SDEF Women’s & Pediatric Dermatology Seminar

NEWPORT BEACH, CALIF. – All it takes to clear up vulvar pruritus in most young girls prior to puberty is a little reminder about proper toilet habits, according to Dr. Bethanee J. Schlosser.

“There are a whole slew of conditions that cause itching of the genitals in young girls, but the most common is poor hygiene,” explained Dr. Schlosser of the departments of dermatology and obstetrics and gynecology at Northwestern University in Chicago.

Afraid they might miss out on something, children often rush bathroom visits and don’t take the time to wipe properly. Itching and redness soon follow. Gentle guidance is mostly all that’s needed to clear the problem. Loose-fitting cotton underwear helps, too, along with quickly changing soiled underpants, avoiding wet wipes, and taking baths to make sure the genitalia are adequately rinsed, Dr. Schlosser said at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Simple as those steps are, they can be overlooked in the clinic. One study found that young girls are sometimes misdiagnosed with candidiasis, and treated with topical antifungals for years, even though yeast infections – the most common cause of vulvovaginal pruritus in adult women – are estrogen dependent, and so far less likely before puberty (Australas. J. Dermatol. 2010;51:118-23). After hygiene issues, lichen sclerosus is perhaps the next most common cause of vulvar pruritus in young girls, and tends to present with more urinary problems and bleeding than in adults, and more GI complaints, especially constipation. It’s “the most common inflammatory vulvar dermatosis that we see, with the possible exception of contact dermatitis,” Dr. Schlosser wrote (Arch. Dermatol. 2004;140:702-6). As in adult women, the first-line treatment is once-daily clobetasol propionate ointment 0.05% for several weeks, followed by maintenance therapy. Dr. Schlosser said she used to switch patients to a less potent topical steroid, but “then I had a couple patients get confused about which tube they were supposed to use at home, so now I taper the frequency of their clobetasol ointment” to once or twice a week instead of switching them to a less potent topical steroid. It’s easier for them, but as with any topical steroid, “you need to continue ongoing monitoring for cutaneous atrophy,” she said.

In general, pelvic exams in pediatric patients “require special consideration. These are not 5-minute visits. You have to take the time to make yourself available. Educate patients and parents about what’s going to happen,” and use the child’s own terms for her genitals, asking parents beforehand what they are, so that the child understands what she’s hearing, Dr. Schlosser said.

“When I see young girls,” mom is in the room and “I only have gauze, gloves, and maybe a Q-tip [swab] here and there. I often” begin by asking the child if it’s okay to look at her scalp, face, and hands, then “gradually work my way down. I think that gives patients some sense of comfort and control,” she said.

Dr. Schlosser said she prefers the frog-leg position, with very young girls in their mothers’ laps. The literature sometimes advocates the prone knee-to-chest position, but “I find it makes people feel very vulnerable. They can’t see you, and they have no idea of what’s going on. I don’t advocate it,” she said.

Dr. Schlosser said she has no relevant financial disclosures.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – All it takes to clear up vulvar pruritus in most young girls prior to puberty is a little reminder about proper toilet habits, according to Dr. Bethanee J. Schlosser.

“There are a whole slew of conditions that cause itching of the genitals in young girls, but the most common is poor hygiene,” explained Dr. Schlosser of the departments of dermatology and obstetrics and gynecology at Northwestern University in Chicago.

Afraid they might miss out on something, children often rush bathroom visits and don’t take the time to wipe properly. Itching and redness soon follow. Gentle guidance is mostly all that’s needed to clear the problem. Loose-fitting cotton underwear helps, too, along with quickly changing soiled underpants, avoiding wet wipes, and taking baths to make sure the genitalia are adequately rinsed, Dr. Schlosser said at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Simple as those steps are, they can be overlooked in the clinic. One study found that young girls are sometimes misdiagnosed with candidiasis, and treated with topical antifungals for years, even though yeast infections – the most common cause of vulvovaginal pruritus in adult women – are estrogen dependent, and so far less likely before puberty (Australas. J. Dermatol. 2010;51:118-23). After hygiene issues, lichen sclerosus is perhaps the next most common cause of vulvar pruritus in young girls, and tends to present with more urinary problems and bleeding than in adults, and more GI complaints, especially constipation. It’s “the most common inflammatory vulvar dermatosis that we see, with the possible exception of contact dermatitis,” Dr. Schlosser wrote (Arch. Dermatol. 2004;140:702-6). As in adult women, the first-line treatment is once-daily clobetasol propionate ointment 0.05% for several weeks, followed by maintenance therapy. Dr. Schlosser said she used to switch patients to a less potent topical steroid, but “then I had a couple patients get confused about which tube they were supposed to use at home, so now I taper the frequency of their clobetasol ointment” to once or twice a week instead of switching them to a less potent topical steroid. It’s easier for them, but as with any topical steroid, “you need to continue ongoing monitoring for cutaneous atrophy,” she said.

In general, pelvic exams in pediatric patients “require special consideration. These are not 5-minute visits. You have to take the time to make yourself available. Educate patients and parents about what’s going to happen,” and use the child’s own terms for her genitals, asking parents beforehand what they are, so that the child understands what she’s hearing, Dr. Schlosser said.

“When I see young girls,” mom is in the room and “I only have gauze, gloves, and maybe a Q-tip [swab] here and there. I often” begin by asking the child if it’s okay to look at her scalp, face, and hands, then “gradually work my way down. I think that gives patients some sense of comfort and control,” she said.

Dr. Schlosser said she prefers the frog-leg position, with very young girls in their mothers’ laps. The literature sometimes advocates the prone knee-to-chest position, but “I find it makes people feel very vulnerable. They can’t see you, and they have no idea of what’s going on. I don’t advocate it,” she said.

Dr. Schlosser said she has no relevant financial disclosures.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – All it takes to clear up vulvar pruritus in most young girls prior to puberty is a little reminder about proper toilet habits, according to Dr. Bethanee J. Schlosser.

“There are a whole slew of conditions that cause itching of the genitals in young girls, but the most common is poor hygiene,” explained Dr. Schlosser of the departments of dermatology and obstetrics and gynecology at Northwestern University in Chicago.

Afraid they might miss out on something, children often rush bathroom visits and don’t take the time to wipe properly. Itching and redness soon follow. Gentle guidance is mostly all that’s needed to clear the problem. Loose-fitting cotton underwear helps, too, along with quickly changing soiled underpants, avoiding wet wipes, and taking baths to make sure the genitalia are adequately rinsed, Dr. Schlosser said at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Simple as those steps are, they can be overlooked in the clinic. One study found that young girls are sometimes misdiagnosed with candidiasis, and treated with topical antifungals for years, even though yeast infections – the most common cause of vulvovaginal pruritus in adult women – are estrogen dependent, and so far less likely before puberty (Australas. J. Dermatol. 2010;51:118-23). After hygiene issues, lichen sclerosus is perhaps the next most common cause of vulvar pruritus in young girls, and tends to present with more urinary problems and bleeding than in adults, and more GI complaints, especially constipation. It’s “the most common inflammatory vulvar dermatosis that we see, with the possible exception of contact dermatitis,” Dr. Schlosser wrote (Arch. Dermatol. 2004;140:702-6). As in adult women, the first-line treatment is once-daily clobetasol propionate ointment 0.05% for several weeks, followed by maintenance therapy. Dr. Schlosser said she used to switch patients to a less potent topical steroid, but “then I had a couple patients get confused about which tube they were supposed to use at home, so now I taper the frequency of their clobetasol ointment” to once or twice a week instead of switching them to a less potent topical steroid. It’s easier for them, but as with any topical steroid, “you need to continue ongoing monitoring for cutaneous atrophy,” she said.

In general, pelvic exams in pediatric patients “require special consideration. These are not 5-minute visits. You have to take the time to make yourself available. Educate patients and parents about what’s going to happen,” and use the child’s own terms for her genitals, asking parents beforehand what they are, so that the child understands what she’s hearing, Dr. Schlosser said.

“When I see young girls,” mom is in the room and “I only have gauze, gloves, and maybe a Q-tip [swab] here and there. I often” begin by asking the child if it’s okay to look at her scalp, face, and hands, then “gradually work my way down. I think that gives patients some sense of comfort and control,” she said.

Dr. Schlosser said she prefers the frog-leg position, with very young girls in their mothers’ laps. The literature sometimes advocates the prone knee-to-chest position, but “I find it makes people feel very vulnerable. They can’t see you, and they have no idea of what’s going on. I don’t advocate it,” she said.

Dr. Schlosser said she has no relevant financial disclosures.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – A history of severe cradle cap and diaper dermatitis helps to differentiate between pediatric psoriasis and atopic dermatitis, so be sure to ask, according to Dr. Alan Menter, chief of the dermatology division at the Baylor University Medical Center in Dallas.

“Both are markers for later onset of psoriasis, and are much more likely to be a marker for psoriasis than atopic eczema,” he said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

The tip to ask about cradle cap and diaper dermatitis is based largely on clinical observation, but is more useful than asking about a family history of psoriasis, because people tend to keep psoriasis to themselves, he noted; family members and even spouses might not know. “It’s a very hidden disease, so family history is of little benefit,” he said.

Recent strep infection also may provide a clue, not only for guttate psoriasis but also probably for plaque psoriasis in children, Dr. Menter said. But the sooner pediatric psoriasis is caught and controlled, the better, no matter how it is detected. Aside from the suffering it causes on its own, psoriasis in children has been linked to diabetes, hypertension, fatty liver disease, obesity, and cardiovascular problems, he noted.

The mechanism of action for these comorbidities remains under investigation. Perhaps mothers with psoriasis gain more weight during pregnancy, and their children are heavier at birth, Dr. Menter said.

Crohn’s disease is far more likely in children with psoriasis, too. Dr. Menter noted that he has had referrals where the diagnosis has been missed, even in the setting of long-standing fatigue and diarrhea. “We have to look for it [Crohn’s] in our psoriasis population,” he said.

Children with psoriasis are often teased, taunted, and bullied, sometimes as young as kindergarten age. The emotional stress, loneliness, and depression can have a major impact on school and social growth, Dr. Menter said.

“Treatment of these kids goes beyond prescribing a topical steroid; they need [both] physical and psychological support,” he emphasized. Talk to parents and teachers about how the child is doing in school and other social settings. Parents might know about grades, but not much about their child’s social interactions. To help catch problems, also “take a quality of life index on all your patients with psoriasis,” he said.

It’s important to intervene early and get children’s skin cleared quickly. “[Although] we’d love to treat [everybody] with topicals and wet compresses,” effective treatment sometimes means systemic therapy, he said.

Cyclosporine is a valid rescue option, particularly for more inflammatory disease. “Rarely, if ever, have I seen any hypertension or serum creatinine issues,” Dr. Menter said. “You just have to warn parents to be careful about gums, because you can get gingival hyperplasia, and girls don’t like the mild hypertrichosis you sometimes get around the temples and forearms,” he said.

Etanercept is another option. It not approved for pediatric psoriasis, but if you try hard enough, you can get insurance companies to cover it, Dr. Menter said. “You have to talk about quality of life and how psoriasis has impacted schooling,” among other topics, he explained.

Clinicians looking for child-oriented resources and support materials can recommend the National Psoriasis Foundation to their patients, he noted. SDEF and this news organization are owned by Frontline Medical Communications.

Dr. Menter disclosed financial relationships with Abbott, AbbVie, and numerous other companies.

aotto@frontlinemedcom.com

NEWPORT BEACH, CALIF. – A history of severe cradle cap and diaper dermatitis helps to differentiate between pediatric psoriasis and atopic dermatitis, so be sure to ask, according to Dr. Alan Menter, chief of the dermatology division at the Baylor University Medical Center in Dallas.

“Both are markers for later onset of psoriasis, and are much more likely to be a marker for psoriasis than atopic eczema,” he said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

The tip to ask about cradle cap and diaper dermatitis is based largely on clinical observation, but is more useful than asking about a family history of psoriasis, because people tend to keep psoriasis to themselves, he noted; family members and even spouses might not know. “It’s a very hidden disease, so family history is of little benefit,” he said.

Recent strep infection also may provide a clue, not only for guttate psoriasis but also probably for plaque psoriasis in children, Dr. Menter said. But the sooner pediatric psoriasis is caught and controlled, the better, no matter how it is detected. Aside from the suffering it causes on its own, psoriasis in children has been linked to diabetes, hypertension, fatty liver disease, obesity, and cardiovascular problems, he noted.

The mechanism of action for these comorbidities remains under investigation. Perhaps mothers with psoriasis gain more weight during pregnancy, and their children are heavier at birth, Dr. Menter said.

Crohn’s disease is far more likely in children with psoriasis, too. Dr. Menter noted that he has had referrals where the diagnosis has been missed, even in the setting of long-standing fatigue and diarrhea. “We have to look for it [Crohn’s] in our psoriasis population,” he said.

Children with psoriasis are often teased, taunted, and bullied, sometimes as young as kindergarten age. The emotional stress, loneliness, and depression can have a major impact on school and social growth, Dr. Menter said.

“Treatment of these kids goes beyond prescribing a topical steroid; they need [both] physical and psychological support,” he emphasized. Talk to parents and teachers about how the child is doing in school and other social settings. Parents might know about grades, but not much about their child’s social interactions. To help catch problems, also “take a quality of life index on all your patients with psoriasis,” he said.

It’s important to intervene early and get children’s skin cleared quickly. “[Although] we’d love to treat [everybody] with topicals and wet compresses,” effective treatment sometimes means systemic therapy, he said.

Cyclosporine is a valid rescue option, particularly for more inflammatory disease. “Rarely, if ever, have I seen any hypertension or serum creatinine issues,” Dr. Menter said. “You just have to warn parents to be careful about gums, because you can get gingival hyperplasia, and girls don’t like the mild hypertrichosis you sometimes get around the temples and forearms,” he said.

Etanercept is another option. It not approved for pediatric psoriasis, but if you try hard enough, you can get insurance companies to cover it, Dr. Menter said. “You have to talk about quality of life and how psoriasis has impacted schooling,” among other topics, he explained.

Clinicians looking for child-oriented resources and support materials can recommend the National Psoriasis Foundation to their patients, he noted. SDEF and this news organization are owned by Frontline Medical Communications.

Dr. Menter disclosed financial relationships with Abbott, AbbVie, and numerous other companies.

aotto@frontlinemedcom.com

NEWPORT BEACH, CALIF. – A history of severe cradle cap and diaper dermatitis helps to differentiate between pediatric psoriasis and atopic dermatitis, so be sure to ask, according to Dr. Alan Menter, chief of the dermatology division at the Baylor University Medical Center in Dallas.

“Both are markers for later onset of psoriasis, and are much more likely to be a marker for psoriasis than atopic eczema,” he said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

The tip to ask about cradle cap and diaper dermatitis is based largely on clinical observation, but is more useful than asking about a family history of psoriasis, because people tend to keep psoriasis to themselves, he noted; family members and even spouses might not know. “It’s a very hidden disease, so family history is of little benefit,” he said.

Recent strep infection also may provide a clue, not only for guttate psoriasis but also probably for plaque psoriasis in children, Dr. Menter said. But the sooner pediatric psoriasis is caught and controlled, the better, no matter how it is detected. Aside from the suffering it causes on its own, psoriasis in children has been linked to diabetes, hypertension, fatty liver disease, obesity, and cardiovascular problems, he noted.

The mechanism of action for these comorbidities remains under investigation. Perhaps mothers with psoriasis gain more weight during pregnancy, and their children are heavier at birth, Dr. Menter said.

Crohn’s disease is far more likely in children with psoriasis, too. Dr. Menter noted that he has had referrals where the diagnosis has been missed, even in the setting of long-standing fatigue and diarrhea. “We have to look for it [Crohn’s] in our psoriasis population,” he said.

Children with psoriasis are often teased, taunted, and bullied, sometimes as young as kindergarten age. The emotional stress, loneliness, and depression can have a major impact on school and social growth, Dr. Menter said.

“Treatment of these kids goes beyond prescribing a topical steroid; they need [both] physical and psychological support,” he emphasized. Talk to parents and teachers about how the child is doing in school and other social settings. Parents might know about grades, but not much about their child’s social interactions. To help catch problems, also “take a quality of life index on all your patients with psoriasis,” he said.

It’s important to intervene early and get children’s skin cleared quickly. “[Although] we’d love to treat [everybody] with topicals and wet compresses,” effective treatment sometimes means systemic therapy, he said.

Cyclosporine is a valid rescue option, particularly for more inflammatory disease. “Rarely, if ever, have I seen any hypertension or serum creatinine issues,” Dr. Menter said. “You just have to warn parents to be careful about gums, because you can get gingival hyperplasia, and girls don’t like the mild hypertrichosis you sometimes get around the temples and forearms,” he said.

Etanercept is another option. It not approved for pediatric psoriasis, but if you try hard enough, you can get insurance companies to cover it, Dr. Menter said. “You have to talk about quality of life and how psoriasis has impacted schooling,” among other topics, he explained.

Clinicians looking for child-oriented resources and support materials can recommend the National Psoriasis Foundation to their patients, he noted. SDEF and this news organization are owned by Frontline Medical Communications.

Dr. Menter disclosed financial relationships with Abbott, AbbVie, and numerous other companies.

aotto@frontlinemedcom.com

NEWPORT BEACH, CALIF.– In children with atopic dermatitis, serious superinfections are more likely to be caused by group A beta-hemolytic Streptococcus than methicillin-resistant Staphylococcus aureus, according to Dr. Victoria Barrio of the University of California, San Diego.

Unless there are classic MRSA signs, “I wouldn’t start off with Bactrim [sulfamethoxazole and trimethoprim] assuming that they have MRSA; Bactrim doesn’t work for strep. You are going to be in trouble if they actually have strep,” she said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Instead, Dr. Barrio is more likely to start empirically with cephalexin (Keflex) three times daily, which also covers staph in most communities. “It’s usually well tolerated, and it does pretty well,” she said, but adding that she adjusts treatment as needed depending on culture results.

This protocol is supported in part by findings from a study by colleagues of Dr. Barrio, which showed that children with atopic dermatitis carry more S. aureus on their skin than do children without eczema, so they are less likely to be infected with community-acquired MRSA, probably because non-MRSA strains outcompete it. In the study, the MRSA the investigators found responded to clindamycin (Pediatr. Dermatol. 2011;28:6-11).

Dr. Barrio cited another study suggesting that group A strep skin infections are a more serious problem than staph is in children with eczema; the children are more likely to be febrile, have systemic involvement, and need hospitalization than those with staph superinfections (Pediatr. Dermatol. 2011;28:230-4).

“These patients are often a lot sicker. You have to be aware that strep is out there, and it can be a problem for kids with eczema,” said Dr. Barrio.

In general, for bacterial superinfections, “bleach baths are a fantastic way to try to keep kids who are always getting infected under control,” she said. It really does keep that overload of bacteria down.”

Current data support her opinion. Following a course of antibiotics, another study showed that twice-weekly baths, followed by intranasal mupirocin ointment had “significantly greater mean reductions from baseline in Eczema Area and Severity Index scores,” compared with placebo (Pediatrics 2009;123:e808-14).

For older children who don’t want to take baths, a bleach soap (CLn Bodywash) is now available, Dr. Barrio noted.

Viral eczema coxsackium skin infections, recently characterized in the literature, remain a problem for children. Presentations can vary and include widespread blisters, erosions, purpura, and petechiae around the mouth or on the arms, legs, and torso. The infection can mimic bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease,and it is a common cause of onychomadesis as well, Dr. Barrio noted (Pediatrics 2013;132:e149-57).

“We saw a lot of it a few years ago. I am still seeing it around. You don’t really think about it as being hand, foot, and mouth” disease, she said.

Dr. Barrio added that eczema is hard on children emotionally as well as physically. They may lose sleep, have a tough time in school, and might blame the illness on themselves, and these and other problems can lead to depression, anxiety, and a big hit to self-esteem, she said.

Clinicians at the University of Nottingham (U.K.) have created a free web resource that might help, which features stories for children. The clinicians have posted several tales, like “The Princess and the Itch,” that make eczema the villain and the child the hero, which helps to externalize the disease. The child’s name can be entered into a template to personalize the story (Pediatr. Dermatol. 2013;30:765-7). Dr. Barrio had no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

NEWPORT BEACH, CALIF.– In children with atopic dermatitis, serious superinfections are more likely to be caused by group A beta-hemolytic Streptococcus than methicillin-resistant Staphylococcus aureus, according to Dr. Victoria Barrio of the University of California, San Diego.

Unless there are classic MRSA signs, “I wouldn’t start off with Bactrim [sulfamethoxazole and trimethoprim] assuming that they have MRSA; Bactrim doesn’t work for strep. You are going to be in trouble if they actually have strep,” she said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Instead, Dr. Barrio is more likely to start empirically with cephalexin (Keflex) three times daily, which also covers staph in most communities. “It’s usually well tolerated, and it does pretty well,” she said, but adding that she adjusts treatment as needed depending on culture results.

This protocol is supported in part by findings from a study by colleagues of Dr. Barrio, which showed that children with atopic dermatitis carry more S. aureus on their skin than do children without eczema, so they are less likely to be infected with community-acquired MRSA, probably because non-MRSA strains outcompete it. In the study, the MRSA the investigators found responded to clindamycin (Pediatr. Dermatol. 2011;28:6-11).

Dr. Barrio cited another study suggesting that group A strep skin infections are a more serious problem than staph is in children with eczema; the children are more likely to be febrile, have systemic involvement, and need hospitalization than those with staph superinfections (Pediatr. Dermatol. 2011;28:230-4).

“These patients are often a lot sicker. You have to be aware that strep is out there, and it can be a problem for kids with eczema,” said Dr. Barrio.

In general, for bacterial superinfections, “bleach baths are a fantastic way to try to keep kids who are always getting infected under control,” she said. It really does keep that overload of bacteria down.”

Current data support her opinion. Following a course of antibiotics, another study showed that twice-weekly baths, followed by intranasal mupirocin ointment had “significantly greater mean reductions from baseline in Eczema Area and Severity Index scores,” compared with placebo (Pediatrics 2009;123:e808-14).

For older children who don’t want to take baths, a bleach soap (CLn Bodywash) is now available, Dr. Barrio noted.

Viral eczema coxsackium skin infections, recently characterized in the literature, remain a problem for children. Presentations can vary and include widespread blisters, erosions, purpura, and petechiae around the mouth or on the arms, legs, and torso. The infection can mimic bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease,and it is a common cause of onychomadesis as well, Dr. Barrio noted (Pediatrics 2013;132:e149-57).

“We saw a lot of it a few years ago. I am still seeing it around. You don’t really think about it as being hand, foot, and mouth” disease, she said.

Dr. Barrio added that eczema is hard on children emotionally as well as physically. They may lose sleep, have a tough time in school, and might blame the illness on themselves, and these and other problems can lead to depression, anxiety, and a big hit to self-esteem, she said.

Clinicians at the University of Nottingham (U.K.) have created a free web resource that might help, which features stories for children. The clinicians have posted several tales, like “The Princess and the Itch,” that make eczema the villain and the child the hero, which helps to externalize the disease. The child’s name can be entered into a template to personalize the story (Pediatr. Dermatol. 2013;30:765-7). Dr. Barrio had no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

NEWPORT BEACH, CALIF.– In children with atopic dermatitis, serious superinfections are more likely to be caused by group A beta-hemolytic Streptococcus than methicillin-resistant Staphylococcus aureus, according to Dr. Victoria Barrio of the University of California, San Diego.

Unless there are classic MRSA signs, “I wouldn’t start off with Bactrim [sulfamethoxazole and trimethoprim] assuming that they have MRSA; Bactrim doesn’t work for strep. You are going to be in trouble if they actually have strep,” she said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Instead, Dr. Barrio is more likely to start empirically with cephalexin (Keflex) three times daily, which also covers staph in most communities. “It’s usually well tolerated, and it does pretty well,” she said, but adding that she adjusts treatment as needed depending on culture results.

This protocol is supported in part by findings from a study by colleagues of Dr. Barrio, which showed that children with atopic dermatitis carry more S. aureus on their skin than do children without eczema, so they are less likely to be infected with community-acquired MRSA, probably because non-MRSA strains outcompete it. In the study, the MRSA the investigators found responded to clindamycin (Pediatr. Dermatol. 2011;28:6-11).

Dr. Barrio cited another study suggesting that group A strep skin infections are a more serious problem than staph is in children with eczema; the children are more likely to be febrile, have systemic involvement, and need hospitalization than those with staph superinfections (Pediatr. Dermatol. 2011;28:230-4).

“These patients are often a lot sicker. You have to be aware that strep is out there, and it can be a problem for kids with eczema,” said Dr. Barrio.

In general, for bacterial superinfections, “bleach baths are a fantastic way to try to keep kids who are always getting infected under control,” she said. It really does keep that overload of bacteria down.”

Current data support her opinion. Following a course of antibiotics, another study showed that twice-weekly baths, followed by intranasal mupirocin ointment had “significantly greater mean reductions from baseline in Eczema Area and Severity Index scores,” compared with placebo (Pediatrics 2009;123:e808-14).

For older children who don’t want to take baths, a bleach soap (CLn Bodywash) is now available, Dr. Barrio noted.

Viral eczema coxsackium skin infections, recently characterized in the literature, remain a problem for children. Presentations can vary and include widespread blisters, erosions, purpura, and petechiae around the mouth or on the arms, legs, and torso. The infection can mimic bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease,and it is a common cause of onychomadesis as well, Dr. Barrio noted (Pediatrics 2013;132:e149-57).

“We saw a lot of it a few years ago. I am still seeing it around. You don’t really think about it as being hand, foot, and mouth” disease, she said.

Dr. Barrio added that eczema is hard on children emotionally as well as physically. They may lose sleep, have a tough time in school, and might blame the illness on themselves, and these and other problems can lead to depression, anxiety, and a big hit to self-esteem, she said.

Clinicians at the University of Nottingham (U.K.) have created a free web resource that might help, which features stories for children. The clinicians have posted several tales, like “The Princess and the Itch,” that make eczema the villain and the child the hero, which helps to externalize the disease. The child’s name can be entered into a template to personalize the story (Pediatr. Dermatol. 2013;30:765-7). Dr. Barrio had no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

NEWPORT BEACH, CALIF. – There is a role for topical cidofovir in the treatment of recalcitrant warts in children, Dr. James R. Treat said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

The drug is not to be used as a first, second, or even third-line option, but can be effective in stubborn cases, said Dr. Treat of Children’s Hospital of Philadelphia.

In an interview at the meeting, Dr. Treat explained how and when he incorporates topical cidofovir and other strategies into managing verruca vulgaris when other treatments fail.

Dr. Treat had no relevant financial conflicts to disclose.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – There is a role for topical cidofovir in the treatment of recalcitrant warts in children, Dr. James R. Treat said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

The drug is not to be used as a first, second, or even third-line option, but can be effective in stubborn cases, said Dr. Treat of Children’s Hospital of Philadelphia.

In an interview at the meeting, Dr. Treat explained how and when he incorporates topical cidofovir and other strategies into managing verruca vulgaris when other treatments fail.

Dr. Treat had no relevant financial conflicts to disclose.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – There is a role for topical cidofovir in the treatment of recalcitrant warts in children, Dr. James R. Treat said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

The drug is not to be used as a first, second, or even third-line option, but can be effective in stubborn cases, said Dr. Treat of Children’s Hospital of Philadelphia.

In an interview at the meeting, Dr. Treat explained how and when he incorporates topical cidofovir and other strategies into managing verruca vulgaris when other treatments fail.

Dr. Treat had no relevant financial conflicts to disclose.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – There is a role for topical cidofovir in the treatment of recalcitrant warts in children, Dr. James R. Treat said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

The drug is not to be used as a first, second, or even third-line option, but can be effective in stubborn cases, said Dr. Treat of Children’s Hospital of Philadelphia.

In an interview at the meeting, Dr. Treat explained how and when he incorporates topical cidofovir and other strategies into managing verruca vulgaris when other treatments fail.

Dr. Treat had no relevant financial conflicts to disclose.

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF. – There is a role for topical cidofovir in the treatment of recalcitrant warts in children, Dr. James R. Treat said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

The drug is not to be used as a first, second, or even third-line option, but can be effective in stubborn cases, said Dr. Treat of Children’s Hospital of Philadelphia.

In an interview at the meeting, Dr. Treat explained how and when he incorporates topical cidofovir and other strategies into managing verruca vulgaris when other treatments fail.

Dr. Treat had no relevant financial conflicts to disclose.

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF. – There is a role for topical cidofovir in the treatment of recalcitrant warts in children, Dr. James R. Treat said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

The drug is not to be used as a first, second, or even third-line option, but can be effective in stubborn cases, said Dr. Treat of Children’s Hospital of Philadelphia.

In an interview at the meeting, Dr. Treat explained how and when he incorporates topical cidofovir and other strategies into managing verruca vulgaris when other treatments fail.

Dr. Treat had no relevant financial conflicts to disclose.

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF.– “The group we worry about are the 1- to 7-year-olds,” when it comes to new-onset acne, Dr. Sheila Fallon Friedlander said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

In an interview at the meeting, Dr. Friedlander, a professor at the University of California, San Diego, explained the additional clinical signs that can indicate a serious problem, and what questions to ask parents.

Tune in for her tips on how to evaluate children aged 1-7 years with acne.

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF.– “The group we worry about are the 1- to 7-year-olds,” when it comes to new-onset acne, Dr. Sheila Fallon Friedlander said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

In an interview at the meeting, Dr. Friedlander, a professor at the University of California, San Diego, explained the additional clinical signs that can indicate a serious problem, and what questions to ask parents.

Tune in for her tips on how to evaluate children aged 1-7 years with acne.

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF.– “The group we worry about are the 1- to 7-year-olds,” when it comes to new-onset acne, Dr. Sheila Fallon Friedlander said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

In an interview at the meeting, Dr. Friedlander, a professor at the University of California, San Diego, explained the additional clinical signs that can indicate a serious problem, and what questions to ask parents.

Tune in for her tips on how to evaluate children aged 1-7 years with acne.

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF.– Patients with discoid lupus should be checked routinely for systemic disease, but complete autoantibody studies aren’t necessary for those patients with a prior work-up and a documented negative antinuclear antibodies, according to Dr. Ruth Ann Vleugels.

“The reason why we are doing these investigations is because between 5% and up to about 20% of our discoid lupus patients can develop systemic disease,” said Dr. Vleugels of Brigham and Women’s Hospital in Boston, Mass. Some patients don’t develop symptoms until years later, she noted.

In an interview at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar, Dr. Vleugels shared her protocol for managing discoid lupus patients. She had no financial conflicts to disclose. SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF.– Patients with discoid lupus should be checked routinely for systemic disease, but complete autoantibody studies aren’t necessary for those patients with a prior work-up and a documented negative antinuclear antibodies, according to Dr. Ruth Ann Vleugels.

“The reason why we are doing these investigations is because between 5% and up to about 20% of our discoid lupus patients can develop systemic disease,” said Dr. Vleugels of Brigham and Women’s Hospital in Boston, Mass. Some patients don’t develop symptoms until years later, she noted.

In an interview at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar, Dr. Vleugels shared her protocol for managing discoid lupus patients. She had no financial conflicts to disclose. SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF.– Patients with discoid lupus should be checked routinely for systemic disease, but complete autoantibody studies aren’t necessary for those patients with a prior work-up and a documented negative antinuclear antibodies, according to Dr. Ruth Ann Vleugels.

“The reason why we are doing these investigations is because between 5% and up to about 20% of our discoid lupus patients can develop systemic disease,” said Dr. Vleugels of Brigham and Women’s Hospital in Boston, Mass. Some patients don’t develop symptoms until years later, she noted.

In an interview at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar, Dr. Vleugels shared her protocol for managing discoid lupus patients. She had no financial conflicts to disclose. SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF.– Desquamation is a handy way to differentiate between Staphylococcus skin infections and molluscum.

Most of the time, the presentation of molluscum “is straightforward, but it’s one of the great imitators,” according to pediatric dermatologist Dr. James Treat of the department of pediatrics at the Children’s Hospital of Philadelphia. Molluscum can present as pearly little drops, inflamed papules that look infected, or even a large cyst. Molluscum also can kick up a small patch of localized eczema that makes it easy to overlook pathognomonic signs, he said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Sometimes, patients wind up being treated for folliculitis, bug bites, and other problems they don’t have. “We see people who get multiple antibiotics. I’ve seen so many patients who have been told they have recurrent MRSA,” Dr. Treat said.

However, methicillin-resistant Staphylococcus aureus (MRSA) secretes a toxin that causes the nearby epidermis to slough off; molluscum does not. “That’s a nice little marker for a staph infection,” Dr. Treat noted. As for pruritus, “You sometimes see a child who presents with a random spot of eczema on an arm, leg, or an inguinal fold that they’ve never had before. Look for molluscum in the center of it. When in doubt, culture,” he said.

Lesions often become inflamed, which makes parents worry about infection, but “the reality is that molluscum is almost never infected. If you take a little blade or needle and pop into it, you are not going to get pus out,” Dr. Treat said.

Instead, inflammation is a sign that the body is attacking the virus, which “is a really good thing.” The phenomenon was recently dubbed the beginning-of-the-end (BOTE) sign. If kids come in with inflamed molluscum, it’s time to “talk parents off the ledge. The body has already done your job for you.” Dr. Treat said.

If the body hasn’t yet done it’s job, the goal of treatment is to irritate the lesion to draw the immune system’s attention to it.

Scraping is the most reliable one-time treatment, but the blood and pain are too much for small children. Salicylic acid and topical imiquimod do the job the first time around in about half of kids, and cantharidin in about a third, Dr. Treat said (Pediatr. Dermatol. 2006;23:574-9).

Freezing and comedone extraction work, too, but they hurt, so are best used in older, “highly motivated” children. Don’t overdo freezing either; it might cause pigment changes, said Dr. Treat.

Also, “it’s reasonable to treat those itchy, red patches” with a low-potency topical steroid “because that’s what’s making the kid uncomfortable,” he said.

Doing nothing is reasonable, too, because molluscum is self-limiting, but it’s wise to tell parents it can take as long as 2 or more years for the condition to burn itself out.

Whether or not observation is the treatment of choice, parents need to know that molluscum can spread through bathing with siblings, and via wet washcloths, bathing suits, towels, and pool toys. Wrestling, assisting other children in gymnastics, and other skin-on-skin activities can spread molluscum, too.

Parents also need to know that molluscum on the face can present as unilateral conjunctivitis. “A random red eye should be evaluated. This is where I might use oral cimetidine. It’s totally off label and has limited data, but it’s also over the counter and reasonable to try,” Dr. Treat said.

Dr. Treat has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

NEWPORT BEACH, CALIF.– Desquamation is a handy way to differentiate between Staphylococcus skin infections and molluscum.

Most of the time, the presentation of molluscum “is straightforward, but it’s one of the great imitators,” according to pediatric dermatologist Dr. James Treat of the department of pediatrics at the Children’s Hospital of Philadelphia. Molluscum can present as pearly little drops, inflamed papules that look infected, or even a large cyst. Molluscum also can kick up a small patch of localized eczema that makes it easy to overlook pathognomonic signs, he said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Sometimes, patients wind up being treated for folliculitis, bug bites, and other problems they don’t have. “We see people who get multiple antibiotics. I’ve seen so many patients who have been told they have recurrent MRSA,” Dr. Treat said.

However, methicillin-resistant Staphylococcus aureus (MRSA) secretes a toxin that causes the nearby epidermis to slough off; molluscum does not. “That’s a nice little marker for a staph infection,” Dr. Treat noted. As for pruritus, “You sometimes see a child who presents with a random spot of eczema on an arm, leg, or an inguinal fold that they’ve never had before. Look for molluscum in the center of it. When in doubt, culture,” he said.

Lesions often become inflamed, which makes parents worry about infection, but “the reality is that molluscum is almost never infected. If you take a little blade or needle and pop into it, you are not going to get pus out,” Dr. Treat said.

Instead, inflammation is a sign that the body is attacking the virus, which “is a really good thing.” The phenomenon was recently dubbed the beginning-of-the-end (BOTE) sign. If kids come in with inflamed molluscum, it’s time to “talk parents off the ledge. The body has already done your job for you.” Dr. Treat said.

If the body hasn’t yet done it’s job, the goal of treatment is to irritate the lesion to draw the immune system’s attention to it.

Scraping is the most reliable one-time treatment, but the blood and pain are too much for small children. Salicylic acid and topical imiquimod do the job the first time around in about half of kids, and cantharidin in about a third, Dr. Treat said (Pediatr. Dermatol. 2006;23:574-9).

Freezing and comedone extraction work, too, but they hurt, so are best used in older, “highly motivated” children. Don’t overdo freezing either; it might cause pigment changes, said Dr. Treat.

Also, “it’s reasonable to treat those itchy, red patches” with a low-potency topical steroid “because that’s what’s making the kid uncomfortable,” he said.

Doing nothing is reasonable, too, because molluscum is self-limiting, but it’s wise to tell parents it can take as long as 2 or more years for the condition to burn itself out.

Whether or not observation is the treatment of choice, parents need to know that molluscum can spread through bathing with siblings, and via wet washcloths, bathing suits, towels, and pool toys. Wrestling, assisting other children in gymnastics, and other skin-on-skin activities can spread molluscum, too.

Parents also need to know that molluscum on the face can present as unilateral conjunctivitis. “A random red eye should be evaluated. This is where I might use oral cimetidine. It’s totally off label and has limited data, but it’s also over the counter and reasonable to try,” Dr. Treat said.

Dr. Treat has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

NEWPORT BEACH, CALIF.– Desquamation is a handy way to differentiate between Staphylococcus skin infections and molluscum.

Most of the time, the presentation of molluscum “is straightforward, but it’s one of the great imitators,” according to pediatric dermatologist Dr. James Treat of the department of pediatrics at the Children’s Hospital of Philadelphia. Molluscum can present as pearly little drops, inflamed papules that look infected, or even a large cyst. Molluscum also can kick up a small patch of localized eczema that makes it easy to overlook pathognomonic signs, he said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

Sometimes, patients wind up being treated for folliculitis, bug bites, and other problems they don’t have. “We see people who get multiple antibiotics. I’ve seen so many patients who have been told they have recurrent MRSA,” Dr. Treat said.

However, methicillin-resistant Staphylococcus aureus (MRSA) secretes a toxin that causes the nearby epidermis to slough off; molluscum does not. “That’s a nice little marker for a staph infection,” Dr. Treat noted. As for pruritus, “You sometimes see a child who presents with a random spot of eczema on an arm, leg, or an inguinal fold that they’ve never had before. Look for molluscum in the center of it. When in doubt, culture,” he said.

Lesions often become inflamed, which makes parents worry about infection, but “the reality is that molluscum is almost never infected. If you take a little blade or needle and pop into it, you are not going to get pus out,” Dr. Treat said.

Instead, inflammation is a sign that the body is attacking the virus, which “is a really good thing.” The phenomenon was recently dubbed the beginning-of-the-end (BOTE) sign. If kids come in with inflamed molluscum, it’s time to “talk parents off the ledge. The body has already done your job for you.” Dr. Treat said.

If the body hasn’t yet done it’s job, the goal of treatment is to irritate the lesion to draw the immune system’s attention to it.

Scraping is the most reliable one-time treatment, but the blood and pain are too much for small children. Salicylic acid and topical imiquimod do the job the first time around in about half of kids, and cantharidin in about a third, Dr. Treat said (Pediatr. Dermatol. 2006;23:574-9).

Freezing and comedone extraction work, too, but they hurt, so are best used in older, “highly motivated” children. Don’t overdo freezing either; it might cause pigment changes, said Dr. Treat.

Also, “it’s reasonable to treat those itchy, red patches” with a low-potency topical steroid “because that’s what’s making the kid uncomfortable,” he said.

Doing nothing is reasonable, too, because molluscum is self-limiting, but it’s wise to tell parents it can take as long as 2 or more years for the condition to burn itself out.

Whether or not observation is the treatment of choice, parents need to know that molluscum can spread through bathing with siblings, and via wet washcloths, bathing suits, towels, and pool toys. Wrestling, assisting other children in gymnastics, and other skin-on-skin activities can spread molluscum, too.

Parents also need to know that molluscum on the face can present as unilateral conjunctivitis. “A random red eye should be evaluated. This is where I might use oral cimetidine. It’s totally off label and has limited data, but it’s also over the counter and reasonable to try,” Dr. Treat said.

Dr. Treat has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

NEWPORT BEACH, CALIF. – The approval of apremilast (Otezla) for the treatment of moderate to severe plaque psoriasis will make a significant impact on patient care, Dr. Alan Menter of Baylor University Medical Center, Dallas, Tex., said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

“I think where this drug is going to have a role is ... patients who are risk averse to needles, have contraindications to TNF-alpha agents ... patients who want a drug with minimal to no long-term side effects,” with the exception of the significant incidence of diarrhea within the early weeks of starting the drug, Dr. Menter explained. Clinicians should explain the risk of diarrhea to patients, and help them get through the first few months. The diarrhea “definitely does vanish with time,” he said. Overall, the risk of side effects is extremely low, he noted. “It is probably the safest drug we have approved for psoriasis today.”

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF. – The approval of apremilast (Otezla) for the treatment of moderate to severe plaque psoriasis will make a significant impact on patient care, Dr. Alan Menter of Baylor University Medical Center, Dallas, Tex., said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

“I think where this drug is going to have a role is ... patients who are risk averse to needles, have contraindications to TNF-alpha agents ... patients who want a drug with minimal to no long-term side effects,” with the exception of the significant incidence of diarrhea within the early weeks of starting the drug, Dr. Menter explained. Clinicians should explain the risk of diarrhea to patients, and help them get through the first few months. The diarrhea “definitely does vanish with time,” he said. Overall, the risk of side effects is extremely low, he noted. “It is probably the safest drug we have approved for psoriasis today.”

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF. – The approval of apremilast (Otezla) for the treatment of moderate to severe plaque psoriasis will make a significant impact on patient care, Dr. Alan Menter of Baylor University Medical Center, Dallas, Tex., said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

“I think where this drug is going to have a role is ... patients who are risk averse to needles, have contraindications to TNF-alpha agents ... patients who want a drug with minimal to no long-term side effects,” with the exception of the significant incidence of diarrhea within the early weeks of starting the drug, Dr. Menter explained. Clinicians should explain the risk of diarrhea to patients, and help them get through the first few months. The diarrhea “definitely does vanish with time,” he said. Overall, the risk of side effects is extremely low, he noted. “It is probably the safest drug we have approved for psoriasis today.”

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF. – Do more women today really have acne? Or are they simply more likely to seek help because they learn of new and better medications?

Acne often causes more psychosocial and psychological stress in adult women than in men or adolescents, Dr. Hilary Baldwin of SUNY Downstate Medical Center, Brooklyn, N.Y., said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

In an interview at the meeting, Dr. Baldwin explained what makes the treatment of acne in adult women distinct from acne treatment for men and adolescents, and what underused medications can yield success.

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF. – Do more women today really have acne? Or are they simply more likely to seek help because they learn of new and better medications?

Acne often causes more psychosocial and psychological stress in adult women than in men or adolescents, Dr. Hilary Baldwin of SUNY Downstate Medical Center, Brooklyn, N.Y., said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

In an interview at the meeting, Dr. Baldwin explained what makes the treatment of acne in adult women distinct from acne treatment for men and adolescents, and what underused medications can yield success.

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com

NEWPORT BEACH, CALIF. – Do more women today really have acne? Or are they simply more likely to seek help because they learn of new and better medications?

Acne often causes more psychosocial and psychological stress in adult women than in men or adolescents, Dr. Hilary Baldwin of SUNY Downstate Medical Center, Brooklyn, N.Y., said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

In an interview at the meeting, Dr. Baldwin explained what makes the treatment of acne in adult women distinct from acne treatment for men and adolescents, and what underused medications can yield success.

SDEF and this news organization are owned by Frontline Medical Communications.

hsplete@frontlinemedcom.com