and requires less time for a scan. Postimage processing requires very sophisticated techniques with MRI, but also is technically challenging with hr-pQCT.

Trabecular and cortical bone architecture of the distal tibia is seen here with hr-pQCT.

High-resolution 3T MRI of the distal tibia shows trabecular and cortical bone architecture. IMAGES COURTESY DR. THOMAS M. LINK

SAN FRANCISCO — Advances in imaging techniques are providing new insights into trabecular and cortical bone structure and may help assess bone quality, a key component of bone strength identified by a 2001 National Institutes of Health consensus panel.

Recent studies suggest that high-resolution MRI (hrMRI), multidetector CT, and high-resolution peripheral quantitative CT (hr-pQCT) each may be useful in assessing bone quality. But each brings different advantages and disadvantages, and it's unclear which imaging modality will be best for identifying osteoporotic fractures and monitoring treatment-related changes in bone structure.

The three imaging modalities can produce significantly different absolute numbers compared with each other when assessing trabecular or cortical bone structure, yet all correlate reasonably well with micro-CT as a standard of reference, Dr. Thomas M. Link said at a conference sponsored by the International Society for Magnetic Resonance in Medicine. Because of differences in acquisition and analysis of the images, bone structure data from the three imaging modalities are not directly comparable.

Trabecular and cortical bone structure are key components of bone quality, which was deemed to be an important component of bone strength, according to NIH (JAMA 2001;285:785–95).

In one randomized, double-blind study, for example, 51 postmenopausal women with osteopenia were treated with alendronate or placebo and followed over a 2-year period by 3T MRI of the radius, tibia and femur, hr-pQCT of the radius and tibia, and dual x-ray absorptiometry measures of bone mineral density. Both 3T MRI and hr-pQCT results for trabecular bone showed moderate but significant correlation with bone density as a reference, even though there was a twofold to fourfold difference between 3T MRI and hr-pQCT in parameter values such as trabecular number, thickness, or separation (J. Bone Miner. Res. 2008;23:463–74).

In earlier studies, hrMRI showed that salmon-calcitonin nasal spray helped maintain trabecular microarchitecture, compared with placebo (J. Bone Miner. Res. 2005;20:1548–61) and that testosterone replacement may improve trabecular architecture in hypogonadal men (J. Clin. Endocrinol. Metab. 2003;88:1497–502).

Another study of 106 postmenopausal women found no difference in conventional bone mineral density measurements between the 35 women with a history of fractures and the fracture-free women in the rest of the cohort, but hr-pQCT imaging showed significant differences in trabecular structure (J. Clin. Endocrinol. Metab. 2005;90:6508–15).

Multidetector CT was used in a separate study showing significant increases in trabecular microstructure in 65 postmenopausal women who were treated for 12 months with teriparatide for osteoporosis (J. Bone Miner. Res. 2007;22:1426–33).

For corticol bone imaging, a newer area of research, two 2008 studies using hr-pQCT showed substantial differences between postmenopausal women with hip or wrist fractures, compared with fracture-free women, said Dr. Link, professor of radiology at the University of California, San Francisco.

Both hrMRI and hr-pQCT are being used experimentally to assess cortical bone porosity, which affects bone stability. One recent study using hr-pQCT found significant differences between normal premenopausal women, normal postmenopausal women, and postmenopausal women with renal osteodystrophy. “This is quite exciting to see these changes in cortical bone porosity. We don't really know what they mean yet, but they're clearly associated with fracture risk,” said Dr. Link, who has has received research funding and support from Merck, which markets medication to treat osteoporosis.

MRI or hr-pQCT provide high spatial resolution and produce no or relatively little radiation, compared with high-radiation exposure from multidetector CT. Multidector CT has the advantage of allowing imaging of more central skeletal sites such as the spine or proximal femur, he said. The hr-pQCT scanners image only peripheral sites such as small areas of the radius and tibia and possibly the calcaneus, while hrMRI covers larger areas of the radius, tibia, and possibly the femur.

The CT techniques provide measures of bone densitometry. Although hrMRI gives no densitometric data, some studies suggest it may be used to analyze bone marrow composition through spectroscopy in order to assess bone stability. The three techniques appear to have similar rates of reproducibility.

MRI is expensive, and the time needed for imaging results in motion artifacts. In comparison, hr-pQCT requires a dedicated scanner. Although the exam time is shorter with hr-pQCT, motion artifacts remain a problem. Multidetector CT is widely available and requires less time for a scan. Postimage processing requires very sophisticated techniques with MRI, but also is technically challenging with hr-pQCT.

Trabecular and cortical bone architecture of the distal tibia is seen here with hr-pQCT.

High-resolution 3T MRI of the distal tibia shows trabecular and cortical bone architecture. IMAGES COURTESY DR. THOMAS M. LINK

SAN FRANCISCO — High-resolution MRI, multidetector CT, and high-resolution peripheral quantitative CT each may be useful in assessing bone quality, according to recent data.

The three imaging modalities can produce significantly different absolute numbers compared with each other when assessing trabecular or cortical bone structure, yet all correlate reasonably well with micro-CT as a standard of reference, Dr. Thomas M. Link said at a conference sponsored by the International Society for Magnetic Resonance in Medicine.

Trabecular and cortical bone structure are key components of bone quality, an important component of bone strength according to the National Institutes of Health (JAMA 2001;285:785–95).

In one randomized, double-blind study, for example, 51 postmenopausal women with osteopenia were treated with alendronate or placebo and followed over a 2-year period by 3T MRI of the radius, tibia, and femur; high-resolution peripheral quantitative CT (hr-pQCT) of the radius and tibia; and dual x-ray absorptiometry measures of bone mineral density. Both high-resolution MRI (hrMRI), and hr-pQCT results for trabecular bone showed moderate but significant correlation with bone density as a reference, even though there was a twofold to fourfold difference between hrMRI and hr-pQCT in parameter values such as trabecular number, thickness, or separation (J. Bone Miner. Res. 2008;23:463–74).

For corticol bone imaging, a newer area of research, two 2008 studies using hr-pQCT showed substantial differences between postmenopausal women with hip or wrist fractures, compared with fracture-free women, said Dr. Link, professor of radiology at the University of California, San Francisco.

Experimentally, hrMRI and hr-pQCT are being used to assess cortical bone porosity, which affects bone stability. One recent study using hr-pQCT found significant differences among normal premenopausal women, normal postmenopausal women, and postmenopausal women with renal osteodystrophy. MRI or hr-pQCT provide high spatial resolution and produce no (or relatively little) radiation, compared with high-radiation exposure from multidetector CT. Multidetector CT allows imaging of more central skeletal sites, he said.

The hr-pQCT scanners image only peripheral sites, whereas hrMRI covers larger areas of the radius, tibia, and possibly the femur.

The CT techniques provide measures of bone densitometry. Although hrMRI gives no densitometric data, some studies suggest it may be used to analyze bone marrow composition through spectroscopy in order to assess bone stability. The three techniques appear to have similar rates of reproducibility.

MRI and hr-pQCT are expensive and prone to motion artifacts. Multidetector CT is available and requires less time for a scan. But postimage processing is challenging for MRI and CT.

Dr. Link reported receiving research funding and support from Merck & Co., which markets medication to treat osteoporosis.

The trabecular and cortical bone architecture in the distal tibia is shown in high-resolution peripheral quantitative CT (left) and high-resolution 3T MRI (right). Images courtesy Dr. Thomas M. Link

SAN FRANCISCO — High-resolution MRI, multidetector CT, and high-resolution peripheral quantitative CT each may be useful in assessing bone quality, according to recent data.

The three imaging modalities can produce significantly different absolute numbers compared with each other when assessing trabecular or cortical bone structure, yet all correlate reasonably well with micro-CT as a standard of reference, Dr. Thomas M. Link said at a conference sponsored by the International Society for Magnetic Resonance in Medicine.

Trabecular and cortical bone structure are key components of bone quality, an important component of bone strength according to the National Institutes of Health (JAMA 2001;285:785–95).

In one randomized, double-blind study, for example, 51 postmenopausal women with osteopenia were treated with alendronate or placebo and followed over a 2-year period by 3T MRI of the radius, tibia, and femur; high-resolution peripheral quantitative CT (hr-pQCT) of the radius and tibia; and dual x-ray absorptiometry measures of bone mineral density. Both high-resolution MRI (hrMRI), and hr-pQCT results for trabecular bone showed moderate but significant correlation with bone density as a reference, even though there was a twofold to fourfold difference between hrMRI and hr-pQCT in parameter values such as trabecular number, thickness, or separation (J. Bone Miner. Res. 2008;23:463–74).

For corticol bone imaging, a newer area of research, two 2008 studies using hr-pQCT showed substantial differences between postmenopausal women with hip or wrist fractures, compared with fracture-free women, said Dr. Link, professor of radiology at the University of California, San Francisco.

Experimentally, hrMRI and hr-pQCT are being used to assess cortical bone porosity, which affects bone stability. One recent study using hr-pQCT found significant differences among normal premenopausal women, normal postmenopausal women, and postmenopausal women with renal osteodystrophy. MRI or hr-pQCT provide high spatial resolution and produce no (or relatively little) radiation, compared with high-radiation exposure from multidetector CT. Multidetector CT allows imaging of more central skeletal sites, he said.

The hr-pQCT scanners image only peripheral sites, whereas hrMRI covers larger areas of the radius, tibia, and possibly the femur.

The CT techniques provide measures of bone densitometry. Although hrMRI gives no densitometric data, some studies suggest it may be used to analyze bone marrow composition through spectroscopy in order to assess bone stability. The three techniques appear to have similar rates of reproducibility.

MRI and hr-pQCT are expensive and prone to motion artifacts. Multidetector CT is available and requires less time for a scan. But postimage processing is challenging for MRI and CT.

Dr. Link reported receiving research funding and support from Merck & Co., which markets medication to treat osteoporosis.

The trabecular and cortical bone architecture in the distal tibia is shown in high-resolution peripheral quantitative CT (left) and high-resolution 3T MRI (right). Images courtesy Dr. Thomas M. Link

SAN FRANCISCO — High-resolution MRI, multidetector CT, and high-resolution peripheral quantitative CT each may be useful in assessing bone quality, according to recent data.

The three imaging modalities can produce significantly different absolute numbers compared with each other when assessing trabecular or cortical bone structure, yet all correlate reasonably well with micro-CT as a standard of reference, Dr. Thomas M. Link said at a conference sponsored by the International Society for Magnetic Resonance in Medicine.

Trabecular and cortical bone structure are key components of bone quality, an important component of bone strength according to the National Institutes of Health (JAMA 2001;285:785–95).

In one randomized, double-blind study, for example, 51 postmenopausal women with osteopenia were treated with alendronate or placebo and followed over a 2-year period by 3T MRI of the radius, tibia, and femur; high-resolution peripheral quantitative CT (hr-pQCT) of the radius and tibia; and dual x-ray absorptiometry measures of bone mineral density. Both high-resolution MRI (hrMRI), and hr-pQCT results for trabecular bone showed moderate but significant correlation with bone density as a reference, even though there was a twofold to fourfold difference between hrMRI and hr-pQCT in parameter values such as trabecular number, thickness, or separation (J. Bone Miner. Res. 2008;23:463–74).

For corticol bone imaging, a newer area of research, two 2008 studies using hr-pQCT showed substantial differences between postmenopausal women with hip or wrist fractures, compared with fracture-free women, said Dr. Link, professor of radiology at the University of California, San Francisco.

Experimentally, hrMRI and hr-pQCT are being used to assess cortical bone porosity, which affects bone stability. One recent study using hr-pQCT found significant differences among normal premenopausal women, normal postmenopausal women, and postmenopausal women with renal osteodystrophy. MRI or hr-pQCT provide high spatial resolution and produce no (or relatively little) radiation, compared with high-radiation exposure from multidetector CT. Multidetector CT allows imaging of more central skeletal sites, he said.

The hr-pQCT scanners image only peripheral sites, whereas hrMRI covers larger areas of the radius, tibia, and possibly the femur.

The CT techniques provide measures of bone densitometry. Although hrMRI gives no densitometric data, some studies suggest it may be used to analyze bone marrow composition through spectroscopy in order to assess bone stability. The three techniques appear to have similar rates of reproducibility.

MRI and hr-pQCT are expensive and prone to motion artifacts. Multidetector CT is available and requires less time for a scan. But postimage processing is challenging for MRI and CT.

Dr. Link reported receiving research funding and support from Merck & Co., which markets medication to treat osteoporosis.

The trabecular and cortical bone architecture in the distal tibia is shown in high-resolution peripheral quantitative CT (left) and high-resolution 3T MRI (right). Images courtesy Dr. Thomas M. Link

SAN FRANCISCO — Aortic valve replacement at the time of coronary artery bypass surgery in patients with mild aortic stenosis did not affect operative mortality or long-term survival rates, a retrospective study of 316 patients found.

Among 107 patients who underwent coronary artery bypass graft (CABG) alone and 209 patients who also had a prophylactic aortic valve replacement, 4% died during surgery. Survival rates over a mean 5-year follow-up were similar between groups—about 60%, Dr. Basar Sareyyupoglu and associates reported in a prize-winning poster at the annual meeting of the Society of Thoracic Surgeons.

Although aortic valve replacement is generally favored for CABG patients with moderate aortic valve stenosis, the benefit has been less clear for those with mild aortic valve stenosis, defined as a mean gradient greater than 15 mm Hg and less than 30 mm Hg.

Among patients who underwent CABG alone, the likelihood of needing aortic valve replacement was low (approximately 10%) in the first 5 years but increased to approximately 50% by year 7 and slightly more than 50% by years 8-10.

The decision to intervene on the valve at the time of CABG depends critically on the incremental operative risk imposed by prophylactic aortic valve replacement and on the number of years a patient is expected to live after the surgery, said Dr. Sareyyupoglu of the Mayo Clinic, Rochester, Minn.

Older patients and those whose aortic valves were replaced at the time of CABG were less likely to need a subsequent replacement. Although aortic valve replacement did not affect later mortality rates, multivariate analyses showed that factors such as comorbid illnesses, small body surface area, low ejection fraction, heart failure, and a preoperative permanent pacemaker significantly increased the odds of death during follow-up.

Before surgery, patients in the CABG plus aortic valve replacement group differed significantly from the CABG-only group in several respects. They were less likely to have a history of MI, and more likely to have a bicuspid aortic valve and mild/moderate aortic regurgitation. In addition, they had a higher mean gradient of stenosis, a smaller aortic valve area, and lower ejection fraction, cardiac output, and cardiac index.

Perioperatively, patients in the CABG plus aortic valve replacement group needed significantly longer cross-clamp time and cardiopulmonary bypass time and had a higher risk of retrograde cardioplegia than did their CABG-only counterparts. They received fewer bypass grafts but were more likely to have associated procedures or to need tamponade or blood products.

Average hospital stays were 12 days for the CABG plus aortic valve replacement group and 9 days for the CABG-only group.

SAN FRANCISCO — Aortic valve replacement at the time of coronary artery bypass surgery in patients with mild aortic stenosis did not affect operative mortality or long-term survival rates, a retrospective study of 316 patients found.

Among 107 patients who underwent coronary artery bypass graft (CABG) alone and 209 patients who also had a prophylactic aortic valve replacement, 4% died during surgery. Survival rates over a mean 5-year follow-up were similar between groups—about 60%, Dr. Basar Sareyyupoglu and associates reported in a prize-winning poster at the annual meeting of the Society of Thoracic Surgeons.

Although aortic valve replacement is generally favored for CABG patients with moderate aortic valve stenosis, the benefit has been less clear for those with mild aortic valve stenosis, defined as a mean gradient greater than 15 mm Hg and less than 30 mm Hg.

Among patients who underwent CABG alone, the likelihood of needing aortic valve replacement was low (approximately 10%) in the first 5 years but increased to approximately 50% by year 7 and slightly more than 50% by years 8-10.

The decision to intervene on the valve at the time of CABG depends critically on the incremental operative risk imposed by prophylactic aortic valve replacement and on the number of years a patient is expected to live after the surgery, said Dr. Sareyyupoglu of the Mayo Clinic, Rochester, Minn.

Older patients and those whose aortic valves were replaced at the time of CABG were less likely to need a subsequent replacement. Although aortic valve replacement did not affect later mortality rates, multivariate analyses showed that factors such as comorbid illnesses, small body surface area, low ejection fraction, heart failure, and a preoperative permanent pacemaker significantly increased the odds of death during follow-up.

Before surgery, patients in the CABG plus aortic valve replacement group differed significantly from the CABG-only group in several respects. They were less likely to have a history of MI, and more likely to have a bicuspid aortic valve and mild/moderate aortic regurgitation. In addition, they had a higher mean gradient of stenosis, a smaller aortic valve area, and lower ejection fraction, cardiac output, and cardiac index.

Perioperatively, patients in the CABG plus aortic valve replacement group needed significantly longer cross-clamp time and cardiopulmonary bypass time and had a higher risk of retrograde cardioplegia than did their CABG-only counterparts. They received fewer bypass grafts but were more likely to have associated procedures or to need tamponade or blood products.

Average hospital stays were 12 days for the CABG plus aortic valve replacement group and 9 days for the CABG-only group.

SAN FRANCISCO — Aortic valve replacement at the time of coronary artery bypass surgery in patients with mild aortic stenosis did not affect operative mortality or long-term survival rates, a retrospective study of 316 patients found.

Among 107 patients who underwent coronary artery bypass graft (CABG) alone and 209 patients who also had a prophylactic aortic valve replacement, 4% died during surgery. Survival rates over a mean 5-year follow-up were similar between groups—about 60%, Dr. Basar Sareyyupoglu and associates reported in a prize-winning poster at the annual meeting of the Society of Thoracic Surgeons.

Although aortic valve replacement is generally favored for CABG patients with moderate aortic valve stenosis, the benefit has been less clear for those with mild aortic valve stenosis, defined as a mean gradient greater than 15 mm Hg and less than 30 mm Hg.

Among patients who underwent CABG alone, the likelihood of needing aortic valve replacement was low (approximately 10%) in the first 5 years but increased to approximately 50% by year 7 and slightly more than 50% by years 8-10.

The decision to intervene on the valve at the time of CABG depends critically on the incremental operative risk imposed by prophylactic aortic valve replacement and on the number of years a patient is expected to live after the surgery, said Dr. Sareyyupoglu of the Mayo Clinic, Rochester, Minn.

Older patients and those whose aortic valves were replaced at the time of CABG were less likely to need a subsequent replacement. Although aortic valve replacement did not affect later mortality rates, multivariate analyses showed that factors such as comorbid illnesses, small body surface area, low ejection fraction, heart failure, and a preoperative permanent pacemaker significantly increased the odds of death during follow-up.

Before surgery, patients in the CABG plus aortic valve replacement group differed significantly from the CABG-only group in several respects. They were less likely to have a history of MI, and more likely to have a bicuspid aortic valve and mild/moderate aortic regurgitation. In addition, they had a higher mean gradient of stenosis, a smaller aortic valve area, and lower ejection fraction, cardiac output, and cardiac index.

Perioperatively, patients in the CABG plus aortic valve replacement group needed significantly longer cross-clamp time and cardiopulmonary bypass time and had a higher risk of retrograde cardioplegia than did their CABG-only counterparts. They received fewer bypass grafts but were more likely to have associated procedures or to need tamponade or blood products.

Average hospital stays were 12 days for the CABG plus aortic valve replacement group and 9 days for the CABG-only group.

More than half of adults with heart disease also had arthritis, and they were 30% more likely to be physically inactive than were those with heart disease alone, in a survey of 757,959 Americans.

The Centers for Disease Control and Prevention analyzed data from all 50 states in the 2005 and 2007 Behavioral Risk Factor Surveillance System. In telephone interviews, 3% of respondents said they had been diagnosed with heart disease alone, 23% reported a diagnosis of arthritis alone, 4% said they had both heart disease and arthritis, and 70% had neither condition.

Arthritis was present in 57% of the respondents with heart disease, compared with 27% of the total population, J. Bolen, Ph.D., and associates reported (MMWR 2009;58 [No. 7]:165–9).

People with heart disease and arthritis had the highest rate of inactivity—29%—compared with rates of 21% in people with heart disease alone, 18% in people with arthritis alone, and 11% in those who had neither heart disease nor arthritis, reported Dr. Bolen of the CDC's National Center for Chronic Disease Prevention and Health Promotion, division of adult and community health.

After adjustment for the effects of age, sex, race or ethnicity, education level, and body mass index, inactivity was 30% more likely in those with heart disease and arthritis, compared with people who had heart disease alone.

Physicians might better address the effects of heart disease and arthritis by integrating interventions for these co-occurring conditions, the investigators suggested. Efforts to help patients become more physically active could benefit those with one or both conditions by improving physical function and lowering blood pressure and LDL-cholesterol levels, they wrote.

Some specialized educational interventions such as the Chronic Disease Self Management Program and the Arthritis Foundation Self-Help Program can help people with arthritis increase physical activity and manage pain. Exercise programs that are appropriate for adults with heart disease and arthritis include EnhanceFitness, the Arthritis Exercise Program, and the Arthritis Foundation Aquatics Program, wrote Dr. Bolen and colleagues. Self-directed low-impact activities such as walking, swimming, and biking also can be appropriate for people with both heart disease and arthritis.

Previous research suggests that people with arthritis may have greater pain initially when they start to exercise, but continued exercise reduces pain symptoms in the long term.

The risk of having one or both conditions increased with age. Men had a higher prevalence of heart disease alone (4%) or heart disease plus arthritis (4%) compared with women (2% and 3.5%, respectively). Women were more likely to have arthritis alone (27%) compared with men (19%). Whites were more likely than were blacks to have one or both conditions. Each of these comparisons between subgroups was significant.

The Behavioral Risk Factor Surveillance System did not collect data for arthritis and heart disease in all states in 2006, so the investigators focused on 2005 and 2007 data. This study, which supports the results of previous analysis, is the first to use a national population-based sample to quantify the relationship between inactivity and heart disease, arthritis, or both.

ELSEVIER GLOBAL MEDICAL NEWS

More than half of adults with heart disease also had arthritis, and they were 30% more likely to be physically inactive than were those with heart disease alone, in a survey of 757,959 Americans.

The Centers for Disease Control and Prevention analyzed data from all 50 states in the 2005 and 2007 Behavioral Risk Factor Surveillance System. In telephone interviews, 3% of respondents said they had been diagnosed with heart disease alone, 23% reported a diagnosis of arthritis alone, 4% said they had both heart disease and arthritis, and 70% had neither condition.

Arthritis was present in 57% of the respondents with heart disease, compared with 27% of the total population, J. Bolen, Ph.D., and associates reported (MMWR 2009;58 [No. 7]:165–9).

People with heart disease and arthritis had the highest rate of inactivity—29%—compared with rates of 21% in people with heart disease alone, 18% in people with arthritis alone, and 11% in those who had neither heart disease nor arthritis, reported Dr. Bolen of the CDC's National Center for Chronic Disease Prevention and Health Promotion, division of adult and community health.

After adjustment for the effects of age, sex, race or ethnicity, education level, and body mass index, inactivity was 30% more likely in those with heart disease and arthritis, compared with people who had heart disease alone.

Physicians might better address the effects of heart disease and arthritis by integrating interventions for these co-occurring conditions, the investigators suggested. Efforts to help patients become more physically active could benefit those with one or both conditions by improving physical function and lowering blood pressure and LDL-cholesterol levels, they wrote.

Some specialized educational interventions such as the Chronic Disease Self Management Program and the Arthritis Foundation Self-Help Program can help people with arthritis increase physical activity and manage pain. Exercise programs that are appropriate for adults with heart disease and arthritis include EnhanceFitness, the Arthritis Exercise Program, and the Arthritis Foundation Aquatics Program, wrote Dr. Bolen and colleagues. Self-directed low-impact activities such as walking, swimming, and biking also can be appropriate for people with both heart disease and arthritis.

Previous research suggests that people with arthritis may have greater pain initially when they start to exercise, but continued exercise reduces pain symptoms in the long term.

The risk of having one or both conditions increased with age. Men had a higher prevalence of heart disease alone (4%) or heart disease plus arthritis (4%) compared with women (2% and 3.5%, respectively). Women were more likely to have arthritis alone (27%) compared with men (19%). Whites were more likely than were blacks to have one or both conditions. Each of these comparisons between subgroups was significant.

The Behavioral Risk Factor Surveillance System did not collect data for arthritis and heart disease in all states in 2006, so the investigators focused on 2005 and 2007 data. This study, which supports the results of previous analysis, is the first to use a national population-based sample to quantify the relationship between inactivity and heart disease, arthritis, or both.

ELSEVIER GLOBAL MEDICAL NEWS

More than half of adults with heart disease also had arthritis, and they were 30% more likely to be physically inactive than were those with heart disease alone, in a survey of 757,959 Americans.

The Centers for Disease Control and Prevention analyzed data from all 50 states in the 2005 and 2007 Behavioral Risk Factor Surveillance System. In telephone interviews, 3% of respondents said they had been diagnosed with heart disease alone, 23% reported a diagnosis of arthritis alone, 4% said they had both heart disease and arthritis, and 70% had neither condition.

Arthritis was present in 57% of the respondents with heart disease, compared with 27% of the total population, J. Bolen, Ph.D., and associates reported (MMWR 2009;58 [No. 7]:165–9).

People with heart disease and arthritis had the highest rate of inactivity—29%—compared with rates of 21% in people with heart disease alone, 18% in people with arthritis alone, and 11% in those who had neither heart disease nor arthritis, reported Dr. Bolen of the CDC's National Center for Chronic Disease Prevention and Health Promotion, division of adult and community health.

After adjustment for the effects of age, sex, race or ethnicity, education level, and body mass index, inactivity was 30% more likely in those with heart disease and arthritis, compared with people who had heart disease alone.

Physicians might better address the effects of heart disease and arthritis by integrating interventions for these co-occurring conditions, the investigators suggested. Efforts to help patients become more physically active could benefit those with one or both conditions by improving physical function and lowering blood pressure and LDL-cholesterol levels, they wrote.

Some specialized educational interventions such as the Chronic Disease Self Management Program and the Arthritis Foundation Self-Help Program can help people with arthritis increase physical activity and manage pain. Exercise programs that are appropriate for adults with heart disease and arthritis include EnhanceFitness, the Arthritis Exercise Program, and the Arthritis Foundation Aquatics Program, wrote Dr. Bolen and colleagues. Self-directed low-impact activities such as walking, swimming, and biking also can be appropriate for people with both heart disease and arthritis.

Previous research suggests that people with arthritis may have greater pain initially when they start to exercise, but continued exercise reduces pain symptoms in the long term.

The risk of having one or both conditions increased with age. Men had a higher prevalence of heart disease alone (4%) or heart disease plus arthritis (4%) compared with women (2% and 3.5%, respectively). Women were more likely to have arthritis alone (27%) compared with men (19%). Whites were more likely than were blacks to have one or both conditions. Each of these comparisons between subgroups was significant.

The Behavioral Risk Factor Surveillance System did not collect data for arthritis and heart disease in all states in 2006, so the investigators focused on 2005 and 2007 data. This study, which supports the results of previous analysis, is the first to use a national population-based sample to quantify the relationship between inactivity and heart disease, arthritis, or both.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Hair loss is not just for adults. Two simple tools can help diagnose early-onset androgenetic alopecia, which affects 15% of adolescents beginning at age 7–17 years.

The hallmark of androgenetic alopecia is miniaturized hairs, meaning the hair follicles get finer and don't grow as long as normal hairs. The number of hair follicles remains the same, but they're short, fine hairs, Dr. Vera H. Price said at a meeting of the Society for Pediatric Dermatology.

She recommended doing a hair-pull test, which will be negative in androgenetic alopecia: Grab a small cluster of scalp hairs (about 0.5 cm in area) between your thumb and forefinger, and pull very slowly to the end of the hairs. If six or more hairs come out during the pull, that's a positive finding indicating a problem other than androgenetic alopecia. If only two to four hairs come out, the pull test is negative.

Next, examine the hairs using a hair card. A hair card is white on one side (to contrast with dark hairs) and black on the other side (to contrast with lighter-colored hairs). Part the hair, place the card next to the scalp, and look at the follicles next to the card. This can be especially helpful for spotting miniaturized hairs in adolescents, who tend to have less obvious hair thinning than do adults with androgenetic alopecia.

Hair miniaturization also can be seen via a dermatoscope, but "if you can teach yourselves to use a piece of white paper, it will do very much what a dermatoscope does" to diagnose androgenetic alopecia, said Dr. Price, director of the hair research center and professor of clinical dermatology at the University of California, San Francisco.

Clinically, the adolescents are hormonally normal, and they may or may not have a family history of androgenetic alopecia. They (or their parents) may complain that the teen's hair is not growing the way it used to, that it seldom needs cutting, and that the ends are wispy.

Boys may have mildly decreased hair density in the frontal and vertex regions, and subtle accentuation of bitemporal recession, the normal end shape of the hairline near the temples. Girls may show a widened central part and increased spacing among hairs. If a girl complains that her ponytail is smaller, shorter, and skimpier than it used to be, that's a very helpful diagnostic sign, and suggests that androgenetic alopecia has been present for some time.

Clinical signs of puberty usually are present and are reassuring that normal androgen development is taking place. Ask about the patient's diet to check for adequate protein intake, and get a list of medications, if any are being taken.

Lab tests aren't necessary unless there's a clinical reason for them, Dr. Price suggested. If you suspect a thyroid problem, order a TSH test and complete blood count. If you do suspect an androgen problem, order tests for total testosterone, dehydroepiandrosterone sulfate, and prolactin, although usually these aren't needed. For menstruating girls, you might want to check ferritin and total iron-binding capacity to make sure iron levels are sufficient.

Among the differential diagnoses, alopecia areata would have a positive hair-pull test and patches of missing hair, neither of which are suggestive of androgenetic alopecia. Trichotillomania also presents with patches of missing hair, and a hair card will show broken ends on the follicles. If there's some reason for hair shedding (such as fever) in the patient's history, the problem may be telogen effluvium. The history would point to anagen arrest as a cause of hair loss if the patient had been on chemotherapy.

Dr. Price treats adolescent androgenetic alopecia with daily applications of minoxidil (Rogaine) if the teenager is willing to make a long-term commitment, because the effects are evaluated after 1 year and will disappear if the drug is stopped. "I tell them it's not forever that they'll be using this; it's until the next good product" comes along, she said.

She does not use finasteride (Propecia) in adolescents because there are no studies of its use in boys younger than age 18 years, and it is contraindicated for girls of childbearing age. Spironolactone does not enlarge hair follicles, so she doesn't use that agent in these patients, either.

Dr. Price has been a consultant for Pfizer Inc., which markets minoxidil and spironolactone, and has received research funds from Pfizer and from Merck & Co., which markets finasteride.

Minoxidil may cause unwanted facial hair in 5% of patients within 4 weeks of starting therapy, but such hair goes away quickly if treatment is stopped.

Cosmetic options—such as using creative hair styling or hair extensions—also can help the patient and family members cope with adolescent alopecia.

Part the hair, place the card next to the scalp, and look at the follicles next to the card to help make a diagnosis. The card test can be especially helpful for spotting miniaturized hairs in adolescents. Courtesy Dr. Vera H. Price

SAN FRANCISCO — Hair loss is not just for adults. Two simple tools can help diagnose early-onset androgenetic alopecia, which affects 15% of adolescents beginning at age 7–17 years.

The hallmark of androgenetic alopecia is miniaturized hairs, meaning the hair follicles get finer and don't grow as long as normal hairs. The number of hair follicles remains the same, but they're short, fine hairs, Dr. Vera H. Price said at a meeting of the Society for Pediatric Dermatology.

She recommended doing a hair-pull test, which will be negative in androgenetic alopecia: Grab a small cluster of scalp hairs (about 0.5 cm in area) between your thumb and forefinger, and pull very slowly to the end of the hairs. If six or more hairs come out during the pull, that's a positive finding indicating a problem other than androgenetic alopecia. If only two to four hairs come out, the pull test is negative.

Next, examine the hairs using a hair card. A hair card is white on one side (to contrast with dark hairs) and black on the other side (to contrast with lighter-colored hairs). Part the hair, place the card next to the scalp, and look at the follicles next to the card. This can be especially helpful for spotting miniaturized hairs in adolescents, who tend to have less obvious hair thinning than do adults with androgenetic alopecia.

Hair miniaturization also can be seen via a dermatoscope, but "if you can teach yourselves to use a piece of white paper, it will do very much what a dermatoscope does" to diagnose androgenetic alopecia, said Dr. Price, director of the hair research center and professor of clinical dermatology at the University of California, San Francisco.

Clinically, the adolescents are hormonally normal, and they may or may not have a family history of androgenetic alopecia. They (or their parents) may complain that the teen's hair is not growing the way it used to, that it seldom needs cutting, and that the ends are wispy.

Boys may have mildly decreased hair density in the frontal and vertex regions, and subtle accentuation of bitemporal recession, the normal end shape of the hairline near the temples. Girls may show a widened central part and increased spacing among hairs. If a girl complains that her ponytail is smaller, shorter, and skimpier than it used to be, that's a very helpful diagnostic sign, and suggests that androgenetic alopecia has been present for some time.

Clinical signs of puberty usually are present and are reassuring that normal androgen development is taking place. Ask about the patient's diet to check for adequate protein intake, and get a list of medications, if any are being taken.

Lab tests aren't necessary unless there's a clinical reason for them, Dr. Price suggested. If you suspect a thyroid problem, order a TSH test and complete blood count. If you do suspect an androgen problem, order tests for total testosterone, dehydroepiandrosterone sulfate, and prolactin, although usually these aren't needed. For menstruating girls, you might want to check ferritin and total iron-binding capacity to make sure iron levels are sufficient.

Among the differential diagnoses, alopecia areata would have a positive hair-pull test and patches of missing hair, neither of which are suggestive of androgenetic alopecia. Trichotillomania also presents with patches of missing hair, and a hair card will show broken ends on the follicles. If there's some reason for hair shedding (such as fever) in the patient's history, the problem may be telogen effluvium. The history would point to anagen arrest as a cause of hair loss if the patient had been on chemotherapy.

Dr. Price treats adolescent androgenetic alopecia with daily applications of minoxidil (Rogaine) if the teenager is willing to make a long-term commitment, because the effects are evaluated after 1 year and will disappear if the drug is stopped. "I tell them it's not forever that they'll be using this; it's until the next good product" comes along, she said.

She does not use finasteride (Propecia) in adolescents because there are no studies of its use in boys younger than age 18 years, and it is contraindicated for girls of childbearing age. Spironolactone does not enlarge hair follicles, so she doesn't use that agent in these patients, either.

Dr. Price has been a consultant for Pfizer Inc., which markets minoxidil and spironolactone, and has received research funds from Pfizer and from Merck & Co., which markets finasteride.

Minoxidil may cause unwanted facial hair in 5% of patients within 4 weeks of starting therapy, but such hair goes away quickly if treatment is stopped.

Cosmetic options—such as using creative hair styling or hair extensions—also can help the patient and family members cope with adolescent alopecia.

Part the hair, place the card next to the scalp, and look at the follicles next to the card to help make a diagnosis. The card test can be especially helpful for spotting miniaturized hairs in adolescents. Courtesy Dr. Vera H. Price

SAN FRANCISCO — Hair loss is not just for adults. Two simple tools can help diagnose early-onset androgenetic alopecia, which affects 15% of adolescents beginning at age 7–17 years.

The hallmark of androgenetic alopecia is miniaturized hairs, meaning the hair follicles get finer and don't grow as long as normal hairs. The number of hair follicles remains the same, but they're short, fine hairs, Dr. Vera H. Price said at a meeting of the Society for Pediatric Dermatology.

She recommended doing a hair-pull test, which will be negative in androgenetic alopecia: Grab a small cluster of scalp hairs (about 0.5 cm in area) between your thumb and forefinger, and pull very slowly to the end of the hairs. If six or more hairs come out during the pull, that's a positive finding indicating a problem other than androgenetic alopecia. If only two to four hairs come out, the pull test is negative.

Next, examine the hairs using a hair card. A hair card is white on one side (to contrast with dark hairs) and black on the other side (to contrast with lighter-colored hairs). Part the hair, place the card next to the scalp, and look at the follicles next to the card. This can be especially helpful for spotting miniaturized hairs in adolescents, who tend to have less obvious hair thinning than do adults with androgenetic alopecia.

Hair miniaturization also can be seen via a dermatoscope, but "if you can teach yourselves to use a piece of white paper, it will do very much what a dermatoscope does" to diagnose androgenetic alopecia, said Dr. Price, director of the hair research center and professor of clinical dermatology at the University of California, San Francisco.

Clinically, the adolescents are hormonally normal, and they may or may not have a family history of androgenetic alopecia. They (or their parents) may complain that the teen's hair is not growing the way it used to, that it seldom needs cutting, and that the ends are wispy.

Boys may have mildly decreased hair density in the frontal and vertex regions, and subtle accentuation of bitemporal recession, the normal end shape of the hairline near the temples. Girls may show a widened central part and increased spacing among hairs. If a girl complains that her ponytail is smaller, shorter, and skimpier than it used to be, that's a very helpful diagnostic sign, and suggests that androgenetic alopecia has been present for some time.

Clinical signs of puberty usually are present and are reassuring that normal androgen development is taking place. Ask about the patient's diet to check for adequate protein intake, and get a list of medications, if any are being taken.

Lab tests aren't necessary unless there's a clinical reason for them, Dr. Price suggested. If you suspect a thyroid problem, order a TSH test and complete blood count. If you do suspect an androgen problem, order tests for total testosterone, dehydroepiandrosterone sulfate, and prolactin, although usually these aren't needed. For menstruating girls, you might want to check ferritin and total iron-binding capacity to make sure iron levels are sufficient.

Among the differential diagnoses, alopecia areata would have a positive hair-pull test and patches of missing hair, neither of which are suggestive of androgenetic alopecia. Trichotillomania also presents with patches of missing hair, and a hair card will show broken ends on the follicles. If there's some reason for hair shedding (such as fever) in the patient's history, the problem may be telogen effluvium. The history would point to anagen arrest as a cause of hair loss if the patient had been on chemotherapy.

Dr. Price treats adolescent androgenetic alopecia with daily applications of minoxidil (Rogaine) if the teenager is willing to make a long-term commitment, because the effects are evaluated after 1 year and will disappear if the drug is stopped. "I tell them it's not forever that they'll be using this; it's until the next good product" comes along, she said.

She does not use finasteride (Propecia) in adolescents because there are no studies of its use in boys younger than age 18 years, and it is contraindicated for girls of childbearing age. Spironolactone does not enlarge hair follicles, so she doesn't use that agent in these patients, either.

Dr. Price has been a consultant for Pfizer Inc., which markets minoxidil and spironolactone, and has received research funds from Pfizer and from Merck & Co., which markets finasteride.

Minoxidil may cause unwanted facial hair in 5% of patients within 4 weeks of starting therapy, but such hair goes away quickly if treatment is stopped.

Cosmetic options—such as using creative hair styling or hair extensions—also can help the patient and family members cope with adolescent alopecia.

Part the hair, place the card next to the scalp, and look at the follicles next to the card to help make a diagnosis. The card test can be especially helpful for spotting miniaturized hairs in adolescents. Courtesy Dr. Vera H. Price

SAN FRANCISCO — High-dose oral steroid treatment can make an ulcerated hemangioma worse, and nobody really knows what to do when that happens, according to an online survey of 77 pediatric dermatologists.

The January 2009 survey of Society for Pediatric Dermatology members provides a snapshot of current management practices for ulcerated hemangiomas, which are guided more by anecdotal reports and clinician intuition than by trials and evidence, Dr. Annette Wagner said at a meeting of the Society.

Almost 80% of respondents said they see one to five patients each month with ulcerated hemangiomas and others see more. Most believe that each of several treatments are at least somewhat effective—barriers, antibiotics, oral steroids, debridement, or off-label topical becaplermin gel (Regranex). Approximately 40% said oral propranolol can help.

Most of those surveyed rated topical steroids or topical imiquimod as ineffective, added Dr. Wagner, a pediatric dermatologist at Northwestern University, Chicago.

When asked if high-dose steroids worsen ulcerations, more than half said they had seen this rarely, and approximately 5% said it was a frequent problem.

"There's always a question in my mind" about the possibility of high-dose steroids worsening ulcerated hemangiomas, and the findings confirm that this does happen, Dr. Wagner said.

When steroids do worsen an ulceration, close to half of physicians surveyed increased the dose, approximately a quarter of them decreased the dose, and another quarter make no changes.

On average, the most common first-line treatment is a barrier with a topical antibiotic. "When that doesn't work," she reported, "we use oral antibiotics," the survey findings suggest.

Pulsed dye laser is the favored next-line treatment, followed by oral steroids, then Regranex. "Those are the mainstays of how we are managing ulcerated hemangiomas," she said.

Vaseline gauze is the preferred dressing, with nearly as many favoring DuoDERM, and a small proportion preferring Mepitel, a nonadherent silicone dressing.

The top choice in antibiotics was metronidazole gel (MetroGel), followed closely in popularity by mupirocin. Most respondents said they do not use propranolol to treat ulcerated hemangiomas; of those who do, most use it rarely.

Close to a third of respondents do not treat with pulsed dye laser. Of those who do, half use it rarely.

More than 40% of respondents do not use Regranex to treat ulcerated hemangiomas. Those who do use it were more likely to prescribe it rarely than frequently.

To Dr. Wagner, this suggests Regranex is underused, given the benefits she's seen with it.

Most respondents said they rarely or never debride ulcerated hemangiomas, and some even suggested that the ulcer's crust should be left on for pain control. "I completely disagree," she said. "You need to get the wound to heal, so you need to get the crust out."

Those who do debride are most likely to do mechanical debridement in the office, while approximately a third would have the patient apply peroxide at home, and fewer would apply peroxide in the office.

The ulcerations take 2–8 weeks to heal, on average, with most healing in 2–4 weeks, responses suggested.

Dr. Wagner reported having no potential conflicts of interest related to these topics.

SAN FRANCISCO — High-dose oral steroid treatment can make an ulcerated hemangioma worse, and nobody really knows what to do when that happens, according to an online survey of 77 pediatric dermatologists.

The January 2009 survey of Society for Pediatric Dermatology members provides a snapshot of current management practices for ulcerated hemangiomas, which are guided more by anecdotal reports and clinician intuition than by trials and evidence, Dr. Annette Wagner said at a meeting of the Society.

Almost 80% of respondents said they see one to five patients each month with ulcerated hemangiomas and others see more. Most believe that each of several treatments are at least somewhat effective—barriers, antibiotics, oral steroids, debridement, or off-label topical becaplermin gel (Regranex). Approximately 40% said oral propranolol can help.

Most of those surveyed rated topical steroids or topical imiquimod as ineffective, added Dr. Wagner, a pediatric dermatologist at Northwestern University, Chicago.

When asked if high-dose steroids worsen ulcerations, more than half said they had seen this rarely, and approximately 5% said it was a frequent problem.

"There's always a question in my mind" about the possibility of high-dose steroids worsening ulcerated hemangiomas, and the findings confirm that this does happen, Dr. Wagner said.

When steroids do worsen an ulceration, close to half of physicians surveyed increased the dose, approximately a quarter of them decreased the dose, and another quarter make no changes.

On average, the most common first-line treatment is a barrier with a topical antibiotic. "When that doesn't work," she reported, "we use oral antibiotics," the survey findings suggest.

Pulsed dye laser is the favored next-line treatment, followed by oral steroids, then Regranex. "Those are the mainstays of how we are managing ulcerated hemangiomas," she said.

Vaseline gauze is the preferred dressing, with nearly as many favoring DuoDERM, and a small proportion preferring Mepitel, a nonadherent silicone dressing.

The top choice in antibiotics was metronidazole gel (MetroGel), followed closely in popularity by mupirocin. Most respondents said they do not use propranolol to treat ulcerated hemangiomas; of those who do, most use it rarely.

Close to a third of respondents do not treat with pulsed dye laser. Of those who do, half use it rarely.

More than 40% of respondents do not use Regranex to treat ulcerated hemangiomas. Those who do use it were more likely to prescribe it rarely than frequently.

To Dr. Wagner, this suggests Regranex is underused, given the benefits she's seen with it.

Most respondents said they rarely or never debride ulcerated hemangiomas, and some even suggested that the ulcer's crust should be left on for pain control. "I completely disagree," she said. "You need to get the wound to heal, so you need to get the crust out."

Those who do debride are most likely to do mechanical debridement in the office, while approximately a third would have the patient apply peroxide at home, and fewer would apply peroxide in the office.

The ulcerations take 2–8 weeks to heal, on average, with most healing in 2–4 weeks, responses suggested.

Dr. Wagner reported having no potential conflicts of interest related to these topics.

SAN FRANCISCO — High-dose oral steroid treatment can make an ulcerated hemangioma worse, and nobody really knows what to do when that happens, according to an online survey of 77 pediatric dermatologists.

The January 2009 survey of Society for Pediatric Dermatology members provides a snapshot of current management practices for ulcerated hemangiomas, which are guided more by anecdotal reports and clinician intuition than by trials and evidence, Dr. Annette Wagner said at a meeting of the Society.

Almost 80% of respondents said they see one to five patients each month with ulcerated hemangiomas and others see more. Most believe that each of several treatments are at least somewhat effective—barriers, antibiotics, oral steroids, debridement, or off-label topical becaplermin gel (Regranex). Approximately 40% said oral propranolol can help.

Most of those surveyed rated topical steroids or topical imiquimod as ineffective, added Dr. Wagner, a pediatric dermatologist at Northwestern University, Chicago.

When asked if high-dose steroids worsen ulcerations, more than half said they had seen this rarely, and approximately 5% said it was a frequent problem.

"There's always a question in my mind" about the possibility of high-dose steroids worsening ulcerated hemangiomas, and the findings confirm that this does happen, Dr. Wagner said.

When steroids do worsen an ulceration, close to half of physicians surveyed increased the dose, approximately a quarter of them decreased the dose, and another quarter make no changes.

On average, the most common first-line treatment is a barrier with a topical antibiotic. "When that doesn't work," she reported, "we use oral antibiotics," the survey findings suggest.

Pulsed dye laser is the favored next-line treatment, followed by oral steroids, then Regranex. "Those are the mainstays of how we are managing ulcerated hemangiomas," she said.

Vaseline gauze is the preferred dressing, with nearly as many favoring DuoDERM, and a small proportion preferring Mepitel, a nonadherent silicone dressing.

The top choice in antibiotics was metronidazole gel (MetroGel), followed closely in popularity by mupirocin. Most respondents said they do not use propranolol to treat ulcerated hemangiomas; of those who do, most use it rarely.

Close to a third of respondents do not treat with pulsed dye laser. Of those who do, half use it rarely.

More than 40% of respondents do not use Regranex to treat ulcerated hemangiomas. Those who do use it were more likely to prescribe it rarely than frequently.

To Dr. Wagner, this suggests Regranex is underused, given the benefits she's seen with it.

Most respondents said they rarely or never debride ulcerated hemangiomas, and some even suggested that the ulcer's crust should be left on for pain control. "I completely disagree," she said. "You need to get the wound to heal, so you need to get the crust out."

Those who do debride are most likely to do mechanical debridement in the office, while approximately a third would have the patient apply peroxide at home, and fewer would apply peroxide in the office.

The ulcerations take 2–8 weeks to heal, on average, with most healing in 2–4 weeks, responses suggested.

Dr. Wagner reported having no potential conflicts of interest related to these topics.

SAN FRANCISCO — The various treatments for ulcerated hemangiomas each help some patients, but some treatments can make a number of patients worse, and it's difficult to know in advance who will be helped or harmed.

The medical literature provides little guidance on the management of ulcerated hemangiomas, Dr. Annette Wagner said at a meeting of the Society for Pediatric Dermatology.

Applying wound barriers to ulcerated hemangiomas reduces the pain of contact, and the ulceration usually heals in 1–2 months. To help preserve the skin edge along the ulceration, make a border of DuoDERM around the edge and leave it on the skin as adhesive dressings are applied or removed, suggested Dr. Wagner, a pediatric dermatologist at Northwestern University, Chicago.

Surprisingly, only one study in the medical literature has compared other treatments for ulcerated hemangiomas.

Among 22 of 60 patients who were treated with 2–3 mg/kg of oral steroids, which are considered the first-line treatment beyond barriers, ulcerations did not respond in 5 (23%). Of the seven patients who received intralesional Kenalog (triamcinolone acetonide), which can be useful for localized, nodular hemangiomas, four (57%) improved, two (29%) did not, and one (15%) worsened. Among 22 patients treated with pulsed dye laser in that study, the ulcerations improved in 11 (50%) but worsened in 1 (5%) patient (J. Am. Acad. Dermatol. 2001;44:962–72).

"For all of these treatments, there's the same story. For some patients, they seem to work really well, but not for all patients. It's difficult to know in whom it will be effective," she said.

Also in that study, five patients were treated with interferon and had no neurologic sequelae, and two patients had their ulcerated hemangiomas excised. Dr. Wagner does excise some smaller nodular ulcerated hemangiomas to end the pain, since "you're going to end up with a bad scar anyway."

There have been at least five case series of ulcerated hemangiomas treated with pulsed dye laser published between 1991 and 2006. The reports varied in the levels of energy used, the intervals between treatments, and response rates.

"The most important thing is, if you treat with laser, it really seems to help with pain control after one treatment," she said. The second most important thing to keep in mind is that laser can harm patients. A previous report of laser treatment on nonulcerated hemangiomas found that treatment caused ulceration, serious bleeding, and bad scarring in some patients.

"You have to use this tool with great caution," Dr. Wagner advised. "I never laser during that early proliferative phase in nonulcerated areas of hemangioma."

An initial trial using off-label becaplermin gel (Regranex) to treat ulcerated perineal hemangiomas that had superficial or mixed morphologies healed them in an average of 10 days, with a range of 3–25 days (Arch. Dermatol. 2002;138:314–6).

Regranex, which is approved to treat diabetic foot ulcers, is a recombinant platelet-derived growth factor that seems to increase fibroblast proliferation and differentiation to help heal ulcerated hemangiomas. It also can lead to more granulation tissue and bleeding, however, so clinicians should be selective in using it, Dr. Wagner cautioned.

She believes Regranex works best on hemangiomas that have a fibrin base and sort of "punched out" ulcerations without a lot of red granulation tissue, "almost like chronic wounds." On the other end of the wound spectrum, she never treats "activated, kind of goopy" wounds with Regranex, which could make them worse.

A black-box warning issued last year by the Food and Drug Administration about Regranex stemmed from evidence that patients with a history of cancer had an increased risk of death after using more than three tubes of Regranex.

Dr. Wagner reported having no potential conflicts of interest.

Nine Tips for Effective Laser Treatment

Preparation, pain management, debridement, and sufficient laser energy are keys to successful pulsed dye laser treatment for ulcerated hemangiomas, Dr. Wagner said.

She sees 65–75 patients a month with hemangiomas, 28–30 of which are ulcerated, and she treats ulcerations with a pulsed dye laser 12 times per month on average. She offered these tips from her experience:

▸ Manage pain. Give the child acetaminophen an hour before laser treatment. Dr. Wagner also uses a topical anesthetic cream but doesn't find that it makes much difference. Explain to parents that the laser treatment is not much worse than the pain of an open ulcer. It may be even better to offer to apply the laser to the parent's forearm first. That usually dispels their fear, she said.

▸ Be prepared. Before you pick up the baby, have the laser set, get the nurses in the room, prepare the dressings and whatever is going to go on them, and make sure the parents are seated. The child is on the table and back into a parent's arms within 1 minute.

▸ Do no harm. This tool can injure, so be cautious. Ulceration will worsen in a subset of patients. Don't re-treat with a laser if the first round made things worse.

▸ Where to laser? Nobody really knows. She lasers open areas in the ulceration and along the rolled edge to try to stimulate cytokine production. Sometimes she'll apply the laser to dark, dusky areas that look like they're about to ulcerate.

▸ Debride. It's not clear how laser treatment helps ulcerated hemangiomas, but it does affect cytokines, and for that living tissue must be treated. Be sure to debride to reach living tissue.

▸ Use sufficient energy. There seems to be a window between 6 and 8 J/cm₂ that provides enough energy to have an effect without causing injury, but no one really knows the best setting.

▸ Dry the field. Before the laser is used, dry the field not only to get debris out, but to prevent splattering. Prepare for bleeding during the procedure, especially if the child has been treated with Regranex (becaplermin). Inform parents to expect more bleeding in the operating room and in the postoperative period, especially from ulcerations in the genital area.

▸ Cover the wound. Do this after laser treatment for pain control.

▸ Re-treat? No study has looked at optimal intervals between laser treatments for ulcerated hemangiomas. Dr. Wagner sees patients again in 2 weeks, although she will occasionally see some patients sooner.

SAN FRANCISCO — The various treatments for ulcerated hemangiomas each help some patients, but some treatments can make a number of patients worse, and it's difficult to know in advance who will be helped or harmed.

The medical literature provides little guidance on the management of ulcerated hemangiomas, Dr. Annette Wagner said at a meeting of the Society for Pediatric Dermatology.

Applying wound barriers to ulcerated hemangiomas reduces the pain of contact, and the ulceration usually heals in 1–2 months. To help preserve the skin edge along the ulceration, make a border of DuoDERM around the edge and leave it on the skin as adhesive dressings are applied or removed, suggested Dr. Wagner, a pediatric dermatologist at Northwestern University, Chicago.

Surprisingly, only one study in the medical literature has compared other treatments for ulcerated hemangiomas.

Among 22 of 60 patients who were treated with 2–3 mg/kg of oral steroids, which are considered the first-line treatment beyond barriers, ulcerations did not respond in 5 (23%). Of the seven patients who received intralesional Kenalog (triamcinolone acetonide), which can be useful for localized, nodular hemangiomas, four (57%) improved, two (29%) did not, and one (15%) worsened. Among 22 patients treated with pulsed dye laser in that study, the ulcerations improved in 11 (50%) but worsened in 1 (5%) patient (J. Am. Acad. Dermatol. 2001;44:962–72).

"For all of these treatments, there's the same story. For some patients, they seem to work really well, but not for all patients. It's difficult to know in whom it will be effective," she said.

Also in that study, five patients were treated with interferon and had no neurologic sequelae, and two patients had their ulcerated hemangiomas excised. Dr. Wagner does excise some smaller nodular ulcerated hemangiomas to end the pain, since "you're going to end up with a bad scar anyway."

There have been at least five case series of ulcerated hemangiomas treated with pulsed dye laser published between 1991 and 2006. The reports varied in the levels of energy used, the intervals between treatments, and response rates.

"The most important thing is, if you treat with laser, it really seems to help with pain control after one treatment," she said. The second most important thing to keep in mind is that laser can harm patients. A previous report of laser treatment on nonulcerated hemangiomas found that treatment caused ulceration, serious bleeding, and bad scarring in some patients.

"You have to use this tool with great caution," Dr. Wagner advised. "I never laser during that early proliferative phase in nonulcerated areas of hemangioma."

An initial trial using off-label becaplermin gel (Regranex) to treat ulcerated perineal hemangiomas that had superficial or mixed morphologies healed them in an average of 10 days, with a range of 3–25 days (Arch. Dermatol. 2002;138:314–6).

Regranex, which is approved to treat diabetic foot ulcers, is a recombinant platelet-derived growth factor that seems to increase fibroblast proliferation and differentiation to help heal ulcerated hemangiomas. It also can lead to more granulation tissue and bleeding, however, so clinicians should be selective in using it, Dr. Wagner cautioned.

She believes Regranex works best on hemangiomas that have a fibrin base and sort of "punched out" ulcerations without a lot of red granulation tissue, "almost like chronic wounds." On the other end of the wound spectrum, she never treats "activated, kind of goopy" wounds with Regranex, which could make them worse.

A black-box warning issued last year by the Food and Drug Administration about Regranex stemmed from evidence that patients with a history of cancer had an increased risk of death after using more than three tubes of Regranex.

Dr. Wagner reported having no potential conflicts of interest.

Nine Tips for Effective Laser Treatment

Preparation, pain management, debridement, and sufficient laser energy are keys to successful pulsed dye laser treatment for ulcerated hemangiomas, Dr. Wagner said.

She sees 65–75 patients a month with hemangiomas, 28–30 of which are ulcerated, and she treats ulcerations with a pulsed dye laser 12 times per month on average. She offered these tips from her experience:

▸ Manage pain. Give the child acetaminophen an hour before laser treatment. Dr. Wagner also uses a topical anesthetic cream but doesn't find that it makes much difference. Explain to parents that the laser treatment is not much worse than the pain of an open ulcer. It may be even better to offer to apply the laser to the parent's forearm first. That usually dispels their fear, she said.

▸ Be prepared. Before you pick up the baby, have the laser set, get the nurses in the room, prepare the dressings and whatever is going to go on them, and make sure the parents are seated. The child is on the table and back into a parent's arms within 1 minute.

▸ Do no harm. This tool can injure, so be cautious. Ulceration will worsen in a subset of patients. Don't re-treat with a laser if the first round made things worse.

▸ Where to laser? Nobody really knows. She lasers open areas in the ulceration and along the rolled edge to try to stimulate cytokine production. Sometimes she'll apply the laser to dark, dusky areas that look like they're about to ulcerate.

▸ Debride. It's not clear how laser treatment helps ulcerated hemangiomas, but it does affect cytokines, and for that living tissue must be treated. Be sure to debride to reach living tissue.

▸ Use sufficient energy. There seems to be a window between 6 and 8 J/cm₂ that provides enough energy to have an effect without causing injury, but no one really knows the best setting.

▸ Dry the field. Before the laser is used, dry the field not only to get debris out, but to prevent splattering. Prepare for bleeding during the procedure, especially if the child has been treated with Regranex (becaplermin). Inform parents to expect more bleeding in the operating room and in the postoperative period, especially from ulcerations in the genital area.

▸ Cover the wound. Do this after laser treatment for pain control.

▸ Re-treat? No study has looked at optimal intervals between laser treatments for ulcerated hemangiomas. Dr. Wagner sees patients again in 2 weeks, although she will occasionally see some patients sooner.

SAN FRANCISCO — The various treatments for ulcerated hemangiomas each help some patients, but some treatments can make a number of patients worse, and it's difficult to know in advance who will be helped or harmed.

The medical literature provides little guidance on the management of ulcerated hemangiomas, Dr. Annette Wagner said at a meeting of the Society for Pediatric Dermatology.

Applying wound barriers to ulcerated hemangiomas reduces the pain of contact, and the ulceration usually heals in 1–2 months. To help preserve the skin edge along the ulceration, make a border of DuoDERM around the edge and leave it on the skin as adhesive dressings are applied or removed, suggested Dr. Wagner, a pediatric dermatologist at Northwestern University, Chicago.

Surprisingly, only one study in the medical literature has compared other treatments for ulcerated hemangiomas.

Among 22 of 60 patients who were treated with 2–3 mg/kg of oral steroids, which are considered the first-line treatment beyond barriers, ulcerations did not respond in 5 (23%). Of the seven patients who received intralesional Kenalog (triamcinolone acetonide), which can be useful for localized, nodular hemangiomas, four (57%) improved, two (29%) did not, and one (15%) worsened. Among 22 patients treated with pulsed dye laser in that study, the ulcerations improved in 11 (50%) but worsened in 1 (5%) patient (J. Am. Acad. Dermatol. 2001;44:962–72).

"For all of these treatments, there's the same story. For some patients, they seem to work really well, but not for all patients. It's difficult to know in whom it will be effective," she said.

Also in that study, five patients were treated with interferon and had no neurologic sequelae, and two patients had their ulcerated hemangiomas excised. Dr. Wagner does excise some smaller nodular ulcerated hemangiomas to end the pain, since "you're going to end up with a bad scar anyway."

There have been at least five case series of ulcerated hemangiomas treated with pulsed dye laser published between 1991 and 2006. The reports varied in the levels of energy used, the intervals between treatments, and response rates.

"The most important thing is, if you treat with laser, it really seems to help with pain control after one treatment," she said. The second most important thing to keep in mind is that laser can harm patients. A previous report of laser treatment on nonulcerated hemangiomas found that treatment caused ulceration, serious bleeding, and bad scarring in some patients.

"You have to use this tool with great caution," Dr. Wagner advised. "I never laser during that early proliferative phase in nonulcerated areas of hemangioma."

An initial trial using off-label becaplermin gel (Regranex) to treat ulcerated perineal hemangiomas that had superficial or mixed morphologies healed them in an average of 10 days, with a range of 3–25 days (Arch. Dermatol. 2002;138:314–6).

Regranex, which is approved to treat diabetic foot ulcers, is a recombinant platelet-derived growth factor that seems to increase fibroblast proliferation and differentiation to help heal ulcerated hemangiomas. It also can lead to more granulation tissue and bleeding, however, so clinicians should be selective in using it, Dr. Wagner cautioned.

She believes Regranex works best on hemangiomas that have a fibrin base and sort of "punched out" ulcerations without a lot of red granulation tissue, "almost like chronic wounds." On the other end of the wound spectrum, she never treats "activated, kind of goopy" wounds with Regranex, which could make them worse.

A black-box warning issued last year by the Food and Drug Administration about Regranex stemmed from evidence that patients with a history of cancer had an increased risk of death after using more than three tubes of Regranex.

Dr. Wagner reported having no potential conflicts of interest.

Nine Tips for Effective Laser Treatment

Preparation, pain management, debridement, and sufficient laser energy are keys to successful pulsed dye laser treatment for ulcerated hemangiomas, Dr. Wagner said.

She sees 65–75 patients a month with hemangiomas, 28–30 of which are ulcerated, and she treats ulcerations with a pulsed dye laser 12 times per month on average. She offered these tips from her experience:

▸ Manage pain. Give the child acetaminophen an hour before laser treatment. Dr. Wagner also uses a topical anesthetic cream but doesn't find that it makes much difference. Explain to parents that the laser treatment is not much worse than the pain of an open ulcer. It may be even better to offer to apply the laser to the parent's forearm first. That usually dispels their fear, she said.

▸ Be prepared. Before you pick up the baby, have the laser set, get the nurses in the room, prepare the dressings and whatever is going to go on them, and make sure the parents are seated. The child is on the table and back into a parent's arms within 1 minute.

▸ Do no harm. This tool can injure, so be cautious. Ulceration will worsen in a subset of patients. Don't re-treat with a laser if the first round made things worse.

▸ Where to laser? Nobody really knows. She lasers open areas in the ulceration and along the rolled edge to try to stimulate cytokine production. Sometimes she'll apply the laser to dark, dusky areas that look like they're about to ulcerate.

▸ Debride. It's not clear how laser treatment helps ulcerated hemangiomas, but it does affect cytokines, and for that living tissue must be treated. Be sure to debride to reach living tissue.

▸ Use sufficient energy. There seems to be a window between 6 and 8 J/cm₂ that provides enough energy to have an effect without causing injury, but no one really knows the best setting.

▸ Dry the field. Before the laser is used, dry the field not only to get debris out, but to prevent splattering. Prepare for bleeding during the procedure, especially if the child has been treated with Regranex (becaplermin). Inform parents to expect more bleeding in the operating room and in the postoperative period, especially from ulcerations in the genital area.

▸ Cover the wound. Do this after laser treatment for pain control.

▸ Re-treat? No study has looked at optimal intervals between laser treatments for ulcerated hemangiomas. Dr. Wagner sees patients again in 2 weeks, although she will occasionally see some patients sooner.