Pediatrics

Screening teens for suicide risk is among the recommendations in a new clinical report from the American Academy of Pediatrics Committee on Adolescence.

Suicide is now the second-leading cause of death for teens aged 15-19 years, having surpassed homicide since 2007, when the last report on adolescent suicide was published by the AAP (Pediatrics. 2016 June 27 doi: 10.1542/peds.2016-1420). Excessive Internet use and cyberbullying are considered to be risk factors for suicide.

KatarzynaBialasiewicz/Thinkstock

In addition to screening for suicide risk, the AAP advises screening for mood disorders, and for substance abuse and dependence. “Ask about emotional difficulties and use of drugs and alcohol, identify lack of developmental progress, and estimate level of distress, impairment of functioning, and level of danger to self and others,” the committee members wrote. The report offers several examples of questions to use for screening during the visit or interview.

“Self-report scales may be helpful, but they do not substitute for pediatricians asking teens directly (and sensitively) about mood disorders, substance use, suicidal and self-harmful thoughts, behaviors, stress, and distress,” Benjamin Shain, MD, PhD, the report’s author and a member of the AAP Committee on Adolescence, said in an interview. “Since ‘black box’ warning labels were added to antidepressants in 2004, new, population-based research has indicated that the benefits of these medications outweigh the risks for many patients. Physicians should not shy away from prescribing these medications when they are clinically indicated.”

Risk factors

A significant risk factor for suicide is involvement in bullying, whether the teen is the victim, the bully, or both, with the latter – bully victims – at the highest risk. The increased risk for suicidal thoughts or attempts extends to involvement with cyberbullying, in addition to physical, social, and verbal bullying, according to the committee members.

Results of a meta-analysis indicate girls who are victims or perpetrators of bullying are at higher risk for suicidal thoughts or attempts regardless of how common or rare the bullying is, whereas boys had an increased risk only when the bullying was frequent. Bullying as early as age 8 years was associated with attempted and completed suicides in adolescence, according to one study.

In a 2013 survey of U.S. high school students, 24% of girls and 16% of boys reported being bullied on school property in the past year. Cyberbullying occurred among 21% of the girls and 9% of the boys.

Teens reporting video game or Internet use for at least 5 hours a day were at higher risk for suicidal thoughts, suicide attempts, and depression, the committee noted. An additional wrinkle of Internet use is that teens may read about others’ suicides, which increases their own risk, or they may seek out pro-suicide websites.

“Suicide-related searches were found to be associated with completed suicides among young adults,” the report noted.

The good news is that major search engines prioritize institutional sites and mental health support sites in response to searches for “suicide,” Dr. Shain said.

“Despite the negatives, there is evidence that the Internet and electronic media, in general, provide a large amount of support, including keeping teens connected to their friends, family, teachers, and others, and also providing entertainment and valuable or interesting information,” Dr. Shain noted. “The Internet may be particularly useful for distressed teens.”

“More than 90% of adolescent suicide victims met criteria for a psychiatric disorder before their death,” the report noted. “Immediate risk factors include agitation, intoxication, and a recent stressful life event.”

Take action to help at-risk teens

The committee advises taking the following steps to assist at-risk teens:

In routine history taking, ask questions about mood disorders, use of drugs and alcohol, suicidal thoughts, bullying, sexual orientation, and other risk factors associated with suicide throughout adolescence.

Develop working relationships with emergency departments and colleagues in child and adolescent psychiatry, clinical psychology, and other mental health professions to optimally evaluate and manage the care of adolescents who are at risk for suicide.

Become familiar with local, state, and national resources that are concerned with treatment of psychopathology and suicide prevention in youth, including local hospitals with psychiatric units, mental health agencies, family and children’s services, crisis hotlines, and crisis intervention centers.

Consider additional training and ongoing education in diagnosing and managing adolescent mood disorders, especially if you practice in an underserved area.

During routine evaluations and where consistent with state law, ask whether firearms are kept in the home and discuss with parents the increased risk of adolescent suicide with the presence of firearms. Specifically for adolescents at risk for suicide, advise parents to remove guns and ammunition from the house and secure supplies of prescription and over-the-counter medications.

Learn about the benefits and risks of antidepressant medications, and how to monitor depressed patients. Educate the family regarding the following warning signs that warrant contacting you: new or more frequent thoughts of wanting to die; self-destructive behavior; signs of increased anxiety/panic, agitation, aggressiveness, impulsivity, insomnia or irritability; new or more involuntary restlessness (akathisia), such as pacing or fidgeting; extreme degree of elation or energy; fast, driven speech; or new onset of unrealistic plans or goals.

Risk factors for suicide

Fixed risk factors

• Family history of suicide or suicide attempts.

• History of adoption.

• Male gender.

• Parental mental health problems.

• Lesbian, gay, bisexual, or questioning sexual orientation.

• Transgender identification.

• A history of physical or sexual abuse.

• Previous suicide attempt.

Social/environmental risk factors

• Bullying.

• Impaired parent-child relationship.

• Living outside of the home (homeless or in a corrections facility or group home).

• Difficulties in school.

• Neither working nor attending school.

• Social isolation.

• Presence of stressful life events, such as legal or romantic difficulties or an argument with a parent.

• An unsupported social environment for LGBTQ adolescents.

Personal mental health problems

• Sleep disturbances.

• Depression.

• Bipolar disorder.

• Substance intoxication and substance use disorders.

• Psychosis.

• Posttraumatic stress disorder.

• Panic attacks.

• A history of aggression.

• Impulsivity.

• Severe anger.

• Pathologic Internet use.

Source: Pediatrics. 2016 June 27 doi: 10.1542/peds.2016-1420.

Screening teens for suicide risk is among the recommendations in a new clinical report from the American Academy of Pediatrics Committee on Adolescence.

Suicide is now the second-leading cause of death for teens aged 15-19 years, having surpassed homicide since 2007, when the last report on adolescent suicide was published by the AAP (Pediatrics. 2016 June 27 doi: 10.1542/peds.2016-1420). Excessive Internet use and cyberbullying are considered to be risk factors for suicide.

KatarzynaBialasiewicz/Thinkstock

In addition to screening for suicide risk, the AAP advises screening for mood disorders, and for substance abuse and dependence. “Ask about emotional difficulties and use of drugs and alcohol, identify lack of developmental progress, and estimate level of distress, impairment of functioning, and level of danger to self and others,” the committee members wrote. The report offers several examples of questions to use for screening during the visit or interview.

“Self-report scales may be helpful, but they do not substitute for pediatricians asking teens directly (and sensitively) about mood disorders, substance use, suicidal and self-harmful thoughts, behaviors, stress, and distress,” Benjamin Shain, MD, PhD, the report’s author and a member of the AAP Committee on Adolescence, said in an interview. “Since ‘black box’ warning labels were added to antidepressants in 2004, new, population-based research has indicated that the benefits of these medications outweigh the risks for many patients. Physicians should not shy away from prescribing these medications when they are clinically indicated.”

Risk factors

A significant risk factor for suicide is involvement in bullying, whether the teen is the victim, the bully, or both, with the latter – bully victims – at the highest risk. The increased risk for suicidal thoughts or attempts extends to involvement with cyberbullying, in addition to physical, social, and verbal bullying, according to the committee members.

Results of a meta-analysis indicate girls who are victims or perpetrators of bullying are at higher risk for suicidal thoughts or attempts regardless of how common or rare the bullying is, whereas boys had an increased risk only when the bullying was frequent. Bullying as early as age 8 years was associated with attempted and completed suicides in adolescence, according to one study.

In a 2013 survey of U.S. high school students, 24% of girls and 16% of boys reported being bullied on school property in the past year. Cyberbullying occurred among 21% of the girls and 9% of the boys.

Teens reporting video game or Internet use for at least 5 hours a day were at higher risk for suicidal thoughts, suicide attempts, and depression, the committee noted. An additional wrinkle of Internet use is that teens may read about others’ suicides, which increases their own risk, or they may seek out pro-suicide websites.

“Suicide-related searches were found to be associated with completed suicides among young adults,” the report noted.

The good news is that major search engines prioritize institutional sites and mental health support sites in response to searches for “suicide,” Dr. Shain said.

“Despite the negatives, there is evidence that the Internet and electronic media, in general, provide a large amount of support, including keeping teens connected to their friends, family, teachers, and others, and also providing entertainment and valuable or interesting information,” Dr. Shain noted. “The Internet may be particularly useful for distressed teens.”

“More than 90% of adolescent suicide victims met criteria for a psychiatric disorder before their death,” the report noted. “Immediate risk factors include agitation, intoxication, and a recent stressful life event.”

Take action to help at-risk teens

The committee advises taking the following steps to assist at-risk teens:

In routine history taking, ask questions about mood disorders, use of drugs and alcohol, suicidal thoughts, bullying, sexual orientation, and other risk factors associated with suicide throughout adolescence.

Develop working relationships with emergency departments and colleagues in child and adolescent psychiatry, clinical psychology, and other mental health professions to optimally evaluate and manage the care of adolescents who are at risk for suicide.

Become familiar with local, state, and national resources that are concerned with treatment of psychopathology and suicide prevention in youth, including local hospitals with psychiatric units, mental health agencies, family and children’s services, crisis hotlines, and crisis intervention centers.

Consider additional training and ongoing education in diagnosing and managing adolescent mood disorders, especially if you practice in an underserved area.

During routine evaluations and where consistent with state law, ask whether firearms are kept in the home and discuss with parents the increased risk of adolescent suicide with the presence of firearms. Specifically for adolescents at risk for suicide, advise parents to remove guns and ammunition from the house and secure supplies of prescription and over-the-counter medications.

Learn about the benefits and risks of antidepressant medications, and how to monitor depressed patients. Educate the family regarding the following warning signs that warrant contacting you: new or more frequent thoughts of wanting to die; self-destructive behavior; signs of increased anxiety/panic, agitation, aggressiveness, impulsivity, insomnia or irritability; new or more involuntary restlessness (akathisia), such as pacing or fidgeting; extreme degree of elation or energy; fast, driven speech; or new onset of unrealistic plans or goals.

Risk factors for suicide

Fixed risk factors

• Family history of suicide or suicide attempts.

• History of adoption.

• Male gender.

• Parental mental health problems.

• Lesbian, gay, bisexual, or questioning sexual orientation.

• Transgender identification.

• A history of physical or sexual abuse.

• Previous suicide attempt.

Social/environmental risk factors

• Bullying.

• Impaired parent-child relationship.

• Living outside of the home (homeless or in a corrections facility or group home).

• Difficulties in school.

• Neither working nor attending school.

• Social isolation.

• Presence of stressful life events, such as legal or romantic difficulties or an argument with a parent.

• An unsupported social environment for LGBTQ adolescents.

Personal mental health problems

• Sleep disturbances.

• Depression.

• Bipolar disorder.

• Substance intoxication and substance use disorders.

• Psychosis.

• Posttraumatic stress disorder.

• Panic attacks.

• A history of aggression.

• Impulsivity.

• Severe anger.

• Pathologic Internet use.

Source: Pediatrics. 2016 June 27 doi: 10.1542/peds.2016-1420.

Screening teens for suicide risk is among the recommendations in a new clinical report from the American Academy of Pediatrics Committee on Adolescence.

Suicide is now the second-leading cause of death for teens aged 15-19 years, having surpassed homicide since 2007, when the last report on adolescent suicide was published by the AAP (Pediatrics. 2016 June 27 doi: 10.1542/peds.2016-1420). Excessive Internet use and cyberbullying are considered to be risk factors for suicide.

KatarzynaBialasiewicz/Thinkstock

In addition to screening for suicide risk, the AAP advises screening for mood disorders, and for substance abuse and dependence. “Ask about emotional difficulties and use of drugs and alcohol, identify lack of developmental progress, and estimate level of distress, impairment of functioning, and level of danger to self and others,” the committee members wrote. The report offers several examples of questions to use for screening during the visit or interview.

“Self-report scales may be helpful, but they do not substitute for pediatricians asking teens directly (and sensitively) about mood disorders, substance use, suicidal and self-harmful thoughts, behaviors, stress, and distress,” Benjamin Shain, MD, PhD, the report’s author and a member of the AAP Committee on Adolescence, said in an interview. “Since ‘black box’ warning labels were added to antidepressants in 2004, new, population-based research has indicated that the benefits of these medications outweigh the risks for many patients. Physicians should not shy away from prescribing these medications when they are clinically indicated.”

Risk factors

A significant risk factor for suicide is involvement in bullying, whether the teen is the victim, the bully, or both, with the latter – bully victims – at the highest risk. The increased risk for suicidal thoughts or attempts extends to involvement with cyberbullying, in addition to physical, social, and verbal bullying, according to the committee members.

Results of a meta-analysis indicate girls who are victims or perpetrators of bullying are at higher risk for suicidal thoughts or attempts regardless of how common or rare the bullying is, whereas boys had an increased risk only when the bullying was frequent. Bullying as early as age 8 years was associated with attempted and completed suicides in adolescence, according to one study.

In a 2013 survey of U.S. high school students, 24% of girls and 16% of boys reported being bullied on school property in the past year. Cyberbullying occurred among 21% of the girls and 9% of the boys.

Teens reporting video game or Internet use for at least 5 hours a day were at higher risk for suicidal thoughts, suicide attempts, and depression, the committee noted. An additional wrinkle of Internet use is that teens may read about others’ suicides, which increases their own risk, or they may seek out pro-suicide websites.

“Suicide-related searches were found to be associated with completed suicides among young adults,” the report noted.

The good news is that major search engines prioritize institutional sites and mental health support sites in response to searches for “suicide,” Dr. Shain said.

“Despite the negatives, there is evidence that the Internet and electronic media, in general, provide a large amount of support, including keeping teens connected to their friends, family, teachers, and others, and also providing entertainment and valuable or interesting information,” Dr. Shain noted. “The Internet may be particularly useful for distressed teens.”

“More than 90% of adolescent suicide victims met criteria for a psychiatric disorder before their death,” the report noted. “Immediate risk factors include agitation, intoxication, and a recent stressful life event.”

Take action to help at-risk teens

The committee advises taking the following steps to assist at-risk teens:

In routine history taking, ask questions about mood disorders, use of drugs and alcohol, suicidal thoughts, bullying, sexual orientation, and other risk factors associated with suicide throughout adolescence.

Develop working relationships with emergency departments and colleagues in child and adolescent psychiatry, clinical psychology, and other mental health professions to optimally evaluate and manage the care of adolescents who are at risk for suicide.

Become familiar with local, state, and national resources that are concerned with treatment of psychopathology and suicide prevention in youth, including local hospitals with psychiatric units, mental health agencies, family and children’s services, crisis hotlines, and crisis intervention centers.

Consider additional training and ongoing education in diagnosing and managing adolescent mood disorders, especially if you practice in an underserved area.

During routine evaluations and where consistent with state law, ask whether firearms are kept in the home and discuss with parents the increased risk of adolescent suicide with the presence of firearms. Specifically for adolescents at risk for suicide, advise parents to remove guns and ammunition from the house and secure supplies of prescription and over-the-counter medications.

Learn about the benefits and risks of antidepressant medications, and how to monitor depressed patients. Educate the family regarding the following warning signs that warrant contacting you: new or more frequent thoughts of wanting to die; self-destructive behavior; signs of increased anxiety/panic, agitation, aggressiveness, impulsivity, insomnia or irritability; new or more involuntary restlessness (akathisia), such as pacing or fidgeting; extreme degree of elation or energy; fast, driven speech; or new onset of unrealistic plans or goals.

Risk factors for suicide

Fixed risk factors

• Family history of suicide or suicide attempts.

• History of adoption.

• Male gender.

• Parental mental health problems.

• Lesbian, gay, bisexual, or questioning sexual orientation.

• Transgender identification.

• A history of physical or sexual abuse.

• Previous suicide attempt.

Social/environmental risk factors

• Bullying.

• Impaired parent-child relationship.

• Living outside of the home (homeless or in a corrections facility or group home).

• Difficulties in school.

• Neither working nor attending school.

• Social isolation.

• Presence of stressful life events, such as legal or romantic difficulties or an argument with a parent.

• An unsupported social environment for LGBTQ adolescents.

Personal mental health problems

• Sleep disturbances.

• Depression.

• Bipolar disorder.

• Substance intoxication and substance use disorders.

• Psychosis.

• Posttraumatic stress disorder.

• Panic attacks.

• A history of aggression.

• Impulsivity.

• Severe anger.

• Pathologic Internet use.

Source: Pediatrics. 2016 June 27 doi: 10.1542/peds.2016-1420.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

Acne affects 85% of teenagers but can frequently persist into adulthood. It causes significant physical and psychological effects for patients including facial scarring, depression, and decreased self-esteem. The initial approach to acne is determined according to presenting severity, emphasizing topical treatment for milder disease and the addition of oral therapy as disease becomes more severe.

Treatment of mild acne can begin with either benzoyl peroxide (BP) or a topical retinoid (TR). Another option for slightly more severe acne is to start with the initially suggested treatment for moderately severe acne, which is topical combination therapy with BP plus a topical antibiotic; TR plus BP; or TR plus BP in combination with a topical antibiotic. Combination therapy can be given either with separate application of the different medicines or by using fixed combination products that include the separate components in one formulation.

BP is an antibacterial agent, with mild comedolytic properties, and it often is added to topical antibiotic therapy to increase effectiveness and reduce the development of resistance. BP is available in strengths from 2.5% to 10% and in a variety of formulations, which can be used as leave-on or wash-off agents. Common side effects include dose dependent skin irritation and bleaching of fabric.

Topical antibiotics, including clindamycin and erythromycin, work through both their antimicrobial and anti-inflammatory affects. Monotherapy with topical antibiotics is no longer recommended; instead they should be used in combination with BP to prevent bacterial resistance. The preferred topical antibiotic is clindamycin 1% solution or gel. Clindamycin is available in a combination with BP, which may enhance compliance with the treatment regimen.

Topical retinoids are vitamin A derivatives that are the core of treatment. They are effective for all forms of acne and should always be used in the treatment of comedonal acne. There are currently three active agents available: tretinoin (0.025%-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% and 0.3% cream or 0.1% lotion), and tazarotene (0.05% and 0.1% cream, gel, or foam). Combination products are available containing clindamycin and BP. The main side effects of retinoids include dryness, peeling, erythema, and skin irritation. Reducing the frequency of application or potency used may be helpful for limiting these side effects. Topical retinoids increase the risk of photosensitivity, so patients should be counseled on daily sunscreen use, and their use is contraindicated in pregnancy.

Dapsone is an alternative topical treatment for mild acne. Topical dapsone is primarily effective in reducing inflammatory lesions, and seems to be more beneficial for female patients. Dapsone can be combined with topical retinoids if comedonal lesions are present.

Moderate acne can be treated with either topical combination therapy as described above, or systemic antibiotics plus a TR and BP, with or without the addition of a topical antibiotic as well. Female patients may also consider combined oral contraceptives or spironolactone for the treatment of moderate acne.

Systemic antibiotics have been used in the treatment of acne vulgaris for many years, and they are indicated for use in moderate to severe acne. They should always be used in combination with topical therapies, specifically a retinoid or BP. Generally, systemic antibiotics should be used for the shortest possible duration, often 3 months, to prevent the development of bacterial resistance. Tetracyclines and macrolides have the strongest evidence for efficacy. Doxycycline and minocycline are considered equally effective and are the preferred first-line oral antibiotics. Azithromycin has been studied in a variety of pulse dose regimens, and is a good alternative for patients who are not candidates for tetracyclines.

Combined oral contraceptive pills (COCs) are another option for the treatment of acne in female patients. COCs improve acne through their antiandrogenic effects. Spironolactone also has antiandrogen properties, and while it is not FDA approved for the treatment of acne, the AAD guidelines support selective use in women. Spironolactone has been studied at doses from 50 to 200 mg daily and has shown clinically significant improvement in acne. Side effects include diuresis, menstrual irregularities, breast tenderness, and rare hyperkalemia.

Severe acne is treated with an oral antibiotic plus topical combination therapy, or oral isotretinoin, with the addition where appropriate of COCs or oral spironolactone.

Oral isotretinoin, an isomer of retinoic acid, is approved by the FDA for the treatment of severe recalcitrant acne. It causes decreased sebum production, acne lesions, and scarring. It can also be considered in the treatment of moderate acne that is resistant to other treatments, relapses quickly, or produces significant scarring or psychosocial distress. Serum cholesterol, triglycerides, and transaminases can rise during treatment, and should be monitored. Because of the risk of teratogenic effects, the FDA has mandated that all patients receiving isotretinoin must participate in the iPLEDGE risk management program, which requires abstinence or two forms of birth control. While isotretinoin requires monitoring and carries the possibility of significant side effects, it is an effective treatment option for patients with severe recalcitrant acne.

The bottom line

Acne is commonly treated by primary care physicians. A clear approach of graded treatment based on severity of disease yields improvement in outcomes. Mild acne should be treated with benzoyl peroxide, retinoids or a combinations of topical treatments. Systemic antibiotics should be combined with topical therapies for moderate to severe acne. Female patients may also consider using combined oral contraceptives and spironolactone. Oral isotretinoin is an effective option for severe acne, but requires close monitoring.

References

Guidelines of care for the management of acne vulgaris (J Am Acad Dermatol. 2016;74[5]:945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Marriott is an attending family physician at Capital Health Primary Care in Hamilton, N.J.

LONDON – Tumor necrosis factor–inhibitor treatment improved refractory skin disease in juvenile dermatomyositis patients in the largest observational study of its kind from the United Kingdom and Ireland Juvenile Dermatomyositis Research Group.

Muscle disease in the juvenile dermatomyositis (JDM) patients largely had already improved with conventional therapies prior to treatment with anti–tumor necrosis factor (TNF)-alpha agents, but it did improve further with anti-TNFs.

The effect of TNF inhibitors was most notable for those with skin calcinosis, lead author Dr. Raquel Campanilho-Marques reported at the European Congress of Rheumatology on behalf of her colleagues in the Juvenile Dermatomyositis Research Group.

Some evidence suggests that TNF-alpha might be involved in the pathogenesis of idiopathic inflammatory myopathies, particularly in more prolonged courses of JDM.

But there is limited prior evidence for the efficacy of TNF inhibitors in JDM patients, where small observational studies and case series have shown improved core-set measures of disease activity in patients treated with anti-TNF agents, noted Dr. Campanilho-Marques, a pediatric rheumatologist in the infection, inflammation and rheumatology section at the University College London Institute of Child Health and the Great Ormond Street Hospital for Children NHS Trust in London.

The 67 patients in the study involved those who were enrolled in the JDM Cohort and Biomarker Study, met Bohan and Peter criteria for JDM, and were on anti-TNF therapy at the time of analysis because of nonresponse to conventional therapy, active skin disease, calcinosis, or muscle weakness. They had at least 3 months of anti-TNF therapy and received either infliximab 6 mg/kg every 4 weeks (after a standard initial induction regimen) or adalimumab (Humira) 24 mg/m² every other week.

A majority of the patients in the study were female (n = 41) and white (n = 54), with a mean age at disease onset of about 5 years. At the time of first use of anti-TNF agents, the patients had a mean age of about 10 years and a mean disease duration of 3.2 years. Treatment with TNF inhibitors lasted for a mean of about 2.5 years.

Of the 67 patients, data were not analyzed for 4 patients; there was insufficient information for 1 patient, while 3 patients had allergic reactions to their anti-TNF therapy on the first or second infusion. The remaining 63 patients included 43 who received infliximab, 4 on adalimumab, and 16 who used both.

Prior to anti-TNF treatment, 52 of 53 patients (98%) were taking methotrexate, azathioprine, hydroxychloroquine, or a combination of those. That declined to 45 of 56 (80%) at the start of anti-TNF therapy and then increased to 44 of 49 (89%) after 12 months of using an anti-TNF agent.

The use of cyclophosphamide declined markedly, from 26 of 65 patients (40%) to 3 of 65 (5%) at the start of TNF inhibition, and then to none after 12 months of anti-TNF therapy. Immunoglobulin therapy also declined, from use in 10%-12% of patients before and at the start of anti-TNF treatment to just 1 of 41 patients (2%) after 12 months of TNF inhibitor therapy.

The median modified Disease Activity Score for skin involvement significantly improved over the course of 12 months of treatment with infliximab, decreasing from 4 to 1. That was also the case for Physician Global Assessment score, as well as muscle outcome measurements on the Childhood Myositis Assessment Scale (CMAS) and the 8-item Manual Muscle Testing (MMT8).

For the 31 patients in the study who had calcinosis, lesions improved (reduced in number and/or size) in 17 patients, including 8 with complete resolution of their lesions. In the other 14 patients, lesions remained stable in 3 (fewer than three lesions) and were widespread or did not improve in 4; the other 7 patients had insufficient data to determine outcomes.

Most patients with muscle involvement already had improved with steroids prior to using anti-TNF drugs. Thus, the improvement in CMAS and MMT8 scores on anti-TNF treatment was not very large, going from about 45 to 53 and from about 74 to 79, respectively.

The investigators did not examine treatment response in relation to muscle-specific antibodies, but Dr. Campanilho-Marques said that it is something they would like to do in the future.

The main indication for anti-TNF agents was active skin disease that had not responded to conventional treatment, noted Dr. Campanilho-Marques, who is also with the departments of rheumatology at the Santa Maria Hospital and the Instituto Português de Reumatologia, both in Lisbon.

For 16 patients who switched from infliximab to adalimumab, the changes in outcome measures were not statistically significant. The switches occurred at a median of 2.35 months after starting infliximab; 10 patients switched because of inefficacy, 4 because of adverse events, and 2 because of patient preference.

After 12 months of anti-TNF therapy, the median prednisolone dose declined from 6 mg to 2.5 mg, but the decline appeared to be driven by five patients who sharply decreased their dose. Seven patients successfully stopped anti-TNF therapy after improvement occurred, Dr. Campanilho-Marques said.

Serious adverse events occurred 12 times during the year-long study period, including nine allergic reactions and three hospitalizations because of infection. Another 19 mild-to-moderate adverse events took place, which involved 15 infections and three local site reactions and skin rash, which led five patients to discontinue the biologic.

Overall, adverse events occurred at a rate of 13.3/100 patient-years, including 5.2 serious events/100 patient-years. One patient died because of a small bowel perforation that was probably secondary to disease-related damage. There were no malignancies or tuberculosis cases.

In a video interview at the meeting, Dr. Campanilho-Marques discussed the study findings and their implications.

The researchers had no relevant disclosures.

jevans@frontlinemedcom.com

LONDON – Tumor necrosis factor–inhibitor treatment improved refractory skin disease in juvenile dermatomyositis patients in the largest observational study of its kind from the United Kingdom and Ireland Juvenile Dermatomyositis Research Group.

Muscle disease in the juvenile dermatomyositis (JDM) patients largely had already improved with conventional therapies prior to treatment with anti–tumor necrosis factor (TNF)-alpha agents, but it did improve further with anti-TNFs.

The effect of TNF inhibitors was most notable for those with skin calcinosis, lead author Dr. Raquel Campanilho-Marques reported at the European Congress of Rheumatology on behalf of her colleagues in the Juvenile Dermatomyositis Research Group.

Some evidence suggests that TNF-alpha might be involved in the pathogenesis of idiopathic inflammatory myopathies, particularly in more prolonged courses of JDM.

But there is limited prior evidence for the efficacy of TNF inhibitors in JDM patients, where small observational studies and case series have shown improved core-set measures of disease activity in patients treated with anti-TNF agents, noted Dr. Campanilho-Marques, a pediatric rheumatologist in the infection, inflammation and rheumatology section at the University College London Institute of Child Health and the Great Ormond Street Hospital for Children NHS Trust in London.

The 67 patients in the study involved those who were enrolled in the JDM Cohort and Biomarker Study, met Bohan and Peter criteria for JDM, and were on anti-TNF therapy at the time of analysis because of nonresponse to conventional therapy, active skin disease, calcinosis, or muscle weakness. They had at least 3 months of anti-TNF therapy and received either infliximab 6 mg/kg every 4 weeks (after a standard initial induction regimen) or adalimumab (Humira) 24 mg/m² every other week.

A majority of the patients in the study were female (n = 41) and white (n = 54), with a mean age at disease onset of about 5 years. At the time of first use of anti-TNF agents, the patients had a mean age of about 10 years and a mean disease duration of 3.2 years. Treatment with TNF inhibitors lasted for a mean of about 2.5 years.

Of the 67 patients, data were not analyzed for 4 patients; there was insufficient information for 1 patient, while 3 patients had allergic reactions to their anti-TNF therapy on the first or second infusion. The remaining 63 patients included 43 who received infliximab, 4 on adalimumab, and 16 who used both.

Prior to anti-TNF treatment, 52 of 53 patients (98%) were taking methotrexate, azathioprine, hydroxychloroquine, or a combination of those. That declined to 45 of 56 (80%) at the start of anti-TNF therapy and then increased to 44 of 49 (89%) after 12 months of using an anti-TNF agent.

The use of cyclophosphamide declined markedly, from 26 of 65 patients (40%) to 3 of 65 (5%) at the start of TNF inhibition, and then to none after 12 months of anti-TNF therapy. Immunoglobulin therapy also declined, from use in 10%-12% of patients before and at the start of anti-TNF treatment to just 1 of 41 patients (2%) after 12 months of TNF inhibitor therapy.

The median modified Disease Activity Score for skin involvement significantly improved over the course of 12 months of treatment with infliximab, decreasing from 4 to 1. That was also the case for Physician Global Assessment score, as well as muscle outcome measurements on the Childhood Myositis Assessment Scale (CMAS) and the 8-item Manual Muscle Testing (MMT8).

For the 31 patients in the study who had calcinosis, lesions improved (reduced in number and/or size) in 17 patients, including 8 with complete resolution of their lesions. In the other 14 patients, lesions remained stable in 3 (fewer than three lesions) and were widespread or did not improve in 4; the other 7 patients had insufficient data to determine outcomes.

Most patients with muscle involvement already had improved with steroids prior to using anti-TNF drugs. Thus, the improvement in CMAS and MMT8 scores on anti-TNF treatment was not very large, going from about 45 to 53 and from about 74 to 79, respectively.

The investigators did not examine treatment response in relation to muscle-specific antibodies, but Dr. Campanilho-Marques said that it is something they would like to do in the future.

The main indication for anti-TNF agents was active skin disease that had not responded to conventional treatment, noted Dr. Campanilho-Marques, who is also with the departments of rheumatology at the Santa Maria Hospital and the Instituto Português de Reumatologia, both in Lisbon.

For 16 patients who switched from infliximab to adalimumab, the changes in outcome measures were not statistically significant. The switches occurred at a median of 2.35 months after starting infliximab; 10 patients switched because of inefficacy, 4 because of adverse events, and 2 because of patient preference.

After 12 months of anti-TNF therapy, the median prednisolone dose declined from 6 mg to 2.5 mg, but the decline appeared to be driven by five patients who sharply decreased their dose. Seven patients successfully stopped anti-TNF therapy after improvement occurred, Dr. Campanilho-Marques said.

Serious adverse events occurred 12 times during the year-long study period, including nine allergic reactions and three hospitalizations because of infection. Another 19 mild-to-moderate adverse events took place, which involved 15 infections and three local site reactions and skin rash, which led five patients to discontinue the biologic.

Overall, adverse events occurred at a rate of 13.3/100 patient-years, including 5.2 serious events/100 patient-years. One patient died because of a small bowel perforation that was probably secondary to disease-related damage. There were no malignancies or tuberculosis cases.

In a video interview at the meeting, Dr. Campanilho-Marques discussed the study findings and their implications.

The researchers had no relevant disclosures.

jevans@frontlinemedcom.com

LONDON – Tumor necrosis factor–inhibitor treatment improved refractory skin disease in juvenile dermatomyositis patients in the largest observational study of its kind from the United Kingdom and Ireland Juvenile Dermatomyositis Research Group.

Muscle disease in the juvenile dermatomyositis (JDM) patients largely had already improved with conventional therapies prior to treatment with anti–tumor necrosis factor (TNF)-alpha agents, but it did improve further with anti-TNFs.

The effect of TNF inhibitors was most notable for those with skin calcinosis, lead author Dr. Raquel Campanilho-Marques reported at the European Congress of Rheumatology on behalf of her colleagues in the Juvenile Dermatomyositis Research Group.

Some evidence suggests that TNF-alpha might be involved in the pathogenesis of idiopathic inflammatory myopathies, particularly in more prolonged courses of JDM.

But there is limited prior evidence for the efficacy of TNF inhibitors in JDM patients, where small observational studies and case series have shown improved core-set measures of disease activity in patients treated with anti-TNF agents, noted Dr. Campanilho-Marques, a pediatric rheumatologist in the infection, inflammation and rheumatology section at the University College London Institute of Child Health and the Great Ormond Street Hospital for Children NHS Trust in London.

The 67 patients in the study involved those who were enrolled in the JDM Cohort and Biomarker Study, met Bohan and Peter criteria for JDM, and were on anti-TNF therapy at the time of analysis because of nonresponse to conventional therapy, active skin disease, calcinosis, or muscle weakness. They had at least 3 months of anti-TNF therapy and received either infliximab 6 mg/kg every 4 weeks (after a standard initial induction regimen) or adalimumab (Humira) 24 mg/m² every other week.

A majority of the patients in the study were female (n = 41) and white (n = 54), with a mean age at disease onset of about 5 years. At the time of first use of anti-TNF agents, the patients had a mean age of about 10 years and a mean disease duration of 3.2 years. Treatment with TNF inhibitors lasted for a mean of about 2.5 years.

Of the 67 patients, data were not analyzed for 4 patients; there was insufficient information for 1 patient, while 3 patients had allergic reactions to their anti-TNF therapy on the first or second infusion. The remaining 63 patients included 43 who received infliximab, 4 on adalimumab, and 16 who used both.

Prior to anti-TNF treatment, 52 of 53 patients (98%) were taking methotrexate, azathioprine, hydroxychloroquine, or a combination of those. That declined to 45 of 56 (80%) at the start of anti-TNF therapy and then increased to 44 of 49 (89%) after 12 months of using an anti-TNF agent.

The use of cyclophosphamide declined markedly, from 26 of 65 patients (40%) to 3 of 65 (5%) at the start of TNF inhibition, and then to none after 12 months of anti-TNF therapy. Immunoglobulin therapy also declined, from use in 10%-12% of patients before and at the start of anti-TNF treatment to just 1 of 41 patients (2%) after 12 months of TNF inhibitor therapy.

The median modified Disease Activity Score for skin involvement significantly improved over the course of 12 months of treatment with infliximab, decreasing from 4 to 1. That was also the case for Physician Global Assessment score, as well as muscle outcome measurements on the Childhood Myositis Assessment Scale (CMAS) and the 8-item Manual Muscle Testing (MMT8).

For the 31 patients in the study who had calcinosis, lesions improved (reduced in number and/or size) in 17 patients, including 8 with complete resolution of their lesions. In the other 14 patients, lesions remained stable in 3 (fewer than three lesions) and were widespread or did not improve in 4; the other 7 patients had insufficient data to determine outcomes.

Most patients with muscle involvement already had improved with steroids prior to using anti-TNF drugs. Thus, the improvement in CMAS and MMT8 scores on anti-TNF treatment was not very large, going from about 45 to 53 and from about 74 to 79, respectively.

The investigators did not examine treatment response in relation to muscle-specific antibodies, but Dr. Campanilho-Marques said that it is something they would like to do in the future.

The main indication for anti-TNF agents was active skin disease that had not responded to conventional treatment, noted Dr. Campanilho-Marques, who is also with the departments of rheumatology at the Santa Maria Hospital and the Instituto Português de Reumatologia, both in Lisbon.

For 16 patients who switched from infliximab to adalimumab, the changes in outcome measures were not statistically significant. The switches occurred at a median of 2.35 months after starting infliximab; 10 patients switched because of inefficacy, 4 because of adverse events, and 2 because of patient preference.

After 12 months of anti-TNF therapy, the median prednisolone dose declined from 6 mg to 2.5 mg, but the decline appeared to be driven by five patients who sharply decreased their dose. Seven patients successfully stopped anti-TNF therapy after improvement occurred, Dr. Campanilho-Marques said.

Serious adverse events occurred 12 times during the year-long study period, including nine allergic reactions and three hospitalizations because of infection. Another 19 mild-to-moderate adverse events took place, which involved 15 infections and three local site reactions and skin rash, which led five patients to discontinue the biologic.

Overall, adverse events occurred at a rate of 13.3/100 patient-years, including 5.2 serious events/100 patient-years. One patient died because of a small bowel perforation that was probably secondary to disease-related damage. There were no malignancies or tuberculosis cases.

In a video interview at the meeting, Dr. Campanilho-Marques discussed the study findings and their implications.

The researchers had no relevant disclosures.

jevans@frontlinemedcom.com

DENVER – A high degree of unwarranted practice variation exists among pediatricians and family physicians with regard to screening children for obstructive sleep apnea in accord with current evidence-based practice guidelines, Sarah M. Honaker, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

The American Academy of Pediatrics and American Academy of Sleep Medicine recommend that children with frequent snoring be referred for a sleep study or to a sleep specialist or otolaryngologist because of the damaging consequences of living with untreated obstructive sleep apnea (OSA). But Dr. Honaker’s study of 8,135 children aged 1-12 years seen at five university-affiliated urban primary care pediatric clinics demonstrated that the identification rate of suspected OSA was abysmally low, and physician practice on this score varied enormously.

Bruce Jancin/Frontline Medical News

“There is a critical need to develop enhanced implementation strategies to support primary care providers’ adherence to evidence-based practice for pediatric OSA,” declared Dr. Honaker of Indiana University in Indianapolis.

She and her coinvestigators have developed a computer decision support system designed to do just that. Known as CHICA, for Child Health Improvement through Computer Automation, the system works like this: While in the clinic waiting room, the parent is handed a computer tablet and asked to complete 20 yes/no items designed to identify priority areas for the primary care provider to address during the current visit. The items are individually tailored based upon the child’s age, past medical history, and previous responses.

One item asks if the child snores three or more nights per week, a well-established indicator of increased risk for OSA. If the answer is yes, CHICA instantly sends a prompt to the child’s electronic medical record noting that the parent reports the child is a frequent snorer and this might indicate OSA.

The primary care provider can either ignore the prompt or respond during or after the visit in one of three ways: “I am concerned about OSA,” “I do not suspect OSA,” or “The parent in the examining room denies hearing frequent snoring.”

The mean age of the patients in Dr. Honaker’s study was 5.8 years, and 83% of the 8,135 children had Medicaid coverage. Parental cooperation with CHICA was high: 98.5% of parents addressed the snoring question. They reported that 28.5% of the children snored at least 3 nights per week, generating a total of 1,094 CHICA prompts to the primary care providers. Forty-four percent of providers didn’t respond to the prompt, which Dr. Honaker said is a typical rate for this sort of computerized assist intervention. Of those who did respond, only 15.9% indicated they suspected OSA. Sixty-three percent declared they didn’t suspect OSA, and the remainder said the parent in the examining room didn’t report frequent snoring.

Although responding providers indicated they suspected OSA in 15.9% of the children, that’s a low figure for frequent snorers. Moreover, 31% of children who got the CHICA frequent snoring prompt were overweight or obese, and 17% had attention-deficit hyperactivity disorder symptoms, both known risk factors for OSA. Some of the kids had both risk factors, but 39% had at least one in addition to their frequent snoring, Dr. Honaker noted.

The investigators carried out multivariate logistic regression analyses of child, provider, and clinic characteristics in search of predictors associated with physician concern that a child might have OSA. It turned out that none of the provider characteristics had any bearing on this endpoint. It didn’t matter if a physician’s specialty was pediatrics or family medicine. Providers had been in practice for 3-42 years, with a mean of 15.1 years, but years in practice weren’t associated with a physician’s rate of identification of possible pediatric OSA. Individual provider rates varied enormously, though. Some physicians never suspected OSA, others did so in nearly 50% of children flagged by the CHICA prompt.

“It’s not clear that type of training plays a large role in this area,” she commented.

The only relevant patient factor was age: children aged 1-2.5 years were 73% less likely to generate physician suspicion of OSA.

“Surprisingly, none of the patient health factors were predictive. So having ADHD symptoms or being overweight or obese did not make it more likely that a child would elicit concern for OSA,” Dr. Honaker observed.

However, which of the five clinics the child attended turned out to make a big difference. Rates of suspected OSA in children with a CHICA snoring prompt ranged from a low of 5% at one clinic to 27% at another.

Dr. Honaker’s recent review of the literature led her to conclude that the Indiana University experience is hardly unique. Despite documented high rates of pediatric sleep disorders in primary care settings, screening and treatment rates are low. Primary care physicians receive little training in sleep medicine (Sleep Med Rev. 2016;25:31-9).

What’s next for CHICA?

Dr. Honaker and coworkers have developed a beefed up CHICA decision support system known as the CHICA OSA Module. In addition to generating a prompt in the medical record if a parent indicates the child snores three or more nights per week, additional OSA signs and symptoms, if present, will be noted on the screen, along with a comment that American Academy of Pediatrics guidelines recommend referral when OSA is suspected. Dr. Honaker plans to conduct a controlled trial in which some clinics get the CHICA OSA Module while others use the older CHICA system.

Her study was funded by the American Sleep Medicine Foundation. She reported having no financial conflicts.

bjancin@frontlinemedcom.com

DENVER – A high degree of unwarranted practice variation exists among pediatricians and family physicians with regard to screening children for obstructive sleep apnea in accord with current evidence-based practice guidelines, Sarah M. Honaker, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

The American Academy of Pediatrics and American Academy of Sleep Medicine recommend that children with frequent snoring be referred for a sleep study or to a sleep specialist or otolaryngologist because of the damaging consequences of living with untreated obstructive sleep apnea (OSA). But Dr. Honaker’s study of 8,135 children aged 1-12 years seen at five university-affiliated urban primary care pediatric clinics demonstrated that the identification rate of suspected OSA was abysmally low, and physician practice on this score varied enormously.

Bruce Jancin/Frontline Medical News

“There is a critical need to develop enhanced implementation strategies to support primary care providers’ adherence to evidence-based practice for pediatric OSA,” declared Dr. Honaker of Indiana University in Indianapolis.

She and her coinvestigators have developed a computer decision support system designed to do just that. Known as CHICA, for Child Health Improvement through Computer Automation, the system works like this: While in the clinic waiting room, the parent is handed a computer tablet and asked to complete 20 yes/no items designed to identify priority areas for the primary care provider to address during the current visit. The items are individually tailored based upon the child’s age, past medical history, and previous responses.

One item asks if the child snores three or more nights per week, a well-established indicator of increased risk for OSA. If the answer is yes, CHICA instantly sends a prompt to the child’s electronic medical record noting that the parent reports the child is a frequent snorer and this might indicate OSA.

The primary care provider can either ignore the prompt or respond during or after the visit in one of three ways: “I am concerned about OSA,” “I do not suspect OSA,” or “The parent in the examining room denies hearing frequent snoring.”

The mean age of the patients in Dr. Honaker’s study was 5.8 years, and 83% of the 8,135 children had Medicaid coverage. Parental cooperation with CHICA was high: 98.5% of parents addressed the snoring question. They reported that 28.5% of the children snored at least 3 nights per week, generating a total of 1,094 CHICA prompts to the primary care providers. Forty-four percent of providers didn’t respond to the prompt, which Dr. Honaker said is a typical rate for this sort of computerized assist intervention. Of those who did respond, only 15.9% indicated they suspected OSA. Sixty-three percent declared they didn’t suspect OSA, and the remainder said the parent in the examining room didn’t report frequent snoring.

Although responding providers indicated they suspected OSA in 15.9% of the children, that’s a low figure for frequent snorers. Moreover, 31% of children who got the CHICA frequent snoring prompt were overweight or obese, and 17% had attention-deficit hyperactivity disorder symptoms, both known risk factors for OSA. Some of the kids had both risk factors, but 39% had at least one in addition to their frequent snoring, Dr. Honaker noted.

The investigators carried out multivariate logistic regression analyses of child, provider, and clinic characteristics in search of predictors associated with physician concern that a child might have OSA. It turned out that none of the provider characteristics had any bearing on this endpoint. It didn’t matter if a physician’s specialty was pediatrics or family medicine. Providers had been in practice for 3-42 years, with a mean of 15.1 years, but years in practice weren’t associated with a physician’s rate of identification of possible pediatric OSA. Individual provider rates varied enormously, though. Some physicians never suspected OSA, others did so in nearly 50% of children flagged by the CHICA prompt.

“It’s not clear that type of training plays a large role in this area,” she commented.

The only relevant patient factor was age: children aged 1-2.5 years were 73% less likely to generate physician suspicion of OSA.

“Surprisingly, none of the patient health factors were predictive. So having ADHD symptoms or being overweight or obese did not make it more likely that a child would elicit concern for OSA,” Dr. Honaker observed.

However, which of the five clinics the child attended turned out to make a big difference. Rates of suspected OSA in children with a CHICA snoring prompt ranged from a low of 5% at one clinic to 27% at another.

Dr. Honaker’s recent review of the literature led her to conclude that the Indiana University experience is hardly unique. Despite documented high rates of pediatric sleep disorders in primary care settings, screening and treatment rates are low. Primary care physicians receive little training in sleep medicine (Sleep Med Rev. 2016;25:31-9).

What’s next for CHICA?

Dr. Honaker and coworkers have developed a beefed up CHICA decision support system known as the CHICA OSA Module. In addition to generating a prompt in the medical record if a parent indicates the child snores three or more nights per week, additional OSA signs and symptoms, if present, will be noted on the screen, along with a comment that American Academy of Pediatrics guidelines recommend referral when OSA is suspected. Dr. Honaker plans to conduct a controlled trial in which some clinics get the CHICA OSA Module while others use the older CHICA system.

Her study was funded by the American Sleep Medicine Foundation. She reported having no financial conflicts.

bjancin@frontlinemedcom.com

DENVER – A high degree of unwarranted practice variation exists among pediatricians and family physicians with regard to screening children for obstructive sleep apnea in accord with current evidence-based practice guidelines, Sarah M. Honaker, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

The American Academy of Pediatrics and American Academy of Sleep Medicine recommend that children with frequent snoring be referred for a sleep study or to a sleep specialist or otolaryngologist because of the damaging consequences of living with untreated obstructive sleep apnea (OSA). But Dr. Honaker’s study of 8,135 children aged 1-12 years seen at five university-affiliated urban primary care pediatric clinics demonstrated that the identification rate of suspected OSA was abysmally low, and physician practice on this score varied enormously.

Bruce Jancin/Frontline Medical News

“There is a critical need to develop enhanced implementation strategies to support primary care providers’ adherence to evidence-based practice for pediatric OSA,” declared Dr. Honaker of Indiana University in Indianapolis.

She and her coinvestigators have developed a computer decision support system designed to do just that. Known as CHICA, for Child Health Improvement through Computer Automation, the system works like this: While in the clinic waiting room, the parent is handed a computer tablet and asked to complete 20 yes/no items designed to identify priority areas for the primary care provider to address during the current visit. The items are individually tailored based upon the child’s age, past medical history, and previous responses.

One item asks if the child snores three or more nights per week, a well-established indicator of increased risk for OSA. If the answer is yes, CHICA instantly sends a prompt to the child’s electronic medical record noting that the parent reports the child is a frequent snorer and this might indicate OSA.

The primary care provider can either ignore the prompt or respond during or after the visit in one of three ways: “I am concerned about OSA,” “I do not suspect OSA,” or “The parent in the examining room denies hearing frequent snoring.”

The mean age of the patients in Dr. Honaker’s study was 5.8 years, and 83% of the 8,135 children had Medicaid coverage. Parental cooperation with CHICA was high: 98.5% of parents addressed the snoring question. They reported that 28.5% of the children snored at least 3 nights per week, generating a total of 1,094 CHICA prompts to the primary care providers. Forty-four percent of providers didn’t respond to the prompt, which Dr. Honaker said is a typical rate for this sort of computerized assist intervention. Of those who did respond, only 15.9% indicated they suspected OSA. Sixty-three percent declared they didn’t suspect OSA, and the remainder said the parent in the examining room didn’t report frequent snoring.

Although responding providers indicated they suspected OSA in 15.9% of the children, that’s a low figure for frequent snorers. Moreover, 31% of children who got the CHICA frequent snoring prompt were overweight or obese, and 17% had attention-deficit hyperactivity disorder symptoms, both known risk factors for OSA. Some of the kids had both risk factors, but 39% had at least one in addition to their frequent snoring, Dr. Honaker noted.

The investigators carried out multivariate logistic regression analyses of child, provider, and clinic characteristics in search of predictors associated with physician concern that a child might have OSA. It turned out that none of the provider characteristics had any bearing on this endpoint. It didn’t matter if a physician’s specialty was pediatrics or family medicine. Providers had been in practice for 3-42 years, with a mean of 15.1 years, but years in practice weren’t associated with a physician’s rate of identification of possible pediatric OSA. Individual provider rates varied enormously, though. Some physicians never suspected OSA, others did so in nearly 50% of children flagged by the CHICA prompt.

“It’s not clear that type of training plays a large role in this area,” she commented.

The only relevant patient factor was age: children aged 1-2.5 years were 73% less likely to generate physician suspicion of OSA.

“Surprisingly, none of the patient health factors were predictive. So having ADHD symptoms or being overweight or obese did not make it more likely that a child would elicit concern for OSA,” Dr. Honaker observed.

However, which of the five clinics the child attended turned out to make a big difference. Rates of suspected OSA in children with a CHICA snoring prompt ranged from a low of 5% at one clinic to 27% at another.

Dr. Honaker’s recent review of the literature led her to conclude that the Indiana University experience is hardly unique. Despite documented high rates of pediatric sleep disorders in primary care settings, screening and treatment rates are low. Primary care physicians receive little training in sleep medicine (Sleep Med Rev. 2016;25:31-9).

What’s next for CHICA?

Dr. Honaker and coworkers have developed a beefed up CHICA decision support system known as the CHICA OSA Module. In addition to generating a prompt in the medical record if a parent indicates the child snores three or more nights per week, additional OSA signs and symptoms, if present, will be noted on the screen, along with a comment that American Academy of Pediatrics guidelines recommend referral when OSA is suspected. Dr. Honaker plans to conduct a controlled trial in which some clinics get the CHICA OSA Module while others use the older CHICA system.

Her study was funded by the American Sleep Medicine Foundation. She reported having no financial conflicts.

bjancin@frontlinemedcom.com

A work group for the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is leaning toward recommending a change from three to two doses of the human papillomavirus (HPV) vaccine in boys and girls aged 11-12 years.

Members of the ACIP Human Papillomavirus Work Group told the entire committee at ACIP’s June meeting that a review of all available data showed that, regardless of whether the HPV vaccine were bivalent, quadrivalent, or nine-valent, two doses were found to be noninferior, compared with three doses. A two-dose schedule, therefore, could possibly be recommended at the next ACIP meeting later this year.

©DesignPics/Thinkstock.com

The work group said it also could recommend that HPV vaccine–naive women up to age 26 years and HPV vaccine-naive men up to age 21 years also receive the vaccine. For persons who initiated but did not complete vaccination before age 15 years, or for persons who initiate the schedule after their 15th birthday – the same schedule as is currently recommended for 11- and 12-year-olds – a similar schedule is likely to be recommended again.

The recommendation for immunocompromised persons of any age would be to receive the three-dose schedule.

If these recommendations are put forth officially, the question of whether families also should be given a three-dose option will need to be decided, work group members said.

Although studies are ongoing to determine antibody persistence and long-term effectiveness after two doses, existing data indicate that waning antibody responses to HPV18 in persons vaccinated with three doses of quadrivalent HPV were not associated with loss of protection. This could mean that protective levels are actually lower than the minimum levels detected by assays, or that antibodies against other epitopes also are protective.

Predictive modeling showed that, if a two-dose schedule can provide more than 20 years of protection, over $118,000 per quality adjusted life year could be realized without sacrificing population health benefits.

The current CDC vaccination schedule for HPV in adolescents is for a three-dose series of the vaccine on a schedule of 0, 1-2, and 6 months. The same vaccination schedule is recommended for “catch-up” of previously unvaccinated adolescents aged 13-18 years.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

A work group for the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is leaning toward recommending a change from three to two doses of the human papillomavirus (HPV) vaccine in boys and girls aged 11-12 years.

Members of the ACIP Human Papillomavirus Work Group told the entire committee at ACIP’s June meeting that a review of all available data showed that, regardless of whether the HPV vaccine were bivalent, quadrivalent, or nine-valent, two doses were found to be noninferior, compared with three doses. A two-dose schedule, therefore, could possibly be recommended at the next ACIP meeting later this year.

©DesignPics/Thinkstock.com

The work group said it also could recommend that HPV vaccine–naive women up to age 26 years and HPV vaccine-naive men up to age 21 years also receive the vaccine. For persons who initiated but did not complete vaccination before age 15 years, or for persons who initiate the schedule after their 15th birthday – the same schedule as is currently recommended for 11- and 12-year-olds – a similar schedule is likely to be recommended again.

The recommendation for immunocompromised persons of any age would be to receive the three-dose schedule.

If these recommendations are put forth officially, the question of whether families also should be given a three-dose option will need to be decided, work group members said.

Although studies are ongoing to determine antibody persistence and long-term effectiveness after two doses, existing data indicate that waning antibody responses to HPV18 in persons vaccinated with three doses of quadrivalent HPV were not associated with loss of protection. This could mean that protective levels are actually lower than the minimum levels detected by assays, or that antibodies against other epitopes also are protective.

Predictive modeling showed that, if a two-dose schedule can provide more than 20 years of protection, over $118,000 per quality adjusted life year could be realized without sacrificing population health benefits.

The current CDC vaccination schedule for HPV in adolescents is for a three-dose series of the vaccine on a schedule of 0, 1-2, and 6 months. The same vaccination schedule is recommended for “catch-up” of previously unvaccinated adolescents aged 13-18 years.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

A work group for the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is leaning toward recommending a change from three to two doses of the human papillomavirus (HPV) vaccine in boys and girls aged 11-12 years.

Members of the ACIP Human Papillomavirus Work Group told the entire committee at ACIP’s June meeting that a review of all available data showed that, regardless of whether the HPV vaccine were bivalent, quadrivalent, or nine-valent, two doses were found to be noninferior, compared with three doses. A two-dose schedule, therefore, could possibly be recommended at the next ACIP meeting later this year.

©DesignPics/Thinkstock.com

The work group said it also could recommend that HPV vaccine–naive women up to age 26 years and HPV vaccine-naive men up to age 21 years also receive the vaccine. For persons who initiated but did not complete vaccination before age 15 years, or for persons who initiate the schedule after their 15th birthday – the same schedule as is currently recommended for 11- and 12-year-olds – a similar schedule is likely to be recommended again.

The recommendation for immunocompromised persons of any age would be to receive the three-dose schedule.

If these recommendations are put forth officially, the question of whether families also should be given a three-dose option will need to be decided, work group members said.

Although studies are ongoing to determine antibody persistence and long-term effectiveness after two doses, existing data indicate that waning antibody responses to HPV18 in persons vaccinated with three doses of quadrivalent HPV were not associated with loss of protection. This could mean that protective levels are actually lower than the minimum levels detected by assays, or that antibodies against other epitopes also are protective.

Predictive modeling showed that, if a two-dose schedule can provide more than 20 years of protection, over $118,000 per quality adjusted life year could be realized without sacrificing population health benefits.

The current CDC vaccination schedule for HPV in adolescents is for a three-dose series of the vaccine on a schedule of 0, 1-2, and 6 months. The same vaccination schedule is recommended for “catch-up” of previously unvaccinated adolescents aged 13-18 years.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

What are the risks of delaying transition until adulthood?

Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.¹ This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.² This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.³ Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.

Can gender dysphoria be diagnosed at an early age?

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.^4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,^6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.³

What are the medical risks with pubertal suppression and cross-sex hormones?

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).⁷ Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,⁸ whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,^9,10 especially after resumption of puberty.

What are the medical risks of using cross-sex hormones?

Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.⁷ Additionally, use of these hormones can induce infertility, and this is not always reversible.⁶ Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.¹¹ There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.¹² Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.

Can children and adolescents make complex, life-changing decisions?

The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.

However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.¹³ However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.

One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.

The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.

References:

1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).

2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.

3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.

4. Dev Psychol. 2008 Jan;44(1):34-45.

5. J Adolesc Health. 2015 Oct;57(4):367-73.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011; 7th ed.

8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.

9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.

10. Clinics (Sao Paulo). 2012;67(6):591-6.

11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.

12. Pediatrics. 2014 Oct;134(4):696-704.

13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.

The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

What are the risks of delaying transition until adulthood?

Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.¹ This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.² This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.³ Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.

Can gender dysphoria be diagnosed at an early age?

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.^4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,^6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.³

What are the medical risks with pubertal suppression and cross-sex hormones?

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).⁷ Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,⁸ whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,^9,10 especially after resumption of puberty.

What are the medical risks of using cross-sex hormones?

Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.⁷ Additionally, use of these hormones can induce infertility, and this is not always reversible.⁶ Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.¹¹ There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.¹² Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.

Can children and adolescents make complex, life-changing decisions?

The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.

However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.¹³ However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.

One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.

The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.

References:

1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).

2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.

3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.

4. Dev Psychol. 2008 Jan;44(1):34-45.

5. J Adolesc Health. 2015 Oct;57(4):367-73.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011; 7th ed.

8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.

9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.

10. Clinics (Sao Paulo). 2012;67(6):591-6.

11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.

12. Pediatrics. 2014 Oct;134(4):696-704.

13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.

The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

What are the risks of delaying transition until adulthood?

Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.¹ This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.² This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.³ Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.

Can gender dysphoria be diagnosed at an early age?

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.^4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,^6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.³

What are the medical risks with pubertal suppression and cross-sex hormones?

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).⁷ Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,⁸ whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,^9,10 especially after resumption of puberty.

What are the medical risks of using cross-sex hormones?

Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.⁷ Additionally, use of these hormones can induce infertility, and this is not always reversible.⁶ Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.¹¹ There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.¹² Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.

Can children and adolescents make complex, life-changing decisions?

The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.

However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.¹³ However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.

One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.

The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.

References:

1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).

2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.

3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.

4. Dev Psychol. 2008 Jan;44(1):34-45.

5. J Adolesc Health. 2015 Oct;57(4):367-73.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011; 7th ed.

8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.

9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.

10. Clinics (Sao Paulo). 2012;67(6):591-6.

11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.

12. Pediatrics. 2014 Oct;134(4):696-704.

13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.

In discussion of pregnancy prevention, a great deal of time is spent on female birth control, and the use of condoms is like a tag line “Oh! And, of course, use a condom.” But are we really educating our teens on condoms, their proper use, and their prevention of sexually transmitted infections (STIs). Condoms are our basic entry level birth control, but despite their relative ease of use and accessibility, their use is on the decline.

When we evaluate unintended pregnancies among teens, it is down almost 20% since 1981, according to data from the Guttmacher Institute, but compared with other developed nations, our rates are high.

In 2013, the AAP published a statement encouraging schools and pediatricians to discuss and make condoms more accessible. Fifty-four studies were done on early education of condom use, and reported a 48% increase in their use and a 42% delay in the initiation of sexual activity by 6 months.¹ Despite these positive findings , condom use is still declining.

Many factors that affect their use are lack of formal education, availability, and the perception that they decrease sexual pleasure. Condom manufacturers have started campaigns that promote the image of escalating sexual pleasure, but they are competing with the media and music industry, which inundate teens with all kinds of sexual images. In review of the media, 77% showed sexual content, compared with 14% that showed risk and responsible sexual activity.

Before educating teens about condoms, we first must educate ourselves. Condoms are available in three forms: latex (80%), lamb’s cecum (15%), and synthetic (5%). Latex is considered the most effective condom in protecting against STIs and birth control. Synthetic is a good alternative to latex when a latex allergy is present, but is more prone to breakage and slippage. Lamb’s cecum prevents spread of some STIs, but because of its porous nature it does not provide protection against viruses such as HIV, hepatitis B, and herpes simplex virus (HSV). Nonlatex has a longer shelf life and is more compatible with lubricants.

Spermicide-coated condoms have fallen out of favor because the spermicide shortens the shelf life of the condom, as well as can cause mucosal irritation. When the mucosa is irritated, there is an associated increase of contracting STIs, particularly HIV.²

Make patients are aware that condoms do expire and that it is important to check the expiration date. Educating patients on the proper technique of putting a condom on is likely an awkward conversation for most, so consider directing them to the website Bedsiders.org, which has great explanations on how to use and put condoms on, along with comparisons of all types of birth control and which one is best for them.

Making condoms easily accessible is the most-important intervention. Studies show that when condoms are readily available, their use increases. The AAP advocates for schools and primary care doctors to hand them out freely.

Education is key in increasing usage of condoms and reducing spread of STIs. Encouraging parents to talk with their teen and provide access to condoms is crucial in lowering STI statistics. Although abstinence is the only 100% proof of protection, proper use of contraception is an alternative.

References

1. “Condom Use by Adolescents,” Pediatrics. 2013 Nov. doi: 10.1542/peds.2013-2821

2. “Contraception for Adolescents,” Pediatrics. 2014 Oct 10;134:e1244-56.

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at pdnews@frontlinemedcom.com.

In discussion of pregnancy prevention, a great deal of time is spent on female birth control, and the use of condoms is like a tag line “Oh! And, of course, use a condom.” But are we really educating our teens on condoms, their proper use, and their prevention of sexually transmitted infections (STIs). Condoms are our basic entry level birth control, but despite their relative ease of use and accessibility, their use is on the decline.

When we evaluate unintended pregnancies among teens, it is down almost 20% since 1981, according to data from the Guttmacher Institute, but compared with other developed nations, our rates are high.

In 2013, the AAP published a statement encouraging schools and pediatricians to discuss and make condoms more accessible. Fifty-four studies were done on early education of condom use, and reported a 48% increase in their use and a 42% delay in the initiation of sexual activity by 6 months.¹ Despite these positive findings , condom use is still declining.

Many factors that affect their use are lack of formal education, availability, and the perception that they decrease sexual pleasure. Condom manufacturers have started campaigns that promote the image of escalating sexual pleasure, but they are competing with the media and music industry, which inundate teens with all kinds of sexual images. In review of the media, 77% showed sexual content, compared with 14% that showed risk and responsible sexual activity.

Before educating teens about condoms, we first must educate ourselves. Condoms are available in three forms: latex (80%), lamb’s cecum (15%), and synthetic (5%). Latex is considered the most effective condom in protecting against STIs and birth control. Synthetic is a good alternative to latex when a latex allergy is present, but is more prone to breakage and slippage. Lamb’s cecum prevents spread of some STIs, but because of its porous nature it does not provide protection against viruses such as HIV, hepatitis B, and herpes simplex virus (HSV). Nonlatex has a longer shelf life and is more compatible with lubricants.

Spermicide-coated condoms have fallen out of favor because the spermicide shortens the shelf life of the condom, as well as can cause mucosal irritation. When the mucosa is irritated, there is an associated increase of contracting STIs, particularly HIV.²

Make patients are aware that condoms do expire and that it is important to check the expiration date. Educating patients on the proper technique of putting a condom on is likely an awkward conversation for most, so consider directing them to the website Bedsiders.org, which has great explanations on how to use and put condoms on, along with comparisons of all types of birth control and which one is best for them.

Making condoms easily accessible is the most-important intervention. Studies show that when condoms are readily available, their use increases. The AAP advocates for schools and primary care doctors to hand them out freely.

Education is key in increasing usage of condoms and reducing spread of STIs. Encouraging parents to talk with their teen and provide access to condoms is crucial in lowering STI statistics. Although abstinence is the only 100% proof of protection, proper use of contraception is an alternative.

References

1. “Condom Use by Adolescents,” Pediatrics. 2013 Nov. doi: 10.1542/peds.2013-2821

2. “Contraception for Adolescents,” Pediatrics. 2014 Oct 10;134:e1244-56.

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at pdnews@frontlinemedcom.com.

In discussion of pregnancy prevention, a great deal of time is spent on female birth control, and the use of condoms is like a tag line “Oh! And, of course, use a condom.” But are we really educating our teens on condoms, their proper use, and their prevention of sexually transmitted infections (STIs). Condoms are our basic entry level birth control, but despite their relative ease of use and accessibility, their use is on the decline.

When we evaluate unintended pregnancies among teens, it is down almost 20% since 1981, according to data from the Guttmacher Institute, but compared with other developed nations, our rates are high.

In 2013, the AAP published a statement encouraging schools and pediatricians to discuss and make condoms more accessible. Fifty-four studies were done on early education of condom use, and reported a 48% increase in their use and a 42% delay in the initiation of sexual activity by 6 months.¹ Despite these positive findings , condom use is still declining.

Many factors that affect their use are lack of formal education, availability, and the perception that they decrease sexual pleasure. Condom manufacturers have started campaigns that promote the image of escalating sexual pleasure, but they are competing with the media and music industry, which inundate teens with all kinds of sexual images. In review of the media, 77% showed sexual content, compared with 14% that showed risk and responsible sexual activity.

Before educating teens about condoms, we first must educate ourselves. Condoms are available in three forms: latex (80%), lamb’s cecum (15%), and synthetic (5%). Latex is considered the most effective condom in protecting against STIs and birth control. Synthetic is a good alternative to latex when a latex allergy is present, but is more prone to breakage and slippage. Lamb’s cecum prevents spread of some STIs, but because of its porous nature it does not provide protection against viruses such as HIV, hepatitis B, and herpes simplex virus (HSV). Nonlatex has a longer shelf life and is more compatible with lubricants.

Spermicide-coated condoms have fallen out of favor because the spermicide shortens the shelf life of the condom, as well as can cause mucosal irritation. When the mucosa is irritated, there is an associated increase of contracting STIs, particularly HIV.²

Make patients are aware that condoms do expire and that it is important to check the expiration date. Educating patients on the proper technique of putting a condom on is likely an awkward conversation for most, so consider directing them to the website Bedsiders.org, which has great explanations on how to use and put condoms on, along with comparisons of all types of birth control and which one is best for them.

Making condoms easily accessible is the most-important intervention. Studies show that when condoms are readily available, their use increases. The AAP advocates for schools and primary care doctors to hand them out freely.

Education is key in increasing usage of condoms and reducing spread of STIs. Encouraging parents to talk with their teen and provide access to condoms is crucial in lowering STI statistics. Although abstinence is the only 100% proof of protection, proper use of contraception is an alternative.

References

1. “Condom Use by Adolescents,” Pediatrics. 2013 Nov. doi: 10.1542/peds.2013-2821

2. “Contraception for Adolescents,” Pediatrics. 2014 Oct 10;134:e1244-56.

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at pdnews@frontlinemedcom.com.