User login
23rd World Congress of Dermatology
Pushing policy makers to take skin diseases seriously
VANCOUVER – Dermatologic thought leaders worldwide have embarked upon a major international initiative aimed at making better skin health a strategic priority for politicians, health policy makers, and the general public.
The Grand Challenges in Global Skin Health Initiative, launched by the International League of Dermatological Societies, is aimed at proving the true value of dermatologic care. The impetus is a strong feeling within the dermatology community that skin diseases got a raw deal in the landmark Global Burden of Disease Study.
The Global Burden of Disease Study (Lancet. 2015 Jun 7. pii: S0140-6736(15)60692-4), funded by the Bill and Melinda Gates Foundation on behalf of the World Health Organization, ranked skin diseases far down on the list of conditions causing lost disability-adjusted life-years (DALYs) worldwide.
But DALYs as an indicator of disease burden tell only part of the story. They have a major limitation: “In the DALY concept, patients are never asked questions about the weight of their burden of disease; those questions are directed to health care professionals and the general public,” Dr. Matthias Augustin explained at the World Congress of Dermatology.
“We need to understand this because governments and other payers make use of these Global Burden of Disease data. We as dermatologists need to make sure that we are not underrepresented in the overall discussion,” said Dr. Augustin, professor of dermatology at the University of Hamburg-Eppendorf (Germany) and director of the Institute for Health Services Research in Dermatology and Nursing Professions at the university.
The true measure of value in health care needs to include patient-reported outcomes, and the Global Burden of Disease Study didn’t do that, he continued.
“There is a discrepancy between objective and subjective outcomes. Many papers have shown that the relationship between PASI scores representing severity of psoriasis and patient quality of life is very loose, if there’s any at all,” the dermatologist said.
Recently an international team of researchers analyzed the world’s published DALY data for psoriasis and concluded that this common skin disease ranked a mere 144th out of 176 conditions in this domain. The investigators argued that this metric vastly underestimates the true disease burden of psoriasis (Br J Dermatol. 2015 Jun;172(6):1665-8).
The investigators noted that the Global Burden of Disease Study treats psoriasis as a single entity consisting of psoriatic skin disease without taking into account the association with psoriatic arthritis, the increased risk of cardiovascular disease, or the enormous psychosocial sequelae of this disfiguring disease, which typically lasts for more than 40 years, or more than 60 years in individuals with childhood-onset psoriasis.
Dr. Augustin and the other founders of the Grand Challenges in Global Skin Initiative recently laid out the case for the project (Br J Dermatol. 2015 Jun;172(6):1469-72). The plan is to develop evidence-based proof of the added value of dermatologic care.
“Innovation in health care delivery has frequently ignored the needs of the whole patient and the populations in which they live. Skin disease has been a casualty in this respect,” the authors wrote. “However, perhaps the most powerful contribution to making skin health a realizable objective over the next 25 years is the recognition, among leaders of governments and nongovernmental organizations, that it is a realistic, affordable, and achievable goal, integral to future health and research strategies.”
The initial round of projects being undertaken through the initiative includes creation of a global psoriasis atlas, documentation of the adverse impact of UV exposure on outdoor workers on every continent, a centers-of-excellence program regarding aging skin, and a project addressing scabies – “a huge problem worldwide, and especially in developing countries,” Dr. Augustin noted.
“We intend to communicate our message to decision makers and let the patients speak; it’s in our common interest,” he said.
He reported having no relevant financial conflicts.
VANCOUVER – Dermatologic thought leaders worldwide have embarked upon a major international initiative aimed at making better skin health a strategic priority for politicians, health policy makers, and the general public.
The Grand Challenges in Global Skin Health Initiative, launched by the International League of Dermatological Societies, is aimed at proving the true value of dermatologic care. The impetus is a strong feeling within the dermatology community that skin diseases got a raw deal in the landmark Global Burden of Disease Study.
The Global Burden of Disease Study (Lancet. 2015 Jun 7. pii: S0140-6736(15)60692-4), funded by the Bill and Melinda Gates Foundation on behalf of the World Health Organization, ranked skin diseases far down on the list of conditions causing lost disability-adjusted life-years (DALYs) worldwide.
But DALYs as an indicator of disease burden tell only part of the story. They have a major limitation: “In the DALY concept, patients are never asked questions about the weight of their burden of disease; those questions are directed to health care professionals and the general public,” Dr. Matthias Augustin explained at the World Congress of Dermatology.
“We need to understand this because governments and other payers make use of these Global Burden of Disease data. We as dermatologists need to make sure that we are not underrepresented in the overall discussion,” said Dr. Augustin, professor of dermatology at the University of Hamburg-Eppendorf (Germany) and director of the Institute for Health Services Research in Dermatology and Nursing Professions at the university.
The true measure of value in health care needs to include patient-reported outcomes, and the Global Burden of Disease Study didn’t do that, he continued.
“There is a discrepancy between objective and subjective outcomes. Many papers have shown that the relationship between PASI scores representing severity of psoriasis and patient quality of life is very loose, if there’s any at all,” the dermatologist said.
Recently an international team of researchers analyzed the world’s published DALY data for psoriasis and concluded that this common skin disease ranked a mere 144th out of 176 conditions in this domain. The investigators argued that this metric vastly underestimates the true disease burden of psoriasis (Br J Dermatol. 2015 Jun;172(6):1665-8).
The investigators noted that the Global Burden of Disease Study treats psoriasis as a single entity consisting of psoriatic skin disease without taking into account the association with psoriatic arthritis, the increased risk of cardiovascular disease, or the enormous psychosocial sequelae of this disfiguring disease, which typically lasts for more than 40 years, or more than 60 years in individuals with childhood-onset psoriasis.
Dr. Augustin and the other founders of the Grand Challenges in Global Skin Initiative recently laid out the case for the project (Br J Dermatol. 2015 Jun;172(6):1469-72). The plan is to develop evidence-based proof of the added value of dermatologic care.
“Innovation in health care delivery has frequently ignored the needs of the whole patient and the populations in which they live. Skin disease has been a casualty in this respect,” the authors wrote. “However, perhaps the most powerful contribution to making skin health a realizable objective over the next 25 years is the recognition, among leaders of governments and nongovernmental organizations, that it is a realistic, affordable, and achievable goal, integral to future health and research strategies.”
The initial round of projects being undertaken through the initiative includes creation of a global psoriasis atlas, documentation of the adverse impact of UV exposure on outdoor workers on every continent, a centers-of-excellence program regarding aging skin, and a project addressing scabies – “a huge problem worldwide, and especially in developing countries,” Dr. Augustin noted.
“We intend to communicate our message to decision makers and let the patients speak; it’s in our common interest,” he said.
He reported having no relevant financial conflicts.
VANCOUVER – Dermatologic thought leaders worldwide have embarked upon a major international initiative aimed at making better skin health a strategic priority for politicians, health policy makers, and the general public.
The Grand Challenges in Global Skin Health Initiative, launched by the International League of Dermatological Societies, is aimed at proving the true value of dermatologic care. The impetus is a strong feeling within the dermatology community that skin diseases got a raw deal in the landmark Global Burden of Disease Study.
The Global Burden of Disease Study (Lancet. 2015 Jun 7. pii: S0140-6736(15)60692-4), funded by the Bill and Melinda Gates Foundation on behalf of the World Health Organization, ranked skin diseases far down on the list of conditions causing lost disability-adjusted life-years (DALYs) worldwide.
But DALYs as an indicator of disease burden tell only part of the story. They have a major limitation: “In the DALY concept, patients are never asked questions about the weight of their burden of disease; those questions are directed to health care professionals and the general public,” Dr. Matthias Augustin explained at the World Congress of Dermatology.
“We need to understand this because governments and other payers make use of these Global Burden of Disease data. We as dermatologists need to make sure that we are not underrepresented in the overall discussion,” said Dr. Augustin, professor of dermatology at the University of Hamburg-Eppendorf (Germany) and director of the Institute for Health Services Research in Dermatology and Nursing Professions at the university.
The true measure of value in health care needs to include patient-reported outcomes, and the Global Burden of Disease Study didn’t do that, he continued.
“There is a discrepancy between objective and subjective outcomes. Many papers have shown that the relationship between PASI scores representing severity of psoriasis and patient quality of life is very loose, if there’s any at all,” the dermatologist said.
Recently an international team of researchers analyzed the world’s published DALY data for psoriasis and concluded that this common skin disease ranked a mere 144th out of 176 conditions in this domain. The investigators argued that this metric vastly underestimates the true disease burden of psoriasis (Br J Dermatol. 2015 Jun;172(6):1665-8).
The investigators noted that the Global Burden of Disease Study treats psoriasis as a single entity consisting of psoriatic skin disease without taking into account the association with psoriatic arthritis, the increased risk of cardiovascular disease, or the enormous psychosocial sequelae of this disfiguring disease, which typically lasts for more than 40 years, or more than 60 years in individuals with childhood-onset psoriasis.
Dr. Augustin and the other founders of the Grand Challenges in Global Skin Initiative recently laid out the case for the project (Br J Dermatol. 2015 Jun;172(6):1469-72). The plan is to develop evidence-based proof of the added value of dermatologic care.
“Innovation in health care delivery has frequently ignored the needs of the whole patient and the populations in which they live. Skin disease has been a casualty in this respect,” the authors wrote. “However, perhaps the most powerful contribution to making skin health a realizable objective over the next 25 years is the recognition, among leaders of governments and nongovernmental organizations, that it is a realistic, affordable, and achievable goal, integral to future health and research strategies.”
The initial round of projects being undertaken through the initiative includes creation of a global psoriasis atlas, documentation of the adverse impact of UV exposure on outdoor workers on every continent, a centers-of-excellence program regarding aging skin, and a project addressing scabies – “a huge problem worldwide, and especially in developing countries,” Dr. Augustin noted.
“We intend to communicate our message to decision makers and let the patients speak; it’s in our common interest,” he said.
He reported having no relevant financial conflicts.
EXPERT ANALYSIS FROM WCD 2015
In melanoma, sentinel node results will drive targeted therapies
VANCOUVER, B.C. – Why should dermatologists care about the role of sentinel lymph node biopsy in melanoma patients? Because SNLB results will inform the use of an explosion of immunotherapies and targeted therapies emerging for melanoma and – because even after melanoma patients have been referred to a comprehensive cancer center – patients will continue to view dermatologists as the primary care providers with respect to the cancer, Dr. Timothy M. Johnson said in a plenary address at the World Congress of Dermatology.
“I guarantee you of that” scenario, predicted Dr. Johnson, professor of dermatology and clinical director of the multidisciplinary melanoma program at the University of Michigan, Ann Arbor, where more than 2,000 melanoma patients are seen each year.
New melanoma therapies are “coming in waves. They seem to be coming weekly,” he said. In June, the National Cancer Institute listed 218 therapeutic clinical trials for advanced melanoma in the United States alone. And some of these new treatments for stage IV melanoma are already starting to make their way into the adjuvant setting for stage III melanoma.
“The first round of adjuvant therapy trials has been done, and the data are being analyzed now. A new round is coming like gangbusters,” Dr. Johnson said. “This is one of the most exciting times ever in melanoma.”
Should some of these novel agents prove safe and effective as adjuvant therapy, SLNB results will determine the need for such therapy based upon individualized patient prognosis. And the SLNB results will determine the type of adjuvant therapy that’s most appropriate based upon the tumor molecular profile.
“Once we have effective adjuvant therapy, it will eradicate the need for total lymph node dissection in patients with a positive node on SLNB. Those with a positive node will likely undergo systemic therapy based on a personalized approach,” he predicted.
For the present, in Dr. Johnson’s view, much of the best guidance on when and how to employ SLNB in melanoma patients comes from the landmark National Cancer Institute–sponsored Multicenter Selective Lymphadenectomy Trial (MSLT-1).
The MSLT-1 results (N Engl J Med. 2014 Feb 13;370:599-609) are deemed controversial by some, Dr. Johnson noted. But they provide a strong case for widespread application of SLNB for accurate staging and regional control of the nodal basin based upon the findings in 1,270 participants with intermediate-thickness melanomas of 1.2-3.5 mm and 290 others with melanomas greater than 3.5 mm thick, he said. Both groups showed significant benefit in terms of 10-year melanoma-specific survival if randomized to SLNB with immediate total lymph node dissection if SLNB positive, as opposed to watchful waiting for an occult nodal metastasis to become clinically evident.
An important finding was that roughly 27% of patients in the observation arms who experienced a clinically evident nodal metastasis during follow-up and then underwent completion total lymph node dissection had four or more positive nodes at that time, compared to 1.6% of those with a positive SLNB who underwent immediate completion dissection.
“If an occult metastasis is present in the lymph node it’s going to grow to the point of becoming clinically evident in an average of 2-3 years. You can deal with it now or you can deal with it later, but you’re likely going to have to deal with it. Failure to detect and treat that disease early will result in increased tumor burden upon completion lymph node dissection, increased morbidity and side effects in order to remove those nodes, and a small but increased likelihood of dying from that disease. That’s a very powerful conversation to have with patients and families to help them make the best informed decision for themselves,” Dr. Johnson said.
At the University of Michigan melanoma program – the nation’s largest – patients are counseled to seriously consider SLNB if they have a clinically localized melanoma 1 mm or more in thickness provided their functional status is favorable. In contrast, there is essentially no evidence to support SLNB in patients with a melanoma less than 0.75 mm in thickness.
In patients with a melanoma thickness of 0.75-0.99 mm, however, Dr. Johnson and his colleagues may recommend SLNB in the presence of certain predictors of increased likelihood of a positive biopsy: ulceration, angiolymphatic invasion, younger age, a positive deep margin on a shave biopsy, extensive dermal regression in excess of 1 mm, and/or a mitotic rate of at least 1 mm2. Age and mitotic rate are continuous variables: The younger the patient and the higher the mitotic rate, the greater the likelihood of a positive SLNB in the setting of a thin melanoma.
At present, the decision regarding whether to recommend SLNB in a patient with a thin melanoma is based upon a general gestalt, said Dr. Johnson. He and his colleagues have received a grant to study more than 2,000 cases of thin melanoma in an effort to develop a system for weighting the individual risk factors.
“As dermatologists – you, me, we – should be one of the lead dogs with respect to melanoma advancement, knowledge, management, and guidance. To do that most effectively, you must learn from and work closely with other specialists – collegially, collaboratively, and humbly,” he concluded.
Dr. Johnson reported having no financial conflicts of interest regarding his talk.
VANCOUVER, B.C. – Why should dermatologists care about the role of sentinel lymph node biopsy in melanoma patients? Because SNLB results will inform the use of an explosion of immunotherapies and targeted therapies emerging for melanoma and – because even after melanoma patients have been referred to a comprehensive cancer center – patients will continue to view dermatologists as the primary care providers with respect to the cancer, Dr. Timothy M. Johnson said in a plenary address at the World Congress of Dermatology.
“I guarantee you of that” scenario, predicted Dr. Johnson, professor of dermatology and clinical director of the multidisciplinary melanoma program at the University of Michigan, Ann Arbor, where more than 2,000 melanoma patients are seen each year.
New melanoma therapies are “coming in waves. They seem to be coming weekly,” he said. In June, the National Cancer Institute listed 218 therapeutic clinical trials for advanced melanoma in the United States alone. And some of these new treatments for stage IV melanoma are already starting to make their way into the adjuvant setting for stage III melanoma.
“The first round of adjuvant therapy trials has been done, and the data are being analyzed now. A new round is coming like gangbusters,” Dr. Johnson said. “This is one of the most exciting times ever in melanoma.”
Should some of these novel agents prove safe and effective as adjuvant therapy, SLNB results will determine the need for such therapy based upon individualized patient prognosis. And the SLNB results will determine the type of adjuvant therapy that’s most appropriate based upon the tumor molecular profile.
“Once we have effective adjuvant therapy, it will eradicate the need for total lymph node dissection in patients with a positive node on SLNB. Those with a positive node will likely undergo systemic therapy based on a personalized approach,” he predicted.
For the present, in Dr. Johnson’s view, much of the best guidance on when and how to employ SLNB in melanoma patients comes from the landmark National Cancer Institute–sponsored Multicenter Selective Lymphadenectomy Trial (MSLT-1).
The MSLT-1 results (N Engl J Med. 2014 Feb 13;370:599-609) are deemed controversial by some, Dr. Johnson noted. But they provide a strong case for widespread application of SLNB for accurate staging and regional control of the nodal basin based upon the findings in 1,270 participants with intermediate-thickness melanomas of 1.2-3.5 mm and 290 others with melanomas greater than 3.5 mm thick, he said. Both groups showed significant benefit in terms of 10-year melanoma-specific survival if randomized to SLNB with immediate total lymph node dissection if SLNB positive, as opposed to watchful waiting for an occult nodal metastasis to become clinically evident.
An important finding was that roughly 27% of patients in the observation arms who experienced a clinically evident nodal metastasis during follow-up and then underwent completion total lymph node dissection had four or more positive nodes at that time, compared to 1.6% of those with a positive SLNB who underwent immediate completion dissection.
“If an occult metastasis is present in the lymph node it’s going to grow to the point of becoming clinically evident in an average of 2-3 years. You can deal with it now or you can deal with it later, but you’re likely going to have to deal with it. Failure to detect and treat that disease early will result in increased tumor burden upon completion lymph node dissection, increased morbidity and side effects in order to remove those nodes, and a small but increased likelihood of dying from that disease. That’s a very powerful conversation to have with patients and families to help them make the best informed decision for themselves,” Dr. Johnson said.
At the University of Michigan melanoma program – the nation’s largest – patients are counseled to seriously consider SLNB if they have a clinically localized melanoma 1 mm or more in thickness provided their functional status is favorable. In contrast, there is essentially no evidence to support SLNB in patients with a melanoma less than 0.75 mm in thickness.
In patients with a melanoma thickness of 0.75-0.99 mm, however, Dr. Johnson and his colleagues may recommend SLNB in the presence of certain predictors of increased likelihood of a positive biopsy: ulceration, angiolymphatic invasion, younger age, a positive deep margin on a shave biopsy, extensive dermal regression in excess of 1 mm, and/or a mitotic rate of at least 1 mm2. Age and mitotic rate are continuous variables: The younger the patient and the higher the mitotic rate, the greater the likelihood of a positive SLNB in the setting of a thin melanoma.
At present, the decision regarding whether to recommend SLNB in a patient with a thin melanoma is based upon a general gestalt, said Dr. Johnson. He and his colleagues have received a grant to study more than 2,000 cases of thin melanoma in an effort to develop a system for weighting the individual risk factors.
“As dermatologists – you, me, we – should be one of the lead dogs with respect to melanoma advancement, knowledge, management, and guidance. To do that most effectively, you must learn from and work closely with other specialists – collegially, collaboratively, and humbly,” he concluded.
Dr. Johnson reported having no financial conflicts of interest regarding his talk.
VANCOUVER, B.C. – Why should dermatologists care about the role of sentinel lymph node biopsy in melanoma patients? Because SNLB results will inform the use of an explosion of immunotherapies and targeted therapies emerging for melanoma and – because even after melanoma patients have been referred to a comprehensive cancer center – patients will continue to view dermatologists as the primary care providers with respect to the cancer, Dr. Timothy M. Johnson said in a plenary address at the World Congress of Dermatology.
“I guarantee you of that” scenario, predicted Dr. Johnson, professor of dermatology and clinical director of the multidisciplinary melanoma program at the University of Michigan, Ann Arbor, where more than 2,000 melanoma patients are seen each year.
New melanoma therapies are “coming in waves. They seem to be coming weekly,” he said. In June, the National Cancer Institute listed 218 therapeutic clinical trials for advanced melanoma in the United States alone. And some of these new treatments for stage IV melanoma are already starting to make their way into the adjuvant setting for stage III melanoma.
“The first round of adjuvant therapy trials has been done, and the data are being analyzed now. A new round is coming like gangbusters,” Dr. Johnson said. “This is one of the most exciting times ever in melanoma.”
Should some of these novel agents prove safe and effective as adjuvant therapy, SLNB results will determine the need for such therapy based upon individualized patient prognosis. And the SLNB results will determine the type of adjuvant therapy that’s most appropriate based upon the tumor molecular profile.
“Once we have effective adjuvant therapy, it will eradicate the need for total lymph node dissection in patients with a positive node on SLNB. Those with a positive node will likely undergo systemic therapy based on a personalized approach,” he predicted.
For the present, in Dr. Johnson’s view, much of the best guidance on when and how to employ SLNB in melanoma patients comes from the landmark National Cancer Institute–sponsored Multicenter Selective Lymphadenectomy Trial (MSLT-1).
The MSLT-1 results (N Engl J Med. 2014 Feb 13;370:599-609) are deemed controversial by some, Dr. Johnson noted. But they provide a strong case for widespread application of SLNB for accurate staging and regional control of the nodal basin based upon the findings in 1,270 participants with intermediate-thickness melanomas of 1.2-3.5 mm and 290 others with melanomas greater than 3.5 mm thick, he said. Both groups showed significant benefit in terms of 10-year melanoma-specific survival if randomized to SLNB with immediate total lymph node dissection if SLNB positive, as opposed to watchful waiting for an occult nodal metastasis to become clinically evident.
An important finding was that roughly 27% of patients in the observation arms who experienced a clinically evident nodal metastasis during follow-up and then underwent completion total lymph node dissection had four or more positive nodes at that time, compared to 1.6% of those with a positive SLNB who underwent immediate completion dissection.
“If an occult metastasis is present in the lymph node it’s going to grow to the point of becoming clinically evident in an average of 2-3 years. You can deal with it now or you can deal with it later, but you’re likely going to have to deal with it. Failure to detect and treat that disease early will result in increased tumor burden upon completion lymph node dissection, increased morbidity and side effects in order to remove those nodes, and a small but increased likelihood of dying from that disease. That’s a very powerful conversation to have with patients and families to help them make the best informed decision for themselves,” Dr. Johnson said.
At the University of Michigan melanoma program – the nation’s largest – patients are counseled to seriously consider SLNB if they have a clinically localized melanoma 1 mm or more in thickness provided their functional status is favorable. In contrast, there is essentially no evidence to support SLNB in patients with a melanoma less than 0.75 mm in thickness.
In patients with a melanoma thickness of 0.75-0.99 mm, however, Dr. Johnson and his colleagues may recommend SLNB in the presence of certain predictors of increased likelihood of a positive biopsy: ulceration, angiolymphatic invasion, younger age, a positive deep margin on a shave biopsy, extensive dermal regression in excess of 1 mm, and/or a mitotic rate of at least 1 mm2. Age and mitotic rate are continuous variables: The younger the patient and the higher the mitotic rate, the greater the likelihood of a positive SLNB in the setting of a thin melanoma.
At present, the decision regarding whether to recommend SLNB in a patient with a thin melanoma is based upon a general gestalt, said Dr. Johnson. He and his colleagues have received a grant to study more than 2,000 cases of thin melanoma in an effort to develop a system for weighting the individual risk factors.
“As dermatologists – you, me, we – should be one of the lead dogs with respect to melanoma advancement, knowledge, management, and guidance. To do that most effectively, you must learn from and work closely with other specialists – collegially, collaboratively, and humbly,” he concluded.
Dr. Johnson reported having no financial conflicts of interest regarding his talk.
EXPERT ANALYSIS FROM WCD 2015
WCD: Watch for These Emerging Infections
VANCOUVER – Two serious emerging skin and soft tissue infections whose progress physicians will want to chart are melioidosis and Acinetobacter baumannii infection, Dr. Dirk M. Elston advised at the World Congress of Dermatology.
Both Burkholderia pseudomallei – the cause of melioidosis – and Acinetobacter baumannii are gram-negative organisms that laboratory staff sometimes mistakenly dismiss as culture contaminants. But melioidosis has a case fatality rate of up to 40%, and A. baumannii is an increasingly multidrug-resistant cause of community-acquired cellulitis, according to Dr. Elston, chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Elston, also managing director of the Ackerman Academy of Dermatopathology in New York, offered his views on these two emerging infections.
Melioidosis
“We know melioidosis from the rice paddies of Vietnam as a plaguelike ulceroglandular syndrome. It has reemerged in the Caribbean,” Dr. Elston reported.
Indeed, investigators at the Centers for Disease Control and Prevention reported earlier this year that melioidosis is now endemic in Puerto Rico based upon its findings of high seropositivity rates among patient contacts plus isolation of the causative organism from soil samples (Clin Infect Dis. 2015 Jan 15;60(2):243-250). The infection, which is believed to be underdiagnosed, also has been reported at numerous other sites in the Caribbean basin and in Latin America and Africa, as well as in Southeast Asia.
Although skin and soft tissue abscesses are common manifestations of this acute febrile illness, the most common clinical presentation of melioidosis is acute pneumonia with or without septicemia, which can be fulminant.
According to the CDC investigators, up to 80% of patients with melioidosis have diabetes, chronic lung disease, and/or excessive alcohol use as risk factors for the infection. In the Puerto Rican study, a history of injection drug use was for the first time identified as another risk factor. When in endemic areas such as Puerto Rico, individuals with diabetes or other risk factors should protect themselves from direct exposure to soil and water to reduce their risk of what is believed to be a transcutaneously acquired infection. The investigators advised that individuals with skin wounds or sores do the same.
The recommended treatment for melioidosis is intravenous ceftazidime, imipenem, or meropenem (N Engl J Med. 2012 Sep 13;367(11):1035-1044).
A. baumannii infection
In a recent report, Dr. Adam J. Friedman and his colleagues at the Albert Einstein College of Medicine in New York said that A. baumannii’s pattern of evolution to date is strikingly similar to that of methicillin-resistant Staphylococcus aureus. A. baumannii has displayed increasing pathogenicity and antibiotic resistance. The investigators warned that there is a real danger that, like MRSA, extensively drug-resistant A. baumannii will become a common community-acquired infection arising in previously healthy patients (JAMA Dermatol. 2014 Aug;150(8):905-906).
“There are some strains of gonococcus and some strains of Acinetobacter baumannii that appear to be resistant to all known antibiotics,” Dr. Elston said.
He reported having no relevant financial conflicts of interest.
VANCOUVER – Two serious emerging skin and soft tissue infections whose progress physicians will want to chart are melioidosis and Acinetobacter baumannii infection, Dr. Dirk M. Elston advised at the World Congress of Dermatology.
Both Burkholderia pseudomallei – the cause of melioidosis – and Acinetobacter baumannii are gram-negative organisms that laboratory staff sometimes mistakenly dismiss as culture contaminants. But melioidosis has a case fatality rate of up to 40%, and A. baumannii is an increasingly multidrug-resistant cause of community-acquired cellulitis, according to Dr. Elston, chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Elston, also managing director of the Ackerman Academy of Dermatopathology in New York, offered his views on these two emerging infections.
Melioidosis
“We know melioidosis from the rice paddies of Vietnam as a plaguelike ulceroglandular syndrome. It has reemerged in the Caribbean,” Dr. Elston reported.
Indeed, investigators at the Centers for Disease Control and Prevention reported earlier this year that melioidosis is now endemic in Puerto Rico based upon its findings of high seropositivity rates among patient contacts plus isolation of the causative organism from soil samples (Clin Infect Dis. 2015 Jan 15;60(2):243-250). The infection, which is believed to be underdiagnosed, also has been reported at numerous other sites in the Caribbean basin and in Latin America and Africa, as well as in Southeast Asia.
Although skin and soft tissue abscesses are common manifestations of this acute febrile illness, the most common clinical presentation of melioidosis is acute pneumonia with or without septicemia, which can be fulminant.
According to the CDC investigators, up to 80% of patients with melioidosis have diabetes, chronic lung disease, and/or excessive alcohol use as risk factors for the infection. In the Puerto Rican study, a history of injection drug use was for the first time identified as another risk factor. When in endemic areas such as Puerto Rico, individuals with diabetes or other risk factors should protect themselves from direct exposure to soil and water to reduce their risk of what is believed to be a transcutaneously acquired infection. The investigators advised that individuals with skin wounds or sores do the same.
The recommended treatment for melioidosis is intravenous ceftazidime, imipenem, or meropenem (N Engl J Med. 2012 Sep 13;367(11):1035-1044).
A. baumannii infection
In a recent report, Dr. Adam J. Friedman and his colleagues at the Albert Einstein College of Medicine in New York said that A. baumannii’s pattern of evolution to date is strikingly similar to that of methicillin-resistant Staphylococcus aureus. A. baumannii has displayed increasing pathogenicity and antibiotic resistance. The investigators warned that there is a real danger that, like MRSA, extensively drug-resistant A. baumannii will become a common community-acquired infection arising in previously healthy patients (JAMA Dermatol. 2014 Aug;150(8):905-906).
“There are some strains of gonococcus and some strains of Acinetobacter baumannii that appear to be resistant to all known antibiotics,” Dr. Elston said.
He reported having no relevant financial conflicts of interest.
VANCOUVER – Two serious emerging skin and soft tissue infections whose progress physicians will want to chart are melioidosis and Acinetobacter baumannii infection, Dr. Dirk M. Elston advised at the World Congress of Dermatology.
Both Burkholderia pseudomallei – the cause of melioidosis – and Acinetobacter baumannii are gram-negative organisms that laboratory staff sometimes mistakenly dismiss as culture contaminants. But melioidosis has a case fatality rate of up to 40%, and A. baumannii is an increasingly multidrug-resistant cause of community-acquired cellulitis, according to Dr. Elston, chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Elston, also managing director of the Ackerman Academy of Dermatopathology in New York, offered his views on these two emerging infections.
Melioidosis
“We know melioidosis from the rice paddies of Vietnam as a plaguelike ulceroglandular syndrome. It has reemerged in the Caribbean,” Dr. Elston reported.
Indeed, investigators at the Centers for Disease Control and Prevention reported earlier this year that melioidosis is now endemic in Puerto Rico based upon its findings of high seropositivity rates among patient contacts plus isolation of the causative organism from soil samples (Clin Infect Dis. 2015 Jan 15;60(2):243-250). The infection, which is believed to be underdiagnosed, also has been reported at numerous other sites in the Caribbean basin and in Latin America and Africa, as well as in Southeast Asia.
Although skin and soft tissue abscesses are common manifestations of this acute febrile illness, the most common clinical presentation of melioidosis is acute pneumonia with or without septicemia, which can be fulminant.
According to the CDC investigators, up to 80% of patients with melioidosis have diabetes, chronic lung disease, and/or excessive alcohol use as risk factors for the infection. In the Puerto Rican study, a history of injection drug use was for the first time identified as another risk factor. When in endemic areas such as Puerto Rico, individuals with diabetes or other risk factors should protect themselves from direct exposure to soil and water to reduce their risk of what is believed to be a transcutaneously acquired infection. The investigators advised that individuals with skin wounds or sores do the same.
The recommended treatment for melioidosis is intravenous ceftazidime, imipenem, or meropenem (N Engl J Med. 2012 Sep 13;367(11):1035-1044).
A. baumannii infection
In a recent report, Dr. Adam J. Friedman and his colleagues at the Albert Einstein College of Medicine in New York said that A. baumannii’s pattern of evolution to date is strikingly similar to that of methicillin-resistant Staphylococcus aureus. A. baumannii has displayed increasing pathogenicity and antibiotic resistance. The investigators warned that there is a real danger that, like MRSA, extensively drug-resistant A. baumannii will become a common community-acquired infection arising in previously healthy patients (JAMA Dermatol. 2014 Aug;150(8):905-906).
“There are some strains of gonococcus and some strains of Acinetobacter baumannii that appear to be resistant to all known antibiotics,” Dr. Elston said.
He reported having no relevant financial conflicts of interest.
EXPERT ANALYSIS FROM WCD 2015
WCD: Watch for these emerging infections
VANCOUVER – Two serious emerging skin and soft tissue infections whose progress physicians will want to chart are melioidosis and Acinetobacter baumannii infection, Dr. Dirk M. Elston advised at the World Congress of Dermatology.
Both Burkholderia pseudomallei – the cause of melioidosis – and Acinetobacter baumannii are gram-negative organisms that laboratory staff sometimes mistakenly dismiss as culture contaminants. But melioidosis has a case fatality rate of up to 40%, and A. baumannii is an increasingly multidrug-resistant cause of community-acquired cellulitis, according to Dr. Elston, chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Elston, also managing director of the Ackerman Academy of Dermatopathology in New York, offered his views on these two emerging infections.
Melioidosis
“We know melioidosis from the rice paddies of Vietnam as a plaguelike ulceroglandular syndrome. It has reemerged in the Caribbean,” Dr. Elston reported.
Indeed, investigators at the Centers for Disease Control and Prevention reported earlier this year that melioidosis is now endemic in Puerto Rico based upon its findings of high seropositivity rates among patient contacts plus isolation of the causative organism from soil samples (Clin Infect Dis. 2015 Jan 15;60(2):243-250). The infection, which is believed to be underdiagnosed, also has been reported at numerous other sites in the Caribbean basin and in Latin America and Africa, as well as in Southeast Asia.
Although skin and soft tissue abscesses are common manifestations of this acute febrile illness, the most common clinical presentation of melioidosis is acute pneumonia with or without septicemia, which can be fulminant.
According to the CDC investigators, up to 80% of patients with melioidosis have diabetes, chronic lung disease, and/or excessive alcohol use as risk factors for the infection. In the Puerto Rican study, a history of injection drug use was for the first time identified as another risk factor. When in endemic areas such as Puerto Rico, individuals with diabetes or other risk factors should protect themselves from direct exposure to soil and water to reduce their risk of what is believed to be a transcutaneously acquired infection. The investigators advised that individuals with skin wounds or sores do the same.
The recommended treatment for melioidosis is intravenous ceftazidime, imipenem, or meropenem (N Engl J Med. 2012 Sep 13;367(11):1035-1044).
A. baumannii infection
In a recent report, Dr. Adam J. Friedman and his colleagues at the Albert Einstein College of Medicine in New York said that A. baumannii’s pattern of evolution to date is strikingly similar to that of methicillin-resistant Staphylococcus aureus. A. baumannii has displayed increasing pathogenicity and antibiotic resistance. The investigators warned that there is a real danger that, like MRSA, extensively drug-resistant A. baumannii will become a common community-acquired infection arising in previously healthy patients (JAMA Dermatol. 2014 Aug;150(8):905-906).
“There are some strains of gonococcus and some strains of Acinetobacter baumannii that appear to be resistant to all known antibiotics,” Dr. Elston said.
He reported having no relevant financial conflicts of interest.
VANCOUVER – Two serious emerging skin and soft tissue infections whose progress physicians will want to chart are melioidosis and Acinetobacter baumannii infection, Dr. Dirk M. Elston advised at the World Congress of Dermatology.
Both Burkholderia pseudomallei – the cause of melioidosis – and Acinetobacter baumannii are gram-negative organisms that laboratory staff sometimes mistakenly dismiss as culture contaminants. But melioidosis has a case fatality rate of up to 40%, and A. baumannii is an increasingly multidrug-resistant cause of community-acquired cellulitis, according to Dr. Elston, chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Elston, also managing director of the Ackerman Academy of Dermatopathology in New York, offered his views on these two emerging infections.
Melioidosis
“We know melioidosis from the rice paddies of Vietnam as a plaguelike ulceroglandular syndrome. It has reemerged in the Caribbean,” Dr. Elston reported.
Indeed, investigators at the Centers for Disease Control and Prevention reported earlier this year that melioidosis is now endemic in Puerto Rico based upon its findings of high seropositivity rates among patient contacts plus isolation of the causative organism from soil samples (Clin Infect Dis. 2015 Jan 15;60(2):243-250). The infection, which is believed to be underdiagnosed, also has been reported at numerous other sites in the Caribbean basin and in Latin America and Africa, as well as in Southeast Asia.
Although skin and soft tissue abscesses are common manifestations of this acute febrile illness, the most common clinical presentation of melioidosis is acute pneumonia with or without septicemia, which can be fulminant.
According to the CDC investigators, up to 80% of patients with melioidosis have diabetes, chronic lung disease, and/or excessive alcohol use as risk factors for the infection. In the Puerto Rican study, a history of injection drug use was for the first time identified as another risk factor. When in endemic areas such as Puerto Rico, individuals with diabetes or other risk factors should protect themselves from direct exposure to soil and water to reduce their risk of what is believed to be a transcutaneously acquired infection. The investigators advised that individuals with skin wounds or sores do the same.
The recommended treatment for melioidosis is intravenous ceftazidime, imipenem, or meropenem (N Engl J Med. 2012 Sep 13;367(11):1035-1044).
A. baumannii infection
In a recent report, Dr. Adam J. Friedman and his colleagues at the Albert Einstein College of Medicine in New York said that A. baumannii’s pattern of evolution to date is strikingly similar to that of methicillin-resistant Staphylococcus aureus. A. baumannii has displayed increasing pathogenicity and antibiotic resistance. The investigators warned that there is a real danger that, like MRSA, extensively drug-resistant A. baumannii will become a common community-acquired infection arising in previously healthy patients (JAMA Dermatol. 2014 Aug;150(8):905-906).
“There are some strains of gonococcus and some strains of Acinetobacter baumannii that appear to be resistant to all known antibiotics,” Dr. Elston said.
He reported having no relevant financial conflicts of interest.
VANCOUVER – Two serious emerging skin and soft tissue infections whose progress physicians will want to chart are melioidosis and Acinetobacter baumannii infection, Dr. Dirk M. Elston advised at the World Congress of Dermatology.
Both Burkholderia pseudomallei – the cause of melioidosis – and Acinetobacter baumannii are gram-negative organisms that laboratory staff sometimes mistakenly dismiss as culture contaminants. But melioidosis has a case fatality rate of up to 40%, and A. baumannii is an increasingly multidrug-resistant cause of community-acquired cellulitis, according to Dr. Elston, chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Elston, also managing director of the Ackerman Academy of Dermatopathology in New York, offered his views on these two emerging infections.
Melioidosis
“We know melioidosis from the rice paddies of Vietnam as a plaguelike ulceroglandular syndrome. It has reemerged in the Caribbean,” Dr. Elston reported.
Indeed, investigators at the Centers for Disease Control and Prevention reported earlier this year that melioidosis is now endemic in Puerto Rico based upon its findings of high seropositivity rates among patient contacts plus isolation of the causative organism from soil samples (Clin Infect Dis. 2015 Jan 15;60(2):243-250). The infection, which is believed to be underdiagnosed, also has been reported at numerous other sites in the Caribbean basin and in Latin America and Africa, as well as in Southeast Asia.
Although skin and soft tissue abscesses are common manifestations of this acute febrile illness, the most common clinical presentation of melioidosis is acute pneumonia with or without septicemia, which can be fulminant.
According to the CDC investigators, up to 80% of patients with melioidosis have diabetes, chronic lung disease, and/or excessive alcohol use as risk factors for the infection. In the Puerto Rican study, a history of injection drug use was for the first time identified as another risk factor. When in endemic areas such as Puerto Rico, individuals with diabetes or other risk factors should protect themselves from direct exposure to soil and water to reduce their risk of what is believed to be a transcutaneously acquired infection. The investigators advised that individuals with skin wounds or sores do the same.
The recommended treatment for melioidosis is intravenous ceftazidime, imipenem, or meropenem (N Engl J Med. 2012 Sep 13;367(11):1035-1044).
A. baumannii infection
In a recent report, Dr. Adam J. Friedman and his colleagues at the Albert Einstein College of Medicine in New York said that A. baumannii’s pattern of evolution to date is strikingly similar to that of methicillin-resistant Staphylococcus aureus. A. baumannii has displayed increasing pathogenicity and antibiotic resistance. The investigators warned that there is a real danger that, like MRSA, extensively drug-resistant A. baumannii will become a common community-acquired infection arising in previously healthy patients (JAMA Dermatol. 2014 Aug;150(8):905-906).
“There are some strains of gonococcus and some strains of Acinetobacter baumannii that appear to be resistant to all known antibiotics,” Dr. Elston said.
He reported having no relevant financial conflicts of interest.
EXPERT ANALYSIS FROM WCD 2015
WCD: Six new technologies will change dermatology practice
VANCOUVER – Six developments – daylight photodynamic therapy, body sculpting, better laser treatments for tattoo removal, marketing of home-use fractionated lasers for skin rejuvenation, novel lasers for vascular malformations, and light-based multiphoton microscopy as an alternative to conventional histopathology – will have significant impact upon dermatologic practice, Dr. Christopher B. Zachary predicted in a keynote address at the World Congress of Dermatology.
Savvy patients will increasingly be asking their dermatologists about them, added Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.
Several of these advances fall within cosmetic dermatology, a field he vigorously defended. Showing before-and-after facial photos of a middle-aged woman who appeared 10-15 years younger following skin resurfacing with an ablative laser, Dr. Zachary asserted, “You can dramatically change people’s lives with this therapy.
“When this lady’s at work, she’s surrounded by younger women who want her job. So, this therapy has social and economic benefits,” he said. “I know that some of you in the audience might think that aesthetics is sort of a Cinderella sister to mainstream dermatology, but it’s important. We’re going to live longer, hopefully, and we want to look good – because in this culture, that’s important.”
• Daylight photodynamic therapy. Developed in Scandinavia as a field therapy for photodamaged skin and precancerous skin conditions, daylight PDT delivers continuous, low-level activation of protoporphyrin IX rather than the faster activation achieved with pulsed dye laser or other artificial light sources.
The big advantage of daylight PDT is that it’s essentially pain free. In contrast, most patients find traditional PDT so unpleasant they are reluctant to return for a second session. Moreover, natural daylight is actually a better light source, in Dr. Zachary’s view, because daylight includes all the relevant absorption wavelengths, including those in the red spectrum that allow for deeper penetration into the skin.
Daylight PDT is quite popular throughout Europe, and it’s sure to catch on here, according to Dr. Zachary, who has published research confirming its safety and efficacy (Lasers Surg. Med. 2015;47:168-72). Because patients receive their daylight therapy at home, it saves time for the patient, physician, and clinic. Plus, physicians avoid the need for expensive equipment, he noted.
Dr. Zachary offered a tip based upon his daylight PDT experience: Because aminolevulinic acid (ALA) is poorly absorbed on the arms and legs, he often pretreats those target areas with a superficial fractional ablative laser to a depth of 20 microns.
“It enhances ALA uptake tremendously,” the dermatologist said.
He also finds daylight PDT to be an excellent therapy for patients with severe, drug-resistant acne. The only difference is they get 4 hours of daylight exposure ALA incubation instead of the 2.5 hours used in field therapy for photodamaged skin. The result is a robust acute PDT reaction, reliably followed by a significant reduction in inflammatory and comedonal acne lesions. Dr. Zachary typically treats at 2- to 3-week intervals and finds fewer and fewer new lesions appear between consecutive treatments.
“This is, to me, a great therapy. But I’ll tell you, these patients come in after the first 2 weeks and say, ‘I’m never going to have this procedure again, ever.’ Then 2 weeks later they call and ask, ‘When can I have my next treatment session?’ Because they actually get phenomenal results,” according to Dr. Zachary.
• Body sculpting. Physicians should expect hard scientific evidence of benefit from the device companies before investing large sums in the purchase of new noninvasive body-sculpting devices. Cryolipolysis is the leading technology in this regard, and for good reason. Careful studies have confirmed that bulk cooling of the fat can provide safe, effective, and long-lasting fat removal. The treatment is relatively painless, and the results are predictable, Dr. Zachary noted.
New studies have demonstrated encouraging outcomes with bulk heating devices, including 1,060-nm infrared laser systems.
“I will tell you that whether you cool or heat fat for a long period actually doesn’t make much difference,” he explained. “In either case, you’re inducing a delayed-onset panniculitis. There are no immediate histologic changes. The low-level panniculitic process is evident histologically at day 14 or so post treatment; with an apoptotic response and gradual fat reduction over the next 2 months.”
Other recent useful developments in body sculpting, albeit for treatment of smaller areas, include the Food and Drug Administration’s approval of ATX-101 for reduction of preplatysmal excess submental fat, or the double chin, and the use of botulinum toxin injections for facial contouring. An example of the latter is botulinum toxin injections to reduce the size of large masseter muscles in order to change the facial shape and reduce the common problem of nighttime teeth grinding known as bruxism, he continued.
• Novel laser therapies for tattoo removal. The new picosecond pulse lasers are what everyone in laser medicine is talking about. “I think this is definitely the pico epoch,” Dr. Zachary declared.
Twenty years in development, these picosecond lasers produce faster results and more complete clearing of tattoos than obtainable with Q-switched nanosecond lasers. The results are particularly impressive when addressing the traditionally challenging green and blue pigments.
Other noteworthy developments in laser tattoo removal include the so-called R20 technique developed by Dr. Dora Kossida and Dr. R. Rox Anderson of Harvard Medical School, Boston, and coworkers (J. Am. Acad. Dermatol. 2012;66:271-7) and the use of topical perfluorodecalin. The R20 technique allows for four treatment passes per session rather than just one pass. However, it’s impractically time consuming, because the passes have to be spaced 20 minutes apart.
Physicians at the Laser and Skin Surgery Center of New York have refined the R20 technique by showing that applying perfluorodecalin speeds resolution of the laser-induced immediate whitening reaction. This effectively turns the R20 technique into R0 (Lasers Surg. Med. 2013;45:76-80).
• Home-use fractionated lasers for skin rejuvenation. The skin rejuvenation lasers that dermatologists use in their offices are being miniaturized and made available for home self-treatment. Do they work?
“Some do,” according to Dr. Zachary. “If you use them frequently – once or twice a week for an entire year – they’ll probably give you the same benefit as with the traditional in-office treatments. Histologically, they cause a similar tissue injury.”
A host of handheld ultrasound devices for home-use skin rejuvenation are coming soon as well, he added.
• Laser treatment of vascular malformations. There is a growing sense among experts that the 595-nm pulsed dye laser, the traditional workhorse in treating port wine stains, is not necessarily the best tool for the job. Utilization of alternative wavelengths may be a better way to prevent lesion recurrences. The long-pulsed Nd:YAG 1,065-nm laser and 755-nm alexandrite laser appear advantageous in this regard. But so too could those wavelengths that target deoxygenated hemoglobin.
• Multiphoton microscopy. At the University of California, Irvine’s Beckman Laser Institute, Dr. Zachary and coworkers are using laser-scanning microscopy to achieve submicron-resolution three-dimensional in vivo images of skin lesions. They have found it compares favorably to standard histopathology of processed biopsy specimens for basal cell carcinoma (JAMA Dermatol. April 24, 2015 [doi:10.1001/jamadermatol.2015.0453]).
In other studies, they have compared in vivo multiphoton microscopy to standard histopathology for melanocytic nevi and melanomas. “In some ways, there is better detail than with H&E staining,” according to the dermatologist.
Will this novel in vivo imaging method replace conventional histopathology? Quite possibly, but not for many years to come, Dr. Zachary cautioned.
”I think what’s going to happen is it will take a whole generation of people to understand this. We’ll have to miniaturize these devices, which currently are very large, and put them into clinics so we can look at tens of thousands of lesions before we feel confident about replacing conventional histopathology with noninvasive imaging,” he predicted.
Dr. Zachary reported serving as a consultant to and receiving honoraria and/or equipment loans from Amway, Solta, Valeant, Cynosure, Sciton, and Zeltiq.
VANCOUVER – Six developments – daylight photodynamic therapy, body sculpting, better laser treatments for tattoo removal, marketing of home-use fractionated lasers for skin rejuvenation, novel lasers for vascular malformations, and light-based multiphoton microscopy as an alternative to conventional histopathology – will have significant impact upon dermatologic practice, Dr. Christopher B. Zachary predicted in a keynote address at the World Congress of Dermatology.
Savvy patients will increasingly be asking their dermatologists about them, added Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.
Several of these advances fall within cosmetic dermatology, a field he vigorously defended. Showing before-and-after facial photos of a middle-aged woman who appeared 10-15 years younger following skin resurfacing with an ablative laser, Dr. Zachary asserted, “You can dramatically change people’s lives with this therapy.
“When this lady’s at work, she’s surrounded by younger women who want her job. So, this therapy has social and economic benefits,” he said. “I know that some of you in the audience might think that aesthetics is sort of a Cinderella sister to mainstream dermatology, but it’s important. We’re going to live longer, hopefully, and we want to look good – because in this culture, that’s important.”
• Daylight photodynamic therapy. Developed in Scandinavia as a field therapy for photodamaged skin and precancerous skin conditions, daylight PDT delivers continuous, low-level activation of protoporphyrin IX rather than the faster activation achieved with pulsed dye laser or other artificial light sources.
The big advantage of daylight PDT is that it’s essentially pain free. In contrast, most patients find traditional PDT so unpleasant they are reluctant to return for a second session. Moreover, natural daylight is actually a better light source, in Dr. Zachary’s view, because daylight includes all the relevant absorption wavelengths, including those in the red spectrum that allow for deeper penetration into the skin.
Daylight PDT is quite popular throughout Europe, and it’s sure to catch on here, according to Dr. Zachary, who has published research confirming its safety and efficacy (Lasers Surg. Med. 2015;47:168-72). Because patients receive their daylight therapy at home, it saves time for the patient, physician, and clinic. Plus, physicians avoid the need for expensive equipment, he noted.
Dr. Zachary offered a tip based upon his daylight PDT experience: Because aminolevulinic acid (ALA) is poorly absorbed on the arms and legs, he often pretreats those target areas with a superficial fractional ablative laser to a depth of 20 microns.
“It enhances ALA uptake tremendously,” the dermatologist said.
He also finds daylight PDT to be an excellent therapy for patients with severe, drug-resistant acne. The only difference is they get 4 hours of daylight exposure ALA incubation instead of the 2.5 hours used in field therapy for photodamaged skin. The result is a robust acute PDT reaction, reliably followed by a significant reduction in inflammatory and comedonal acne lesions. Dr. Zachary typically treats at 2- to 3-week intervals and finds fewer and fewer new lesions appear between consecutive treatments.
“This is, to me, a great therapy. But I’ll tell you, these patients come in after the first 2 weeks and say, ‘I’m never going to have this procedure again, ever.’ Then 2 weeks later they call and ask, ‘When can I have my next treatment session?’ Because they actually get phenomenal results,” according to Dr. Zachary.
• Body sculpting. Physicians should expect hard scientific evidence of benefit from the device companies before investing large sums in the purchase of new noninvasive body-sculpting devices. Cryolipolysis is the leading technology in this regard, and for good reason. Careful studies have confirmed that bulk cooling of the fat can provide safe, effective, and long-lasting fat removal. The treatment is relatively painless, and the results are predictable, Dr. Zachary noted.
New studies have demonstrated encouraging outcomes with bulk heating devices, including 1,060-nm infrared laser systems.
“I will tell you that whether you cool or heat fat for a long period actually doesn’t make much difference,” he explained. “In either case, you’re inducing a delayed-onset panniculitis. There are no immediate histologic changes. The low-level panniculitic process is evident histologically at day 14 or so post treatment; with an apoptotic response and gradual fat reduction over the next 2 months.”
Other recent useful developments in body sculpting, albeit for treatment of smaller areas, include the Food and Drug Administration’s approval of ATX-101 for reduction of preplatysmal excess submental fat, or the double chin, and the use of botulinum toxin injections for facial contouring. An example of the latter is botulinum toxin injections to reduce the size of large masseter muscles in order to change the facial shape and reduce the common problem of nighttime teeth grinding known as bruxism, he continued.
• Novel laser therapies for tattoo removal. The new picosecond pulse lasers are what everyone in laser medicine is talking about. “I think this is definitely the pico epoch,” Dr. Zachary declared.
Twenty years in development, these picosecond lasers produce faster results and more complete clearing of tattoos than obtainable with Q-switched nanosecond lasers. The results are particularly impressive when addressing the traditionally challenging green and blue pigments.
Other noteworthy developments in laser tattoo removal include the so-called R20 technique developed by Dr. Dora Kossida and Dr. R. Rox Anderson of Harvard Medical School, Boston, and coworkers (J. Am. Acad. Dermatol. 2012;66:271-7) and the use of topical perfluorodecalin. The R20 technique allows for four treatment passes per session rather than just one pass. However, it’s impractically time consuming, because the passes have to be spaced 20 minutes apart.
Physicians at the Laser and Skin Surgery Center of New York have refined the R20 technique by showing that applying perfluorodecalin speeds resolution of the laser-induced immediate whitening reaction. This effectively turns the R20 technique into R0 (Lasers Surg. Med. 2013;45:76-80).
• Home-use fractionated lasers for skin rejuvenation. The skin rejuvenation lasers that dermatologists use in their offices are being miniaturized and made available for home self-treatment. Do they work?
“Some do,” according to Dr. Zachary. “If you use them frequently – once or twice a week for an entire year – they’ll probably give you the same benefit as with the traditional in-office treatments. Histologically, they cause a similar tissue injury.”
A host of handheld ultrasound devices for home-use skin rejuvenation are coming soon as well, he added.
• Laser treatment of vascular malformations. There is a growing sense among experts that the 595-nm pulsed dye laser, the traditional workhorse in treating port wine stains, is not necessarily the best tool for the job. Utilization of alternative wavelengths may be a better way to prevent lesion recurrences. The long-pulsed Nd:YAG 1,065-nm laser and 755-nm alexandrite laser appear advantageous in this regard. But so too could those wavelengths that target deoxygenated hemoglobin.
• Multiphoton microscopy. At the University of California, Irvine’s Beckman Laser Institute, Dr. Zachary and coworkers are using laser-scanning microscopy to achieve submicron-resolution three-dimensional in vivo images of skin lesions. They have found it compares favorably to standard histopathology of processed biopsy specimens for basal cell carcinoma (JAMA Dermatol. April 24, 2015 [doi:10.1001/jamadermatol.2015.0453]).
In other studies, they have compared in vivo multiphoton microscopy to standard histopathology for melanocytic nevi and melanomas. “In some ways, there is better detail than with H&E staining,” according to the dermatologist.
Will this novel in vivo imaging method replace conventional histopathology? Quite possibly, but not for many years to come, Dr. Zachary cautioned.
”I think what’s going to happen is it will take a whole generation of people to understand this. We’ll have to miniaturize these devices, which currently are very large, and put them into clinics so we can look at tens of thousands of lesions before we feel confident about replacing conventional histopathology with noninvasive imaging,” he predicted.
Dr. Zachary reported serving as a consultant to and receiving honoraria and/or equipment loans from Amway, Solta, Valeant, Cynosure, Sciton, and Zeltiq.
VANCOUVER – Six developments – daylight photodynamic therapy, body sculpting, better laser treatments for tattoo removal, marketing of home-use fractionated lasers for skin rejuvenation, novel lasers for vascular malformations, and light-based multiphoton microscopy as an alternative to conventional histopathology – will have significant impact upon dermatologic practice, Dr. Christopher B. Zachary predicted in a keynote address at the World Congress of Dermatology.
Savvy patients will increasingly be asking their dermatologists about them, added Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.
Several of these advances fall within cosmetic dermatology, a field he vigorously defended. Showing before-and-after facial photos of a middle-aged woman who appeared 10-15 years younger following skin resurfacing with an ablative laser, Dr. Zachary asserted, “You can dramatically change people’s lives with this therapy.
“When this lady’s at work, she’s surrounded by younger women who want her job. So, this therapy has social and economic benefits,” he said. “I know that some of you in the audience might think that aesthetics is sort of a Cinderella sister to mainstream dermatology, but it’s important. We’re going to live longer, hopefully, and we want to look good – because in this culture, that’s important.”
• Daylight photodynamic therapy. Developed in Scandinavia as a field therapy for photodamaged skin and precancerous skin conditions, daylight PDT delivers continuous, low-level activation of protoporphyrin IX rather than the faster activation achieved with pulsed dye laser or other artificial light sources.
The big advantage of daylight PDT is that it’s essentially pain free. In contrast, most patients find traditional PDT so unpleasant they are reluctant to return for a second session. Moreover, natural daylight is actually a better light source, in Dr. Zachary’s view, because daylight includes all the relevant absorption wavelengths, including those in the red spectrum that allow for deeper penetration into the skin.
Daylight PDT is quite popular throughout Europe, and it’s sure to catch on here, according to Dr. Zachary, who has published research confirming its safety and efficacy (Lasers Surg. Med. 2015;47:168-72). Because patients receive their daylight therapy at home, it saves time for the patient, physician, and clinic. Plus, physicians avoid the need for expensive equipment, he noted.
Dr. Zachary offered a tip based upon his daylight PDT experience: Because aminolevulinic acid (ALA) is poorly absorbed on the arms and legs, he often pretreats those target areas with a superficial fractional ablative laser to a depth of 20 microns.
“It enhances ALA uptake tremendously,” the dermatologist said.
He also finds daylight PDT to be an excellent therapy for patients with severe, drug-resistant acne. The only difference is they get 4 hours of daylight exposure ALA incubation instead of the 2.5 hours used in field therapy for photodamaged skin. The result is a robust acute PDT reaction, reliably followed by a significant reduction in inflammatory and comedonal acne lesions. Dr. Zachary typically treats at 2- to 3-week intervals and finds fewer and fewer new lesions appear between consecutive treatments.
“This is, to me, a great therapy. But I’ll tell you, these patients come in after the first 2 weeks and say, ‘I’m never going to have this procedure again, ever.’ Then 2 weeks later they call and ask, ‘When can I have my next treatment session?’ Because they actually get phenomenal results,” according to Dr. Zachary.
• Body sculpting. Physicians should expect hard scientific evidence of benefit from the device companies before investing large sums in the purchase of new noninvasive body-sculpting devices. Cryolipolysis is the leading technology in this regard, and for good reason. Careful studies have confirmed that bulk cooling of the fat can provide safe, effective, and long-lasting fat removal. The treatment is relatively painless, and the results are predictable, Dr. Zachary noted.
New studies have demonstrated encouraging outcomes with bulk heating devices, including 1,060-nm infrared laser systems.
“I will tell you that whether you cool or heat fat for a long period actually doesn’t make much difference,” he explained. “In either case, you’re inducing a delayed-onset panniculitis. There are no immediate histologic changes. The low-level panniculitic process is evident histologically at day 14 or so post treatment; with an apoptotic response and gradual fat reduction over the next 2 months.”
Other recent useful developments in body sculpting, albeit for treatment of smaller areas, include the Food and Drug Administration’s approval of ATX-101 for reduction of preplatysmal excess submental fat, or the double chin, and the use of botulinum toxin injections for facial contouring. An example of the latter is botulinum toxin injections to reduce the size of large masseter muscles in order to change the facial shape and reduce the common problem of nighttime teeth grinding known as bruxism, he continued.
• Novel laser therapies for tattoo removal. The new picosecond pulse lasers are what everyone in laser medicine is talking about. “I think this is definitely the pico epoch,” Dr. Zachary declared.
Twenty years in development, these picosecond lasers produce faster results and more complete clearing of tattoos than obtainable with Q-switched nanosecond lasers. The results are particularly impressive when addressing the traditionally challenging green and blue pigments.
Other noteworthy developments in laser tattoo removal include the so-called R20 technique developed by Dr. Dora Kossida and Dr. R. Rox Anderson of Harvard Medical School, Boston, and coworkers (J. Am. Acad. Dermatol. 2012;66:271-7) and the use of topical perfluorodecalin. The R20 technique allows for four treatment passes per session rather than just one pass. However, it’s impractically time consuming, because the passes have to be spaced 20 minutes apart.
Physicians at the Laser and Skin Surgery Center of New York have refined the R20 technique by showing that applying perfluorodecalin speeds resolution of the laser-induced immediate whitening reaction. This effectively turns the R20 technique into R0 (Lasers Surg. Med. 2013;45:76-80).
• Home-use fractionated lasers for skin rejuvenation. The skin rejuvenation lasers that dermatologists use in their offices are being miniaturized and made available for home self-treatment. Do they work?
“Some do,” according to Dr. Zachary. “If you use them frequently – once or twice a week for an entire year – they’ll probably give you the same benefit as with the traditional in-office treatments. Histologically, they cause a similar tissue injury.”
A host of handheld ultrasound devices for home-use skin rejuvenation are coming soon as well, he added.
• Laser treatment of vascular malformations. There is a growing sense among experts that the 595-nm pulsed dye laser, the traditional workhorse in treating port wine stains, is not necessarily the best tool for the job. Utilization of alternative wavelengths may be a better way to prevent lesion recurrences. The long-pulsed Nd:YAG 1,065-nm laser and 755-nm alexandrite laser appear advantageous in this regard. But so too could those wavelengths that target deoxygenated hemoglobin.
• Multiphoton microscopy. At the University of California, Irvine’s Beckman Laser Institute, Dr. Zachary and coworkers are using laser-scanning microscopy to achieve submicron-resolution three-dimensional in vivo images of skin lesions. They have found it compares favorably to standard histopathology of processed biopsy specimens for basal cell carcinoma (JAMA Dermatol. April 24, 2015 [doi:10.1001/jamadermatol.2015.0453]).
In other studies, they have compared in vivo multiphoton microscopy to standard histopathology for melanocytic nevi and melanomas. “In some ways, there is better detail than with H&E staining,” according to the dermatologist.
Will this novel in vivo imaging method replace conventional histopathology? Quite possibly, but not for many years to come, Dr. Zachary cautioned.
”I think what’s going to happen is it will take a whole generation of people to understand this. We’ll have to miniaturize these devices, which currently are very large, and put them into clinics so we can look at tens of thousands of lesions before we feel confident about replacing conventional histopathology with noninvasive imaging,” he predicted.
Dr. Zachary reported serving as a consultant to and receiving honoraria and/or equipment loans from Amway, Solta, Valeant, Cynosure, Sciton, and Zeltiq.
EXPERT ANALYSIS FROM WCD 2015
A Call to Action on Metabolic Syndrome and Pediatric Psoriasis
VANCOUVER – Dermatologists and primary care physicians working collaboratively have a golden opportunity to improve the long-term health of pediatric psoriasis patients by addressing their predisposition to components of the metabolic syndrome, Dr. Amy S. Paller declared at the World Congress of Dermatology.
“I think we as dermatologists should be in touch with the primary care doctors of every one of our children with psoriasis. Together, we should be thinking about whether the child has metabolic issues and working jointly to most effectively counsel and evaluate these children for their potential risk for these metabolic disorders,” said Dr. Paller, professor and chair of the department of dermatology and professor of pediatrics at Northwestern University, Chicago.
Pediatric psoriasis is commonly associated with other comorbid conditions in addition to metabolic disorders. But the metabolic syndrome has recently become the focus of increasing attention given that cardiovascular disease is the No. 1 cause of death in the United States, and it appears that children with psoriasis may be getting a jump start on the atherosclerotic process.
By now, it’s well established that plaque psoriasis in adults is strongly associated with increased risks of diabetes, obesity, dyslipidemia, the metabolic syndrome, and cardiovascular disease. Mounting evidence indicates children and adolescents with psoriasis face the same risks.
Everyone knows how difficult it can be to make the long-term lifestyle changes that reverse obesity and its related metabolic disorders. But dermatologists, pediatricians, and family physicians have some leverage when it comes to pediatric psoriasis.
“Think about the fact that 30% of children with psoriasis have a first-degree relative with psoriasis, usually a parent. I think we need to think about counseling young adults with psoriasis early on, especially if that adult is overweight or obese, about the need for adopting a healthy lifestyle. If they do that, it’s not just for themselves but for their children, and we just might prevent pediatric psoriasis in that family or temper its severity through that healthy lifestyle intervention,” Dr. Paller continued.
The hope is that effectively addressing the metabolic comorbidities of pediatric psoriasis will modulate and improve the skin disease; in other words, that weight loss could improve psoriasis. As yet, however, that’s just a hope, as there is no persuasive supporting evidence.
“We’re looking towards ongoing adult trials to give us some clues about whether that’s the case,” she said.
Evidence for comorbidities
Some of the key evidence regarding the metabolic comorbidities of pediatric psoriasis comes from a landmark German epidemiologic study involving 33,981 pediatric psoriasis patients. The prevalence of psoriasis in German youth rose linearly from 0.12% at age 1 year to 1.2% at age 18. Pediatric psoriasis patients had significantly higher rates of diabetes, hyperlipidemia, obesity, and hypertension than did nonpsoriatic controls (Br. J. Dermatol. 2010;162:633-6).
A Kaiser Permanente study of nearly 711,000 youths aged 2-19 years showed that those who were overweight were 2.8-fold more likely than normal-weight youth to have severe or widespread psoriasis, while those who were moderately obese were at 2.9-fold increased risk and extremely obese youth were at 4.2-fold increased risk. Among adolescents, having psoriasis was associated with significantly higher mean total and LDL cholesterol, triglycerides, and alanine aminotransferase levels (J. Pediatr. 2011;159:577-83).
Recent evidence suggests that even before increased levels of LDL cholesterol and triglycerides are apparent in children with psoriasis, abnormalities in lipid function are present and may potentially serve as a novel marker for early cardiovascular risk. Dr. Paller cited a study presented by Dr. Wynnis L. Tom of Rady Children’s Hospital, San Diego, at the 2015 annual meeting of the Society for Investigative Dermatology. The case-control study included 50 children with psoriasis and 50 matched controls with a mean age of 13 years.
Like other investigators, Dr. Tom found that the psoriatic children had higher waist/hip ratios and more insulin resistance. While fasting lipid levels didn’t differ between the two groups, the psoriasis patients had significantly higher levels of atherogenic apolipoprotein B, fewer of the particularly cardioprotective large-size HDL particles, and reduced HDL efflux capacity. Stay tuned regarding these potential early markers, Dr. Paller advised.
She was lead author of a 409-patient international study that showed the risks of obesity and a high waist circumference rise with greater severity of pediatric psoriasis. Children with severe psoriasis were at 4.92-fold increased risk of obesity, compared with controls, while even those with mild psoriasis were at 3.6-fold increased risk (JAMA Dermatol. 2013;149:166-76).
Which comes first?
The question arises: Which comes first in children, the excess adiposity or the psoriasis? Dr. Paller said that although the final word isn’t in, she and her coworkers found in a pilot study of 27 overweight or obese children with psoriasis that excess adiposity typically came first. Moreover, among the roughly one-half of children with a family history of obesity, onset of psoriasis occurred a full 3 years earlier than in those without a positive family history (JAMA Dermatol. 2014;150:573-4).
In another small study, this by investigators at Tufts University, Boston, 6 of 20 children with psoriasis (30%) met criteria for the metabolic syndrome, compared with just 1 of 20 matched nonpsoriatic controls (Pediatr. Dermatol. 2013;30:700-5).
Dr. Paller said that if dermatologists and primary care physicians are to successfully collaborate in tackling the comorbid metabolic disorders associated with pediatric psoriasis, a prerequisite is that dermatologists are going to have to do a better job of educating their primary care colleagues about the skin disease as manifest in children.
“I think it’s very important that pediatricians are aware that psoriasis is a risk factor for metabolic syndrome. But pediatric psoriasis is often misdiagnosed by primary care physicians who mistake it for eczema or tinea infection or contact dermatitis,” according to the pediatric dermatologist.
In one eye-catching Australian study, she noted, a mere 9% of patients with pediatric psoriasis were correctly diagnosed before referral to a dermatologist (Australas. J. Dermatol. 2012;53:98-105).
Pediatric psoriasis: not just skin deep
In addition to the increased risk of metabolic disorders faced by pediatric psoriasis patients, other common comorbidities include depression, anxiety disorders, impaired self-esteem and quality of life, arthritis, and Crohn’s disease, Dr. Paller observed.
• Quality of life. “The quality of life impact of psoriasis is profound. It’s a highly visible disorder, which affects the development of self-esteem and social relationships,” Dr. Paller said.
Investigators at Texas A&M University applied the Pediatric Quality of Life Inventory Version 4.0 to 208 patients aged 2-17 years with moderate to severe psoriasis and compared the results to published data on children with arthritis, asthma, diabetes, and psychiatric disorders. Health-related quality of life turned out to be more impaired in the psoriasis patients than in those with diabetes. The quality-of-life impairment associated with pediatric psoriasis was comparable to that of having asthma or arthritis, albeit not as severe as for pediatric psychiatric disorders (Eur. J. Pediatr. 2012;171:485-92).
• Psychiatric disorders. A study of more than 7,400 pediatric psoriasis patients concluded they had an adjusted 25% increased risk of developing depression, compared with psoriasis-free controls, as well as a 32% increased risk of anxiety disorders and a 55% greater risk of bipolar disorder (J. Am. Acad. Dermatol. 2012;67:651-7.e2).
• Psoriatic arthritis. An estimated 1 in 10 U.S. children with psoriasis report having arthritis, often classified as juvenile idiopathic arthritis (JAMA Dermatol. 2013;149:1180-5).
• Crohn’s disease. A large German epidemiologic study concluded that psoriasis was associated with a 3.69-fold increased risk of Crohn’s disease. There was no increased risk of ulcerative colitis (Br. J. Dermatol. 2010;162:633-6).
Dr. Paller reported receiving research grants from Amgen and Leo and serving as a consultant to AbbVie.
VANCOUVER – Dermatologists and primary care physicians working collaboratively have a golden opportunity to improve the long-term health of pediatric psoriasis patients by addressing their predisposition to components of the metabolic syndrome, Dr. Amy S. Paller declared at the World Congress of Dermatology.
“I think we as dermatologists should be in touch with the primary care doctors of every one of our children with psoriasis. Together, we should be thinking about whether the child has metabolic issues and working jointly to most effectively counsel and evaluate these children for their potential risk for these metabolic disorders,” said Dr. Paller, professor and chair of the department of dermatology and professor of pediatrics at Northwestern University, Chicago.
Pediatric psoriasis is commonly associated with other comorbid conditions in addition to metabolic disorders. But the metabolic syndrome has recently become the focus of increasing attention given that cardiovascular disease is the No. 1 cause of death in the United States, and it appears that children with psoriasis may be getting a jump start on the atherosclerotic process.
By now, it’s well established that plaque psoriasis in adults is strongly associated with increased risks of diabetes, obesity, dyslipidemia, the metabolic syndrome, and cardiovascular disease. Mounting evidence indicates children and adolescents with psoriasis face the same risks.
Everyone knows how difficult it can be to make the long-term lifestyle changes that reverse obesity and its related metabolic disorders. But dermatologists, pediatricians, and family physicians have some leverage when it comes to pediatric psoriasis.
“Think about the fact that 30% of children with psoriasis have a first-degree relative with psoriasis, usually a parent. I think we need to think about counseling young adults with psoriasis early on, especially if that adult is overweight or obese, about the need for adopting a healthy lifestyle. If they do that, it’s not just for themselves but for their children, and we just might prevent pediatric psoriasis in that family or temper its severity through that healthy lifestyle intervention,” Dr. Paller continued.
The hope is that effectively addressing the metabolic comorbidities of pediatric psoriasis will modulate and improve the skin disease; in other words, that weight loss could improve psoriasis. As yet, however, that’s just a hope, as there is no persuasive supporting evidence.
“We’re looking towards ongoing adult trials to give us some clues about whether that’s the case,” she said.
Evidence for comorbidities
Some of the key evidence regarding the metabolic comorbidities of pediatric psoriasis comes from a landmark German epidemiologic study involving 33,981 pediatric psoriasis patients. The prevalence of psoriasis in German youth rose linearly from 0.12% at age 1 year to 1.2% at age 18. Pediatric psoriasis patients had significantly higher rates of diabetes, hyperlipidemia, obesity, and hypertension than did nonpsoriatic controls (Br. J. Dermatol. 2010;162:633-6).
A Kaiser Permanente study of nearly 711,000 youths aged 2-19 years showed that those who were overweight were 2.8-fold more likely than normal-weight youth to have severe or widespread psoriasis, while those who were moderately obese were at 2.9-fold increased risk and extremely obese youth were at 4.2-fold increased risk. Among adolescents, having psoriasis was associated with significantly higher mean total and LDL cholesterol, triglycerides, and alanine aminotransferase levels (J. Pediatr. 2011;159:577-83).
Recent evidence suggests that even before increased levels of LDL cholesterol and triglycerides are apparent in children with psoriasis, abnormalities in lipid function are present and may potentially serve as a novel marker for early cardiovascular risk. Dr. Paller cited a study presented by Dr. Wynnis L. Tom of Rady Children’s Hospital, San Diego, at the 2015 annual meeting of the Society for Investigative Dermatology. The case-control study included 50 children with psoriasis and 50 matched controls with a mean age of 13 years.
Like other investigators, Dr. Tom found that the psoriatic children had higher waist/hip ratios and more insulin resistance. While fasting lipid levels didn’t differ between the two groups, the psoriasis patients had significantly higher levels of atherogenic apolipoprotein B, fewer of the particularly cardioprotective large-size HDL particles, and reduced HDL efflux capacity. Stay tuned regarding these potential early markers, Dr. Paller advised.
She was lead author of a 409-patient international study that showed the risks of obesity and a high waist circumference rise with greater severity of pediatric psoriasis. Children with severe psoriasis were at 4.92-fold increased risk of obesity, compared with controls, while even those with mild psoriasis were at 3.6-fold increased risk (JAMA Dermatol. 2013;149:166-76).
Which comes first?
The question arises: Which comes first in children, the excess adiposity or the psoriasis? Dr. Paller said that although the final word isn’t in, she and her coworkers found in a pilot study of 27 overweight or obese children with psoriasis that excess adiposity typically came first. Moreover, among the roughly one-half of children with a family history of obesity, onset of psoriasis occurred a full 3 years earlier than in those without a positive family history (JAMA Dermatol. 2014;150:573-4).
In another small study, this by investigators at Tufts University, Boston, 6 of 20 children with psoriasis (30%) met criteria for the metabolic syndrome, compared with just 1 of 20 matched nonpsoriatic controls (Pediatr. Dermatol. 2013;30:700-5).
Dr. Paller said that if dermatologists and primary care physicians are to successfully collaborate in tackling the comorbid metabolic disorders associated with pediatric psoriasis, a prerequisite is that dermatologists are going to have to do a better job of educating their primary care colleagues about the skin disease as manifest in children.
“I think it’s very important that pediatricians are aware that psoriasis is a risk factor for metabolic syndrome. But pediatric psoriasis is often misdiagnosed by primary care physicians who mistake it for eczema or tinea infection or contact dermatitis,” according to the pediatric dermatologist.
In one eye-catching Australian study, she noted, a mere 9% of patients with pediatric psoriasis were correctly diagnosed before referral to a dermatologist (Australas. J. Dermatol. 2012;53:98-105).
Pediatric psoriasis: not just skin deep
In addition to the increased risk of metabolic disorders faced by pediatric psoriasis patients, other common comorbidities include depression, anxiety disorders, impaired self-esteem and quality of life, arthritis, and Crohn’s disease, Dr. Paller observed.
• Quality of life. “The quality of life impact of psoriasis is profound. It’s a highly visible disorder, which affects the development of self-esteem and social relationships,” Dr. Paller said.
Investigators at Texas A&M University applied the Pediatric Quality of Life Inventory Version 4.0 to 208 patients aged 2-17 years with moderate to severe psoriasis and compared the results to published data on children with arthritis, asthma, diabetes, and psychiatric disorders. Health-related quality of life turned out to be more impaired in the psoriasis patients than in those with diabetes. The quality-of-life impairment associated with pediatric psoriasis was comparable to that of having asthma or arthritis, albeit not as severe as for pediatric psychiatric disorders (Eur. J. Pediatr. 2012;171:485-92).
• Psychiatric disorders. A study of more than 7,400 pediatric psoriasis patients concluded they had an adjusted 25% increased risk of developing depression, compared with psoriasis-free controls, as well as a 32% increased risk of anxiety disorders and a 55% greater risk of bipolar disorder (J. Am. Acad. Dermatol. 2012;67:651-7.e2).
• Psoriatic arthritis. An estimated 1 in 10 U.S. children with psoriasis report having arthritis, often classified as juvenile idiopathic arthritis (JAMA Dermatol. 2013;149:1180-5).
• Crohn’s disease. A large German epidemiologic study concluded that psoriasis was associated with a 3.69-fold increased risk of Crohn’s disease. There was no increased risk of ulcerative colitis (Br. J. Dermatol. 2010;162:633-6).
Dr. Paller reported receiving research grants from Amgen and Leo and serving as a consultant to AbbVie.
VANCOUVER – Dermatologists and primary care physicians working collaboratively have a golden opportunity to improve the long-term health of pediatric psoriasis patients by addressing their predisposition to components of the metabolic syndrome, Dr. Amy S. Paller declared at the World Congress of Dermatology.
“I think we as dermatologists should be in touch with the primary care doctors of every one of our children with psoriasis. Together, we should be thinking about whether the child has metabolic issues and working jointly to most effectively counsel and evaluate these children for their potential risk for these metabolic disorders,” said Dr. Paller, professor and chair of the department of dermatology and professor of pediatrics at Northwestern University, Chicago.
Pediatric psoriasis is commonly associated with other comorbid conditions in addition to metabolic disorders. But the metabolic syndrome has recently become the focus of increasing attention given that cardiovascular disease is the No. 1 cause of death in the United States, and it appears that children with psoriasis may be getting a jump start on the atherosclerotic process.
By now, it’s well established that plaque psoriasis in adults is strongly associated with increased risks of diabetes, obesity, dyslipidemia, the metabolic syndrome, and cardiovascular disease. Mounting evidence indicates children and adolescents with psoriasis face the same risks.
Everyone knows how difficult it can be to make the long-term lifestyle changes that reverse obesity and its related metabolic disorders. But dermatologists, pediatricians, and family physicians have some leverage when it comes to pediatric psoriasis.
“Think about the fact that 30% of children with psoriasis have a first-degree relative with psoriasis, usually a parent. I think we need to think about counseling young adults with psoriasis early on, especially if that adult is overweight or obese, about the need for adopting a healthy lifestyle. If they do that, it’s not just for themselves but for their children, and we just might prevent pediatric psoriasis in that family or temper its severity through that healthy lifestyle intervention,” Dr. Paller continued.
The hope is that effectively addressing the metabolic comorbidities of pediatric psoriasis will modulate and improve the skin disease; in other words, that weight loss could improve psoriasis. As yet, however, that’s just a hope, as there is no persuasive supporting evidence.
“We’re looking towards ongoing adult trials to give us some clues about whether that’s the case,” she said.
Evidence for comorbidities
Some of the key evidence regarding the metabolic comorbidities of pediatric psoriasis comes from a landmark German epidemiologic study involving 33,981 pediatric psoriasis patients. The prevalence of psoriasis in German youth rose linearly from 0.12% at age 1 year to 1.2% at age 18. Pediatric psoriasis patients had significantly higher rates of diabetes, hyperlipidemia, obesity, and hypertension than did nonpsoriatic controls (Br. J. Dermatol. 2010;162:633-6).
A Kaiser Permanente study of nearly 711,000 youths aged 2-19 years showed that those who were overweight were 2.8-fold more likely than normal-weight youth to have severe or widespread psoriasis, while those who were moderately obese were at 2.9-fold increased risk and extremely obese youth were at 4.2-fold increased risk. Among adolescents, having psoriasis was associated with significantly higher mean total and LDL cholesterol, triglycerides, and alanine aminotransferase levels (J. Pediatr. 2011;159:577-83).
Recent evidence suggests that even before increased levels of LDL cholesterol and triglycerides are apparent in children with psoriasis, abnormalities in lipid function are present and may potentially serve as a novel marker for early cardiovascular risk. Dr. Paller cited a study presented by Dr. Wynnis L. Tom of Rady Children’s Hospital, San Diego, at the 2015 annual meeting of the Society for Investigative Dermatology. The case-control study included 50 children with psoriasis and 50 matched controls with a mean age of 13 years.
Like other investigators, Dr. Tom found that the psoriatic children had higher waist/hip ratios and more insulin resistance. While fasting lipid levels didn’t differ between the two groups, the psoriasis patients had significantly higher levels of atherogenic apolipoprotein B, fewer of the particularly cardioprotective large-size HDL particles, and reduced HDL efflux capacity. Stay tuned regarding these potential early markers, Dr. Paller advised.
She was lead author of a 409-patient international study that showed the risks of obesity and a high waist circumference rise with greater severity of pediatric psoriasis. Children with severe psoriasis were at 4.92-fold increased risk of obesity, compared with controls, while even those with mild psoriasis were at 3.6-fold increased risk (JAMA Dermatol. 2013;149:166-76).
Which comes first?
The question arises: Which comes first in children, the excess adiposity or the psoriasis? Dr. Paller said that although the final word isn’t in, she and her coworkers found in a pilot study of 27 overweight or obese children with psoriasis that excess adiposity typically came first. Moreover, among the roughly one-half of children with a family history of obesity, onset of psoriasis occurred a full 3 years earlier than in those without a positive family history (JAMA Dermatol. 2014;150:573-4).
In another small study, this by investigators at Tufts University, Boston, 6 of 20 children with psoriasis (30%) met criteria for the metabolic syndrome, compared with just 1 of 20 matched nonpsoriatic controls (Pediatr. Dermatol. 2013;30:700-5).
Dr. Paller said that if dermatologists and primary care physicians are to successfully collaborate in tackling the comorbid metabolic disorders associated with pediatric psoriasis, a prerequisite is that dermatologists are going to have to do a better job of educating their primary care colleagues about the skin disease as manifest in children.
“I think it’s very important that pediatricians are aware that psoriasis is a risk factor for metabolic syndrome. But pediatric psoriasis is often misdiagnosed by primary care physicians who mistake it for eczema or tinea infection or contact dermatitis,” according to the pediatric dermatologist.
In one eye-catching Australian study, she noted, a mere 9% of patients with pediatric psoriasis were correctly diagnosed before referral to a dermatologist (Australas. J. Dermatol. 2012;53:98-105).
Pediatric psoriasis: not just skin deep
In addition to the increased risk of metabolic disorders faced by pediatric psoriasis patients, other common comorbidities include depression, anxiety disorders, impaired self-esteem and quality of life, arthritis, and Crohn’s disease, Dr. Paller observed.
• Quality of life. “The quality of life impact of psoriasis is profound. It’s a highly visible disorder, which affects the development of self-esteem and social relationships,” Dr. Paller said.
Investigators at Texas A&M University applied the Pediatric Quality of Life Inventory Version 4.0 to 208 patients aged 2-17 years with moderate to severe psoriasis and compared the results to published data on children with arthritis, asthma, diabetes, and psychiatric disorders. Health-related quality of life turned out to be more impaired in the psoriasis patients than in those with diabetes. The quality-of-life impairment associated with pediatric psoriasis was comparable to that of having asthma or arthritis, albeit not as severe as for pediatric psychiatric disorders (Eur. J. Pediatr. 2012;171:485-92).
• Psychiatric disorders. A study of more than 7,400 pediatric psoriasis patients concluded they had an adjusted 25% increased risk of developing depression, compared with psoriasis-free controls, as well as a 32% increased risk of anxiety disorders and a 55% greater risk of bipolar disorder (J. Am. Acad. Dermatol. 2012;67:651-7.e2).
• Psoriatic arthritis. An estimated 1 in 10 U.S. children with psoriasis report having arthritis, often classified as juvenile idiopathic arthritis (JAMA Dermatol. 2013;149:1180-5).
• Crohn’s disease. A large German epidemiologic study concluded that psoriasis was associated with a 3.69-fold increased risk of Crohn’s disease. There was no increased risk of ulcerative colitis (Br. J. Dermatol. 2010;162:633-6).
Dr. Paller reported receiving research grants from Amgen and Leo and serving as a consultant to AbbVie.
EXPERT ANALYSIS FROM WCD 2015
A call to action on metabolic syndrome and pediatric psoriasis
VANCOUVER – Dermatologists and primary care physicians working collaboratively have a golden opportunity to improve the long-term health of pediatric psoriasis patients by addressing their predisposition to components of the metabolic syndrome, Dr. Amy S. Paller declared at the World Congress of Dermatology.
“I think we as dermatologists should be in touch with the primary care doctors of every one of our children with psoriasis. Together, we should be thinking about whether the child has metabolic issues and working jointly to most effectively counsel and evaluate these children for their potential risk for these metabolic disorders,” said Dr. Paller, professor and chair of the department of dermatology and professor of pediatrics at Northwestern University, Chicago.
Pediatric psoriasis is commonly associated with other comorbid conditions in addition to metabolic disorders. But the metabolic syndrome has recently become the focus of increasing attention given that cardiovascular disease is the No. 1 cause of death in the United States, and it appears that children with psoriasis may be getting a jump start on the atherosclerotic process.
By now, it’s well established that plaque psoriasis in adults is strongly associated with increased risks of diabetes, obesity, dyslipidemia, the metabolic syndrome, and cardiovascular disease. Mounting evidence indicates children and adolescents with psoriasis face the same risks.
Everyone knows how difficult it can be to make the long-term lifestyle changes that reverse obesity and its related metabolic disorders. But dermatologists, pediatricians, and family physicians have some leverage when it comes to pediatric psoriasis.
“Think about the fact that 30% of children with psoriasis have a first-degree relative with psoriasis, usually a parent. I think we need to think about counseling young adults with psoriasis early on, especially if that adult is overweight or obese, about the need for adopting a healthy lifestyle. If they do that, it’s not just for themselves but for their children, and we just might prevent pediatric psoriasis in that family or temper its severity through that healthy lifestyle intervention,” Dr. Paller continued.
The hope is that effectively addressing the metabolic comorbidities of pediatric psoriasis will modulate and improve the skin disease; in other words, that weight loss could improve psoriasis. As yet, however, that’s just a hope, as there is no persuasive supporting evidence.
“We’re looking towards ongoing adult trials to give us some clues about whether that’s the case,” she said.
Evidence for comorbidities
Some of the key evidence regarding the metabolic comorbidities of pediatric psoriasis comes from a landmark German epidemiologic study involving 33,981 pediatric psoriasis patients. The prevalence of psoriasis in German youth rose linearly from 0.12% at age 1 year to 1.2% at age 18. Pediatric psoriasis patients had significantly higher rates of diabetes, hyperlipidemia, obesity, and hypertension than did nonpsoriatic controls (Br. J. Dermatol. 2010;162:633-6).
A Kaiser Permanente study of nearly 711,000 youths aged 2-19 years showed that those who were overweight were 2.8-fold more likely than normal-weight youth to have severe or widespread psoriasis, while those who were moderately obese were at 2.9-fold increased risk and extremely obese youth were at 4.2-fold increased risk. Among adolescents, having psoriasis was associated with significantly higher mean total and LDL cholesterol, triglycerides, and alanine aminotransferase levels (J. Pediatr. 2011;159:577-83).
Recent evidence suggests that even before increased levels of LDL cholesterol and triglycerides are apparent in children with psoriasis, abnormalities in lipid function are present and may potentially serve as a novel marker for early cardiovascular risk. Dr. Paller cited a study presented by Dr. Wynnis L. Tom of Rady Children’s Hospital, San Diego, at the 2015 annual meeting of the Society for Investigative Dermatology. The case-control study included 50 children with psoriasis and 50 matched controls with a mean age of 13 years.
Like other investigators, Dr. Tom found that the psoriatic children had higher waist/hip ratios and more insulin resistance. While fasting lipid levels didn’t differ between the two groups, the psoriasis patients had significantly higher levels of atherogenic apolipoprotein B, fewer of the particularly cardioprotective large-size HDL particles, and reduced HDL efflux capacity. Stay tuned regarding these potential early markers, Dr. Paller advised.
She was lead author of a 409-patient international study that showed the risks of obesity and a high waist circumference rise with greater severity of pediatric psoriasis. Children with severe psoriasis were at 4.92-fold increased risk of obesity, compared with controls, while even those with mild psoriasis were at 3.6-fold increased risk (JAMA Dermatol. 2013;149:166-76).
Which comes first?
The question arises: Which comes first in children, the excess adiposity or the psoriasis? Dr. Paller said that although the final word isn’t in, she and her coworkers found in a pilot study of 27 overweight or obese children with psoriasis that excess adiposity typically came first. Moreover, among the roughly one-half of children with a family history of obesity, onset of psoriasis occurred a full 3 years earlier than in those without a positive family history (JAMA Dermatol. 2014;150:573-4).
In another small study, this by investigators at Tufts University, Boston, 6 of 20 children with psoriasis (30%) met criteria for the metabolic syndrome, compared with just 1 of 20 matched nonpsoriatic controls (Pediatr. Dermatol. 2013;30:700-5).
Dr. Paller said that if dermatologists and primary care physicians are to successfully collaborate in tackling the comorbid metabolic disorders associated with pediatric psoriasis, a prerequisite is that dermatologists are going to have to do a better job of educating their primary care colleagues about the skin disease as manifest in children.
“I think it’s very important that pediatricians are aware that psoriasis is a risk factor for metabolic syndrome. But pediatric psoriasis is often misdiagnosed by primary care physicians who mistake it for eczema or tinea infection or contact dermatitis,” according to the pediatric dermatologist.
In one eye-catching Australian study, she noted, a mere 9% of patients with pediatric psoriasis were correctly diagnosed before referral to a dermatologist (Australas. J. Dermatol. 2012;53:98-105).
Pediatric psoriasis: not just skin deep
In addition to the increased risk of metabolic disorders faced by pediatric psoriasis patients, other common comorbidities include depression, anxiety disorders, impaired self-esteem and quality of life, arthritis, and Crohn’s disease, Dr. Paller observed.
• Quality of life. “The quality of life impact of psoriasis is profound. It’s a highly visible disorder, which affects the development of self-esteem and social relationships,” Dr. Paller said.
Investigators at Texas A&M University applied the Pediatric Quality of Life Inventory Version 4.0 to 208 patients aged 2-17 years with moderate to severe psoriasis and compared the results to published data on children with arthritis, asthma, diabetes, and psychiatric disorders. Health-related quality of life turned out to be more impaired in the psoriasis patients than in those with diabetes. The quality-of-life impairment associated with pediatric psoriasis was comparable to that of having asthma or arthritis, albeit not as severe as for pediatric psychiatric disorders (Eur. J. Pediatr. 2012;171:485-92).
• Psychiatric disorders. A study of more than 7,400 pediatric psoriasis patients concluded they had an adjusted 25% increased risk of developing depression, compared with psoriasis-free controls, as well as a 32% increased risk of anxiety disorders and a 55% greater risk of bipolar disorder (J. Am. Acad. Dermatol. 2012;67:651-7.e2).
• Psoriatic arthritis. An estimated 1 in 10 U.S. children with psoriasis report having arthritis, often classified as juvenile idiopathic arthritis (JAMA Dermatol. 2013;149:1180-5).
• Crohn’s disease. A large German epidemiologic study concluded that psoriasis was associated with a 3.69-fold increased risk of Crohn’s disease. There was no increased risk of ulcerative colitis (Br. J. Dermatol. 2010;162:633-6).
Dr. Paller reported receiving research grants from Amgen and Leo and serving as a consultant to AbbVie.
VANCOUVER – Dermatologists and primary care physicians working collaboratively have a golden opportunity to improve the long-term health of pediatric psoriasis patients by addressing their predisposition to components of the metabolic syndrome, Dr. Amy S. Paller declared at the World Congress of Dermatology.
“I think we as dermatologists should be in touch with the primary care doctors of every one of our children with psoriasis. Together, we should be thinking about whether the child has metabolic issues and working jointly to most effectively counsel and evaluate these children for their potential risk for these metabolic disorders,” said Dr. Paller, professor and chair of the department of dermatology and professor of pediatrics at Northwestern University, Chicago.
Pediatric psoriasis is commonly associated with other comorbid conditions in addition to metabolic disorders. But the metabolic syndrome has recently become the focus of increasing attention given that cardiovascular disease is the No. 1 cause of death in the United States, and it appears that children with psoriasis may be getting a jump start on the atherosclerotic process.
By now, it’s well established that plaque psoriasis in adults is strongly associated with increased risks of diabetes, obesity, dyslipidemia, the metabolic syndrome, and cardiovascular disease. Mounting evidence indicates children and adolescents with psoriasis face the same risks.
Everyone knows how difficult it can be to make the long-term lifestyle changes that reverse obesity and its related metabolic disorders. But dermatologists, pediatricians, and family physicians have some leverage when it comes to pediatric psoriasis.
“Think about the fact that 30% of children with psoriasis have a first-degree relative with psoriasis, usually a parent. I think we need to think about counseling young adults with psoriasis early on, especially if that adult is overweight or obese, about the need for adopting a healthy lifestyle. If they do that, it’s not just for themselves but for their children, and we just might prevent pediatric psoriasis in that family or temper its severity through that healthy lifestyle intervention,” Dr. Paller continued.
The hope is that effectively addressing the metabolic comorbidities of pediatric psoriasis will modulate and improve the skin disease; in other words, that weight loss could improve psoriasis. As yet, however, that’s just a hope, as there is no persuasive supporting evidence.
“We’re looking towards ongoing adult trials to give us some clues about whether that’s the case,” she said.
Evidence for comorbidities
Some of the key evidence regarding the metabolic comorbidities of pediatric psoriasis comes from a landmark German epidemiologic study involving 33,981 pediatric psoriasis patients. The prevalence of psoriasis in German youth rose linearly from 0.12% at age 1 year to 1.2% at age 18. Pediatric psoriasis patients had significantly higher rates of diabetes, hyperlipidemia, obesity, and hypertension than did nonpsoriatic controls (Br. J. Dermatol. 2010;162:633-6).
A Kaiser Permanente study of nearly 711,000 youths aged 2-19 years showed that those who were overweight were 2.8-fold more likely than normal-weight youth to have severe or widespread psoriasis, while those who were moderately obese were at 2.9-fold increased risk and extremely obese youth were at 4.2-fold increased risk. Among adolescents, having psoriasis was associated with significantly higher mean total and LDL cholesterol, triglycerides, and alanine aminotransferase levels (J. Pediatr. 2011;159:577-83).
Recent evidence suggests that even before increased levels of LDL cholesterol and triglycerides are apparent in children with psoriasis, abnormalities in lipid function are present and may potentially serve as a novel marker for early cardiovascular risk. Dr. Paller cited a study presented by Dr. Wynnis L. Tom of Rady Children’s Hospital, San Diego, at the 2015 annual meeting of the Society for Investigative Dermatology. The case-control study included 50 children with psoriasis and 50 matched controls with a mean age of 13 years.
Like other investigators, Dr. Tom found that the psoriatic children had higher waist/hip ratios and more insulin resistance. While fasting lipid levels didn’t differ between the two groups, the psoriasis patients had significantly higher levels of atherogenic apolipoprotein B, fewer of the particularly cardioprotective large-size HDL particles, and reduced HDL efflux capacity. Stay tuned regarding these potential early markers, Dr. Paller advised.
She was lead author of a 409-patient international study that showed the risks of obesity and a high waist circumference rise with greater severity of pediatric psoriasis. Children with severe psoriasis were at 4.92-fold increased risk of obesity, compared with controls, while even those with mild psoriasis were at 3.6-fold increased risk (JAMA Dermatol. 2013;149:166-76).
Which comes first?
The question arises: Which comes first in children, the excess adiposity or the psoriasis? Dr. Paller said that although the final word isn’t in, she and her coworkers found in a pilot study of 27 overweight or obese children with psoriasis that excess adiposity typically came first. Moreover, among the roughly one-half of children with a family history of obesity, onset of psoriasis occurred a full 3 years earlier than in those without a positive family history (JAMA Dermatol. 2014;150:573-4).
In another small study, this by investigators at Tufts University, Boston, 6 of 20 children with psoriasis (30%) met criteria for the metabolic syndrome, compared with just 1 of 20 matched nonpsoriatic controls (Pediatr. Dermatol. 2013;30:700-5).
Dr. Paller said that if dermatologists and primary care physicians are to successfully collaborate in tackling the comorbid metabolic disorders associated with pediatric psoriasis, a prerequisite is that dermatologists are going to have to do a better job of educating their primary care colleagues about the skin disease as manifest in children.
“I think it’s very important that pediatricians are aware that psoriasis is a risk factor for metabolic syndrome. But pediatric psoriasis is often misdiagnosed by primary care physicians who mistake it for eczema or tinea infection or contact dermatitis,” according to the pediatric dermatologist.
In one eye-catching Australian study, she noted, a mere 9% of patients with pediatric psoriasis were correctly diagnosed before referral to a dermatologist (Australas. J. Dermatol. 2012;53:98-105).
Pediatric psoriasis: not just skin deep
In addition to the increased risk of metabolic disorders faced by pediatric psoriasis patients, other common comorbidities include depression, anxiety disorders, impaired self-esteem and quality of life, arthritis, and Crohn’s disease, Dr. Paller observed.
• Quality of life. “The quality of life impact of psoriasis is profound. It’s a highly visible disorder, which affects the development of self-esteem and social relationships,” Dr. Paller said.
Investigators at Texas A&M University applied the Pediatric Quality of Life Inventory Version 4.0 to 208 patients aged 2-17 years with moderate to severe psoriasis and compared the results to published data on children with arthritis, asthma, diabetes, and psychiatric disorders. Health-related quality of life turned out to be more impaired in the psoriasis patients than in those with diabetes. The quality-of-life impairment associated with pediatric psoriasis was comparable to that of having asthma or arthritis, albeit not as severe as for pediatric psychiatric disorders (Eur. J. Pediatr. 2012;171:485-92).
• Psychiatric disorders. A study of more than 7,400 pediatric psoriasis patients concluded they had an adjusted 25% increased risk of developing depression, compared with psoriasis-free controls, as well as a 32% increased risk of anxiety disorders and a 55% greater risk of bipolar disorder (J. Am. Acad. Dermatol. 2012;67:651-7.e2).
• Psoriatic arthritis. An estimated 1 in 10 U.S. children with psoriasis report having arthritis, often classified as juvenile idiopathic arthritis (JAMA Dermatol. 2013;149:1180-5).
• Crohn’s disease. A large German epidemiologic study concluded that psoriasis was associated with a 3.69-fold increased risk of Crohn’s disease. There was no increased risk of ulcerative colitis (Br. J. Dermatol. 2010;162:633-6).
Dr. Paller reported receiving research grants from Amgen and Leo and serving as a consultant to AbbVie.
VANCOUVER – Dermatologists and primary care physicians working collaboratively have a golden opportunity to improve the long-term health of pediatric psoriasis patients by addressing their predisposition to components of the metabolic syndrome, Dr. Amy S. Paller declared at the World Congress of Dermatology.
“I think we as dermatologists should be in touch with the primary care doctors of every one of our children with psoriasis. Together, we should be thinking about whether the child has metabolic issues and working jointly to most effectively counsel and evaluate these children for their potential risk for these metabolic disorders,” said Dr. Paller, professor and chair of the department of dermatology and professor of pediatrics at Northwestern University, Chicago.
Pediatric psoriasis is commonly associated with other comorbid conditions in addition to metabolic disorders. But the metabolic syndrome has recently become the focus of increasing attention given that cardiovascular disease is the No. 1 cause of death in the United States, and it appears that children with psoriasis may be getting a jump start on the atherosclerotic process.
By now, it’s well established that plaque psoriasis in adults is strongly associated with increased risks of diabetes, obesity, dyslipidemia, the metabolic syndrome, and cardiovascular disease. Mounting evidence indicates children and adolescents with psoriasis face the same risks.
Everyone knows how difficult it can be to make the long-term lifestyle changes that reverse obesity and its related metabolic disorders. But dermatologists, pediatricians, and family physicians have some leverage when it comes to pediatric psoriasis.
“Think about the fact that 30% of children with psoriasis have a first-degree relative with psoriasis, usually a parent. I think we need to think about counseling young adults with psoriasis early on, especially if that adult is overweight or obese, about the need for adopting a healthy lifestyle. If they do that, it’s not just for themselves but for their children, and we just might prevent pediatric psoriasis in that family or temper its severity through that healthy lifestyle intervention,” Dr. Paller continued.
The hope is that effectively addressing the metabolic comorbidities of pediatric psoriasis will modulate and improve the skin disease; in other words, that weight loss could improve psoriasis. As yet, however, that’s just a hope, as there is no persuasive supporting evidence.
“We’re looking towards ongoing adult trials to give us some clues about whether that’s the case,” she said.
Evidence for comorbidities
Some of the key evidence regarding the metabolic comorbidities of pediatric psoriasis comes from a landmark German epidemiologic study involving 33,981 pediatric psoriasis patients. The prevalence of psoriasis in German youth rose linearly from 0.12% at age 1 year to 1.2% at age 18. Pediatric psoriasis patients had significantly higher rates of diabetes, hyperlipidemia, obesity, and hypertension than did nonpsoriatic controls (Br. J. Dermatol. 2010;162:633-6).
A Kaiser Permanente study of nearly 711,000 youths aged 2-19 years showed that those who were overweight were 2.8-fold more likely than normal-weight youth to have severe or widespread psoriasis, while those who were moderately obese were at 2.9-fold increased risk and extremely obese youth were at 4.2-fold increased risk. Among adolescents, having psoriasis was associated with significantly higher mean total and LDL cholesterol, triglycerides, and alanine aminotransferase levels (J. Pediatr. 2011;159:577-83).
Recent evidence suggests that even before increased levels of LDL cholesterol and triglycerides are apparent in children with psoriasis, abnormalities in lipid function are present and may potentially serve as a novel marker for early cardiovascular risk. Dr. Paller cited a study presented by Dr. Wynnis L. Tom of Rady Children’s Hospital, San Diego, at the 2015 annual meeting of the Society for Investigative Dermatology. The case-control study included 50 children with psoriasis and 50 matched controls with a mean age of 13 years.
Like other investigators, Dr. Tom found that the psoriatic children had higher waist/hip ratios and more insulin resistance. While fasting lipid levels didn’t differ between the two groups, the psoriasis patients had significantly higher levels of atherogenic apolipoprotein B, fewer of the particularly cardioprotective large-size HDL particles, and reduced HDL efflux capacity. Stay tuned regarding these potential early markers, Dr. Paller advised.
She was lead author of a 409-patient international study that showed the risks of obesity and a high waist circumference rise with greater severity of pediatric psoriasis. Children with severe psoriasis were at 4.92-fold increased risk of obesity, compared with controls, while even those with mild psoriasis were at 3.6-fold increased risk (JAMA Dermatol. 2013;149:166-76).
Which comes first?
The question arises: Which comes first in children, the excess adiposity or the psoriasis? Dr. Paller said that although the final word isn’t in, she and her coworkers found in a pilot study of 27 overweight or obese children with psoriasis that excess adiposity typically came first. Moreover, among the roughly one-half of children with a family history of obesity, onset of psoriasis occurred a full 3 years earlier than in those without a positive family history (JAMA Dermatol. 2014;150:573-4).
In another small study, this by investigators at Tufts University, Boston, 6 of 20 children with psoriasis (30%) met criteria for the metabolic syndrome, compared with just 1 of 20 matched nonpsoriatic controls (Pediatr. Dermatol. 2013;30:700-5).
Dr. Paller said that if dermatologists and primary care physicians are to successfully collaborate in tackling the comorbid metabolic disorders associated with pediatric psoriasis, a prerequisite is that dermatologists are going to have to do a better job of educating their primary care colleagues about the skin disease as manifest in children.
“I think it’s very important that pediatricians are aware that psoriasis is a risk factor for metabolic syndrome. But pediatric psoriasis is often misdiagnosed by primary care physicians who mistake it for eczema or tinea infection or contact dermatitis,” according to the pediatric dermatologist.
In one eye-catching Australian study, she noted, a mere 9% of patients with pediatric psoriasis were correctly diagnosed before referral to a dermatologist (Australas. J. Dermatol. 2012;53:98-105).
Pediatric psoriasis: not just skin deep
In addition to the increased risk of metabolic disorders faced by pediatric psoriasis patients, other common comorbidities include depression, anxiety disorders, impaired self-esteem and quality of life, arthritis, and Crohn’s disease, Dr. Paller observed.
• Quality of life. “The quality of life impact of psoriasis is profound. It’s a highly visible disorder, which affects the development of self-esteem and social relationships,” Dr. Paller said.
Investigators at Texas A&M University applied the Pediatric Quality of Life Inventory Version 4.0 to 208 patients aged 2-17 years with moderate to severe psoriasis and compared the results to published data on children with arthritis, asthma, diabetes, and psychiatric disorders. Health-related quality of life turned out to be more impaired in the psoriasis patients than in those with diabetes. The quality-of-life impairment associated with pediatric psoriasis was comparable to that of having asthma or arthritis, albeit not as severe as for pediatric psychiatric disorders (Eur. J. Pediatr. 2012;171:485-92).
• Psychiatric disorders. A study of more than 7,400 pediatric psoriasis patients concluded they had an adjusted 25% increased risk of developing depression, compared with psoriasis-free controls, as well as a 32% increased risk of anxiety disorders and a 55% greater risk of bipolar disorder (J. Am. Acad. Dermatol. 2012;67:651-7.e2).
• Psoriatic arthritis. An estimated 1 in 10 U.S. children with psoriasis report having arthritis, often classified as juvenile idiopathic arthritis (JAMA Dermatol. 2013;149:1180-5).
• Crohn’s disease. A large German epidemiologic study concluded that psoriasis was associated with a 3.69-fold increased risk of Crohn’s disease. There was no increased risk of ulcerative colitis (Br. J. Dermatol. 2010;162:633-6).
Dr. Paller reported receiving research grants from Amgen and Leo and serving as a consultant to AbbVie.
EXPERT ANALYSIS FROM WCD 2015
WCD: EDTA wash eliminates toluidine blue staining artifacts in Mohs surgery
VANCOUVER – Investigators at the Memorial Sloan Kettering Skin Cancer Center in Hauppauge, N.Y. have found a simple solution for a vexing problem in Mohs surgery, histology sections that don’t fully stain with toluidine blue.
The problem, it turns out, is that aluminum chloride and Monsel’s solution (ferric subsulfate) – common topical hemostatics used during the procedure – block the stain from binding tissue. Washing sections in ethylenediaminetetraacetic acid (EDTA) before staining completely eliminates the problem.
“I think this will be very useful for Mohs surgeons. It’s a very simple step, a simple modification of routine staining protocol that [eradicates] this type of artifact. When technicians collect the specimen onto the slide, they wash it with EDTA solution for about 10 seconds.” Toluidine blue staining afterward “will be perfect. There won’t be any artifact,” said senior investigator Dr. Chih-Shan Jason Chen, director of dermatologic surgery at the Hauppauge center.
It’s an important finding (and one not yet published in the medical literature, according to Dr. Chen) because staining artifacts make it impossible to read toluidine blue sections with confidence, so Mohs surgeons have to go back and take more sections, creating a deeper wound.
Over a period of the past 2 years, the EDTA wash “has made a significant difference in my practice. I never see this type of artifact anymore. I can be very comfortable taking a very thin layer of tissue and don’t need to take extra stages. We don’t need to do fancy reconstructive surgery” for the wound to heal. “This process fits with the spirit of Mohs surgery, the concept of tissue conservation,” Dr. Chen said at the World Congress of Dermatology.
Perhaps about 20% of Mohs surgeons rely heavily on toluidine blue, especially to stain for basal cell carcinomas. “The nests of cancer cells are very small, so if you have an artifact, you are going to miss them,” he noted.
The first clue that hemostatic agents were to blame was that the artifacts didn’t occur with the first Mohs cut, but only in second and subsequent sections after hemostatic agents had been applied, and especially in thinner sections more permeable to those agents. Dr. Chen tried the EDTA wash, and it worked.
His research assistant, Curtis Chen, an incoming medical student at the University of Miami, figured out the chemistry. Aluminum and iron cations from the agents bind the tissue sample, inhibiting adherence of toluidine blue. EDTA, a chelating agent, scavenges the ions, releasing the tissue for staining.
Dr. Chen and Mr. Chen had no relevant financial disclosures, and there was no outside funding for the work.
VANCOUVER – Investigators at the Memorial Sloan Kettering Skin Cancer Center in Hauppauge, N.Y. have found a simple solution for a vexing problem in Mohs surgery, histology sections that don’t fully stain with toluidine blue.
The problem, it turns out, is that aluminum chloride and Monsel’s solution (ferric subsulfate) – common topical hemostatics used during the procedure – block the stain from binding tissue. Washing sections in ethylenediaminetetraacetic acid (EDTA) before staining completely eliminates the problem.
“I think this will be very useful for Mohs surgeons. It’s a very simple step, a simple modification of routine staining protocol that [eradicates] this type of artifact. When technicians collect the specimen onto the slide, they wash it with EDTA solution for about 10 seconds.” Toluidine blue staining afterward “will be perfect. There won’t be any artifact,” said senior investigator Dr. Chih-Shan Jason Chen, director of dermatologic surgery at the Hauppauge center.
It’s an important finding (and one not yet published in the medical literature, according to Dr. Chen) because staining artifacts make it impossible to read toluidine blue sections with confidence, so Mohs surgeons have to go back and take more sections, creating a deeper wound.
Over a period of the past 2 years, the EDTA wash “has made a significant difference in my practice. I never see this type of artifact anymore. I can be very comfortable taking a very thin layer of tissue and don’t need to take extra stages. We don’t need to do fancy reconstructive surgery” for the wound to heal. “This process fits with the spirit of Mohs surgery, the concept of tissue conservation,” Dr. Chen said at the World Congress of Dermatology.
Perhaps about 20% of Mohs surgeons rely heavily on toluidine blue, especially to stain for basal cell carcinomas. “The nests of cancer cells are very small, so if you have an artifact, you are going to miss them,” he noted.
The first clue that hemostatic agents were to blame was that the artifacts didn’t occur with the first Mohs cut, but only in second and subsequent sections after hemostatic agents had been applied, and especially in thinner sections more permeable to those agents. Dr. Chen tried the EDTA wash, and it worked.
His research assistant, Curtis Chen, an incoming medical student at the University of Miami, figured out the chemistry. Aluminum and iron cations from the agents bind the tissue sample, inhibiting adherence of toluidine blue. EDTA, a chelating agent, scavenges the ions, releasing the tissue for staining.
Dr. Chen and Mr. Chen had no relevant financial disclosures, and there was no outside funding for the work.
VANCOUVER – Investigators at the Memorial Sloan Kettering Skin Cancer Center in Hauppauge, N.Y. have found a simple solution for a vexing problem in Mohs surgery, histology sections that don’t fully stain with toluidine blue.
The problem, it turns out, is that aluminum chloride and Monsel’s solution (ferric subsulfate) – common topical hemostatics used during the procedure – block the stain from binding tissue. Washing sections in ethylenediaminetetraacetic acid (EDTA) before staining completely eliminates the problem.
“I think this will be very useful for Mohs surgeons. It’s a very simple step, a simple modification of routine staining protocol that [eradicates] this type of artifact. When technicians collect the specimen onto the slide, they wash it with EDTA solution for about 10 seconds.” Toluidine blue staining afterward “will be perfect. There won’t be any artifact,” said senior investigator Dr. Chih-Shan Jason Chen, director of dermatologic surgery at the Hauppauge center.
It’s an important finding (and one not yet published in the medical literature, according to Dr. Chen) because staining artifacts make it impossible to read toluidine blue sections with confidence, so Mohs surgeons have to go back and take more sections, creating a deeper wound.
Over a period of the past 2 years, the EDTA wash “has made a significant difference in my practice. I never see this type of artifact anymore. I can be very comfortable taking a very thin layer of tissue and don’t need to take extra stages. We don’t need to do fancy reconstructive surgery” for the wound to heal. “This process fits with the spirit of Mohs surgery, the concept of tissue conservation,” Dr. Chen said at the World Congress of Dermatology.
Perhaps about 20% of Mohs surgeons rely heavily on toluidine blue, especially to stain for basal cell carcinomas. “The nests of cancer cells are very small, so if you have an artifact, you are going to miss them,” he noted.
The first clue that hemostatic agents were to blame was that the artifacts didn’t occur with the first Mohs cut, but only in second and subsequent sections after hemostatic agents had been applied, and especially in thinner sections more permeable to those agents. Dr. Chen tried the EDTA wash, and it worked.
His research assistant, Curtis Chen, an incoming medical student at the University of Miami, figured out the chemistry. Aluminum and iron cations from the agents bind the tissue sample, inhibiting adherence of toluidine blue. EDTA, a chelating agent, scavenges the ions, releasing the tissue for staining.
Dr. Chen and Mr. Chen had no relevant financial disclosures, and there was no outside funding for the work.
EXPERT ANALYSIS FROM WCD 2015
WCD: Pramocaine Is a Common Contact Sensitizer
VANCOUVER – Pramocaine, a topical anesthetic long used in many OTC anti-itch preparations, turns out to itself be a common cause of contact sensitization, Dr. Mariam Abbas reported at the World Congress of Dermatology.
Pramocaine, also known as pramoxine, is an ingredient in Gold Bond cream, some forms of calamine lotion, hemorrhoid relief products, and other OTC antipruritic agents. It’s not available in commercial patch test kits, so Dr. Abbas created a test material comprised of 2% pramocaine in petrolatum.
Seven of 232 patients (3%) referred to a university patch test clinic and who underwent testing to pramocaine along with recognized contact sensitizers showed a clear positive response to pramocaine at 96 hours. The reactions were clinically relevant, according to Dr. Abbas of the University of Alberta, Edmonton.
That 3% positive rate is in the range of published figures for such well-known problem contact sensitizers as neomycin, thiuram mix, and Balsam of Peru.
Dr. Mariam Abbas reported having no financial conflicts regarding this study, conducted free of commercial support.
VANCOUVER – Pramocaine, a topical anesthetic long used in many OTC anti-itch preparations, turns out to itself be a common cause of contact sensitization, Dr. Mariam Abbas reported at the World Congress of Dermatology.
Pramocaine, also known as pramoxine, is an ingredient in Gold Bond cream, some forms of calamine lotion, hemorrhoid relief products, and other OTC antipruritic agents. It’s not available in commercial patch test kits, so Dr. Abbas created a test material comprised of 2% pramocaine in petrolatum.
Seven of 232 patients (3%) referred to a university patch test clinic and who underwent testing to pramocaine along with recognized contact sensitizers showed a clear positive response to pramocaine at 96 hours. The reactions were clinically relevant, according to Dr. Abbas of the University of Alberta, Edmonton.
That 3% positive rate is in the range of published figures for such well-known problem contact sensitizers as neomycin, thiuram mix, and Balsam of Peru.
Dr. Mariam Abbas reported having no financial conflicts regarding this study, conducted free of commercial support.
VANCOUVER – Pramocaine, a topical anesthetic long used in many OTC anti-itch preparations, turns out to itself be a common cause of contact sensitization, Dr. Mariam Abbas reported at the World Congress of Dermatology.
Pramocaine, also known as pramoxine, is an ingredient in Gold Bond cream, some forms of calamine lotion, hemorrhoid relief products, and other OTC antipruritic agents. It’s not available in commercial patch test kits, so Dr. Abbas created a test material comprised of 2% pramocaine in petrolatum.
Seven of 232 patients (3%) referred to a university patch test clinic and who underwent testing to pramocaine along with recognized contact sensitizers showed a clear positive response to pramocaine at 96 hours. The reactions were clinically relevant, according to Dr. Abbas of the University of Alberta, Edmonton.
That 3% positive rate is in the range of published figures for such well-known problem contact sensitizers as neomycin, thiuram mix, and Balsam of Peru.
Dr. Mariam Abbas reported having no financial conflicts regarding this study, conducted free of commercial support.
AT WCD 2015
WCD: Pramocaine is a common contact sensitizer
VANCOUVER – Pramocaine, a topical anesthetic long used in many OTC anti-itch preparations, turns out to itself be a common cause of contact sensitization, Dr. Mariam Abbas reported at the World Congress of Dermatology.
Pramocaine, also known as pramoxine, is an ingredient in Gold Bond cream, some forms of calamine lotion, hemorrhoid relief products, and other OTC antipruritic agents. It’s not available in commercial patch test kits, so Dr. Abbas created a test material comprised of 2% pramocaine in petrolatum.
Seven of 232 patients (3%) referred to a university patch test clinic and who underwent testing to pramocaine along with recognized contact sensitizers showed a clear positive response to pramocaine at 96 hours. The reactions were clinically relevant, according to Dr. Abbas of the University of Alberta, Edmonton.
That 3% positive rate is in the range of published figures for such well-known problem contact sensitizers as neomycin, thiuram mix, and Balsam of Peru.
Dr. Mariam Abbas reported having no financial conflicts regarding this study, conducted free of commercial support.
VANCOUVER – Pramocaine, a topical anesthetic long used in many OTC anti-itch preparations, turns out to itself be a common cause of contact sensitization, Dr. Mariam Abbas reported at the World Congress of Dermatology.
Pramocaine, also known as pramoxine, is an ingredient in Gold Bond cream, some forms of calamine lotion, hemorrhoid relief products, and other OTC antipruritic agents. It’s not available in commercial patch test kits, so Dr. Abbas created a test material comprised of 2% pramocaine in petrolatum.
Seven of 232 patients (3%) referred to a university patch test clinic and who underwent testing to pramocaine along with recognized contact sensitizers showed a clear positive response to pramocaine at 96 hours. The reactions were clinically relevant, according to Dr. Abbas of the University of Alberta, Edmonton.
That 3% positive rate is in the range of published figures for such well-known problem contact sensitizers as neomycin, thiuram mix, and Balsam of Peru.
Dr. Mariam Abbas reported having no financial conflicts regarding this study, conducted free of commercial support.
VANCOUVER – Pramocaine, a topical anesthetic long used in many OTC anti-itch preparations, turns out to itself be a common cause of contact sensitization, Dr. Mariam Abbas reported at the World Congress of Dermatology.
Pramocaine, also known as pramoxine, is an ingredient in Gold Bond cream, some forms of calamine lotion, hemorrhoid relief products, and other OTC antipruritic agents. It’s not available in commercial patch test kits, so Dr. Abbas created a test material comprised of 2% pramocaine in petrolatum.
Seven of 232 patients (3%) referred to a university patch test clinic and who underwent testing to pramocaine along with recognized contact sensitizers showed a clear positive response to pramocaine at 96 hours. The reactions were clinically relevant, according to Dr. Abbas of the University of Alberta, Edmonton.
That 3% positive rate is in the range of published figures for such well-known problem contact sensitizers as neomycin, thiuram mix, and Balsam of Peru.
Dr. Mariam Abbas reported having no financial conflicts regarding this study, conducted free of commercial support.
AT WCD 2015
Key clinical point: Pramocaine, a topical anesthetic that’s an ingredient in many widely used OTC anti-itch products, turns out to be a common cause of contact sensitization.
Major finding: Seven of 232 patients (3%) referred to a patch test clinic showed a clinically relevant positive test to pramocaine.
Data source: A prospective study of 232 patients referred to a patch test clinic.
Disclosures: Dr. Mariam Abbas reported having no financial conflicts regarding this study, conducted free of commercial support.