SDEF Hawaii Dermatology Seminar 2013

MAUI, HAWAII – Within the next year or two, two promising new topical medications may join the roster of products for managing rosacea, according to Dr. Joseph F. Fowler Jr.

The two coming attractions are brimonidine tartrate 0.5% gel and oxymetazoline cream. Brimonidine is further along in development; Galderma has submitted an application for Food and Drug Administration marketing approval of the product. Phase II studies of oxymetazoline cream are ongoing.

"Having seen both of these drugs in studies, I think both are going to be effective," said Dr. Fowler, of the University of Louisville (Ky.). "I have no idea if one will be more effective than the other, but I can tell you that both of them are probably going to be a lot better than anything else we have now for the erythema of rosacea," he noted.

"It usually takes around a year after that for a drug to reach the market, assuming no problems arise," Dr. Fowler said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/IMNG Medical Media

Both drugs are vasoconstrictors; they are already marketed in other formulations for indications other than rosacea. Oxymetazoline is used as a decongestant in some versions of Afrin nasal spray. Brimonidine is an alpha-2 agonist formulated as a prescription eye drop for the treatment of glaucoma, said Dr. Fowler, who was codirector of the seminar.

The only two topical therapies currently approved for treatment of rosacea – metronidazole and azelaic acid – don’t do much at all to improve the erythematous component of rosacea, in Dr. Fowler’s view. They do reduce inflammatory lesion counts, but not the background redness, he said.

In a separate presentation during the seminar, Dr. Guy W. Webster described his off-label experience in treating rosacea using oxymetazoline and brimonidine in their current formulations.

"These are two off-label products that really work," he said. "I have rosacea patients who are such spectacular flushers that they can’t go outside in the wintertime, but many of them do great with one of these two off-label medicines. It’s something to think about" when other efforts to improve erythema and flushing fail, said Dr. Webster of Thomas Jefferson University, Philadelphia.

Of the two products, the brimonidine eye drops work better when applied to the skin, said Dr. Webster. In fact, the eye drops are so effective that patients require careful instruction in off-label use or they will end up with white streaking on a background of untreated redness that may last for 4-8 hours, he said. Dr. Webster also recommends a preemptive phone call to a patient’s pharmacist to confirm that the "apply to cheeks" instruction on the prescription for the glaucoma medication is in fact correct.

Alternatively, the version of Afrin that contains oxymetazoline can be sprayed on the cheeks for temporary relief of rosacea. However, the investigational cream formulation works better, Dr. Webster said.

Dr. Webster also discussed the use of the two approved topical agents for rosacea and several other drugs with well-established off-label use.

Topical metronidazole 0.75% was the first the original concentration approved for rosacea, but the more recently approved 1% concentration is "vastly superior," in Dr. Webster’s view.

"Unfortunately, a lot of our insurers make patients get the old generic form, which I find is like a placebo," he noted.

Dr. Webster said that some of his patients respond to azelaic acid – the other FDA-approved topical drug – but not to metronidazole, and vice versa.

Topical benzoyl peroxide/clindamycin products often improve papular inflammatory rosacea, although the mechanism of action is unclear, he added.

Dr. Webster said he is unimpressed with the efficacy of sodium sulfacetamide/sulfur for rosacea. "For the amount of activity it gives, it’s almost not worth the expense," he said.

In Dr. Webster’s experience, tacrolimus and pimecrolimus are not useful in uncomplicated rosacea, but he said he finds the topical calcineurin inhibitors invaluable in patients whose rosacea is exacerbated by comorbid atopic dermatitis or seborrheic dermatitis.

"I find I can’t get the rosacea better when it’s being tweaked by a coexisting inflammatory disease unless I get the atopic dermatitis or seborrheic dermatitis better. These two drugs, off label, are critical to getting the rosacea to be able to respond because rosacea is provoked by other inflammation," he explained.

Dr. Webster serves as a consultant to half a dozen pharmaceutical companies, including Galderma and Allergan, which are developing brimonidine gel and oxymetazoline cream, respectively, as rosacea drugs.

Dr. Fowler is a consultant to multiple pharmaceutical companies, including Galderma, and is a research investigator for multiple companies including Galderma and Allergan.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Within the next year or two, two promising new topical medications may join the roster of products for managing rosacea, according to Dr. Joseph F. Fowler Jr.

The two coming attractions are brimonidine tartrate 0.5% gel and oxymetazoline cream. Brimonidine is further along in development; Galderma has submitted an application for Food and Drug Administration marketing approval of the product. Phase II studies of oxymetazoline cream are ongoing.

"Having seen both of these drugs in studies, I think both are going to be effective," said Dr. Fowler, of the University of Louisville (Ky.). "I have no idea if one will be more effective than the other, but I can tell you that both of them are probably going to be a lot better than anything else we have now for the erythema of rosacea," he noted.

"It usually takes around a year after that for a drug to reach the market, assuming no problems arise," Dr. Fowler said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/IMNG Medical Media

Both drugs are vasoconstrictors; they are already marketed in other formulations for indications other than rosacea. Oxymetazoline is used as a decongestant in some versions of Afrin nasal spray. Brimonidine is an alpha-2 agonist formulated as a prescription eye drop for the treatment of glaucoma, said Dr. Fowler, who was codirector of the seminar.

The only two topical therapies currently approved for treatment of rosacea – metronidazole and azelaic acid – don’t do much at all to improve the erythematous component of rosacea, in Dr. Fowler’s view. They do reduce inflammatory lesion counts, but not the background redness, he said.

In a separate presentation during the seminar, Dr. Guy W. Webster described his off-label experience in treating rosacea using oxymetazoline and brimonidine in their current formulations.

"These are two off-label products that really work," he said. "I have rosacea patients who are such spectacular flushers that they can’t go outside in the wintertime, but many of them do great with one of these two off-label medicines. It’s something to think about" when other efforts to improve erythema and flushing fail, said Dr. Webster of Thomas Jefferson University, Philadelphia.

Of the two products, the brimonidine eye drops work better when applied to the skin, said Dr. Webster. In fact, the eye drops are so effective that patients require careful instruction in off-label use or they will end up with white streaking on a background of untreated redness that may last for 4-8 hours, he said. Dr. Webster also recommends a preemptive phone call to a patient’s pharmacist to confirm that the "apply to cheeks" instruction on the prescription for the glaucoma medication is in fact correct.

Alternatively, the version of Afrin that contains oxymetazoline can be sprayed on the cheeks for temporary relief of rosacea. However, the investigational cream formulation works better, Dr. Webster said.

Dr. Webster also discussed the use of the two approved topical agents for rosacea and several other drugs with well-established off-label use.

Topical metronidazole 0.75% was the first the original concentration approved for rosacea, but the more recently approved 1% concentration is "vastly superior," in Dr. Webster’s view.

"Unfortunately, a lot of our insurers make patients get the old generic form, which I find is like a placebo," he noted.

Dr. Webster said that some of his patients respond to azelaic acid – the other FDA-approved topical drug – but not to metronidazole, and vice versa.

Topical benzoyl peroxide/clindamycin products often improve papular inflammatory rosacea, although the mechanism of action is unclear, he added.

Dr. Webster said he is unimpressed with the efficacy of sodium sulfacetamide/sulfur for rosacea. "For the amount of activity it gives, it’s almost not worth the expense," he said.

In Dr. Webster’s experience, tacrolimus and pimecrolimus are not useful in uncomplicated rosacea, but he said he finds the topical calcineurin inhibitors invaluable in patients whose rosacea is exacerbated by comorbid atopic dermatitis or seborrheic dermatitis.

"I find I can’t get the rosacea better when it’s being tweaked by a coexisting inflammatory disease unless I get the atopic dermatitis or seborrheic dermatitis better. These two drugs, off label, are critical to getting the rosacea to be able to respond because rosacea is provoked by other inflammation," he explained.

Dr. Webster serves as a consultant to half a dozen pharmaceutical companies, including Galderma and Allergan, which are developing brimonidine gel and oxymetazoline cream, respectively, as rosacea drugs.

Dr. Fowler is a consultant to multiple pharmaceutical companies, including Galderma, and is a research investigator for multiple companies including Galderma and Allergan.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Within the next year or two, two promising new topical medications may join the roster of products for managing rosacea, according to Dr. Joseph F. Fowler Jr.

The two coming attractions are brimonidine tartrate 0.5% gel and oxymetazoline cream. Brimonidine is further along in development; Galderma has submitted an application for Food and Drug Administration marketing approval of the product. Phase II studies of oxymetazoline cream are ongoing.

"Having seen both of these drugs in studies, I think both are going to be effective," said Dr. Fowler, of the University of Louisville (Ky.). "I have no idea if one will be more effective than the other, but I can tell you that both of them are probably going to be a lot better than anything else we have now for the erythema of rosacea," he noted.

"It usually takes around a year after that for a drug to reach the market, assuming no problems arise," Dr. Fowler said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/IMNG Medical Media

Both drugs are vasoconstrictors; they are already marketed in other formulations for indications other than rosacea. Oxymetazoline is used as a decongestant in some versions of Afrin nasal spray. Brimonidine is an alpha-2 agonist formulated as a prescription eye drop for the treatment of glaucoma, said Dr. Fowler, who was codirector of the seminar.

The only two topical therapies currently approved for treatment of rosacea – metronidazole and azelaic acid – don’t do much at all to improve the erythematous component of rosacea, in Dr. Fowler’s view. They do reduce inflammatory lesion counts, but not the background redness, he said.

In a separate presentation during the seminar, Dr. Guy W. Webster described his off-label experience in treating rosacea using oxymetazoline and brimonidine in their current formulations.

"These are two off-label products that really work," he said. "I have rosacea patients who are such spectacular flushers that they can’t go outside in the wintertime, but many of them do great with one of these two off-label medicines. It’s something to think about" when other efforts to improve erythema and flushing fail, said Dr. Webster of Thomas Jefferson University, Philadelphia.

Of the two products, the brimonidine eye drops work better when applied to the skin, said Dr. Webster. In fact, the eye drops are so effective that patients require careful instruction in off-label use or they will end up with white streaking on a background of untreated redness that may last for 4-8 hours, he said. Dr. Webster also recommends a preemptive phone call to a patient’s pharmacist to confirm that the "apply to cheeks" instruction on the prescription for the glaucoma medication is in fact correct.

Alternatively, the version of Afrin that contains oxymetazoline can be sprayed on the cheeks for temporary relief of rosacea. However, the investigational cream formulation works better, Dr. Webster said.

Dr. Webster also discussed the use of the two approved topical agents for rosacea and several other drugs with well-established off-label use.

Topical metronidazole 0.75% was the first the original concentration approved for rosacea, but the more recently approved 1% concentration is "vastly superior," in Dr. Webster’s view.

"Unfortunately, a lot of our insurers make patients get the old generic form, which I find is like a placebo," he noted.

Dr. Webster said that some of his patients respond to azelaic acid – the other FDA-approved topical drug – but not to metronidazole, and vice versa.

Topical benzoyl peroxide/clindamycin products often improve papular inflammatory rosacea, although the mechanism of action is unclear, he added.

Dr. Webster said he is unimpressed with the efficacy of sodium sulfacetamide/sulfur for rosacea. "For the amount of activity it gives, it’s almost not worth the expense," he said.

In Dr. Webster’s experience, tacrolimus and pimecrolimus are not useful in uncomplicated rosacea, but he said he finds the topical calcineurin inhibitors invaluable in patients whose rosacea is exacerbated by comorbid atopic dermatitis or seborrheic dermatitis.

"I find I can’t get the rosacea better when it’s being tweaked by a coexisting inflammatory disease unless I get the atopic dermatitis or seborrheic dermatitis better. These two drugs, off label, are critical to getting the rosacea to be able to respond because rosacea is provoked by other inflammation," he explained.

Dr. Webster serves as a consultant to half a dozen pharmaceutical companies, including Galderma and Allergan, which are developing brimonidine gel and oxymetazoline cream, respectively, as rosacea drugs.

Dr. Fowler is a consultant to multiple pharmaceutical companies, including Galderma, and is a research investigator for multiple companies including Galderma and Allergan.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Current thinking on the role of food allergy in pediatric atopic dermatitis suggests a greatly diminished role for allergy testing compared with times past, according to Dr. Joseph F. Fowler Jr.

Guidelines issued by a National Institute of Allergy and Infectious Diseases expert consensus panel – mostly allergists, with little input from dermatologists – concluded that food allergy is actually fairly uncommon in atopics. It affects less than 10% of children under age 2 who have eczema, and a far smaller percentage of older atopic children.

Moreover, the voluminous 58-page report (J. Allergy Clin. Immunol. 2010;126:S1-58) makes the point that allergy testing is time consuming, costly, and not terribly reliable due to high false-positive rates for both scratch testing and RAST (radioallergosorbent tests).

"The bottom line on all this is you probably don’t need to do food allergy testing very often at all in atopics because in those few who did have an allergy to foods, the big three – eggs, milk, and peanuts – accounted for the vast majority of food allergy. So if you’re not sure, what you can do is eliminate those three from the diet, then add them back in one at a time after a few weeks of elimination. That ought to give you a sense of whether there’s really and truly a food allergy operative in that individual," Dr. Fowler said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

"It’s true that occasionally you see allergy to wheat or fish or chocolate or soy or who knows whatever else, but all those other things are very, very uncommon. So while I wouldn’t say you should never do food allergy testing or send a little atopic with recalcitrant eczema for food allergy testing, I think the yield is really going to be relatively low. Doing the elimination trial first is probably the best thing. A good, motivated, observant caregiver is going to be more informative than what the test will tell you," said Dr. Fowler, clinical professor of dermatology at the University of Louisville (Ky.) and codirector of the SDEF seminar.

SDEF and this news organization are owned by the same parent company.

Dr. Fowler is on the speakers bureaus of Galderma, Ranbaxy, and SmartPractice and has received research grants from numerous pharmaceutical companies.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Current thinking on the role of food allergy in pediatric atopic dermatitis suggests a greatly diminished role for allergy testing compared with times past, according to Dr. Joseph F. Fowler Jr.

Guidelines issued by a National Institute of Allergy and Infectious Diseases expert consensus panel – mostly allergists, with little input from dermatologists – concluded that food allergy is actually fairly uncommon in atopics. It affects less than 10% of children under age 2 who have eczema, and a far smaller percentage of older atopic children.

Moreover, the voluminous 58-page report (J. Allergy Clin. Immunol. 2010;126:S1-58) makes the point that allergy testing is time consuming, costly, and not terribly reliable due to high false-positive rates for both scratch testing and RAST (radioallergosorbent tests).

"The bottom line on all this is you probably don’t need to do food allergy testing very often at all in atopics because in those few who did have an allergy to foods, the big three – eggs, milk, and peanuts – accounted for the vast majority of food allergy. So if you’re not sure, what you can do is eliminate those three from the diet, then add them back in one at a time after a few weeks of elimination. That ought to give you a sense of whether there’s really and truly a food allergy operative in that individual," Dr. Fowler said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

"It’s true that occasionally you see allergy to wheat or fish or chocolate or soy or who knows whatever else, but all those other things are very, very uncommon. So while I wouldn’t say you should never do food allergy testing or send a little atopic with recalcitrant eczema for food allergy testing, I think the yield is really going to be relatively low. Doing the elimination trial first is probably the best thing. A good, motivated, observant caregiver is going to be more informative than what the test will tell you," said Dr. Fowler, clinical professor of dermatology at the University of Louisville (Ky.) and codirector of the SDEF seminar.

SDEF and this news organization are owned by the same parent company.

Dr. Fowler is on the speakers bureaus of Galderma, Ranbaxy, and SmartPractice and has received research grants from numerous pharmaceutical companies.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Current thinking on the role of food allergy in pediatric atopic dermatitis suggests a greatly diminished role for allergy testing compared with times past, according to Dr. Joseph F. Fowler Jr.

Guidelines issued by a National Institute of Allergy and Infectious Diseases expert consensus panel – mostly allergists, with little input from dermatologists – concluded that food allergy is actually fairly uncommon in atopics. It affects less than 10% of children under age 2 who have eczema, and a far smaller percentage of older atopic children.

Moreover, the voluminous 58-page report (J. Allergy Clin. Immunol. 2010;126:S1-58) makes the point that allergy testing is time consuming, costly, and not terribly reliable due to high false-positive rates for both scratch testing and RAST (radioallergosorbent tests).

"The bottom line on all this is you probably don’t need to do food allergy testing very often at all in atopics because in those few who did have an allergy to foods, the big three – eggs, milk, and peanuts – accounted for the vast majority of food allergy. So if you’re not sure, what you can do is eliminate those three from the diet, then add them back in one at a time after a few weeks of elimination. That ought to give you a sense of whether there’s really and truly a food allergy operative in that individual," Dr. Fowler said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

"It’s true that occasionally you see allergy to wheat or fish or chocolate or soy or who knows whatever else, but all those other things are very, very uncommon. So while I wouldn’t say you should never do food allergy testing or send a little atopic with recalcitrant eczema for food allergy testing, I think the yield is really going to be relatively low. Doing the elimination trial first is probably the best thing. A good, motivated, observant caregiver is going to be more informative than what the test will tell you," said Dr. Fowler, clinical professor of dermatology at the University of Louisville (Ky.) and codirector of the SDEF seminar.

SDEF and this news organization are owned by the same parent company.

Dr. Fowler is on the speakers bureaus of Galderma, Ranbaxy, and SmartPractice and has received research grants from numerous pharmaceutical companies.

bjancin@frontlinemedcom.com

MAUI, HAWAII – The relationship between diet and acne risk has grown more intriguing as a consequence of a recent Italian study linking milk consumption to an increased risk, while eating fish had a protective effect.

"This was a well-done, very large, multicenter case-control study," said Dr. Lawrence F. Eichenfield, who presented highlights of the Italian investigation at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Courtesy Lynda Banzi

A diet-acne link has been an endless topic of debate for many years among dermatologists and dieticians, with the public looking on attentively. Conventional wisdom formerly held that chocolate and greasy foods exacerbated acne, a notion that later was dispelled. A recent literature review of 27 published studies implicated high-glycemic-index foods and milk (J. Acad. Nutr. Diet. 2013;113:416-30).

The Italian study Dr. Eichenfield spotlighted included 205 consecutive patients aged 10-24 years who were newly diagnosed with moderate to severe acne. The control group consisted of 358 patients with no or only mild acne who consulted a dermatologist for a concern other than acne. Investigators inquired about family history, diet, personal habits, and menstrual history.

Family history of acne emerged as a strong risk factor. A history of acne in a first-degree relative was associated with a 3.4-fold increased risk of moderate to severe acne.

Drinking milk more than three times per week was associated with a 1.8-fold increased risk of significant acne. The risk was more pronounced in skim-milk drinkers than whole-milk drinkers, with consumption of more than three servings per week of nonfat milk being associated with a 2.2-fold increased risk of moderate to severe acne (J. Am. Acad. Dermatol. 2012;67:1129-35).

In contrast, regular consumption of fish was associated with a 32% reduction in the likelihood of having moderate to severe acne.

Body mass index was *directly associated with acne: Adolescents and young adults with a BMI greater than 18.5 kg/m² were at 1.9-fold greater risk of significant acne than those with a smaller BMI. This protective effect of a low BMI was stronger in male than female subjects.

Neither menstrual factors nor smoking showed any relationship with acne risk in the Italian study, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego.

"How do I take this new information and use it in the clinic? The answer is, I don’t, because I really don’t know what the impact will be of dietary changes in my actual care of individuals with acne who come to me. But this whole issue of diet and acne is a really fascinating one," the pediatric dermatologist commented.

SDEF and this news organization are owned by the same parent company.

Dr. Eichenfield reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

bjancin@frontlinemedcom.com

*Correction (04/09/13): A previous version of this story mischaracterized the association between BMI and acne in one instance. This story has been updated. 

MAUI, HAWAII – The relationship between diet and acne risk has grown more intriguing as a consequence of a recent Italian study linking milk consumption to an increased risk, while eating fish had a protective effect.

"This was a well-done, very large, multicenter case-control study," said Dr. Lawrence F. Eichenfield, who presented highlights of the Italian investigation at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Courtesy Lynda Banzi

A diet-acne link has been an endless topic of debate for many years among dermatologists and dieticians, with the public looking on attentively. Conventional wisdom formerly held that chocolate and greasy foods exacerbated acne, a notion that later was dispelled. A recent literature review of 27 published studies implicated high-glycemic-index foods and milk (J. Acad. Nutr. Diet. 2013;113:416-30).

The Italian study Dr. Eichenfield spotlighted included 205 consecutive patients aged 10-24 years who were newly diagnosed with moderate to severe acne. The control group consisted of 358 patients with no or only mild acne who consulted a dermatologist for a concern other than acne. Investigators inquired about family history, diet, personal habits, and menstrual history.

Family history of acne emerged as a strong risk factor. A history of acne in a first-degree relative was associated with a 3.4-fold increased risk of moderate to severe acne.

Drinking milk more than three times per week was associated with a 1.8-fold increased risk of significant acne. The risk was more pronounced in skim-milk drinkers than whole-milk drinkers, with consumption of more than three servings per week of nonfat milk being associated with a 2.2-fold increased risk of moderate to severe acne (J. Am. Acad. Dermatol. 2012;67:1129-35).

In contrast, regular consumption of fish was associated with a 32% reduction in the likelihood of having moderate to severe acne.

Body mass index was *directly associated with acne: Adolescents and young adults with a BMI greater than 18.5 kg/m² were at 1.9-fold greater risk of significant acne than those with a smaller BMI. This protective effect of a low BMI was stronger in male than female subjects.

Neither menstrual factors nor smoking showed any relationship with acne risk in the Italian study, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego.

"How do I take this new information and use it in the clinic? The answer is, I don’t, because I really don’t know what the impact will be of dietary changes in my actual care of individuals with acne who come to me. But this whole issue of diet and acne is a really fascinating one," the pediatric dermatologist commented.

SDEF and this news organization are owned by the same parent company.

Dr. Eichenfield reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

bjancin@frontlinemedcom.com

*Correction (04/09/13): A previous version of this story mischaracterized the association between BMI and acne in one instance. This story has been updated. 

MAUI, HAWAII – The relationship between diet and acne risk has grown more intriguing as a consequence of a recent Italian study linking milk consumption to an increased risk, while eating fish had a protective effect.

"This was a well-done, very large, multicenter case-control study," said Dr. Lawrence F. Eichenfield, who presented highlights of the Italian investigation at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Courtesy Lynda Banzi

A diet-acne link has been an endless topic of debate for many years among dermatologists and dieticians, with the public looking on attentively. Conventional wisdom formerly held that chocolate and greasy foods exacerbated acne, a notion that later was dispelled. A recent literature review of 27 published studies implicated high-glycemic-index foods and milk (J. Acad. Nutr. Diet. 2013;113:416-30).

The Italian study Dr. Eichenfield spotlighted included 205 consecutive patients aged 10-24 years who were newly diagnosed with moderate to severe acne. The control group consisted of 358 patients with no or only mild acne who consulted a dermatologist for a concern other than acne. Investigators inquired about family history, diet, personal habits, and menstrual history.

Family history of acne emerged as a strong risk factor. A history of acne in a first-degree relative was associated with a 3.4-fold increased risk of moderate to severe acne.

Drinking milk more than three times per week was associated with a 1.8-fold increased risk of significant acne. The risk was more pronounced in skim-milk drinkers than whole-milk drinkers, with consumption of more than three servings per week of nonfat milk being associated with a 2.2-fold increased risk of moderate to severe acne (J. Am. Acad. Dermatol. 2012;67:1129-35).

In contrast, regular consumption of fish was associated with a 32% reduction in the likelihood of having moderate to severe acne.

Body mass index was *directly associated with acne: Adolescents and young adults with a BMI greater than 18.5 kg/m² were at 1.9-fold greater risk of significant acne than those with a smaller BMI. This protective effect of a low BMI was stronger in male than female subjects.

Neither menstrual factors nor smoking showed any relationship with acne risk in the Italian study, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego.

"How do I take this new information and use it in the clinic? The answer is, I don’t, because I really don’t know what the impact will be of dietary changes in my actual care of individuals with acne who come to me. But this whole issue of diet and acne is a really fascinating one," the pediatric dermatologist commented.

SDEF and this news organization are owned by the same parent company.

Dr. Eichenfield reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

bjancin@frontlinemedcom.com

*Correction (04/09/13): A previous version of this story mischaracterized the association between BMI and acne in one instance. This story has been updated. 

WAILEA, HAWAII – Acne arising in a 1- to 7-year-old means "it’s time to worry," according to Dr. Lawrence F. Eichenfield.

Acne originating in this midchildhood age range is very uncommon. It signals the need for a detailed endocrinologic work-up. Possible underlying causes include precocious adrenarche, congenital adrenal hyperplasia, Cushing’s syndrome, precocious puberty, and a gonadal or adrenal tumor, he noted at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

"If you want to take it on yourself you can, but the standard is going to be an evaluation that includes a growth chart, a bone age assessment, Tanner staging, and measurement of total and free testosterone, LH [luteinizing hormone], FSH [follicle-stimulating hormone], prolactin, DHEAS [dehydroepiandrosterone sulfate], andrestenedione, and 17-hydroxyprogesterone. Generally we say refer to a pediatric endocrinologist," said Dr. Eichenfield, professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego.

He noted that acne occurring at age 1-7 is prominently identified as a red flag in guidelines for the management of pediatric acne developed by the American Acne and Rosacea Society and subsequently approved by the American Academy of Pediatrics. Dr. Eichenfield was cochair of the expert panel that crafted the guidelines.

The comprehensive guidelines – the first ever to specifically address acne in the pediatric age range – include a general acne categorization scheme based upon age. While acne in a 1- to 7-year-old is characterized as a cause for concern, acne arising in a seemingly healthy slightly older preadolescent – roughly age 7-12 – is not.

"Acne in a child in this age group who otherwise looks well and has no signs or history that would make you suspicious of an underlying endocrinopathy is essentially a normal variant we now call preadolescent acne. You do not need to refer that patient for further evaluation," the pediatric dermatologist explained.

Nonworrisome preadolescent acne presents as comedone-predominant disease typically concentrated on the forehead and midface, with truncal involvement much less frequent. The acne may precede other signs of puberty. There is solid evidence that the more pronounced the expression of early preadolescent acne – that is, the greater the number of facial comedones present – the more severe the acne will be in adolescence. Indeed, severe preadolescent acne is often a harbinger of the later need for isotretinoin.

Acne developing within the first 6 weeks of life is most often an erythematous papulopustular eruption categorized in the guidelines as neonatal acne, also known as neonatal cephalic pustulosis. It is not true acne, but rather a self-limited condition associated with Malassezia globosa and M. sympodialis.

In contrast, infantile acne is true acne, mainly comedonal, which typically doesn’t show up until a baby is several months old and lasts for up to about a year.

The guidelines put forth detailed treatment algorithms featuring multiple options available for each acne age category and degree of severity. Of note, benzoyl peroxide is listed as a first-line treatment across the board, either as monotherapy or in combination with an antibiotic or topical retinoid.

"There is a theme that whenever one is using an antibiotic – whether a systemic drug or a topical product like clindamycin – benzoyl peroxide is advised in the regimen of care because of the feeling that if you use an unopposed antibiotic, you can have the development of bacterial resistance," Dr. Eichenfield noted.

He reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAILEA, HAWAII – Acne arising in a 1- to 7-year-old means "it’s time to worry," according to Dr. Lawrence F. Eichenfield.

Acne originating in this midchildhood age range is very uncommon. It signals the need for a detailed endocrinologic work-up. Possible underlying causes include precocious adrenarche, congenital adrenal hyperplasia, Cushing’s syndrome, precocious puberty, and a gonadal or adrenal tumor, he noted at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

"If you want to take it on yourself you can, but the standard is going to be an evaluation that includes a growth chart, a bone age assessment, Tanner staging, and measurement of total and free testosterone, LH [luteinizing hormone], FSH [follicle-stimulating hormone], prolactin, DHEAS [dehydroepiandrosterone sulfate], andrestenedione, and 17-hydroxyprogesterone. Generally we say refer to a pediatric endocrinologist," said Dr. Eichenfield, professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego.

He noted that acne occurring at age 1-7 is prominently identified as a red flag in guidelines for the management of pediatric acne developed by the American Acne and Rosacea Society and subsequently approved by the American Academy of Pediatrics. Dr. Eichenfield was cochair of the expert panel that crafted the guidelines.

The comprehensive guidelines – the first ever to specifically address acne in the pediatric age range – include a general acne categorization scheme based upon age. While acne in a 1- to 7-year-old is characterized as a cause for concern, acne arising in a seemingly healthy slightly older preadolescent – roughly age 7-12 – is not.

"Acne in a child in this age group who otherwise looks well and has no signs or history that would make you suspicious of an underlying endocrinopathy is essentially a normal variant we now call preadolescent acne. You do not need to refer that patient for further evaluation," the pediatric dermatologist explained.

Nonworrisome preadolescent acne presents as comedone-predominant disease typically concentrated on the forehead and midface, with truncal involvement much less frequent. The acne may precede other signs of puberty. There is solid evidence that the more pronounced the expression of early preadolescent acne – that is, the greater the number of facial comedones present – the more severe the acne will be in adolescence. Indeed, severe preadolescent acne is often a harbinger of the later need for isotretinoin.

Acne developing within the first 6 weeks of life is most often an erythematous papulopustular eruption categorized in the guidelines as neonatal acne, also known as neonatal cephalic pustulosis. It is not true acne, but rather a self-limited condition associated with Malassezia globosa and M. sympodialis.

In contrast, infantile acne is true acne, mainly comedonal, which typically doesn’t show up until a baby is several months old and lasts for up to about a year.

The guidelines put forth detailed treatment algorithms featuring multiple options available for each acne age category and degree of severity. Of note, benzoyl peroxide is listed as a first-line treatment across the board, either as monotherapy or in combination with an antibiotic or topical retinoid.

"There is a theme that whenever one is using an antibiotic – whether a systemic drug or a topical product like clindamycin – benzoyl peroxide is advised in the regimen of care because of the feeling that if you use an unopposed antibiotic, you can have the development of bacterial resistance," Dr. Eichenfield noted.

He reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAILEA, HAWAII – Acne arising in a 1- to 7-year-old means "it’s time to worry," according to Dr. Lawrence F. Eichenfield.

Acne originating in this midchildhood age range is very uncommon. It signals the need for a detailed endocrinologic work-up. Possible underlying causes include precocious adrenarche, congenital adrenal hyperplasia, Cushing’s syndrome, precocious puberty, and a gonadal or adrenal tumor, he noted at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

"If you want to take it on yourself you can, but the standard is going to be an evaluation that includes a growth chart, a bone age assessment, Tanner staging, and measurement of total and free testosterone, LH [luteinizing hormone], FSH [follicle-stimulating hormone], prolactin, DHEAS [dehydroepiandrosterone sulfate], andrestenedione, and 17-hydroxyprogesterone. Generally we say refer to a pediatric endocrinologist," said Dr. Eichenfield, professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego.

He noted that acne occurring at age 1-7 is prominently identified as a red flag in guidelines for the management of pediatric acne developed by the American Acne and Rosacea Society and subsequently approved by the American Academy of Pediatrics. Dr. Eichenfield was cochair of the expert panel that crafted the guidelines.

The comprehensive guidelines – the first ever to specifically address acne in the pediatric age range – include a general acne categorization scheme based upon age. While acne in a 1- to 7-year-old is characterized as a cause for concern, acne arising in a seemingly healthy slightly older preadolescent – roughly age 7-12 – is not.

"Acne in a child in this age group who otherwise looks well and has no signs or history that would make you suspicious of an underlying endocrinopathy is essentially a normal variant we now call preadolescent acne. You do not need to refer that patient for further evaluation," the pediatric dermatologist explained.

Nonworrisome preadolescent acne presents as comedone-predominant disease typically concentrated on the forehead and midface, with truncal involvement much less frequent. The acne may precede other signs of puberty. There is solid evidence that the more pronounced the expression of early preadolescent acne – that is, the greater the number of facial comedones present – the more severe the acne will be in adolescence. Indeed, severe preadolescent acne is often a harbinger of the later need for isotretinoin.

Acne developing within the first 6 weeks of life is most often an erythematous papulopustular eruption categorized in the guidelines as neonatal acne, also known as neonatal cephalic pustulosis. It is not true acne, but rather a self-limited condition associated with Malassezia globosa and M. sympodialis.

In contrast, infantile acne is true acne, mainly comedonal, which typically doesn’t show up until a baby is several months old and lasts for up to about a year.

The guidelines put forth detailed treatment algorithms featuring multiple options available for each acne age category and degree of severity. Of note, benzoyl peroxide is listed as a first-line treatment across the board, either as monotherapy or in combination with an antibiotic or topical retinoid.

"There is a theme that whenever one is using an antibiotic – whether a systemic drug or a topical product like clindamycin – benzoyl peroxide is advised in the regimen of care because of the feeling that if you use an unopposed antibiotic, you can have the development of bacterial resistance," Dr. Eichenfield noted.

He reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Are British academic podiatrists out to bring down dermatology?

That possibility was raised, tongue firmly in cheek, by Dr. Andrew C. Krakowski at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation in light of the results of the EVerT (Effective Verruca Treatments) trial.

EVerT was a multicenter clinical trial in which university podiatrists in England, Scotland, and Ireland randomized 240 patients with plantar warts to one of two venerable treatments: cryotherapy or salicylic acid.

The investigators declared salicylic acid the winner – or as they put it in more rococo British fashion, "cryotherapy is the dominated alternative" – on the grounds that although the two treatments showed equal efficacy, cryotherapy cost an average of 101 British pounds (U.S.$153) more per patient over the course of the 12-week study.

"Will dermatologists be out of business? Cryotherapy is sort of our livelihood. It’s something we all do every day," noted Dr. Krakowski, a pediatric dermatologist at the University of California, San Diego.

So, is this the end of the line for a bread-and-butter dermatologic procedure? Not bloody likely. While the EVerT trial is sure to draw the attention of U.K. health policy makers – it was, after all, funded by the U.K. National Institute for Health Research Health Technology Assessment Programme – the study was a bit of a dog’s breakfast, with numerous methodologic flaws that undermined the investigators’ conclusions, in Dr. Krakowski’s view.

Patients in the cryotherapy arm received up to four liquid-nitrogen treatments 2-3 weeks apart. Those assigned to salicylic acid were instructed to file and pare the wart and apply 50% salicylic acid at home daily for up to 8 weeks. The primary endpoint – complete plantar wart clearance at 12 weeks by photographic assessment – was attained in 14.3% of the salicylic acid group and 13.6% of cryotherapy-treated patients, a nonsignificant difference.

Fourteen adverse events, none serious, were noted in each study arm. Self-reported clearance of warts at 6 months was similar in both groups as well: 31% in the salicylic acid group and 34% with cryotherapy (BMJ 2011;342:d3271).

A subsequent comprehensive cost-effectiveness analysis tabulated the mean total cost of cryotherapy through 12 weeks at 150.39 pounds ($228), compared with 49.22 pounds ($75) for treatment with salicylic acid (J. Foot Ankle Res. 2012;5:28).

From the perspective of a dermatologist, however, there are problems aplenty with EVerT, according to Dr. Krakowski.

For one, the cryotherapy was done mainly by nurses; dermatologists – the acknowledged experts in cryotherapy – weren’t part of the study. The technique wasn’t standardized, and it’s not clear that all cryotherapy applications followed the accepted 10-second freeze/create-an-iceball approach. In addition, the notion that patients would be compliant with a home regimen entailing daily wart filing and application of salicylic acid requires a considerable leap of faith. Moreover, basing outcome analysis on evaluation of photographs was considerably less convincing than if wart clearance was assessed by direct patient examination by a dermatologist using a dermoscope, which can show definitively whether a wart is completely gone.

Last, the investigators downplayed the importance of their patient satisfaction data: 62% of patients whose plantar warts were treated using liquid nitrogen pronounced themselves "happy with their treatment," compared with just 41% of those in the salicylic acid group, Dr. Krakowski noted.

He added that his own "best and most used" treatment for cutaneous warts, including plantar warts, combines both elements of the EVerT trial: paring with duct tape with application of salicylic acid at home along with in-office cryotherapy.

"I freeze it, then in the next 2 days there may or may not be some home therapy that goes on, although that’s what I try to push. Then I see the patients back in a month and freeze the wart again," the dermatologist explained.

One of his favorite techniques is to utilize a hemostat or tweezers to tackle warts in challenging locations.

"The thing I do the most for any wart that’s tricky is I’ll grab an Adson forceps with teeth and freeze it – just drop it into a Styrofoam cup and put in liquid nitrogen to make the tip cold – then I’ll pick up the forceps very carefully, sometimes using gauze to protect my fingers, and I’ll either grab the wart with the forceps or just touch it. You can be very careful in that way such that the surrounding skin isn’t even affected," according to Dr. Krakowski.

SDEF and this news organization are owned by the same parent company.

Dr. Krakowski reported having no financial conflicts.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Are British academic podiatrists out to bring down dermatology?

That possibility was raised, tongue firmly in cheek, by Dr. Andrew C. Krakowski at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation in light of the results of the EVerT (Effective Verruca Treatments) trial.

EVerT was a multicenter clinical trial in which university podiatrists in England, Scotland, and Ireland randomized 240 patients with plantar warts to one of two venerable treatments: cryotherapy or salicylic acid.

The investigators declared salicylic acid the winner – or as they put it in more rococo British fashion, "cryotherapy is the dominated alternative" – on the grounds that although the two treatments showed equal efficacy, cryotherapy cost an average of 101 British pounds (U.S.$153) more per patient over the course of the 12-week study.

"Will dermatologists be out of business? Cryotherapy is sort of our livelihood. It’s something we all do every day," noted Dr. Krakowski, a pediatric dermatologist at the University of California, San Diego.

So, is this the end of the line for a bread-and-butter dermatologic procedure? Not bloody likely. While the EVerT trial is sure to draw the attention of U.K. health policy makers – it was, after all, funded by the U.K. National Institute for Health Research Health Technology Assessment Programme – the study was a bit of a dog’s breakfast, with numerous methodologic flaws that undermined the investigators’ conclusions, in Dr. Krakowski’s view.

Patients in the cryotherapy arm received up to four liquid-nitrogen treatments 2-3 weeks apart. Those assigned to salicylic acid were instructed to file and pare the wart and apply 50% salicylic acid at home daily for up to 8 weeks. The primary endpoint – complete plantar wart clearance at 12 weeks by photographic assessment – was attained in 14.3% of the salicylic acid group and 13.6% of cryotherapy-treated patients, a nonsignificant difference.

Fourteen adverse events, none serious, were noted in each study arm. Self-reported clearance of warts at 6 months was similar in both groups as well: 31% in the salicylic acid group and 34% with cryotherapy (BMJ 2011;342:d3271).

A subsequent comprehensive cost-effectiveness analysis tabulated the mean total cost of cryotherapy through 12 weeks at 150.39 pounds ($228), compared with 49.22 pounds ($75) for treatment with salicylic acid (J. Foot Ankle Res. 2012;5:28).

From the perspective of a dermatologist, however, there are problems aplenty with EVerT, according to Dr. Krakowski.

For one, the cryotherapy was done mainly by nurses; dermatologists – the acknowledged experts in cryotherapy – weren’t part of the study. The technique wasn’t standardized, and it’s not clear that all cryotherapy applications followed the accepted 10-second freeze/create-an-iceball approach. In addition, the notion that patients would be compliant with a home regimen entailing daily wart filing and application of salicylic acid requires a considerable leap of faith. Moreover, basing outcome analysis on evaluation of photographs was considerably less convincing than if wart clearance was assessed by direct patient examination by a dermatologist using a dermoscope, which can show definitively whether a wart is completely gone.

Last, the investigators downplayed the importance of their patient satisfaction data: 62% of patients whose plantar warts were treated using liquid nitrogen pronounced themselves "happy with their treatment," compared with just 41% of those in the salicylic acid group, Dr. Krakowski noted.

He added that his own "best and most used" treatment for cutaneous warts, including plantar warts, combines both elements of the EVerT trial: paring with duct tape with application of salicylic acid at home along with in-office cryotherapy.

"I freeze it, then in the next 2 days there may or may not be some home therapy that goes on, although that’s what I try to push. Then I see the patients back in a month and freeze the wart again," the dermatologist explained.

One of his favorite techniques is to utilize a hemostat or tweezers to tackle warts in challenging locations.

"The thing I do the most for any wart that’s tricky is I’ll grab an Adson forceps with teeth and freeze it – just drop it into a Styrofoam cup and put in liquid nitrogen to make the tip cold – then I’ll pick up the forceps very carefully, sometimes using gauze to protect my fingers, and I’ll either grab the wart with the forceps or just touch it. You can be very careful in that way such that the surrounding skin isn’t even affected," according to Dr. Krakowski.

SDEF and this news organization are owned by the same parent company.

Dr. Krakowski reported having no financial conflicts.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Are British academic podiatrists out to bring down dermatology?

That possibility was raised, tongue firmly in cheek, by Dr. Andrew C. Krakowski at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation in light of the results of the EVerT (Effective Verruca Treatments) trial.

EVerT was a multicenter clinical trial in which university podiatrists in England, Scotland, and Ireland randomized 240 patients with plantar warts to one of two venerable treatments: cryotherapy or salicylic acid.

The investigators declared salicylic acid the winner – or as they put it in more rococo British fashion, "cryotherapy is the dominated alternative" – on the grounds that although the two treatments showed equal efficacy, cryotherapy cost an average of 101 British pounds (U.S.$153) more per patient over the course of the 12-week study.

"Will dermatologists be out of business? Cryotherapy is sort of our livelihood. It’s something we all do every day," noted Dr. Krakowski, a pediatric dermatologist at the University of California, San Diego.

So, is this the end of the line for a bread-and-butter dermatologic procedure? Not bloody likely. While the EVerT trial is sure to draw the attention of U.K. health policy makers – it was, after all, funded by the U.K. National Institute for Health Research Health Technology Assessment Programme – the study was a bit of a dog’s breakfast, with numerous methodologic flaws that undermined the investigators’ conclusions, in Dr. Krakowski’s view.

Patients in the cryotherapy arm received up to four liquid-nitrogen treatments 2-3 weeks apart. Those assigned to salicylic acid were instructed to file and pare the wart and apply 50% salicylic acid at home daily for up to 8 weeks. The primary endpoint – complete plantar wart clearance at 12 weeks by photographic assessment – was attained in 14.3% of the salicylic acid group and 13.6% of cryotherapy-treated patients, a nonsignificant difference.

Fourteen adverse events, none serious, were noted in each study arm. Self-reported clearance of warts at 6 months was similar in both groups as well: 31% in the salicylic acid group and 34% with cryotherapy (BMJ 2011;342:d3271).

A subsequent comprehensive cost-effectiveness analysis tabulated the mean total cost of cryotherapy through 12 weeks at 150.39 pounds ($228), compared with 49.22 pounds ($75) for treatment with salicylic acid (J. Foot Ankle Res. 2012;5:28).

From the perspective of a dermatologist, however, there are problems aplenty with EVerT, according to Dr. Krakowski.

For one, the cryotherapy was done mainly by nurses; dermatologists – the acknowledged experts in cryotherapy – weren’t part of the study. The technique wasn’t standardized, and it’s not clear that all cryotherapy applications followed the accepted 10-second freeze/create-an-iceball approach. In addition, the notion that patients would be compliant with a home regimen entailing daily wart filing and application of salicylic acid requires a considerable leap of faith. Moreover, basing outcome analysis on evaluation of photographs was considerably less convincing than if wart clearance was assessed by direct patient examination by a dermatologist using a dermoscope, which can show definitively whether a wart is completely gone.

Last, the investigators downplayed the importance of their patient satisfaction data: 62% of patients whose plantar warts were treated using liquid nitrogen pronounced themselves "happy with their treatment," compared with just 41% of those in the salicylic acid group, Dr. Krakowski noted.

He added that his own "best and most used" treatment for cutaneous warts, including plantar warts, combines both elements of the EVerT trial: paring with duct tape with application of salicylic acid at home along with in-office cryotherapy.

"I freeze it, then in the next 2 days there may or may not be some home therapy that goes on, although that’s what I try to push. Then I see the patients back in a month and freeze the wart again," the dermatologist explained.

One of his favorite techniques is to utilize a hemostat or tweezers to tackle warts in challenging locations.

"The thing I do the most for any wart that’s tricky is I’ll grab an Adson forceps with teeth and freeze it – just drop it into a Styrofoam cup and put in liquid nitrogen to make the tip cold – then I’ll pick up the forceps very carefully, sometimes using gauze to protect my fingers, and I’ll either grab the wart with the forceps or just touch it. You can be very careful in that way such that the surrounding skin isn’t even affected," according to Dr. Krakowski.

SDEF and this news organization are owned by the same parent company.

Dr. Krakowski reported having no financial conflicts.

bjancin@frontlinemedcom.com

WAILEA, HAWAII – While psoriasis experts typically emphasize the disease’s chronic nature and the importance of effective long-term therapy, in reality the first big question when a patient presents to the office should be, ‘What’s the urgency of treatment?’ according to Dr. Kenneth B. Gordon, professor of dermatology at Northwestern University, Chicago.

Two patients can have equally extensive disease yet dissimilar treatment urgencies – and different treatments of choice as a result, he said at the Hawaii Dermatology Seminar, sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

The list of preferred medications for patients with high treatment urgency is short: "When you need to get people better fast, infliximab and cyclosporine are the go-to drugs," the dermatologist stressed.

Insurance companies will often insist that a patient try methotrexate before resorting to a far costlier biologic agent. That’s unreasonable when the treatment urgency is high.

"Methotrexate doesn’t have a high enough level of predictability or efficacy of response. Additionally, it takes a long time to act. When someone is acutely ill, you don’t want to have to wait 16 weeks to figure out what’s the highest level of efficacy you’re going to get. You want to know that answer in 10 weeks, like you do with infliximab. Infliximab is a wonderful short-term therapy for patients who have urgent disease. And with cyclosporine you see effects in 4-8 weeks," Dr. Gordon continued.

He noted that in the open-label RESTORE 1 trial, in which 868 psoriasis patients were randomized to infliximab or methotrexate, the PASI-75 response rate at week 6 in the infliximab group was already close to 60%. By week 10, the PASI-75 rate was 75% in the infliximab group and 27% in the methotrexate group (Br. J. Dermatol. 2011;165:1109-17).

The main safety concern with cyclosporine is renal toxicity, which doesn’t emerge as a real problem until after about a year on the drug, Dr. Gordon said. The safety concerns associated with short-term use (6-8 weeks) to treat an acute exacerbation of psoriasis before transitioning to a different medication are modest, and limited to relatively uncommon increases in blood pressure.

Factors that might raise a patient’s treatment urgency level range from sleep deprivation because of psoriasis pain and itching to workplace hassles because of extensive sick leave, to an important public appearance scheduled within 6-8 weeks.

Session moderator Dr. Craig L. Leonardi remarked that getting payer approval for infliximab often takes a month.

"Unless you’re university based, it’s unlikely you’re going to get infliximab fast, so cyclosporine becomes a real mainstay of treatment when it’s hot and bothersome psoriasis," he said. "And it’s the treatment of choice for psoriasis during pregnancy, absolutely. It’s category C, but there’s a lot of experience with it in the transplant population," noted Dr. Leonardi of St. Louis University.

Dr. Gordon also described a clinical scenario completely different from high treatment urgency – the patient with extensive, yet stable disease. In such a case, the priority is to select a drug the patient can tolerate for a year or more, with good long-term safety and little loss of efficacy over time.

The therapeutic responses to infliximab and adalimumab tend to fade over time, but the majority of patients still do well after 1-3 years of continuous therapy, said Dr. Gordon. His analysis of the phase III REVEAL trial extension showed that 83% of patients with at least a PASI-75 response through the first 33 weeks of adalimumab therapy continued to have a PASI-75 or better response through 100 weeks, and 76% of the original responders were still in that category after 160 weeks of therapy (J. Am. Acad. Dermatol. 2012;66:241-51).

The data on the long-term safety of antitumor necrosis factor agents are extensive and largely reassuring, Dr. Gordon noted.

"I make the argument that there is more known about anti-TNF therapy in terms of safety than any other medicines ever," Dr. Gordon said. Much of the data come courtesy of Europe, where most patients are able to get on anti-TNF therapy only if a physician enrolls them in a registry, he added.

The primary safety risk posed by biologic therapy is serious infections, in Dr. Gordon’s opinion. The collective registry experience in rheumatoid arthritis patients suggests that risk is about 20% greater than in patients on methotrexate, and this risk appears to be stable over time. But it’s probably a mistake to extrapolate from the rheumatologic experience to psoriasis, Dr. Gordon said. He and his colleagues have shown that rheumatoid arthritis patients on biologic therapy tend to be older and more likely to be on concomitant systemic corticosteroids and other immunosuppressive drugs than are psoriasis patients (Ann. Rheum. Dis. 2009;68:1863-9). More data on the risks of biologic therapies in psoriasis patients are anticipated from PSOLAR and other large ongoing patient registries, he said.

A key issue in long-term therapy is the desire of many psoriasis patients to see how they will fare without medication, and the issue has been studied extensively in clinical trials. Dr. Gordon tells patients who would like to discontinue therapy until they relapse, and that there is a one in three chance that they won’t improve upon retreatment. These patients would then need to try another medication. Today there are other medications, and there will likely be more in the coming years, he said.

"But there is a group of patients – and I think we all have them – who are just burning through these medications and don’t respond as well as they did before. So I think we have to be careful and try to convince patients they might be better off staying on their medicine," he said.

SDEF and this news organization are owned by the same parent company.

Dr. Gordon reported receiving research support and/or serving as a consultant to several pharmaceutical companies including Abbott, Amgen, Lilly, and Pfizer.

bjancin@frontlinlinemedcom.com

WAILEA, HAWAII – While psoriasis experts typically emphasize the disease’s chronic nature and the importance of effective long-term therapy, in reality the first big question when a patient presents to the office should be, ‘What’s the urgency of treatment?’ according to Dr. Kenneth B. Gordon, professor of dermatology at Northwestern University, Chicago.

Two patients can have equally extensive disease yet dissimilar treatment urgencies – and different treatments of choice as a result, he said at the Hawaii Dermatology Seminar, sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

The list of preferred medications for patients with high treatment urgency is short: "When you need to get people better fast, infliximab and cyclosporine are the go-to drugs," the dermatologist stressed.

Insurance companies will often insist that a patient try methotrexate before resorting to a far costlier biologic agent. That’s unreasonable when the treatment urgency is high.

"Methotrexate doesn’t have a high enough level of predictability or efficacy of response. Additionally, it takes a long time to act. When someone is acutely ill, you don’t want to have to wait 16 weeks to figure out what’s the highest level of efficacy you’re going to get. You want to know that answer in 10 weeks, like you do with infliximab. Infliximab is a wonderful short-term therapy for patients who have urgent disease. And with cyclosporine you see effects in 4-8 weeks," Dr. Gordon continued.

He noted that in the open-label RESTORE 1 trial, in which 868 psoriasis patients were randomized to infliximab or methotrexate, the PASI-75 response rate at week 6 in the infliximab group was already close to 60%. By week 10, the PASI-75 rate was 75% in the infliximab group and 27% in the methotrexate group (Br. J. Dermatol. 2011;165:1109-17).

The main safety concern with cyclosporine is renal toxicity, which doesn’t emerge as a real problem until after about a year on the drug, Dr. Gordon said. The safety concerns associated with short-term use (6-8 weeks) to treat an acute exacerbation of psoriasis before transitioning to a different medication are modest, and limited to relatively uncommon increases in blood pressure.

Factors that might raise a patient’s treatment urgency level range from sleep deprivation because of psoriasis pain and itching to workplace hassles because of extensive sick leave, to an important public appearance scheduled within 6-8 weeks.

Session moderator Dr. Craig L. Leonardi remarked that getting payer approval for infliximab often takes a month.

"Unless you’re university based, it’s unlikely you’re going to get infliximab fast, so cyclosporine becomes a real mainstay of treatment when it’s hot and bothersome psoriasis," he said. "And it’s the treatment of choice for psoriasis during pregnancy, absolutely. It’s category C, but there’s a lot of experience with it in the transplant population," noted Dr. Leonardi of St. Louis University.

Dr. Gordon also described a clinical scenario completely different from high treatment urgency – the patient with extensive, yet stable disease. In such a case, the priority is to select a drug the patient can tolerate for a year or more, with good long-term safety and little loss of efficacy over time.

The therapeutic responses to infliximab and adalimumab tend to fade over time, but the majority of patients still do well after 1-3 years of continuous therapy, said Dr. Gordon. His analysis of the phase III REVEAL trial extension showed that 83% of patients with at least a PASI-75 response through the first 33 weeks of adalimumab therapy continued to have a PASI-75 or better response through 100 weeks, and 76% of the original responders were still in that category after 160 weeks of therapy (J. Am. Acad. Dermatol. 2012;66:241-51).

The data on the long-term safety of antitumor necrosis factor agents are extensive and largely reassuring, Dr. Gordon noted.

"I make the argument that there is more known about anti-TNF therapy in terms of safety than any other medicines ever," Dr. Gordon said. Much of the data come courtesy of Europe, where most patients are able to get on anti-TNF therapy only if a physician enrolls them in a registry, he added.

The primary safety risk posed by biologic therapy is serious infections, in Dr. Gordon’s opinion. The collective registry experience in rheumatoid arthritis patients suggests that risk is about 20% greater than in patients on methotrexate, and this risk appears to be stable over time. But it’s probably a mistake to extrapolate from the rheumatologic experience to psoriasis, Dr. Gordon said. He and his colleagues have shown that rheumatoid arthritis patients on biologic therapy tend to be older and more likely to be on concomitant systemic corticosteroids and other immunosuppressive drugs than are psoriasis patients (Ann. Rheum. Dis. 2009;68:1863-9). More data on the risks of biologic therapies in psoriasis patients are anticipated from PSOLAR and other large ongoing patient registries, he said.

A key issue in long-term therapy is the desire of many psoriasis patients to see how they will fare without medication, and the issue has been studied extensively in clinical trials. Dr. Gordon tells patients who would like to discontinue therapy until they relapse, and that there is a one in three chance that they won’t improve upon retreatment. These patients would then need to try another medication. Today there are other medications, and there will likely be more in the coming years, he said.

"But there is a group of patients – and I think we all have them – who are just burning through these medications and don’t respond as well as they did before. So I think we have to be careful and try to convince patients they might be better off staying on their medicine," he said.

SDEF and this news organization are owned by the same parent company.

Dr. Gordon reported receiving research support and/or serving as a consultant to several pharmaceutical companies including Abbott, Amgen, Lilly, and Pfizer.

bjancin@frontlinlinemedcom.com

WAILEA, HAWAII – While psoriasis experts typically emphasize the disease’s chronic nature and the importance of effective long-term therapy, in reality the first big question when a patient presents to the office should be, ‘What’s the urgency of treatment?’ according to Dr. Kenneth B. Gordon, professor of dermatology at Northwestern University, Chicago.

Two patients can have equally extensive disease yet dissimilar treatment urgencies – and different treatments of choice as a result, he said at the Hawaii Dermatology Seminar, sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

The list of preferred medications for patients with high treatment urgency is short: "When you need to get people better fast, infliximab and cyclosporine are the go-to drugs," the dermatologist stressed.

Insurance companies will often insist that a patient try methotrexate before resorting to a far costlier biologic agent. That’s unreasonable when the treatment urgency is high.

"Methotrexate doesn’t have a high enough level of predictability or efficacy of response. Additionally, it takes a long time to act. When someone is acutely ill, you don’t want to have to wait 16 weeks to figure out what’s the highest level of efficacy you’re going to get. You want to know that answer in 10 weeks, like you do with infliximab. Infliximab is a wonderful short-term therapy for patients who have urgent disease. And with cyclosporine you see effects in 4-8 weeks," Dr. Gordon continued.

He noted that in the open-label RESTORE 1 trial, in which 868 psoriasis patients were randomized to infliximab or methotrexate, the PASI-75 response rate at week 6 in the infliximab group was already close to 60%. By week 10, the PASI-75 rate was 75% in the infliximab group and 27% in the methotrexate group (Br. J. Dermatol. 2011;165:1109-17).

The main safety concern with cyclosporine is renal toxicity, which doesn’t emerge as a real problem until after about a year on the drug, Dr. Gordon said. The safety concerns associated with short-term use (6-8 weeks) to treat an acute exacerbation of psoriasis before transitioning to a different medication are modest, and limited to relatively uncommon increases in blood pressure.

Factors that might raise a patient’s treatment urgency level range from sleep deprivation because of psoriasis pain and itching to workplace hassles because of extensive sick leave, to an important public appearance scheduled within 6-8 weeks.

Session moderator Dr. Craig L. Leonardi remarked that getting payer approval for infliximab often takes a month.

"Unless you’re university based, it’s unlikely you’re going to get infliximab fast, so cyclosporine becomes a real mainstay of treatment when it’s hot and bothersome psoriasis," he said. "And it’s the treatment of choice for psoriasis during pregnancy, absolutely. It’s category C, but there’s a lot of experience with it in the transplant population," noted Dr. Leonardi of St. Louis University.

Dr. Gordon also described a clinical scenario completely different from high treatment urgency – the patient with extensive, yet stable disease. In such a case, the priority is to select a drug the patient can tolerate for a year or more, with good long-term safety and little loss of efficacy over time.

The therapeutic responses to infliximab and adalimumab tend to fade over time, but the majority of patients still do well after 1-3 years of continuous therapy, said Dr. Gordon. His analysis of the phase III REVEAL trial extension showed that 83% of patients with at least a PASI-75 response through the first 33 weeks of adalimumab therapy continued to have a PASI-75 or better response through 100 weeks, and 76% of the original responders were still in that category after 160 weeks of therapy (J. Am. Acad. Dermatol. 2012;66:241-51).

The data on the long-term safety of antitumor necrosis factor agents are extensive and largely reassuring, Dr. Gordon noted.

"I make the argument that there is more known about anti-TNF therapy in terms of safety than any other medicines ever," Dr. Gordon said. Much of the data come courtesy of Europe, where most patients are able to get on anti-TNF therapy only if a physician enrolls them in a registry, he added.

The primary safety risk posed by biologic therapy is serious infections, in Dr. Gordon’s opinion. The collective registry experience in rheumatoid arthritis patients suggests that risk is about 20% greater than in patients on methotrexate, and this risk appears to be stable over time. But it’s probably a mistake to extrapolate from the rheumatologic experience to psoriasis, Dr. Gordon said. He and his colleagues have shown that rheumatoid arthritis patients on biologic therapy tend to be older and more likely to be on concomitant systemic corticosteroids and other immunosuppressive drugs than are psoriasis patients (Ann. Rheum. Dis. 2009;68:1863-9). More data on the risks of biologic therapies in psoriasis patients are anticipated from PSOLAR and other large ongoing patient registries, he said.

A key issue in long-term therapy is the desire of many psoriasis patients to see how they will fare without medication, and the issue has been studied extensively in clinical trials. Dr. Gordon tells patients who would like to discontinue therapy until they relapse, and that there is a one in three chance that they won’t improve upon retreatment. These patients would then need to try another medication. Today there are other medications, and there will likely be more in the coming years, he said.

"But there is a group of patients – and I think we all have them – who are just burning through these medications and don’t respond as well as they did before. So I think we have to be careful and try to convince patients they might be better off staying on their medicine," he said.

SDEF and this news organization are owned by the same parent company.

Dr. Gordon reported receiving research support and/or serving as a consultant to several pharmaceutical companies including Abbott, Amgen, Lilly, and Pfizer.

bjancin@frontlinlinemedcom.com

MAUI, HAWAII – Routine screening for hepatitis B and C has become a must prior to initiation of chronic immunosuppressive therapy for psoriasis, Dr. Craig L. Leonardi said.

"Universal screening for hepatitis B and hepatitis C infection is not optional in 2013," he stressed at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

That said, professional society guidelines are at odds and in flux on this issue. The American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, and the Centers for Disease Control and Prevention all recommend routine screening for hepatitis B surface antigen and hepatitis B core antibody prior to initiation of immunosuppressive therapy. The CDC also recommends universal pretreatment testing for antibody to hepatitis B surface antibody.

In contrast, the American College of Rheumatology recommends HBV screening only in high-risk patients and those treated with specific drugs (Arthritis Rheum. 2008;59:762-84).

For now, the American Academy of Dermatology guidelines take a middle-of-the-road position, which Dr. Leonardi said he finds unconvincing. The current guidelines recommend hepatitis B screening in the appropriate setting (J. Am. Acad. Dermatol. 2008;58:826-50).

"Well, the appropriate setting is when you’re going to use immunosuppressive agents," he asserted. "So I think we all need to start ordering these tests and be on the lookout for the problem. Prophylactic antiviral therapy may be more than the average dermatologist wants to take on. Nonetheless, you want to do the testing and then refer affected patients to an experienced hepatology center."

Chronic immunosuppressive therapy for psoriasis encompasses all the biologics agents – the tumor necrosis factor inhibitors as well as the interleukin 12/23 inhibitor ustekinumab, said Dr. Leonardi of the dermatology department at St. Louis University.

It seems likely that the next iteration of the AAD psoriasis guidelines will firmly recommend universal pretreatment screening for hepatitis. That hand was tipped in a recent review article coauthored by Dr. Alan Menter, chair of the AAD psoriasis guidelines committee.

Dr. Menter and his coauthors endorsed universal screening for hepatitis B surface antigen and HBV core antigen prior to initiating anti-TNF therapy in psoriasis patients. And while the American College of Rheumatology guidelines say anti-TNF therapy is contraindicated in patients with chronic hepatitis B, Dr. Menter and his colleagues took issue. They argued that these important biologic therapies can be used safely for psoriasis, citing evidence that the risk of reactivation of hepatitis B can be greatly minimized or eliminated altogether by preemptive antiviral therapy (J. Am. Acad. Dermatol. 2012;67:1349-61).

They advocated preferential consideration of etanercept over the other TNF-inhibitors in light of evidence suggesting it renders HBV reactivation less likely. They further recommended monthly testing of serum transaminase levels for the first 6 months of therapy in patients with chronic HBV, quarterly testing thereafter, and referral to a hepatologist if liver enzyme levels climb above three times baseline.

A major impetus behind the increased attention being given to screening for hepatitis in patients prior to long-term immunosuppressive therapy was an influential paper published last year by investigators at the CDC, the American Association for the Study of Liver Diseases, and other institutions. The authors underscored the risk of HBV reactivation during such therapy, calling it a neglected danger that is poorly recognized in some professional medical groups’ treatment guidelines (Ann. Intern. Med. 2012;156:743-5).

The risk of HBV reactivation is substantial with anti-TNF therapy in patients who express surface antigen – in the 40% range in one review – but less than 5% in those who are core antibody–positive only.

The risk of hepatitis B reactivation during immunosuppressive therapy has gotten most of the recent attention because of the vast scope of HBV worldwide, with close to 400 million people being chronically infected. In his own busy, universally screened psoriasis practice, however, Dr. Leonardi said that uncovering chronic hepatitis C comes up far more commonly.

The medical board at the National Psoriasis Foundation has cautioned that standard interferon-alpha therapy for HCV seriously exacerbates psoriasis. The group recommends considering the full range of therapeutic options in treating psoriasis in HCV-positive patients. Topical therapies are called the best option for those with limited skin disease. Second-line therapies include UVB phototherapy, acitretin, etanercept, PUVA, and possibly the other TNF-antagonists, with cyclosporine and azathioprine held in reserve as the third line (J. Am. Acad. Dermatol. 2009;61:1044-55).

The recommendation is to monitor quantitative hepatitis C viral counts and liver enzymes during psoriasis therapy and refer to a hepatologist early should levels spike.

As yet, there are very few data on the impact of ustekinumab in patients who are HBV or HCV positive, and no meaningful conclusions as to risk are possible yet, Dr. Leonardi said.

He reported that he serves as a consultant to and recipient of research grants from all the major pharmaceutical companies having an interest in biologic therapies for psoriasis. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Routine screening for hepatitis B and C has become a must prior to initiation of chronic immunosuppressive therapy for psoriasis, Dr. Craig L. Leonardi said.

"Universal screening for hepatitis B and hepatitis C infection is not optional in 2013," he stressed at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

That said, professional society guidelines are at odds and in flux on this issue. The American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, and the Centers for Disease Control and Prevention all recommend routine screening for hepatitis B surface antigen and hepatitis B core antibody prior to initiation of immunosuppressive therapy. The CDC also recommends universal pretreatment testing for antibody to hepatitis B surface antibody.

In contrast, the American College of Rheumatology recommends HBV screening only in high-risk patients and those treated with specific drugs (Arthritis Rheum. 2008;59:762-84).

For now, the American Academy of Dermatology guidelines take a middle-of-the-road position, which Dr. Leonardi said he finds unconvincing. The current guidelines recommend hepatitis B screening in the appropriate setting (J. Am. Acad. Dermatol. 2008;58:826-50).

"Well, the appropriate setting is when you’re going to use immunosuppressive agents," he asserted. "So I think we all need to start ordering these tests and be on the lookout for the problem. Prophylactic antiviral therapy may be more than the average dermatologist wants to take on. Nonetheless, you want to do the testing and then refer affected patients to an experienced hepatology center."

Chronic immunosuppressive therapy for psoriasis encompasses all the biologics agents – the tumor necrosis factor inhibitors as well as the interleukin 12/23 inhibitor ustekinumab, said Dr. Leonardi of the dermatology department at St. Louis University.

It seems likely that the next iteration of the AAD psoriasis guidelines will firmly recommend universal pretreatment screening for hepatitis. That hand was tipped in a recent review article coauthored by Dr. Alan Menter, chair of the AAD psoriasis guidelines committee.

Dr. Menter and his coauthors endorsed universal screening for hepatitis B surface antigen and HBV core antigen prior to initiating anti-TNF therapy in psoriasis patients. And while the American College of Rheumatology guidelines say anti-TNF therapy is contraindicated in patients with chronic hepatitis B, Dr. Menter and his colleagues took issue. They argued that these important biologic therapies can be used safely for psoriasis, citing evidence that the risk of reactivation of hepatitis B can be greatly minimized or eliminated altogether by preemptive antiviral therapy (J. Am. Acad. Dermatol. 2012;67:1349-61).

They advocated preferential consideration of etanercept over the other TNF-inhibitors in light of evidence suggesting it renders HBV reactivation less likely. They further recommended monthly testing of serum transaminase levels for the first 6 months of therapy in patients with chronic HBV, quarterly testing thereafter, and referral to a hepatologist if liver enzyme levels climb above three times baseline.

A major impetus behind the increased attention being given to screening for hepatitis in patients prior to long-term immunosuppressive therapy was an influential paper published last year by investigators at the CDC, the American Association for the Study of Liver Diseases, and other institutions. The authors underscored the risk of HBV reactivation during such therapy, calling it a neglected danger that is poorly recognized in some professional medical groups’ treatment guidelines (Ann. Intern. Med. 2012;156:743-5).

The risk of HBV reactivation is substantial with anti-TNF therapy in patients who express surface antigen – in the 40% range in one review – but less than 5% in those who are core antibody–positive only.

The risk of hepatitis B reactivation during immunosuppressive therapy has gotten most of the recent attention because of the vast scope of HBV worldwide, with close to 400 million people being chronically infected. In his own busy, universally screened psoriasis practice, however, Dr. Leonardi said that uncovering chronic hepatitis C comes up far more commonly.

The medical board at the National Psoriasis Foundation has cautioned that standard interferon-alpha therapy for HCV seriously exacerbates psoriasis. The group recommends considering the full range of therapeutic options in treating psoriasis in HCV-positive patients. Topical therapies are called the best option for those with limited skin disease. Second-line therapies include UVB phototherapy, acitretin, etanercept, PUVA, and possibly the other TNF-antagonists, with cyclosporine and azathioprine held in reserve as the third line (J. Am. Acad. Dermatol. 2009;61:1044-55).

The recommendation is to monitor quantitative hepatitis C viral counts and liver enzymes during psoriasis therapy and refer to a hepatologist early should levels spike.

As yet, there are very few data on the impact of ustekinumab in patients who are HBV or HCV positive, and no meaningful conclusions as to risk are possible yet, Dr. Leonardi said.

He reported that he serves as a consultant to and recipient of research grants from all the major pharmaceutical companies having an interest in biologic therapies for psoriasis. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Routine screening for hepatitis B and C has become a must prior to initiation of chronic immunosuppressive therapy for psoriasis, Dr. Craig L. Leonardi said.

"Universal screening for hepatitis B and hepatitis C infection is not optional in 2013," he stressed at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

That said, professional society guidelines are at odds and in flux on this issue. The American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, and the Centers for Disease Control and Prevention all recommend routine screening for hepatitis B surface antigen and hepatitis B core antibody prior to initiation of immunosuppressive therapy. The CDC also recommends universal pretreatment testing for antibody to hepatitis B surface antibody.

In contrast, the American College of Rheumatology recommends HBV screening only in high-risk patients and those treated with specific drugs (Arthritis Rheum. 2008;59:762-84).

For now, the American Academy of Dermatology guidelines take a middle-of-the-road position, which Dr. Leonardi said he finds unconvincing. The current guidelines recommend hepatitis B screening in the appropriate setting (J. Am. Acad. Dermatol. 2008;58:826-50).

"Well, the appropriate setting is when you’re going to use immunosuppressive agents," he asserted. "So I think we all need to start ordering these tests and be on the lookout for the problem. Prophylactic antiviral therapy may be more than the average dermatologist wants to take on. Nonetheless, you want to do the testing and then refer affected patients to an experienced hepatology center."

Chronic immunosuppressive therapy for psoriasis encompasses all the biologics agents – the tumor necrosis factor inhibitors as well as the interleukin 12/23 inhibitor ustekinumab, said Dr. Leonardi of the dermatology department at St. Louis University.

It seems likely that the next iteration of the AAD psoriasis guidelines will firmly recommend universal pretreatment screening for hepatitis. That hand was tipped in a recent review article coauthored by Dr. Alan Menter, chair of the AAD psoriasis guidelines committee.

Dr. Menter and his coauthors endorsed universal screening for hepatitis B surface antigen and HBV core antigen prior to initiating anti-TNF therapy in psoriasis patients. And while the American College of Rheumatology guidelines say anti-TNF therapy is contraindicated in patients with chronic hepatitis B, Dr. Menter and his colleagues took issue. They argued that these important biologic therapies can be used safely for psoriasis, citing evidence that the risk of reactivation of hepatitis B can be greatly minimized or eliminated altogether by preemptive antiviral therapy (J. Am. Acad. Dermatol. 2012;67:1349-61).

They advocated preferential consideration of etanercept over the other TNF-inhibitors in light of evidence suggesting it renders HBV reactivation less likely. They further recommended monthly testing of serum transaminase levels for the first 6 months of therapy in patients with chronic HBV, quarterly testing thereafter, and referral to a hepatologist if liver enzyme levels climb above three times baseline.

A major impetus behind the increased attention being given to screening for hepatitis in patients prior to long-term immunosuppressive therapy was an influential paper published last year by investigators at the CDC, the American Association for the Study of Liver Diseases, and other institutions. The authors underscored the risk of HBV reactivation during such therapy, calling it a neglected danger that is poorly recognized in some professional medical groups’ treatment guidelines (Ann. Intern. Med. 2012;156:743-5).

The risk of HBV reactivation is substantial with anti-TNF therapy in patients who express surface antigen – in the 40% range in one review – but less than 5% in those who are core antibody–positive only.

The risk of hepatitis B reactivation during immunosuppressive therapy has gotten most of the recent attention because of the vast scope of HBV worldwide, with close to 400 million people being chronically infected. In his own busy, universally screened psoriasis practice, however, Dr. Leonardi said that uncovering chronic hepatitis C comes up far more commonly.

The medical board at the National Psoriasis Foundation has cautioned that standard interferon-alpha therapy for HCV seriously exacerbates psoriasis. The group recommends considering the full range of therapeutic options in treating psoriasis in HCV-positive patients. Topical therapies are called the best option for those with limited skin disease. Second-line therapies include UVB phototherapy, acitretin, etanercept, PUVA, and possibly the other TNF-antagonists, with cyclosporine and azathioprine held in reserve as the third line (J. Am. Acad. Dermatol. 2009;61:1044-55).

The recommendation is to monitor quantitative hepatitis C viral counts and liver enzymes during psoriasis therapy and refer to a hepatologist early should levels spike.

As yet, there are very few data on the impact of ustekinumab in patients who are HBV or HCV positive, and no meaningful conclusions as to risk are possible yet, Dr. Leonardi said.

He reported that he serves as a consultant to and recipient of research grants from all the major pharmaceutical companies having an interest in biologic therapies for psoriasis. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Conventional wisdom holds that systemic therapy is necessary for effective treatment of onychomycosis. Not so in children, according to Dr. Sheila F. Friedlander.

"You can have different treatment plans depending on the severity of disease. If you have a child with minimal involvement – not involving the nail matrix – I would consider topical therapy rather than systemic," Dr. Friedlander said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Friedlander and her coinvestigators conducted a prospective trial of 40 children and teens aged 2-16 years with nonmatrix onychomycosis. The patients were randomized 3 to 1 to receive topical ciclopirox nail lacquer or a vehicle control. The lacquer was applied daily, with weekly removal and nail trimming, for the duration of the 32-week trial.

At 32 weeks, the mycologic cure and effective treatment rates were 77% and 71%, respectively, in the ciclopirox group compared with 22% for both mycologic cure and effective treatment rates in controls.

"Those treatment success rates in excess of 70% were exciting to us. Those are data you never see in adults," said Dr. Friedlander, professor of clinical medicine and pediatrics at the University of California, San Diego, and president of the Society for Pediatric Dermatology. "If you were to do this study of ciclopirox in adults, the numbers would be in the teens or twenties," she said.

Ninety-two percent of patients with mycologic cure at 32 weeks remained clear after 1 year, and the only adverse effect noted was transient discoloration of the nails.

Topical therapy is so much more effective in children and teens because they have thinner, faster-growing nails than adults, Dr. Friedlander explained.

The families of the patients loved this treatment, she added. More than 90% said they would definitely or probably undergo the treatment again.

Eighty-two percent of study participants had one or more family members with onychomycosis, which raises the question of whether the participants’ fungal diseases were caused by environmental exposure or genetic susceptibility, Dr. Friedlander said.

Systemic antifungal therapy is clearly more effective than is topical therapy, Dr. Friedlander noted. But her preferred oral therapy, terbinafine, requires 3 months of daily use to cure a pediatric toenail infection. Also, the Food and Drug Administration recommends that patients get liver function tests when using this drug, which makes terbinafine a tough sell to parents.

"Families are loath to put their children on prolonged systemic therapy. And they do not want their children poked for lab studies," she observed.

Dr. Friedlander reported having no financial conflicts. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Conventional wisdom holds that systemic therapy is necessary for effective treatment of onychomycosis. Not so in children, according to Dr. Sheila F. Friedlander.

"You can have different treatment plans depending on the severity of disease. If you have a child with minimal involvement – not involving the nail matrix – I would consider topical therapy rather than systemic," Dr. Friedlander said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Friedlander and her coinvestigators conducted a prospective trial of 40 children and teens aged 2-16 years with nonmatrix onychomycosis. The patients were randomized 3 to 1 to receive topical ciclopirox nail lacquer or a vehicle control. The lacquer was applied daily, with weekly removal and nail trimming, for the duration of the 32-week trial.

At 32 weeks, the mycologic cure and effective treatment rates were 77% and 71%, respectively, in the ciclopirox group compared with 22% for both mycologic cure and effective treatment rates in controls.

"Those treatment success rates in excess of 70% were exciting to us. Those are data you never see in adults," said Dr. Friedlander, professor of clinical medicine and pediatrics at the University of California, San Diego, and president of the Society for Pediatric Dermatology. "If you were to do this study of ciclopirox in adults, the numbers would be in the teens or twenties," she said.

Ninety-two percent of patients with mycologic cure at 32 weeks remained clear after 1 year, and the only adverse effect noted was transient discoloration of the nails.

Topical therapy is so much more effective in children and teens because they have thinner, faster-growing nails than adults, Dr. Friedlander explained.

The families of the patients loved this treatment, she added. More than 90% said they would definitely or probably undergo the treatment again.

Eighty-two percent of study participants had one or more family members with onychomycosis, which raises the question of whether the participants’ fungal diseases were caused by environmental exposure or genetic susceptibility, Dr. Friedlander said.

Systemic antifungal therapy is clearly more effective than is topical therapy, Dr. Friedlander noted. But her preferred oral therapy, terbinafine, requires 3 months of daily use to cure a pediatric toenail infection. Also, the Food and Drug Administration recommends that patients get liver function tests when using this drug, which makes terbinafine a tough sell to parents.

"Families are loath to put their children on prolonged systemic therapy. And they do not want their children poked for lab studies," she observed.

Dr. Friedlander reported having no financial conflicts. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – Conventional wisdom holds that systemic therapy is necessary for effective treatment of onychomycosis. Not so in children, according to Dr. Sheila F. Friedlander.

"You can have different treatment plans depending on the severity of disease. If you have a child with minimal involvement – not involving the nail matrix – I would consider topical therapy rather than systemic," Dr. Friedlander said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Friedlander and her coinvestigators conducted a prospective trial of 40 children and teens aged 2-16 years with nonmatrix onychomycosis. The patients were randomized 3 to 1 to receive topical ciclopirox nail lacquer or a vehicle control. The lacquer was applied daily, with weekly removal and nail trimming, for the duration of the 32-week trial.

At 32 weeks, the mycologic cure and effective treatment rates were 77% and 71%, respectively, in the ciclopirox group compared with 22% for both mycologic cure and effective treatment rates in controls.

"Those treatment success rates in excess of 70% were exciting to us. Those are data you never see in adults," said Dr. Friedlander, professor of clinical medicine and pediatrics at the University of California, San Diego, and president of the Society for Pediatric Dermatology. "If you were to do this study of ciclopirox in adults, the numbers would be in the teens or twenties," she said.

Ninety-two percent of patients with mycologic cure at 32 weeks remained clear after 1 year, and the only adverse effect noted was transient discoloration of the nails.

Topical therapy is so much more effective in children and teens because they have thinner, faster-growing nails than adults, Dr. Friedlander explained.

The families of the patients loved this treatment, she added. More than 90% said they would definitely or probably undergo the treatment again.

Eighty-two percent of study participants had one or more family members with onychomycosis, which raises the question of whether the participants’ fungal diseases were caused by environmental exposure or genetic susceptibility, Dr. Friedlander said.

Systemic antifungal therapy is clearly more effective than is topical therapy, Dr. Friedlander noted. But her preferred oral therapy, terbinafine, requires 3 months of daily use to cure a pediatric toenail infection. Also, the Food and Drug Administration recommends that patients get liver function tests when using this drug, which makes terbinafine a tough sell to parents.

"Families are loath to put their children on prolonged systemic therapy. And they do not want their children poked for lab studies," she observed.

Dr. Friedlander reported having no financial conflicts. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

MAUI, HAWAII – The cardiovascular comorbidity associated with psoriasis has drawn much attention, yet depression is arguably an even more important psoriatic comorbid condition.

"I think the most important comorbidity of psoriasis is depression. We all talk about heart disease, we talk about diabetes, but depression is something that we see every day in the office. It’s a big, massively important issue in our psoriasis patients," Dr. Kenneth B. Gordon said at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

Moreover, depression also is the comorbidity in which dermatologists can clearly make the biggest difference. While there is great hope that effective treatment of psoriasis will reduce comorbid cardiovascular morbidity and mortality, that hasn’t yet been proved true. In contrast, there are persuasive clinical trials data demonstrating that effectively treating psoriasis markedly improves patients’ comorbid depression, according to Dr. Gordon, professor of dermatology at Northwestern University, Chicago.

For example, a clinical trial involving 1,230 psoriasis patients randomized to ustekinumab or placebo showed that at baseline 27% of subjects had clinically significant depression based upon the Hospital Anxiety and Depression Scale (HADS). After 12 weeks of therapy, the ustekinumab group showed a highly significant 29% decrease in mean HADS scores, compared with baseline. At the 12-week mark, 8.7% of placebo-treated controls had moderate depression as defined by a HADS score of 11-14, compared with 3.9% on ustekinumab. Severe depression, with a HADS score of 15-21, was present in 2.7% of controls and just 0.8% of patients on ustekinumab (J. Am. Acad. Dermatol. 2010;63:457-65).

"Maybe you don’t think of ustekinumab as a treatment for depression, but the size of the severely depressed group on ustekinumab markedly diminished over time. You’re taking people with clinically very significant depression and making it better," Dr. Gordon observed.

Similarly, a randomized trial in which 96 psoriasis patients received 40 mg of adalimumab or placebo every 2 weeks showed that patients with a 75% or greater decrease in baseline Psoriasis Area and Severity Index scores, or PASI-75 response, at 12 weeks averaged a 10.6-point reduction on the Zung Self-Rating Depression Scale. Nonresponders to the tumor necrosis factor inhibitor had a nonsignificant 1.4-point drop in Zung scores (J. Am. Acad. Dermatol. 2010;62:812-8).

This antidepressant effect of psoriasis treatment is not limited to the biologic agents, either, the dermatologist noted. He pointed to a recent study in which patients with refractory psoriasis were placed on the Goeckerman regimen involving UV phototherapy and coal tar. They received an average of 30 treatment sessions over 4-6 weeks. As their mean PASI scores fell from 27.1 to 6.9, their mean HADS depression scores dropped from 9.1 to 6.8 (Acta Derm. Venereol. 2011;91:447-51).

Based upon these and other data, Dr. Gordon proposed that the quality measures now being developed for psoriasis management ought to include identification of comorbid depression and demonstration of its improvement during psoriasis therapy.

The SDEF and this news organization are owned by the same parent company.

Dr. Gordon reported receiving research support and/or serving as a consultant to seven pharmaceutical companies but is not on any speakers bureaus.

MAUI, HAWAII – The cardiovascular comorbidity associated with psoriasis has drawn much attention, yet depression is arguably an even more important psoriatic comorbid condition.

"I think the most important comorbidity of psoriasis is depression. We all talk about heart disease, we talk about diabetes, but depression is something that we see every day in the office. It’s a big, massively important issue in our psoriasis patients," Dr. Kenneth B. Gordon said at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

Moreover, depression also is the comorbidity in which dermatologists can clearly make the biggest difference. While there is great hope that effective treatment of psoriasis will reduce comorbid cardiovascular morbidity and mortality, that hasn’t yet been proved true. In contrast, there are persuasive clinical trials data demonstrating that effectively treating psoriasis markedly improves patients’ comorbid depression, according to Dr. Gordon, professor of dermatology at Northwestern University, Chicago.

For example, a clinical trial involving 1,230 psoriasis patients randomized to ustekinumab or placebo showed that at baseline 27% of subjects had clinically significant depression based upon the Hospital Anxiety and Depression Scale (HADS). After 12 weeks of therapy, the ustekinumab group showed a highly significant 29% decrease in mean HADS scores, compared with baseline. At the 12-week mark, 8.7% of placebo-treated controls had moderate depression as defined by a HADS score of 11-14, compared with 3.9% on ustekinumab. Severe depression, with a HADS score of 15-21, was present in 2.7% of controls and just 0.8% of patients on ustekinumab (J. Am. Acad. Dermatol. 2010;63:457-65).

"Maybe you don’t think of ustekinumab as a treatment for depression, but the size of the severely depressed group on ustekinumab markedly diminished over time. You’re taking people with clinically very significant depression and making it better," Dr. Gordon observed.

Similarly, a randomized trial in which 96 psoriasis patients received 40 mg of adalimumab or placebo every 2 weeks showed that patients with a 75% or greater decrease in baseline Psoriasis Area and Severity Index scores, or PASI-75 response, at 12 weeks averaged a 10.6-point reduction on the Zung Self-Rating Depression Scale. Nonresponders to the tumor necrosis factor inhibitor had a nonsignificant 1.4-point drop in Zung scores (J. Am. Acad. Dermatol. 2010;62:812-8).

This antidepressant effect of psoriasis treatment is not limited to the biologic agents, either, the dermatologist noted. He pointed to a recent study in which patients with refractory psoriasis were placed on the Goeckerman regimen involving UV phototherapy and coal tar. They received an average of 30 treatment sessions over 4-6 weeks. As their mean PASI scores fell from 27.1 to 6.9, their mean HADS depression scores dropped from 9.1 to 6.8 (Acta Derm. Venereol. 2011;91:447-51).

Based upon these and other data, Dr. Gordon proposed that the quality measures now being developed for psoriasis management ought to include identification of comorbid depression and demonstration of its improvement during psoriasis therapy.

The SDEF and this news organization are owned by the same parent company.

Dr. Gordon reported receiving research support and/or serving as a consultant to seven pharmaceutical companies but is not on any speakers bureaus.

MAUI, HAWAII – The cardiovascular comorbidity associated with psoriasis has drawn much attention, yet depression is arguably an even more important psoriatic comorbid condition.

"I think the most important comorbidity of psoriasis is depression. We all talk about heart disease, we talk about diabetes, but depression is something that we see every day in the office. It’s a big, massively important issue in our psoriasis patients," Dr. Kenneth B. Gordon said at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

Moreover, depression also is the comorbidity in which dermatologists can clearly make the biggest difference. While there is great hope that effective treatment of psoriasis will reduce comorbid cardiovascular morbidity and mortality, that hasn’t yet been proved true. In contrast, there are persuasive clinical trials data demonstrating that effectively treating psoriasis markedly improves patients’ comorbid depression, according to Dr. Gordon, professor of dermatology at Northwestern University, Chicago.

For example, a clinical trial involving 1,230 psoriasis patients randomized to ustekinumab or placebo showed that at baseline 27% of subjects had clinically significant depression based upon the Hospital Anxiety and Depression Scale (HADS). After 12 weeks of therapy, the ustekinumab group showed a highly significant 29% decrease in mean HADS scores, compared with baseline. At the 12-week mark, 8.7% of placebo-treated controls had moderate depression as defined by a HADS score of 11-14, compared with 3.9% on ustekinumab. Severe depression, with a HADS score of 15-21, was present in 2.7% of controls and just 0.8% of patients on ustekinumab (J. Am. Acad. Dermatol. 2010;63:457-65).

"Maybe you don’t think of ustekinumab as a treatment for depression, but the size of the severely depressed group on ustekinumab markedly diminished over time. You’re taking people with clinically very significant depression and making it better," Dr. Gordon observed.

Similarly, a randomized trial in which 96 psoriasis patients received 40 mg of adalimumab or placebo every 2 weeks showed that patients with a 75% or greater decrease in baseline Psoriasis Area and Severity Index scores, or PASI-75 response, at 12 weeks averaged a 10.6-point reduction on the Zung Self-Rating Depression Scale. Nonresponders to the tumor necrosis factor inhibitor had a nonsignificant 1.4-point drop in Zung scores (J. Am. Acad. Dermatol. 2010;62:812-8).

This antidepressant effect of psoriasis treatment is not limited to the biologic agents, either, the dermatologist noted. He pointed to a recent study in which patients with refractory psoriasis were placed on the Goeckerman regimen involving UV phototherapy and coal tar. They received an average of 30 treatment sessions over 4-6 weeks. As their mean PASI scores fell from 27.1 to 6.9, their mean HADS depression scores dropped from 9.1 to 6.8 (Acta Derm. Venereol. 2011;91:447-51).

Based upon these and other data, Dr. Gordon proposed that the quality measures now being developed for psoriasis management ought to include identification of comorbid depression and demonstration of its improvement during psoriasis therapy.

The SDEF and this news organization are owned by the same parent company.

Dr. Gordon reported receiving research support and/or serving as a consultant to seven pharmaceutical companies but is not on any speakers bureaus.

Topical timolol for the treatment of infantile hemangiomas is emerging as a safer, easier alternative to oral propranolol in selected patients, according to Dr. Sheila Fallon Friedlander.

"I think this [timolol] is something that’s very, very useful. You’re going to be seeing more of it around in use for this condition. We’ve seen encouraging results in the past 2½ years. It’s well tolerated, and I think there will come a day when even primary care physicians will be using topical timolol with comfort," she said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/IMNG Medical Media

Topical timolol works best for small, relatively thin hemangiomas, such as eyelid lesions, advised Dr. Friedlander, president of the Society for Pediatric Dermatology and a pediatric dermatologist at the University of California, San Diego.

"You don’t put timolol on big, thick lesions and expect it to work; it won’t," she said.

At this point, the evidence base for topical timolol is far smaller than for propranolol, which has become the clear drug of choice for children requiring systemic therapy. To date, there are at least 20 articles involving about 175 timolol-treated patients, with the single largest published series consisting of 73 children (Pediatr. Dermatol. 2012;29:28-31).

Topical timolol is outpatient therapy. Used judiciously, it doesn’t appear to result in significant systemic absorption. The dose most experts recommend is 1 drop of 0.5% timolol ophthalmic gel-forming solution applied twice daily to the lesion.

Dr. Friedlander and her colleagues at Rady Children’s Hospital in San Diego are about to embark on a large, prospective study of topical timolol for infantile hemangiomas to further define the treatment efficacy; the systemic risk, if any; and appropriate patient monitoring.

Meanwhile, now that the dust has settled, propranolol is the unequivocal drug of choice when systemic therapy is warranted. It has replaced corticosteroid therapy, which is what most dermatologists were trained to use.

"Propranolol for hemangiomas is the most important thing that’s happened in pediatric dermatology in the last few years. It’s a wonderful, wonderful agent that we now have available to help us," Dr. Friedlander said.

There are more than 2,000 publications on propranolol, including a new systematic review of nearly 1,300 patients treated by dermatologists at the University of California, San Francisco, who reported a 98% response rate and a low rate of side effects (Pediatr. Dermatol. 2013 Feb. 14 [doi:10.1111/pde.12089]).

In addition, recent expert consensus guidelines on the use of propranolol for the treatment of infantile hemangiomas (Pediatrics 2013;131:128-40) are "very helpful," Dr. Friedlander continued.

Today, inpatient propranolol therapy is reserved for very young infants of less than 8 weeks’ corrected gestational age, those with comorbid cardiac conditions or asthma, and kids who don’t have reliable family support. Most children are now treated as outpatients, typically beginning at about 6 months of age. The usual starting dose is 0.5 mg/kg per day, titrating up to about 2 mg/kg per day. Dr. Friedlander said she typically continues treatment for about 10 months; discontinuing too early can lead to rebound.

The recommended monitoring consists of heart rate and blood pressure measurements at baseline and 1 and 2 hours after the initial dose of propranolol, with repeat monitoring required only when the dose is increased by more than 0.5 mg/kg per day. Although routine blood glucose testing isn’t recommended, propranolol does lower the blood glucose level, so it’s essential that a treated child feeds often, and that the drug is stopped when a child has a gastrointestinal illness with vomiting or diarrhea, or is not feeding adequately for his or her age.

In addition to making sure an infant doesn’t have a cardiac condition or upper airway issues before starting the child on propranolol, check for a segmental hemangioma greater than about 5 cm on the face or neck, which is a red flag. A child with such a lesion is at risk for the PHACE syndrome and needs to undergo brain imaging to make sure the arterial vasculature is normal before propranolol therapy is started, Dr. Friedlander emphasized.

She reported having no relevant financial conflicts. SDEF and this news organization are owned by the same parent company.

b.jancin@elsevier.com

Topical timolol for the treatment of infantile hemangiomas is emerging as a safer, easier alternative to oral propranolol in selected patients, according to Dr. Sheila Fallon Friedlander.

"I think this [timolol] is something that’s very, very useful. You’re going to be seeing more of it around in use for this condition. We’ve seen encouraging results in the past 2½ years. It’s well tolerated, and I think there will come a day when even primary care physicians will be using topical timolol with comfort," she said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/IMNG Medical Media

Topical timolol works best for small, relatively thin hemangiomas, such as eyelid lesions, advised Dr. Friedlander, president of the Society for Pediatric Dermatology and a pediatric dermatologist at the University of California, San Diego.

"You don’t put timolol on big, thick lesions and expect it to work; it won’t," she said.

At this point, the evidence base for topical timolol is far smaller than for propranolol, which has become the clear drug of choice for children requiring systemic therapy. To date, there are at least 20 articles involving about 175 timolol-treated patients, with the single largest published series consisting of 73 children (Pediatr. Dermatol. 2012;29:28-31).

Topical timolol is outpatient therapy. Used judiciously, it doesn’t appear to result in significant systemic absorption. The dose most experts recommend is 1 drop of 0.5% timolol ophthalmic gel-forming solution applied twice daily to the lesion.

Dr. Friedlander and her colleagues at Rady Children’s Hospital in San Diego are about to embark on a large, prospective study of topical timolol for infantile hemangiomas to further define the treatment efficacy; the systemic risk, if any; and appropriate patient monitoring.

Meanwhile, now that the dust has settled, propranolol is the unequivocal drug of choice when systemic therapy is warranted. It has replaced corticosteroid therapy, which is what most dermatologists were trained to use.

"Propranolol for hemangiomas is the most important thing that’s happened in pediatric dermatology in the last few years. It’s a wonderful, wonderful agent that we now have available to help us," Dr. Friedlander said.

There are more than 2,000 publications on propranolol, including a new systematic review of nearly 1,300 patients treated by dermatologists at the University of California, San Francisco, who reported a 98% response rate and a low rate of side effects (Pediatr. Dermatol. 2013 Feb. 14 [doi:10.1111/pde.12089]).

In addition, recent expert consensus guidelines on the use of propranolol for the treatment of infantile hemangiomas (Pediatrics 2013;131:128-40) are "very helpful," Dr. Friedlander continued.

Today, inpatient propranolol therapy is reserved for very young infants of less than 8 weeks’ corrected gestational age, those with comorbid cardiac conditions or asthma, and kids who don’t have reliable family support. Most children are now treated as outpatients, typically beginning at about 6 months of age. The usual starting dose is 0.5 mg/kg per day, titrating up to about 2 mg/kg per day. Dr. Friedlander said she typically continues treatment for about 10 months; discontinuing too early can lead to rebound.

The recommended monitoring consists of heart rate and blood pressure measurements at baseline and 1 and 2 hours after the initial dose of propranolol, with repeat monitoring required only when the dose is increased by more than 0.5 mg/kg per day. Although routine blood glucose testing isn’t recommended, propranolol does lower the blood glucose level, so it’s essential that a treated child feeds often, and that the drug is stopped when a child has a gastrointestinal illness with vomiting or diarrhea, or is not feeding adequately for his or her age.

In addition to making sure an infant doesn’t have a cardiac condition or upper airway issues before starting the child on propranolol, check for a segmental hemangioma greater than about 5 cm on the face or neck, which is a red flag. A child with such a lesion is at risk for the PHACE syndrome and needs to undergo brain imaging to make sure the arterial vasculature is normal before propranolol therapy is started, Dr. Friedlander emphasized.

She reported having no relevant financial conflicts. SDEF and this news organization are owned by the same parent company.

b.jancin@elsevier.com

Topical timolol for the treatment of infantile hemangiomas is emerging as a safer, easier alternative to oral propranolol in selected patients, according to Dr. Sheila Fallon Friedlander.

"I think this [timolol] is something that’s very, very useful. You’re going to be seeing more of it around in use for this condition. We’ve seen encouraging results in the past 2½ years. It’s well tolerated, and I think there will come a day when even primary care physicians will be using topical timolol with comfort," she said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/IMNG Medical Media

Topical timolol works best for small, relatively thin hemangiomas, such as eyelid lesions, advised Dr. Friedlander, president of the Society for Pediatric Dermatology and a pediatric dermatologist at the University of California, San Diego.

"You don’t put timolol on big, thick lesions and expect it to work; it won’t," she said.

At this point, the evidence base for topical timolol is far smaller than for propranolol, which has become the clear drug of choice for children requiring systemic therapy. To date, there are at least 20 articles involving about 175 timolol-treated patients, with the single largest published series consisting of 73 children (Pediatr. Dermatol. 2012;29:28-31).

Topical timolol is outpatient therapy. Used judiciously, it doesn’t appear to result in significant systemic absorption. The dose most experts recommend is 1 drop of 0.5% timolol ophthalmic gel-forming solution applied twice daily to the lesion.

Dr. Friedlander and her colleagues at Rady Children’s Hospital in San Diego are about to embark on a large, prospective study of topical timolol for infantile hemangiomas to further define the treatment efficacy; the systemic risk, if any; and appropriate patient monitoring.

Meanwhile, now that the dust has settled, propranolol is the unequivocal drug of choice when systemic therapy is warranted. It has replaced corticosteroid therapy, which is what most dermatologists were trained to use.

"Propranolol for hemangiomas is the most important thing that’s happened in pediatric dermatology in the last few years. It’s a wonderful, wonderful agent that we now have available to help us," Dr. Friedlander said.

There are more than 2,000 publications on propranolol, including a new systematic review of nearly 1,300 patients treated by dermatologists at the University of California, San Francisco, who reported a 98% response rate and a low rate of side effects (Pediatr. Dermatol. 2013 Feb. 14 [doi:10.1111/pde.12089]).

In addition, recent expert consensus guidelines on the use of propranolol for the treatment of infantile hemangiomas (Pediatrics 2013;131:128-40) are "very helpful," Dr. Friedlander continued.

Today, inpatient propranolol therapy is reserved for very young infants of less than 8 weeks’ corrected gestational age, those with comorbid cardiac conditions or asthma, and kids who don’t have reliable family support. Most children are now treated as outpatients, typically beginning at about 6 months of age. The usual starting dose is 0.5 mg/kg per day, titrating up to about 2 mg/kg per day. Dr. Friedlander said she typically continues treatment for about 10 months; discontinuing too early can lead to rebound.

The recommended monitoring consists of heart rate and blood pressure measurements at baseline and 1 and 2 hours after the initial dose of propranolol, with repeat monitoring required only when the dose is increased by more than 0.5 mg/kg per day. Although routine blood glucose testing isn’t recommended, propranolol does lower the blood glucose level, so it’s essential that a treated child feeds often, and that the drug is stopped when a child has a gastrointestinal illness with vomiting or diarrhea, or is not feeding adequately for his or her age.

In addition to making sure an infant doesn’t have a cardiac condition or upper airway issues before starting the child on propranolol, check for a segmental hemangioma greater than about 5 cm on the face or neck, which is a red flag. A child with such a lesion is at risk for the PHACE syndrome and needs to undergo brain imaging to make sure the arterial vasculature is normal before propranolol therapy is started, Dr. Friedlander emphasized.

She reported having no relevant financial conflicts. SDEF and this news organization are owned by the same parent company.

b.jancin@elsevier.com