SDEF Hawaii Dermatology Seminar 2013

Emerging data strongly suggest that children with atopic dermatitis are at increased risk for attention-deficit/hyperactivity disorder.

"The first paper was actually a really good paper, but it was just one study and so we did not quite believe it. But now there’s a confirmatory study by a separate group with really big data," Dr. Lawrence K. Eichenfield said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

In addition, the second study pointed to a possible higher risk of autism in children with atopic dermatitis, and it also confirmed other reports of increased rates of depression and anxiety, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, also in San Diego.

Atopic dermatitis is the most common chronic inflammatory condition in childhood. Attention-deficit/hyperactivity disorder is the most common psychiatric disorder. The first study to report an association between the two was a German, case-control, population-based study involving 1,436 atopic dermatitis patients aged 6-17 years and an equal number of age- and gender-matched controls without the skin disease.

The prevalence of diagnosed ADHD was 5.2% in the atopic dermatitis patients and 3.4% in controls (P = 0.02). In a multivariate logistic regression analysis, atopic dermatitis was an independent predictor of prevalent ADHD, with an associated 47% increased risk of the psychiatric disorder compared with youths without atopic dermatitis. Moreover, there was a suggestion that the more severe a patient’s atopic dermatitis, the greater the likelihood of comorbid ADHD, since the likelihood of ADHD increased with each additional physician visit for atopic dermatitis (JAMA 2009;301:724-6).

More recently, in a study presented at a major meeting but not yet published, Dr. Eric L. Simpson and his coinvestigators at Oregon Health and Science University, Portland, confirmed the initial German finding that pediatric atopic dermatitis is associated with ADHD, this time in a database of 90,000 U.S. children. Once again, the more severe the skin disease, the greater the risk of ADHD. In this study, atopic dermatitis was also associated with increased risks of depression, anxiety, and autism.

Possible mechanisms underlying the observed association between atopic dermatitis and comorbid psychiatric conditions include sleep disturbance – a prominent feature in atopic dermatitis – and systemic inflammation, according to Dr. Eichenfield.

The well-established atopic comorbidities associated with atopic dermatitis are asthma, allergic rhinitis, and food allergy. Dr. Eichenfield said that he welcomes the evolving evidence of psychologic comorbidities for the opportunity it provides to encourage treatment adherence. Like other treating physicians, he finds topical steroid phobia to be a huge problem.

"I actually use this information in my clinical practice as a way to get my families to adequately treat atopic dermatitis," he said. "If I have families that are very steroid phobic, I’ll say, ‘You know, you really want to treat your kid with appropriate topical therapy to minimize the disease impact: to minimize the sleep disturbance and potentially minimize the neurobehavioral impact of atopic dermatitis.’ I use that as a tool to stay with our regimens of care."

Steroid phobia is a problem worldwide, not just in the United States. For example, Dr. Eichenfield noted that when French dermatologists recently surveyed 208 consecutive atopic dermatitis patients or their parents using a detailed 69-item questionnaire, 81% reported having fears about topical corticosteroids – the mainstay of atopic dermatitis treatment – and 36% admitted to treatment nonadherence as a result of their worries. Fears did not correlate with disease severity (Br. J. Dermatol. 2011;165:808-14).

"I think that in all of dermatology there’s probably no greater chasm between where our families are at in terms of concerns about a medication and where we are as physicians in terms of not having concerns than in the area of topical steroids for atopic dermatitis," Dr. Eichenfield said.

He noted that he makes extensive use of parental educational handouts and written action plans in addition to face-to-face discussion of safety concerns at the time he prescribes topical steroids. One strategy that he’s recently realized makes a big difference in terms of adherence is to explain carefully that the midpotency topical steroids used in treating atopic dermatitis – as distinct from potent and superpotent topical steroids – do not have the side effects and systemic absorption issues steroid-phobic parents are worried about.

Another effective strategy is to be very specific about the quantity of topical medication he wants the patient to use for flare control.

"Instead of saying, ‘Twice a day application of a midstrength topical steroid for 2 weeks,’ now I’ll say, "I would like you to use up this 80-g tube in the next 2 weeks and then I’ll see you back – and it’s safe to use this amount for this particular length of time.’ I find that makes a huge difference in terms of outcomes if I explain it that way," Dr. Eichenfield said.

He reported serving as a consultant to Bayer, Galderma, GlaxoSmithKline, and Valeant.

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

b.jancin@elsevier.com

Emerging data strongly suggest that children with atopic dermatitis are at increased risk for attention-deficit/hyperactivity disorder.

"The first paper was actually a really good paper, but it was just one study and so we did not quite believe it. But now there’s a confirmatory study by a separate group with really big data," Dr. Lawrence K. Eichenfield said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

In addition, the second study pointed to a possible higher risk of autism in children with atopic dermatitis, and it also confirmed other reports of increased rates of depression and anxiety, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, also in San Diego.

Atopic dermatitis is the most common chronic inflammatory condition in childhood. Attention-deficit/hyperactivity disorder is the most common psychiatric disorder. The first study to report an association between the two was a German, case-control, population-based study involving 1,436 atopic dermatitis patients aged 6-17 years and an equal number of age- and gender-matched controls without the skin disease.

The prevalence of diagnosed ADHD was 5.2% in the atopic dermatitis patients and 3.4% in controls (P = 0.02). In a multivariate logistic regression analysis, atopic dermatitis was an independent predictor of prevalent ADHD, with an associated 47% increased risk of the psychiatric disorder compared with youths without atopic dermatitis. Moreover, there was a suggestion that the more severe a patient’s atopic dermatitis, the greater the likelihood of comorbid ADHD, since the likelihood of ADHD increased with each additional physician visit for atopic dermatitis (JAMA 2009;301:724-6).

More recently, in a study presented at a major meeting but not yet published, Dr. Eric L. Simpson and his coinvestigators at Oregon Health and Science University, Portland, confirmed the initial German finding that pediatric atopic dermatitis is associated with ADHD, this time in a database of 90,000 U.S. children. Once again, the more severe the skin disease, the greater the risk of ADHD. In this study, atopic dermatitis was also associated with increased risks of depression, anxiety, and autism.

Possible mechanisms underlying the observed association between atopic dermatitis and comorbid psychiatric conditions include sleep disturbance – a prominent feature in atopic dermatitis – and systemic inflammation, according to Dr. Eichenfield.

The well-established atopic comorbidities associated with atopic dermatitis are asthma, allergic rhinitis, and food allergy. Dr. Eichenfield said that he welcomes the evolving evidence of psychologic comorbidities for the opportunity it provides to encourage treatment adherence. Like other treating physicians, he finds topical steroid phobia to be a huge problem.

"I actually use this information in my clinical practice as a way to get my families to adequately treat atopic dermatitis," he said. "If I have families that are very steroid phobic, I’ll say, ‘You know, you really want to treat your kid with appropriate topical therapy to minimize the disease impact: to minimize the sleep disturbance and potentially minimize the neurobehavioral impact of atopic dermatitis.’ I use that as a tool to stay with our regimens of care."

Steroid phobia is a problem worldwide, not just in the United States. For example, Dr. Eichenfield noted that when French dermatologists recently surveyed 208 consecutive atopic dermatitis patients or their parents using a detailed 69-item questionnaire, 81% reported having fears about topical corticosteroids – the mainstay of atopic dermatitis treatment – and 36% admitted to treatment nonadherence as a result of their worries. Fears did not correlate with disease severity (Br. J. Dermatol. 2011;165:808-14).

"I think that in all of dermatology there’s probably no greater chasm between where our families are at in terms of concerns about a medication and where we are as physicians in terms of not having concerns than in the area of topical steroids for atopic dermatitis," Dr. Eichenfield said.

He noted that he makes extensive use of parental educational handouts and written action plans in addition to face-to-face discussion of safety concerns at the time he prescribes topical steroids. One strategy that he’s recently realized makes a big difference in terms of adherence is to explain carefully that the midpotency topical steroids used in treating atopic dermatitis – as distinct from potent and superpotent topical steroids – do not have the side effects and systemic absorption issues steroid-phobic parents are worried about.

Another effective strategy is to be very specific about the quantity of topical medication he wants the patient to use for flare control.

"Instead of saying, ‘Twice a day application of a midstrength topical steroid for 2 weeks,’ now I’ll say, "I would like you to use up this 80-g tube in the next 2 weeks and then I’ll see you back – and it’s safe to use this amount for this particular length of time.’ I find that makes a huge difference in terms of outcomes if I explain it that way," Dr. Eichenfield said.

He reported serving as a consultant to Bayer, Galderma, GlaxoSmithKline, and Valeant.

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

b.jancin@elsevier.com

Emerging data strongly suggest that children with atopic dermatitis are at increased risk for attention-deficit/hyperactivity disorder.

"The first paper was actually a really good paper, but it was just one study and so we did not quite believe it. But now there’s a confirmatory study by a separate group with really big data," Dr. Lawrence K. Eichenfield said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

In addition, the second study pointed to a possible higher risk of autism in children with atopic dermatitis, and it also confirmed other reports of increased rates of depression and anxiety, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital, also in San Diego.

Atopic dermatitis is the most common chronic inflammatory condition in childhood. Attention-deficit/hyperactivity disorder is the most common psychiatric disorder. The first study to report an association between the two was a German, case-control, population-based study involving 1,436 atopic dermatitis patients aged 6-17 years and an equal number of age- and gender-matched controls without the skin disease.

The prevalence of diagnosed ADHD was 5.2% in the atopic dermatitis patients and 3.4% in controls (P = 0.02). In a multivariate logistic regression analysis, atopic dermatitis was an independent predictor of prevalent ADHD, with an associated 47% increased risk of the psychiatric disorder compared with youths without atopic dermatitis. Moreover, there was a suggestion that the more severe a patient’s atopic dermatitis, the greater the likelihood of comorbid ADHD, since the likelihood of ADHD increased with each additional physician visit for atopic dermatitis (JAMA 2009;301:724-6).

More recently, in a study presented at a major meeting but not yet published, Dr. Eric L. Simpson and his coinvestigators at Oregon Health and Science University, Portland, confirmed the initial German finding that pediatric atopic dermatitis is associated with ADHD, this time in a database of 90,000 U.S. children. Once again, the more severe the skin disease, the greater the risk of ADHD. In this study, atopic dermatitis was also associated with increased risks of depression, anxiety, and autism.

Possible mechanisms underlying the observed association between atopic dermatitis and comorbid psychiatric conditions include sleep disturbance – a prominent feature in atopic dermatitis – and systemic inflammation, according to Dr. Eichenfield.

The well-established atopic comorbidities associated with atopic dermatitis are asthma, allergic rhinitis, and food allergy. Dr. Eichenfield said that he welcomes the evolving evidence of psychologic comorbidities for the opportunity it provides to encourage treatment adherence. Like other treating physicians, he finds topical steroid phobia to be a huge problem.

"I actually use this information in my clinical practice as a way to get my families to adequately treat atopic dermatitis," he said. "If I have families that are very steroid phobic, I’ll say, ‘You know, you really want to treat your kid with appropriate topical therapy to minimize the disease impact: to minimize the sleep disturbance and potentially minimize the neurobehavioral impact of atopic dermatitis.’ I use that as a tool to stay with our regimens of care."

Steroid phobia is a problem worldwide, not just in the United States. For example, Dr. Eichenfield noted that when French dermatologists recently surveyed 208 consecutive atopic dermatitis patients or their parents using a detailed 69-item questionnaire, 81% reported having fears about topical corticosteroids – the mainstay of atopic dermatitis treatment – and 36% admitted to treatment nonadherence as a result of their worries. Fears did not correlate with disease severity (Br. J. Dermatol. 2011;165:808-14).

"I think that in all of dermatology there’s probably no greater chasm between where our families are at in terms of concerns about a medication and where we are as physicians in terms of not having concerns than in the area of topical steroids for atopic dermatitis," Dr. Eichenfield said.

He noted that he makes extensive use of parental educational handouts and written action plans in addition to face-to-face discussion of safety concerns at the time he prescribes topical steroids. One strategy that he’s recently realized makes a big difference in terms of adherence is to explain carefully that the midpotency topical steroids used in treating atopic dermatitis – as distinct from potent and superpotent topical steroids – do not have the side effects and systemic absorption issues steroid-phobic parents are worried about.

Another effective strategy is to be very specific about the quantity of topical medication he wants the patient to use for flare control.

"Instead of saying, ‘Twice a day application of a midstrength topical steroid for 2 weeks,’ now I’ll say, "I would like you to use up this 80-g tube in the next 2 weeks and then I’ll see you back – and it’s safe to use this amount for this particular length of time.’ I find that makes a huge difference in terms of outcomes if I explain it that way," Dr. Eichenfield said.

He reported serving as a consultant to Bayer, Galderma, GlaxoSmithKline, and Valeant.

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

b.jancin@elsevier.com

MAUI, HAWAII  – Combination therapy for severe acne, with a trio of familiar, well tolerated agents, knocked down the skin disease severity in a phase IV study such that 80% of patients deemed candidates for isotretinoin at baseline no longer qualified for the powerful oral retinoid 12 weeks later, Dr. Guy F. Webster reported at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

These data provide welcome news for patients who can’t take isotretinoin or don’t want to, as well as for the many physicians reluctant to prescribe the drug because of the considerable regulatory hassles and potentially serious side effects, including teratogenicity.

The treatment regimen in this open-label multicenter study consisted of an oral antibiotic, a topical antibiotic/retinoid agent, and benzoyl peroxide. More specifically, the 97 study participants aged 12-29 years, all with grade 3-4 moderate to severe facial acne by Investigator’s Global Assessment (IGA), were placed on once-daily minocycline HCL extended release at about 1 mg/kg, clindamycin phosphate 1.2%/tretinoin 0.025% gel, and 6% benzoyl peroxide foaming cloths. Patients were evaluated at weeks 0, 2, 4, 8, and 12.

At week 2, 44% of subjects already had at least a 1-grade improvement in IGA; by week 12, 89% did. Moreover, 56% of patients had at least a 2-grade improvement in IGA.

At least a 1-grade improvement on the Global Aesthetic Improvement Scale was documented in 83% of subjects at week 2 and 96% at week 12.

"With this therapy, you can get patients with really bad acne from bad to really mild without resorting to big-time drugs," observed Dr. Webster, professor of dermatology and internal medicine at Thomas Jefferson University, Philadelphia.

Week 12 mean facial inflammatory lesion counts fell by 62%, and noninflammatory lesion counts decreased by 49% from baselines of 33 and 44 lesions, respectively.

At baseline, 69 patients were judged by three blinded assessors of clinical photos to have acne sufficiently severe for them to be candidates for isotretinoin therapy. By week 12, this number had dwindled to 14 patients. In other words, 80% of patients were no longer deemed to be candidates for isotretinoin.

Eight patients experienced treatment-related adverse events consisting of transient mild to moderate irritation and/or redness, burning, stinging, and dry skin.

The results of this Phase-4 study are consistent with studies of other multidrug regimens for acne, albeit mostly conducted in less severely affected patients.

"The general paradigm is that mixed therapies are useful because other than isotretinoin and maybe spironolactone, no one drug is strong enough to stop acne effectively. If you just hit the [Propionibacterium acnes] hard, you can’t get it down to where there’s no P. acnes. If you blunt the immune response, you’re still just blunting it, not turning it off. And if you’re addressing the plug in the follicle, it’s not a complete or rapid response," the dermatologist explained.

In clinical practice, Dr. Webster said he typically stops the oral antibiotic cold at about 12 weeks to avoid pigmentary changes and other side effects of long-term antibiotic therapy. At least 75% of patients can maintain their gains with topical therapy alone.

Compliance is often an issue with combination therapy. Patients need to understand that if they don’t use all of the medications consistently from day 1 they won’t get better.

"It’s tough with kids because kids expect to get better overnight. They see it on the Proactiv commercials and wonder why in the world they’re not better in 2 days," the dermatologist observed.

In this phase IV study, however, patient compliance was consistently excellent, perhaps because of the high disease severity. The treatment compliance rate was 91% at week 2 and 86% at week 12.

Dr. Webster is a consultant for several pharmaceutical companies, including Valeant, whose subsidiary Medicis sponsored the phase IV study.

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

b.jancin@elsevier.com

*This story was updated March 1, 2013.

MAUI, HAWAII  – Combination therapy for severe acne, with a trio of familiar, well tolerated agents, knocked down the skin disease severity in a phase IV study such that 80% of patients deemed candidates for isotretinoin at baseline no longer qualified for the powerful oral retinoid 12 weeks later, Dr. Guy F. Webster reported at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

These data provide welcome news for patients who can’t take isotretinoin or don’t want to, as well as for the many physicians reluctant to prescribe the drug because of the considerable regulatory hassles and potentially serious side effects, including teratogenicity.

The treatment regimen in this open-label multicenter study consisted of an oral antibiotic, a topical antibiotic/retinoid agent, and benzoyl peroxide. More specifically, the 97 study participants aged 12-29 years, all with grade 3-4 moderate to severe facial acne by Investigator’s Global Assessment (IGA), were placed on once-daily minocycline HCL extended release at about 1 mg/kg, clindamycin phosphate 1.2%/tretinoin 0.025% gel, and 6% benzoyl peroxide foaming cloths. Patients were evaluated at weeks 0, 2, 4, 8, and 12.

At week 2, 44% of subjects already had at least a 1-grade improvement in IGA; by week 12, 89% did. Moreover, 56% of patients had at least a 2-grade improvement in IGA.

At least a 1-grade improvement on the Global Aesthetic Improvement Scale was documented in 83% of subjects at week 2 and 96% at week 12.

"With this therapy, you can get patients with really bad acne from bad to really mild without resorting to big-time drugs," observed Dr. Webster, professor of dermatology and internal medicine at Thomas Jefferson University, Philadelphia.

Week 12 mean facial inflammatory lesion counts fell by 62%, and noninflammatory lesion counts decreased by 49% from baselines of 33 and 44 lesions, respectively.

At baseline, 69 patients were judged by three blinded assessors of clinical photos to have acne sufficiently severe for them to be candidates for isotretinoin therapy. By week 12, this number had dwindled to 14 patients. In other words, 80% of patients were no longer deemed to be candidates for isotretinoin.

Eight patients experienced treatment-related adverse events consisting of transient mild to moderate irritation and/or redness, burning, stinging, and dry skin.

The results of this Phase-4 study are consistent with studies of other multidrug regimens for acne, albeit mostly conducted in less severely affected patients.

"The general paradigm is that mixed therapies are useful because other than isotretinoin and maybe spironolactone, no one drug is strong enough to stop acne effectively. If you just hit the [Propionibacterium acnes] hard, you can’t get it down to where there’s no P. acnes. If you blunt the immune response, you’re still just blunting it, not turning it off. And if you’re addressing the plug in the follicle, it’s not a complete or rapid response," the dermatologist explained.

In clinical practice, Dr. Webster said he typically stops the oral antibiotic cold at about 12 weeks to avoid pigmentary changes and other side effects of long-term antibiotic therapy. At least 75% of patients can maintain their gains with topical therapy alone.

Compliance is often an issue with combination therapy. Patients need to understand that if they don’t use all of the medications consistently from day 1 they won’t get better.

"It’s tough with kids because kids expect to get better overnight. They see it on the Proactiv commercials and wonder why in the world they’re not better in 2 days," the dermatologist observed.

In this phase IV study, however, patient compliance was consistently excellent, perhaps because of the high disease severity. The treatment compliance rate was 91% at week 2 and 86% at week 12.

Dr. Webster is a consultant for several pharmaceutical companies, including Valeant, whose subsidiary Medicis sponsored the phase IV study.

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

b.jancin@elsevier.com

*This story was updated March 1, 2013.

MAUI, HAWAII  – Combination therapy for severe acne, with a trio of familiar, well tolerated agents, knocked down the skin disease severity in a phase IV study such that 80% of patients deemed candidates for isotretinoin at baseline no longer qualified for the powerful oral retinoid 12 weeks later, Dr. Guy F. Webster reported at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

These data provide welcome news for patients who can’t take isotretinoin or don’t want to, as well as for the many physicians reluctant to prescribe the drug because of the considerable regulatory hassles and potentially serious side effects, including teratogenicity.

The treatment regimen in this open-label multicenter study consisted of an oral antibiotic, a topical antibiotic/retinoid agent, and benzoyl peroxide. More specifically, the 97 study participants aged 12-29 years, all with grade 3-4 moderate to severe facial acne by Investigator’s Global Assessment (IGA), were placed on once-daily minocycline HCL extended release at about 1 mg/kg, clindamycin phosphate 1.2%/tretinoin 0.025% gel, and 6% benzoyl peroxide foaming cloths. Patients were evaluated at weeks 0, 2, 4, 8, and 12.

At week 2, 44% of subjects already had at least a 1-grade improvement in IGA; by week 12, 89% did. Moreover, 56% of patients had at least a 2-grade improvement in IGA.

At least a 1-grade improvement on the Global Aesthetic Improvement Scale was documented in 83% of subjects at week 2 and 96% at week 12.

"With this therapy, you can get patients with really bad acne from bad to really mild without resorting to big-time drugs," observed Dr. Webster, professor of dermatology and internal medicine at Thomas Jefferson University, Philadelphia.

Week 12 mean facial inflammatory lesion counts fell by 62%, and noninflammatory lesion counts decreased by 49% from baselines of 33 and 44 lesions, respectively.

At baseline, 69 patients were judged by three blinded assessors of clinical photos to have acne sufficiently severe for them to be candidates for isotretinoin therapy. By week 12, this number had dwindled to 14 patients. In other words, 80% of patients were no longer deemed to be candidates for isotretinoin.

Eight patients experienced treatment-related adverse events consisting of transient mild to moderate irritation and/or redness, burning, stinging, and dry skin.

The results of this Phase-4 study are consistent with studies of other multidrug regimens for acne, albeit mostly conducted in less severely affected patients.

"The general paradigm is that mixed therapies are useful because other than isotretinoin and maybe spironolactone, no one drug is strong enough to stop acne effectively. If you just hit the [Propionibacterium acnes] hard, you can’t get it down to where there’s no P. acnes. If you blunt the immune response, you’re still just blunting it, not turning it off. And if you’re addressing the plug in the follicle, it’s not a complete or rapid response," the dermatologist explained.

In clinical practice, Dr. Webster said he typically stops the oral antibiotic cold at about 12 weeks to avoid pigmentary changes and other side effects of long-term antibiotic therapy. At least 75% of patients can maintain their gains with topical therapy alone.

Compliance is often an issue with combination therapy. Patients need to understand that if they don’t use all of the medications consistently from day 1 they won’t get better.

"It’s tough with kids because kids expect to get better overnight. They see it on the Proactiv commercials and wonder why in the world they’re not better in 2 days," the dermatologist observed.

In this phase IV study, however, patient compliance was consistently excellent, perhaps because of the high disease severity. The treatment compliance rate was 91% at week 2 and 86% at week 12.

Dr. Webster is a consultant for several pharmaceutical companies, including Valeant, whose subsidiary Medicis sponsored the phase IV study.

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

b.jancin@elsevier.com

*This story was updated March 1, 2013.

The postpartum period is often a time when women with moderate to severe psoriasis experience a significant disease flare – and if they’re breastfeeding, treatment options are limited, according to Dr. Alan Menter.

This postpartum major flare of psoriasis is an underappreciated phenomenon that catches many dermatologists and most ob.gyns. off guard, he said.

"Fifty to 60% of psoriasis patients have genital involvement. A woman with genital psoriasis in the postpartum period or during delivery really needs help, and I think we in dermatology should be addressing these issues because most of the obstetricians are not sure how to treat these patients," said Dr. Menter, chief of the division of dermatology at Baylor University Medical Center, Dallas, and chair of the American Academy of Dermatology psoriasis guidelines committee.

Psoriasis is equally common in men and women, and two-thirds of affected individuals present before age 40 – for women, the childbearing years. Thorny psoriasis management issues in pregnancy and postpartum are common.

Psoriasis slowly improves during pregnancy in roughly two-thirds of patients, as is true for other immune-mediated diseases. But for that other third, many of the mainstay therapies for tough psoriasis are off limits during pregnancy and/or post partum. UVB is a good, safe option, albeit inconvenient. Retinoids and cyclosporine are out because of teratogenicity.

Cyclosporine probably should be considered the go-to drug for significant disease during pregnancy. Its strengths are its fast onset of action and the safety reassurance provided by vast patient registries started back in the 1980s when the drug was first used in transplant recipients.

"We’re all comfortable using cyclosporine," Dr. Menter said. "Our AAD guidelines state it is appropriate for 1 year of continuous use. The European guidelines say, ‘2 years of continuous use.’ But I think most of us use it as an interventional therapy for 3-6 months. I actually think we should be using it a little more frequently as an interventional therapy."

Cyclosporine must be stopped in month 8 of pregnancy to allow the drug to clear from the patient’s system before delivery, since it is secreted in breast milk.

For the breastfeeding woman experiencing a major disease flare, the options are basically potent topical steroids, which physicians should feel comfortable in prescribing according to the standard dosing schedule used in nonpregnant patients, or – when topical therapy won’t get the job done – the biologic agents, listed by the Food and Drug Administration as category B.

The most forward-thinking approach to take with young women who require systemic therapy for psoriasis is to discuss pregnancy-related issues before pregnancy occurs. In particular, a prospective case-control study from the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project concluded that women with psoriasis were significantly more likely to smoke, carry a diagnosis of depression, and be overweight or obese before pregnancy – factors that increase their risk for adverse pregnancy outcomes (Br. J. Dermatol. 2010;163:334-9).

Moreover, other studies have shown that psoriasis patients, men as well as women, have an increased prevalence of the metabolic syndrome, which increases their long-term risk of cardiovascular disease. Women with an adverse cardiovascular risk profile who are considering pregnancy and parenthood may be in a teachable moment where they are more amenable to lifestyle changes that reduce the risks both to their baby and themselves, Dr. Menter said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Of course, half of pregnancies in the United States are unplanned, so the potential for unintended first-trimester fetal exposure to a teratogenic drug is substantial. While methotrexate is rated by the FDA as category X in pregnancy, dermatologists can derive some comfort from a well-executed review of 101 methotrexate-exposed pregnancies in rheumatology patients (Clin. Exp. Rheumatol. 2009;27:678-84). The 23% miscarriage rate wasn’t significantly different from that seen in pregnant psoriasis patients not on systemic agents. The live birth rate was 66%, with a 5% rate of neonatal malformations, all minor.

"The outcomes were actually better than any of us would have anticipated," Dr. Menter commented.

Psoriasis appears to have an inherent adverse impact upon pregnancy, he continued, pointing to an Israeli study of 68 deliveries in 35 women with moderate to severe psoriasis and 237 deliveries in 236 controls without psoriasis matched for age, parity, and gestational age.

"I think this is something we have to very gently discuss with our female patients who are considering pregnancy. We should tell them to be cautious in pregnancy because of this link between psoriasis and a slightly increased risk of spontaneous abortions. And I also discuss it with our ob.gyn. colleagues, who really are not aware of this link," the dermatologist said.

Dr. Menter reported receiving research support and/or consultant or lecture fees from roughly 20 pharmaceutical companies. SDEF and this news organization are owned by the same parent company.

b.jancin@elsevier.com

*This story was updated March 1, 2013.

The postpartum period is often a time when women with moderate to severe psoriasis experience a significant disease flare – and if they’re breastfeeding, treatment options are limited, according to Dr. Alan Menter.

This postpartum major flare of psoriasis is an underappreciated phenomenon that catches many dermatologists and most ob.gyns. off guard, he said.

"Fifty to 60% of psoriasis patients have genital involvement. A woman with genital psoriasis in the postpartum period or during delivery really needs help, and I think we in dermatology should be addressing these issues because most of the obstetricians are not sure how to treat these patients," said Dr. Menter, chief of the division of dermatology at Baylor University Medical Center, Dallas, and chair of the American Academy of Dermatology psoriasis guidelines committee.

Psoriasis is equally common in men and women, and two-thirds of affected individuals present before age 40 – for women, the childbearing years. Thorny psoriasis management issues in pregnancy and postpartum are common.

Psoriasis slowly improves during pregnancy in roughly two-thirds of patients, as is true for other immune-mediated diseases. But for that other third, many of the mainstay therapies for tough psoriasis are off limits during pregnancy and/or post partum. UVB is a good, safe option, albeit inconvenient. Retinoids and cyclosporine are out because of teratogenicity.

Cyclosporine probably should be considered the go-to drug for significant disease during pregnancy. Its strengths are its fast onset of action and the safety reassurance provided by vast patient registries started back in the 1980s when the drug was first used in transplant recipients.

"We’re all comfortable using cyclosporine," Dr. Menter said. "Our AAD guidelines state it is appropriate for 1 year of continuous use. The European guidelines say, ‘2 years of continuous use.’ But I think most of us use it as an interventional therapy for 3-6 months. I actually think we should be using it a little more frequently as an interventional therapy."

Cyclosporine must be stopped in month 8 of pregnancy to allow the drug to clear from the patient’s system before delivery, since it is secreted in breast milk.

For the breastfeeding woman experiencing a major disease flare, the options are basically potent topical steroids, which physicians should feel comfortable in prescribing according to the standard dosing schedule used in nonpregnant patients, or – when topical therapy won’t get the job done – the biologic agents, listed by the Food and Drug Administration as category B.

The most forward-thinking approach to take with young women who require systemic therapy for psoriasis is to discuss pregnancy-related issues before pregnancy occurs. In particular, a prospective case-control study from the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project concluded that women with psoriasis were significantly more likely to smoke, carry a diagnosis of depression, and be overweight or obese before pregnancy – factors that increase their risk for adverse pregnancy outcomes (Br. J. Dermatol. 2010;163:334-9).

Moreover, other studies have shown that psoriasis patients, men as well as women, have an increased prevalence of the metabolic syndrome, which increases their long-term risk of cardiovascular disease. Women with an adverse cardiovascular risk profile who are considering pregnancy and parenthood may be in a teachable moment where they are more amenable to lifestyle changes that reduce the risks both to their baby and themselves, Dr. Menter said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Of course, half of pregnancies in the United States are unplanned, so the potential for unintended first-trimester fetal exposure to a teratogenic drug is substantial. While methotrexate is rated by the FDA as category X in pregnancy, dermatologists can derive some comfort from a well-executed review of 101 methotrexate-exposed pregnancies in rheumatology patients (Clin. Exp. Rheumatol. 2009;27:678-84). The 23% miscarriage rate wasn’t significantly different from that seen in pregnant psoriasis patients not on systemic agents. The live birth rate was 66%, with a 5% rate of neonatal malformations, all minor.

"The outcomes were actually better than any of us would have anticipated," Dr. Menter commented.

Psoriasis appears to have an inherent adverse impact upon pregnancy, he continued, pointing to an Israeli study of 68 deliveries in 35 women with moderate to severe psoriasis and 237 deliveries in 236 controls without psoriasis matched for age, parity, and gestational age.

"I think this is something we have to very gently discuss with our female patients who are considering pregnancy. We should tell them to be cautious in pregnancy because of this link between psoriasis and a slightly increased risk of spontaneous abortions. And I also discuss it with our ob.gyn. colleagues, who really are not aware of this link," the dermatologist said.

Dr. Menter reported receiving research support and/or consultant or lecture fees from roughly 20 pharmaceutical companies. SDEF and this news organization are owned by the same parent company.

b.jancin@elsevier.com

*This story was updated March 1, 2013.

The postpartum period is often a time when women with moderate to severe psoriasis experience a significant disease flare – and if they’re breastfeeding, treatment options are limited, according to Dr. Alan Menter.

This postpartum major flare of psoriasis is an underappreciated phenomenon that catches many dermatologists and most ob.gyns. off guard, he said.

"Fifty to 60% of psoriasis patients have genital involvement. A woman with genital psoriasis in the postpartum period or during delivery really needs help, and I think we in dermatology should be addressing these issues because most of the obstetricians are not sure how to treat these patients," said Dr. Menter, chief of the division of dermatology at Baylor University Medical Center, Dallas, and chair of the American Academy of Dermatology psoriasis guidelines committee.

Psoriasis is equally common in men and women, and two-thirds of affected individuals present before age 40 – for women, the childbearing years. Thorny psoriasis management issues in pregnancy and postpartum are common.

Psoriasis slowly improves during pregnancy in roughly two-thirds of patients, as is true for other immune-mediated diseases. But for that other third, many of the mainstay therapies for tough psoriasis are off limits during pregnancy and/or post partum. UVB is a good, safe option, albeit inconvenient. Retinoids and cyclosporine are out because of teratogenicity.

Cyclosporine probably should be considered the go-to drug for significant disease during pregnancy. Its strengths are its fast onset of action and the safety reassurance provided by vast patient registries started back in the 1980s when the drug was first used in transplant recipients.

"We’re all comfortable using cyclosporine," Dr. Menter said. "Our AAD guidelines state it is appropriate for 1 year of continuous use. The European guidelines say, ‘2 years of continuous use.’ But I think most of us use it as an interventional therapy for 3-6 months. I actually think we should be using it a little more frequently as an interventional therapy."

Cyclosporine must be stopped in month 8 of pregnancy to allow the drug to clear from the patient’s system before delivery, since it is secreted in breast milk.

For the breastfeeding woman experiencing a major disease flare, the options are basically potent topical steroids, which physicians should feel comfortable in prescribing according to the standard dosing schedule used in nonpregnant patients, or – when topical therapy won’t get the job done – the biologic agents, listed by the Food and Drug Administration as category B.

The most forward-thinking approach to take with young women who require systemic therapy for psoriasis is to discuss pregnancy-related issues before pregnancy occurs. In particular, a prospective case-control study from the Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project concluded that women with psoriasis were significantly more likely to smoke, carry a diagnosis of depression, and be overweight or obese before pregnancy – factors that increase their risk for adverse pregnancy outcomes (Br. J. Dermatol. 2010;163:334-9).

Moreover, other studies have shown that psoriasis patients, men as well as women, have an increased prevalence of the metabolic syndrome, which increases their long-term risk of cardiovascular disease. Women with an adverse cardiovascular risk profile who are considering pregnancy and parenthood may be in a teachable moment where they are more amenable to lifestyle changes that reduce the risks both to their baby and themselves, Dr. Menter said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Of course, half of pregnancies in the United States are unplanned, so the potential for unintended first-trimester fetal exposure to a teratogenic drug is substantial. While methotrexate is rated by the FDA as category X in pregnancy, dermatologists can derive some comfort from a well-executed review of 101 methotrexate-exposed pregnancies in rheumatology patients (Clin. Exp. Rheumatol. 2009;27:678-84). The 23% miscarriage rate wasn’t significantly different from that seen in pregnant psoriasis patients not on systemic agents. The live birth rate was 66%, with a 5% rate of neonatal malformations, all minor.

"The outcomes were actually better than any of us would have anticipated," Dr. Menter commented.

Psoriasis appears to have an inherent adverse impact upon pregnancy, he continued, pointing to an Israeli study of 68 deliveries in 35 women with moderate to severe psoriasis and 237 deliveries in 236 controls without psoriasis matched for age, parity, and gestational age.

"I think this is something we have to very gently discuss with our female patients who are considering pregnancy. We should tell them to be cautious in pregnancy because of this link between psoriasis and a slightly increased risk of spontaneous abortions. And I also discuss it with our ob.gyn. colleagues, who really are not aware of this link," the dermatologist said.

Dr. Menter reported receiving research support and/or consultant or lecture fees from roughly 20 pharmaceutical companies. SDEF and this news organization are owned by the same parent company.

b.jancin@elsevier.com

*This story was updated March 1, 2013.

For genetic skin diseases, the future is nearly here.

"It seems like every other day there’s another article published based on using next-generation gene sequencing to find out what’s causing disease, and then using that information to work toward personalized gene and pharmacologic therapy," said Dr. Amy Paller, the Walter J. Hamlin Professor and chair of dermatology at Northwestern University, Chicago. "We’re talking about these things not only in the very near future, but right now."

Viral vectors have made possible enormous advances in the treatment of genetic skin disorders, but they are far from perfect, Dr. Paller said in an interview. Researchers are looking beyond them, hoping to sidestep their problems while capitalizing on the delivery of genetic material to highly targeted areas.

"The problem with viral vectors – and particularly with the ones that are out there now – is that they insert their genetic information randomly into the chromosome. If they insert it into the wrong place, it can cause oncogenesis. We know that leukemia and lymphomas have developed because of this. The next frontier is to develop other techniques" that would avoid the problem altogether, she said at the Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

One of the most exciting areas of research is the topical delivery of genetic therapy, she said. Researchers are wrestling with the problem of effectively delivering molecules to target areas.

"Getting through the epidermal barrier is a major problem for topical genetic modulation therapy. What we are trying to do is conquer this barrier using physical or chemical techniques to decrease its integrity."

A number of methods are under investigation, including microneedles coated with the desired genetic material, which can be injected into very specific sites.

Topically delivering therapeutic nanoparticles is another hot area. Last summer, Dr. Paller’s team obtained some early positive results with spherical nucleic acid nanoparticle conjugates – gold cores surrounded by small interfering RNA. They used a commercially available topical emollient as the vehicle and showed that the nanoparticles penetrated almost 100% of keratinocytes in both mouse and human epidermis. The treatment induced a complete knockdown of epidermal growth factor receptor expression and, in hairless mice, decreased skin thickness by 40%.

One big benefit of this approach is that it requires no compromise of the epidermal barrier, Dr. Paller said. Treatment doesn’t appear to induce any inflammatory cytokines or lead to local or systemic toxicity.

Her lab has moved on from animal models to humans. "We’re looking at real disease now, working on skin cancers and wound healing, psoriasis, and dominant negative keratin gene disorders."

But although the field of gene therapy is rapidly progressing, the process of diagnosis seems mired in the past.

"Diagnosis of genetic disease is still made clinically," Dr. Paller said. While diagnosis can be supplemented by information on family history, extracutaneous exams, and other testing, most children in the U.S. don’t get a complete genetic work-up to pinpoint their unique problem. "In Europe, many children with genetic skin disease undergo genotype analysis, but only a minority of children in the United States does so."

Cost is probably the biggest barrier, "especially without insurance, or if insurance won’t cover the testing. For example, testing six genes for autosomal recessive congenital ichthyosis in a collodion baby can cost more than $12,000."

Some argue that the testing doesn’t provide much practical information. "There are limited genotype-phenotype correlations that predict prognosis," Dr. Paller said. "And unless the information is used for family planning purposes, it has limited value."

Fortunately, genotyping technology is improving even as the cost is coming down. Next-generation sequencing can analyze the entire genome, and even whole-exome sequences – a refinement that could identify about 85% of mutations and allows a detailed look at very small, specific regions. Experts predict that the cost of next-generation sequencing is going to decrease exponentially over the next few years, into the range of $1,000-$5,000.

Leveraging next-generation sequencing could help patients with genetic skin disorders in a number of ways, Dr. Paller said. In addition to finding low-frequency mutations in known genes, the process could identify mutations in newly associated genes and pave the way for the genotype-phenotype correlations that could help diagnosis.

Next-generation sequencing might even make it possible to predict drug response, leading to a truly individualized prescription of genetic treatment, Dr. Paller said.

"These discoveries have translated into new therapy for patients with genetic disorders and will guide innovative treatment in the future. New technology will revolutionize our knowledge of the human genome and disease, facilitating mutation-based gene and pharmacologic therapy."

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

*This story was updated March 1, 2013.

For genetic skin diseases, the future is nearly here.

"It seems like every other day there’s another article published based on using next-generation gene sequencing to find out what’s causing disease, and then using that information to work toward personalized gene and pharmacologic therapy," said Dr. Amy Paller, the Walter J. Hamlin Professor and chair of dermatology at Northwestern University, Chicago. "We’re talking about these things not only in the very near future, but right now."

Viral vectors have made possible enormous advances in the treatment of genetic skin disorders, but they are far from perfect, Dr. Paller said in an interview. Researchers are looking beyond them, hoping to sidestep their problems while capitalizing on the delivery of genetic material to highly targeted areas.

"The problem with viral vectors – and particularly with the ones that are out there now – is that they insert their genetic information randomly into the chromosome. If they insert it into the wrong place, it can cause oncogenesis. We know that leukemia and lymphomas have developed because of this. The next frontier is to develop other techniques" that would avoid the problem altogether, she said at the Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

One of the most exciting areas of research is the topical delivery of genetic therapy, she said. Researchers are wrestling with the problem of effectively delivering molecules to target areas.

"Getting through the epidermal barrier is a major problem for topical genetic modulation therapy. What we are trying to do is conquer this barrier using physical or chemical techniques to decrease its integrity."

A number of methods are under investigation, including microneedles coated with the desired genetic material, which can be injected into very specific sites.

Topically delivering therapeutic nanoparticles is another hot area. Last summer, Dr. Paller’s team obtained some early positive results with spherical nucleic acid nanoparticle conjugates – gold cores surrounded by small interfering RNA. They used a commercially available topical emollient as the vehicle and showed that the nanoparticles penetrated almost 100% of keratinocytes in both mouse and human epidermis. The treatment induced a complete knockdown of epidermal growth factor receptor expression and, in hairless mice, decreased skin thickness by 40%.

One big benefit of this approach is that it requires no compromise of the epidermal barrier, Dr. Paller said. Treatment doesn’t appear to induce any inflammatory cytokines or lead to local or systemic toxicity.

Her lab has moved on from animal models to humans. "We’re looking at real disease now, working on skin cancers and wound healing, psoriasis, and dominant negative keratin gene disorders."

But although the field of gene therapy is rapidly progressing, the process of diagnosis seems mired in the past.

"Diagnosis of genetic disease is still made clinically," Dr. Paller said. While diagnosis can be supplemented by information on family history, extracutaneous exams, and other testing, most children in the U.S. don’t get a complete genetic work-up to pinpoint their unique problem. "In Europe, many children with genetic skin disease undergo genotype analysis, but only a minority of children in the United States does so."

Cost is probably the biggest barrier, "especially without insurance, or if insurance won’t cover the testing. For example, testing six genes for autosomal recessive congenital ichthyosis in a collodion baby can cost more than $12,000."

Some argue that the testing doesn’t provide much practical information. "There are limited genotype-phenotype correlations that predict prognosis," Dr. Paller said. "And unless the information is used for family planning purposes, it has limited value."

Fortunately, genotyping technology is improving even as the cost is coming down. Next-generation sequencing can analyze the entire genome, and even whole-exome sequences – a refinement that could identify about 85% of mutations and allows a detailed look at very small, specific regions. Experts predict that the cost of next-generation sequencing is going to decrease exponentially over the next few years, into the range of $1,000-$5,000.

Leveraging next-generation sequencing could help patients with genetic skin disorders in a number of ways, Dr. Paller said. In addition to finding low-frequency mutations in known genes, the process could identify mutations in newly associated genes and pave the way for the genotype-phenotype correlations that could help diagnosis.

Next-generation sequencing might even make it possible to predict drug response, leading to a truly individualized prescription of genetic treatment, Dr. Paller said.

"These discoveries have translated into new therapy for patients with genetic disorders and will guide innovative treatment in the future. New technology will revolutionize our knowledge of the human genome and disease, facilitating mutation-based gene and pharmacologic therapy."

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

*This story was updated March 1, 2013.

For genetic skin diseases, the future is nearly here.

"It seems like every other day there’s another article published based on using next-generation gene sequencing to find out what’s causing disease, and then using that information to work toward personalized gene and pharmacologic therapy," said Dr. Amy Paller, the Walter J. Hamlin Professor and chair of dermatology at Northwestern University, Chicago. "We’re talking about these things not only in the very near future, but right now."

Viral vectors have made possible enormous advances in the treatment of genetic skin disorders, but they are far from perfect, Dr. Paller said in an interview. Researchers are looking beyond them, hoping to sidestep their problems while capitalizing on the delivery of genetic material to highly targeted areas.

"The problem with viral vectors – and particularly with the ones that are out there now – is that they insert their genetic information randomly into the chromosome. If they insert it into the wrong place, it can cause oncogenesis. We know that leukemia and lymphomas have developed because of this. The next frontier is to develop other techniques" that would avoid the problem altogether, she said at the Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

One of the most exciting areas of research is the topical delivery of genetic therapy, she said. Researchers are wrestling with the problem of effectively delivering molecules to target areas.

"Getting through the epidermal barrier is a major problem for topical genetic modulation therapy. What we are trying to do is conquer this barrier using physical or chemical techniques to decrease its integrity."

A number of methods are under investigation, including microneedles coated with the desired genetic material, which can be injected into very specific sites.

Topically delivering therapeutic nanoparticles is another hot area. Last summer, Dr. Paller’s team obtained some early positive results with spherical nucleic acid nanoparticle conjugates – gold cores surrounded by small interfering RNA. They used a commercially available topical emollient as the vehicle and showed that the nanoparticles penetrated almost 100% of keratinocytes in both mouse and human epidermis. The treatment induced a complete knockdown of epidermal growth factor receptor expression and, in hairless mice, decreased skin thickness by 40%.

One big benefit of this approach is that it requires no compromise of the epidermal barrier, Dr. Paller said. Treatment doesn’t appear to induce any inflammatory cytokines or lead to local or systemic toxicity.

Her lab has moved on from animal models to humans. "We’re looking at real disease now, working on skin cancers and wound healing, psoriasis, and dominant negative keratin gene disorders."

But although the field of gene therapy is rapidly progressing, the process of diagnosis seems mired in the past.

"Diagnosis of genetic disease is still made clinically," Dr. Paller said. While diagnosis can be supplemented by information on family history, extracutaneous exams, and other testing, most children in the U.S. don’t get a complete genetic work-up to pinpoint their unique problem. "In Europe, many children with genetic skin disease undergo genotype analysis, but only a minority of children in the United States does so."

Cost is probably the biggest barrier, "especially without insurance, or if insurance won’t cover the testing. For example, testing six genes for autosomal recessive congenital ichthyosis in a collodion baby can cost more than $12,000."

Some argue that the testing doesn’t provide much practical information. "There are limited genotype-phenotype correlations that predict prognosis," Dr. Paller said. "And unless the information is used for family planning purposes, it has limited value."

Fortunately, genotyping technology is improving even as the cost is coming down. Next-generation sequencing can analyze the entire genome, and even whole-exome sequences – a refinement that could identify about 85% of mutations and allows a detailed look at very small, specific regions. Experts predict that the cost of next-generation sequencing is going to decrease exponentially over the next few years, into the range of $1,000-$5,000.

Leveraging next-generation sequencing could help patients with genetic skin disorders in a number of ways, Dr. Paller said. In addition to finding low-frequency mutations in known genes, the process could identify mutations in newly associated genes and pave the way for the genotype-phenotype correlations that could help diagnosis.

Next-generation sequencing might even make it possible to predict drug response, leading to a truly individualized prescription of genetic treatment, Dr. Paller said.

"These discoveries have translated into new therapy for patients with genetic disorders and will guide innovative treatment in the future. New technology will revolutionize our knowledge of the human genome and disease, facilitating mutation-based gene and pharmacologic therapy."

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

*This story was updated March 1, 2013.

Many doctors probably enjoy using Facebook and other social networking sites to connect with family and friends. But if social media doesn’t play a role in your medical practice, you are missing opportunities, according to Dr. Jeffrey Benabio.

Social media is here to stay. In fact, today’s technology is just the modern incarnation of the human need to connect with other people and share information, Dr. Benabio said. At the SDEF Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Benabio, physician director at Kaiser Permanente in San Diego and an avid social media user, explained three ways doctors can harness the power of current social media:

• Marketing your practice. If your website isn’t interactive, make it so. Patients want to interact, and they want information. Many patients are searching for information about specific treatments, and an informative, interactive website can be "a powerful way to relate to patients," Dr. Benabio said. And if you have an electronic medical records system, investigate options for allowing patients to make appointments online, he added.

• Connecting with other doctors. Do you have a challenging case? Want some advice? Try one of the doctor-only information sharing sites; Doximity and Sermo are two.

• Managing your reputation. Like it or not, doctor rating sites are here to stay, Dr. Benabio said. But don’t let one bad review keep you up at night. Instead, think about what type of positive content you can create online, via website, blog, twitter, or all of the above, and make social media work for you.

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

–Heidi Splete

h.splete@elsevier.com

*This story was updated March 1, 2013.

Many doctors probably enjoy using Facebook and other social networking sites to connect with family and friends. But if social media doesn’t play a role in your medical practice, you are missing opportunities, according to Dr. Jeffrey Benabio.

Social media is here to stay. In fact, today’s technology is just the modern incarnation of the human need to connect with other people and share information, Dr. Benabio said. At the SDEF Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Benabio, physician director at Kaiser Permanente in San Diego and an avid social media user, explained three ways doctors can harness the power of current social media:

• Marketing your practice. If your website isn’t interactive, make it so. Patients want to interact, and they want information. Many patients are searching for information about specific treatments, and an informative, interactive website can be "a powerful way to relate to patients," Dr. Benabio said. And if you have an electronic medical records system, investigate options for allowing patients to make appointments online, he added.

• Connecting with other doctors. Do you have a challenging case? Want some advice? Try one of the doctor-only information sharing sites; Doximity and Sermo are two.

• Managing your reputation. Like it or not, doctor rating sites are here to stay, Dr. Benabio said. But don’t let one bad review keep you up at night. Instead, think about what type of positive content you can create online, via website, blog, twitter, or all of the above, and make social media work for you.

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

–Heidi Splete

h.splete@elsevier.com

*This story was updated March 1, 2013.

Many doctors probably enjoy using Facebook and other social networking sites to connect with family and friends. But if social media doesn’t play a role in your medical practice, you are missing opportunities, according to Dr. Jeffrey Benabio.

Social media is here to stay. In fact, today’s technology is just the modern incarnation of the human need to connect with other people and share information, Dr. Benabio said. At the SDEF Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Benabio, physician director at Kaiser Permanente in San Diego and an avid social media user, explained three ways doctors can harness the power of current social media:

• Marketing your practice. If your website isn’t interactive, make it so. Patients want to interact, and they want information. Many patients are searching for information about specific treatments, and an informative, interactive website can be "a powerful way to relate to patients," Dr. Benabio said. And if you have an electronic medical records system, investigate options for allowing patients to make appointments online, he added.

• Connecting with other doctors. Do you have a challenging case? Want some advice? Try one of the doctor-only information sharing sites; Doximity and Sermo are two.

• Managing your reputation. Like it or not, doctor rating sites are here to stay, Dr. Benabio said. But don’t let one bad review keep you up at night. Instead, think about what type of positive content you can create online, via website, blog, twitter, or all of the above, and make social media work for you.

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

–Heidi Splete

h.splete@elsevier.com

*This story was updated March 1, 2013.

In many ways, office efficiency and patient satisfaction go hand in hand. Effective communication is one key to achieving both, according to Dr. Roger I. Ceilley.

During a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Ceilley of the University of Iowa, Iowa City, offered several tips for improving patient interactions through such communication.

A good first step is to be prepared.

"Always review the patient record before entering the room," he said, noting that this will provide a quick recall of the patient’s history and will provide the patient with the knowledge that he or she will be receiving informed care. Look for notes from assistants, who may have noted why the patient is being seen and if the patient is upset or has special concerns.

Also, it is fine for a provider to enter the room quickly, but be sure to always leave slowly. Offer a warm handshake, and remember the value and healing power of "laying on hands," he said.

During the visit, make a note of something personal about the patient, and put it in the chart to reference at the next visit. For example, "Patient will celebrate 50th anniversary on June 20."

During the encounter, sit down for a brief time whenever possible, look directly at the patient when speaking, and convey that you care and that you enjoy what you are doing, Dr. Ceilley advised.

Interject humor whenever possible, he added. When used appropriately, humor will further put the patient at ease in what may be an uncomfortable circumstance. Keep in mind that some patients have hearing loss and lip read to some degree and want to see your expressions.

On average, physicians give patients less than 30 seconds to express concerns, and physicians tend to focus on the first problem that a patient mentions. The first one they mention may not be the one of most concern, so take time to hear their other concerns as well, he said.

Be sure to take an inventory of patient expectations and discuss realistic expectations of treatment options available, carefully review the treatment plan and costs, and obtain informed consent prior to any procedure (including disclosure of expectations, side effects, and costs,) he added.

At the close of the visit, supply handouts and provide enough refills until the next visit or for 60-90 days depending on insurance requirements, and ask the patient if there is anything else he or she needs. You may not be able to take care of these needs, but they should be addressed. Then schedule a follow-up appointment, refer the patient, or have the clinical staff assist them, Dr. Ceilley said.

"And remember, patients won’t remember everything exactly as you said or everything that you did, but they will remember how you made them feel," he said.

A few other things that can contribute to patient satisfaction and/or office efficiency are samples and supplies (provided with instructions and quality handouts), a dedicated check-in and check-out process, a communication center (for making appointments, handling referrals, managing faxes and other communications, and triaging patients), and a website to serve as a patient resource.

Dr. Ceilley also offered tips for hiring and training practices that can improve office efficiency and physician, staff, and patient satisfaction. When hiring staff, take your time and don’t settle for less than you need, he advised.

A tiered interviewing process by which prospective employees are interviewed first by management, then by lead staff, and finally by the physician is optimal. The inclusion of at least a few hours of shadowing with staff before a position is offered to a final candidate can help improve the likelihood that the best hiring decision will be made.

Among the factors to consider in a candidate are attitude, intelligence, experience, loyalty, stability, enthusiasm, judgment, and technical ability. Staff efficiency is best achieved with high-quality staff, and that efficiency will more than make up for the extra pay likely required to hire the best, he said.

"One excellent staff [member] at 20% over market rate pay will equal or exceed in work output 1.5 average staff at the market rate – at less cost," Dr. Ceilley said.

To further ensure the highest level of efficiency, consider personally training your assistants, he said, noting that the physician’s role in creating an efficient office environment involves earning the trust of employees – this is where communication also can benefit this aspect of practice. Employees need to know that they won’t be taken unfair advantage of, and this is communicated by demonstrating consistency (which provides a sense that things will be handled in an even and predictable manner every day) and conveying confidence, (which provides a sense that things are under control).

An efficient office with good communication leads to personal and staff satisfaction, patient satisfaction, good quality care, efficient care, and profitable care, he concluded.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

sknews@elsevier.com

*This story was updated March 1, 2013.

In many ways, office efficiency and patient satisfaction go hand in hand. Effective communication is one key to achieving both, according to Dr. Roger I. Ceilley.

During a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Ceilley of the University of Iowa, Iowa City, offered several tips for improving patient interactions through such communication.

A good first step is to be prepared.

"Always review the patient record before entering the room," he said, noting that this will provide a quick recall of the patient’s history and will provide the patient with the knowledge that he or she will be receiving informed care. Look for notes from assistants, who may have noted why the patient is being seen and if the patient is upset or has special concerns.

Also, it is fine for a provider to enter the room quickly, but be sure to always leave slowly. Offer a warm handshake, and remember the value and healing power of "laying on hands," he said.

During the visit, make a note of something personal about the patient, and put it in the chart to reference at the next visit. For example, "Patient will celebrate 50th anniversary on June 20."

During the encounter, sit down for a brief time whenever possible, look directly at the patient when speaking, and convey that you care and that you enjoy what you are doing, Dr. Ceilley advised.

Interject humor whenever possible, he added. When used appropriately, humor will further put the patient at ease in what may be an uncomfortable circumstance. Keep in mind that some patients have hearing loss and lip read to some degree and want to see your expressions.

On average, physicians give patients less than 30 seconds to express concerns, and physicians tend to focus on the first problem that a patient mentions. The first one they mention may not be the one of most concern, so take time to hear their other concerns as well, he said.

Be sure to take an inventory of patient expectations and discuss realistic expectations of treatment options available, carefully review the treatment plan and costs, and obtain informed consent prior to any procedure (including disclosure of expectations, side effects, and costs,) he added.

At the close of the visit, supply handouts and provide enough refills until the next visit or for 60-90 days depending on insurance requirements, and ask the patient if there is anything else he or she needs. You may not be able to take care of these needs, but they should be addressed. Then schedule a follow-up appointment, refer the patient, or have the clinical staff assist them, Dr. Ceilley said.

"And remember, patients won’t remember everything exactly as you said or everything that you did, but they will remember how you made them feel," he said.

A few other things that can contribute to patient satisfaction and/or office efficiency are samples and supplies (provided with instructions and quality handouts), a dedicated check-in and check-out process, a communication center (for making appointments, handling referrals, managing faxes and other communications, and triaging patients), and a website to serve as a patient resource.

Dr. Ceilley also offered tips for hiring and training practices that can improve office efficiency and physician, staff, and patient satisfaction. When hiring staff, take your time and don’t settle for less than you need, he advised.

A tiered interviewing process by which prospective employees are interviewed first by management, then by lead staff, and finally by the physician is optimal. The inclusion of at least a few hours of shadowing with staff before a position is offered to a final candidate can help improve the likelihood that the best hiring decision will be made.

Among the factors to consider in a candidate are attitude, intelligence, experience, loyalty, stability, enthusiasm, judgment, and technical ability. Staff efficiency is best achieved with high-quality staff, and that efficiency will more than make up for the extra pay likely required to hire the best, he said.

"One excellent staff [member] at 20% over market rate pay will equal or exceed in work output 1.5 average staff at the market rate – at less cost," Dr. Ceilley said.

To further ensure the highest level of efficiency, consider personally training your assistants, he said, noting that the physician’s role in creating an efficient office environment involves earning the trust of employees – this is where communication also can benefit this aspect of practice. Employees need to know that they won’t be taken unfair advantage of, and this is communicated by demonstrating consistency (which provides a sense that things will be handled in an even and predictable manner every day) and conveying confidence, (which provides a sense that things are under control).

An efficient office with good communication leads to personal and staff satisfaction, patient satisfaction, good quality care, efficient care, and profitable care, he concluded.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

sknews@elsevier.com

*This story was updated March 1, 2013.

In many ways, office efficiency and patient satisfaction go hand in hand. Effective communication is one key to achieving both, according to Dr. Roger I. Ceilley.

During a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Ceilley of the University of Iowa, Iowa City, offered several tips for improving patient interactions through such communication.

A good first step is to be prepared.

"Always review the patient record before entering the room," he said, noting that this will provide a quick recall of the patient’s history and will provide the patient with the knowledge that he or she will be receiving informed care. Look for notes from assistants, who may have noted why the patient is being seen and if the patient is upset or has special concerns.

Also, it is fine for a provider to enter the room quickly, but be sure to always leave slowly. Offer a warm handshake, and remember the value and healing power of "laying on hands," he said.

During the visit, make a note of something personal about the patient, and put it in the chart to reference at the next visit. For example, "Patient will celebrate 50th anniversary on June 20."

During the encounter, sit down for a brief time whenever possible, look directly at the patient when speaking, and convey that you care and that you enjoy what you are doing, Dr. Ceilley advised.

Interject humor whenever possible, he added. When used appropriately, humor will further put the patient at ease in what may be an uncomfortable circumstance. Keep in mind that some patients have hearing loss and lip read to some degree and want to see your expressions.

On average, physicians give patients less than 30 seconds to express concerns, and physicians tend to focus on the first problem that a patient mentions. The first one they mention may not be the one of most concern, so take time to hear their other concerns as well, he said.

Be sure to take an inventory of patient expectations and discuss realistic expectations of treatment options available, carefully review the treatment plan and costs, and obtain informed consent prior to any procedure (including disclosure of expectations, side effects, and costs,) he added.

At the close of the visit, supply handouts and provide enough refills until the next visit or for 60-90 days depending on insurance requirements, and ask the patient if there is anything else he or she needs. You may not be able to take care of these needs, but they should be addressed. Then schedule a follow-up appointment, refer the patient, or have the clinical staff assist them, Dr. Ceilley said.

"And remember, patients won’t remember everything exactly as you said or everything that you did, but they will remember how you made them feel," he said.

A few other things that can contribute to patient satisfaction and/or office efficiency are samples and supplies (provided with instructions and quality handouts), a dedicated check-in and check-out process, a communication center (for making appointments, handling referrals, managing faxes and other communications, and triaging patients), and a website to serve as a patient resource.

Dr. Ceilley also offered tips for hiring and training practices that can improve office efficiency and physician, staff, and patient satisfaction. When hiring staff, take your time and don’t settle for less than you need, he advised.

A tiered interviewing process by which prospective employees are interviewed first by management, then by lead staff, and finally by the physician is optimal. The inclusion of at least a few hours of shadowing with staff before a position is offered to a final candidate can help improve the likelihood that the best hiring decision will be made.

Among the factors to consider in a candidate are attitude, intelligence, experience, loyalty, stability, enthusiasm, judgment, and technical ability. Staff efficiency is best achieved with high-quality staff, and that efficiency will more than make up for the extra pay likely required to hire the best, he said.

"One excellent staff [member] at 20% over market rate pay will equal or exceed in work output 1.5 average staff at the market rate – at less cost," Dr. Ceilley said.

To further ensure the highest level of efficiency, consider personally training your assistants, he said, noting that the physician’s role in creating an efficient office environment involves earning the trust of employees – this is where communication also can benefit this aspect of practice. Employees need to know that they won’t be taken unfair advantage of, and this is communicated by demonstrating consistency (which provides a sense that things will be handled in an even and predictable manner every day) and conveying confidence, (which provides a sense that things are under control).

An efficient office with good communication leads to personal and staff satisfaction, patient satisfaction, good quality care, efficient care, and profitable care, he concluded.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

sknews@elsevier.com

*This story was updated March 1, 2013.

Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.

The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

A sample checklist that he shared included the following items:

• Referring physician.

• Who did the biopsy?

• Sign consent.

• Circle surgery site with patient verification.

• Verify and record pacemaker/defibrillator or other electronic implants.

• Review allergies to any anesthesia/antibiotics/latex/bandages.

• Check and record anticoagulants.

• Prophylactic antibiotics needed? If so, why?

• Record blood pressure and pulse – notify provider if elevated or too low.

• Check for special health concerns such as diabetes, etc.

• Buffered and unbuffered anesthesia on the field.

• Mapping card.

• Verify pathology report.

• Photo.

• Miscellaneous patient concerns.

Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.

Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.

This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.

Dr. Ceilley covered several other topics:

• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.

The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.

• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.

He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.

• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.

• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.

• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.

• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.

"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.

Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.

• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.

"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

sknews@elsevier.com

*This story was updated March 1, 2013.

Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.

The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

A sample checklist that he shared included the following items:

• Referring physician.

• Who did the biopsy?

• Sign consent.

• Circle surgery site with patient verification.

• Verify and record pacemaker/defibrillator or other electronic implants.

• Review allergies to any anesthesia/antibiotics/latex/bandages.

• Check and record anticoagulants.

• Prophylactic antibiotics needed? If so, why?

• Record blood pressure and pulse – notify provider if elevated or too low.

• Check for special health concerns such as diabetes, etc.

• Buffered and unbuffered anesthesia on the field.

• Mapping card.

• Verify pathology report.

• Photo.

• Miscellaneous patient concerns.

Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.

Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.

This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.

Dr. Ceilley covered several other topics:

• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.

The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.

• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.

He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.

• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.

• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.

• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.

• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.

"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.

Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.

• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.

"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

sknews@elsevier.com

*This story was updated March 1, 2013.

Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.

The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

A sample checklist that he shared included the following items:

• Referring physician.

• Who did the biopsy?

• Sign consent.

• Circle surgery site with patient verification.

• Verify and record pacemaker/defibrillator or other electronic implants.

• Review allergies to any anesthesia/antibiotics/latex/bandages.

• Check and record anticoagulants.

• Prophylactic antibiotics needed? If so, why?

• Record blood pressure and pulse – notify provider if elevated or too low.

• Check for special health concerns such as diabetes, etc.

• Buffered and unbuffered anesthesia on the field.

• Mapping card.

• Verify pathology report.

• Photo.

• Miscellaneous patient concerns.

Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.

Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.

This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.

Dr. Ceilley covered several other topics:

• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.

The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.

• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.

He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.

• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.

• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.

• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.

• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.

"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.

Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.

• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.

"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

sknews@elsevier.com

*This story was updated March 1, 2013.