Greg Muirhead

MAUI, HAWAII – A high-fat ketogenic diet is effective in helping epilepsy patients control their seizures, but it is underused because it is misunderstood, said Dr. Eileen P.G. Vining.

The diet is not difficult. It can be palatable, adaptable, and inexpensive, she explained at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

It has been estimated that the diet is initiated in only about 2,500 patients each year, based on a rough calculation of published data, while approximately 100 million people worldwide have epilepsy, according to the World Health Organization, she said.

The ketogenic diet is a high-fat, low-carbohydrate diet that provides adequate protein (1 g/kg per day), but greatly restricts carbohydrate intake, Dr. Vining said at the meeting, also sponsored by California Chapter 2 of the AAP. The effect of the diet is to mimic ketosis. The ketogenic diet's fat-to-carbohydrate and protein ratio may range from 2:1 (less strict) to 4:1 (very strict), with an average of 3:1. At a 3:1 ratio, fat intake accounts for 80%-90% of calories.

“We know the diet is effective for a wide variety of seizures,” said Dr. Vining, director of the John M. Freeman Pediatric Epilepsy Center at the Johns Hopkins Hospital, Baltimore.

She admitted, however, that “we don't understand the biology of the ketogenic diet.”

About 46% of patients on the diet have greater than 90% control of seizures at 12 months, she said. For those using the diet, medications often can be decreased, although for patients helped by just two or three medications, it may make sense to continue them.

But a study on more “aggressive” discontinuation of medications found good results even within 1 month (Epilepsy Behav. 2004;5:499–502). “There are some 'superresponders' who become seizure free within the first 2 weeks,” added Dr. Vining, who is also professor of neurology and pediatrics at Johns Hopkins University.

The diet emerged in the 1920s, when it was discovered that a person who is fasting becomes ketotic, she explained.

Researchers at the Mayo Clinic developed the idea that changing the nutrient structure of a diet would mimic fasting. By using the ketogenic diet, a person is put in a constant state of ketosis. The diet was popular until phenytoin came on the market and was seen as easier to use than maintaining the diet, she said. But the diet has had a resurgence since the mid-1990s. It is comparable to the popular Atkins diet for weight loss (Epilepsia 2006;47:421–4).

Prior to beginning the diet at Johns Hopkins' clinic, children fast for 24 hours and are seen in the clinic on Monday morning. They are then admitted to the clinic for 4 days (Monday-Thursday), where they are given eggnog to increase the fat in their diet from one-third to two-thirds of the full calories, and finally to a full percentage of calories using regular food. Individual adjustments are made to maintain 80–160 mmol urinary ketosis and to avoid significant weight gain or loss.

Dr. Vining cited several studies in support of the effectiveness of the diet.

A large prospective study that was conducted at Johns Hopkins enrolled 150 children with a mean age of 5.3 years and a mean monthly seizure rate of 410. The children used a mean of 6.2 antiepileptic drugs prior to initiating the diet. At 3 months, 83% remained on the diet, and 34% experienced greater than 90% reduction in seizures. At 12 months, 55% of the children remained on the diet, and 27% had greater than 90% reduction in seizures. The diet appeared to work across a wide spectrum of ages and seizure types.

Another study found that after 1 year of being on the diet, 74% of pediatric patients were able to reduce their medications, with the number on two medications was reduced from 79% to 23%. No medications were needed by 48%. There was a 67% reduction in medication costs, resulting in an average savings of about $1,000 per child per year (J. Child. Neurol. 1999;14:469–71).

A downside to the diet is impaired growth. A study conducted by Dr. Vining of 237 children ranging in age from 2 months to 9 years and 10 months found at 1 year that weight had not substantially increased and linear growth had also been reduced (Dev. Med. Child. Neurol. 2002;44:796–802).

Another study by Dr. Vining and her associates found that use of the diet for as long as 2 years resulted in elevated triglycerides, total cholesterol, and LDL cholesterol levels but no rise in HDL cholesterol levels (JAMA 2003;290:912–20). Also, acidosis is seen routinely.

Kidney stone risk was found to increase to 5.4% (6/112), with a calcium/creatinine ratio greater than 0.2 being an important risk factor in one study (Epilepsia 2000;43:1168–71). But treatment with Polycitra-K (an oral potassium citrate supplement) appears to reduce this risk, she said.

A 2004 study found that the ketogenic diet is used at 80 centers in the United States and at 70 centers in 41 countries. Continued use in patients has ranged from 1 to 45 years, with a median of 8 years. The average number of people per country using the diet was 71.6, with 5.4 started per year–with a range of 0–40 (Epilepsia 2004;45:1163).

MAUI, HAWAII – A high-fat ketogenic diet is effective in helping epilepsy patients control their seizures, but it is underused because it is misunderstood, said Dr. Eileen P.G. Vining.

The diet is not difficult. It can be palatable, adaptable, and inexpensive, she explained at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

It has been estimated that the diet is initiated in only about 2,500 patients each year, based on a rough calculation of published data, while approximately 100 million people worldwide have epilepsy, according to the World Health Organization, she said.

The ketogenic diet is a high-fat, low-carbohydrate diet that provides adequate protein (1 g/kg per day), but greatly restricts carbohydrate intake, Dr. Vining said at the meeting, also sponsored by California Chapter 2 of the AAP. The effect of the diet is to mimic ketosis. The ketogenic diet's fat-to-carbohydrate and protein ratio may range from 2:1 (less strict) to 4:1 (very strict), with an average of 3:1. At a 3:1 ratio, fat intake accounts for 80%-90% of calories.

“We know the diet is effective for a wide variety of seizures,” said Dr. Vining, director of the John M. Freeman Pediatric Epilepsy Center at the Johns Hopkins Hospital, Baltimore.

She admitted, however, that “we don't understand the biology of the ketogenic diet.”

About 46% of patients on the diet have greater than 90% control of seizures at 12 months, she said. For those using the diet, medications often can be decreased, although for patients helped by just two or three medications, it may make sense to continue them.

But a study on more “aggressive” discontinuation of medications found good results even within 1 month (Epilepsy Behav. 2004;5:499–502). “There are some 'superresponders' who become seizure free within the first 2 weeks,” added Dr. Vining, who is also professor of neurology and pediatrics at Johns Hopkins University.

The diet emerged in the 1920s, when it was discovered that a person who is fasting becomes ketotic, she explained.

Researchers at the Mayo Clinic developed the idea that changing the nutrient structure of a diet would mimic fasting. By using the ketogenic diet, a person is put in a constant state of ketosis. The diet was popular until phenytoin came on the market and was seen as easier to use than maintaining the diet, she said. But the diet has had a resurgence since the mid-1990s. It is comparable to the popular Atkins diet for weight loss (Epilepsia 2006;47:421–4).

Prior to beginning the diet at Johns Hopkins' clinic, children fast for 24 hours and are seen in the clinic on Monday morning. They are then admitted to the clinic for 4 days (Monday-Thursday), where they are given eggnog to increase the fat in their diet from one-third to two-thirds of the full calories, and finally to a full percentage of calories using regular food. Individual adjustments are made to maintain 80–160 mmol urinary ketosis and to avoid significant weight gain or loss.

Dr. Vining cited several studies in support of the effectiveness of the diet.

A large prospective study that was conducted at Johns Hopkins enrolled 150 children with a mean age of 5.3 years and a mean monthly seizure rate of 410. The children used a mean of 6.2 antiepileptic drugs prior to initiating the diet. At 3 months, 83% remained on the diet, and 34% experienced greater than 90% reduction in seizures. At 12 months, 55% of the children remained on the diet, and 27% had greater than 90% reduction in seizures. The diet appeared to work across a wide spectrum of ages and seizure types.

Another study found that after 1 year of being on the diet, 74% of pediatric patients were able to reduce their medications, with the number on two medications was reduced from 79% to 23%. No medications were needed by 48%. There was a 67% reduction in medication costs, resulting in an average savings of about $1,000 per child per year (J. Child. Neurol. 1999;14:469–71).

A downside to the diet is impaired growth. A study conducted by Dr. Vining of 237 children ranging in age from 2 months to 9 years and 10 months found at 1 year that weight had not substantially increased and linear growth had also been reduced (Dev. Med. Child. Neurol. 2002;44:796–802).

Another study by Dr. Vining and her associates found that use of the diet for as long as 2 years resulted in elevated triglycerides, total cholesterol, and LDL cholesterol levels but no rise in HDL cholesterol levels (JAMA 2003;290:912–20). Also, acidosis is seen routinely.

Kidney stone risk was found to increase to 5.4% (6/112), with a calcium/creatinine ratio greater than 0.2 being an important risk factor in one study (Epilepsia 2000;43:1168–71). But treatment with Polycitra-K (an oral potassium citrate supplement) appears to reduce this risk, she said.

A 2004 study found that the ketogenic diet is used at 80 centers in the United States and at 70 centers in 41 countries. Continued use in patients has ranged from 1 to 45 years, with a median of 8 years. The average number of people per country using the diet was 71.6, with 5.4 started per year–with a range of 0–40 (Epilepsia 2004;45:1163).

MAUI, HAWAII – A high-fat ketogenic diet is effective in helping epilepsy patients control their seizures, but it is underused because it is misunderstood, said Dr. Eileen P.G. Vining.

The diet is not difficult. It can be palatable, adaptable, and inexpensive, she explained at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

It has been estimated that the diet is initiated in only about 2,500 patients each year, based on a rough calculation of published data, while approximately 100 million people worldwide have epilepsy, according to the World Health Organization, she said.

The ketogenic diet is a high-fat, low-carbohydrate diet that provides adequate protein (1 g/kg per day), but greatly restricts carbohydrate intake, Dr. Vining said at the meeting, also sponsored by California Chapter 2 of the AAP. The effect of the diet is to mimic ketosis. The ketogenic diet's fat-to-carbohydrate and protein ratio may range from 2:1 (less strict) to 4:1 (very strict), with an average of 3:1. At a 3:1 ratio, fat intake accounts for 80%-90% of calories.

“We know the diet is effective for a wide variety of seizures,” said Dr. Vining, director of the John M. Freeman Pediatric Epilepsy Center at the Johns Hopkins Hospital, Baltimore.

She admitted, however, that “we don't understand the biology of the ketogenic diet.”

About 46% of patients on the diet have greater than 90% control of seizures at 12 months, she said. For those using the diet, medications often can be decreased, although for patients helped by just two or three medications, it may make sense to continue them.

But a study on more “aggressive” discontinuation of medications found good results even within 1 month (Epilepsy Behav. 2004;5:499–502). “There are some 'superresponders' who become seizure free within the first 2 weeks,” added Dr. Vining, who is also professor of neurology and pediatrics at Johns Hopkins University.

The diet emerged in the 1920s, when it was discovered that a person who is fasting becomes ketotic, she explained.

Researchers at the Mayo Clinic developed the idea that changing the nutrient structure of a diet would mimic fasting. By using the ketogenic diet, a person is put in a constant state of ketosis. The diet was popular until phenytoin came on the market and was seen as easier to use than maintaining the diet, she said. But the diet has had a resurgence since the mid-1990s. It is comparable to the popular Atkins diet for weight loss (Epilepsia 2006;47:421–4).

Prior to beginning the diet at Johns Hopkins' clinic, children fast for 24 hours and are seen in the clinic on Monday morning. They are then admitted to the clinic for 4 days (Monday-Thursday), where they are given eggnog to increase the fat in their diet from one-third to two-thirds of the full calories, and finally to a full percentage of calories using regular food. Individual adjustments are made to maintain 80–160 mmol urinary ketosis and to avoid significant weight gain or loss.

Dr. Vining cited several studies in support of the effectiveness of the diet.

A large prospective study that was conducted at Johns Hopkins enrolled 150 children with a mean age of 5.3 years and a mean monthly seizure rate of 410. The children used a mean of 6.2 antiepileptic drugs prior to initiating the diet. At 3 months, 83% remained on the diet, and 34% experienced greater than 90% reduction in seizures. At 12 months, 55% of the children remained on the diet, and 27% had greater than 90% reduction in seizures. The diet appeared to work across a wide spectrum of ages and seizure types.

Another study found that after 1 year of being on the diet, 74% of pediatric patients were able to reduce their medications, with the number on two medications was reduced from 79% to 23%. No medications were needed by 48%. There was a 67% reduction in medication costs, resulting in an average savings of about $1,000 per child per year (J. Child. Neurol. 1999;14:469–71).

A downside to the diet is impaired growth. A study conducted by Dr. Vining of 237 children ranging in age from 2 months to 9 years and 10 months found at 1 year that weight had not substantially increased and linear growth had also been reduced (Dev. Med. Child. Neurol. 2002;44:796–802).

Another study by Dr. Vining and her associates found that use of the diet for as long as 2 years resulted in elevated triglycerides, total cholesterol, and LDL cholesterol levels but no rise in HDL cholesterol levels (JAMA 2003;290:912–20). Also, acidosis is seen routinely.

Kidney stone risk was found to increase to 5.4% (6/112), with a calcium/creatinine ratio greater than 0.2 being an important risk factor in one study (Epilepsia 2000;43:1168–71). But treatment with Polycitra-K (an oral potassium citrate supplement) appears to reduce this risk, she said.

A 2004 study found that the ketogenic diet is used at 80 centers in the United States and at 70 centers in 41 countries. Continued use in patients has ranged from 1 to 45 years, with a median of 8 years. The average number of people per country using the diet was 71.6, with 5.4 started per year–with a range of 0–40 (Epilepsia 2004;45:1163).

HONOLULU — Bazedoxifene reduced the risk of new vertebral fractures in postmenopausal women with osteoporosis, according to the results of a 3-year, phase III, placebo-controlled trial presented at the annual meeting of the American Society for Bone and Mineral Research.

“In postmenopausal women with osteoporosis, bazedoxifene reduced the incidence of new vertebral fractures up to 42%,” said Dr. Stuart L. Silverman, medical director of the Osteoporosis Medical Center, in Beverly Hills, Calif. Funding for this study came from Wyeth Pharmaceuticals. Dr. Silverman disclosed that he had received research grants from Wyeth as well as several other pharmaceutical companies

“The treatment effect did not appear to be different between women with or without prevalent vertebral fractures,” he said, and added, however, “Overall there was no significant treatment effect on nonvertebral fracture.”

The trial included 7,492 healthy postmenopausal women, aged 55–85 years, who had lumbar spine or femoral neck T scores less than or equal to -2.5 and no vertebral fractures, or who had no lumbar spine or femoral neck T scores greater than or equal to -4.0 but had vertebral fractures. Their mean age was 66 years, and all were postmenopausal by at least 2 years. At baseline, 56% of the women had one or more vertebral fractures, most of which were mild.

The objective of the trial was to assess the efficacy and safety of therapy with bazedoxifene, compared with raloxifene and placebo, in postmenopausal osteoporotic women.

The women were randomized to receive, daily, 20 mg or 40 mg bazedoxifene, 60 mg raloxifene, or placebo. In addition, participants received daily supplements of up to 1,200 mg oral calcium and up to 800 IU oral vitamin D.

The primary outcome was incidence of new vertebral fractures by month 36 of treatment, whereas incidence of new nonvertebral fractures was a secondary outcome. As of month 36, incidence of new vertebral fractures was 2.3% and 2.5%, respectively, for women taking 20 mg or 40 mg bazedoxifene; 2.3% for those taking 60 mg raloxifene; and 4.1% for those taking placebo.

As for the secondary outcome, no overall effect from treatment was found in the prevention of nonvertebral fractures. However, a post hoc analysis found that in 1,782 women at higher risk for fractures, reduction of nonvertebral fracture incidence was 3.0% and 3.8% for women taking 20 mg or 40 mg bazedoxifene, respectively; 5.9% for those taking 60 mg raloxifene; and 6.3% for those taking placebo (Osteoporos. Int. 2007;18:761–70).

Of the 7,492 patients who enrolled in the trial, 2,501 discontinued participation. Overall, 7,186 patients reported at least one adverse event. Almost all of the adverse events were treatment emergent, and the incidence of these was similar for all treatment groups.

In patients using bazedoxifene, no safety concerns were found regarding gynecologic and cardiovascular systems. However, a higher incidence of deep vein thrombosis was found in bazedoxifene users, compared with patients using placebo.

Differences in mortality among the treatment groups were not statistically significant. Two subjects from each treatment group—a total of eight—died from myocardial infarction.

ELSEVIER GLOBAL MEDICAL NEWS

HONOLULU — Bazedoxifene reduced the risk of new vertebral fractures in postmenopausal women with osteoporosis, according to the results of a 3-year, phase III, placebo-controlled trial presented at the annual meeting of the American Society for Bone and Mineral Research.

“In postmenopausal women with osteoporosis, bazedoxifene reduced the incidence of new vertebral fractures up to 42%,” said Dr. Stuart L. Silverman, medical director of the Osteoporosis Medical Center, in Beverly Hills, Calif. Funding for this study came from Wyeth Pharmaceuticals. Dr. Silverman disclosed that he had received research grants from Wyeth as well as several other pharmaceutical companies

“The treatment effect did not appear to be different between women with or without prevalent vertebral fractures,” he said, and added, however, “Overall there was no significant treatment effect on nonvertebral fracture.”

The trial included 7,492 healthy postmenopausal women, aged 55–85 years, who had lumbar spine or femoral neck T scores less than or equal to -2.5 and no vertebral fractures, or who had no lumbar spine or femoral neck T scores greater than or equal to -4.0 but had vertebral fractures. Their mean age was 66 years, and all were postmenopausal by at least 2 years. At baseline, 56% of the women had one or more vertebral fractures, most of which were mild.

The objective of the trial was to assess the efficacy and safety of therapy with bazedoxifene, compared with raloxifene and placebo, in postmenopausal osteoporotic women.

The women were randomized to receive, daily, 20 mg or 40 mg bazedoxifene, 60 mg raloxifene, or placebo. In addition, participants received daily supplements of up to 1,200 mg oral calcium and up to 800 IU oral vitamin D.

The primary outcome was incidence of new vertebral fractures by month 36 of treatment, whereas incidence of new nonvertebral fractures was a secondary outcome. As of month 36, incidence of new vertebral fractures was 2.3% and 2.5%, respectively, for women taking 20 mg or 40 mg bazedoxifene; 2.3% for those taking 60 mg raloxifene; and 4.1% for those taking placebo.

As for the secondary outcome, no overall effect from treatment was found in the prevention of nonvertebral fractures. However, a post hoc analysis found that in 1,782 women at higher risk for fractures, reduction of nonvertebral fracture incidence was 3.0% and 3.8% for women taking 20 mg or 40 mg bazedoxifene, respectively; 5.9% for those taking 60 mg raloxifene; and 6.3% for those taking placebo (Osteoporos. Int. 2007;18:761–70).

Of the 7,492 patients who enrolled in the trial, 2,501 discontinued participation. Overall, 7,186 patients reported at least one adverse event. Almost all of the adverse events were treatment emergent, and the incidence of these was similar for all treatment groups.

In patients using bazedoxifene, no safety concerns were found regarding gynecologic and cardiovascular systems. However, a higher incidence of deep vein thrombosis was found in bazedoxifene users, compared with patients using placebo.

Differences in mortality among the treatment groups were not statistically significant. Two subjects from each treatment group—a total of eight—died from myocardial infarction.

ELSEVIER GLOBAL MEDICAL NEWS

HONOLULU — Bazedoxifene reduced the risk of new vertebral fractures in postmenopausal women with osteoporosis, according to the results of a 3-year, phase III, placebo-controlled trial presented at the annual meeting of the American Society for Bone and Mineral Research.

“In postmenopausal women with osteoporosis, bazedoxifene reduced the incidence of new vertebral fractures up to 42%,” said Dr. Stuart L. Silverman, medical director of the Osteoporosis Medical Center, in Beverly Hills, Calif. Funding for this study came from Wyeth Pharmaceuticals. Dr. Silverman disclosed that he had received research grants from Wyeth as well as several other pharmaceutical companies

“The treatment effect did not appear to be different between women with or without prevalent vertebral fractures,” he said, and added, however, “Overall there was no significant treatment effect on nonvertebral fracture.”

The trial included 7,492 healthy postmenopausal women, aged 55–85 years, who had lumbar spine or femoral neck T scores less than or equal to -2.5 and no vertebral fractures, or who had no lumbar spine or femoral neck T scores greater than or equal to -4.0 but had vertebral fractures. Their mean age was 66 years, and all were postmenopausal by at least 2 years. At baseline, 56% of the women had one or more vertebral fractures, most of which were mild.

The objective of the trial was to assess the efficacy and safety of therapy with bazedoxifene, compared with raloxifene and placebo, in postmenopausal osteoporotic women.

The women were randomized to receive, daily, 20 mg or 40 mg bazedoxifene, 60 mg raloxifene, or placebo. In addition, participants received daily supplements of up to 1,200 mg oral calcium and up to 800 IU oral vitamin D.

The primary outcome was incidence of new vertebral fractures by month 36 of treatment, whereas incidence of new nonvertebral fractures was a secondary outcome. As of month 36, incidence of new vertebral fractures was 2.3% and 2.5%, respectively, for women taking 20 mg or 40 mg bazedoxifene; 2.3% for those taking 60 mg raloxifene; and 4.1% for those taking placebo.

As for the secondary outcome, no overall effect from treatment was found in the prevention of nonvertebral fractures. However, a post hoc analysis found that in 1,782 women at higher risk for fractures, reduction of nonvertebral fracture incidence was 3.0% and 3.8% for women taking 20 mg or 40 mg bazedoxifene, respectively; 5.9% for those taking 60 mg raloxifene; and 6.3% for those taking placebo (Osteoporos. Int. 2007;18:761–70).

Of the 7,492 patients who enrolled in the trial, 2,501 discontinued participation. Overall, 7,186 patients reported at least one adverse event. Almost all of the adverse events were treatment emergent, and the incidence of these was similar for all treatment groups.

In patients using bazedoxifene, no safety concerns were found regarding gynecologic and cardiovascular systems. However, a higher incidence of deep vein thrombosis was found in bazedoxifene users, compared with patients using placebo.

Differences in mortality among the treatment groups were not statistically significant. Two subjects from each treatment group—a total of eight—died from myocardial infarction.

ELSEVIER GLOBAL MEDICAL NEWS

HONOLULU — Although many black men with pseudofolliculitis barbae, otherwise known as "razor bumps," may express horror at the idea of shaving every day, this may be their best option, said Dr. Milton Moore at the annual meeting of the National Medical Association.

"You'd be surprised at how many African American men, when you talk about shaving with razors, [say,] 'Oh no, I can't do that!' " said Dr. Moore, who is in private practice in Houston. "Many of them don't even know that they can shave. They know Dad couldn't, and Dad didn't, and Dad didn't show them how to shave with razors, so they assume that they will have a problem if they use a razor."

As a result, these men may not be getting the best results in managing pseudofolliculitis barbae (PFB), he said. "The razor is the best shave."

The quality of the blade can make a big difference in treatment, he noted. "Some of the lesser expensive blades are very ineffective in shaving for someone with PFB," because they can get dull before the shaving process is finished. "You're already causing a problem by dragging and pulling the hair when trying to cut these hairs."

"The more expensive blades are more expensive because they are coated with different ingredients that harden the blade," he said. They also are made with a better grade of steel.

"I find that you can use a good razor for anywhere between five to seven shaves before you have to discard it," said Dr. Moore. While there are many blades on the market, the brands that have three to five blades with a lubricating strip are the best.

He disclosed that he has a patent for the Moore Technique Shaving System for treatment of PFB.

PFB affects about 60% of young black men, and 10%-15% of white men. In PFB, hair has grown out from the skin, curled over, and then pierced and reentered the skin. In the treatment of this condition, it is important to prevent this reentrance to the skin. Symptoms range widely in severity, from two or three papules in some white men to a great many found in black men. Shaving of the papules can result in bleeding. And because the papules are present, many men start shaving less frequently to avoid discomfort or they grow beards instead.

By lifting the hair before shaving, and by shaving every day, the hair doesn't grow long enough to curl back and pierce and reenter the skin, he explained. "That is why it is essential that a person shave daily, or every other day in someone who has very slow-growing hair."

To help with shaving, an exfoliant may be used, especially one that focuses on the beard area but not to the extent that discoloration and irritation occur.

An antibacterial preparation also may be needed because of infection in PFB. Products commonly used include "sulfur salicylic acid, which causes exfoliation and does have antibacterial activity," he said. Other antibacterials that have been used include clindamycin and benzoyl peroxide. Using a combination of these products in a patient with both PFB and acne can help treat both problems. "But antibacterial agents alone are not sufficient to control PFB," because hair does still grow and is trapped in the skin, he noted.

Dr. Moore has found that the optimal PFB treatment may differ between people, but most individuals can get good results. Helpful agents soften the hair, and cause "some exfoliation around the hair follicle."

Depilatories have been the mainstay of reducing razor bumps, he said. These products dissolve hair. But many people have found this treatment inadequate. Depilatories can irritate the skin and may not allow men to be clean shaven every day. "They may have to shave every 2 or 3 days," he added. Their appearance may not be good between shaves.

As with the use of depilatories, the use of clippers can be "somewhat effective," he said, in reducing the number of hairs that are trapped beneath the skin. But clippers don't cut the hair very short.

Another common technique is to use tweezers to pluck out the hairs that are trapped, but this can make the condition worse because the plucked hair is typically broken off at the core of the follicle. As it grows back, the result can be more papule formation.

Lastly, while laser hair-removal treatments may be helpful, these can be expensive, he concluded.

HONOLULU — Although many black men with pseudofolliculitis barbae, otherwise known as "razor bumps," may express horror at the idea of shaving every day, this may be their best option, said Dr. Milton Moore at the annual meeting of the National Medical Association.

"You'd be surprised at how many African American men, when you talk about shaving with razors, [say,] 'Oh no, I can't do that!' " said Dr. Moore, who is in private practice in Houston. "Many of them don't even know that they can shave. They know Dad couldn't, and Dad didn't, and Dad didn't show them how to shave with razors, so they assume that they will have a problem if they use a razor."

As a result, these men may not be getting the best results in managing pseudofolliculitis barbae (PFB), he said. "The razor is the best shave."

The quality of the blade can make a big difference in treatment, he noted. "Some of the lesser expensive blades are very ineffective in shaving for someone with PFB," because they can get dull before the shaving process is finished. "You're already causing a problem by dragging and pulling the hair when trying to cut these hairs."

"The more expensive blades are more expensive because they are coated with different ingredients that harden the blade," he said. They also are made with a better grade of steel.

"I find that you can use a good razor for anywhere between five to seven shaves before you have to discard it," said Dr. Moore. While there are many blades on the market, the brands that have three to five blades with a lubricating strip are the best.

He disclosed that he has a patent for the Moore Technique Shaving System for treatment of PFB.

PFB affects about 60% of young black men, and 10%-15% of white men. In PFB, hair has grown out from the skin, curled over, and then pierced and reentered the skin. In the treatment of this condition, it is important to prevent this reentrance to the skin. Symptoms range widely in severity, from two or three papules in some white men to a great many found in black men. Shaving of the papules can result in bleeding. And because the papules are present, many men start shaving less frequently to avoid discomfort or they grow beards instead.

By lifting the hair before shaving, and by shaving every day, the hair doesn't grow long enough to curl back and pierce and reenter the skin, he explained. "That is why it is essential that a person shave daily, or every other day in someone who has very slow-growing hair."

To help with shaving, an exfoliant may be used, especially one that focuses on the beard area but not to the extent that discoloration and irritation occur.

An antibacterial preparation also may be needed because of infection in PFB. Products commonly used include "sulfur salicylic acid, which causes exfoliation and does have antibacterial activity," he said. Other antibacterials that have been used include clindamycin and benzoyl peroxide. Using a combination of these products in a patient with both PFB and acne can help treat both problems. "But antibacterial agents alone are not sufficient to control PFB," because hair does still grow and is trapped in the skin, he noted.

Dr. Moore has found that the optimal PFB treatment may differ between people, but most individuals can get good results. Helpful agents soften the hair, and cause "some exfoliation around the hair follicle."

Depilatories have been the mainstay of reducing razor bumps, he said. These products dissolve hair. But many people have found this treatment inadequate. Depilatories can irritate the skin and may not allow men to be clean shaven every day. "They may have to shave every 2 or 3 days," he added. Their appearance may not be good between shaves.

As with the use of depilatories, the use of clippers can be "somewhat effective," he said, in reducing the number of hairs that are trapped beneath the skin. But clippers don't cut the hair very short.

Another common technique is to use tweezers to pluck out the hairs that are trapped, but this can make the condition worse because the plucked hair is typically broken off at the core of the follicle. As it grows back, the result can be more papule formation.

Lastly, while laser hair-removal treatments may be helpful, these can be expensive, he concluded.

HONOLULU — Although many black men with pseudofolliculitis barbae, otherwise known as "razor bumps," may express horror at the idea of shaving every day, this may be their best option, said Dr. Milton Moore at the annual meeting of the National Medical Association.

"You'd be surprised at how many African American men, when you talk about shaving with razors, [say,] 'Oh no, I can't do that!' " said Dr. Moore, who is in private practice in Houston. "Many of them don't even know that they can shave. They know Dad couldn't, and Dad didn't, and Dad didn't show them how to shave with razors, so they assume that they will have a problem if they use a razor."

As a result, these men may not be getting the best results in managing pseudofolliculitis barbae (PFB), he said. "The razor is the best shave."

The quality of the blade can make a big difference in treatment, he noted. "Some of the lesser expensive blades are very ineffective in shaving for someone with PFB," because they can get dull before the shaving process is finished. "You're already causing a problem by dragging and pulling the hair when trying to cut these hairs."

"The more expensive blades are more expensive because they are coated with different ingredients that harden the blade," he said. They also are made with a better grade of steel.

"I find that you can use a good razor for anywhere between five to seven shaves before you have to discard it," said Dr. Moore. While there are many blades on the market, the brands that have three to five blades with a lubricating strip are the best.

He disclosed that he has a patent for the Moore Technique Shaving System for treatment of PFB.

PFB affects about 60% of young black men, and 10%-15% of white men. In PFB, hair has grown out from the skin, curled over, and then pierced and reentered the skin. In the treatment of this condition, it is important to prevent this reentrance to the skin. Symptoms range widely in severity, from two or three papules in some white men to a great many found in black men. Shaving of the papules can result in bleeding. And because the papules are present, many men start shaving less frequently to avoid discomfort or they grow beards instead.

By lifting the hair before shaving, and by shaving every day, the hair doesn't grow long enough to curl back and pierce and reenter the skin, he explained. "That is why it is essential that a person shave daily, or every other day in someone who has very slow-growing hair."

To help with shaving, an exfoliant may be used, especially one that focuses on the beard area but not to the extent that discoloration and irritation occur.

An antibacterial preparation also may be needed because of infection in PFB. Products commonly used include "sulfur salicylic acid, which causes exfoliation and does have antibacterial activity," he said. Other antibacterials that have been used include clindamycin and benzoyl peroxide. Using a combination of these products in a patient with both PFB and acne can help treat both problems. "But antibacterial agents alone are not sufficient to control PFB," because hair does still grow and is trapped in the skin, he noted.

Dr. Moore has found that the optimal PFB treatment may differ between people, but most individuals can get good results. Helpful agents soften the hair, and cause "some exfoliation around the hair follicle."

Depilatories have been the mainstay of reducing razor bumps, he said. These products dissolve hair. But many people have found this treatment inadequate. Depilatories can irritate the skin and may not allow men to be clean shaven every day. "They may have to shave every 2 or 3 days," he added. Their appearance may not be good between shaves.

As with the use of depilatories, the use of clippers can be "somewhat effective," he said, in reducing the number of hairs that are trapped beneath the skin. But clippers don't cut the hair very short.

Another common technique is to use tweezers to pluck out the hairs that are trapped, but this can make the condition worse because the plucked hair is typically broken off at the core of the follicle. As it grows back, the result can be more papule formation.

Lastly, while laser hair-removal treatments may be helpful, these can be expensive, he concluded.

MAUI, HAWAII — Although a high-fat ketogenic diet is effective in helping epilepsy patients control their seizures, it is underutilized because it is misunderstood, said Dr. Eileen P.G. Vining.

The diet is not difficult. It can be palatable, adaptable, and inexpensive, she explained at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

It is estimated that the diet is initiated in only 2,500 patients per year based on a rough calculation of published data, while about 100 million people worldwide have epilepsy, according to the World Health Organization, she said.

The ketogenic diet is a high-fat, low-carbohydrate diet that provides adequate protein (1 g/kg per day), but greatly restricts carbohydrate intake, Dr. Vining said at the meeting, also sponsored by California Chapter 2 of the AAP. The effect of the diet is to mimic ketosis. The ketogenic diet's fat-to-carbohydrate and protein ratio may range from 2:1 (less strict) to 4:1 (very strict), with an average of 3:1. At a 3:1 ratio, fat intake accounts for 80%–90% of calories.

“We know the diet is effective for a wide variety of seizures,” said Dr. Vining, director of the John M. Freeman Pediatric Epilepsy Center at the Johns Hopkins Hospital in Baltimore. She acknowledged, however, that “we don't understand the biology of the ketogenic diet.”

About 46% of patients on the diet have greater than 90% control of seizures at 12 months, she said. For those using the diet, medications often can be decreased, although for patients helped by just two or three medications, it may make sense to continue them. She noted that a study on more “aggressive” discontinuation of medications found good results even within 1 month (Epilepsy Behav. 2004;5:499-502). “There are some 'superresponders' who become seizure free within the first 2 weeks,” added Dr. Vining, who is also professor of neurology and pediatrics at Johns Hopkins University.

The diet emerged in the 1920s, when it was discovered that a person who is fasting becomes ketotic, she explained. Researchers at The Mayo Clinic developed the idea that changing the nutrient structure of a diet would mimic fasting. By using the ketogenic diet, a person is put in a constant state of ketosis. The diet was popular until phenytoin came on the market and was seen as easier to use than maintaining the diet, she said. But the diet has had a resurgence since the mid-1990s. It is comparable to the popular Atkins diet for weight loss (Epilepsia 2006;47:421-4).

Prior to beginning the diet at Johns Hopkins' clinic, children fast for 24 hours and are seen in the clinic Monday morning. They are then admitted to the clinic for 4 days (Monday-Thursday), where they are given eggnog to increase the fat in their diet from one-third to two-thirds of the full calories, and finally to a full percentage of calories using regular food. Individual adjustments are made to maintain 80–160 mmol urinary ketosis and to avoid significant weight gain or loss.

Dr. Vining cited several studies in support of the effectiveness of the diet.

A large prospective study conducted at Johns Hopkins enrolled 150 children with a mean age of 5.3 years and a mean monthly seizure rate of 410. The children used a mean of 6.2 antiepileptic drugs prior to initiating the diet. At 3 months, 83% remained on the diet, and 34% experienced greater than 90% reduction in seizures. At 12 months, 55% remained on the diet, and 27% had greater than 90% reduction in seizures. The diet appeared to work across a wide spectrum of ages and seizure types.

Another study found that after 1 year of being on the diet, 74% of pediatric patients were able to reduce their medications, with the number on two medications was reduced from 79% to 23%. No medications were needed by 48%. There was a 67% reduction in medication costs, resulting in an average savings of about $1,000 per child per year (J. Child Neurol. 1999;14:469-71).

A downside to the diet is impaired growth. A study conducted by Dr. Vining of 237 children ranging in age from 2 months to 9 years and 10 months found at 1 year that weight had not substantially increased and linear growth had also been reduced (Dev. Med. Child Neurol. 2002;44:796-802).

Another study by Dr. Vining and her associates found that use of the diet for as long as 2 years resulted in elevated triglycerides, total cholesterol, and LDL cholesterol levels but no rise in HDL cholesterol levels (JAMA 2003;290:912-20). Also, acidosis is seen routinely.

A 2004 study found that the ketogenic diet is used at 80 U.S. centers and at 70 centers in 41 countries. Continued use in patients has ranged from 1 to 45 years, with a median of 8 years. The average number of people per country using the diet was 71.6, with 5.4 started per year, in a range of 0 to 40 (Epilepsia 2004;45:1163).

MAUI, HAWAII — Although a high-fat ketogenic diet is effective in helping epilepsy patients control their seizures, it is underutilized because it is misunderstood, said Dr. Eileen P.G. Vining.

The diet is not difficult. It can be palatable, adaptable, and inexpensive, she explained at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

It is estimated that the diet is initiated in only 2,500 patients per year based on a rough calculation of published data, while about 100 million people worldwide have epilepsy, according to the World Health Organization, she said.

The ketogenic diet is a high-fat, low-carbohydrate diet that provides adequate protein (1 g/kg per day), but greatly restricts carbohydrate intake, Dr. Vining said at the meeting, also sponsored by California Chapter 2 of the AAP. The effect of the diet is to mimic ketosis. The ketogenic diet's fat-to-carbohydrate and protein ratio may range from 2:1 (less strict) to 4:1 (very strict), with an average of 3:1. At a 3:1 ratio, fat intake accounts for 80%–90% of calories.

“We know the diet is effective for a wide variety of seizures,” said Dr. Vining, director of the John M. Freeman Pediatric Epilepsy Center at the Johns Hopkins Hospital in Baltimore. She acknowledged, however, that “we don't understand the biology of the ketogenic diet.”

About 46% of patients on the diet have greater than 90% control of seizures at 12 months, she said. For those using the diet, medications often can be decreased, although for patients helped by just two or three medications, it may make sense to continue them. She noted that a study on more “aggressive” discontinuation of medications found good results even within 1 month (Epilepsy Behav. 2004;5:499-502). “There are some 'superresponders' who become seizure free within the first 2 weeks,” added Dr. Vining, who is also professor of neurology and pediatrics at Johns Hopkins University.

The diet emerged in the 1920s, when it was discovered that a person who is fasting becomes ketotic, she explained. Researchers at The Mayo Clinic developed the idea that changing the nutrient structure of a diet would mimic fasting. By using the ketogenic diet, a person is put in a constant state of ketosis. The diet was popular until phenytoin came on the market and was seen as easier to use than maintaining the diet, she said. But the diet has had a resurgence since the mid-1990s. It is comparable to the popular Atkins diet for weight loss (Epilepsia 2006;47:421-4).

Prior to beginning the diet at Johns Hopkins' clinic, children fast for 24 hours and are seen in the clinic Monday morning. They are then admitted to the clinic for 4 days (Monday-Thursday), where they are given eggnog to increase the fat in their diet from one-third to two-thirds of the full calories, and finally to a full percentage of calories using regular food. Individual adjustments are made to maintain 80–160 mmol urinary ketosis and to avoid significant weight gain or loss.

Dr. Vining cited several studies in support of the effectiveness of the diet.

A large prospective study conducted at Johns Hopkins enrolled 150 children with a mean age of 5.3 years and a mean monthly seizure rate of 410. The children used a mean of 6.2 antiepileptic drugs prior to initiating the diet. At 3 months, 83% remained on the diet, and 34% experienced greater than 90% reduction in seizures. At 12 months, 55% remained on the diet, and 27% had greater than 90% reduction in seizures. The diet appeared to work across a wide spectrum of ages and seizure types.

Another study found that after 1 year of being on the diet, 74% of pediatric patients were able to reduce their medications, with the number on two medications was reduced from 79% to 23%. No medications were needed by 48%. There was a 67% reduction in medication costs, resulting in an average savings of about $1,000 per child per year (J. Child Neurol. 1999;14:469-71).

A downside to the diet is impaired growth. A study conducted by Dr. Vining of 237 children ranging in age from 2 months to 9 years and 10 months found at 1 year that weight had not substantially increased and linear growth had also been reduced (Dev. Med. Child Neurol. 2002;44:796-802).

Another study by Dr. Vining and her associates found that use of the diet for as long as 2 years resulted in elevated triglycerides, total cholesterol, and LDL cholesterol levels but no rise in HDL cholesterol levels (JAMA 2003;290:912-20). Also, acidosis is seen routinely.

A 2004 study found that the ketogenic diet is used at 80 U.S. centers and at 70 centers in 41 countries. Continued use in patients has ranged from 1 to 45 years, with a median of 8 years. The average number of people per country using the diet was 71.6, with 5.4 started per year, in a range of 0 to 40 (Epilepsia 2004;45:1163).

MAUI, HAWAII — Although a high-fat ketogenic diet is effective in helping epilepsy patients control their seizures, it is underutilized because it is misunderstood, said Dr. Eileen P.G. Vining.

The diet is not difficult. It can be palatable, adaptable, and inexpensive, she explained at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

It is estimated that the diet is initiated in only 2,500 patients per year based on a rough calculation of published data, while about 100 million people worldwide have epilepsy, according to the World Health Organization, she said.

The ketogenic diet is a high-fat, low-carbohydrate diet that provides adequate protein (1 g/kg per day), but greatly restricts carbohydrate intake, Dr. Vining said at the meeting, also sponsored by California Chapter 2 of the AAP. The effect of the diet is to mimic ketosis. The ketogenic diet's fat-to-carbohydrate and protein ratio may range from 2:1 (less strict) to 4:1 (very strict), with an average of 3:1. At a 3:1 ratio, fat intake accounts for 80%–90% of calories.

“We know the diet is effective for a wide variety of seizures,” said Dr. Vining, director of the John M. Freeman Pediatric Epilepsy Center at the Johns Hopkins Hospital in Baltimore. She acknowledged, however, that “we don't understand the biology of the ketogenic diet.”

About 46% of patients on the diet have greater than 90% control of seizures at 12 months, she said. For those using the diet, medications often can be decreased, although for patients helped by just two or three medications, it may make sense to continue them. She noted that a study on more “aggressive” discontinuation of medications found good results even within 1 month (Epilepsy Behav. 2004;5:499-502). “There are some 'superresponders' who become seizure free within the first 2 weeks,” added Dr. Vining, who is also professor of neurology and pediatrics at Johns Hopkins University.

The diet emerged in the 1920s, when it was discovered that a person who is fasting becomes ketotic, she explained. Researchers at The Mayo Clinic developed the idea that changing the nutrient structure of a diet would mimic fasting. By using the ketogenic diet, a person is put in a constant state of ketosis. The diet was popular until phenytoin came on the market and was seen as easier to use than maintaining the diet, she said. But the diet has had a resurgence since the mid-1990s. It is comparable to the popular Atkins diet for weight loss (Epilepsia 2006;47:421-4).

Prior to beginning the diet at Johns Hopkins' clinic, children fast for 24 hours and are seen in the clinic Monday morning. They are then admitted to the clinic for 4 days (Monday-Thursday), where they are given eggnog to increase the fat in their diet from one-third to two-thirds of the full calories, and finally to a full percentage of calories using regular food. Individual adjustments are made to maintain 80–160 mmol urinary ketosis and to avoid significant weight gain or loss.

Dr. Vining cited several studies in support of the effectiveness of the diet.

A large prospective study conducted at Johns Hopkins enrolled 150 children with a mean age of 5.3 years and a mean monthly seizure rate of 410. The children used a mean of 6.2 antiepileptic drugs prior to initiating the diet. At 3 months, 83% remained on the diet, and 34% experienced greater than 90% reduction in seizures. At 12 months, 55% remained on the diet, and 27% had greater than 90% reduction in seizures. The diet appeared to work across a wide spectrum of ages and seizure types.

Another study found that after 1 year of being on the diet, 74% of pediatric patients were able to reduce their medications, with the number on two medications was reduced from 79% to 23%. No medications were needed by 48%. There was a 67% reduction in medication costs, resulting in an average savings of about $1,000 per child per year (J. Child Neurol. 1999;14:469-71).

A downside to the diet is impaired growth. A study conducted by Dr. Vining of 237 children ranging in age from 2 months to 9 years and 10 months found at 1 year that weight had not substantially increased and linear growth had also been reduced (Dev. Med. Child Neurol. 2002;44:796-802).

Another study by Dr. Vining and her associates found that use of the diet for as long as 2 years resulted in elevated triglycerides, total cholesterol, and LDL cholesterol levels but no rise in HDL cholesterol levels (JAMA 2003;290:912-20). Also, acidosis is seen routinely.

A 2004 study found that the ketogenic diet is used at 80 U.S. centers and at 70 centers in 41 countries. Continued use in patients has ranged from 1 to 45 years, with a median of 8 years. The average number of people per country using the diet was 71.6, with 5.4 started per year, in a range of 0 to 40 (Epilepsia 2004;45:1163).

MAUI, HAWAII — Look for clues and comorbidities to diagnose sinusitis, a condition that is overdiagnosed and misdiagnosed in children.

When examining with an otoscope or nasal speculum, look at the location and the character of the secretions, and see if they are clear, thin, and strandy, suggestive of an allergic process, or mucoid and purulent, suggesting infection, Dr. Seth M. Pransky said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

See whether the secretions are truly coming from the sinuses. A foul odor may be present. A look after decongesting the nose may be helpful, said Dr. Pransky, director of pediatric otolaryngology at Rady Children's Hospital, San Diego.

Children with chronic sinusitis feel miserable, with primary symptoms of nasal congestion, cough, nasal discharge, and headache or facial pain, Dr. Pransky explained. He added that ancillary symptoms include foul breath, sore throat, postnasal drip and throat clearing, as well as nausea, vomiting, and other gastrointestinal complaints. But note that fever often is absent.

Sinusitis may complicate upper respiratory infections, which may develop six to eight times per year, with 10 days per episode, he said, “meaning a good proportion of the time, a child is going to be ill, especially in the winter months.”

Gastroesophageal reflux disease (GERD) may be another factor. Most pediatric otolaryngologists believe there is some relationship between GERD and otitis, rhinitis, and sinusitis, as well as laryngeal problems, he noted. Reflux therapy has been supported by research that showed improvement of sinus symptoms for many patients with sinusitis (Arch. Otolaryngol. Head Neck Surg. 2000:126:831-6).

When considering the need for antibiotics he said, a culture should be taken from the middle meatus. “A culture from the nasopharynx is not sufficient, is not accurate, and does not reflect sinus disease.”

Choices for treatment may include the use of antibiotics, oral or nasal steroids, antihistamine therapy with sprays or oral agents, a leukotriene receptor antagonist, anticholinergic sprays, mast cell stabilizers, nasal saline sprays, decongestants, mucolytics, and GERD medications. “But, in reality, all of this is not needed,” he pointed out. It's important to determine what's appropriate for the individual child.

There probably is no role for parenteral antibiotics for chronic sinus disease, Dr. Pransky said at the meeting, also sponsored by California Chapter 2 of the AAP.

When using oral steroids, consider the duration, dose, complications, and other concerns.

When using topical steroids—cortico-steroid sprays, which are more classically used—consider appropriate age limitations, difficulty of administration, and issues of penetration, absorption, and duration. “They are approved now down to 2 years, and there's one preparation that's for even younger [children],” Dr. Pransky observed, adding that there is no real concern regarding impact on growth from their use.

Corticosteroid sprays are difficult to use, he noted. Parents should administer nasal sprays because children often do not self-administer them effectively, he advised. Parents should be taught how to administer the sprays correctly because directions from the package insert are inadequate.

Adjuvant therapies, including mucolytics, decongestants, and xylitol, are probably not helpful, he said. But saline solutions for nasal irrigation are “extremely valuable,” as they help clear out “dry, crusty secretions to get the normal physiological function of the nose going.” But keep in mind that the impact of saline solutions on ciliary function is unclear.

A comprehensive medical evaluation should precede surgical interventions, he said, because pediatric sinusitis is much more a medical disease than a problem that requires direct sinus surgery. Allergies should be assessed in all children before considering surgery because of an overlap in symptoms and a comorbidity rate that exceeds 50%.

Plain films frequently are misinterpreted in radiologic assessments, Dr. Pransky emphasized. “They're very difficult to interpret in a young child.”

X-rays of routine viral respiratory infections look like sinusitis, but it could be that the child simply has a cold, he continued. CT scans should not be taken during the winter respiratory infection season nor during or immediately after a respiratory infection. Keep in mind that one CT scan alone is not enough; it should be repeated before any surgical intervention.

In looking at the anatomy, assess the turbinates, he advised. When appropriate, an inferior turbinate reduction can be helpful. “The technology has improved over the years; we don't take the turbinates out. We don't do anything to the mucosa. We'll do a submucosal resection. And the current form of therapy is to do a radiofrequency ablation of the turbinate.” As a result, not only is the airflow improved, but medications [also] can be used more effectively—as they can be more directly targeted without obstruction.

An adenoidectomy can make a difference for many children, Dr. Pransky said. Even small adenoids can be a problem. Improvement of symptoms ranges from 50% to 70%. Often younger children respond better than older ones.

About 10%–15% of the population has concha bullosa—an aerated middle turbinate.

Dr. Pransky said he is involved with research with ArthroCare Corp. and Medtronic Inc.

MAUI, HAWAII — Look for clues and comorbidities to diagnose sinusitis, a condition that is overdiagnosed and misdiagnosed in children.

When examining with an otoscope or nasal speculum, look at the location and the character of the secretions, and see if they are clear, thin, and strandy, suggestive of an allergic process, or mucoid and purulent, suggesting infection, Dr. Seth M. Pransky said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

See whether the secretions are truly coming from the sinuses. A foul odor may be present. A look after decongesting the nose may be helpful, said Dr. Pransky, director of pediatric otolaryngology at Rady Children's Hospital, San Diego.

Children with chronic sinusitis feel miserable, with primary symptoms of nasal congestion, cough, nasal discharge, and headache or facial pain, Dr. Pransky explained. He added that ancillary symptoms include foul breath, sore throat, postnasal drip and throat clearing, as well as nausea, vomiting, and other gastrointestinal complaints. But note that fever often is absent.

Sinusitis may complicate upper respiratory infections, which may develop six to eight times per year, with 10 days per episode, he said, “meaning a good proportion of the time, a child is going to be ill, especially in the winter months.”

Gastroesophageal reflux disease (GERD) may be another factor. Most pediatric otolaryngologists believe there is some relationship between GERD and otitis, rhinitis, and sinusitis, as well as laryngeal problems, he noted. Reflux therapy has been supported by research that showed improvement of sinus symptoms for many patients with sinusitis (Arch. Otolaryngol. Head Neck Surg. 2000:126:831-6).

When considering the need for antibiotics he said, a culture should be taken from the middle meatus. “A culture from the nasopharynx is not sufficient, is not accurate, and does not reflect sinus disease.”

Choices for treatment may include the use of antibiotics, oral or nasal steroids, antihistamine therapy with sprays or oral agents, a leukotriene receptor antagonist, anticholinergic sprays, mast cell stabilizers, nasal saline sprays, decongestants, mucolytics, and GERD medications. “But, in reality, all of this is not needed,” he pointed out. It's important to determine what's appropriate for the individual child.

There probably is no role for parenteral antibiotics for chronic sinus disease, Dr. Pransky said at the meeting, also sponsored by California Chapter 2 of the AAP.

When using oral steroids, consider the duration, dose, complications, and other concerns.

When using topical steroids—cortico-steroid sprays, which are more classically used—consider appropriate age limitations, difficulty of administration, and issues of penetration, absorption, and duration. “They are approved now down to 2 years, and there's one preparation that's for even younger [children],” Dr. Pransky observed, adding that there is no real concern regarding impact on growth from their use.

Corticosteroid sprays are difficult to use, he noted. Parents should administer nasal sprays because children often do not self-administer them effectively, he advised. Parents should be taught how to administer the sprays correctly because directions from the package insert are inadequate.

Adjuvant therapies, including mucolytics, decongestants, and xylitol, are probably not helpful, he said. But saline solutions for nasal irrigation are “extremely valuable,” as they help clear out “dry, crusty secretions to get the normal physiological function of the nose going.” But keep in mind that the impact of saline solutions on ciliary function is unclear.

A comprehensive medical evaluation should precede surgical interventions, he said, because pediatric sinusitis is much more a medical disease than a problem that requires direct sinus surgery. Allergies should be assessed in all children before considering surgery because of an overlap in symptoms and a comorbidity rate that exceeds 50%.

Plain films frequently are misinterpreted in radiologic assessments, Dr. Pransky emphasized. “They're very difficult to interpret in a young child.”

X-rays of routine viral respiratory infections look like sinusitis, but it could be that the child simply has a cold, he continued. CT scans should not be taken during the winter respiratory infection season nor during or immediately after a respiratory infection. Keep in mind that one CT scan alone is not enough; it should be repeated before any surgical intervention.

In looking at the anatomy, assess the turbinates, he advised. When appropriate, an inferior turbinate reduction can be helpful. “The technology has improved over the years; we don't take the turbinates out. We don't do anything to the mucosa. We'll do a submucosal resection. And the current form of therapy is to do a radiofrequency ablation of the turbinate.” As a result, not only is the airflow improved, but medications [also] can be used more effectively—as they can be more directly targeted without obstruction.

An adenoidectomy can make a difference for many children, Dr. Pransky said. Even small adenoids can be a problem. Improvement of symptoms ranges from 50% to 70%. Often younger children respond better than older ones.

About 10%–15% of the population has concha bullosa—an aerated middle turbinate.

Dr. Pransky said he is involved with research with ArthroCare Corp. and Medtronic Inc.

MAUI, HAWAII — Look for clues and comorbidities to diagnose sinusitis, a condition that is overdiagnosed and misdiagnosed in children.

When examining with an otoscope or nasal speculum, look at the location and the character of the secretions, and see if they are clear, thin, and strandy, suggestive of an allergic process, or mucoid and purulent, suggesting infection, Dr. Seth M. Pransky said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

See whether the secretions are truly coming from the sinuses. A foul odor may be present. A look after decongesting the nose may be helpful, said Dr. Pransky, director of pediatric otolaryngology at Rady Children's Hospital, San Diego.

Children with chronic sinusitis feel miserable, with primary symptoms of nasal congestion, cough, nasal discharge, and headache or facial pain, Dr. Pransky explained. He added that ancillary symptoms include foul breath, sore throat, postnasal drip and throat clearing, as well as nausea, vomiting, and other gastrointestinal complaints. But note that fever often is absent.

Sinusitis may complicate upper respiratory infections, which may develop six to eight times per year, with 10 days per episode, he said, “meaning a good proportion of the time, a child is going to be ill, especially in the winter months.”

Gastroesophageal reflux disease (GERD) may be another factor. Most pediatric otolaryngologists believe there is some relationship between GERD and otitis, rhinitis, and sinusitis, as well as laryngeal problems, he noted. Reflux therapy has been supported by research that showed improvement of sinus symptoms for many patients with sinusitis (Arch. Otolaryngol. Head Neck Surg. 2000:126:831-6).

When considering the need for antibiotics he said, a culture should be taken from the middle meatus. “A culture from the nasopharynx is not sufficient, is not accurate, and does not reflect sinus disease.”

Choices for treatment may include the use of antibiotics, oral or nasal steroids, antihistamine therapy with sprays or oral agents, a leukotriene receptor antagonist, anticholinergic sprays, mast cell stabilizers, nasal saline sprays, decongestants, mucolytics, and GERD medications. “But, in reality, all of this is not needed,” he pointed out. It's important to determine what's appropriate for the individual child.

There probably is no role for parenteral antibiotics for chronic sinus disease, Dr. Pransky said at the meeting, also sponsored by California Chapter 2 of the AAP.

When using oral steroids, consider the duration, dose, complications, and other concerns.

When using topical steroids—cortico-steroid sprays, which are more classically used—consider appropriate age limitations, difficulty of administration, and issues of penetration, absorption, and duration. “They are approved now down to 2 years, and there's one preparation that's for even younger [children],” Dr. Pransky observed, adding that there is no real concern regarding impact on growth from their use.

Corticosteroid sprays are difficult to use, he noted. Parents should administer nasal sprays because children often do not self-administer them effectively, he advised. Parents should be taught how to administer the sprays correctly because directions from the package insert are inadequate.

Adjuvant therapies, including mucolytics, decongestants, and xylitol, are probably not helpful, he said. But saline solutions for nasal irrigation are “extremely valuable,” as they help clear out “dry, crusty secretions to get the normal physiological function of the nose going.” But keep in mind that the impact of saline solutions on ciliary function is unclear.

A comprehensive medical evaluation should precede surgical interventions, he said, because pediatric sinusitis is much more a medical disease than a problem that requires direct sinus surgery. Allergies should be assessed in all children before considering surgery because of an overlap in symptoms and a comorbidity rate that exceeds 50%.

Plain films frequently are misinterpreted in radiologic assessments, Dr. Pransky emphasized. “They're very difficult to interpret in a young child.”

X-rays of routine viral respiratory infections look like sinusitis, but it could be that the child simply has a cold, he continued. CT scans should not be taken during the winter respiratory infection season nor during or immediately after a respiratory infection. Keep in mind that one CT scan alone is not enough; it should be repeated before any surgical intervention.

In looking at the anatomy, assess the turbinates, he advised. When appropriate, an inferior turbinate reduction can be helpful. “The technology has improved over the years; we don't take the turbinates out. We don't do anything to the mucosa. We'll do a submucosal resection. And the current form of therapy is to do a radiofrequency ablation of the turbinate.” As a result, not only is the airflow improved, but medications [also] can be used more effectively—as they can be more directly targeted without obstruction.

An adenoidectomy can make a difference for many children, Dr. Pransky said. Even small adenoids can be a problem. Improvement of symptoms ranges from 50% to 70%. Often younger children respond better than older ones.

About 10%–15% of the population has concha bullosa—an aerated middle turbinate.

Dr. Pransky said he is involved with research with ArthroCare Corp. and Medtronic Inc.

MAUI, HAWAII — Questions that are commonly asked of pediatric dermatologists by parents range from how to get rid of warts to what to do about community-acquired methicillin-resistant Staphylococcus aureus infections, reported Dr. Sheila F. Friedlander.

The director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego, Dr. Friedlander gave some examples of the top questions asked, together with her answers, at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics:

▸ How can you get rid of my child's warts? Warts account for 8% of dermatology visits; up to 20% of school-age children are affected. Many warts just go away. The average cure rate for warts with placebo is 27% at 15 weeks, Dr. Friedlander said.

For treatment of warts, the best evidence available comes from five trials supporting the use of salicylic acid. A 6-week study of wart treatment with duct tape on 103 children found a modest but insignificant effect: 16% duct tape vs. 6% placebo.

Although cryotherapy is not well supported by studies, and the manner of application varies widely, empirically it works. Dr. Friedlander said she uses an approach she calls the "triple whammy": salicylic acid, salicylic bandage, and then duct tape.

If you try immunotherapy, skin test allergens are used: Candida, mumps, or Trichophyton. For the largest warts, inject 0.1–0.3 cc directly into the wart. Repeat the immunotherapy treatment every 3 weeks for 3–5 treatments.

The adult cure rate with Candida is 88% for local warts and 66% for distal ones. The relapse rate at 2 years is 5%, compared with 39% for cryotherapy, and 10% for laser.

Genital warts are now preventable by the quadrivalent human papillomavirus (HPV) vaccine Gardasil (Merck). It protects against HPV 6/11/16/18 and is 95% effective for as long as 4.5 years.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends routine vaccination of all girls ages 11–12 years with 3 doses, but it can be given at ages 9–26. The goal is to administer the vaccine prior to sexual contact.

About 30% of 9th graders and 60% of 12th graders are estimated to be sexually active. Cervical cancer, caused by HPV, is the second most common cancer in women worldwide, with 233,000 deaths per year, Dr. Friedlander said.

▸ What can be done about head lice? Dislodged by towels and hair dryers, lice can be transmitted by fomites, with eggs landing on fabrics, bedding, and furniture. These all need to be cleaned. For treatment, Dr. Friedlander recommends starting with topical over-the-counter (OTC) pyrethrin or permethrins.

The use of malathion is an option, but be aware that it is flammable—the patient should avoid the use of hairdryers and flames during treatment. Also, she observed, "It stinks to high heaven."

Another option, used in England and Israel, is to wash the hair, add hair conditioner (which makes the hair slippery and hard for eggs to adhere), and comb with a fine-tooth comb.

The use of Cetaphil cleanser is yet another option. The OTC cleanser is applied on a dry scalp and spread over the head until the hair is wet. Then the hair is blow-dried, and the cleanser is washed out the next day. The procedure is repeated in 7–10 days.

An effective hair dryer treatment is LouseBuster. It is slightly cooler than a standard blow dryer, but provides twice the volume of air, which kills head lice. Its effectiveness is 100% ovicidal, with 80% mortality of hatched lice (Pediatrics 2006;118:1962–70).

Use of oral ivermectin is another option, she said, "But I certainly wouldn't go with it for first-line therapy."

Dr. Friedlander suggested using the Cetaphil cleanser treatment combined with the use of a hair dryer.

▸ How can varicella infection be avoided? "We need to remember that chicken pox is tamed, but not conquered," Dr. Friedlander said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

Varivax, the live attenuated varicella vaccine available since 1995, has a protection rate of 85%; it is 97% effective in preventing moderate to severe disease. Hospitalization rates for varicella have decreased from 2.3/100,000 in 1994 to 0.3/100,000 in 2002, and mortality also has decreased (N. Engl. J. Med. 2005;352:450–8).

But there has been a problem with more severe disease developing in children who have not been vaccinated for more than 5 years. Therefore, children should receive two vaccinations, with the first dose given at 12–15 months, and the second between ages 4 and 6 years. All others should receive "catch-up" doses. Quadrivalent vaccines (MMRV, Proquad) are options, she said.

▸ What can be done about melanoma in children? The incidence of melanoma in children is low but rising. In children, the disease can present as nodular lesions and amelanotic lesions, and it can be mistaken for pyogenic granuloma. Risk factors include a family history of melanoma, large numbers of moles, atypical moles, fair skin, freckling, red hair, sun exposure, and BRAF and NRAS activating gene mutations in tissue (Oncogene 2003;22:3053–62; Am. J. Hum. Genet. 2003;73:301–13).

The most effective treatment is high-dose interferon alpha-2b. Some data suggest that the younger the patient, the greater the likelihood of event-free survival (Cancer 2005;103:780–7).

▸ How can children be protected from the sun? "I always emphasize physical protection," Dr. Friedlander said. "Get the cap out, get the clothing out, and reserve the sunscreen for areas you can't cover." Sunscreens should provide UVA protection as well as UVB. Good options include Helioplex (Neutrogena), which contains a new stabilizer at strengths of SPF 30 and 45, and Anthelios (La Roche Posay), which contains mexoryl, SPF 15, she said.

Although it's been found that a little sun exposure is good for getting vitamin D, consider food alternatives, including milk, Dr. Friedlander said.

▸ Hemangiomas: Which ones may lead to a complication? The problem hemangiomas are those that are large, segmental, located on the face, and/or that obstruct a vital function. The number of hemangiomas may increase risk, particularly if there are more than six or seven, she said.

Therapy includes "watchful waiting" and the use of systemic prednisolone (2–3 mg/kg per day).

Orapred 15 mg/5 mL tastes better. It should be given in the morning for 4–8 weeks and then tapered as much as possible. This is effective in 84% of patients with hemangioma of infancy, Dr. Friedlander said.

Other options include the use of topical class 1 steroids (clobetasol) and intralesional corticosteroids—but beware that the latter can cause thromboses of the eye.

Another option is laser therapy, but not as first-line treatment. Difficult cases may be treated with vincristine, but it is phlebitic, she said.

Large facial hemangiomas require a careful physical exam, eye exam, and cardiac exam with echocardiography. Consider cranial magnetic resonance angiography and be aware of long-term vasculo-occlusive risks.

Hemangiomas that present in a "beard distribution" may mark underlying airway hemangiomas that compromise the airway.

For these, short courses of oral steroids may improve for a while but also may delay diagnosis. Pay attention also to midline and sacral lesions.

Ulcerated hemangiomas can be treated with saline compresses, topical antibiotics (mupirocin, Bacitracin, metronidazole), occlusive dressings (DuoDERM, Vigilon, OmniDerm), pulsed dye laser therapy, systemic and intralesional steroids, excision, and 0.01% topical Becaplermin, Dr. Friedlander said.

▸ How about pediatric onychomycosis? Topical treatment options include ciclopirox, amorolfine lacquer, bifonazole with 40% urea, and topical terbinafine.

Terbinafine 5 mg/kg per day can be used for the fingernails 6 weeks or toenails 12 weeks, but don't exceed 250 mg.

Fluconazole 6 mg/kg can be used once per week for 12 weeks on the fingernails and 26 weeks on the toenails.

Itraconazole caps 5 mg/kg per day pulse therapy can be used—two pulses for the fingernails and three pulses for the toenails, she said.

▸ What can be done about atopic dermatitis? "Corticosteroids are very helpful, but they can cause thinning of the skin and skin atrophy," she said. "And if too much is absorbed, they can cause stunting of growth; so we have to be careful when we use them."

There is an emerging class of topical agents that focuses on barrier function—physiologic moisturizers. Options include ceramide formulations in special delivery systems (Cerave, Epiceram); palmitoylethanolamide (PEA); MimyX, a cream containing endogenous fatty acid; and glycyrrhetinic acid/hyaluronic acid/shea butter combination cream (Atopiclair). "They're very expensive," she cautioned. "You should start out with Vaseline or Aquaphor."

Dr. Friedlander disclosed that she is a speaker on the speakers' bureau, a consultant, and/or involved with clinical research trials for the following companies: Novartis, Connetics Corp., Astellas Pharma Inc., Dermik Laboratories, and Graceway Pharmaceuticals.

MAUI, HAWAII — Questions that are commonly asked of pediatric dermatologists by parents range from how to get rid of warts to what to do about community-acquired methicillin-resistant Staphylococcus aureus infections, reported Dr. Sheila F. Friedlander.

The director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego, Dr. Friedlander gave some examples of the top questions asked, together with her answers, at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics:

▸ How can you get rid of my child's warts? Warts account for 8% of dermatology visits; up to 20% of school-age children are affected. Many warts just go away. The average cure rate for warts with placebo is 27% at 15 weeks, Dr. Friedlander said.

For treatment of warts, the best evidence available comes from five trials supporting the use of salicylic acid. A 6-week study of wart treatment with duct tape on 103 children found a modest but insignificant effect: 16% duct tape vs. 6% placebo.

Although cryotherapy is not well supported by studies, and the manner of application varies widely, empirically it works. Dr. Friedlander said she uses an approach she calls the "triple whammy": salicylic acid, salicylic bandage, and then duct tape.

If you try immunotherapy, skin test allergens are used: Candida, mumps, or Trichophyton. For the largest warts, inject 0.1–0.3 cc directly into the wart. Repeat the immunotherapy treatment every 3 weeks for 3–5 treatments.

The adult cure rate with Candida is 88% for local warts and 66% for distal ones. The relapse rate at 2 years is 5%, compared with 39% for cryotherapy, and 10% for laser.

Genital warts are now preventable by the quadrivalent human papillomavirus (HPV) vaccine Gardasil (Merck). It protects against HPV 6/11/16/18 and is 95% effective for as long as 4.5 years.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends routine vaccination of all girls ages 11–12 years with 3 doses, but it can be given at ages 9–26. The goal is to administer the vaccine prior to sexual contact.

About 30% of 9th graders and 60% of 12th graders are estimated to be sexually active. Cervical cancer, caused by HPV, is the second most common cancer in women worldwide, with 233,000 deaths per year, Dr. Friedlander said.

▸ What can be done about head lice? Dislodged by towels and hair dryers, lice can be transmitted by fomites, with eggs landing on fabrics, bedding, and furniture. These all need to be cleaned. For treatment, Dr. Friedlander recommends starting with topical over-the-counter (OTC) pyrethrin or permethrins.

The use of malathion is an option, but be aware that it is flammable—the patient should avoid the use of hairdryers and flames during treatment. Also, she observed, "It stinks to high heaven."

Another option, used in England and Israel, is to wash the hair, add hair conditioner (which makes the hair slippery and hard for eggs to adhere), and comb with a fine-tooth comb.

The use of Cetaphil cleanser is yet another option. The OTC cleanser is applied on a dry scalp and spread over the head until the hair is wet. Then the hair is blow-dried, and the cleanser is washed out the next day. The procedure is repeated in 7–10 days.

An effective hair dryer treatment is LouseBuster. It is slightly cooler than a standard blow dryer, but provides twice the volume of air, which kills head lice. Its effectiveness is 100% ovicidal, with 80% mortality of hatched lice (Pediatrics 2006;118:1962–70).

Use of oral ivermectin is another option, she said, "But I certainly wouldn't go with it for first-line therapy."

Dr. Friedlander suggested using the Cetaphil cleanser treatment combined with the use of a hair dryer.

▸ How can varicella infection be avoided? "We need to remember that chicken pox is tamed, but not conquered," Dr. Friedlander said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

Varivax, the live attenuated varicella vaccine available since 1995, has a protection rate of 85%; it is 97% effective in preventing moderate to severe disease. Hospitalization rates for varicella have decreased from 2.3/100,000 in 1994 to 0.3/100,000 in 2002, and mortality also has decreased (N. Engl. J. Med. 2005;352:450–8).

But there has been a problem with more severe disease developing in children who have not been vaccinated for more than 5 years. Therefore, children should receive two vaccinations, with the first dose given at 12–15 months, and the second between ages 4 and 6 years. All others should receive "catch-up" doses. Quadrivalent vaccines (MMRV, Proquad) are options, she said.

▸ What can be done about melanoma in children? The incidence of melanoma in children is low but rising. In children, the disease can present as nodular lesions and amelanotic lesions, and it can be mistaken for pyogenic granuloma. Risk factors include a family history of melanoma, large numbers of moles, atypical moles, fair skin, freckling, red hair, sun exposure, and BRAF and NRAS activating gene mutations in tissue (Oncogene 2003;22:3053–62; Am. J. Hum. Genet. 2003;73:301–13).

The most effective treatment is high-dose interferon alpha-2b. Some data suggest that the younger the patient, the greater the likelihood of event-free survival (Cancer 2005;103:780–7).

▸ How can children be protected from the sun? "I always emphasize physical protection," Dr. Friedlander said. "Get the cap out, get the clothing out, and reserve the sunscreen for areas you can't cover." Sunscreens should provide UVA protection as well as UVB. Good options include Helioplex (Neutrogena), which contains a new stabilizer at strengths of SPF 30 and 45, and Anthelios (La Roche Posay), which contains mexoryl, SPF 15, she said.

Although it's been found that a little sun exposure is good for getting vitamin D, consider food alternatives, including milk, Dr. Friedlander said.

▸ Hemangiomas: Which ones may lead to a complication? The problem hemangiomas are those that are large, segmental, located on the face, and/or that obstruct a vital function. The number of hemangiomas may increase risk, particularly if there are more than six or seven, she said.

Therapy includes "watchful waiting" and the use of systemic prednisolone (2–3 mg/kg per day).

Orapred 15 mg/5 mL tastes better. It should be given in the morning for 4–8 weeks and then tapered as much as possible. This is effective in 84% of patients with hemangioma of infancy, Dr. Friedlander said.

Other options include the use of topical class 1 steroids (clobetasol) and intralesional corticosteroids—but beware that the latter can cause thromboses of the eye.

Another option is laser therapy, but not as first-line treatment. Difficult cases may be treated with vincristine, but it is phlebitic, she said.

Large facial hemangiomas require a careful physical exam, eye exam, and cardiac exam with echocardiography. Consider cranial magnetic resonance angiography and be aware of long-term vasculo-occlusive risks.

Hemangiomas that present in a "beard distribution" may mark underlying airway hemangiomas that compromise the airway.

For these, short courses of oral steroids may improve for a while but also may delay diagnosis. Pay attention also to midline and sacral lesions.

Ulcerated hemangiomas can be treated with saline compresses, topical antibiotics (mupirocin, Bacitracin, metronidazole), occlusive dressings (DuoDERM, Vigilon, OmniDerm), pulsed dye laser therapy, systemic and intralesional steroids, excision, and 0.01% topical Becaplermin, Dr. Friedlander said.

▸ How about pediatric onychomycosis? Topical treatment options include ciclopirox, amorolfine lacquer, bifonazole with 40% urea, and topical terbinafine.

Terbinafine 5 mg/kg per day can be used for the fingernails 6 weeks or toenails 12 weeks, but don't exceed 250 mg.

Fluconazole 6 mg/kg can be used once per week for 12 weeks on the fingernails and 26 weeks on the toenails.

Itraconazole caps 5 mg/kg per day pulse therapy can be used—two pulses for the fingernails and three pulses for the toenails, she said.

▸ What can be done about atopic dermatitis? "Corticosteroids are very helpful, but they can cause thinning of the skin and skin atrophy," she said. "And if too much is absorbed, they can cause stunting of growth; so we have to be careful when we use them."

There is an emerging class of topical agents that focuses on barrier function—physiologic moisturizers. Options include ceramide formulations in special delivery systems (Cerave, Epiceram); palmitoylethanolamide (PEA); MimyX, a cream containing endogenous fatty acid; and glycyrrhetinic acid/hyaluronic acid/shea butter combination cream (Atopiclair). "They're very expensive," she cautioned. "You should start out with Vaseline or Aquaphor."

Dr. Friedlander disclosed that she is a speaker on the speakers' bureau, a consultant, and/or involved with clinical research trials for the following companies: Novartis, Connetics Corp., Astellas Pharma Inc., Dermik Laboratories, and Graceway Pharmaceuticals.

MAUI, HAWAII — Questions that are commonly asked of pediatric dermatologists by parents range from how to get rid of warts to what to do about community-acquired methicillin-resistant Staphylococcus aureus infections, reported Dr. Sheila F. Friedlander.

The director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego, Dr. Friedlander gave some examples of the top questions asked, together with her answers, at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics:

▸ How can you get rid of my child's warts? Warts account for 8% of dermatology visits; up to 20% of school-age children are affected. Many warts just go away. The average cure rate for warts with placebo is 27% at 15 weeks, Dr. Friedlander said.

For treatment of warts, the best evidence available comes from five trials supporting the use of salicylic acid. A 6-week study of wart treatment with duct tape on 103 children found a modest but insignificant effect: 16% duct tape vs. 6% placebo.

Although cryotherapy is not well supported by studies, and the manner of application varies widely, empirically it works. Dr. Friedlander said she uses an approach she calls the "triple whammy": salicylic acid, salicylic bandage, and then duct tape.

If you try immunotherapy, skin test allergens are used: Candida, mumps, or Trichophyton. For the largest warts, inject 0.1–0.3 cc directly into the wart. Repeat the immunotherapy treatment every 3 weeks for 3–5 treatments.

The adult cure rate with Candida is 88% for local warts and 66% for distal ones. The relapse rate at 2 years is 5%, compared with 39% for cryotherapy, and 10% for laser.

Genital warts are now preventable by the quadrivalent human papillomavirus (HPV) vaccine Gardasil (Merck). It protects against HPV 6/11/16/18 and is 95% effective for as long as 4.5 years.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends routine vaccination of all girls ages 11–12 years with 3 doses, but it can be given at ages 9–26. The goal is to administer the vaccine prior to sexual contact.

About 30% of 9th graders and 60% of 12th graders are estimated to be sexually active. Cervical cancer, caused by HPV, is the second most common cancer in women worldwide, with 233,000 deaths per year, Dr. Friedlander said.

▸ What can be done about head lice? Dislodged by towels and hair dryers, lice can be transmitted by fomites, with eggs landing on fabrics, bedding, and furniture. These all need to be cleaned. For treatment, Dr. Friedlander recommends starting with topical over-the-counter (OTC) pyrethrin or permethrins.

The use of malathion is an option, but be aware that it is flammable—the patient should avoid the use of hairdryers and flames during treatment. Also, she observed, "It stinks to high heaven."

Another option, used in England and Israel, is to wash the hair, add hair conditioner (which makes the hair slippery and hard for eggs to adhere), and comb with a fine-tooth comb.

The use of Cetaphil cleanser is yet another option. The OTC cleanser is applied on a dry scalp and spread over the head until the hair is wet. Then the hair is blow-dried, and the cleanser is washed out the next day. The procedure is repeated in 7–10 days.

An effective hair dryer treatment is LouseBuster. It is slightly cooler than a standard blow dryer, but provides twice the volume of air, which kills head lice. Its effectiveness is 100% ovicidal, with 80% mortality of hatched lice (Pediatrics 2006;118:1962–70).

Use of oral ivermectin is another option, she said, "But I certainly wouldn't go with it for first-line therapy."

Dr. Friedlander suggested using the Cetaphil cleanser treatment combined with the use of a hair dryer.

▸ How can varicella infection be avoided? "We need to remember that chicken pox is tamed, but not conquered," Dr. Friedlander said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

Varivax, the live attenuated varicella vaccine available since 1995, has a protection rate of 85%; it is 97% effective in preventing moderate to severe disease. Hospitalization rates for varicella have decreased from 2.3/100,000 in 1994 to 0.3/100,000 in 2002, and mortality also has decreased (N. Engl. J. Med. 2005;352:450–8).

But there has been a problem with more severe disease developing in children who have not been vaccinated for more than 5 years. Therefore, children should receive two vaccinations, with the first dose given at 12–15 months, and the second between ages 4 and 6 years. All others should receive "catch-up" doses. Quadrivalent vaccines (MMRV, Proquad) are options, she said.

▸ What can be done about melanoma in children? The incidence of melanoma in children is low but rising. In children, the disease can present as nodular lesions and amelanotic lesions, and it can be mistaken for pyogenic granuloma. Risk factors include a family history of melanoma, large numbers of moles, atypical moles, fair skin, freckling, red hair, sun exposure, and BRAF and NRAS activating gene mutations in tissue (Oncogene 2003;22:3053–62; Am. J. Hum. Genet. 2003;73:301–13).

The most effective treatment is high-dose interferon alpha-2b. Some data suggest that the younger the patient, the greater the likelihood of event-free survival (Cancer 2005;103:780–7).

▸ How can children be protected from the sun? "I always emphasize physical protection," Dr. Friedlander said. "Get the cap out, get the clothing out, and reserve the sunscreen for areas you can't cover." Sunscreens should provide UVA protection as well as UVB. Good options include Helioplex (Neutrogena), which contains a new stabilizer at strengths of SPF 30 and 45, and Anthelios (La Roche Posay), which contains mexoryl, SPF 15, she said.

Although it's been found that a little sun exposure is good for getting vitamin D, consider food alternatives, including milk, Dr. Friedlander said.

▸ Hemangiomas: Which ones may lead to a complication? The problem hemangiomas are those that are large, segmental, located on the face, and/or that obstruct a vital function. The number of hemangiomas may increase risk, particularly if there are more than six or seven, she said.

Therapy includes "watchful waiting" and the use of systemic prednisolone (2–3 mg/kg per day).

Orapred 15 mg/5 mL tastes better. It should be given in the morning for 4–8 weeks and then tapered as much as possible. This is effective in 84% of patients with hemangioma of infancy, Dr. Friedlander said.

Other options include the use of topical class 1 steroids (clobetasol) and intralesional corticosteroids—but beware that the latter can cause thromboses of the eye.

Another option is laser therapy, but not as first-line treatment. Difficult cases may be treated with vincristine, but it is phlebitic, she said.

Large facial hemangiomas require a careful physical exam, eye exam, and cardiac exam with echocardiography. Consider cranial magnetic resonance angiography and be aware of long-term vasculo-occlusive risks.

Hemangiomas that present in a "beard distribution" may mark underlying airway hemangiomas that compromise the airway.

For these, short courses of oral steroids may improve for a while but also may delay diagnosis. Pay attention also to midline and sacral lesions.

Ulcerated hemangiomas can be treated with saline compresses, topical antibiotics (mupirocin, Bacitracin, metronidazole), occlusive dressings (DuoDERM, Vigilon, OmniDerm), pulsed dye laser therapy, systemic and intralesional steroids, excision, and 0.01% topical Becaplermin, Dr. Friedlander said.

▸ How about pediatric onychomycosis? Topical treatment options include ciclopirox, amorolfine lacquer, bifonazole with 40% urea, and topical terbinafine.

Terbinafine 5 mg/kg per day can be used for the fingernails 6 weeks or toenails 12 weeks, but don't exceed 250 mg.

Fluconazole 6 mg/kg can be used once per week for 12 weeks on the fingernails and 26 weeks on the toenails.

Itraconazole caps 5 mg/kg per day pulse therapy can be used—two pulses for the fingernails and three pulses for the toenails, she said.

▸ What can be done about atopic dermatitis? "Corticosteroids are very helpful, but they can cause thinning of the skin and skin atrophy," she said. "And if too much is absorbed, they can cause stunting of growth; so we have to be careful when we use them."

There is an emerging class of topical agents that focuses on barrier function—physiologic moisturizers. Options include ceramide formulations in special delivery systems (Cerave, Epiceram); palmitoylethanolamide (PEA); MimyX, a cream containing endogenous fatty acid; and glycyrrhetinic acid/hyaluronic acid/shea butter combination cream (Atopiclair). "They're very expensive," she cautioned. "You should start out with Vaseline or Aquaphor."

Dr. Friedlander disclosed that she is a speaker on the speakers' bureau, a consultant, and/or involved with clinical research trials for the following companies: Novartis, Connetics Corp., Astellas Pharma Inc., Dermik Laboratories, and Graceway Pharmaceuticals.

MAUI, HAWAII — Because tinea capitis in children can be mistaken for a number of different diseases, Dr. Sheila Fallon Friedlander urged physicians, "I want you to culture."

"Classically, people have thought that you look for hair loss and scaling, but my experience has been that most scalps that scale are not tinea capitis," she said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

Although with some presentations tinea capitis can be easy to diagnose, the infection can look unusual and be harder to detect, she said at the meeting, also sponsored by California Chapter 2 of the AAP.

Diseases and conditions that can be mistaken for tinea capitis include seborrheic dermatitis, eczema, psoriasis, alopecia areata, cradle cap, traction folliculitis leading to traction alopecia, and the effects of head lice.

In their study, Dr. Friedlander and a colleague examined 200 children, with half in her organization's clinic and half in other pediatric practices in San Diego. "What we found is a heck of a lot of kids have scale on their scalp," she said.

"And a heck of a lot of kids—if you look for it—have [enlarged] lymph nodes in their neck." On the basis of these two symptoms plus hair loss, many pediatricians have been trained to diagnose tinea capitis, said Dr. Friedlander, director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

"But that's inaccurate," she said. "That's not appropriate. In our study, we found that 22% of kids just walking into the pediatrician's office had scale, and 55% of them had [enlarged] lymph nodes. Very few of those kids had tinea capitis" (Pediatrics 2005;115:e1–6).

She encouraged checking the lymph nodes, however. "If a child comes in who has scaling and has hair loss and has large lymph nodes, then you are very likely to be dealing with tinea capitis." But the child needs to be cultured to confirm the diagnosis.

Dr. Friedlander said her center has done a study that supports taking cultures with a cotton swab, a transport medium otherwise used for strep throat. She instructed the audience to swab all four quadrants of the patient's scalp and send it out to a lab. Even if the sample swab sits at room temperature in the office for a couple of days before delivery to the lab, the results still should be good.

"Ninety-five percent of tinea capitis in this country is caused by Trichophyton tonsurans," she said, which is believed to have come from Central and South America.

Tinea capitis is the most common dermatophyte infection in children, frequently affecting those who are aged 3–7 years, she noted. "It commonly affects the preschool age group."

"The prevalence is somewhere between 0% and 8% in any given place, depending on the city you're looking at," she said, and it's even higher in some urban populations and among African Americans. Prevalence appears to be relatively higher in immigrants from Africa.

While taking the patient's history, Dr. Friedlander continued, also ask about family members, "because often there will be somebody else in the house who is scaling."

As for treatment, a meta-analysis of six studies found that a 2- to 4-week course of terbinafine is "at least as effective" as a 6- to 8-week course of griseofulvin for Trichophyton. But for Microsporum infections, griseofulvin is likely the better treatment (Pediatrics 2004;114:1312–5).

"High-dose griseofulvin is the current drug of choice; it's FDA approved," she pointed out. It should be given with food to aid absorption. Keep in mind that children clear the drug faster than do adults, and therefore need a high dose. Patients should be rechecked in 4 weeks. Most of Dr. Friedlander's patients are treated for 8 weeks. Lab tests are not needed if patients use the drug for 8 weeks or less.

"Consider off-label use of terbinafine if there is griseofulvin failure," she said.

As an aid to therapy, the use of antifungal lotions and shampoos help decrease the time of infectivity, Dr. Friedlander said. She has her patients use Nizoral shampoo twice a week. Selenium sulfite is another option.

Dr. Friedlander disclosed that she is on the speakers' bureau, a consultant, and/or involved with clinical research trials for Novartis AG, Pfizer Inc., and Dermik Laboratories.

MAUI, HAWAII — Because tinea capitis in children can be mistaken for a number of different diseases, Dr. Sheila Fallon Friedlander urged physicians, "I want you to culture."

"Classically, people have thought that you look for hair loss and scaling, but my experience has been that most scalps that scale are not tinea capitis," she said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

Although with some presentations tinea capitis can be easy to diagnose, the infection can look unusual and be harder to detect, she said at the meeting, also sponsored by California Chapter 2 of the AAP.

Diseases and conditions that can be mistaken for tinea capitis include seborrheic dermatitis, eczema, psoriasis, alopecia areata, cradle cap, traction folliculitis leading to traction alopecia, and the effects of head lice.

In their study, Dr. Friedlander and a colleague examined 200 children, with half in her organization's clinic and half in other pediatric practices in San Diego. "What we found is a heck of a lot of kids have scale on their scalp," she said.

"And a heck of a lot of kids—if you look for it—have [enlarged] lymph nodes in their neck." On the basis of these two symptoms plus hair loss, many pediatricians have been trained to diagnose tinea capitis, said Dr. Friedlander, director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

"But that's inaccurate," she said. "That's not appropriate. In our study, we found that 22% of kids just walking into the pediatrician's office had scale, and 55% of them had [enlarged] lymph nodes. Very few of those kids had tinea capitis" (Pediatrics 2005;115:e1–6).

She encouraged checking the lymph nodes, however. "If a child comes in who has scaling and has hair loss and has large lymph nodes, then you are very likely to be dealing with tinea capitis." But the child needs to be cultured to confirm the diagnosis.

Dr. Friedlander said her center has done a study that supports taking cultures with a cotton swab, a transport medium otherwise used for strep throat. She instructed the audience to swab all four quadrants of the patient's scalp and send it out to a lab. Even if the sample swab sits at room temperature in the office for a couple of days before delivery to the lab, the results still should be good.

"Ninety-five percent of tinea capitis in this country is caused by Trichophyton tonsurans," she said, which is believed to have come from Central and South America.

Tinea capitis is the most common dermatophyte infection in children, frequently affecting those who are aged 3–7 years, she noted. "It commonly affects the preschool age group."

"The prevalence is somewhere between 0% and 8% in any given place, depending on the city you're looking at," she said, and it's even higher in some urban populations and among African Americans. Prevalence appears to be relatively higher in immigrants from Africa.

While taking the patient's history, Dr. Friedlander continued, also ask about family members, "because often there will be somebody else in the house who is scaling."

As for treatment, a meta-analysis of six studies found that a 2- to 4-week course of terbinafine is "at least as effective" as a 6- to 8-week course of griseofulvin for Trichophyton. But for Microsporum infections, griseofulvin is likely the better treatment (Pediatrics 2004;114:1312–5).

"High-dose griseofulvin is the current drug of choice; it's FDA approved," she pointed out. It should be given with food to aid absorption. Keep in mind that children clear the drug faster than do adults, and therefore need a high dose. Patients should be rechecked in 4 weeks. Most of Dr. Friedlander's patients are treated for 8 weeks. Lab tests are not needed if patients use the drug for 8 weeks or less.

"Consider off-label use of terbinafine if there is griseofulvin failure," she said.

As an aid to therapy, the use of antifungal lotions and shampoos help decrease the time of infectivity, Dr. Friedlander said. She has her patients use Nizoral shampoo twice a week. Selenium sulfite is another option.

Dr. Friedlander disclosed that she is on the speakers' bureau, a consultant, and/or involved with clinical research trials for Novartis AG, Pfizer Inc., and Dermik Laboratories.

MAUI, HAWAII — Because tinea capitis in children can be mistaken for a number of different diseases, Dr. Sheila Fallon Friedlander urged physicians, "I want you to culture."

"Classically, people have thought that you look for hair loss and scaling, but my experience has been that most scalps that scale are not tinea capitis," she said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

Although with some presentations tinea capitis can be easy to diagnose, the infection can look unusual and be harder to detect, she said at the meeting, also sponsored by California Chapter 2 of the AAP.

Diseases and conditions that can be mistaken for tinea capitis include seborrheic dermatitis, eczema, psoriasis, alopecia areata, cradle cap, traction folliculitis leading to traction alopecia, and the effects of head lice.

In their study, Dr. Friedlander and a colleague examined 200 children, with half in her organization's clinic and half in other pediatric practices in San Diego. "What we found is a heck of a lot of kids have scale on their scalp," she said.

"And a heck of a lot of kids—if you look for it—have [enlarged] lymph nodes in their neck." On the basis of these two symptoms plus hair loss, many pediatricians have been trained to diagnose tinea capitis, said Dr. Friedlander, director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

"But that's inaccurate," she said. "That's not appropriate. In our study, we found that 22% of kids just walking into the pediatrician's office had scale, and 55% of them had [enlarged] lymph nodes. Very few of those kids had tinea capitis" (Pediatrics 2005;115:e1–6).

She encouraged checking the lymph nodes, however. "If a child comes in who has scaling and has hair loss and has large lymph nodes, then you are very likely to be dealing with tinea capitis." But the child needs to be cultured to confirm the diagnosis.

Dr. Friedlander said her center has done a study that supports taking cultures with a cotton swab, a transport medium otherwise used for strep throat. She instructed the audience to swab all four quadrants of the patient's scalp and send it out to a lab. Even if the sample swab sits at room temperature in the office for a couple of days before delivery to the lab, the results still should be good.

"Ninety-five percent of tinea capitis in this country is caused by Trichophyton tonsurans," she said, which is believed to have come from Central and South America.

Tinea capitis is the most common dermatophyte infection in children, frequently affecting those who are aged 3–7 years, she noted. "It commonly affects the preschool age group."

"The prevalence is somewhere between 0% and 8% in any given place, depending on the city you're looking at," she said, and it's even higher in some urban populations and among African Americans. Prevalence appears to be relatively higher in immigrants from Africa.

While taking the patient's history, Dr. Friedlander continued, also ask about family members, "because often there will be somebody else in the house who is scaling."

As for treatment, a meta-analysis of six studies found that a 2- to 4-week course of terbinafine is "at least as effective" as a 6- to 8-week course of griseofulvin for Trichophyton. But for Microsporum infections, griseofulvin is likely the better treatment (Pediatrics 2004;114:1312–5).

"High-dose griseofulvin is the current drug of choice; it's FDA approved," she pointed out. It should be given with food to aid absorption. Keep in mind that children clear the drug faster than do adults, and therefore need a high dose. Patients should be rechecked in 4 weeks. Most of Dr. Friedlander's patients are treated for 8 weeks. Lab tests are not needed if patients use the drug for 8 weeks or less.

"Consider off-label use of terbinafine if there is griseofulvin failure," she said.

As an aid to therapy, the use of antifungal lotions and shampoos help decrease the time of infectivity, Dr. Friedlander said. She has her patients use Nizoral shampoo twice a week. Selenium sulfite is another option.

Dr. Friedlander disclosed that she is on the speakers' bureau, a consultant, and/or involved with clinical research trials for Novartis AG, Pfizer Inc., and Dermik Laboratories.

MAUI, HAWAII — “Ask about pets in every febrile patient you see” was one of the take-home messages from Dr. Jay M. Lieberman as he discussed infections you can get from your pets.

And in particular, he said, “Consider cat-scratch disease in any patient with fever of unknown origin who has contact with cats—particularly if they're kittens.”

He presented several cases of children with prolonged fevers who remained without a diagnosis, despite extensive evaluations, until the possibility of cat-scratch disease was entertained and a history of contact with kittens was obtained. The diagnosis of cat-scratch disease often can be made from the history and physical examination, and serologies may not be reliable, Dr. Lieberman said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

Kittens are more likely to cause cat-scratch disease than are older cats. The disease is caused by Bartonella henselae, and approximately 40% of cats are bacteremic with the organism, explained Dr. Lieberman, professor of clinical pediatrics at the University of California, Irvine.

Cat-scratch disease is transmitted to humans through scratches, licks, or bites from kittens, less often from older cats, and sometimes from dogs.

A primary papule may be seen 3–12 days after inoculation time, followed 7–60 days (average 12–14 days) later by regional lymphadenopathy that may suppurate or regress over 2–4 months. Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients, and malaise, anorexia, and headache also may occur.

The area around the nodes may be noninflamed but can be warm, tender, and erythematous, Dr. Lieberman said at the meeting, which also was sponsored by California Chapter 2 of the AAP. As many as 30% of nodes will suppurate spontaneously.

Atypical presentations of cat-scratch disease included prolonged fever/fever of unknown origin, granulomatous hepatitis, conjunctivitis with preauricular adenopathy (Pari-naud's oculoglandular syndrome), encephalopathy/encephalitis, osteomyelitis, and ocular disease.

Although patients may be treated with rifampin or gentamicin or trimethoprim-sulfamethoxazole (TMP/SMZ), or a combination of anti-infectives, Dr. Lieberman does not routinely recommend their use. “In general, we have not treated our patients with antimicrobial therapy,” he said. “Most patients do not require specific therapy, and the illness resolves on its own.”

One prospective randomized trial of azithromycin vs. placebo found a significantly greater decrease in lymph node size in azithromycin-treated patients at 30 days, but there was no significant difference thereafter (Pediatr. Infect. Dis. J. 1998;17:447–52).

Dr. Lieberman then discussed other infections that can be acquired from pets:

▸ Dog- and cat-bite wound infections. Approximately 5%–15% of dog bites lead to infections, as do 20%–50% of cat bites. Pasteurella species, short gram-negative coccobacilli that are part of the normal flora of cats and dogs, are isolated from 75% of infections from cat bites and 50% of infections from dog bites. Pasteurella organisms are not susceptible to cephalexin or dicloxacillin, he said.

To help prevent infection from bites, wounds should be cleaned, debrided, and closed. Bite wounds should be reevaluated in 1–2 days. When indicated, there may be a need for tetanus and/or rabies prophylaxis.

Antibiotic prophylaxis is indicated for puncture wounds (including all cat bites), bites over tendons, joints, and bone; bites on the face and/or genitals; bites involving an immunocompromised person; and bites that cannot be well cleaned and debrided. Antibiotic prophylaxis, when indicated, may be used for 48–72 hours.

Amoxicillin-clavulanate is the antibiotic of choice for prevention or treatment of animal bite wound infections, he said. Alternatives include a combination of cephalexin or dicloxacillin and penicillin V or a combination of clindamycin and trimethoprim-sulfamethoxazole.

▸ Rat-bite fever. This is “caused by Streptobacillus moniliformis, an unusual gram-negative pleomorphic rod. It is normal oral flora in rats and can be excreted in rat urine. Humans are infected after a bite or scratch—or kiss—from an infected rat, or after handling a rat or ingesting food or water contaminated with rat excreta,” explained Dr. Lieberman.

There is an incubation period of 2–10 days, followed by rapid onset of fever, chills, headache, and myalgia. Rash may develop 2–4 days after the onset of fever. The rash usually is maculopapular, often including the palms of hands and soles of feet, and it may evolve into petechiae, purpura, and vesicles. About half of patients develop an asymmetric septic polyarthritis. Dr. Lieberman described three children with rat-bite fever seen at his hospital over the past several years, all of whom presented with fevers, polyarthritis, and the characteristic rash, which was most prominent on the soles of the feet.

The treatment of choice is penicillin G. P Salmonellosis. About 3% of U.S. households have reptiles, most commonly lizards, snakes, and turtles. Tortoises are chronic, intermittent shedders of Salmonella, and the Centers for Disease Control and Prevention estimates that more than 70,000 reptile-associated U.S. cases of salmonellosis occur each year, Dr. Lieberman said. Reptiles should be kept out of child care centers and households in which children are younger than 5 years or immunocompromised people live, he noted.

Dr. Lieberman disclosed that he is a consultant and a member of the speakers' bureaus for GlaxoSmithKline, Sanofi Pasteur, and Merck & Co.

Cat-scratch disease can be transmitted to humans by kittens, older cats, and sometimes dogs. DR. LIEBERMAN

Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients. Courtesy Dr. Sherif Emil

MAUI, HAWAII — “Ask about pets in every febrile patient you see” was one of the take-home messages from Dr. Jay M. Lieberman as he discussed infections you can get from your pets.

And in particular, he said, “Consider cat-scratch disease in any patient with fever of unknown origin who has contact with cats—particularly if they're kittens.”

He presented several cases of children with prolonged fevers who remained without a diagnosis, despite extensive evaluations, until the possibility of cat-scratch disease was entertained and a history of contact with kittens was obtained. The diagnosis of cat-scratch disease often can be made from the history and physical examination, and serologies may not be reliable, Dr. Lieberman said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

Kittens are more likely to cause cat-scratch disease than are older cats. The disease is caused by Bartonella henselae, and approximately 40% of cats are bacteremic with the organism, explained Dr. Lieberman, professor of clinical pediatrics at the University of California, Irvine.

Cat-scratch disease is transmitted to humans through scratches, licks, or bites from kittens, less often from older cats, and sometimes from dogs.

A primary papule may be seen 3–12 days after inoculation time, followed 7–60 days (average 12–14 days) later by regional lymphadenopathy that may suppurate or regress over 2–4 months. Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients, and malaise, anorexia, and headache also may occur.

The area around the nodes may be noninflamed but can be warm, tender, and erythematous, Dr. Lieberman said at the meeting, which also was sponsored by California Chapter 2 of the AAP. As many as 30% of nodes will suppurate spontaneously.

Atypical presentations of cat-scratch disease included prolonged fever/fever of unknown origin, granulomatous hepatitis, conjunctivitis with preauricular adenopathy (Pari-naud's oculoglandular syndrome), encephalopathy/encephalitis, osteomyelitis, and ocular disease.

Although patients may be treated with rifampin or gentamicin or trimethoprim-sulfamethoxazole (TMP/SMZ), or a combination of anti-infectives, Dr. Lieberman does not routinely recommend their use. “In general, we have not treated our patients with antimicrobial therapy,” he said. “Most patients do not require specific therapy, and the illness resolves on its own.”

One prospective randomized trial of azithromycin vs. placebo found a significantly greater decrease in lymph node size in azithromycin-treated patients at 30 days, but there was no significant difference thereafter (Pediatr. Infect. Dis. J. 1998;17:447–52).

Dr. Lieberman then discussed other infections that can be acquired from pets:

▸ Dog- and cat-bite wound infections. Approximately 5%–15% of dog bites lead to infections, as do 20%–50% of cat bites. Pasteurella species, short gram-negative coccobacilli that are part of the normal flora of cats and dogs, are isolated from 75% of infections from cat bites and 50% of infections from dog bites. Pasteurella organisms are not susceptible to cephalexin or dicloxacillin, he said.

To help prevent infection from bites, wounds should be cleaned, debrided, and closed. Bite wounds should be reevaluated in 1–2 days. When indicated, there may be a need for tetanus and/or rabies prophylaxis.

Antibiotic prophylaxis is indicated for puncture wounds (including all cat bites), bites over tendons, joints, and bone; bites on the face and/or genitals; bites involving an immunocompromised person; and bites that cannot be well cleaned and debrided. Antibiotic prophylaxis, when indicated, may be used for 48–72 hours.

Amoxicillin-clavulanate is the antibiotic of choice for prevention or treatment of animal bite wound infections, he said. Alternatives include a combination of cephalexin or dicloxacillin and penicillin V or a combination of clindamycin and trimethoprim-sulfamethoxazole.

▸ Rat-bite fever. This is “caused by Streptobacillus moniliformis, an unusual gram-negative pleomorphic rod. It is normal oral flora in rats and can be excreted in rat urine. Humans are infected after a bite or scratch—or kiss—from an infected rat, or after handling a rat or ingesting food or water contaminated with rat excreta,” explained Dr. Lieberman.

There is an incubation period of 2–10 days, followed by rapid onset of fever, chills, headache, and myalgia. Rash may develop 2–4 days after the onset of fever. The rash usually is maculopapular, often including the palms of hands and soles of feet, and it may evolve into petechiae, purpura, and vesicles. About half of patients develop an asymmetric septic polyarthritis. Dr. Lieberman described three children with rat-bite fever seen at his hospital over the past several years, all of whom presented with fevers, polyarthritis, and the characteristic rash, which was most prominent on the soles of the feet.

The treatment of choice is penicillin G. P Salmonellosis. About 3% of U.S. households have reptiles, most commonly lizards, snakes, and turtles. Tortoises are chronic, intermittent shedders of Salmonella, and the Centers for Disease Control and Prevention estimates that more than 70,000 reptile-associated U.S. cases of salmonellosis occur each year, Dr. Lieberman said. Reptiles should be kept out of child care centers and households in which children are younger than 5 years or immunocompromised people live, he noted.

Dr. Lieberman disclosed that he is a consultant and a member of the speakers' bureaus for GlaxoSmithKline, Sanofi Pasteur, and Merck & Co.

Cat-scratch disease can be transmitted to humans by kittens, older cats, and sometimes dogs. DR. LIEBERMAN

Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients. Courtesy Dr. Sherif Emil

MAUI, HAWAII — “Ask about pets in every febrile patient you see” was one of the take-home messages from Dr. Jay M. Lieberman as he discussed infections you can get from your pets.

And in particular, he said, “Consider cat-scratch disease in any patient with fever of unknown origin who has contact with cats—particularly if they're kittens.”

He presented several cases of children with prolonged fevers who remained without a diagnosis, despite extensive evaluations, until the possibility of cat-scratch disease was entertained and a history of contact with kittens was obtained. The diagnosis of cat-scratch disease often can be made from the history and physical examination, and serologies may not be reliable, Dr. Lieberman said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

Kittens are more likely to cause cat-scratch disease than are older cats. The disease is caused by Bartonella henselae, and approximately 40% of cats are bacteremic with the organism, explained Dr. Lieberman, professor of clinical pediatrics at the University of California, Irvine.

Cat-scratch disease is transmitted to humans through scratches, licks, or bites from kittens, less often from older cats, and sometimes from dogs.

A primary papule may be seen 3–12 days after inoculation time, followed 7–60 days (average 12–14 days) later by regional lymphadenopathy that may suppurate or regress over 2–4 months. Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients, and malaise, anorexia, and headache also may occur.

The area around the nodes may be noninflamed but can be warm, tender, and erythematous, Dr. Lieberman said at the meeting, which also was sponsored by California Chapter 2 of the AAP. As many as 30% of nodes will suppurate spontaneously.

Atypical presentations of cat-scratch disease included prolonged fever/fever of unknown origin, granulomatous hepatitis, conjunctivitis with preauricular adenopathy (Pari-naud's oculoglandular syndrome), encephalopathy/encephalitis, osteomyelitis, and ocular disease.

Although patients may be treated with rifampin or gentamicin or trimethoprim-sulfamethoxazole (TMP/SMZ), or a combination of anti-infectives, Dr. Lieberman does not routinely recommend their use. “In general, we have not treated our patients with antimicrobial therapy,” he said. “Most patients do not require specific therapy, and the illness resolves on its own.”

One prospective randomized trial of azithromycin vs. placebo found a significantly greater decrease in lymph node size in azithromycin-treated patients at 30 days, but there was no significant difference thereafter (Pediatr. Infect. Dis. J. 1998;17:447–52).

Dr. Lieberman then discussed other infections that can be acquired from pets:

▸ Dog- and cat-bite wound infections. Approximately 5%–15% of dog bites lead to infections, as do 20%–50% of cat bites. Pasteurella species, short gram-negative coccobacilli that are part of the normal flora of cats and dogs, are isolated from 75% of infections from cat bites and 50% of infections from dog bites. Pasteurella organisms are not susceptible to cephalexin or dicloxacillin, he said.

To help prevent infection from bites, wounds should be cleaned, debrided, and closed. Bite wounds should be reevaluated in 1–2 days. When indicated, there may be a need for tetanus and/or rabies prophylaxis.

Antibiotic prophylaxis is indicated for puncture wounds (including all cat bites), bites over tendons, joints, and bone; bites on the face and/or genitals; bites involving an immunocompromised person; and bites that cannot be well cleaned and debrided. Antibiotic prophylaxis, when indicated, may be used for 48–72 hours.

Amoxicillin-clavulanate is the antibiotic of choice for prevention or treatment of animal bite wound infections, he said. Alternatives include a combination of cephalexin or dicloxacillin and penicillin V or a combination of clindamycin and trimethoprim-sulfamethoxazole.

▸ Rat-bite fever. This is “caused by Streptobacillus moniliformis, an unusual gram-negative pleomorphic rod. It is normal oral flora in rats and can be excreted in rat urine. Humans are infected after a bite or scratch—or kiss—from an infected rat, or after handling a rat or ingesting food or water contaminated with rat excreta,” explained Dr. Lieberman.

There is an incubation period of 2–10 days, followed by rapid onset of fever, chills, headache, and myalgia. Rash may develop 2–4 days after the onset of fever. The rash usually is maculopapular, often including the palms of hands and soles of feet, and it may evolve into petechiae, purpura, and vesicles. About half of patients develop an asymmetric septic polyarthritis. Dr. Lieberman described three children with rat-bite fever seen at his hospital over the past several years, all of whom presented with fevers, polyarthritis, and the characteristic rash, which was most prominent on the soles of the feet.

The treatment of choice is penicillin G. P Salmonellosis. About 3% of U.S. households have reptiles, most commonly lizards, snakes, and turtles. Tortoises are chronic, intermittent shedders of Salmonella, and the Centers for Disease Control and Prevention estimates that more than 70,000 reptile-associated U.S. cases of salmonellosis occur each year, Dr. Lieberman said. Reptiles should be kept out of child care centers and households in which children are younger than 5 years or immunocompromised people live, he noted.

Dr. Lieberman disclosed that he is a consultant and a member of the speakers' bureaus for GlaxoSmithKline, Sanofi Pasteur, and Merck & Co.

Cat-scratch disease can be transmitted to humans by kittens, older cats, and sometimes dogs. DR. LIEBERMAN

Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients. Courtesy Dr. Sherif Emil

MAUI, HAWAII — Foreign travel can pose particular dangers to infants and children. If it is important that young children travel internationally, specific precautions can reduce the risk of infectious complications and increase the likelihood that the trip will be safe and enjoyable, instructed Dr. Jay M. Lieberman.

In general, there should be risk assessment for children traveling to other countries to determine the risks of the destination, mode of travel, and the special conditions of the traveler. Vaccinations should be given when indicated, and chemoprophylaxis should be used when appropriate, he added.

A key source of information for foreign travel is the Centers for Disease Control and Prevention Web site, www.cdc.gov/travel

Common travel problems and preventives include sun hazards, countered by sunscreen; travel safety, enhanced with car seats and seat belts; mosquitoes, warded off by repellents and nets. Other problems may include animal bites, envenomation, sexually transmitted infections for adolescents, travelers' diarrhea, and altitude illness, Dr. Lieberman said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

Dr. Lieberman, professor of clinical pediatrics at the University of California, Irvine, provided the following advice on taking preventive measures prior to travel:

▸ Routine immunizations. Review and complete the age-appropriate immunization schedule. DTaP, polio, Haemophilus influenzae type b (Hib) conjugate, and pneumococcal conjugate vaccines may be given at 4-week intervals, if necessary, to complete the primary series before travel. Hepatitis B vaccine should be given if patients are not vaccinated already. “Infants 6–11 months old should receive one dose of measles vaccine—preferably monovalent,” he recommended. Consider a second dose of measles, mumps, and rubella (MMR) and varicella vaccines before travel for children who have received only their first dose.

▸ Travelers' diarrhea. “Travelers' diarrhea is among the most common travel-related problem affecting young children,” especially infants, he warned. This results from ingesting food and water contaminated by feces, and is caused by bacteria (85%), parasites (10%), and viruses (5%). For young infants, breast-feeding is the best way to avoid water- and food-borne illnesses. Otherwise, be scrupulous about washing hands and use only purified water in ice cubes and for drinking, brushing teeth, and mixing infant formulas. Avoid food from street vendors, raw or undercooked meat and seafood, and unpasteurized dairy products. Fresh fruits and vegetables must be adequately cooked or washed well and peeled. Other potential preventive measures include the use of probiotics and bismuth subsalicylate; antibiotics generally are not recommended for this purpose but may be brought along for empiric treatment, if needed.

▸ Malaria. “For chemoprophylaxis, the standard for a long time was chloroquine given weekly, but the emergence of resistance has dramatically limited its use,” observed Dr. Lieberman. Options include mefloquine given weekly, although it has CNS side effects; doxycycline given daily, but not for children younger than 8 years; or atovaquone/proguanil given daily, but not for infants weighing less than 5 kg. Chemoprophylaxis should begin prior to travel and should be used continuously while in malaria-endemic areas and for 4 weeks (using chloroquine, mefloquine, or doxycycline) or 7 days (using atovaquone/proguanil) after leaving those areas. Detailed recommendations for preventing malaria are available 24 hours a day at 877-394-8747 or at the www.cdc.gov/travel

▸ Hepatitis A. Vaccination now is recommended routinely for all children, with the first dose at 12–23 months of age. Immune globulin is indicated for infants younger than 12 months; it can be given with the vaccine to ensure immediate protection if travel is imminent (although it's probably unnecessary, according to Dr. Lieberman).

▸ Meningococcal vaccine. The conjugate vaccination now is recommended routinely for all children aged 11–18 years. For children aged 2–10 years, only the polysaccharide vaccine is licensed.

▸ Typhoid fever. There are two “moderately effective” vaccines available: Ty21a live attenuated oral vaccine, given as a four-dose series on alternate days for persons 6 years of age or older; or Vi capsular polysaccharide vaccine, single dose, for persons 2 years of age or older.

▸ Yellow fever. This is endemic in equatorial Africa and South America, Dr. Lieberman noted, and proof of vaccination is required for entry in some countries. A live, attenuated virus vaccine is available. Vaccine side effects include headaches, myalgias, fever, and encephalitis. Infants are at increased risk for encephalitis from the vaccine. Travelers with infants younger than 9 months should be strongly advised to not travel to yellow fever-endemic areas.

▸ Japanese encephalitis. This is endemic in Southeast Asia, he said. Immunization for this is given as a series of three injections on days 0, 7, and 30, with a booster given 24 months later. Children aged 1–2 years receive a 0.5-mL dose. There may be associated local reactions and mild systemic effects such as fever, headache, and myalgias. For a short-term stay in an urban area, immunization is not recommended.

▸ Rabies. The decision to vaccinate should be based on the itinerary and expected activities. As prophylaxis, the vaccine should be given as a four-dose series of injections on days 0, 7, 21, and 28.

Dr. Lieberman disclosed that he has a financial relationship as a consultant and as a member of the speakers' bureaus for GlaxoSmithKline, Sanofi Pasteur, and Merck & Co.

MAUI, HAWAII — Foreign travel can pose particular dangers to infants and children. If it is important that young children travel internationally, specific precautions can reduce the risk of infectious complications and increase the likelihood that the trip will be safe and enjoyable, instructed Dr. Jay M. Lieberman.

In general, there should be risk assessment for children traveling to other countries to determine the risks of the destination, mode of travel, and the special conditions of the traveler. Vaccinations should be given when indicated, and chemoprophylaxis should be used when appropriate, he added.

A key source of information for foreign travel is the Centers for Disease Control and Prevention Web site, www.cdc.gov/travel

Common travel problems and preventives include sun hazards, countered by sunscreen; travel safety, enhanced with car seats and seat belts; mosquitoes, warded off by repellents and nets. Other problems may include animal bites, envenomation, sexually transmitted infections for adolescents, travelers' diarrhea, and altitude illness, Dr. Lieberman said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

Dr. Lieberman, professor of clinical pediatrics at the University of California, Irvine, provided the following advice on taking preventive measures prior to travel:

▸ Routine immunizations. Review and complete the age-appropriate immunization schedule. DTaP, polio, Haemophilus influenzae type b (Hib) conjugate, and pneumococcal conjugate vaccines may be given at 4-week intervals, if necessary, to complete the primary series before travel. Hepatitis B vaccine should be given if patients are not vaccinated already. “Infants 6–11 months old should receive one dose of measles vaccine—preferably monovalent,” he recommended. Consider a second dose of measles, mumps, and rubella (MMR) and varicella vaccines before travel for children who have received only their first dose.

▸ Travelers' diarrhea. “Travelers' diarrhea is among the most common travel-related problem affecting young children,” especially infants, he warned. This results from ingesting food and water contaminated by feces, and is caused by bacteria (85%), parasites (10%), and viruses (5%). For young infants, breast-feeding is the best way to avoid water- and food-borne illnesses. Otherwise, be scrupulous about washing hands and use only purified water in ice cubes and for drinking, brushing teeth, and mixing infant formulas. Avoid food from street vendors, raw or undercooked meat and seafood, and unpasteurized dairy products. Fresh fruits and vegetables must be adequately cooked or washed well and peeled. Other potential preventive measures include the use of probiotics and bismuth subsalicylate; antibiotics generally are not recommended for this purpose but may be brought along for empiric treatment, if needed.

▸ Malaria. “For chemoprophylaxis, the standard for a long time was chloroquine given weekly, but the emergence of resistance has dramatically limited its use,” observed Dr. Lieberman. Options include mefloquine given weekly, although it has CNS side effects; doxycycline given daily, but not for children younger than 8 years; or atovaquone/proguanil given daily, but not for infants weighing less than 5 kg. Chemoprophylaxis should begin prior to travel and should be used continuously while in malaria-endemic areas and for 4 weeks (using chloroquine, mefloquine, or doxycycline) or 7 days (using atovaquone/proguanil) after leaving those areas. Detailed recommendations for preventing malaria are available 24 hours a day at 877-394-8747 or at the www.cdc.gov/travel

▸ Hepatitis A. Vaccination now is recommended routinely for all children, with the first dose at 12–23 months of age. Immune globulin is indicated for infants younger than 12 months; it can be given with the vaccine to ensure immediate protection if travel is imminent (although it's probably unnecessary, according to Dr. Lieberman).

▸ Meningococcal vaccine. The conjugate vaccination now is recommended routinely for all children aged 11–18 years. For children aged 2–10 years, only the polysaccharide vaccine is licensed.

▸ Typhoid fever. There are two “moderately effective” vaccines available: Ty21a live attenuated oral vaccine, given as a four-dose series on alternate days for persons 6 years of age or older; or Vi capsular polysaccharide vaccine, single dose, for persons 2 years of age or older.

▸ Yellow fever. This is endemic in equatorial Africa and South America, Dr. Lieberman noted, and proof of vaccination is required for entry in some countries. A live, attenuated virus vaccine is available. Vaccine side effects include headaches, myalgias, fever, and encephalitis. Infants are at increased risk for encephalitis from the vaccine. Travelers with infants younger than 9 months should be strongly advised to not travel to yellow fever-endemic areas.

▸ Japanese encephalitis. This is endemic in Southeast Asia, he said. Immunization for this is given as a series of three injections on days 0, 7, and 30, with a booster given 24 months later. Children aged 1–2 years receive a 0.5-mL dose. There may be associated local reactions and mild systemic effects such as fever, headache, and myalgias. For a short-term stay in an urban area, immunization is not recommended.

▸ Rabies. The decision to vaccinate should be based on the itinerary and expected activities. As prophylaxis, the vaccine should be given as a four-dose series of injections on days 0, 7, 21, and 28.

Dr. Lieberman disclosed that he has a financial relationship as a consultant and as a member of the speakers' bureaus for GlaxoSmithKline, Sanofi Pasteur, and Merck & Co.

MAUI, HAWAII — Foreign travel can pose particular dangers to infants and children. If it is important that young children travel internationally, specific precautions can reduce the risk of infectious complications and increase the likelihood that the trip will be safe and enjoyable, instructed Dr. Jay M. Lieberman.

In general, there should be risk assessment for children traveling to other countries to determine the risks of the destination, mode of travel, and the special conditions of the traveler. Vaccinations should be given when indicated, and chemoprophylaxis should be used when appropriate, he added.

A key source of information for foreign travel is the Centers for Disease Control and Prevention Web site, www.cdc.gov/travel

Common travel problems and preventives include sun hazards, countered by sunscreen; travel safety, enhanced with car seats and seat belts; mosquitoes, warded off by repellents and nets. Other problems may include animal bites, envenomation, sexually transmitted infections for adolescents, travelers' diarrhea, and altitude illness, Dr. Lieberman said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

Dr. Lieberman, professor of clinical pediatrics at the University of California, Irvine, provided the following advice on taking preventive measures prior to travel:

▸ Routine immunizations. Review and complete the age-appropriate immunization schedule. DTaP, polio, Haemophilus influenzae type b (Hib) conjugate, and pneumococcal conjugate vaccines may be given at 4-week intervals, if necessary, to complete the primary series before travel. Hepatitis B vaccine should be given if patients are not vaccinated already. “Infants 6–11 months old should receive one dose of measles vaccine—preferably monovalent,” he recommended. Consider a second dose of measles, mumps, and rubella (MMR) and varicella vaccines before travel for children who have received only their first dose.

▸ Travelers' diarrhea. “Travelers' diarrhea is among the most common travel-related problem affecting young children,” especially infants, he warned. This results from ingesting food and water contaminated by feces, and is caused by bacteria (85%), parasites (10%), and viruses (5%). For young infants, breast-feeding is the best way to avoid water- and food-borne illnesses. Otherwise, be scrupulous about washing hands and use only purified water in ice cubes and for drinking, brushing teeth, and mixing infant formulas. Avoid food from street vendors, raw or undercooked meat and seafood, and unpasteurized dairy products. Fresh fruits and vegetables must be adequately cooked or washed well and peeled. Other potential preventive measures include the use of probiotics and bismuth subsalicylate; antibiotics generally are not recommended for this purpose but may be brought along for empiric treatment, if needed.

▸ Malaria. “For chemoprophylaxis, the standard for a long time was chloroquine given weekly, but the emergence of resistance has dramatically limited its use,” observed Dr. Lieberman. Options include mefloquine given weekly, although it has CNS side effects; doxycycline given daily, but not for children younger than 8 years; or atovaquone/proguanil given daily, but not for infants weighing less than 5 kg. Chemoprophylaxis should begin prior to travel and should be used continuously while in malaria-endemic areas and for 4 weeks (using chloroquine, mefloquine, or doxycycline) or 7 days (using atovaquone/proguanil) after leaving those areas. Detailed recommendations for preventing malaria are available 24 hours a day at 877-394-8747 or at the www.cdc.gov/travel

▸ Hepatitis A. Vaccination now is recommended routinely for all children, with the first dose at 12–23 months of age. Immune globulin is indicated for infants younger than 12 months; it can be given with the vaccine to ensure immediate protection if travel is imminent (although it's probably unnecessary, according to Dr. Lieberman).

▸ Meningococcal vaccine. The conjugate vaccination now is recommended routinely for all children aged 11–18 years. For children aged 2–10 years, only the polysaccharide vaccine is licensed.

▸ Typhoid fever. There are two “moderately effective” vaccines available: Ty21a live attenuated oral vaccine, given as a four-dose series on alternate days for persons 6 years of age or older; or Vi capsular polysaccharide vaccine, single dose, for persons 2 years of age or older.

▸ Yellow fever. This is endemic in equatorial Africa and South America, Dr. Lieberman noted, and proof of vaccination is required for entry in some countries. A live, attenuated virus vaccine is available. Vaccine side effects include headaches, myalgias, fever, and encephalitis. Infants are at increased risk for encephalitis from the vaccine. Travelers with infants younger than 9 months should be strongly advised to not travel to yellow fever-endemic areas.

▸ Japanese encephalitis. This is endemic in Southeast Asia, he said. Immunization for this is given as a series of three injections on days 0, 7, and 30, with a booster given 24 months later. Children aged 1–2 years receive a 0.5-mL dose. There may be associated local reactions and mild systemic effects such as fever, headache, and myalgias. For a short-term stay in an urban area, immunization is not recommended.

▸ Rabies. The decision to vaccinate should be based on the itinerary and expected activities. As prophylaxis, the vaccine should be given as a four-dose series of injections on days 0, 7, 21, and 28.

Dr. Lieberman disclosed that he has a financial relationship as a consultant and as a member of the speakers' bureaus for GlaxoSmithKline, Sanofi Pasteur, and Merck & Co.

MAUI, HAWAII — “Ask about pets in every febrile patient you see” was one of the take-home messages from Dr. Jay M. Lieberman as he discussed infections you can get from your pets.

And in particular, he said, “Consider cat-scratch disease in any patient with fever of unknown origin who has contact with cats—particularly if they're kittens.”

He presented several cases of children with prolonged fevers who remained without a diagnosis, despite extensive evaluations, until the possibility of cat-scratch disease was entertained and a history of contact with kittens was obtained. The diagnosis of cat-scratch disease often can be made from the history and physical examination, and serologies may not be reliable, Dr. Lieberman said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

Kittens are more likely to cause cat-scratch disease than are older cats. The disease is caused by Bartonella henselae, and approximately 40% of cats are bacteremic with the organism, explained Dr. Lieberman, professor of clinical pediatrics at the University of California, Irvine.

Cat-scratch disease is transmitted to humans through scratches, licks, or bites from kittens, less often from older cats, and sometimes from dogs.

A primary papule may be seen 3–12 days after inoculation time, followed 7–60 days (average 12–14 days) later by regional lymphadenopathy that may suppurate or regress over 2–4 months. Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients, and malaise, anorexia, and headache also may occur.

The area around the nodes may be noninflamed but can be warm, tender, and erythematous, Dr. Lieberman said at the meeting, which also was sponsored by California Chapter 2 of the AAP. As many as 30% of nodes will suppurate spontaneously.

Atypical presentations of cat-scratch disease included prolonged fever/fever of unknown origin, granulomatous hepatitis, conjunctivitis with preauricular adenopathy (Parinaud's oculoglandular syndrome), encephalopathy/encephalitis, osteomyelitis, and ocular disease.

Although patients may be treated with rifampin or gentamicin or trimethoprim-sulfamethoxazole (TMP/SMZ), or a combination of anti-infectives, Dr. Lieberman does not routinely recommend their use. “In general, we have not treated our patients with antimicrobial therapy,” he said. “Most patients do not require specific therapy, and the illness resolves on its own.”

One prospective randomized trial of azithromycin vs. placebo found a significantly greater decrease in lymph node size in azithromycin-treated patients at 30 days, but there was no significant difference thereafter (Pediatr. Infect. Dis. J. 1998;17:447-52).

Dr. Lieberman also noted that approximately 5%–15% of dog bites lead to infections, as do 20%–50% of cat bites. Pasteurella species, short gram-negative coccobacilli that are part of the normal flora of cats and dogs, are isolated from 75% of infections from cat bites and 50% of infections from dog bites. Pasteurella organisms are not susceptible to cephalexin or dicloxacillin, Dr. Lieberman said.

To help prevent infection from bites, wounds should be cleaned, debrided, and closed. Bite wounds should be reevaluated in 1–2 days. When indicated, there may be a need for tetanus and/or rabies prophylaxis.

Antibiotic prophylaxis is indicated for puncture wounds (including all cat bites), bites over tendons, joints, and bone; bites on the face and/or genitals; bites involving an immunocompromised person; and bites that cannot be well cleaned and debrided. Antibiotic prophylaxis, when indicated, may be used for 48–72 hours.

Amoxicillin-clavulanate is the antibiotic of choice for prevention or treatment of animal bite wound infections, he said. Dr. Lieberman disclosed that he is on a speakers' bureau for GlaxoSmithKline.

Regional lymphadenopathy, as shown in this 8-year-old patient, can appear 7–60 days after a primary papule. Courtesy Dr. Sherif Emil

MAUI, HAWAII — “Ask about pets in every febrile patient you see” was one of the take-home messages from Dr. Jay M. Lieberman as he discussed infections you can get from your pets.

And in particular, he said, “Consider cat-scratch disease in any patient with fever of unknown origin who has contact with cats—particularly if they're kittens.”

He presented several cases of children with prolonged fevers who remained without a diagnosis, despite extensive evaluations, until the possibility of cat-scratch disease was entertained and a history of contact with kittens was obtained. The diagnosis of cat-scratch disease often can be made from the history and physical examination, and serologies may not be reliable, Dr. Lieberman said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

Kittens are more likely to cause cat-scratch disease than are older cats. The disease is caused by Bartonella henselae, and approximately 40% of cats are bacteremic with the organism, explained Dr. Lieberman, professor of clinical pediatrics at the University of California, Irvine.

Cat-scratch disease is transmitted to humans through scratches, licks, or bites from kittens, less often from older cats, and sometimes from dogs.

A primary papule may be seen 3–12 days after inoculation time, followed 7–60 days (average 12–14 days) later by regional lymphadenopathy that may suppurate or regress over 2–4 months. Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients, and malaise, anorexia, and headache also may occur.

The area around the nodes may be noninflamed but can be warm, tender, and erythematous, Dr. Lieberman said at the meeting, which also was sponsored by California Chapter 2 of the AAP. As many as 30% of nodes will suppurate spontaneously.

Atypical presentations of cat-scratch disease included prolonged fever/fever of unknown origin, granulomatous hepatitis, conjunctivitis with preauricular adenopathy (Parinaud's oculoglandular syndrome), encephalopathy/encephalitis, osteomyelitis, and ocular disease.

Although patients may be treated with rifampin or gentamicin or trimethoprim-sulfamethoxazole (TMP/SMZ), or a combination of anti-infectives, Dr. Lieberman does not routinely recommend their use. “In general, we have not treated our patients with antimicrobial therapy,” he said. “Most patients do not require specific therapy, and the illness resolves on its own.”

One prospective randomized trial of azithromycin vs. placebo found a significantly greater decrease in lymph node size in azithromycin-treated patients at 30 days, but there was no significant difference thereafter (Pediatr. Infect. Dis. J. 1998;17:447-52).

Dr. Lieberman also noted that approximately 5%–15% of dog bites lead to infections, as do 20%–50% of cat bites. Pasteurella species, short gram-negative coccobacilli that are part of the normal flora of cats and dogs, are isolated from 75% of infections from cat bites and 50% of infections from dog bites. Pasteurella organisms are not susceptible to cephalexin or dicloxacillin, Dr. Lieberman said.

To help prevent infection from bites, wounds should be cleaned, debrided, and closed. Bite wounds should be reevaluated in 1–2 days. When indicated, there may be a need for tetanus and/or rabies prophylaxis.

Antibiotic prophylaxis is indicated for puncture wounds (including all cat bites), bites over tendons, joints, and bone; bites on the face and/or genitals; bites involving an immunocompromised person; and bites that cannot be well cleaned and debrided. Antibiotic prophylaxis, when indicated, may be used for 48–72 hours.

Amoxicillin-clavulanate is the antibiotic of choice for prevention or treatment of animal bite wound infections, he said. Dr. Lieberman disclosed that he is on a speakers' bureau for GlaxoSmithKline.

Regional lymphadenopathy, as shown in this 8-year-old patient, can appear 7–60 days after a primary papule. Courtesy Dr. Sherif Emil

MAUI, HAWAII — “Ask about pets in every febrile patient you see” was one of the take-home messages from Dr. Jay M. Lieberman as he discussed infections you can get from your pets.

And in particular, he said, “Consider cat-scratch disease in any patient with fever of unknown origin who has contact with cats—particularly if they're kittens.”

He presented several cases of children with prolonged fevers who remained without a diagnosis, despite extensive evaluations, until the possibility of cat-scratch disease was entertained and a history of contact with kittens was obtained. The diagnosis of cat-scratch disease often can be made from the history and physical examination, and serologies may not be reliable, Dr. Lieberman said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

Kittens are more likely to cause cat-scratch disease than are older cats. The disease is caused by Bartonella henselae, and approximately 40% of cats are bacteremic with the organism, explained Dr. Lieberman, professor of clinical pediatrics at the University of California, Irvine.

Cat-scratch disease is transmitted to humans through scratches, licks, or bites from kittens, less often from older cats, and sometimes from dogs.

A primary papule may be seen 3–12 days after inoculation time, followed 7–60 days (average 12–14 days) later by regional lymphadenopathy that may suppurate or regress over 2–4 months. Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients, and malaise, anorexia, and headache also may occur.

The area around the nodes may be noninflamed but can be warm, tender, and erythematous, Dr. Lieberman said at the meeting, which also was sponsored by California Chapter 2 of the AAP. As many as 30% of nodes will suppurate spontaneously.

Atypical presentations of cat-scratch disease included prolonged fever/fever of unknown origin, granulomatous hepatitis, conjunctivitis with preauricular adenopathy (Parinaud's oculoglandular syndrome), encephalopathy/encephalitis, osteomyelitis, and ocular disease.

Although patients may be treated with rifampin or gentamicin or trimethoprim-sulfamethoxazole (TMP/SMZ), or a combination of anti-infectives, Dr. Lieberman does not routinely recommend their use. “In general, we have not treated our patients with antimicrobial therapy,” he said. “Most patients do not require specific therapy, and the illness resolves on its own.”

One prospective randomized trial of azithromycin vs. placebo found a significantly greater decrease in lymph node size in azithromycin-treated patients at 30 days, but there was no significant difference thereafter (Pediatr. Infect. Dis. J. 1998;17:447-52).

Dr. Lieberman also noted that approximately 5%–15% of dog bites lead to infections, as do 20%–50% of cat bites. Pasteurella species, short gram-negative coccobacilli that are part of the normal flora of cats and dogs, are isolated from 75% of infections from cat bites and 50% of infections from dog bites. Pasteurella organisms are not susceptible to cephalexin or dicloxacillin, Dr. Lieberman said.

To help prevent infection from bites, wounds should be cleaned, debrided, and closed. Bite wounds should be reevaluated in 1–2 days. When indicated, there may be a need for tetanus and/or rabies prophylaxis.

Antibiotic prophylaxis is indicated for puncture wounds (including all cat bites), bites over tendons, joints, and bone; bites on the face and/or genitals; bites involving an immunocompromised person; and bites that cannot be well cleaned and debrided. Antibiotic prophylaxis, when indicated, may be used for 48–72 hours.

Amoxicillin-clavulanate is the antibiotic of choice for prevention or treatment of animal bite wound infections, he said. Dr. Lieberman disclosed that he is on a speakers' bureau for GlaxoSmithKline.

Regional lymphadenopathy, as shown in this 8-year-old patient, can appear 7–60 days after a primary papule. Courtesy Dr. Sherif Emil