Sherry Boschert

PHOENIX — Using behavioral interventions for attention-deficit/hyperactivity disorder delayed the start of medication and reduced the dose needed in a randomized, controlled study of 127 schoolchildren.

The study is the first to use behavioral modification before initiating medication for attention-deficit/hyperactivity disorder (ADHD), Erika K. Coles, Ph.D., said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

The researchers also took the unusual approach of basing the need for medication on measures of impairment, not symptoms, and separated treatment of the disorder at school from treatment at home.

The study enrolled children aged 5–12 years who had participated in a tightly controlled 9-week summer treatment program and research study of three intensities of behavior modification and four doses of medication for ADHD. All of the students started the school year unmedicated.

Dr. Coles and her associates randomized them to follow-up with or without behavioral consultation. The behavioral consultations started with three meetings with teachers and parents, often before school started, to set up behavioral intervention plans and daily report cards to track success and identify problems.

Children randomized to the behavioral modification group went longer into the school year before starting methylphenidate either in school or at home and were significantly less likely to use the drug at home (24%), compared with those who did not get behavioral consultations (of whom 53% took methylphenidate at home).

By the end of the school year, the proportion of children who had started the drug did not differ significantly between groups (70% in the behavioral modification group and 80% in the control group), but the average weekly dose of methylphenidate was significantly lower in the behavioral intervention group (157 mg/day), compared with the control group (234 mg/day), said Dr. Coles, an assistant professor of psychology at the University of Maine, Orono.

In both groups, teachers and parents completed a weekly Impairment Rating Scale for seven domains of functioning such as academics, getting along with peers or family, interrupting the classroom, and more.

In the control group, a spike in teacher or parent ratings of impairment triggered a medication assessment for initiation of short-acting methylphenidate. In the behavioral modification group, a ratings spike triggered an emergency consultation to try to adjust the behavioral plan. If parents or teachers remained concerned about a child's impairment for 2 more consecutive weeks, a medication assessment began.

The only factor that predicted that a child would start medication was a history of methylphenidate use prior to the summer program, a finding that surprised the investigators. “We looked at socioeconomic status, comorbidity, and other factors—nothing else predicted it,” Dr. Coles said.

Before the summer program, 77% of the cohort had taken medication at school for ADHD. Of these, 17% also had taken medication at home.

Among children who went on medication at school during the study, parents opted for weekend medication as well for 18% in the behavioral consult group and 56% in the control group, a significant difference.

The idea that the need for medication can be determined separately for school and home could counter a trend toward use of longer-acting doses of methylphenidate.

“This study is starting to show that doesn't necessarily have to be true. You can reduce the amount of medication if you just medicate [when] children are impaired,” she said, adding that many studies of behavioral interventions for ADHD focus on reducing symptoms and may miss the benefits of reducing impairment.

Dr. Coles has no association with makers of ADHD treatments.

PHOENIX — Using behavioral interventions for attention-deficit/hyperactivity disorder delayed the start of medication and reduced the dose needed in a randomized, controlled study of 127 schoolchildren.

The study is the first to use behavioral modification before initiating medication for attention-deficit/hyperactivity disorder (ADHD), Erika K. Coles, Ph.D., said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

The researchers also took the unusual approach of basing the need for medication on measures of impairment, not symptoms, and separated treatment of the disorder at school from treatment at home.

The study enrolled children aged 5–12 years who had participated in a tightly controlled 9-week summer treatment program and research study of three intensities of behavior modification and four doses of medication for ADHD. All of the students started the school year unmedicated.

Dr. Coles and her associates randomized them to follow-up with or without behavioral consultation. The behavioral consultations started with three meetings with teachers and parents, often before school started, to set up behavioral intervention plans and daily report cards to track success and identify problems.

Children randomized to the behavioral modification group went longer into the school year before starting methylphenidate either in school or at home and were significantly less likely to use the drug at home (24%), compared with those who did not get behavioral consultations (of whom 53% took methylphenidate at home).

By the end of the school year, the proportion of children who had started the drug did not differ significantly between groups (70% in the behavioral modification group and 80% in the control group), but the average weekly dose of methylphenidate was significantly lower in the behavioral intervention group (157 mg/day), compared with the control group (234 mg/day), said Dr. Coles, an assistant professor of psychology at the University of Maine, Orono.

In both groups, teachers and parents completed a weekly Impairment Rating Scale for seven domains of functioning such as academics, getting along with peers or family, interrupting the classroom, and more.

In the control group, a spike in teacher or parent ratings of impairment triggered a medication assessment for initiation of short-acting methylphenidate. In the behavioral modification group, a ratings spike triggered an emergency consultation to try to adjust the behavioral plan. If parents or teachers remained concerned about a child's impairment for 2 more consecutive weeks, a medication assessment began.

The only factor that predicted that a child would start medication was a history of methylphenidate use prior to the summer program, a finding that surprised the investigators. “We looked at socioeconomic status, comorbidity, and other factors—nothing else predicted it,” Dr. Coles said.

Before the summer program, 77% of the cohort had taken medication at school for ADHD. Of these, 17% also had taken medication at home.

Among children who went on medication at school during the study, parents opted for weekend medication as well for 18% in the behavioral consult group and 56% in the control group, a significant difference.

The idea that the need for medication can be determined separately for school and home could counter a trend toward use of longer-acting doses of methylphenidate.

“This study is starting to show that doesn't necessarily have to be true. You can reduce the amount of medication if you just medicate [when] children are impaired,” she said, adding that many studies of behavioral interventions for ADHD focus on reducing symptoms and may miss the benefits of reducing impairment.

Dr. Coles has no association with makers of ADHD treatments.

PHOENIX — Using behavioral interventions for attention-deficit/hyperactivity disorder delayed the start of medication and reduced the dose needed in a randomized, controlled study of 127 schoolchildren.

The study is the first to use behavioral modification before initiating medication for attention-deficit/hyperactivity disorder (ADHD), Erika K. Coles, Ph.D., said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

The researchers also took the unusual approach of basing the need for medication on measures of impairment, not symptoms, and separated treatment of the disorder at school from treatment at home.

The study enrolled children aged 5–12 years who had participated in a tightly controlled 9-week summer treatment program and research study of three intensities of behavior modification and four doses of medication for ADHD. All of the students started the school year unmedicated.

Dr. Coles and her associates randomized them to follow-up with or without behavioral consultation. The behavioral consultations started with three meetings with teachers and parents, often before school started, to set up behavioral intervention plans and daily report cards to track success and identify problems.

Children randomized to the behavioral modification group went longer into the school year before starting methylphenidate either in school or at home and were significantly less likely to use the drug at home (24%), compared with those who did not get behavioral consultations (of whom 53% took methylphenidate at home).

By the end of the school year, the proportion of children who had started the drug did not differ significantly between groups (70% in the behavioral modification group and 80% in the control group), but the average weekly dose of methylphenidate was significantly lower in the behavioral intervention group (157 mg/day), compared with the control group (234 mg/day), said Dr. Coles, an assistant professor of psychology at the University of Maine, Orono.

In both groups, teachers and parents completed a weekly Impairment Rating Scale for seven domains of functioning such as academics, getting along with peers or family, interrupting the classroom, and more.

In the control group, a spike in teacher or parent ratings of impairment triggered a medication assessment for initiation of short-acting methylphenidate. In the behavioral modification group, a ratings spike triggered an emergency consultation to try to adjust the behavioral plan. If parents or teachers remained concerned about a child's impairment for 2 more consecutive weeks, a medication assessment began.

The only factor that predicted that a child would start medication was a history of methylphenidate use prior to the summer program, a finding that surprised the investigators. “We looked at socioeconomic status, comorbidity, and other factors—nothing else predicted it,” Dr. Coles said.

Before the summer program, 77% of the cohort had taken medication at school for ADHD. Of these, 17% also had taken medication at home.

Among children who went on medication at school during the study, parents opted for weekend medication as well for 18% in the behavioral consult group and 56% in the control group, a significant difference.

The idea that the need for medication can be determined separately for school and home could counter a trend toward use of longer-acting doses of methylphenidate.

“This study is starting to show that doesn't necessarily have to be true. You can reduce the amount of medication if you just medicate [when] children are impaired,” she said, adding that many studies of behavioral interventions for ADHD focus on reducing symptoms and may miss the benefits of reducing impairment.

Dr. Coles has no association with makers of ADHD treatments.

STANFORD, CALIF. — Two approved therapies for pediatric warts and several off-label options each carry advantages and disadvantages that can help inform treatment selection.

Watchful waiting may be the best option because most pediatric warts are self-limiting, but when you or the parents decide it is time for treatment, consider the child's age, personality, and the number and location of the lesions, Dr. Lillian F. Soohoo said at a pediatric update sponsored by Stanford (Calif.) University.

Up to two-thirds of pediatric warts resolve within 2 years without treatment. “I usually wait until a child is 9 years old before I begin talking about painful therapy” to remove warts, said Dr. Soohoo of the university. She never restrains children for such therapy.

She described the pros and cons of the two approved treatments—salicylic acid or cryotherapy—and discussed several off-label therapies being used:

▸ Salicylic acid. Many over-the-counter preparations are available in the form of topical solutions, gels, pads, patches, or plasters containing 17%–40% salicylic acid, depending on the product. Dr. Soohoo generally doesn't use the 40% preparations in younger children but may use them in teenagers, who have thicker skin.

The advantages of salicylic acid start with cure rates of 70%–80%. These preparations are readily available, inexpensive, and may be combined with other therapies.

Salicylic acid requires daily applications for weeks or months to be effective, however, so diligence on the part of the patient or parents is a must, she said. Many parents resist this over-the-counter therapy and demand a prescription-strength treatment. Salicylic acid also can cause irritation of the skin, eye, and mucous membranes.

▸ Cryotherapy. The most effective version of cryotherapy for pediatric warts is liquid nitrogen, which provides cure rates of 50%–80%. Less effective versions include Verruca-Freeze (chlorodifluoromethane and propane), Histofreezer (dimethyl ether and propane), or Wartner (dimethyl ether and propane), which produce less than half the chill of liquid nitrogen, she said.

Leading the disadvantages of cryotherapy is the pain it causes, which usually is too traumatic for patients under 9 years of age. Cryotherapy usually requires repeat treatments, and can cause scarring or doughnut-wart (also called ring wart) recurrences.

Dr. Soohoo's cryotherapy technique starts by asking the child to hold an ice pack to the wart to pretreat the area, then applying liquid nitrogen to the wart and a 2-mm surrounding area for 3–6 seconds until the tissue is white. Allow the area to thaw completely and repeat. Schedule the patient for a follow-up visit in 2–4 weeks and discuss blister care with the parents.

▸ Cantharidin. A topical preparation made of purified secretions from the blister beetle (Cantharis vesicatoria), cantharidin can be applied in the office and will cause blistering and desquamation of the wart at home. Cantharidin is highly toxic if ingested and so is not approved for wart treatment, but the Food and Drug Administration in 1998 said it will not take regulatory action if its use is limited to topical use in the professional office setting, Dr. Soohoo said.

Cantharidin is easy to administer in the office, has a low risk for scarring, and both the application and the blistering is painless if applied appropriately. The blistering occurs within 24–48 hours and takes 4–7 days to heal. There have been some reports of lymphangitis or lymphedema associated with cantharidin use.

The wooden end of a cotton-tipped applicator can be used to apply a small drop to each lesion. Allow it to dry completely, then cover with tape, and advise parents to wash off the treated area 4–6 hours later, or sooner if burning or pain develops, Dr. Soohoo advised. Discuss blister care with parents. If needed, repeat treatment in 2 weeks.

▸ Immunotherapy. Although not approved for common pediatric warts, topical 5% imiquimod cream (Aldara) often is used and is approved for treatment of genital warts in patients aged 12 years and older.

Aldara cream is painless, well tolerated by all ages, and may induce immunity to warts. On the downside, it requires 4 months or more of nightly applications and is expensive, although many insurers now cover it for the treatment of warts, she said. To avoid irritation, do not use it to treat warts on the face, neck, occluded areas like the diaper area or genitals, she advised. It causes erythema in 30% of cases and, in rare cases, has been associated with flulike symptoms, fever, or photosensitivity.

Dr. Soohoo reserves another off-label topical immunotherapy, squaric acid dibutyl ester, for recalcitrant warts. The treatment seems to be painless and induces immunity to human papillomavirus. It can cause an allergic contact dermatitis, however, and should not be used for facial warts because of irritation.

Start use of squaric acid dibutyl ester by applying a 2% solution to a small, quarter-size area of normal skin on the forearm and wait 2 weeks to check for sensitization, she recommended. If none occurs, parents could apply a 0.2% solution to warts 3–7 times per week.

An intralesional immunotherapy, Candida antigen injection, is more painful. The injections are thought to be less painful than cryotherapy but still too painful for young children, Dr. Soohoo said. Some teenagers may tolerate it. It seems to be effective and induces immunity but is expensive and can cause itching as well as pain at the treatment site.

▸ Other off-label therapies. Among other off-label therapies, topical 5-fluorouracil can be applied to warts daily for 6 weeks. “I use it a fair amount in older kids and teens, especially if they're too busy to come back for visits,” Dr. Soohoo said. It is an FDA Pregnancy Category X and is available in compounded formulations by mail order from pharmacies.

Topical retinoic acid has been applied to flat warts on the face for up to 8 weeks of daily treatment but can cause local skin irritation, she said.

A study of pulsed dye laser therapy in 56 children found no support for its use as first-line therapy for pediatric warts (J. Am. Acad. Dermatol. 2007;56:205-10).

Duct tape does not work as monotherapy but may boost the efficacy of other topical therapies when used in combination, she concluded.

Dr. Soohoo reported no conflicts of interest.

STANFORD, CALIF. — Two approved therapies for pediatric warts and several off-label options each carry advantages and disadvantages that can help inform treatment selection.

Watchful waiting may be the best option because most pediatric warts are self-limiting, but when you or the parents decide it is time for treatment, consider the child's age, personality, and the number and location of the lesions, Dr. Lillian F. Soohoo said at a pediatric update sponsored by Stanford (Calif.) University.

Up to two-thirds of pediatric warts resolve within 2 years without treatment. “I usually wait until a child is 9 years old before I begin talking about painful therapy” to remove warts, said Dr. Soohoo of the university. She never restrains children for such therapy.

She described the pros and cons of the two approved treatments—salicylic acid or cryotherapy—and discussed several off-label therapies being used:

▸ Salicylic acid. Many over-the-counter preparations are available in the form of topical solutions, gels, pads, patches, or plasters containing 17%–40% salicylic acid, depending on the product. Dr. Soohoo generally doesn't use the 40% preparations in younger children but may use them in teenagers, who have thicker skin.

The advantages of salicylic acid start with cure rates of 70%–80%. These preparations are readily available, inexpensive, and may be combined with other therapies.

Salicylic acid requires daily applications for weeks or months to be effective, however, so diligence on the part of the patient or parents is a must, she said. Many parents resist this over-the-counter therapy and demand a prescription-strength treatment. Salicylic acid also can cause irritation of the skin, eye, and mucous membranes.

▸ Cryotherapy. The most effective version of cryotherapy for pediatric warts is liquid nitrogen, which provides cure rates of 50%–80%. Less effective versions include Verruca-Freeze (chlorodifluoromethane and propane), Histofreezer (dimethyl ether and propane), or Wartner (dimethyl ether and propane), which produce less than half the chill of liquid nitrogen, she said.

Leading the disadvantages of cryotherapy is the pain it causes, which usually is too traumatic for patients under 9 years of age. Cryotherapy usually requires repeat treatments, and can cause scarring or doughnut-wart (also called ring wart) recurrences.

Dr. Soohoo's cryotherapy technique starts by asking the child to hold an ice pack to the wart to pretreat the area, then applying liquid nitrogen to the wart and a 2-mm surrounding area for 3–6 seconds until the tissue is white. Allow the area to thaw completely and repeat. Schedule the patient for a follow-up visit in 2–4 weeks and discuss blister care with the parents.

▸ Cantharidin. A topical preparation made of purified secretions from the blister beetle (Cantharis vesicatoria), cantharidin can be applied in the office and will cause blistering and desquamation of the wart at home. Cantharidin is highly toxic if ingested and so is not approved for wart treatment, but the Food and Drug Administration in 1998 said it will not take regulatory action if its use is limited to topical use in the professional office setting, Dr. Soohoo said.

Cantharidin is easy to administer in the office, has a low risk for scarring, and both the application and the blistering is painless if applied appropriately. The blistering occurs within 24–48 hours and takes 4–7 days to heal. There have been some reports of lymphangitis or lymphedema associated with cantharidin use.

The wooden end of a cotton-tipped applicator can be used to apply a small drop to each lesion. Allow it to dry completely, then cover with tape, and advise parents to wash off the treated area 4–6 hours later, or sooner if burning or pain develops, Dr. Soohoo advised. Discuss blister care with parents. If needed, repeat treatment in 2 weeks.

▸ Immunotherapy. Although not approved for common pediatric warts, topical 5% imiquimod cream (Aldara) often is used and is approved for treatment of genital warts in patients aged 12 years and older.

Aldara cream is painless, well tolerated by all ages, and may induce immunity to warts. On the downside, it requires 4 months or more of nightly applications and is expensive, although many insurers now cover it for the treatment of warts, she said. To avoid irritation, do not use it to treat warts on the face, neck, occluded areas like the diaper area or genitals, she advised. It causes erythema in 30% of cases and, in rare cases, has been associated with flulike symptoms, fever, or photosensitivity.

Dr. Soohoo reserves another off-label topical immunotherapy, squaric acid dibutyl ester, for recalcitrant warts. The treatment seems to be painless and induces immunity to human papillomavirus. It can cause an allergic contact dermatitis, however, and should not be used for facial warts because of irritation.

Start use of squaric acid dibutyl ester by applying a 2% solution to a small, quarter-size area of normal skin on the forearm and wait 2 weeks to check for sensitization, she recommended. If none occurs, parents could apply a 0.2% solution to warts 3–7 times per week.

An intralesional immunotherapy, Candida antigen injection, is more painful. The injections are thought to be less painful than cryotherapy but still too painful for young children, Dr. Soohoo said. Some teenagers may tolerate it. It seems to be effective and induces immunity but is expensive and can cause itching as well as pain at the treatment site.

▸ Other off-label therapies. Among other off-label therapies, topical 5-fluorouracil can be applied to warts daily for 6 weeks. “I use it a fair amount in older kids and teens, especially if they're too busy to come back for visits,” Dr. Soohoo said. It is an FDA Pregnancy Category X and is available in compounded formulations by mail order from pharmacies.

Topical retinoic acid has been applied to flat warts on the face for up to 8 weeks of daily treatment but can cause local skin irritation, she said.

A study of pulsed dye laser therapy in 56 children found no support for its use as first-line therapy for pediatric warts (J. Am. Acad. Dermatol. 2007;56:205-10).

Duct tape does not work as monotherapy but may boost the efficacy of other topical therapies when used in combination, she concluded.

Dr. Soohoo reported no conflicts of interest.

STANFORD, CALIF. — Two approved therapies for pediatric warts and several off-label options each carry advantages and disadvantages that can help inform treatment selection.

Watchful waiting may be the best option because most pediatric warts are self-limiting, but when you or the parents decide it is time for treatment, consider the child's age, personality, and the number and location of the lesions, Dr. Lillian F. Soohoo said at a pediatric update sponsored by Stanford (Calif.) University.

Up to two-thirds of pediatric warts resolve within 2 years without treatment. “I usually wait until a child is 9 years old before I begin talking about painful therapy” to remove warts, said Dr. Soohoo of the university. She never restrains children for such therapy.

She described the pros and cons of the two approved treatments—salicylic acid or cryotherapy—and discussed several off-label therapies being used:

▸ Salicylic acid. Many over-the-counter preparations are available in the form of topical solutions, gels, pads, patches, or plasters containing 17%–40% salicylic acid, depending on the product. Dr. Soohoo generally doesn't use the 40% preparations in younger children but may use them in teenagers, who have thicker skin.

The advantages of salicylic acid start with cure rates of 70%–80%. These preparations are readily available, inexpensive, and may be combined with other therapies.

Salicylic acid requires daily applications for weeks or months to be effective, however, so diligence on the part of the patient or parents is a must, she said. Many parents resist this over-the-counter therapy and demand a prescription-strength treatment. Salicylic acid also can cause irritation of the skin, eye, and mucous membranes.

▸ Cryotherapy. The most effective version of cryotherapy for pediatric warts is liquid nitrogen, which provides cure rates of 50%–80%. Less effective versions include Verruca-Freeze (chlorodifluoromethane and propane), Histofreezer (dimethyl ether and propane), or Wartner (dimethyl ether and propane), which produce less than half the chill of liquid nitrogen, she said.

Leading the disadvantages of cryotherapy is the pain it causes, which usually is too traumatic for patients under 9 years of age. Cryotherapy usually requires repeat treatments, and can cause scarring or doughnut-wart (also called ring wart) recurrences.

Dr. Soohoo's cryotherapy technique starts by asking the child to hold an ice pack to the wart to pretreat the area, then applying liquid nitrogen to the wart and a 2-mm surrounding area for 3–6 seconds until the tissue is white. Allow the area to thaw completely and repeat. Schedule the patient for a follow-up visit in 2–4 weeks and discuss blister care with the parents.

▸ Cantharidin. A topical preparation made of purified secretions from the blister beetle (Cantharis vesicatoria), cantharidin can be applied in the office and will cause blistering and desquamation of the wart at home. Cantharidin is highly toxic if ingested and so is not approved for wart treatment, but the Food and Drug Administration in 1998 said it will not take regulatory action if its use is limited to topical use in the professional office setting, Dr. Soohoo said.

Cantharidin is easy to administer in the office, has a low risk for scarring, and both the application and the blistering is painless if applied appropriately. The blistering occurs within 24–48 hours and takes 4–7 days to heal. There have been some reports of lymphangitis or lymphedema associated with cantharidin use.

The wooden end of a cotton-tipped applicator can be used to apply a small drop to each lesion. Allow it to dry completely, then cover with tape, and advise parents to wash off the treated area 4–6 hours later, or sooner if burning or pain develops, Dr. Soohoo advised. Discuss blister care with parents. If needed, repeat treatment in 2 weeks.

▸ Immunotherapy. Although not approved for common pediatric warts, topical 5% imiquimod cream (Aldara) often is used and is approved for treatment of genital warts in patients aged 12 years and older.

Aldara cream is painless, well tolerated by all ages, and may induce immunity to warts. On the downside, it requires 4 months or more of nightly applications and is expensive, although many insurers now cover it for the treatment of warts, she said. To avoid irritation, do not use it to treat warts on the face, neck, occluded areas like the diaper area or genitals, she advised. It causes erythema in 30% of cases and, in rare cases, has been associated with flulike symptoms, fever, or photosensitivity.

Dr. Soohoo reserves another off-label topical immunotherapy, squaric acid dibutyl ester, for recalcitrant warts. The treatment seems to be painless and induces immunity to human papillomavirus. It can cause an allergic contact dermatitis, however, and should not be used for facial warts because of irritation.

Start use of squaric acid dibutyl ester by applying a 2% solution to a small, quarter-size area of normal skin on the forearm and wait 2 weeks to check for sensitization, she recommended. If none occurs, parents could apply a 0.2% solution to warts 3–7 times per week.

An intralesional immunotherapy, Candida antigen injection, is more painful. The injections are thought to be less painful than cryotherapy but still too painful for young children, Dr. Soohoo said. Some teenagers may tolerate it. It seems to be effective and induces immunity but is expensive and can cause itching as well as pain at the treatment site.

▸ Other off-label therapies. Among other off-label therapies, topical 5-fluorouracil can be applied to warts daily for 6 weeks. “I use it a fair amount in older kids and teens, especially if they're too busy to come back for visits,” Dr. Soohoo said. It is an FDA Pregnancy Category X and is available in compounded formulations by mail order from pharmacies.

Topical retinoic acid has been applied to flat warts on the face for up to 8 weeks of daily treatment but can cause local skin irritation, she said.

A study of pulsed dye laser therapy in 56 children found no support for its use as first-line therapy for pediatric warts (J. Am. Acad. Dermatol. 2007;56:205-10).

Duct tape does not work as monotherapy but may boost the efficacy of other topical therapies when used in combination, she concluded.

Dr. Soohoo reported no conflicts of interest.

SAN FRANCISCO — Postmenopausal women with coronary heart disease were less likely to develop atrial fibrillation if they were taking statins, a secondary analysis of data on 2,673 patients found.

The prevalence of atrial fibrillation was 65% lower, and the incidence was 55% lower, in women on statin therapy after adjustment for the effects of age, race, heart failure, or history of MI or revascularization. Several previous studies have shown a reduced risk for atrial fibrillation in patients with coronary disease on statins, but those cohorts were 75% male. This is the first study to show a specific benefit in women, Dr. Cara N. Pellegrini and her associates reported at the annual meeting of the Heart Rhythm Society.

The findings are not a reason to use statins specifically to prevent atrial fibrillation in this population, but do provide yet another good reason for women with coronary disease who are on statins to keep taking them, said Dr. Pellegrini of the University of California, San Francisco. She reported that she has no potential conflicts of interest related to the study.

The data came from the Heart and Estrogen-Progestin Replacement Study (HERS) of 2,763 postmenopausal women with coronary heart disease who were randomized to treatment with hormone replacement therapy or placebo, and followed for cardiovascular outcomes for more than 4 years. The current analysis excluded 90 women because of the presence of other arrhythmias at enrollment.

Compared with the women with no atrial fibrillation, the 88 patients (3%) with atrial fibrillation during the study were significantly more likely to be older (70 years vs. 67 years), to have a history of heart failure (35% vs. 12%), and to be on an antiarrhythmic medication (5% vs. 1%). In the atrial fibrillation group, 22% were on statins, vs. 37% of women who did not have atrial fibrillation, a significant difference.

Although statin therapy protected against atrial fibrillation in several previous mostly-male studies, atrial fibrillation is different in women than in men. Women are more likely to have higher heart rates in atrial fibrillation, and to develop paroxysms, thromboembolism, or bleeding, among other differences. These differences prompted the investigators to conduct the current study, Dr. Pellegrini said.

A growing understanding of inflammation's role in atrial fibrillation has increased exploration of nonantiarrhythmic agents such as statins for prevention of atrial fibrillation. Previous studies that linked atrial fibrillation and inflammation predominantly examined men.

The findings are yet another good reason for women with coronary disease who are on statins to keep taking them. DR. PELLEGRINI

SAN FRANCISCO — Postmenopausal women with coronary heart disease were less likely to develop atrial fibrillation if they were taking statins, a secondary analysis of data on 2,673 patients found.

The prevalence of atrial fibrillation was 65% lower, and the incidence was 55% lower, in women on statin therapy after adjustment for the effects of age, race, heart failure, or history of MI or revascularization. Several previous studies have shown a reduced risk for atrial fibrillation in patients with coronary disease on statins, but those cohorts were 75% male. This is the first study to show a specific benefit in women, Dr. Cara N. Pellegrini and her associates reported at the annual meeting of the Heart Rhythm Society.

The findings are not a reason to use statins specifically to prevent atrial fibrillation in this population, but do provide yet another good reason for women with coronary disease who are on statins to keep taking them, said Dr. Pellegrini of the University of California, San Francisco. She reported that she has no potential conflicts of interest related to the study.

The data came from the Heart and Estrogen-Progestin Replacement Study (HERS) of 2,763 postmenopausal women with coronary heart disease who were randomized to treatment with hormone replacement therapy or placebo, and followed for cardiovascular outcomes for more than 4 years. The current analysis excluded 90 women because of the presence of other arrhythmias at enrollment.

Compared with the women with no atrial fibrillation, the 88 patients (3%) with atrial fibrillation during the study were significantly more likely to be older (70 years vs. 67 years), to have a history of heart failure (35% vs. 12%), and to be on an antiarrhythmic medication (5% vs. 1%). In the atrial fibrillation group, 22% were on statins, vs. 37% of women who did not have atrial fibrillation, a significant difference.

Although statin therapy protected against atrial fibrillation in several previous mostly-male studies, atrial fibrillation is different in women than in men. Women are more likely to have higher heart rates in atrial fibrillation, and to develop paroxysms, thromboembolism, or bleeding, among other differences. These differences prompted the investigators to conduct the current study, Dr. Pellegrini said.

A growing understanding of inflammation's role in atrial fibrillation has increased exploration of nonantiarrhythmic agents such as statins for prevention of atrial fibrillation. Previous studies that linked atrial fibrillation and inflammation predominantly examined men.

The findings are yet another good reason for women with coronary disease who are on statins to keep taking them. DR. PELLEGRINI

SAN FRANCISCO — Postmenopausal women with coronary heart disease were less likely to develop atrial fibrillation if they were taking statins, a secondary analysis of data on 2,673 patients found.

The prevalence of atrial fibrillation was 65% lower, and the incidence was 55% lower, in women on statin therapy after adjustment for the effects of age, race, heart failure, or history of MI or revascularization. Several previous studies have shown a reduced risk for atrial fibrillation in patients with coronary disease on statins, but those cohorts were 75% male. This is the first study to show a specific benefit in women, Dr. Cara N. Pellegrini and her associates reported at the annual meeting of the Heart Rhythm Society.

The findings are not a reason to use statins specifically to prevent atrial fibrillation in this population, but do provide yet another good reason for women with coronary disease who are on statins to keep taking them, said Dr. Pellegrini of the University of California, San Francisco. She reported that she has no potential conflicts of interest related to the study.

The data came from the Heart and Estrogen-Progestin Replacement Study (HERS) of 2,763 postmenopausal women with coronary heart disease who were randomized to treatment with hormone replacement therapy or placebo, and followed for cardiovascular outcomes for more than 4 years. The current analysis excluded 90 women because of the presence of other arrhythmias at enrollment.

Compared with the women with no atrial fibrillation, the 88 patients (3%) with atrial fibrillation during the study were significantly more likely to be older (70 years vs. 67 years), to have a history of heart failure (35% vs. 12%), and to be on an antiarrhythmic medication (5% vs. 1%). In the atrial fibrillation group, 22% were on statins, vs. 37% of women who did not have atrial fibrillation, a significant difference.

Although statin therapy protected against atrial fibrillation in several previous mostly-male studies, atrial fibrillation is different in women than in men. Women are more likely to have higher heart rates in atrial fibrillation, and to develop paroxysms, thromboembolism, or bleeding, among other differences. These differences prompted the investigators to conduct the current study, Dr. Pellegrini said.

A growing understanding of inflammation's role in atrial fibrillation has increased exploration of nonantiarrhythmic agents such as statins for prevention of atrial fibrillation. Previous studies that linked atrial fibrillation and inflammation predominantly examined men.

The findings are yet another good reason for women with coronary disease who are on statins to keep taking them. DR. PELLEGRINI

SAN FRANCISCO — Atrial fibrillation affects the quality of life of both patients and their spouses in equal measure, a survey of 264 patients and 94 spouses suggests.

“When you're educating patients about atrial fibrillation, it's important to educate the spouses as well,” Dr. Bruce A. Koplan said at the annual meeting of the Heart Rhythm Society.

“That means don't leave the spouses sitting out in the waiting room. Encourage patients to bring their spouses in for their clinic visit, especially the first visit, when they're learning about the condition,” said Dr. Koplan of Brigham and Women's Hospital, Boston.

Asked to rate the extent of the effect of atrial fibrillation on their own quality of life, 45% of patients and 43% of spouses said it had no effect or a minor effect, 29% of patients and 26% of spouses reported a moderate effect, and 26% of patients and 31% of spouses said there was a significant effect. The differences between groups were not statistically significant.

Ratings also did not differ between patients and spouses when asked about the effects of atrial fibrillation on specific aspects of quality of life, including daily activities, work/professional life, and sex life.

The effects of atrial fibrillation on the quality of daily activities were rated mild by 56% of patients and 54% of spouses, rated as moderate by 30% of patients and 36% of spouses, and rated as significant by 12% of patients and 10% of spouses.

Atrial fibrillation had a mild effect on the quality of work/professional life, according to 72% of patients and 80% of spouses. Another 19% of patients and 14% of spouses reported a moderate effect, and 29% of patients and 26% of spouses reported a significant effect on the quality of work/professional life.

The effects on the quality of sex life were rated as mild by 62% of each group, as moderate by 14% of patients and 13% of spouses, and as significant by 23% of patients and 24% of spouses.

“Atrial fibrillation by itself is almost never a life-threatening condition,” Dr. Koplan noted. “When we treat atrial fibrillation, we're reducing the risk of stroke and we're reducing the fast heart rate, but the other important aspect in management is the effect it has on overall quality of life, not quantity of life.”

Anxiety about atrial fibrillation and lack of understanding of the condition play a role in perception of quality of life. Some patients end up on psychiatric medications to deal with anxiety or depression related to atrial fibrillation. “If you're not addressing the spouse as well, you're not completely dealing with the condition,” Dr. Koplan said.

Dr. Koplan has been a consultant for and received honoraria from Boston Scientific, Medtronic, St. Jude Medical, and St. Jude Inc. Dr. Albert has been a consultant for Guidant Inc. and received research grants from St. Jude Medical.

SAN FRANCISCO — Atrial fibrillation affects the quality of life of both patients and their spouses in equal measure, a survey of 264 patients and 94 spouses suggests.

“When you're educating patients about atrial fibrillation, it's important to educate the spouses as well,” Dr. Bruce A. Koplan said at the annual meeting of the Heart Rhythm Society.

“That means don't leave the spouses sitting out in the waiting room. Encourage patients to bring their spouses in for their clinic visit, especially the first visit, when they're learning about the condition,” said Dr. Koplan of Brigham and Women's Hospital, Boston.

Asked to rate the extent of the effect of atrial fibrillation on their own quality of life, 45% of patients and 43% of spouses said it had no effect or a minor effect, 29% of patients and 26% of spouses reported a moderate effect, and 26% of patients and 31% of spouses said there was a significant effect. The differences between groups were not statistically significant.

Ratings also did not differ between patients and spouses when asked about the effects of atrial fibrillation on specific aspects of quality of life, including daily activities, work/professional life, and sex life.

The effects of atrial fibrillation on the quality of daily activities were rated mild by 56% of patients and 54% of spouses, rated as moderate by 30% of patients and 36% of spouses, and rated as significant by 12% of patients and 10% of spouses.

Atrial fibrillation had a mild effect on the quality of work/professional life, according to 72% of patients and 80% of spouses. Another 19% of patients and 14% of spouses reported a moderate effect, and 29% of patients and 26% of spouses reported a significant effect on the quality of work/professional life.

The effects on the quality of sex life were rated as mild by 62% of each group, as moderate by 14% of patients and 13% of spouses, and as significant by 23% of patients and 24% of spouses.

“Atrial fibrillation by itself is almost never a life-threatening condition,” Dr. Koplan noted. “When we treat atrial fibrillation, we're reducing the risk of stroke and we're reducing the fast heart rate, but the other important aspect in management is the effect it has on overall quality of life, not quantity of life.”

Anxiety about atrial fibrillation and lack of understanding of the condition play a role in perception of quality of life. Some patients end up on psychiatric medications to deal with anxiety or depression related to atrial fibrillation. “If you're not addressing the spouse as well, you're not completely dealing with the condition,” Dr. Koplan said.

Dr. Koplan has been a consultant for and received honoraria from Boston Scientific, Medtronic, St. Jude Medical, and St. Jude Inc. Dr. Albert has been a consultant for Guidant Inc. and received research grants from St. Jude Medical.

SAN FRANCISCO — Atrial fibrillation affects the quality of life of both patients and their spouses in equal measure, a survey of 264 patients and 94 spouses suggests.

“When you're educating patients about atrial fibrillation, it's important to educate the spouses as well,” Dr. Bruce A. Koplan said at the annual meeting of the Heart Rhythm Society.

“That means don't leave the spouses sitting out in the waiting room. Encourage patients to bring their spouses in for their clinic visit, especially the first visit, when they're learning about the condition,” said Dr. Koplan of Brigham and Women's Hospital, Boston.

Asked to rate the extent of the effect of atrial fibrillation on their own quality of life, 45% of patients and 43% of spouses said it had no effect or a minor effect, 29% of patients and 26% of spouses reported a moderate effect, and 26% of patients and 31% of spouses said there was a significant effect. The differences between groups were not statistically significant.

Ratings also did not differ between patients and spouses when asked about the effects of atrial fibrillation on specific aspects of quality of life, including daily activities, work/professional life, and sex life.

The effects of atrial fibrillation on the quality of daily activities were rated mild by 56% of patients and 54% of spouses, rated as moderate by 30% of patients and 36% of spouses, and rated as significant by 12% of patients and 10% of spouses.

Atrial fibrillation had a mild effect on the quality of work/professional life, according to 72% of patients and 80% of spouses. Another 19% of patients and 14% of spouses reported a moderate effect, and 29% of patients and 26% of spouses reported a significant effect on the quality of work/professional life.

The effects on the quality of sex life were rated as mild by 62% of each group, as moderate by 14% of patients and 13% of spouses, and as significant by 23% of patients and 24% of spouses.

“Atrial fibrillation by itself is almost never a life-threatening condition,” Dr. Koplan noted. “When we treat atrial fibrillation, we're reducing the risk of stroke and we're reducing the fast heart rate, but the other important aspect in management is the effect it has on overall quality of life, not quantity of life.”

Anxiety about atrial fibrillation and lack of understanding of the condition play a role in perception of quality of life. Some patients end up on psychiatric medications to deal with anxiety or depression related to atrial fibrillation. “If you're not addressing the spouse as well, you're not completely dealing with the condition,” Dr. Koplan said.

Dr. Koplan has been a consultant for and received honoraria from Boston Scientific, Medtronic, St. Jude Medical, and St. Jude Inc. Dr. Albert has been a consultant for Guidant Inc. and received research grants from St. Jude Medical.

SAN FRANCISCO — Inappropriate shocks from implantable cardioverter defibrillators are common and may cause harm, a review of the literature suggests.

“There are not a great deal of data that enable us to separate out the adverse effects of inappropriate versus appropriate shocks,” but both seem to be associated with an increased risk for death and other adverse outcomes, Dr. Alfred E. Buxton said at the annual meeting of the Heart Rhythm Society.

The literature suggests that 30%–60% of patients with implantable cardioverter defibrillators (ICDs) get appropriate shocks to terminate a life-threatening arrhythmia, and as many as 20%–30% of patients get inappropriate shocks at other times.

“ICD shocks, while potentially life saving, have potential adverse effects,” said Dr. Buxton, professor of medicine at Brown University, Providence, R.I. Shocks have been associated with increased noncardiac mortality, reduced quality of life, and device-induced proarrhythmias.

Compared with patients who had never been shocked by their ICDs, patients who'd had any ICD shock had a quadrupled risk for death from any cause in an analysis of data from the 719-patient Multicenter Automatic Defibrillator Implantation Trial II (MADIT II). Inappropriate shocks were associated with a doubling in all-cause mortality, and appropriate shocks were associated with a tripling in all-cause mortality, compared with no shocks (J. Am. Coll. Cardiol. 2008;51:357-65).

Inappropriate shocks occurred in 12% of patients and comprised 31% of all shocks in the MADIT II trial.

Clearly, needing an ICD shock to terminate a life-threatening arrhythmia puts a person at risk for death, “but there is probably also some additive effect of inappropriate shocks,” Dr. Buxton said. He has been a consultant or speaker or received funding from companies that make cardiac devices including Boston Scientific, GEHealthcare, Medtronic, and St. Jude Medical.

Previous analyses also identified adverse effects associated with ICD shocks. Approximately half of 60 patients were shocked by their ICDs within 2 years of implantation in a 1998 study. Anxiety and sadness increased and initiation of new activities decreased in patients who'd had a shock, compared with those with no shocks, and the same was seen in patients with five or more shocks, compared with just one or no shocks, he said.

A 1999 analysis of the Coronary Artery Bypass Graft (CABG) Patch trial found no difference in quality of life after 6 months between 228 control patients without ICDs and 101 patients with ICDs who had not been shocked, but lower quality of life in 101 other patients with ICDs who had been shocked, compared with controls.

About a third of 373 patients with ICDs in the Antiarrhythmics vs. Implantable Defibrillators (AVID) trial received at least one shock within 1 year, and receiving more than one shock was associated with a significant reduction in mental well-being and physical function, a 2002 analysis concluded.

Data from several studies suggest a complex interaction between depression and ICD shocks. Depression may increase the likelihood of developing arrhythmias and having shocks, and has been associated with decreased heart rate variability, he said. But a 1993 study of 241 patients followed for a mean of 26 months found no significant difference in overall survival rates for patients who had or had not been shocked. At least one shock occurred in 76% of patients, and 63% of the cohort had inappropriate shocks. Mortality rates were similar for patients with appropriate shocks (38% died) and inappropriate shocks (35%).

And an unpublished secondary analysis of the 2004 Defibrillator in Acute Myocardial Infarction (DINAMIT) trial found a significantly higher death rate in patients who had received ICD shocks, compared with non-ICD patients and those with ICDs but no shocks, Dr. Buxton said.

'There is probably also some additive effect of inappropriate shocks.' DR. BUXTON

SAN FRANCISCO — Inappropriate shocks from implantable cardioverter defibrillators are common and may cause harm, a review of the literature suggests.

“There are not a great deal of data that enable us to separate out the adverse effects of inappropriate versus appropriate shocks,” but both seem to be associated with an increased risk for death and other adverse outcomes, Dr. Alfred E. Buxton said at the annual meeting of the Heart Rhythm Society.

The literature suggests that 30%–60% of patients with implantable cardioverter defibrillators (ICDs) get appropriate shocks to terminate a life-threatening arrhythmia, and as many as 20%–30% of patients get inappropriate shocks at other times.

“ICD shocks, while potentially life saving, have potential adverse effects,” said Dr. Buxton, professor of medicine at Brown University, Providence, R.I. Shocks have been associated with increased noncardiac mortality, reduced quality of life, and device-induced proarrhythmias.

Compared with patients who had never been shocked by their ICDs, patients who'd had any ICD shock had a quadrupled risk for death from any cause in an analysis of data from the 719-patient Multicenter Automatic Defibrillator Implantation Trial II (MADIT II). Inappropriate shocks were associated with a doubling in all-cause mortality, and appropriate shocks were associated with a tripling in all-cause mortality, compared with no shocks (J. Am. Coll. Cardiol. 2008;51:357-65).

Inappropriate shocks occurred in 12% of patients and comprised 31% of all shocks in the MADIT II trial.

Clearly, needing an ICD shock to terminate a life-threatening arrhythmia puts a person at risk for death, “but there is probably also some additive effect of inappropriate shocks,” Dr. Buxton said. He has been a consultant or speaker or received funding from companies that make cardiac devices including Boston Scientific, GEHealthcare, Medtronic, and St. Jude Medical.

Previous analyses also identified adverse effects associated with ICD shocks. Approximately half of 60 patients were shocked by their ICDs within 2 years of implantation in a 1998 study. Anxiety and sadness increased and initiation of new activities decreased in patients who'd had a shock, compared with those with no shocks, and the same was seen in patients with five or more shocks, compared with just one or no shocks, he said.

A 1999 analysis of the Coronary Artery Bypass Graft (CABG) Patch trial found no difference in quality of life after 6 months between 228 control patients without ICDs and 101 patients with ICDs who had not been shocked, but lower quality of life in 101 other patients with ICDs who had been shocked, compared with controls.

About a third of 373 patients with ICDs in the Antiarrhythmics vs. Implantable Defibrillators (AVID) trial received at least one shock within 1 year, and receiving more than one shock was associated with a significant reduction in mental well-being and physical function, a 2002 analysis concluded.

Data from several studies suggest a complex interaction between depression and ICD shocks. Depression may increase the likelihood of developing arrhythmias and having shocks, and has been associated with decreased heart rate variability, he said. But a 1993 study of 241 patients followed for a mean of 26 months found no significant difference in overall survival rates for patients who had or had not been shocked. At least one shock occurred in 76% of patients, and 63% of the cohort had inappropriate shocks. Mortality rates were similar for patients with appropriate shocks (38% died) and inappropriate shocks (35%).

And an unpublished secondary analysis of the 2004 Defibrillator in Acute Myocardial Infarction (DINAMIT) trial found a significantly higher death rate in patients who had received ICD shocks, compared with non-ICD patients and those with ICDs but no shocks, Dr. Buxton said.

'There is probably also some additive effect of inappropriate shocks.' DR. BUXTON

SAN FRANCISCO — Inappropriate shocks from implantable cardioverter defibrillators are common and may cause harm, a review of the literature suggests.

“There are not a great deal of data that enable us to separate out the adverse effects of inappropriate versus appropriate shocks,” but both seem to be associated with an increased risk for death and other adverse outcomes, Dr. Alfred E. Buxton said at the annual meeting of the Heart Rhythm Society.

The literature suggests that 30%–60% of patients with implantable cardioverter defibrillators (ICDs) get appropriate shocks to terminate a life-threatening arrhythmia, and as many as 20%–30% of patients get inappropriate shocks at other times.

“ICD shocks, while potentially life saving, have potential adverse effects,” said Dr. Buxton, professor of medicine at Brown University, Providence, R.I. Shocks have been associated with increased noncardiac mortality, reduced quality of life, and device-induced proarrhythmias.

Compared with patients who had never been shocked by their ICDs, patients who'd had any ICD shock had a quadrupled risk for death from any cause in an analysis of data from the 719-patient Multicenter Automatic Defibrillator Implantation Trial II (MADIT II). Inappropriate shocks were associated with a doubling in all-cause mortality, and appropriate shocks were associated with a tripling in all-cause mortality, compared with no shocks (J. Am. Coll. Cardiol. 2008;51:357-65).

Inappropriate shocks occurred in 12% of patients and comprised 31% of all shocks in the MADIT II trial.

Clearly, needing an ICD shock to terminate a life-threatening arrhythmia puts a person at risk for death, “but there is probably also some additive effect of inappropriate shocks,” Dr. Buxton said. He has been a consultant or speaker or received funding from companies that make cardiac devices including Boston Scientific, GEHealthcare, Medtronic, and St. Jude Medical.

Previous analyses also identified adverse effects associated with ICD shocks. Approximately half of 60 patients were shocked by their ICDs within 2 years of implantation in a 1998 study. Anxiety and sadness increased and initiation of new activities decreased in patients who'd had a shock, compared with those with no shocks, and the same was seen in patients with five or more shocks, compared with just one or no shocks, he said.

A 1999 analysis of the Coronary Artery Bypass Graft (CABG) Patch trial found no difference in quality of life after 6 months between 228 control patients without ICDs and 101 patients with ICDs who had not been shocked, but lower quality of life in 101 other patients with ICDs who had been shocked, compared with controls.

About a third of 373 patients with ICDs in the Antiarrhythmics vs. Implantable Defibrillators (AVID) trial received at least one shock within 1 year, and receiving more than one shock was associated with a significant reduction in mental well-being and physical function, a 2002 analysis concluded.

Data from several studies suggest a complex interaction between depression and ICD shocks. Depression may increase the likelihood of developing arrhythmias and having shocks, and has been associated with decreased heart rate variability, he said. But a 1993 study of 241 patients followed for a mean of 26 months found no significant difference in overall survival rates for patients who had or had not been shocked. At least one shock occurred in 76% of patients, and 63% of the cohort had inappropriate shocks. Mortality rates were similar for patients with appropriate shocks (38% died) and inappropriate shocks (35%).

And an unpublished secondary analysis of the 2004 Defibrillator in Acute Myocardial Infarction (DINAMIT) trial found a significantly higher death rate in patients who had received ICD shocks, compared with non-ICD patients and those with ICDs but no shocks, Dr. Buxton said.

'There is probably also some additive effect of inappropriate shocks.' DR. BUXTON

STANFORD, CALIF. — Two approved therapies for pediatric warts and several off-label options each carry advantages and disadvantages that can help inform treatment selection.

Watchful waiting may be the best option because most pediatric warts are self-limiting, but when you or the parents decide it is time for treatment, consider the child's age, personality, and the number and location of the lesions, Dr. Lillian F. Soohoo said at a pediatric update sponsored by Stanford (Calif.) University.

Up to two-thirds of pediatric warts resolve within 2 years without treatment. "I usually wait until a child is 9 years old before I begin talking about painful therapy" to remove warts, said Dr. Soohoo of the university.

She never restrains children for such therapy.

She described the pros and cons of the two approved treatments—salicylic acid or cryotherapy—and discussed several off-label therapies being used to treat pediatric warts:

▸ Salicylic acid. Many over-the-counter preparations are available in the form of topical solutions, gels, pads, patches, or plasters containing 17%–40% salicylic acid, depending on the product.

Dr. Soohoo generally doesn't use the 40% preparations in younger children but may use them in teenagers, who have thicker skin.

The advantages of salicylic acid start with cure rates of 70%–80%. These preparations are readily available, inexpensive, and may be combined with other therapies, Dr. Soohoo said.

Salicylic acid requires daily applications for weeks or months to be effective, however, so diligence on the part of the patient or parents is a must, she said.

Many parents resist this over-the-counter therapy and demand a prescription-strength treatment.

Salicylic acid also can cause irritation of the skin, eye, and mucous membranes, she said.

▸ Cryotherapy. The most effective version of cryotherapy for pediatric warts is liquid nitrogen, which provides cure rates of 50%–80%. Less effective versions include Verruca-Freeze (chlorodifluoromethane and propane), Histofreezer (dimethyl ether and propane), or Wartner (dimethyl ether and propane), which produce less than half the chill of liquid nitrogen, she said.

Leading the disadvantages of cryotherapy is the pain it causes, which usually is too traumatic for patients under 9 years of age.

Cryotherapy usually requires repeat treatments, and can cause scarring or doughnut-wart (also called ring wart) recurrences.

Dr. Soohoo's cryotherapy technique starts by asking the child to hold an ice pack to the wart to pretreat the area, then applying liquid nitrogen to the wart and a 2-mm surrounding area for 3–6 seconds until the tissue is white.

Allow the area to thaw completely and repeat.

Schedule the patient for a follow-up visit in 2–4 weeks and discuss blister care with the parents.

▸ Cantharidin. A topical preparation made of purified secretions from the blister beetle (Cantharis vesicatoria), cantharidin can be applied in the office and will cause blistering and desquamation of the wart at home.

Cantharidin is highly toxic if ingested and so is not approved for wart treatment, but the Food and Drug Administration in 1998 said it will not take regulatory action if its use is limited to topical use in the professional office setting, according to Dr. Soohoo.

Cantharidin is easy to administer in the office, has a low risk for scarring, and both the application and the blistering are painless if applied appropriately.

The blistering occurs within 24–48 hours and takes 4–7 days to heal.

There have been some reports of lymphangitis or lymphedema associated with cantharidin use.

The wooden end of a cotton-tipped applicator can be used to apply a small drop to each lesion.

Allow it to dry completely, then cover with tape, and advise parents to wash off the treated area 4–6 hours later, or sooner if burning or pain develops, Dr. Soohoo advised.

Discuss blister care with parents. If needed, repeat treatment in 2 weeks.

▸ Immunotherapy. Although not approved for common pediatric warts, topical 5% imiquimod cream (Aldara) often is used and is approved for treatment of genital warts in patients aged 12 years and older.

Aldara cream is painless, well tolerated by all ages, and may induce immunity to warts.

On the downside, it requires 4 months or more of nightly applications and is expensive, although many insurers now cover it for the treatment of warts, she said. To avoid irritation, do not use it to treat warts on the face, neck, or occluded areas like the diaper area or genitals, she advised.

It causes erythema in 30% of cases and, in rare cases, has been associated with flulike symptoms, fever, or photosensitivity.

Dr. Soohoo reserves another off-label topical immunotherapy, squaric acid dibutyl ester, for recalcitrant warts. The treatment seems to be painless and induces immunity to human papillomavirus. It can cause an allergic contact dermatitis, however, and should not be used for facial warts because of irritation.

Start use of squaric acid dibutyl ester by applying a 2% solution to a small, quarter-size area of normal skin on the forearm and wait 2 weeks to check for sensitization, she recommended.

If none occurs, parents could apply a 0.2% solution to warts 3–7 times per week.

An intralesional immunotherapy, Candida antigen injection, is more painful.

The injections are thought to be less painful than cryotherapy but still too painful for young children, she said.

Some teenagers may tolerate it. It seems to be effective and induces immunity but is expensive and can cause itching as well as pain at the treatment site.

▸ Other off-label therapies. Among other off-label therapies, topical 5-fluorouracil can be applied to warts daily for 6 weeks.

"I use it a fair amount in older kids and teens, especially if they're too busy to come back for visits," Dr. Soohoo said. It is an FDA Pregnancy Category X and is available in compounded formulations by mail order from pharmacies.

Topical retinoic acid has been applied to flat warts on the face for up to 8 weeks of daily treatment but can cause local skin irritation, she said.

A study of pulsed dye laser therapy in 56 children found no support for its use as first-line therapy for pediatric warts (J. Am. Acad. Dermatol. 2007;56:205–10).

Duct tape does not work as monotherapy but may boost the efficacy of other topical therapies when used in combination, she concluded.

Dr. Soohoo reported no conflicts of interest.

Treatment Choice Decided by Age, Type of Wart

Dr. Soohoo's preferred wart treatments depend on the patient's age and type of warts, as shown in the following:

▸ Common and plantar warts. For children under age 9 years, salicylic acid is first-line therapy, "but usually by the time parents see me, they've tried this," she said. Cantharidin plus Aldara are her next choice, with squaric acid a "distant third" choice.

For older children, salicylic acid plus liquid nitrogen would be her first choice for therapy, "but often they're too busy to come back" for repeat treatments, in which case she opts for topical 5-fluorouracil instead. Candida antigen injections are a distant third choice for these warts.

▸ Flat warts. Dr. Soohoo would pick tretinoin cream first, with light cryotherapy as her second choice. Sometimes Aldara can be used on these warts, "but with caution," she said.

▸ Periungual warts. Cryotherapy plus salicylic acid comprise first-line treatment for periungual warts in Dr. Soohoo's office. Second in line is topical 5-fluorouracil. Her third option is cantharidin applied in the office plus Aldara applied at home. Rarely, she resorts to Candida antigen injections or squaric acid for these warts.

STANFORD, CALIF. — Two approved therapies for pediatric warts and several off-label options each carry advantages and disadvantages that can help inform treatment selection.

Watchful waiting may be the best option because most pediatric warts are self-limiting, but when you or the parents decide it is time for treatment, consider the child's age, personality, and the number and location of the lesions, Dr. Lillian F. Soohoo said at a pediatric update sponsored by Stanford (Calif.) University.

Up to two-thirds of pediatric warts resolve within 2 years without treatment. "I usually wait until a child is 9 years old before I begin talking about painful therapy" to remove warts, said Dr. Soohoo of the university.

She never restrains children for such therapy.

She described the pros and cons of the two approved treatments—salicylic acid or cryotherapy—and discussed several off-label therapies being used to treat pediatric warts:

▸ Salicylic acid. Many over-the-counter preparations are available in the form of topical solutions, gels, pads, patches, or plasters containing 17%–40% salicylic acid, depending on the product.

Dr. Soohoo generally doesn't use the 40% preparations in younger children but may use them in teenagers, who have thicker skin.

The advantages of salicylic acid start with cure rates of 70%–80%. These preparations are readily available, inexpensive, and may be combined with other therapies, Dr. Soohoo said.

Salicylic acid requires daily applications for weeks or months to be effective, however, so diligence on the part of the patient or parents is a must, she said.

Many parents resist this over-the-counter therapy and demand a prescription-strength treatment.

Salicylic acid also can cause irritation of the skin, eye, and mucous membranes, she said.

▸ Cryotherapy. The most effective version of cryotherapy for pediatric warts is liquid nitrogen, which provides cure rates of 50%–80%. Less effective versions include Verruca-Freeze (chlorodifluoromethane and propane), Histofreezer (dimethyl ether and propane), or Wartner (dimethyl ether and propane), which produce less than half the chill of liquid nitrogen, she said.

Leading the disadvantages of cryotherapy is the pain it causes, which usually is too traumatic for patients under 9 years of age.

Cryotherapy usually requires repeat treatments, and can cause scarring or doughnut-wart (also called ring wart) recurrences.

Dr. Soohoo's cryotherapy technique starts by asking the child to hold an ice pack to the wart to pretreat the area, then applying liquid nitrogen to the wart and a 2-mm surrounding area for 3–6 seconds until the tissue is white.

Allow the area to thaw completely and repeat.

Schedule the patient for a follow-up visit in 2–4 weeks and discuss blister care with the parents.

▸ Cantharidin. A topical preparation made of purified secretions from the blister beetle (Cantharis vesicatoria), cantharidin can be applied in the office and will cause blistering and desquamation of the wart at home.

Cantharidin is highly toxic if ingested and so is not approved for wart treatment, but the Food and Drug Administration in 1998 said it will not take regulatory action if its use is limited to topical use in the professional office setting, according to Dr. Soohoo.

Cantharidin is easy to administer in the office, has a low risk for scarring, and both the application and the blistering are painless if applied appropriately.

The blistering occurs within 24–48 hours and takes 4–7 days to heal.

There have been some reports of lymphangitis or lymphedema associated with cantharidin use.

The wooden end of a cotton-tipped applicator can be used to apply a small drop to each lesion.

Allow it to dry completely, then cover with tape, and advise parents to wash off the treated area 4–6 hours later, or sooner if burning or pain develops, Dr. Soohoo advised.

Discuss blister care with parents. If needed, repeat treatment in 2 weeks.

▸ Immunotherapy. Although not approved for common pediatric warts, topical 5% imiquimod cream (Aldara) often is used and is approved for treatment of genital warts in patients aged 12 years and older.

Aldara cream is painless, well tolerated by all ages, and may induce immunity to warts.

On the downside, it requires 4 months or more of nightly applications and is expensive, although many insurers now cover it for the treatment of warts, she said. To avoid irritation, do not use it to treat warts on the face, neck, or occluded areas like the diaper area or genitals, she advised.

It causes erythema in 30% of cases and, in rare cases, has been associated with flulike symptoms, fever, or photosensitivity.

Dr. Soohoo reserves another off-label topical immunotherapy, squaric acid dibutyl ester, for recalcitrant warts. The treatment seems to be painless and induces immunity to human papillomavirus. It can cause an allergic contact dermatitis, however, and should not be used for facial warts because of irritation.

Start use of squaric acid dibutyl ester by applying a 2% solution to a small, quarter-size area of normal skin on the forearm and wait 2 weeks to check for sensitization, she recommended.

If none occurs, parents could apply a 0.2% solution to warts 3–7 times per week.

An intralesional immunotherapy, Candida antigen injection, is more painful.

The injections are thought to be less painful than cryotherapy but still too painful for young children, she said.

Some teenagers may tolerate it. It seems to be effective and induces immunity but is expensive and can cause itching as well as pain at the treatment site.

▸ Other off-label therapies. Among other off-label therapies, topical 5-fluorouracil can be applied to warts daily for 6 weeks.

"I use it a fair amount in older kids and teens, especially if they're too busy to come back for visits," Dr. Soohoo said. It is an FDA Pregnancy Category X and is available in compounded formulations by mail order from pharmacies.

Topical retinoic acid has been applied to flat warts on the face for up to 8 weeks of daily treatment but can cause local skin irritation, she said.

A study of pulsed dye laser therapy in 56 children found no support for its use as first-line therapy for pediatric warts (J. Am. Acad. Dermatol. 2007;56:205–10).

Duct tape does not work as monotherapy but may boost the efficacy of other topical therapies when used in combination, she concluded.

Dr. Soohoo reported no conflicts of interest.

Treatment Choice Decided by Age, Type of Wart

Dr. Soohoo's preferred wart treatments depend on the patient's age and type of warts, as shown in the following:

▸ Common and plantar warts. For children under age 9 years, salicylic acid is first-line therapy, "but usually by the time parents see me, they've tried this," she said. Cantharidin plus Aldara are her next choice, with squaric acid a "distant third" choice.

For older children, salicylic acid plus liquid nitrogen would be her first choice for therapy, "but often they're too busy to come back" for repeat treatments, in which case she opts for topical 5-fluorouracil instead. Candida antigen injections are a distant third choice for these warts.

▸ Flat warts. Dr. Soohoo would pick tretinoin cream first, with light cryotherapy as her second choice. Sometimes Aldara can be used on these warts, "but with caution," she said.

▸ Periungual warts. Cryotherapy plus salicylic acid comprise first-line treatment for periungual warts in Dr. Soohoo's office. Second in line is topical 5-fluorouracil. Her third option is cantharidin applied in the office plus Aldara applied at home. Rarely, she resorts to Candida antigen injections or squaric acid for these warts.

STANFORD, CALIF. — Two approved therapies for pediatric warts and several off-label options each carry advantages and disadvantages that can help inform treatment selection.

Watchful waiting may be the best option because most pediatric warts are self-limiting, but when you or the parents decide it is time for treatment, consider the child's age, personality, and the number and location of the lesions, Dr. Lillian F. Soohoo said at a pediatric update sponsored by Stanford (Calif.) University.

Up to two-thirds of pediatric warts resolve within 2 years without treatment. "I usually wait until a child is 9 years old before I begin talking about painful therapy" to remove warts, said Dr. Soohoo of the university.

She never restrains children for such therapy.

She described the pros and cons of the two approved treatments—salicylic acid or cryotherapy—and discussed several off-label therapies being used to treat pediatric warts:

▸ Salicylic acid. Many over-the-counter preparations are available in the form of topical solutions, gels, pads, patches, or plasters containing 17%–40% salicylic acid, depending on the product.

Dr. Soohoo generally doesn't use the 40% preparations in younger children but may use them in teenagers, who have thicker skin.

The advantages of salicylic acid start with cure rates of 70%–80%. These preparations are readily available, inexpensive, and may be combined with other therapies, Dr. Soohoo said.

Salicylic acid requires daily applications for weeks or months to be effective, however, so diligence on the part of the patient or parents is a must, she said.

Many parents resist this over-the-counter therapy and demand a prescription-strength treatment.

Salicylic acid also can cause irritation of the skin, eye, and mucous membranes, she said.

▸ Cryotherapy. The most effective version of cryotherapy for pediatric warts is liquid nitrogen, which provides cure rates of 50%–80%. Less effective versions include Verruca-Freeze (chlorodifluoromethane and propane), Histofreezer (dimethyl ether and propane), or Wartner (dimethyl ether and propane), which produce less than half the chill of liquid nitrogen, she said.

Leading the disadvantages of cryotherapy is the pain it causes, which usually is too traumatic for patients under 9 years of age.

Cryotherapy usually requires repeat treatments, and can cause scarring or doughnut-wart (also called ring wart) recurrences.

Dr. Soohoo's cryotherapy technique starts by asking the child to hold an ice pack to the wart to pretreat the area, then applying liquid nitrogen to the wart and a 2-mm surrounding area for 3–6 seconds until the tissue is white.

Allow the area to thaw completely and repeat.

Schedule the patient for a follow-up visit in 2–4 weeks and discuss blister care with the parents.

▸ Cantharidin. A topical preparation made of purified secretions from the blister beetle (Cantharis vesicatoria), cantharidin can be applied in the office and will cause blistering and desquamation of the wart at home.

Cantharidin is highly toxic if ingested and so is not approved for wart treatment, but the Food and Drug Administration in 1998 said it will not take regulatory action if its use is limited to topical use in the professional office setting, according to Dr. Soohoo.

Cantharidin is easy to administer in the office, has a low risk for scarring, and both the application and the blistering are painless if applied appropriately.

The blistering occurs within 24–48 hours and takes 4–7 days to heal.

There have been some reports of lymphangitis or lymphedema associated with cantharidin use.

The wooden end of a cotton-tipped applicator can be used to apply a small drop to each lesion.

Allow it to dry completely, then cover with tape, and advise parents to wash off the treated area 4–6 hours later, or sooner if burning or pain develops, Dr. Soohoo advised.

Discuss blister care with parents. If needed, repeat treatment in 2 weeks.

▸ Immunotherapy. Although not approved for common pediatric warts, topical 5% imiquimod cream (Aldara) often is used and is approved for treatment of genital warts in patients aged 12 years and older.

Aldara cream is painless, well tolerated by all ages, and may induce immunity to warts.

On the downside, it requires 4 months or more of nightly applications and is expensive, although many insurers now cover it for the treatment of warts, she said. To avoid irritation, do not use it to treat warts on the face, neck, or occluded areas like the diaper area or genitals, she advised.

It causes erythema in 30% of cases and, in rare cases, has been associated with flulike symptoms, fever, or photosensitivity.

Dr. Soohoo reserves another off-label topical immunotherapy, squaric acid dibutyl ester, for recalcitrant warts. The treatment seems to be painless and induces immunity to human papillomavirus. It can cause an allergic contact dermatitis, however, and should not be used for facial warts because of irritation.

Start use of squaric acid dibutyl ester by applying a 2% solution to a small, quarter-size area of normal skin on the forearm and wait 2 weeks to check for sensitization, she recommended.

If none occurs, parents could apply a 0.2% solution to warts 3–7 times per week.

An intralesional immunotherapy, Candida antigen injection, is more painful.

The injections are thought to be less painful than cryotherapy but still too painful for young children, she said.

Some teenagers may tolerate it. It seems to be effective and induces immunity but is expensive and can cause itching as well as pain at the treatment site.

▸ Other off-label therapies. Among other off-label therapies, topical 5-fluorouracil can be applied to warts daily for 6 weeks.

"I use it a fair amount in older kids and teens, especially if they're too busy to come back for visits," Dr. Soohoo said. It is an FDA Pregnancy Category X and is available in compounded formulations by mail order from pharmacies.

Topical retinoic acid has been applied to flat warts on the face for up to 8 weeks of daily treatment but can cause local skin irritation, she said.

A study of pulsed dye laser therapy in 56 children found no support for its use as first-line therapy for pediatric warts (J. Am. Acad. Dermatol. 2007;56:205–10).

Duct tape does not work as monotherapy but may boost the efficacy of other topical therapies when used in combination, she concluded.

Dr. Soohoo reported no conflicts of interest.

Treatment Choice Decided by Age, Type of Wart

Dr. Soohoo's preferred wart treatments depend on the patient's age and type of warts, as shown in the following:

▸ Common and plantar warts. For children under age 9 years, salicylic acid is first-line therapy, "but usually by the time parents see me, they've tried this," she said. Cantharidin plus Aldara are her next choice, with squaric acid a "distant third" choice.

For older children, salicylic acid plus liquid nitrogen would be her first choice for therapy, "but often they're too busy to come back" for repeat treatments, in which case she opts for topical 5-fluorouracil instead. Candida antigen injections are a distant third choice for these warts.

▸ Flat warts. Dr. Soohoo would pick tretinoin cream first, with light cryotherapy as her second choice. Sometimes Aldara can be used on these warts, "but with caution," she said.

▸ Periungual warts. Cryotherapy plus salicylic acid comprise first-line treatment for periungual warts in Dr. Soohoo's office. Second in line is topical 5-fluorouracil. Her third option is cantharidin applied in the office plus Aldara applied at home. Rarely, she resorts to Candida antigen injections or squaric acid for these warts.

STANFORD, CALIF. — A rare genetic disorder that usually is lethal to male babies and can leave abnormalities of the skin, eyes, and other body parts in females, may be more common than originally thought.

Incontinentia pigmenti is caused by a mutation in the IKBKG gene (also known as NEMO), which resides on the X chromosome. A genetic diagnosis can be helpful in females with suspected incontinentia pigmenti because they carry a 50:50 risk of passing the mutation on to their offspring, Dr. Louanne Hudgins said at a pediatric update sponsored by Stanford University.

Typically, blistering on the skin of a neonate or infant progresses to a wart-like rash, swirling macular hyperpigmentation, and linear hypopigmentation.

Other ectodermal-derived tissues are affected, too. Patients with incontinentia pigmenti often have patchy alopecia of the scalp, dystrophic nails, and tooth abnormalities (fewer teeth than normal or abnormal tooth formation, such as a cone-shaped tooth). Associated eye problems are the most significant finding in survivors with incontinentia pigmenti. They often have retinal vascular proliferation, which can lead to retinal detachment.

"The mother may look completely normal or may have linear patches without as much hair" as a typical scalp, but genetic testing can identify incontinentia pigmenti in 80% of cases, said Dr. Hudgins, professor of pediatrics and chief of medical genetics at Stanford.

She and her associates used to test for incontinentia pigmenti only in girls who had all of the associated findings, and rarely made the diagnosis. More recently, however, "we've been doing the testing in kids with a few findings, and are finding the mutation. I think it's more common than we thought it was," she said. "In our genetic disorders of the skin clinic, we see as many as four or five cases per year" of incontinentia pigmenti.

Even with a presumptive diagnosis, it's important to order an ophthalmologic exam. "If this child is at risk for retinal detachment, you need to have that child followed by ophthalmology on a regular basis so you can maintain the best vision possible," she said. Dental and dermatologic evaluations also are warranted. "If they have ongoing skin problems, it's certainly a good idea to have a dermatologist follow them," said Dr. Hudgins, who reported having no conflicts of interest.

STANFORD, CALIF. — A rare genetic disorder that usually is lethal to male babies and can leave abnormalities of the skin, eyes, and other body parts in females, may be more common than originally thought.

Incontinentia pigmenti is caused by a mutation in the IKBKG gene (also known as NEMO), which resides on the X chromosome. A genetic diagnosis can be helpful in females with suspected incontinentia pigmenti because they carry a 50:50 risk of passing the mutation on to their offspring, Dr. Louanne Hudgins said at a pediatric update sponsored by Stanford University.

Typically, blistering on the skin of a neonate or infant progresses to a wart-like rash, swirling macular hyperpigmentation, and linear hypopigmentation.

Other ectodermal-derived tissues are affected, too. Patients with incontinentia pigmenti often have patchy alopecia of the scalp, dystrophic nails, and tooth abnormalities (fewer teeth than normal or abnormal tooth formation, such as a cone-shaped tooth). Associated eye problems are the most significant finding in survivors with incontinentia pigmenti. They often have retinal vascular proliferation, which can lead to retinal detachment.

"The mother may look completely normal or may have linear patches without as much hair" as a typical scalp, but genetic testing can identify incontinentia pigmenti in 80% of cases, said Dr. Hudgins, professor of pediatrics and chief of medical genetics at Stanford.

She and her associates used to test for incontinentia pigmenti only in girls who had all of the associated findings, and rarely made the diagnosis. More recently, however, "we've been doing the testing in kids with a few findings, and are finding the mutation. I think it's more common than we thought it was," she said. "In our genetic disorders of the skin clinic, we see as many as four or five cases per year" of incontinentia pigmenti.

Even with a presumptive diagnosis, it's important to order an ophthalmologic exam. "If this child is at risk for retinal detachment, you need to have that child followed by ophthalmology on a regular basis so you can maintain the best vision possible," she said. Dental and dermatologic evaluations also are warranted. "If they have ongoing skin problems, it's certainly a good idea to have a dermatologist follow them," said Dr. Hudgins, who reported having no conflicts of interest.

STANFORD, CALIF. — A rare genetic disorder that usually is lethal to male babies and can leave abnormalities of the skin, eyes, and other body parts in females, may be more common than originally thought.

Incontinentia pigmenti is caused by a mutation in the IKBKG gene (also known as NEMO), which resides on the X chromosome. A genetic diagnosis can be helpful in females with suspected incontinentia pigmenti because they carry a 50:50 risk of passing the mutation on to their offspring, Dr. Louanne Hudgins said at a pediatric update sponsored by Stanford University.

Typically, blistering on the skin of a neonate or infant progresses to a wart-like rash, swirling macular hyperpigmentation, and linear hypopigmentation.

Other ectodermal-derived tissues are affected, too. Patients with incontinentia pigmenti often have patchy alopecia of the scalp, dystrophic nails, and tooth abnormalities (fewer teeth than normal or abnormal tooth formation, such as a cone-shaped tooth). Associated eye problems are the most significant finding in survivors with incontinentia pigmenti. They often have retinal vascular proliferation, which can lead to retinal detachment.

"The mother may look completely normal or may have linear patches without as much hair" as a typical scalp, but genetic testing can identify incontinentia pigmenti in 80% of cases, said Dr. Hudgins, professor of pediatrics and chief of medical genetics at Stanford.

She and her associates used to test for incontinentia pigmenti only in girls who had all of the associated findings, and rarely made the diagnosis. More recently, however, "we've been doing the testing in kids with a few findings, and are finding the mutation. I think it's more common than we thought it was," she said. "In our genetic disorders of the skin clinic, we see as many as four or five cases per year" of incontinentia pigmenti.

Even with a presumptive diagnosis, it's important to order an ophthalmologic exam. "If this child is at risk for retinal detachment, you need to have that child followed by ophthalmology on a regular basis so you can maintain the best vision possible," she said. Dental and dermatologic evaluations also are warranted. "If they have ongoing skin problems, it's certainly a good idea to have a dermatologist follow them," said Dr. Hudgins, who reported having no conflicts of interest.

STANFORD, CALIF. — The art and science of treating acne in adolescents start with touching the patient.

"Many adolescents have a feeling that their acne is very dirty, and they take it personally," Dr. Alfred T. Lane said at a pediatric update sponsored by Stanford (Calif.) University.

They think of themselves as bad people, he suggested, but "I think that by touching them, we develop a relationship with them that says we're very accepting of their condition."

He first asks permission by saying, "May I touch your skin?" and makes sure that the patient saw him clean his hands with an antiseptic gel when he entered the exam room.

Making sure patients are motivated to adhere to a treatment regimen and helping them to set reasonable expectations for results are important next steps, said Dr. Lane, professor of dermatology and pediatrics at the university.

As a pediatrician, before training in dermatology, he often would offer to treat adolescent acne detected during visits for other reasons, such as for a sports physical exam. The teenager usually would agree, then not return for the 6-week follow-up visit. If he saw the patient months later for some other reason, the acne typically would be unchanged and the teen would say he or she didn't use the medication.

"Then, when I started my dermatology residency, I used the same medications and 6 weeks later everybody was better. It was because they were motivated" to adhere to topical or oral therapy, he said. "Now, if I see patients for another condition and I notice their acne, I don't even ask about it, unless they ask me."

Even motivated adolescents will have unreasonable expectations, however, and must be educated that improvements from acne therapy won't be seen for 4–8 weeks or sometimes more. "An adolescent wants instant results, just like with their text messaging," said Dr. Lane, who is also chair of dermatology at the university.

When choosing the therapy, match your choice to the type of problem, he added, as in the following examples:

▸ "Cocktail party" acne. When someone approaches Dr. Lane at a party and asks what to use for their child's acne, over-the-counter benzoyl peroxide lotion is the simplest and safest answer, he said.

▸ Papules. The benzoyl peroxide lotion or a prescription gel version and topical retinoids are the treatments of choice for acne papules, often in a combination regimen of benzoyl peroxide applications in the morning and a retinoid at night.

Benzoyl peroxide can be used once or twice daily but can cause dry skin and irritant dermatitis, especially if used more frequently. Chronic use can cause allergic contact dermatitis in about 1% of patients, so start by applying it to an arm for several days before moving to the face.

The retinoids—tretinoin or adapalene cream or gel—may cause photosensitivity, which can be minimized by applying it in the evening. In the first few weeks these agents may cause irritant dermatitis or even some acne pustules, so tell the patient "there's a chance that you may get worse before you're better," said Dr. Lane, who reported having no conflicts of interest.

Ask patients to wait 20–30 minutes after washing their face before using a retinoid, which should be applied to dry skin. For some adolescent boys, this is a deal-breaker, "so I tell them 'If you can't wait 30 minutes, just put the retinoid on and don't wash your face,'" he said.

Using benzoyl peroxide in the morning and a retinoid at night provides synergistic effects, but applying anything at the same time as a retinoid is likely to cause skin irritation, he added.

▸ Pustules. If pustules are present, add a twice-daily topical antibiotic (erythromycin or clindamycin), which is safe to combine with benzoyl peroxide but shouldn't be applied at the same time as a tretinoin.

Some vehicles may dry the skin, while others may feel greasy, either of which can work to the advantage of individual patients. Rarely, clindamycin may cause diarrhea.

Acne on the back or chest often does not respond well to retinoids or benzoyl peroxide, and teenage boys often won't adhere to any topical therapy (including topical antibiotics), so systemic antibiotics may be needed before you can get them to transition to topical therapies, Dr. Lane noted. Tetracyclines are his first choice for systemic therapy, followed by erythromycin.

Systemic side effects can cause GI irritation or yeast vaginitis and may decrease the effectiveness of oral contraceptives.

Some adolescent girls with acne may benefit from hormonal therapy, but Dr. Lane leaves this approach to the patient's primary care physician.

▸ Cysts and scars. More aggressive treatment is appropriate for acne with cysts and scars, and many of these patients will end up receiving isotretinoin from a dermatologist who can follow them carefully for numerous potential side effects.

For patients aged 18–25 years, isotretinoin therapy will get rid of acne for 10 years or longer in 30%, and 40% will have recurrent acne that responds to topical therapies or antibiotics. The odds are even better for patients aged 12–15 years, Dr. Lane said.

Many adolescents feel that their acne is dirty, and they take it personally. ©Scott

STANFORD, CALIF. — The art and science of treating acne in adolescents start with touching the patient.

"Many adolescents have a feeling that their acne is very dirty, and they take it personally," Dr. Alfred T. Lane said at a pediatric update sponsored by Stanford (Calif.) University.

They think of themselves as bad people, he suggested, but "I think that by touching them, we develop a relationship with them that says we're very accepting of their condition."

He first asks permission by saying, "May I touch your skin?" and makes sure that the patient saw him clean his hands with an antiseptic gel when he entered the exam room.

Making sure patients are motivated to adhere to a treatment regimen and helping them to set reasonable expectations for results are important next steps, said Dr. Lane, professor of dermatology and pediatrics at the university.

As a pediatrician, before training in dermatology, he often would offer to treat adolescent acne detected during visits for other reasons, such as for a sports physical exam. The teenager usually would agree, then not return for the 6-week follow-up visit. If he saw the patient months later for some other reason, the acne typically would be unchanged and the teen would say he or she didn't use the medication.

"Then, when I started my dermatology residency, I used the same medications and 6 weeks later everybody was better. It was because they were motivated" to adhere to topical or oral therapy, he said. "Now, if I see patients for another condition and I notice their acne, I don't even ask about it, unless they ask me."

Even motivated adolescents will have unreasonable expectations, however, and must be educated that improvements from acne therapy won't be seen for 4–8 weeks or sometimes more. "An adolescent wants instant results, just like with their text messaging," said Dr. Lane, who is also chair of dermatology at the university.

When choosing the therapy, match your choice to the type of problem, he added, as in the following examples:

▸ "Cocktail party" acne. When someone approaches Dr. Lane at a party and asks what to use for their child's acne, over-the-counter benzoyl peroxide lotion is the simplest and safest answer, he said.

▸ Papules. The benzoyl peroxide lotion or a prescription gel version and topical retinoids are the treatments of choice for acne papules, often in a combination regimen of benzoyl peroxide applications in the morning and a retinoid at night.

Benzoyl peroxide can be used once or twice daily but can cause dry skin and irritant dermatitis, especially if used more frequently. Chronic use can cause allergic contact dermatitis in about 1% of patients, so start by applying it to an arm for several days before moving to the face.

The retinoids—tretinoin or adapalene cream or gel—may cause photosensitivity, which can be minimized by applying it in the evening. In the first few weeks these agents may cause irritant dermatitis or even some acne pustules, so tell the patient "there's a chance that you may get worse before you're better," said Dr. Lane, who reported having no conflicts of interest.

Ask patients to wait 20–30 minutes after washing their face before using a retinoid, which should be applied to dry skin. For some adolescent boys, this is a deal-breaker, "so I tell them 'If you can't wait 30 minutes, just put the retinoid on and don't wash your face,'" he said.

Using benzoyl peroxide in the morning and a retinoid at night provides synergistic effects, but applying anything at the same time as a retinoid is likely to cause skin irritation, he added.

▸ Pustules. If pustules are present, add a twice-daily topical antibiotic (erythromycin or clindamycin), which is safe to combine with benzoyl peroxide but shouldn't be applied at the same time as a tretinoin.

Some vehicles may dry the skin, while others may feel greasy, either of which can work to the advantage of individual patients. Rarely, clindamycin may cause diarrhea.

Acne on the back or chest often does not respond well to retinoids or benzoyl peroxide, and teenage boys often won't adhere to any topical therapy (including topical antibiotics), so systemic antibiotics may be needed before you can get them to transition to topical therapies, Dr. Lane noted. Tetracyclines are his first choice for systemic therapy, followed by erythromycin.

Systemic side effects can cause GI irritation or yeast vaginitis and may decrease the effectiveness of oral contraceptives.

Some adolescent girls with acne may benefit from hormonal therapy, but Dr. Lane leaves this approach to the patient's primary care physician.

▸ Cysts and scars. More aggressive treatment is appropriate for acne with cysts and scars, and many of these patients will end up receiving isotretinoin from a dermatologist who can follow them carefully for numerous potential side effects.

For patients aged 18–25 years, isotretinoin therapy will get rid of acne for 10 years or longer in 30%, and 40% will have recurrent acne that responds to topical therapies or antibiotics. The odds are even better for patients aged 12–15 years, Dr. Lane said.

Many adolescents feel that their acne is dirty, and they take it personally. ©Scott

STANFORD, CALIF. — The art and science of treating acne in adolescents start with touching the patient.

"Many adolescents have a feeling that their acne is very dirty, and they take it personally," Dr. Alfred T. Lane said at a pediatric update sponsored by Stanford (Calif.) University.

They think of themselves as bad people, he suggested, but "I think that by touching them, we develop a relationship with them that says we're very accepting of their condition."

He first asks permission by saying, "May I touch your skin?" and makes sure that the patient saw him clean his hands with an antiseptic gel when he entered the exam room.

Making sure patients are motivated to adhere to a treatment regimen and helping them to set reasonable expectations for results are important next steps, said Dr. Lane, professor of dermatology and pediatrics at the university.

As a pediatrician, before training in dermatology, he often would offer to treat adolescent acne detected during visits for other reasons, such as for a sports physical exam. The teenager usually would agree, then not return for the 6-week follow-up visit. If he saw the patient months later for some other reason, the acne typically would be unchanged and the teen would say he or she didn't use the medication.

"Then, when I started my dermatology residency, I used the same medications and 6 weeks later everybody was better. It was because they were motivated" to adhere to topical or oral therapy, he said. "Now, if I see patients for another condition and I notice their acne, I don't even ask about it, unless they ask me."

Even motivated adolescents will have unreasonable expectations, however, and must be educated that improvements from acne therapy won't be seen for 4–8 weeks or sometimes more. "An adolescent wants instant results, just like with their text messaging," said Dr. Lane, who is also chair of dermatology at the university.

When choosing the therapy, match your choice to the type of problem, he added, as in the following examples:

▸ "Cocktail party" acne. When someone approaches Dr. Lane at a party and asks what to use for their child's acne, over-the-counter benzoyl peroxide lotion is the simplest and safest answer, he said.

▸ Papules. The benzoyl peroxide lotion or a prescription gel version and topical retinoids are the treatments of choice for acne papules, often in a combination regimen of benzoyl peroxide applications in the morning and a retinoid at night.

Benzoyl peroxide can be used once or twice daily but can cause dry skin and irritant dermatitis, especially if used more frequently. Chronic use can cause allergic contact dermatitis in about 1% of patients, so start by applying it to an arm for several days before moving to the face.

The retinoids—tretinoin or adapalene cream or gel—may cause photosensitivity, which can be minimized by applying it in the evening. In the first few weeks these agents may cause irritant dermatitis or even some acne pustules, so tell the patient "there's a chance that you may get worse before you're better," said Dr. Lane, who reported having no conflicts of interest.

Ask patients to wait 20–30 minutes after washing their face before using a retinoid, which should be applied to dry skin. For some adolescent boys, this is a deal-breaker, "so I tell them 'If you can't wait 30 minutes, just put the retinoid on and don't wash your face,'" he said.

Using benzoyl peroxide in the morning and a retinoid at night provides synergistic effects, but applying anything at the same time as a retinoid is likely to cause skin irritation, he added.

▸ Pustules. If pustules are present, add a twice-daily topical antibiotic (erythromycin or clindamycin), which is safe to combine with benzoyl peroxide but shouldn't be applied at the same time as a tretinoin.

Some vehicles may dry the skin, while others may feel greasy, either of which can work to the advantage of individual patients. Rarely, clindamycin may cause diarrhea.

Acne on the back or chest often does not respond well to retinoids or benzoyl peroxide, and teenage boys often won't adhere to any topical therapy (including topical antibiotics), so systemic antibiotics may be needed before you can get them to transition to topical therapies, Dr. Lane noted. Tetracyclines are his first choice for systemic therapy, followed by erythromycin.

Systemic side effects can cause GI irritation or yeast vaginitis and may decrease the effectiveness of oral contraceptives.

Some adolescent girls with acne may benefit from hormonal therapy, but Dr. Lane leaves this approach to the patient's primary care physician.

▸ Cysts and scars. More aggressive treatment is appropriate for acne with cysts and scars, and many of these patients will end up receiving isotretinoin from a dermatologist who can follow them carefully for numerous potential side effects.

For patients aged 18–25 years, isotretinoin therapy will get rid of acne for 10 years or longer in 30%, and 40% will have recurrent acne that responds to topical therapies or antibiotics. The odds are even better for patients aged 12–15 years, Dr. Lane said.

Many adolescents feel that their acne is dirty, and they take it personally. ©Scott

SAN FRANCISCO — Inappropriate shocks from implantable cardioverter defibrillators are common and may cause harm, a review of the medical literature suggests.

“There are not a great deal of data that enable us to separate out the adverse effects of inappropriate versus appropriate shocks,” but both seem to be associated with an increased risk for death and other adverse outcomes, Dr. Alfred E. Buxton said at the annual meeting of the Heart Rhythm Society.

The literature suggests that 30%-60% of patients with implantable cardioverter defibrillators (ICDs) get appropriate shocks delivered to terminate a life-threatening arrhythmia, and as many as 20%-30% of patients get inappropriate shocks at other times.

“ICD shocks, while potentially life saving, have potential adverse effects,” said Dr. Buxton, professor of medicine at Brown University, Providence, R.I. Shocks have been associated with increased noncardiac mortality, reduced quality of life, and device-induced proarrhythmias.

Compared with patients who had never been shocked by their ICDs, patients who'd had any ICD shock had a quadrupled risk for death from any cause in an analysis of data from the 719-patient Multicenter Automatic Defibrillator Implantation Trial II (MADIT II). Inappropriate shocks were associated with a doubling in all-cause mortality, and appropriate shocks were associated with a tripling in all-cause mortality, compared with no shocks (J. Am. Coll. Cardiol. 2008;51:357-65).

Inappropriate shocks occurred in 12% of patients and comprised 31% of all shocks in the MADIT II trial.

Clearly, needing an ICD shock to terminate a life-threatening arrhythmia puts a person at risk for death, “but there is probably also some additive effect of inappropriate shocks,” Dr. Buxton said. He has been a consultant or speaker or received funding from companies that make cardiac devices including Boston Scientific, GEHealthcare, Medtronic, and St. Jude Medical.

Previous analyses also identified adverse effects associated with ICD shocks. Approximately half of 60 patients were shocked by their ICDs within 2 years of implantation in a 1998 study. Anxiety and sadness increased and initiation of new activities decreased in patients who'd had a shock compared with no shocks, and the same was seen in patients with five or more shocks, compared with just one or no shocks, he said.

A 1999 analysis of the Coronary Artery Bypass Graft Patch trial found no difference in quality of life after 6 months between 228 control patients without ICDs and 101 patients with ICDs who hadn't been shocked, but lower quality of life in 101 other patients with ICDs who had been shocked, compared with controls.

About a third of 373 patients with ICDs in the Antiarrhythmics vs. Implantable Defibrillators (AVID) trial received at least one shock within 1 year, and receiving more than one shock was associated with a significant reduction in mental well-being and physical function, a 2002 analysis concluded.

Data from several studies suggest that there is a complex interaction between depression and ICD shocks.

Depression may increase the likelihood of developing arrhythmias and having shocks, and has been associated with decreased heart rate variability, he said. But a 1993 study of 241 patients followed for a mean of 26 months found no significant difference in overall survival rates for patients who had or had not been shocked. At least one shock occurred in 76% of patients, and 63% of the cohort had inappropriate shocks. Mortality rates were similar for patients with appropriate shocks (38% died) and inappropriate shocks (35%).

And an unpublished secondary analysis of the 2004 Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) found a significantly higher death rate in patients who had received ICD shocks, compared with non-ICD patients and those with ICDs but no shocks, Dr. Buxton said.

'ICD shocks, while potentially life saving, [also] have potential adverse effects.' DR. BUXTON

SAN FRANCISCO — Inappropriate shocks from implantable cardioverter defibrillators are common and may cause harm, a review of the medical literature suggests.

“There are not a great deal of data that enable us to separate out the adverse effects of inappropriate versus appropriate shocks,” but both seem to be associated with an increased risk for death and other adverse outcomes, Dr. Alfred E. Buxton said at the annual meeting of the Heart Rhythm Society.

The literature suggests that 30%-60% of patients with implantable cardioverter defibrillators (ICDs) get appropriate shocks delivered to terminate a life-threatening arrhythmia, and as many as 20%-30% of patients get inappropriate shocks at other times.

“ICD shocks, while potentially life saving, have potential adverse effects,” said Dr. Buxton, professor of medicine at Brown University, Providence, R.I. Shocks have been associated with increased noncardiac mortality, reduced quality of life, and device-induced proarrhythmias.

Compared with patients who had never been shocked by their ICDs, patients who'd had any ICD shock had a quadrupled risk for death from any cause in an analysis of data from the 719-patient Multicenter Automatic Defibrillator Implantation Trial II (MADIT II). Inappropriate shocks were associated with a doubling in all-cause mortality, and appropriate shocks were associated with a tripling in all-cause mortality, compared with no shocks (J. Am. Coll. Cardiol. 2008;51:357-65).

Inappropriate shocks occurred in 12% of patients and comprised 31% of all shocks in the MADIT II trial.

Clearly, needing an ICD shock to terminate a life-threatening arrhythmia puts a person at risk for death, “but there is probably also some additive effect of inappropriate shocks,” Dr. Buxton said. He has been a consultant or speaker or received funding from companies that make cardiac devices including Boston Scientific, GEHealthcare, Medtronic, and St. Jude Medical.

Previous analyses also identified adverse effects associated with ICD shocks. Approximately half of 60 patients were shocked by their ICDs within 2 years of implantation in a 1998 study. Anxiety and sadness increased and initiation of new activities decreased in patients who'd had a shock compared with no shocks, and the same was seen in patients with five or more shocks, compared with just one or no shocks, he said.

A 1999 analysis of the Coronary Artery Bypass Graft Patch trial found no difference in quality of life after 6 months between 228 control patients without ICDs and 101 patients with ICDs who hadn't been shocked, but lower quality of life in 101 other patients with ICDs who had been shocked, compared with controls.

About a third of 373 patients with ICDs in the Antiarrhythmics vs. Implantable Defibrillators (AVID) trial received at least one shock within 1 year, and receiving more than one shock was associated with a significant reduction in mental well-being and physical function, a 2002 analysis concluded.

Data from several studies suggest that there is a complex interaction between depression and ICD shocks.

Depression may increase the likelihood of developing arrhythmias and having shocks, and has been associated with decreased heart rate variability, he said. But a 1993 study of 241 patients followed for a mean of 26 months found no significant difference in overall survival rates for patients who had or had not been shocked. At least one shock occurred in 76% of patients, and 63% of the cohort had inappropriate shocks. Mortality rates were similar for patients with appropriate shocks (38% died) and inappropriate shocks (35%).

And an unpublished secondary analysis of the 2004 Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) found a significantly higher death rate in patients who had received ICD shocks, compared with non-ICD patients and those with ICDs but no shocks, Dr. Buxton said.

'ICD shocks, while potentially life saving, [also] have potential adverse effects.' DR. BUXTON

SAN FRANCISCO — Inappropriate shocks from implantable cardioverter defibrillators are common and may cause harm, a review of the medical literature suggests.

“There are not a great deal of data that enable us to separate out the adverse effects of inappropriate versus appropriate shocks,” but both seem to be associated with an increased risk for death and other adverse outcomes, Dr. Alfred E. Buxton said at the annual meeting of the Heart Rhythm Society.

The literature suggests that 30%-60% of patients with implantable cardioverter defibrillators (ICDs) get appropriate shocks delivered to terminate a life-threatening arrhythmia, and as many as 20%-30% of patients get inappropriate shocks at other times.

“ICD shocks, while potentially life saving, have potential adverse effects,” said Dr. Buxton, professor of medicine at Brown University, Providence, R.I. Shocks have been associated with increased noncardiac mortality, reduced quality of life, and device-induced proarrhythmias.

Compared with patients who had never been shocked by their ICDs, patients who'd had any ICD shock had a quadrupled risk for death from any cause in an analysis of data from the 719-patient Multicenter Automatic Defibrillator Implantation Trial II (MADIT II). Inappropriate shocks were associated with a doubling in all-cause mortality, and appropriate shocks were associated with a tripling in all-cause mortality, compared with no shocks (J. Am. Coll. Cardiol. 2008;51:357-65).

Inappropriate shocks occurred in 12% of patients and comprised 31% of all shocks in the MADIT II trial.

Clearly, needing an ICD shock to terminate a life-threatening arrhythmia puts a person at risk for death, “but there is probably also some additive effect of inappropriate shocks,” Dr. Buxton said. He has been a consultant or speaker or received funding from companies that make cardiac devices including Boston Scientific, GEHealthcare, Medtronic, and St. Jude Medical.

Previous analyses also identified adverse effects associated with ICD shocks. Approximately half of 60 patients were shocked by their ICDs within 2 years of implantation in a 1998 study. Anxiety and sadness increased and initiation of new activities decreased in patients who'd had a shock compared with no shocks, and the same was seen in patients with five or more shocks, compared with just one or no shocks, he said.

A 1999 analysis of the Coronary Artery Bypass Graft Patch trial found no difference in quality of life after 6 months between 228 control patients without ICDs and 101 patients with ICDs who hadn't been shocked, but lower quality of life in 101 other patients with ICDs who had been shocked, compared with controls.

About a third of 373 patients with ICDs in the Antiarrhythmics vs. Implantable Defibrillators (AVID) trial received at least one shock within 1 year, and receiving more than one shock was associated with a significant reduction in mental well-being and physical function, a 2002 analysis concluded.

Data from several studies suggest that there is a complex interaction between depression and ICD shocks.

Depression may increase the likelihood of developing arrhythmias and having shocks, and has been associated with decreased heart rate variability, he said. But a 1993 study of 241 patients followed for a mean of 26 months found no significant difference in overall survival rates for patients who had or had not been shocked. At least one shock occurred in 76% of patients, and 63% of the cohort had inappropriate shocks. Mortality rates were similar for patients with appropriate shocks (38% died) and inappropriate shocks (35%).

And an unpublished secondary analysis of the 2004 Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) found a significantly higher death rate in patients who had received ICD shocks, compared with non-ICD patients and those with ICDs but no shocks, Dr. Buxton said.

'ICD shocks, while potentially life saving, [also] have potential adverse effects.' DR. BUXTON

SAN FRANCISCO — From age 15 years onward, Hispanic females in the United States are significantly more likely to be diagnosed with incident type 2 diabetes than type 1 diabetes, according to an analysis of data from the Search for Diabetes in Youth study.

In addition, at ages 10-14 years, Hispanic females in the United States had twice the incidence of type 2 diabetes in 2002-2005, compared with Hispanic males. The study looked at youths less than 20 years old in populations from six states, Jean M. Lawrence and her associates reported at the annual scientific sessions of the American Diabetes Association.

During that period, 635 youths were diagnosed with diabetes out of a population of more than 3 million, with incidence rates peaking for females at ages 5-9 years and for males at ages 10-14 years, said Ms. Lawrence of Kaiser Permanente Southern California, in Pasadena. She had no conflicts of interest related to the study.

Incidence rates for type 1 diabetes in girls were 9/100,000 in ages 0-4 years, 20/100,000 in ages 5-9 years, 16/100,000 in ages 10-14 years, and 7/100,000 in ages 15-19 years. For boys, incidence rates for type 1 diabetes were 11/100,000 in ages 0-4 years, 16/100,000 in ages 5-9 years, 20/100,000 in ages 10-14 years, and 9/100,000 in ages 15-19 years.

Type 2 diabetes rarely was diagnosed in children less than 10 years old. For ages 10-14 years, the incidence of type 2 diabetes was 15/100,000 for girls and 7/100,000 for boys. For ages 15-19 years, the incidence was 13/100,000 for girls and 11/100,000 for boys.

The study identified prevalent diabetes in the year 2001 in 781 out of more than 641,000 Hispanic youths—most of it type 1 rather than type 2. Prevalence rates did not differ significantly by sex in any of the age groups.

The prevalence increased with age for both diabetes types in both sexes. In individuals ages 15-17 years, the prevalence of type 1 diabetes was 1.6/1,000 for girls and 1.8/1,000 for boys, and the prevalence of type 2 diabetes was 0.8/1,000 for girls and 0.6/1,000 for boys, Ms. Lawrence said.

Data from two additional studies presented in the same session at the meeting showed steep increases in the incidence and prevalence of diabetes in Canadians and a faster than predicted rise in type 1 diabetes in Finland, the world's hot spot for the disease.

In the Canadian study, data on diabetes in all residents younger than 20 years of age in the province of Alberta found 2,301 prevalent cases among 840,000 children and adolescents, for a rate of 28/10,000. Approximately 80% of cases were in 10- to 19-year-olds, Jeffrey A. Johnson, Ph.D., of the University of Alberta, Edmonton, and his associates reported. He had no conflicts of interest in this study.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — From age 15 years onward, Hispanic females in the United States are significantly more likely to be diagnosed with incident type 2 diabetes than type 1 diabetes, according to an analysis of data from the Search for Diabetes in Youth study.

In addition, at ages 10-14 years, Hispanic females in the United States had twice the incidence of type 2 diabetes in 2002-2005, compared with Hispanic males. The study looked at youths less than 20 years old in populations from six states, Jean M. Lawrence and her associates reported at the annual scientific sessions of the American Diabetes Association.

During that period, 635 youths were diagnosed with diabetes out of a population of more than 3 million, with incidence rates peaking for females at ages 5-9 years and for males at ages 10-14 years, said Ms. Lawrence of Kaiser Permanente Southern California, in Pasadena. She had no conflicts of interest related to the study.

Incidence rates for type 1 diabetes in girls were 9/100,000 in ages 0-4 years, 20/100,000 in ages 5-9 years, 16/100,000 in ages 10-14 years, and 7/100,000 in ages 15-19 years. For boys, incidence rates for type 1 diabetes were 11/100,000 in ages 0-4 years, 16/100,000 in ages 5-9 years, 20/100,000 in ages 10-14 years, and 9/100,000 in ages 15-19 years.

Type 2 diabetes rarely was diagnosed in children less than 10 years old. For ages 10-14 years, the incidence of type 2 diabetes was 15/100,000 for girls and 7/100,000 for boys. For ages 15-19 years, the incidence was 13/100,000 for girls and 11/100,000 for boys.

The study identified prevalent diabetes in the year 2001 in 781 out of more than 641,000 Hispanic youths—most of it type 1 rather than type 2. Prevalence rates did not differ significantly by sex in any of the age groups.

The prevalence increased with age for both diabetes types in both sexes. In individuals ages 15-17 years, the prevalence of type 1 diabetes was 1.6/1,000 for girls and 1.8/1,000 for boys, and the prevalence of type 2 diabetes was 0.8/1,000 for girls and 0.6/1,000 for boys, Ms. Lawrence said.

Data from two additional studies presented in the same session at the meeting showed steep increases in the incidence and prevalence of diabetes in Canadians and a faster than predicted rise in type 1 diabetes in Finland, the world's hot spot for the disease.

In the Canadian study, data on diabetes in all residents younger than 20 years of age in the province of Alberta found 2,301 prevalent cases among 840,000 children and adolescents, for a rate of 28/10,000. Approximately 80% of cases were in 10- to 19-year-olds, Jeffrey A. Johnson, Ph.D., of the University of Alberta, Edmonton, and his associates reported. He had no conflicts of interest in this study.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — From age 15 years onward, Hispanic females in the United States are significantly more likely to be diagnosed with incident type 2 diabetes than type 1 diabetes, according to an analysis of data from the Search for Diabetes in Youth study.

In addition, at ages 10-14 years, Hispanic females in the United States had twice the incidence of type 2 diabetes in 2002-2005, compared with Hispanic males. The study looked at youths less than 20 years old in populations from six states, Jean M. Lawrence and her associates reported at the annual scientific sessions of the American Diabetes Association.

During that period, 635 youths were diagnosed with diabetes out of a population of more than 3 million, with incidence rates peaking for females at ages 5-9 years and for males at ages 10-14 years, said Ms. Lawrence of Kaiser Permanente Southern California, in Pasadena. She had no conflicts of interest related to the study.

Incidence rates for type 1 diabetes in girls were 9/100,000 in ages 0-4 years, 20/100,000 in ages 5-9 years, 16/100,000 in ages 10-14 years, and 7/100,000 in ages 15-19 years. For boys, incidence rates for type 1 diabetes were 11/100,000 in ages 0-4 years, 16/100,000 in ages 5-9 years, 20/100,000 in ages 10-14 years, and 9/100,000 in ages 15-19 years.

Type 2 diabetes rarely was diagnosed in children less than 10 years old. For ages 10-14 years, the incidence of type 2 diabetes was 15/100,000 for girls and 7/100,000 for boys. For ages 15-19 years, the incidence was 13/100,000 for girls and 11/100,000 for boys.

The study identified prevalent diabetes in the year 2001 in 781 out of more than 641,000 Hispanic youths—most of it type 1 rather than type 2. Prevalence rates did not differ significantly by sex in any of the age groups.

The prevalence increased with age for both diabetes types in both sexes. In individuals ages 15-17 years, the prevalence of type 1 diabetes was 1.6/1,000 for girls and 1.8/1,000 for boys, and the prevalence of type 2 diabetes was 0.8/1,000 for girls and 0.6/1,000 for boys, Ms. Lawrence said.

Data from two additional studies presented in the same session at the meeting showed steep increases in the incidence and prevalence of diabetes in Canadians and a faster than predicted rise in type 1 diabetes in Finland, the world's hot spot for the disease.

In the Canadian study, data on diabetes in all residents younger than 20 years of age in the province of Alberta found 2,301 prevalent cases among 840,000 children and adolescents, for a rate of 28/10,000. Approximately 80% of cases were in 10- to 19-year-olds, Jeffrey A. Johnson, Ph.D., of the University of Alberta, Edmonton, and his associates reported. He had no conflicts of interest in this study.

ELSEVIER GLOBAL MEDICAL NEWS