Sherry Boschert

SAN FRANCISCO – Deaths from gunshot wounds doubled between 2000 and 2012 in the region served by one New Jersey trauma center and gun-related homicides as a proportion of violent crimes increased by 27% in southern Arizona after the state stopped requiring permits for concealed weapons, separate studies found.

In 2000, 8% of patients treated for gunshot wounds died. That rate increased to 15% in 2011, according to a retrospective study of 6,323 gunshot wounds seen at the New Jersey Trauma Center, a Level I trauma center in Newark. The proportion of 15-minute time increments in which the hospital was treating two or more patients for gunshot wounds increased from approximately 10% in 2000 to nearly 30% by the end of 2011, and the proportion of 15-minute increments in which three or more gunshot wounds were being treated increased from 1% to 16%, reported Dr. David H. Livingston and his associates.

Surgery on 71% of these patients plus other services incurred $115 million in costs, 75% of it unreimbursed. The mean cost per patient increased by 282% during the study period, reported Dr. Livingston of University Hospital, Newark, N.J., and a professor of surgery at Rutgers University, also in Newark.

"I think nationally this could be billions of dollars," perhaps double that, if these conservative estimates are extrapolated, he said at the annual meeting of the American Association for the Surgery of Trauma.

The drain on trauma center resources is enormous, he said. Half of the patients in his study needed ICU care, a third needed a ventilator, and just less than a third needed blood transfusions. All of these parameters increased by 50% to 180% during the study period.

The search for data produced a surprise relying solely on trauma registries for data on gunshot wounds and deaths would have missed one out of every five cases because 19% of patients were treated in the emergency department (ED) and sometimes admitted to services other than the trauma unit, he said. The study tapped not only the trauma registry but also ED billing records and the hospital’s financial records.

Joshuashearn/Wikimedia Commons/Creative Commons License

Further, there was a doubling of both the proportion of cases with three or more gunshot wounds (from 10% to 20%) and the proportion of cases with three or more body areas that had been shot (from 5% to 10%).

Data suggest that gun violence in New Jersey is geographically restricted and not random, he said. Five cities in the state accounted for 85% of gunshot wounds (Newark, Irvington, East Orange, Orange, and Elizabeth); 75% of patients were shot in the city in which they lived, 55% within a mile of home, 25% within a block of home, and 15% in their homes. Half of gunshot wounds occurred in 15% of the region by Census tract.

The New Jersey study included only interpersonal gunshot injuries, not self-inflicted wounds or shots from police. Patients in that study were predominantly young, black men who had been shot with a handgun. The mean age was 27 years, and 98% of cases involved a handgun. The cohort was 86% black, 9% Hispanic, 4% white, and 1% Asian. "This demographic is different than the demographic of our catchment area," Dr. Livingston noted.

A separate study compared gun-related injury and deaths in the 2 years before and the 2 years after July 2010, when Arizona made it legal in that state to carry a concealed weapon without a permit or training. The proportion of homicides related to guns in southern Arizona increased significantly from 1.97% to 2.45% after that law was passed and deaths by firearms increased by 24% among victims of violent crimes and accidents, Dr. Rashna F. Ginwalla and her associates reported in a separate presentation.

The number of violent crimes and accidents stayed relatively stable, but the risk of any gun-related injury or death increased significantly by 11% after concealed-weapons regulations were eliminated, said Dr. Ginwalla, who led the study while at the University of Arizona, Tucson. Dr. Ginwalla now works in Rwanda for the University of Virginia, Charlottesville.

During the study period, Arizonans were more likely than was the general U.S. population to undergo a background check during a gun purchase, which the researchers used as a proxy for gun ownership. The study used data from the National Instant Criminal Background Check system, the trauma registry of the University of Arizona Medical Center (the only Level I trauma center for southern Arizona), the Pima County Medical Examiner’s Office, and the Tucson Police Department.

"While causality has not been established by this observational study, we have demonstrated an association between an increase in gun availability and gun-related homicides in the state," she said.

Dr. Ginwalla cited news reports that the United States has the highest per-capita gun ownership in the world – 89 gun owners/100,000 people, compared with the next-highest rates of 55/100,000 in Yemen, 46/100,000 in Switzerland, 45/100,000 in Finland, and 38/100,000 in Serbia.

Data on gun violence have been scarce since the U.S. Congress stopped funding federal research on gun violence in 1996. President Obama rescinded the ban in January 2013. The speakers said more research data could better inform debates about gun violence that invariably flare up after a mass shooting grabs headlines, such as the September 2013 shooting at the Washington Navy Yard and the December 2012 massacre at a Newtown, Conn. elementary school.

Perceptions of gun violence tend to be driven by these individual sensational events rather than "routine" gunshot wounds that happen much more frequently and in greater numbers, Dr. Livingston said. While the combined number of people killed and injured in the Navy Yard and Newtown shootings total in the dozens, an average of 527 people per year were treated for gunshot wounds just in the New Jersey study region. Of the 30,000 annual gunshot wounds, approximately half are self-inflicted and slightly less than half are the "routine" gunshot wounds happening every day, he said.

"Firearm violence continues to be a major public health problem in the United States," he said. "Unfortunately, it’s also a political football. Potential solutions are obfuscated and entwined with the controversy over gun control, turning a public health problem into a political debate."

Nonfatal gunshot wounds accounted for 85% of wounds in the study. "These are the ones that no one knows a lot about" because of the dearth of research, he added.

Dr. Livingston and Dr. Ginwalla reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Deaths from gunshot wounds doubled between 2000 and 2012 in the region served by one New Jersey trauma center and gun-related homicides as a proportion of violent crimes increased by 27% in southern Arizona after the state stopped requiring permits for concealed weapons, separate studies found.

In 2000, 8% of patients treated for gunshot wounds died. That rate increased to 15% in 2011, according to a retrospective study of 6,323 gunshot wounds seen at the New Jersey Trauma Center, a Level I trauma center in Newark. The proportion of 15-minute time increments in which the hospital was treating two or more patients for gunshot wounds increased from approximately 10% in 2000 to nearly 30% by the end of 2011, and the proportion of 15-minute increments in which three or more gunshot wounds were being treated increased from 1% to 16%, reported Dr. David H. Livingston and his associates.

Surgery on 71% of these patients plus other services incurred $115 million in costs, 75% of it unreimbursed. The mean cost per patient increased by 282% during the study period, reported Dr. Livingston of University Hospital, Newark, N.J., and a professor of surgery at Rutgers University, also in Newark.

"I think nationally this could be billions of dollars," perhaps double that, if these conservative estimates are extrapolated, he said at the annual meeting of the American Association for the Surgery of Trauma.

The drain on trauma center resources is enormous, he said. Half of the patients in his study needed ICU care, a third needed a ventilator, and just less than a third needed blood transfusions. All of these parameters increased by 50% to 180% during the study period.

The search for data produced a surprise relying solely on trauma registries for data on gunshot wounds and deaths would have missed one out of every five cases because 19% of patients were treated in the emergency department (ED) and sometimes admitted to services other than the trauma unit, he said. The study tapped not only the trauma registry but also ED billing records and the hospital’s financial records.

Joshuashearn/Wikimedia Commons/Creative Commons License

Further, there was a doubling of both the proportion of cases with three or more gunshot wounds (from 10% to 20%) and the proportion of cases with three or more body areas that had been shot (from 5% to 10%).

Data suggest that gun violence in New Jersey is geographically restricted and not random, he said. Five cities in the state accounted for 85% of gunshot wounds (Newark, Irvington, East Orange, Orange, and Elizabeth); 75% of patients were shot in the city in which they lived, 55% within a mile of home, 25% within a block of home, and 15% in their homes. Half of gunshot wounds occurred in 15% of the region by Census tract.

The New Jersey study included only interpersonal gunshot injuries, not self-inflicted wounds or shots from police. Patients in that study were predominantly young, black men who had been shot with a handgun. The mean age was 27 years, and 98% of cases involved a handgun. The cohort was 86% black, 9% Hispanic, 4% white, and 1% Asian. "This demographic is different than the demographic of our catchment area," Dr. Livingston noted.

A separate study compared gun-related injury and deaths in the 2 years before and the 2 years after July 2010, when Arizona made it legal in that state to carry a concealed weapon without a permit or training. The proportion of homicides related to guns in southern Arizona increased significantly from 1.97% to 2.45% after that law was passed and deaths by firearms increased by 24% among victims of violent crimes and accidents, Dr. Rashna F. Ginwalla and her associates reported in a separate presentation.

The number of violent crimes and accidents stayed relatively stable, but the risk of any gun-related injury or death increased significantly by 11% after concealed-weapons regulations were eliminated, said Dr. Ginwalla, who led the study while at the University of Arizona, Tucson. Dr. Ginwalla now works in Rwanda for the University of Virginia, Charlottesville.

During the study period, Arizonans were more likely than was the general U.S. population to undergo a background check during a gun purchase, which the researchers used as a proxy for gun ownership. The study used data from the National Instant Criminal Background Check system, the trauma registry of the University of Arizona Medical Center (the only Level I trauma center for southern Arizona), the Pima County Medical Examiner’s Office, and the Tucson Police Department.

"While causality has not been established by this observational study, we have demonstrated an association between an increase in gun availability and gun-related homicides in the state," she said.

Dr. Ginwalla cited news reports that the United States has the highest per-capita gun ownership in the world – 89 gun owners/100,000 people, compared with the next-highest rates of 55/100,000 in Yemen, 46/100,000 in Switzerland, 45/100,000 in Finland, and 38/100,000 in Serbia.

Data on gun violence have been scarce since the U.S. Congress stopped funding federal research on gun violence in 1996. President Obama rescinded the ban in January 2013. The speakers said more research data could better inform debates about gun violence that invariably flare up after a mass shooting grabs headlines, such as the September 2013 shooting at the Washington Navy Yard and the December 2012 massacre at a Newtown, Conn. elementary school.

Perceptions of gun violence tend to be driven by these individual sensational events rather than "routine" gunshot wounds that happen much more frequently and in greater numbers, Dr. Livingston said. While the combined number of people killed and injured in the Navy Yard and Newtown shootings total in the dozens, an average of 527 people per year were treated for gunshot wounds just in the New Jersey study region. Of the 30,000 annual gunshot wounds, approximately half are self-inflicted and slightly less than half are the "routine" gunshot wounds happening every day, he said.

"Firearm violence continues to be a major public health problem in the United States," he said. "Unfortunately, it’s also a political football. Potential solutions are obfuscated and entwined with the controversy over gun control, turning a public health problem into a political debate."

Nonfatal gunshot wounds accounted for 85% of wounds in the study. "These are the ones that no one knows a lot about" because of the dearth of research, he added.

Dr. Livingston and Dr. Ginwalla reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Deaths from gunshot wounds doubled between 2000 and 2012 in the region served by one New Jersey trauma center and gun-related homicides as a proportion of violent crimes increased by 27% in southern Arizona after the state stopped requiring permits for concealed weapons, separate studies found.

In 2000, 8% of patients treated for gunshot wounds died. That rate increased to 15% in 2011, according to a retrospective study of 6,323 gunshot wounds seen at the New Jersey Trauma Center, a Level I trauma center in Newark. The proportion of 15-minute time increments in which the hospital was treating two or more patients for gunshot wounds increased from approximately 10% in 2000 to nearly 30% by the end of 2011, and the proportion of 15-minute increments in which three or more gunshot wounds were being treated increased from 1% to 16%, reported Dr. David H. Livingston and his associates.

Surgery on 71% of these patients plus other services incurred $115 million in costs, 75% of it unreimbursed. The mean cost per patient increased by 282% during the study period, reported Dr. Livingston of University Hospital, Newark, N.J., and a professor of surgery at Rutgers University, also in Newark.

"I think nationally this could be billions of dollars," perhaps double that, if these conservative estimates are extrapolated, he said at the annual meeting of the American Association for the Surgery of Trauma.

The drain on trauma center resources is enormous, he said. Half of the patients in his study needed ICU care, a third needed a ventilator, and just less than a third needed blood transfusions. All of these parameters increased by 50% to 180% during the study period.

The search for data produced a surprise relying solely on trauma registries for data on gunshot wounds and deaths would have missed one out of every five cases because 19% of patients were treated in the emergency department (ED) and sometimes admitted to services other than the trauma unit, he said. The study tapped not only the trauma registry but also ED billing records and the hospital’s financial records.

Joshuashearn/Wikimedia Commons/Creative Commons License

Further, there was a doubling of both the proportion of cases with three or more gunshot wounds (from 10% to 20%) and the proportion of cases with three or more body areas that had been shot (from 5% to 10%).

Data suggest that gun violence in New Jersey is geographically restricted and not random, he said. Five cities in the state accounted for 85% of gunshot wounds (Newark, Irvington, East Orange, Orange, and Elizabeth); 75% of patients were shot in the city in which they lived, 55% within a mile of home, 25% within a block of home, and 15% in their homes. Half of gunshot wounds occurred in 15% of the region by Census tract.

The New Jersey study included only interpersonal gunshot injuries, not self-inflicted wounds or shots from police. Patients in that study were predominantly young, black men who had been shot with a handgun. The mean age was 27 years, and 98% of cases involved a handgun. The cohort was 86% black, 9% Hispanic, 4% white, and 1% Asian. "This demographic is different than the demographic of our catchment area," Dr. Livingston noted.

A separate study compared gun-related injury and deaths in the 2 years before and the 2 years after July 2010, when Arizona made it legal in that state to carry a concealed weapon without a permit or training. The proportion of homicides related to guns in southern Arizona increased significantly from 1.97% to 2.45% after that law was passed and deaths by firearms increased by 24% among victims of violent crimes and accidents, Dr. Rashna F. Ginwalla and her associates reported in a separate presentation.

The number of violent crimes and accidents stayed relatively stable, but the risk of any gun-related injury or death increased significantly by 11% after concealed-weapons regulations were eliminated, said Dr. Ginwalla, who led the study while at the University of Arizona, Tucson. Dr. Ginwalla now works in Rwanda for the University of Virginia, Charlottesville.

During the study period, Arizonans were more likely than was the general U.S. population to undergo a background check during a gun purchase, which the researchers used as a proxy for gun ownership. The study used data from the National Instant Criminal Background Check system, the trauma registry of the University of Arizona Medical Center (the only Level I trauma center for southern Arizona), the Pima County Medical Examiner’s Office, and the Tucson Police Department.

"While causality has not been established by this observational study, we have demonstrated an association between an increase in gun availability and gun-related homicides in the state," she said.

Dr. Ginwalla cited news reports that the United States has the highest per-capita gun ownership in the world – 89 gun owners/100,000 people, compared with the next-highest rates of 55/100,000 in Yemen, 46/100,000 in Switzerland, 45/100,000 in Finland, and 38/100,000 in Serbia.

Data on gun violence have been scarce since the U.S. Congress stopped funding federal research on gun violence in 1996. President Obama rescinded the ban in January 2013. The speakers said more research data could better inform debates about gun violence that invariably flare up after a mass shooting grabs headlines, such as the September 2013 shooting at the Washington Navy Yard and the December 2012 massacre at a Newtown, Conn. elementary school.

Perceptions of gun violence tend to be driven by these individual sensational events rather than "routine" gunshot wounds that happen much more frequently and in greater numbers, Dr. Livingston said. While the combined number of people killed and injured in the Navy Yard and Newtown shootings total in the dozens, an average of 527 people per year were treated for gunshot wounds just in the New Jersey study region. Of the 30,000 annual gunshot wounds, approximately half are self-inflicted and slightly less than half are the "routine" gunshot wounds happening every day, he said.

"Firearm violence continues to be a major public health problem in the United States," he said. "Unfortunately, it’s also a political football. Potential solutions are obfuscated and entwined with the controversy over gun control, turning a public health problem into a political debate."

Nonfatal gunshot wounds accounted for 85% of wounds in the study. "These are the ones that no one knows a lot about" because of the dearth of research, he added.

Dr. Livingston and Dr. Ginwalla reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SANTA BARBARA, CALIF. – Some fertility specialists are pairing guarantees with pricing to entice patients to their assisted reproductive technology services.

Dr. Bill Yee offers a step-by-step approach in his fees. A patient who comes in, gets monitored, and is taken to egg retrieval pays a minimum of $1,000. If no egg gets retrieved, the fee stops there. If an egg is retrieved for attempted fertilization, however, the fee increases to $2,000, where it stays if fertilization is unsuccessful. Successful fertilization that produces an embryo increases the fee to $3,000 total. If the embryo doesn’t divide on day 3 or doesn’t look to be of suitable quality for cryopreservation, the fee remains at $3,000. If the embryo does become suitable for freezing and transfer, the fee is $5,000.

"It’s very, very simple," he said at the UCLA annual in vitro fertilization and embryo transfer update 2013. While this fee structure may seem controversial, "we find that patients love this," said Dr. Yee, a reproductive endocrinology and infertility specialist in group practice in Westminster, Calif. "This certainly is an alternative, especially for your poor responders."

Keeping costs down is an important strategy for gaining patients in the competitive field of fertility treatments. "It’s very expensive to do IVF in Southern California," said Dr. Yee.

Another innovative pricing schedule at a fertility center in Davis, Calif., drew attention in a November 2012 article in the Los Angeles Times, which reported "an ethics debate over embryos on the cheap." Dr. Richard J. Paulson, who gave a separate presentation at the meeting, said that he contacted the physicians at that clinic, which uses donor eggs and donor sperm to create a batch of embryos that get divided up among several patients for attempted pregnancies.

While one horrified critic called this the "commodification of children" in the news article, Dr. Paulson noted that it sharply cuts costs. The Davis center told him that they now charge $12,500 per patient for up to three transfers of one or two blastocysts; the center matches two to five recipients per donor cycle. If a woman is not pregnant after three transfers, she can choose either to get her $12,500 back or to roll the money into another three transfers. If there’s no successful pregnancy after that, there’s no refund.

"They say they’ve had about 200 patients and 90-plus are pregnant," said Dr. Paulson, professor of obstetrics and gynecology and chief of the division of reproductive endocrinology and infertility at the University of Southern California in Los Angeles.

"I’m not advocating it, but it’s an interesting way of putting your money where your mouth is," he said. "If we’re so confident that sperm really doesn’t matter, and that it’s all about the egg, and that egg freezing doesn’t matter because cryopreserved or vitrified oocytes have the same efficiency as fresh, then why wouldn’t we use this same kind of model and allow patients to be able to have this kind of money-back guarantee?"

Dr. Paulson said he is bothered by modern egg donation practices that match one recipient to one egg donor with 20 embryos, 19 of which stay in a cryopreservation tank for the next 15-20 years if the recipient gets pregnant on the first elective single-embryo transfer.

"I think egg freezing would be a good way of getting around that and convincing patients that it’s worth going this way," he said. "I think if we offer them some sort of money back, it might be helpful."

At the same time, he’s not thrilled with that idea. "I don’t like money-back [strategies]. I’m a very traditional guy and I like providing a service, and they pay you," he said, adding with a smile, "I’m very confused."

Dr. Yee reported having no relevant financial disclosures. Dr. Paulson has been a speaker for Ferring Pharmaceuticals and an adviser to Cooper Surgical.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SANTA BARBARA, CALIF. – Some fertility specialists are pairing guarantees with pricing to entice patients to their assisted reproductive technology services.

Dr. Bill Yee offers a step-by-step approach in his fees. A patient who comes in, gets monitored, and is taken to egg retrieval pays a minimum of $1,000. If no egg gets retrieved, the fee stops there. If an egg is retrieved for attempted fertilization, however, the fee increases to $2,000, where it stays if fertilization is unsuccessful. Successful fertilization that produces an embryo increases the fee to $3,000 total. If the embryo doesn’t divide on day 3 or doesn’t look to be of suitable quality for cryopreservation, the fee remains at $3,000. If the embryo does become suitable for freezing and transfer, the fee is $5,000.

"It’s very, very simple," he said at the UCLA annual in vitro fertilization and embryo transfer update 2013. While this fee structure may seem controversial, "we find that patients love this," said Dr. Yee, a reproductive endocrinology and infertility specialist in group practice in Westminster, Calif. "This certainly is an alternative, especially for your poor responders."

Keeping costs down is an important strategy for gaining patients in the competitive field of fertility treatments. "It’s very expensive to do IVF in Southern California," said Dr. Yee.

Another innovative pricing schedule at a fertility center in Davis, Calif., drew attention in a November 2012 article in the Los Angeles Times, which reported "an ethics debate over embryos on the cheap." Dr. Richard J. Paulson, who gave a separate presentation at the meeting, said that he contacted the physicians at that clinic, which uses donor eggs and donor sperm to create a batch of embryos that get divided up among several patients for attempted pregnancies.

While one horrified critic called this the "commodification of children" in the news article, Dr. Paulson noted that it sharply cuts costs. The Davis center told him that they now charge $12,500 per patient for up to three transfers of one or two blastocysts; the center matches two to five recipients per donor cycle. If a woman is not pregnant after three transfers, she can choose either to get her $12,500 back or to roll the money into another three transfers. If there’s no successful pregnancy after that, there’s no refund.

"They say they’ve had about 200 patients and 90-plus are pregnant," said Dr. Paulson, professor of obstetrics and gynecology and chief of the division of reproductive endocrinology and infertility at the University of Southern California in Los Angeles.

"I’m not advocating it, but it’s an interesting way of putting your money where your mouth is," he said. "If we’re so confident that sperm really doesn’t matter, and that it’s all about the egg, and that egg freezing doesn’t matter because cryopreserved or vitrified oocytes have the same efficiency as fresh, then why wouldn’t we use this same kind of model and allow patients to be able to have this kind of money-back guarantee?"

Dr. Paulson said he is bothered by modern egg donation practices that match one recipient to one egg donor with 20 embryos, 19 of which stay in a cryopreservation tank for the next 15-20 years if the recipient gets pregnant on the first elective single-embryo transfer.

"I think egg freezing would be a good way of getting around that and convincing patients that it’s worth going this way," he said. "I think if we offer them some sort of money back, it might be helpful."

At the same time, he’s not thrilled with that idea. "I don’t like money-back [strategies]. I’m a very traditional guy and I like providing a service, and they pay you," he said, adding with a smile, "I’m very confused."

Dr. Yee reported having no relevant financial disclosures. Dr. Paulson has been a speaker for Ferring Pharmaceuticals and an adviser to Cooper Surgical.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SANTA BARBARA, CALIF. – Some fertility specialists are pairing guarantees with pricing to entice patients to their assisted reproductive technology services.

Dr. Bill Yee offers a step-by-step approach in his fees. A patient who comes in, gets monitored, and is taken to egg retrieval pays a minimum of $1,000. If no egg gets retrieved, the fee stops there. If an egg is retrieved for attempted fertilization, however, the fee increases to $2,000, where it stays if fertilization is unsuccessful. Successful fertilization that produces an embryo increases the fee to $3,000 total. If the embryo doesn’t divide on day 3 or doesn’t look to be of suitable quality for cryopreservation, the fee remains at $3,000. If the embryo does become suitable for freezing and transfer, the fee is $5,000.

"It’s very, very simple," he said at the UCLA annual in vitro fertilization and embryo transfer update 2013. While this fee structure may seem controversial, "we find that patients love this," said Dr. Yee, a reproductive endocrinology and infertility specialist in group practice in Westminster, Calif. "This certainly is an alternative, especially for your poor responders."

Keeping costs down is an important strategy for gaining patients in the competitive field of fertility treatments. "It’s very expensive to do IVF in Southern California," said Dr. Yee.

Another innovative pricing schedule at a fertility center in Davis, Calif., drew attention in a November 2012 article in the Los Angeles Times, which reported "an ethics debate over embryos on the cheap." Dr. Richard J. Paulson, who gave a separate presentation at the meeting, said that he contacted the physicians at that clinic, which uses donor eggs and donor sperm to create a batch of embryos that get divided up among several patients for attempted pregnancies.

While one horrified critic called this the "commodification of children" in the news article, Dr. Paulson noted that it sharply cuts costs. The Davis center told him that they now charge $12,500 per patient for up to three transfers of one or two blastocysts; the center matches two to five recipients per donor cycle. If a woman is not pregnant after three transfers, she can choose either to get her $12,500 back or to roll the money into another three transfers. If there’s no successful pregnancy after that, there’s no refund.

"They say they’ve had about 200 patients and 90-plus are pregnant," said Dr. Paulson, professor of obstetrics and gynecology and chief of the division of reproductive endocrinology and infertility at the University of Southern California in Los Angeles.

"I’m not advocating it, but it’s an interesting way of putting your money where your mouth is," he said. "If we’re so confident that sperm really doesn’t matter, and that it’s all about the egg, and that egg freezing doesn’t matter because cryopreserved or vitrified oocytes have the same efficiency as fresh, then why wouldn’t we use this same kind of model and allow patients to be able to have this kind of money-back guarantee?"

Dr. Paulson said he is bothered by modern egg donation practices that match one recipient to one egg donor with 20 embryos, 19 of which stay in a cryopreservation tank for the next 15-20 years if the recipient gets pregnant on the first elective single-embryo transfer.

"I think egg freezing would be a good way of getting around that and convincing patients that it’s worth going this way," he said. "I think if we offer them some sort of money back, it might be helpful."

At the same time, he’s not thrilled with that idea. "I don’t like money-back [strategies]. I’m a very traditional guy and I like providing a service, and they pay you," he said, adding with a smile, "I’m very confused."

Dr. Yee reported having no relevant financial disclosures. Dr. Paulson has been a speaker for Ferring Pharmaceuticals and an adviser to Cooper Surgical.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SANTA BARBARA, CALIF. – Acupuncture does not significantly increase pregnancy rates in women undergoing IVF, reanalyses of a prior meta-analysis of 24 studies suggested.

Although the original meta-analysis reported a significant 20% increase in the pregnancy rate with acupuncture, a more rigorous reanalysis that excluded eight lesser-quality studies found no statistically significant difference in IVF pregnancy rates between women who did or did not have acupuncture, Dr. David R. Meldrum said at the UCLA annual in vitro fertilization and embryo transfer update 2013.

When data were looked at only from six studies that used the Streitberger mock acupuncture technique (a widely accepted control technique in acupuncture studies), the odds ratio for clinical pregnancy in the acupuncture group was 0.89 with the confidence interval crossing 1, "indicating lack of a true effect of acupuncture," he said.

When Dr. Meldrum and his associates compared separate reanalyses of studies that did or did not use Streitberger mock acupuncture, the confidence interval for results in the placebo group straddled 1 in the studies using the Streitberger technique but did not cross 1 in non-Streitberger studies.

"Based on this, we think that at the present time acupuncture appears to have a placebo effect. There are not enough data to say whether it has a specific effect," said Dr. Meldrum, a reproductive endocrinology and infertility specialist in group practice in Redondo Beach, Calif.

Studies since 1996 have reported varying results from acupuncture as part of IVF programs. Although the 2012 meta-analysis of 24 studies reported a significantly higher pregnancy rate with acupuncture compared with placebo or no acupuncture, the birth rate did not differ significantly between groups (Fertil. Steril. 2012;97:599-611).

That report "stimulated me to look at it in more detail," said Dr. Meldrum.

The authors of the meta-analysis also conducted a secondary analysis of the data minus studies that used a widely accepted type of sham control, reasoning that the sham procedure created pressure that might be therapeutic. With this more limited data set, the birth rate was significantly higher with acupuncture than without it, they reported.

That didn’t seem right to Dr. Meldrum, so he and three colleagues with epidemiologic training conducted their own reanalysis of the meta-analysis, excluding at least 8 of the 24 studies in the original data set that they felt "didn’t belong in it," he said.

One of the excluded studies was not randomized. Two studies compared acupuncture to a combination of anesthesia drugs that "we know could have a negative effect," he said. Another excluded study compared acupuncture to general anesthesia. One study compared the control to acupuncture plus "special Chinese medical drug seeds" instead of acupuncture alone. Three excluded studies compared data from multiple arms in the trials rather than just acupuncture versus control.

Without those studies, a redone meta-analysis of 16 studies yielded a statistically nonsignificant odds ratio for pregnancy of 1.14 for acupuncture (Fertil. Steril. 2013;99:1821-4).

He and his associates also reanalyzed data from just the three studies that reported birth rates, and found an odds ratio for birth of 0.74 in the acupuncture groups versus controls (confidence interval, 0.58-0.95), indicating a reduced chance of IVF success, he added. One of these studies "recorded rotating, lifting, and thrusting the needle. I think a lot of our patients might find that stressful," he said.

"We’re not saying that patients should be dissuaded from having acupuncture, because it is widely used, but I think we have to be frank that it’s questionable whether there’s a specific benefit," Dr. Meldrum said.

Most of the acupuncture studies were carried out in IVF centers, so if patients choose to receive acupuncture, it may be best for them to receive it at the IVF center if possible so there is minimal disruption. One study that found a reduced pregnancy rate after acupuncture had subjects who had never undergone acupuncture get the acupuncture at a separate location from the IVF clinic, possibly adding stress, he noted.

It would be helpful to have patients who choose acupuncture follow the techniques used in the studies that reported improved IVF success with acupuncture, but that may be difficult because the acupuncture techniques varied so widely. "I would think that if acupuncture had a specific effect, the placements of the needle would be consistent. They were widely variable in different studies. So, I am somewhat skeptical as to whether acupuncture, even with much larger experience, has a specific effect."

Dr. Meldrum is president of the Sexuality Education Network, which operates the websites erectile-function.com and lifechoicesandfertility.com. He reported having no other relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SANTA BARBARA, CALIF. – Acupuncture does not significantly increase pregnancy rates in women undergoing IVF, reanalyses of a prior meta-analysis of 24 studies suggested.

Although the original meta-analysis reported a significant 20% increase in the pregnancy rate with acupuncture, a more rigorous reanalysis that excluded eight lesser-quality studies found no statistically significant difference in IVF pregnancy rates between women who did or did not have acupuncture, Dr. David R. Meldrum said at the UCLA annual in vitro fertilization and embryo transfer update 2013.

When data were looked at only from six studies that used the Streitberger mock acupuncture technique (a widely accepted control technique in acupuncture studies), the odds ratio for clinical pregnancy in the acupuncture group was 0.89 with the confidence interval crossing 1, "indicating lack of a true effect of acupuncture," he said.

When Dr. Meldrum and his associates compared separate reanalyses of studies that did or did not use Streitberger mock acupuncture, the confidence interval for results in the placebo group straddled 1 in the studies using the Streitberger technique but did not cross 1 in non-Streitberger studies.

"Based on this, we think that at the present time acupuncture appears to have a placebo effect. There are not enough data to say whether it has a specific effect," said Dr. Meldrum, a reproductive endocrinology and infertility specialist in group practice in Redondo Beach, Calif.

Studies since 1996 have reported varying results from acupuncture as part of IVF programs. Although the 2012 meta-analysis of 24 studies reported a significantly higher pregnancy rate with acupuncture compared with placebo or no acupuncture, the birth rate did not differ significantly between groups (Fertil. Steril. 2012;97:599-611).

That report "stimulated me to look at it in more detail," said Dr. Meldrum.

The authors of the meta-analysis also conducted a secondary analysis of the data minus studies that used a widely accepted type of sham control, reasoning that the sham procedure created pressure that might be therapeutic. With this more limited data set, the birth rate was significantly higher with acupuncture than without it, they reported.

That didn’t seem right to Dr. Meldrum, so he and three colleagues with epidemiologic training conducted their own reanalysis of the meta-analysis, excluding at least 8 of the 24 studies in the original data set that they felt "didn’t belong in it," he said.

One of the excluded studies was not randomized. Two studies compared acupuncture to a combination of anesthesia drugs that "we know could have a negative effect," he said. Another excluded study compared acupuncture to general anesthesia. One study compared the control to acupuncture plus "special Chinese medical drug seeds" instead of acupuncture alone. Three excluded studies compared data from multiple arms in the trials rather than just acupuncture versus control.

Without those studies, a redone meta-analysis of 16 studies yielded a statistically nonsignificant odds ratio for pregnancy of 1.14 for acupuncture (Fertil. Steril. 2013;99:1821-4).

He and his associates also reanalyzed data from just the three studies that reported birth rates, and found an odds ratio for birth of 0.74 in the acupuncture groups versus controls (confidence interval, 0.58-0.95), indicating a reduced chance of IVF success, he added. One of these studies "recorded rotating, lifting, and thrusting the needle. I think a lot of our patients might find that stressful," he said.

"We’re not saying that patients should be dissuaded from having acupuncture, because it is widely used, but I think we have to be frank that it’s questionable whether there’s a specific benefit," Dr. Meldrum said.

Most of the acupuncture studies were carried out in IVF centers, so if patients choose to receive acupuncture, it may be best for them to receive it at the IVF center if possible so there is minimal disruption. One study that found a reduced pregnancy rate after acupuncture had subjects who had never undergone acupuncture get the acupuncture at a separate location from the IVF clinic, possibly adding stress, he noted.

It would be helpful to have patients who choose acupuncture follow the techniques used in the studies that reported improved IVF success with acupuncture, but that may be difficult because the acupuncture techniques varied so widely. "I would think that if acupuncture had a specific effect, the placements of the needle would be consistent. They were widely variable in different studies. So, I am somewhat skeptical as to whether acupuncture, even with much larger experience, has a specific effect."

Dr. Meldrum is president of the Sexuality Education Network, which operates the websites erectile-function.com and lifechoicesandfertility.com. He reported having no other relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SANTA BARBARA, CALIF. – Acupuncture does not significantly increase pregnancy rates in women undergoing IVF, reanalyses of a prior meta-analysis of 24 studies suggested.

Although the original meta-analysis reported a significant 20% increase in the pregnancy rate with acupuncture, a more rigorous reanalysis that excluded eight lesser-quality studies found no statistically significant difference in IVF pregnancy rates between women who did or did not have acupuncture, Dr. David R. Meldrum said at the UCLA annual in vitro fertilization and embryo transfer update 2013.

When data were looked at only from six studies that used the Streitberger mock acupuncture technique (a widely accepted control technique in acupuncture studies), the odds ratio for clinical pregnancy in the acupuncture group was 0.89 with the confidence interval crossing 1, "indicating lack of a true effect of acupuncture," he said.

When Dr. Meldrum and his associates compared separate reanalyses of studies that did or did not use Streitberger mock acupuncture, the confidence interval for results in the placebo group straddled 1 in the studies using the Streitberger technique but did not cross 1 in non-Streitberger studies.

"Based on this, we think that at the present time acupuncture appears to have a placebo effect. There are not enough data to say whether it has a specific effect," said Dr. Meldrum, a reproductive endocrinology and infertility specialist in group practice in Redondo Beach, Calif.

Studies since 1996 have reported varying results from acupuncture as part of IVF programs. Although the 2012 meta-analysis of 24 studies reported a significantly higher pregnancy rate with acupuncture compared with placebo or no acupuncture, the birth rate did not differ significantly between groups (Fertil. Steril. 2012;97:599-611).

That report "stimulated me to look at it in more detail," said Dr. Meldrum.

The authors of the meta-analysis also conducted a secondary analysis of the data minus studies that used a widely accepted type of sham control, reasoning that the sham procedure created pressure that might be therapeutic. With this more limited data set, the birth rate was significantly higher with acupuncture than without it, they reported.

That didn’t seem right to Dr. Meldrum, so he and three colleagues with epidemiologic training conducted their own reanalysis of the meta-analysis, excluding at least 8 of the 24 studies in the original data set that they felt "didn’t belong in it," he said.

One of the excluded studies was not randomized. Two studies compared acupuncture to a combination of anesthesia drugs that "we know could have a negative effect," he said. Another excluded study compared acupuncture to general anesthesia. One study compared the control to acupuncture plus "special Chinese medical drug seeds" instead of acupuncture alone. Three excluded studies compared data from multiple arms in the trials rather than just acupuncture versus control.

Without those studies, a redone meta-analysis of 16 studies yielded a statistically nonsignificant odds ratio for pregnancy of 1.14 for acupuncture (Fertil. Steril. 2013;99:1821-4).

He and his associates also reanalyzed data from just the three studies that reported birth rates, and found an odds ratio for birth of 0.74 in the acupuncture groups versus controls (confidence interval, 0.58-0.95), indicating a reduced chance of IVF success, he added. One of these studies "recorded rotating, lifting, and thrusting the needle. I think a lot of our patients might find that stressful," he said.

"We’re not saying that patients should be dissuaded from having acupuncture, because it is widely used, but I think we have to be frank that it’s questionable whether there’s a specific benefit," Dr. Meldrum said.

Most of the acupuncture studies were carried out in IVF centers, so if patients choose to receive acupuncture, it may be best for them to receive it at the IVF center if possible so there is minimal disruption. One study that found a reduced pregnancy rate after acupuncture had subjects who had never undergone acupuncture get the acupuncture at a separate location from the IVF clinic, possibly adding stress, he noted.

It would be helpful to have patients who choose acupuncture follow the techniques used in the studies that reported improved IVF success with acupuncture, but that may be difficult because the acupuncture techniques varied so widely. "I would think that if acupuncture had a specific effect, the placements of the needle would be consistent. They were widely variable in different studies. So, I am somewhat skeptical as to whether acupuncture, even with much larger experience, has a specific effect."

Dr. Meldrum is president of the Sexuality Education Network, which operates the websites erectile-function.com and lifechoicesandfertility.com. He reported having no other relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Two months of pre-IVF supplementation with coenzyme Q10 was associated with a 41% rate of aneuploidies in 9 oocytes, compared with aneuploidies in 51% of 13 oocytes from women randomized to placebo, a small prospective study found.

"This difference didn’t reach significance because of the small numbers, but at least it’s trending in the right direction," Dr. Robert F. Casper said at the UCLA annual in vitro fertilization and embryo transfer update 2013.

The study took 2-3 years to enroll and randomize 39 women aged 38 years or older who were undergoing IVF at his institution, a lengthy process because of patient reluctance to enter the study.

He said the investigators didn’t really know how long to pretreat with coenzyme Q10 (CoQ10) in hopes of rejuvenating the mitochondria of aging oocytes, so they settled on 2 months because they didn’t think these older women would agree to a longer time frame. Even with that compromise, most eligible patients still were unwilling to risk being randomized to placebo and so refused enrollment, said Dr. Casper, professor of ob.gyn. and of medicine (division of endocrinology) at the University of Toronto and the Camille Dan Family research chair in translational cell biology at the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto.

The encouraging trend in reduced risk of aneuploidy suggests that a much larger prospective study should be conducted, perhaps with younger IVF patients who "wouldn’t be so stressed about being randomized to placebo for a few months," he said.

Patients took six capsules per day that gave them either placebo or 600 mg/day of CoQ10 in the form of ubiquinone.

The study originally randomized 39 women, 27 of whom completed 2 months of pretreatment. Twenty-two oocytes were available for aneuploidy analysis after IVF and embryo transfer: 9 in the CoQ10 group and 13 in the placebo group.

Although the average estradiol level on the day of human chorionic gonadotropin (HCG) was higher in the CoQ10 group and the average progesterone level was lower on the day of HCG than in the placebo group, these differences did not reach statistical significance. The groups also did not differ significantly in average age, follicle-stimulating hormone level on cycle day 3, the day of HCG, or total international units of Menopur (menotropins) used.

No major side effects were seen. Most women in the CoQ10 group reported feeling more energetic, Dr. Casper said. Some who complained of insomnia were instructed to take all six capsules in the morning.

The study was inspired by two previous studies in mice by the same investigators. One found that CoQ10 supplementation in old mice improved ovarian response to stimulation, increased the number of cumulus cells and oocyte mitochondrial function, restored normal nuclear spindles, and delayed ovarian follicle loss due to aging. The second study showed that disrupting CoQ10 production in mice oocytes mimicked reproductive aging. Disrupting CoQ10 production accelerated oocyte loss and premature ovarian failure, impaired mitochondrial function with reduced energy production, and increased chromosomal abnormalities, all of which were bypassed with CoQ10 supplementation.

Dr. Casper has been a consultant for Fertility Nutraceuticals, which is making a brand of CoQ10, and he disclosed financial relationships with multiple other companies unrelated to this topic.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Two months of pre-IVF supplementation with coenzyme Q10 was associated with a 41% rate of aneuploidies in 9 oocytes, compared with aneuploidies in 51% of 13 oocytes from women randomized to placebo, a small prospective study found.

"This difference didn’t reach significance because of the small numbers, but at least it’s trending in the right direction," Dr. Robert F. Casper said at the UCLA annual in vitro fertilization and embryo transfer update 2013.

The study took 2-3 years to enroll and randomize 39 women aged 38 years or older who were undergoing IVF at his institution, a lengthy process because of patient reluctance to enter the study.

He said the investigators didn’t really know how long to pretreat with coenzyme Q10 (CoQ10) in hopes of rejuvenating the mitochondria of aging oocytes, so they settled on 2 months because they didn’t think these older women would agree to a longer time frame. Even with that compromise, most eligible patients still were unwilling to risk being randomized to placebo and so refused enrollment, said Dr. Casper, professor of ob.gyn. and of medicine (division of endocrinology) at the University of Toronto and the Camille Dan Family research chair in translational cell biology at the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto.

The encouraging trend in reduced risk of aneuploidy suggests that a much larger prospective study should be conducted, perhaps with younger IVF patients who "wouldn’t be so stressed about being randomized to placebo for a few months," he said.

Patients took six capsules per day that gave them either placebo or 600 mg/day of CoQ10 in the form of ubiquinone.

The study originally randomized 39 women, 27 of whom completed 2 months of pretreatment. Twenty-two oocytes were available for aneuploidy analysis after IVF and embryo transfer: 9 in the CoQ10 group and 13 in the placebo group.

Although the average estradiol level on the day of human chorionic gonadotropin (HCG) was higher in the CoQ10 group and the average progesterone level was lower on the day of HCG than in the placebo group, these differences did not reach statistical significance. The groups also did not differ significantly in average age, follicle-stimulating hormone level on cycle day 3, the day of HCG, or total international units of Menopur (menotropins) used.

No major side effects were seen. Most women in the CoQ10 group reported feeling more energetic, Dr. Casper said. Some who complained of insomnia were instructed to take all six capsules in the morning.

The study was inspired by two previous studies in mice by the same investigators. One found that CoQ10 supplementation in old mice improved ovarian response to stimulation, increased the number of cumulus cells and oocyte mitochondrial function, restored normal nuclear spindles, and delayed ovarian follicle loss due to aging. The second study showed that disrupting CoQ10 production in mice oocytes mimicked reproductive aging. Disrupting CoQ10 production accelerated oocyte loss and premature ovarian failure, impaired mitochondrial function with reduced energy production, and increased chromosomal abnormalities, all of which were bypassed with CoQ10 supplementation.

Dr. Casper has been a consultant for Fertility Nutraceuticals, which is making a brand of CoQ10, and he disclosed financial relationships with multiple other companies unrelated to this topic.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Two months of pre-IVF supplementation with coenzyme Q10 was associated with a 41% rate of aneuploidies in 9 oocytes, compared with aneuploidies in 51% of 13 oocytes from women randomized to placebo, a small prospective study found.

"This difference didn’t reach significance because of the small numbers, but at least it’s trending in the right direction," Dr. Robert F. Casper said at the UCLA annual in vitro fertilization and embryo transfer update 2013.

The study took 2-3 years to enroll and randomize 39 women aged 38 years or older who were undergoing IVF at his institution, a lengthy process because of patient reluctance to enter the study.

He said the investigators didn’t really know how long to pretreat with coenzyme Q10 (CoQ10) in hopes of rejuvenating the mitochondria of aging oocytes, so they settled on 2 months because they didn’t think these older women would agree to a longer time frame. Even with that compromise, most eligible patients still were unwilling to risk being randomized to placebo and so refused enrollment, said Dr. Casper, professor of ob.gyn. and of medicine (division of endocrinology) at the University of Toronto and the Camille Dan Family research chair in translational cell biology at the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto.

The encouraging trend in reduced risk of aneuploidy suggests that a much larger prospective study should be conducted, perhaps with younger IVF patients who "wouldn’t be so stressed about being randomized to placebo for a few months," he said.

Patients took six capsules per day that gave them either placebo or 600 mg/day of CoQ10 in the form of ubiquinone.

The study originally randomized 39 women, 27 of whom completed 2 months of pretreatment. Twenty-two oocytes were available for aneuploidy analysis after IVF and embryo transfer: 9 in the CoQ10 group and 13 in the placebo group.

Although the average estradiol level on the day of human chorionic gonadotropin (HCG) was higher in the CoQ10 group and the average progesterone level was lower on the day of HCG than in the placebo group, these differences did not reach statistical significance. The groups also did not differ significantly in average age, follicle-stimulating hormone level on cycle day 3, the day of HCG, or total international units of Menopur (menotropins) used.

No major side effects were seen. Most women in the CoQ10 group reported feeling more energetic, Dr. Casper said. Some who complained of insomnia were instructed to take all six capsules in the morning.

The study was inspired by two previous studies in mice by the same investigators. One found that CoQ10 supplementation in old mice improved ovarian response to stimulation, increased the number of cumulus cells and oocyte mitochondrial function, restored normal nuclear spindles, and delayed ovarian follicle loss due to aging. The second study showed that disrupting CoQ10 production in mice oocytes mimicked reproductive aging. Disrupting CoQ10 production accelerated oocyte loss and premature ovarian failure, impaired mitochondrial function with reduced energy production, and increased chromosomal abnormalities, all of which were bypassed with CoQ10 supplementation.

Dr. Casper has been a consultant for Fertility Nutraceuticals, which is making a brand of CoQ10, and he disclosed financial relationships with multiple other companies unrelated to this topic.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – When your first or second attempts to help a skin wound heal haven’t worked, ask yourself three questions, Dr. Theodora Mauro suggested:

• Have you diagnosed the wound correctly?

• What systemic conditions are keeping the wound from healing?

• Have you tailored your treatment to the wound correctly?

Most dermatologists are pretty good at diagnosing ulcers that are caused by single etiologies. What Dr. Mauro sees more commonly in her busy referral practice, however, are wounds that won’t heal because of a combination of causes – often venous insufficiency plus something else, she said at the annual meeting of the Pacific Dermatologic Association.

"That can make the diagnosis a little more confusing," said Dr. Mauro, professor of dermatology at the University of California, San Francisco and chief of the dermatology service at the San Francisco Veterans Affairs Medical Center.

Ulcer types

The most common skin ulcer in the United States is due to venous insufficiency. These patients tend to be spread among dermatologists, vascular surgeons, and podiatrists and "are not well served by being scattered among different disciplines," she said.

Arterial ulcers make up 6%-10% of skin ulcers in the medical literature, and the incidence of diabetic ulcers is increasing, she added. Pressure ulcers are becoming more common as the population ages.

Morphology and the location of ulcers usually can distinguish the different types, but don’t forget to check the patient’s pulses and sensations, Dr. Mauro said. If you can feel pedal pulses, the patient is very likely to have a normal ankle brachial index (greater than 0.8). "It’s an easy thing to do and very helpful," she said. Also, break a Q-tip cotton swab in half and poke the patient with the sharp end. "You’d be surprised at the number of people who have altered sensation" that’s contributing to the ulceration.

A common "combination" that gets missed is a nonmelanoma skin cancer and an ulcer at that site from venous insufficiency. Consider taking biopsies of nonhealing ulcers to look for skin cancer, she said. Long-standing ulcers can develop squamous cell carcinoma within them. A basal cell carcinoma can look like a healing ulcer, but not heal.

Bullous diseases also can be hidden in ulcers, particularly in the elderly. "There seems to be a two-hit thing with venous insufficiency where you have a little bit of blistering disease and you have a lot of hydrostatic pressure, and people will get their bullae on their legs long before they get it anyplace else," Dr. Mauro said. "You put compression on and they come back next week and now they have intact bullae. Think about that as another cause."

Less common ulcerative problems that can be confusing include pyoderma gangrenosum (which may be half as common as people think, studies suggest), an underlying vasculitis, or mycobacterial infections. If you see a nonhealing hyperkeratotic lesion, consider an atypical mycobacterial infection. In Dr. Mauro’s region, these usually are in patients who went mountain biking and inoculated themselves through an ankle scratch or in patients exposed to the organism through infected water during a pedicure.

Systemic conditions

Wound healing can be inhibited by things that doctors do, and by things that patients do.

Taking antimetabolite medications (such as hydroxyurea or methotrexate), prednisone, or nonsteroidal anti-inflammatory drugs can impair wound healing, as does smoking. Radiation to the site also inhibits healing. Think twice before irradiating a basal cell carcinoma on the leg of a patient with venous insufficiency. "It’s much better to either try some topical medication or just bite the bullet, do surgery, and put the Unna boot on after the surgery, because if you irradiate [the basal cell carcinoma] and it ulcerates, then it’s really hard to heal," she said.

Coexisting cancer or arterial disease can inhibit wound healing. If you check pulses and can’t feel them, send the patient for an ankle brachial index to determine if there’s arterial disease, in which case the patient should see a vascular surgeon, she said.

When you’re taking patients’ histories, ask what they’re eating so you can assess whether they’re getting enough protein, zinc, and vitamin C. "You’d be surprised at the number of nutritional deficiencies that we see" in patients with nonhealing wounds. Her clinic picks up a zinc deficiency three to four times per year and a protein deficiency approximately twice a year. "All of these are things that you need to make collagen and granulation tissue," she explained. Supplementation with Ensure can provide these nutrients, but a less-expensive option is Carnation Breakfast Essentials, at about one-fifth the cost, she added.

Tailor therapy appropriately

Dressings can make wounds worse. Most commonly, putting a hydrocolloid dressing (such as DuoDERM) on an ulcer that has a lot of drainage will macerate and enlarge the wound. Putting stiff foams or self-adherent wraps such as Coban on wounds with a lot of edema can create secondary ulcers. And avoid compression on the legs of people with arterial insufficiency, Dr. Mauro said.

Artifactual ulcers from patients scratching or picking at wounds are increasing, she said. These patients usually will not report that they’re messing with the wound, but your level of suspicion should increase if the ulcer is above the knee. Hydrocolloid dressings work pretty well for this problem. Consider sending some of these patients to an expert in the growing field of medication therapy for dysesthesia.

Ask patients about home remedies, because they will put all kinds of things on wounds to try and help them heal. Neomycin can cause contact dermatitis. Patients may apply full-strength hydrogen peroxide, thinking that they need a disinfectant, which tends to damage the epithelium and can impair wound healing. If they insist on using hydrogen peroxide, recommend a half-strength solution.

For patients with venous insufficiency, the hydrostatic pressure from sitting can be nearly as bad as from standing. Ask patients with nonhealing wounds what they do at home and at work. If they’re sitting much of that time, recommend products to alleviate the pressure. Dr. Mauro said she has virtually become a saleswoman for La-Z-Boy furniture during her medical career because La-Z-Boy products allow patients to eat, work at computers, and function in positions with less hydrostatic pressure.

When to refer

Consider referring patients with chronic wounds that have not lost at least 50% of their width and height within 6 weeks. When a wound has been present long enough, the physiology shifts from acute to chronic. "It’s as if the body decides that it’s tired of trying to heal it and its new equilibrium is just going to be, ‘I have a wound,’ " she said.

If you want to try treating chronic wounds, applying Promogran Prisma matrix wound dressing in those without good granulation tissue may stimulate granulation tissue, she said.

Debriding an ulcer is "kind of a poor man’s way of getting platelet-derived growth factor," she added. Dr. Mauro applies a compounded 30% lidocaine ("but you can use any topical lidocaine"), leaves it on for 20-25 minutes, and debrides using a curette, which is much more precise than a scalpel. "What you’re trying to do is ‘reboot the computer’ and trick the ulcer into thinking it’s an acute ulcer rather than a chronic one," she said.

Dr. Mauro said she refers patients with arterial insufficiency to vascular surgeons. She sends patients with diabetes to podiatrists, preferably before they develop ulcers. The podiatrist can regularly trim nails for patients with poor sight and loss of sensation who may cut themselves, and can design footwear to avoid pressure that could cause an ulcer. "That will keep you out of trouble" with diabetic patients, she said.

Dr. Mauro has been a consultant for Unilever, but not in a wound-healing capacity.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – When your first or second attempts to help a skin wound heal haven’t worked, ask yourself three questions, Dr. Theodora Mauro suggested:

• Have you diagnosed the wound correctly?

• What systemic conditions are keeping the wound from healing?

• Have you tailored your treatment to the wound correctly?

Most dermatologists are pretty good at diagnosing ulcers that are caused by single etiologies. What Dr. Mauro sees more commonly in her busy referral practice, however, are wounds that won’t heal because of a combination of causes – often venous insufficiency plus something else, she said at the annual meeting of the Pacific Dermatologic Association.

"That can make the diagnosis a little more confusing," said Dr. Mauro, professor of dermatology at the University of California, San Francisco and chief of the dermatology service at the San Francisco Veterans Affairs Medical Center.

Ulcer types

The most common skin ulcer in the United States is due to venous insufficiency. These patients tend to be spread among dermatologists, vascular surgeons, and podiatrists and "are not well served by being scattered among different disciplines," she said.

Arterial ulcers make up 6%-10% of skin ulcers in the medical literature, and the incidence of diabetic ulcers is increasing, she added. Pressure ulcers are becoming more common as the population ages.

Morphology and the location of ulcers usually can distinguish the different types, but don’t forget to check the patient’s pulses and sensations, Dr. Mauro said. If you can feel pedal pulses, the patient is very likely to have a normal ankle brachial index (greater than 0.8). "It’s an easy thing to do and very helpful," she said. Also, break a Q-tip cotton swab in half and poke the patient with the sharp end. "You’d be surprised at the number of people who have altered sensation" that’s contributing to the ulceration.

A common "combination" that gets missed is a nonmelanoma skin cancer and an ulcer at that site from venous insufficiency. Consider taking biopsies of nonhealing ulcers to look for skin cancer, she said. Long-standing ulcers can develop squamous cell carcinoma within them. A basal cell carcinoma can look like a healing ulcer, but not heal.

Bullous diseases also can be hidden in ulcers, particularly in the elderly. "There seems to be a two-hit thing with venous insufficiency where you have a little bit of blistering disease and you have a lot of hydrostatic pressure, and people will get their bullae on their legs long before they get it anyplace else," Dr. Mauro said. "You put compression on and they come back next week and now they have intact bullae. Think about that as another cause."

Less common ulcerative problems that can be confusing include pyoderma gangrenosum (which may be half as common as people think, studies suggest), an underlying vasculitis, or mycobacterial infections. If you see a nonhealing hyperkeratotic lesion, consider an atypical mycobacterial infection. In Dr. Mauro’s region, these usually are in patients who went mountain biking and inoculated themselves through an ankle scratch or in patients exposed to the organism through infected water during a pedicure.

Systemic conditions

Wound healing can be inhibited by things that doctors do, and by things that patients do.

Taking antimetabolite medications (such as hydroxyurea or methotrexate), prednisone, or nonsteroidal anti-inflammatory drugs can impair wound healing, as does smoking. Radiation to the site also inhibits healing. Think twice before irradiating a basal cell carcinoma on the leg of a patient with venous insufficiency. "It’s much better to either try some topical medication or just bite the bullet, do surgery, and put the Unna boot on after the surgery, because if you irradiate [the basal cell carcinoma] and it ulcerates, then it’s really hard to heal," she said.

Coexisting cancer or arterial disease can inhibit wound healing. If you check pulses and can’t feel them, send the patient for an ankle brachial index to determine if there’s arterial disease, in which case the patient should see a vascular surgeon, she said.

When you’re taking patients’ histories, ask what they’re eating so you can assess whether they’re getting enough protein, zinc, and vitamin C. "You’d be surprised at the number of nutritional deficiencies that we see" in patients with nonhealing wounds. Her clinic picks up a zinc deficiency three to four times per year and a protein deficiency approximately twice a year. "All of these are things that you need to make collagen and granulation tissue," she explained. Supplementation with Ensure can provide these nutrients, but a less-expensive option is Carnation Breakfast Essentials, at about one-fifth the cost, she added.

Tailor therapy appropriately

Dressings can make wounds worse. Most commonly, putting a hydrocolloid dressing (such as DuoDERM) on an ulcer that has a lot of drainage will macerate and enlarge the wound. Putting stiff foams or self-adherent wraps such as Coban on wounds with a lot of edema can create secondary ulcers. And avoid compression on the legs of people with arterial insufficiency, Dr. Mauro said.

Artifactual ulcers from patients scratching or picking at wounds are increasing, she said. These patients usually will not report that they’re messing with the wound, but your level of suspicion should increase if the ulcer is above the knee. Hydrocolloid dressings work pretty well for this problem. Consider sending some of these patients to an expert in the growing field of medication therapy for dysesthesia.

Ask patients about home remedies, because they will put all kinds of things on wounds to try and help them heal. Neomycin can cause contact dermatitis. Patients may apply full-strength hydrogen peroxide, thinking that they need a disinfectant, which tends to damage the epithelium and can impair wound healing. If they insist on using hydrogen peroxide, recommend a half-strength solution.

For patients with venous insufficiency, the hydrostatic pressure from sitting can be nearly as bad as from standing. Ask patients with nonhealing wounds what they do at home and at work. If they’re sitting much of that time, recommend products to alleviate the pressure. Dr. Mauro said she has virtually become a saleswoman for La-Z-Boy furniture during her medical career because La-Z-Boy products allow patients to eat, work at computers, and function in positions with less hydrostatic pressure.

When to refer

Consider referring patients with chronic wounds that have not lost at least 50% of their width and height within 6 weeks. When a wound has been present long enough, the physiology shifts from acute to chronic. "It’s as if the body decides that it’s tired of trying to heal it and its new equilibrium is just going to be, ‘I have a wound,’ " she said.

If you want to try treating chronic wounds, applying Promogran Prisma matrix wound dressing in those without good granulation tissue may stimulate granulation tissue, she said.

Debriding an ulcer is "kind of a poor man’s way of getting platelet-derived growth factor," she added. Dr. Mauro applies a compounded 30% lidocaine ("but you can use any topical lidocaine"), leaves it on for 20-25 minutes, and debrides using a curette, which is much more precise than a scalpel. "What you’re trying to do is ‘reboot the computer’ and trick the ulcer into thinking it’s an acute ulcer rather than a chronic one," she said.

Dr. Mauro said she refers patients with arterial insufficiency to vascular surgeons. She sends patients with diabetes to podiatrists, preferably before they develop ulcers. The podiatrist can regularly trim nails for patients with poor sight and loss of sensation who may cut themselves, and can design footwear to avoid pressure that could cause an ulcer. "That will keep you out of trouble" with diabetic patients, she said.

Dr. Mauro has been a consultant for Unilever, but not in a wound-healing capacity.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – When your first or second attempts to help a skin wound heal haven’t worked, ask yourself three questions, Dr. Theodora Mauro suggested:

• Have you diagnosed the wound correctly?

• What systemic conditions are keeping the wound from healing?

• Have you tailored your treatment to the wound correctly?

Most dermatologists are pretty good at diagnosing ulcers that are caused by single etiologies. What Dr. Mauro sees more commonly in her busy referral practice, however, are wounds that won’t heal because of a combination of causes – often venous insufficiency plus something else, she said at the annual meeting of the Pacific Dermatologic Association.

"That can make the diagnosis a little more confusing," said Dr. Mauro, professor of dermatology at the University of California, San Francisco and chief of the dermatology service at the San Francisco Veterans Affairs Medical Center.

Ulcer types

The most common skin ulcer in the United States is due to venous insufficiency. These patients tend to be spread among dermatologists, vascular surgeons, and podiatrists and "are not well served by being scattered among different disciplines," she said.

Arterial ulcers make up 6%-10% of skin ulcers in the medical literature, and the incidence of diabetic ulcers is increasing, she added. Pressure ulcers are becoming more common as the population ages.

Morphology and the location of ulcers usually can distinguish the different types, but don’t forget to check the patient’s pulses and sensations, Dr. Mauro said. If you can feel pedal pulses, the patient is very likely to have a normal ankle brachial index (greater than 0.8). "It’s an easy thing to do and very helpful," she said. Also, break a Q-tip cotton swab in half and poke the patient with the sharp end. "You’d be surprised at the number of people who have altered sensation" that’s contributing to the ulceration.

A common "combination" that gets missed is a nonmelanoma skin cancer and an ulcer at that site from venous insufficiency. Consider taking biopsies of nonhealing ulcers to look for skin cancer, she said. Long-standing ulcers can develop squamous cell carcinoma within them. A basal cell carcinoma can look like a healing ulcer, but not heal.

Bullous diseases also can be hidden in ulcers, particularly in the elderly. "There seems to be a two-hit thing with venous insufficiency where you have a little bit of blistering disease and you have a lot of hydrostatic pressure, and people will get their bullae on their legs long before they get it anyplace else," Dr. Mauro said. "You put compression on and they come back next week and now they have intact bullae. Think about that as another cause."

Less common ulcerative problems that can be confusing include pyoderma gangrenosum (which may be half as common as people think, studies suggest), an underlying vasculitis, or mycobacterial infections. If you see a nonhealing hyperkeratotic lesion, consider an atypical mycobacterial infection. In Dr. Mauro’s region, these usually are in patients who went mountain biking and inoculated themselves through an ankle scratch or in patients exposed to the organism through infected water during a pedicure.

Systemic conditions

Wound healing can be inhibited by things that doctors do, and by things that patients do.

Taking antimetabolite medications (such as hydroxyurea or methotrexate), prednisone, or nonsteroidal anti-inflammatory drugs can impair wound healing, as does smoking. Radiation to the site also inhibits healing. Think twice before irradiating a basal cell carcinoma on the leg of a patient with venous insufficiency. "It’s much better to either try some topical medication or just bite the bullet, do surgery, and put the Unna boot on after the surgery, because if you irradiate [the basal cell carcinoma] and it ulcerates, then it’s really hard to heal," she said.

Coexisting cancer or arterial disease can inhibit wound healing. If you check pulses and can’t feel them, send the patient for an ankle brachial index to determine if there’s arterial disease, in which case the patient should see a vascular surgeon, she said.

When you’re taking patients’ histories, ask what they’re eating so you can assess whether they’re getting enough protein, zinc, and vitamin C. "You’d be surprised at the number of nutritional deficiencies that we see" in patients with nonhealing wounds. Her clinic picks up a zinc deficiency three to four times per year and a protein deficiency approximately twice a year. "All of these are things that you need to make collagen and granulation tissue," she explained. Supplementation with Ensure can provide these nutrients, but a less-expensive option is Carnation Breakfast Essentials, at about one-fifth the cost, she added.

Tailor therapy appropriately

Dressings can make wounds worse. Most commonly, putting a hydrocolloid dressing (such as DuoDERM) on an ulcer that has a lot of drainage will macerate and enlarge the wound. Putting stiff foams or self-adherent wraps such as Coban on wounds with a lot of edema can create secondary ulcers. And avoid compression on the legs of people with arterial insufficiency, Dr. Mauro said.

Artifactual ulcers from patients scratching or picking at wounds are increasing, she said. These patients usually will not report that they’re messing with the wound, but your level of suspicion should increase if the ulcer is above the knee. Hydrocolloid dressings work pretty well for this problem. Consider sending some of these patients to an expert in the growing field of medication therapy for dysesthesia.

Ask patients about home remedies, because they will put all kinds of things on wounds to try and help them heal. Neomycin can cause contact dermatitis. Patients may apply full-strength hydrogen peroxide, thinking that they need a disinfectant, which tends to damage the epithelium and can impair wound healing. If they insist on using hydrogen peroxide, recommend a half-strength solution.

For patients with venous insufficiency, the hydrostatic pressure from sitting can be nearly as bad as from standing. Ask patients with nonhealing wounds what they do at home and at work. If they’re sitting much of that time, recommend products to alleviate the pressure. Dr. Mauro said she has virtually become a saleswoman for La-Z-Boy furniture during her medical career because La-Z-Boy products allow patients to eat, work at computers, and function in positions with less hydrostatic pressure.

When to refer

Consider referring patients with chronic wounds that have not lost at least 50% of their width and height within 6 weeks. When a wound has been present long enough, the physiology shifts from acute to chronic. "It’s as if the body decides that it’s tired of trying to heal it and its new equilibrium is just going to be, ‘I have a wound,’ " she said.

If you want to try treating chronic wounds, applying Promogran Prisma matrix wound dressing in those without good granulation tissue may stimulate granulation tissue, she said.

Debriding an ulcer is "kind of a poor man’s way of getting platelet-derived growth factor," she added. Dr. Mauro applies a compounded 30% lidocaine ("but you can use any topical lidocaine"), leaves it on for 20-25 minutes, and debrides using a curette, which is much more precise than a scalpel. "What you’re trying to do is ‘reboot the computer’ and trick the ulcer into thinking it’s an acute ulcer rather than a chronic one," she said.

Dr. Mauro said she refers patients with arterial insufficiency to vascular surgeons. She sends patients with diabetes to podiatrists, preferably before they develop ulcers. The podiatrist can regularly trim nails for patients with poor sight and loss of sensation who may cut themselves, and can design footwear to avoid pressure that could cause an ulcer. "That will keep you out of trouble" with diabetic patients, she said.

Dr. Mauro has been a consultant for Unilever, but not in a wound-healing capacity.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Three distinct stages of pattern hair loss in women are related to the age of onset, and are not necessarily androgen related.

Between puberty and age 40 years, hair miniaturization in females tends to be caused by androgenetic alopecia, a common hereditary thinning or balding induced by androgens in genetically susceptible people of both sexes. By contrast, women in their 60s or older may develop hair thinning from age-related, or "senescent" alopecia, which is distinct from androgenetic alopecia because senescent alopecia is not mediated by dihydrotestosterone, Dr. Vera H. Price said at the annual meeting of the Pacific Dermatologic Association.

However, a newly identified stage that often occurs between 45 and 55 years of age is gaining popularity in the lexicon of hair loss. In this stage, called "female pattern hair loss," the role of androgens is less clear-cut, and other hormonal and nonhormonal factors may play a role, said Dr. Price, professor of dermatology at the University of California, San Francisco.

All three stages show similar histopathology, with follicular downsizing, normal sebaceous glands, and no significant inflammation. However, recognizing and understanding the three stages help inform management, said Dr. Price.

Treatment with minoxidil is suitable for all three stages of hair loss, for example, but androgen blockade via off-label treatment with finasteride is not helpful in senescent alopecia. "I don’t use it after 60 years of age in women or men," she said.

Millions of men who have taken finasteride 5 mg/day for benign prostatic hypertrophy have not regrown scalp hair, evidence that senescent alopecia is not dihydrotestosterone mediated, she noted.

• Androgenetic alopecia. To screen for suspected androgenetic alopecia in women, check for menstrual irregularities, infertility, hirsutism, severe cystic acne, galactorrhea, and virilization. "If none are present, you do not have to do a single hormonal test" because it’s not androgenetic alopecia causing the hair loss, Dr. Price said.

If any one of those conditions is present, however, check levels of testosterone, dehydroepiandrosterone sulfate (DHEAS), and prolactin.

In all hair loss patients, get a complete blood count and check for normal levels of thyroid-stimulating hormone (TSH), ferritin, and 25-hydroxyvitamin D; the latter two are required for a normal hair cycle. Be sure to order the ferritin level specifically, because ordering "iron studies" won’t include a ferritin level, she added.

• Female pattern hair loss. The pathogenesis behind female pattern hair loss is not well understood. As women go through menopause, hair growth parameters change. The hair growth rate slows, the anagen/telogen ratio decreases, and hair diameters become smaller, Dr. Price explained.

Hormonal and molecular factors that may influence female pattern hair loss need to be better defined, including the possible roles of estrogen, estrogen receptor (ER)-beta, aromatase, 5-alpha-reductase, dihydrotestosterone, and androgen receptors, she said.

"When we understand that, we’ll understand this group a little more clearly," she added. "I’ve always been puzzled a little bit when the onset is in this age group."

• Senescent alopecia. "I call it ‘wisdom-related’ alopecia," quipped Dr. Price. The gene expression profiles of androgenetic alopecia and senescent alopecia differ. In the former, hair growth cycle genes are differentially expressed. In the latter, systemic senescent/aging genes are differentially expressed, suggesting these are two distinct disorders.

• Management. For any stage of hair loss, minoxidil (Rogaine) may help if used properly over an extended period of time, said Dr. Price. Apply the 2% or 5% solution every single day directly to a dry scalp, not right after a shower, and spread it gently across the scalp, she advised. Give minoxidil time to absorb without spraying, moussing, or blow-drying the hair while it absorbs. Once-daily minoxidil foam 5% also has been approved for women and is less oily and absorbed faster.

Of note, androgen blockade via off-label oral finasteride 1 mg/day for confirmed androgenetic alopecia is contraindicated in women who may be or may become pregnant because it will cause hypospadias in a male fetus, said Dr. Price. Prescribe concurrent oral contraception in premenopausal women or make sure the woman is postmenopausal when using finasteride.

"Do I use it in women? I do, but I’m very careful," she said. "They have to be post hysterectomy or post tubal ligation. I want to be certain that they’re not going to conceive."

In appropriate patients, minoxidil and finasteride could be used together if the patient can afford it, she added.

Spironolactone, an androgen receptor inhibitor, also has been used in a dose of 200 mg/day to retard hair thinning due to androgenetic alopecia. Data show that spironolactone 50-200 mg/day can be used successfully to treat acne and hirsutism, but there are no evidence-based studies showing that it helps hair regrowth.

"I use very little spironolactone for androgenetic alopecia," Dr. Price said. "It will not grow hair. I think it’s used a lot because people aren’t familiar with minoxidil or don’t know about using finasteride if there’s no possibility of pregnancy."

Dr. Price reported having financial associations with Allergan and Follica, neither of which was pertinent to this topic.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Three distinct stages of pattern hair loss in women are related to the age of onset, and are not necessarily androgen related.

Between puberty and age 40 years, hair miniaturization in females tends to be caused by androgenetic alopecia, a common hereditary thinning or balding induced by androgens in genetically susceptible people of both sexes. By contrast, women in their 60s or older may develop hair thinning from age-related, or "senescent" alopecia, which is distinct from androgenetic alopecia because senescent alopecia is not mediated by dihydrotestosterone, Dr. Vera H. Price said at the annual meeting of the Pacific Dermatologic Association.

However, a newly identified stage that often occurs between 45 and 55 years of age is gaining popularity in the lexicon of hair loss. In this stage, called "female pattern hair loss," the role of androgens is less clear-cut, and other hormonal and nonhormonal factors may play a role, said Dr. Price, professor of dermatology at the University of California, San Francisco.

All three stages show similar histopathology, with follicular downsizing, normal sebaceous glands, and no significant inflammation. However, recognizing and understanding the three stages help inform management, said Dr. Price.

Treatment with minoxidil is suitable for all three stages of hair loss, for example, but androgen blockade via off-label treatment with finasteride is not helpful in senescent alopecia. "I don’t use it after 60 years of age in women or men," she said.

Millions of men who have taken finasteride 5 mg/day for benign prostatic hypertrophy have not regrown scalp hair, evidence that senescent alopecia is not dihydrotestosterone mediated, she noted.

• Androgenetic alopecia. To screen for suspected androgenetic alopecia in women, check for menstrual irregularities, infertility, hirsutism, severe cystic acne, galactorrhea, and virilization. "If none are present, you do not have to do a single hormonal test" because it’s not androgenetic alopecia causing the hair loss, Dr. Price said.

If any one of those conditions is present, however, check levels of testosterone, dehydroepiandrosterone sulfate (DHEAS), and prolactin.

In all hair loss patients, get a complete blood count and check for normal levels of thyroid-stimulating hormone (TSH), ferritin, and 25-hydroxyvitamin D; the latter two are required for a normal hair cycle. Be sure to order the ferritin level specifically, because ordering "iron studies" won’t include a ferritin level, she added.

• Female pattern hair loss. The pathogenesis behind female pattern hair loss is not well understood. As women go through menopause, hair growth parameters change. The hair growth rate slows, the anagen/telogen ratio decreases, and hair diameters become smaller, Dr. Price explained.

Hormonal and molecular factors that may influence female pattern hair loss need to be better defined, including the possible roles of estrogen, estrogen receptor (ER)-beta, aromatase, 5-alpha-reductase, dihydrotestosterone, and androgen receptors, she said.

"When we understand that, we’ll understand this group a little more clearly," she added. "I’ve always been puzzled a little bit when the onset is in this age group."

• Senescent alopecia. "I call it ‘wisdom-related’ alopecia," quipped Dr. Price. The gene expression profiles of androgenetic alopecia and senescent alopecia differ. In the former, hair growth cycle genes are differentially expressed. In the latter, systemic senescent/aging genes are differentially expressed, suggesting these are two distinct disorders.

• Management. For any stage of hair loss, minoxidil (Rogaine) may help if used properly over an extended period of time, said Dr. Price. Apply the 2% or 5% solution every single day directly to a dry scalp, not right after a shower, and spread it gently across the scalp, she advised. Give minoxidil time to absorb without spraying, moussing, or blow-drying the hair while it absorbs. Once-daily minoxidil foam 5% also has been approved for women and is less oily and absorbed faster.

Of note, androgen blockade via off-label oral finasteride 1 mg/day for confirmed androgenetic alopecia is contraindicated in women who may be or may become pregnant because it will cause hypospadias in a male fetus, said Dr. Price. Prescribe concurrent oral contraception in premenopausal women or make sure the woman is postmenopausal when using finasteride.

"Do I use it in women? I do, but I’m very careful," she said. "They have to be post hysterectomy or post tubal ligation. I want to be certain that they’re not going to conceive."

In appropriate patients, minoxidil and finasteride could be used together if the patient can afford it, she added.

Spironolactone, an androgen receptor inhibitor, also has been used in a dose of 200 mg/day to retard hair thinning due to androgenetic alopecia. Data show that spironolactone 50-200 mg/day can be used successfully to treat acne and hirsutism, but there are no evidence-based studies showing that it helps hair regrowth.

"I use very little spironolactone for androgenetic alopecia," Dr. Price said. "It will not grow hair. I think it’s used a lot because people aren’t familiar with minoxidil or don’t know about using finasteride if there’s no possibility of pregnancy."

Dr. Price reported having financial associations with Allergan and Follica, neither of which was pertinent to this topic.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Three distinct stages of pattern hair loss in women are related to the age of onset, and are not necessarily androgen related.

Between puberty and age 40 years, hair miniaturization in females tends to be caused by androgenetic alopecia, a common hereditary thinning or balding induced by androgens in genetically susceptible people of both sexes. By contrast, women in their 60s or older may develop hair thinning from age-related, or "senescent" alopecia, which is distinct from androgenetic alopecia because senescent alopecia is not mediated by dihydrotestosterone, Dr. Vera H. Price said at the annual meeting of the Pacific Dermatologic Association.

However, a newly identified stage that often occurs between 45 and 55 years of age is gaining popularity in the lexicon of hair loss. In this stage, called "female pattern hair loss," the role of androgens is less clear-cut, and other hormonal and nonhormonal factors may play a role, said Dr. Price, professor of dermatology at the University of California, San Francisco.

All three stages show similar histopathology, with follicular downsizing, normal sebaceous glands, and no significant inflammation. However, recognizing and understanding the three stages help inform management, said Dr. Price.

Treatment with minoxidil is suitable for all three stages of hair loss, for example, but androgen blockade via off-label treatment with finasteride is not helpful in senescent alopecia. "I don’t use it after 60 years of age in women or men," she said.

Millions of men who have taken finasteride 5 mg/day for benign prostatic hypertrophy have not regrown scalp hair, evidence that senescent alopecia is not dihydrotestosterone mediated, she noted.

• Androgenetic alopecia. To screen for suspected androgenetic alopecia in women, check for menstrual irregularities, infertility, hirsutism, severe cystic acne, galactorrhea, and virilization. "If none are present, you do not have to do a single hormonal test" because it’s not androgenetic alopecia causing the hair loss, Dr. Price said.

If any one of those conditions is present, however, check levels of testosterone, dehydroepiandrosterone sulfate (DHEAS), and prolactin.

In all hair loss patients, get a complete blood count and check for normal levels of thyroid-stimulating hormone (TSH), ferritin, and 25-hydroxyvitamin D; the latter two are required for a normal hair cycle. Be sure to order the ferritin level specifically, because ordering "iron studies" won’t include a ferritin level, she added.

• Female pattern hair loss. The pathogenesis behind female pattern hair loss is not well understood. As women go through menopause, hair growth parameters change. The hair growth rate slows, the anagen/telogen ratio decreases, and hair diameters become smaller, Dr. Price explained.

Hormonal and molecular factors that may influence female pattern hair loss need to be better defined, including the possible roles of estrogen, estrogen receptor (ER)-beta, aromatase, 5-alpha-reductase, dihydrotestosterone, and androgen receptors, she said.

"When we understand that, we’ll understand this group a little more clearly," she added. "I’ve always been puzzled a little bit when the onset is in this age group."

• Senescent alopecia. "I call it ‘wisdom-related’ alopecia," quipped Dr. Price. The gene expression profiles of androgenetic alopecia and senescent alopecia differ. In the former, hair growth cycle genes are differentially expressed. In the latter, systemic senescent/aging genes are differentially expressed, suggesting these are two distinct disorders.

• Management. For any stage of hair loss, minoxidil (Rogaine) may help if used properly over an extended period of time, said Dr. Price. Apply the 2% or 5% solution every single day directly to a dry scalp, not right after a shower, and spread it gently across the scalp, she advised. Give minoxidil time to absorb without spraying, moussing, or blow-drying the hair while it absorbs. Once-daily minoxidil foam 5% also has been approved for women and is less oily and absorbed faster.

Of note, androgen blockade via off-label oral finasteride 1 mg/day for confirmed androgenetic alopecia is contraindicated in women who may be or may become pregnant because it will cause hypospadias in a male fetus, said Dr. Price. Prescribe concurrent oral contraception in premenopausal women or make sure the woman is postmenopausal when using finasteride.

"Do I use it in women? I do, but I’m very careful," she said. "They have to be post hysterectomy or post tubal ligation. I want to be certain that they’re not going to conceive."

In appropriate patients, minoxidil and finasteride could be used together if the patient can afford it, she added.

Spironolactone, an androgen receptor inhibitor, also has been used in a dose of 200 mg/day to retard hair thinning due to androgenetic alopecia. Data show that spironolactone 50-200 mg/day can be used successfully to treat acne and hirsutism, but there are no evidence-based studies showing that it helps hair regrowth.

"I use very little spironolactone for androgenetic alopecia," Dr. Price said. "It will not grow hair. I think it’s used a lot because people aren’t familiar with minoxidil or don’t know about using finasteride if there’s no possibility of pregnancy."

Dr. Price reported having financial associations with Allergan and Follica, neither of which was pertinent to this topic.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SANTA BARBARA, CALIF. – Comprehensive chromosomal screening followed by single-embryo transfer resulted in similar delivery rates but significantly fewer multiple gestations, and better maternal and fetal outcomes, compared with conventional transfer of two embryos without screening, a prospective randomized trial of 175 patients found.

As a result, overall costs per delivery are so much lower after comprehensive chromosomal screening and single-embryo transfer (eSET) that these techniques may prove to be the most cost-effective development ever in the field of IVF, Dr. Richard T. Scott Jr. said at the UCLA annual in vitro fertilization and embryo transfer update 2013.

An intent-to-treat analysis by Dr. Scott and his associates found that 61% of 89 patients in the study who received single-euploid blastocysts gave birth, compared with 65% of 86 patients who received two embryos without screening,

All single-euploid blastocysts produced singletons. "We were fortunate enough to have no monozygotic twins, at least not yet," he said. In the double-embryo transfer group (DET), 48% developed multiple gestations, including one set of triplets due to monozygotic twins from one of the embryos.

In general, approximately 99% of long-term sequelae from in vitro fertilization (IVF) relates to multiple gestations, he noted. Comprehensive chromosomal screening plus eSET may be a way to maintain high delivery rates without multiple gestations, said Dr. Scott, professor of obstetrics, gynecology and reproductive services and director of the division reproductive endocrinology at Robert Wood Johnson Medical School, New Brunswick, N.J.

Clinical miscarriages were greatly reduced in the eSET group (12%) compared with the DET group (20%). For each single gestational sac, the difference was even more pronounced, with a 31% clinical miscarriage rate for DET.* Five women in the eSET group required dilation and curettage for clinical miscarriage, none due to aneuploidy, as did eight in the DET group, two with documented aneuploidy. Two nonviable second-trimester twins were delivered in the DET group.

The rate of preterm deliveries in the eSET group (8.9%) was similar to the U.S. average for the general population of pregnancies in women who did not receive IVF services (8%), both of which were significantly lower than the 28% preterm birth rate in the DET group.

Admissions to the neonatal intensive care unit affected 11% in the eSET group and 26% after DET, but the difference did not reach statistical significance. Stays in the neonatal ICU were shorter after eSET than after DET, with the exception of one infant who underwent elective premature delivery because of acute maternal health problems.

"The most compelling data" from the study showed significantly better obstetrical outcomes from comprehensive chromosomal screening and eSET, Dr. Scott said. Mean birth weights were 3,408 g in the eSET group and 2,745 g in the DET group. Rates of low birth weight (less than 2,500 g) were 4% after eSET and 32% after DET. No infants in the eSET group had a very low birth weight (less than 1,500 g), compared with 7% of the DET group, although this difference did not reach statistical significance.

"These are dramatic, dramatic differences" just from reducing double-embryo transfers to single embryos with comprehensive chromosomal screening, Dr. Scott said. "This is not putting three and four [embryos] back; this is not Octomom. We’re talking about two-embryo transfers in the other group."

The study has been submitted to the journal Fertility and Sterility for publication, said Dr. Scott, who is the clinical and scientific director of Reproductive Medicine Associates of New Jersey, Morristown, the clinical center that serves the medical school’s division of reproductive endocrinology.

The findings should be applicable to the general IVF population, not just selected patients, he added. A separate analysis of 210 single-euploid blastocyst transfers and 1,435 untested double-blastocyst transfers at his institution found similar ongoing pregnancy rates (68% each) but a nearly threefold higher risk for preterm delivery after DET (30%) compared with eSET (11%), which was statistically significant.

Dr. Scott and his associates also analyzed actual cost data for comprehensive chromosomal screening and eSET, which averaged less than $40,000 per live-born delivery, compared with more than $70,000 per delivery with conventional IVF treatment, both national and regional averages showed. The costs included sometimes multiple cycles of IVF, the costs of comprehensive chromosomal screening and medications, and the costs for delivery and subsequent hospital stays through 28 days of life, he said.

The savings come from fewer IVF cycles with comprehensive chromosomal screening and eSET, better outcomes, and reduced obstetric and pediatric costs that, combined, "could more than pay for all of their infertility care," Dr. Scott said.

"This is not only cost effective, this is massively cost effective, perhaps the most cost-effective thing we’ve ever done in our field," he said.

Dr. Scott has been an adviser to EMD Serono and Ferring Pharmaceuticals.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

*Correction, 9/11/2013: An earlier version of this story attributed the 31% clinical miscarriage rate per single gestational sac to the wrong treatment group.

SANTA BARBARA, CALIF. – Comprehensive chromosomal screening followed by single-embryo transfer resulted in similar delivery rates but significantly fewer multiple gestations, and better maternal and fetal outcomes, compared with conventional transfer of two embryos without screening, a prospective randomized trial of 175 patients found.

As a result, overall costs per delivery are so much lower after comprehensive chromosomal screening and single-embryo transfer (eSET) that these techniques may prove to be the most cost-effective development ever in the field of IVF, Dr. Richard T. Scott Jr. said at the UCLA annual in vitro fertilization and embryo transfer update 2013.

An intent-to-treat analysis by Dr. Scott and his associates found that 61% of 89 patients in the study who received single-euploid blastocysts gave birth, compared with 65% of 86 patients who received two embryos without screening,

All single-euploid blastocysts produced singletons. "We were fortunate enough to have no monozygotic twins, at least not yet," he said. In the double-embryo transfer group (DET), 48% developed multiple gestations, including one set of triplets due to monozygotic twins from one of the embryos.

In general, approximately 99% of long-term sequelae from in vitro fertilization (IVF) relates to multiple gestations, he noted. Comprehensive chromosomal screening plus eSET may be a way to maintain high delivery rates without multiple gestations, said Dr. Scott, professor of obstetrics, gynecology and reproductive services and director of the division reproductive endocrinology at Robert Wood Johnson Medical School, New Brunswick, N.J.

Clinical miscarriages were greatly reduced in the eSET group (12%) compared with the DET group (20%). For each single gestational sac, the difference was even more pronounced, with a 31% clinical miscarriage rate for DET.* Five women in the eSET group required dilation and curettage for clinical miscarriage, none due to aneuploidy, as did eight in the DET group, two with documented aneuploidy. Two nonviable second-trimester twins were delivered in the DET group.

The rate of preterm deliveries in the eSET group (8.9%) was similar to the U.S. average for the general population of pregnancies in women who did not receive IVF services (8%), both of which were significantly lower than the 28% preterm birth rate in the DET group.

Admissions to the neonatal intensive care unit affected 11% in the eSET group and 26% after DET, but the difference did not reach statistical significance. Stays in the neonatal ICU were shorter after eSET than after DET, with the exception of one infant who underwent elective premature delivery because of acute maternal health problems.

"The most compelling data" from the study showed significantly better obstetrical outcomes from comprehensive chromosomal screening and eSET, Dr. Scott said. Mean birth weights were 3,408 g in the eSET group and 2,745 g in the DET group. Rates of low birth weight (less than 2,500 g) were 4% after eSET and 32% after DET. No infants in the eSET group had a very low birth weight (less than 1,500 g), compared with 7% of the DET group, although this difference did not reach statistical significance.

"These are dramatic, dramatic differences" just from reducing double-embryo transfers to single embryos with comprehensive chromosomal screening, Dr. Scott said. "This is not putting three and four [embryos] back; this is not Octomom. We’re talking about two-embryo transfers in the other group."

The study has been submitted to the journal Fertility and Sterility for publication, said Dr. Scott, who is the clinical and scientific director of Reproductive Medicine Associates of New Jersey, Morristown, the clinical center that serves the medical school’s division of reproductive endocrinology.

The findings should be applicable to the general IVF population, not just selected patients, he added. A separate analysis of 210 single-euploid blastocyst transfers and 1,435 untested double-blastocyst transfers at his institution found similar ongoing pregnancy rates (68% each) but a nearly threefold higher risk for preterm delivery after DET (30%) compared with eSET (11%), which was statistically significant.

Dr. Scott and his associates also analyzed actual cost data for comprehensive chromosomal screening and eSET, which averaged less than $40,000 per live-born delivery, compared with more than $70,000 per delivery with conventional IVF treatment, both national and regional averages showed. The costs included sometimes multiple cycles of IVF, the costs of comprehensive chromosomal screening and medications, and the costs for delivery and subsequent hospital stays through 28 days of life, he said.

The savings come from fewer IVF cycles with comprehensive chromosomal screening and eSET, better outcomes, and reduced obstetric and pediatric costs that, combined, "could more than pay for all of their infertility care," Dr. Scott said.

"This is not only cost effective, this is massively cost effective, perhaps the most cost-effective thing we’ve ever done in our field," he said.

Dr. Scott has been an adviser to EMD Serono and Ferring Pharmaceuticals.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

*Correction, 9/11/2013: An earlier version of this story attributed the 31% clinical miscarriage rate per single gestational sac to the wrong treatment group.

SANTA BARBARA, CALIF. – Comprehensive chromosomal screening followed by single-embryo transfer resulted in similar delivery rates but significantly fewer multiple gestations, and better maternal and fetal outcomes, compared with conventional transfer of two embryos without screening, a prospective randomized trial of 175 patients found.

As a result, overall costs per delivery are so much lower after comprehensive chromosomal screening and single-embryo transfer (eSET) that these techniques may prove to be the most cost-effective development ever in the field of IVF, Dr. Richard T. Scott Jr. said at the UCLA annual in vitro fertilization and embryo transfer update 2013.

An intent-to-treat analysis by Dr. Scott and his associates found that 61% of 89 patients in the study who received single-euploid blastocysts gave birth, compared with 65% of 86 patients who received two embryos without screening,

All single-euploid blastocysts produced singletons. "We were fortunate enough to have no monozygotic twins, at least not yet," he said. In the double-embryo transfer group (DET), 48% developed multiple gestations, including one set of triplets due to monozygotic twins from one of the embryos.

In general, approximately 99% of long-term sequelae from in vitro fertilization (IVF) relates to multiple gestations, he noted. Comprehensive chromosomal screening plus eSET may be a way to maintain high delivery rates without multiple gestations, said Dr. Scott, professor of obstetrics, gynecology and reproductive services and director of the division reproductive endocrinology at Robert Wood Johnson Medical School, New Brunswick, N.J.

Clinical miscarriages were greatly reduced in the eSET group (12%) compared with the DET group (20%). For each single gestational sac, the difference was even more pronounced, with a 31% clinical miscarriage rate for DET.* Five women in the eSET group required dilation and curettage for clinical miscarriage, none due to aneuploidy, as did eight in the DET group, two with documented aneuploidy. Two nonviable second-trimester twins were delivered in the DET group.

The rate of preterm deliveries in the eSET group (8.9%) was similar to the U.S. average for the general population of pregnancies in women who did not receive IVF services (8%), both of which were significantly lower than the 28% preterm birth rate in the DET group.

Admissions to the neonatal intensive care unit affected 11% in the eSET group and 26% after DET, but the difference did not reach statistical significance. Stays in the neonatal ICU were shorter after eSET than after DET, with the exception of one infant who underwent elective premature delivery because of acute maternal health problems.

"The most compelling data" from the study showed significantly better obstetrical outcomes from comprehensive chromosomal screening and eSET, Dr. Scott said. Mean birth weights were 3,408 g in the eSET group and 2,745 g in the DET group. Rates of low birth weight (less than 2,500 g) were 4% after eSET and 32% after DET. No infants in the eSET group had a very low birth weight (less than 1,500 g), compared with 7% of the DET group, although this difference did not reach statistical significance.

"These are dramatic, dramatic differences" just from reducing double-embryo transfers to single embryos with comprehensive chromosomal screening, Dr. Scott said. "This is not putting three and four [embryos] back; this is not Octomom. We’re talking about two-embryo transfers in the other group."

The study has been submitted to the journal Fertility and Sterility for publication, said Dr. Scott, who is the clinical and scientific director of Reproductive Medicine Associates of New Jersey, Morristown, the clinical center that serves the medical school’s division of reproductive endocrinology.

The findings should be applicable to the general IVF population, not just selected patients, he added. A separate analysis of 210 single-euploid blastocyst transfers and 1,435 untested double-blastocyst transfers at his institution found similar ongoing pregnancy rates (68% each) but a nearly threefold higher risk for preterm delivery after DET (30%) compared with eSET (11%), which was statistically significant.

Dr. Scott and his associates also analyzed actual cost data for comprehensive chromosomal screening and eSET, which averaged less than $40,000 per live-born delivery, compared with more than $70,000 per delivery with conventional IVF treatment, both national and regional averages showed. The costs included sometimes multiple cycles of IVF, the costs of comprehensive chromosomal screening and medications, and the costs for delivery and subsequent hospital stays through 28 days of life, he said.

The savings come from fewer IVF cycles with comprehensive chromosomal screening and eSET, better outcomes, and reduced obstetric and pediatric costs that, combined, "could more than pay for all of their infertility care," Dr. Scott said.

"This is not only cost effective, this is massively cost effective, perhaps the most cost-effective thing we’ve ever done in our field," he said.

Dr. Scott has been an adviser to EMD Serono and Ferring Pharmaceuticals.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

*Correction, 9/11/2013: An earlier version of this story attributed the 31% clinical miscarriage rate per single gestational sac to the wrong treatment group.

SAN FRANCISCO – A 3-minute MRI allowed a radiologist to rule out breast cancer with 99% accuracy in a prospective study of 443 women at a slightly increased or intermediate lifetime risk of breast cancer.

Extending the expert’s reading time to no more than 30 seconds to also interpret the first postcontrast subtracted (FAST) images provided the same sensitivity and specificity as a full diagnostic MRI protocol that had patients on the MRI table for 21 minutes on average, Dr. Christiane K. Kuhl reported at a breast cancer symposium sponsored by the American Society of Clinical Oncology.

Courtesy Dr. Christiane K. Kuhl

Conventional breast MRI protocols are time consuming and more expensive, because they are designed for diagnosis, not screening, said Dr. Kuhl, director of the department of diagnostic and interventional radiology at Rheinisch-Westfälische Technische Hochschule Aachen (Germany) University. The study aimed to trade some of the high sensitivity of MRI in detecting breast cancer for faster image acquisition and interpretation, perhaps eventually leading to lower cost and greater accessibility to MRI.

For the study, experienced breast radiologists were asked to review the maximum intensity projection (MIP) of the FAST images to determine whether there was significant enhancement. They then examined the FAST images for possible further categorization of any enhancement seen on the MIP, and analyzed the MRI under the full diagnostic protocol.

The prospective proof-of-concept study included patients who had imaging done between January 2009 and June 2010 and who were followed for 2 years to validate negative diagnoses. These were asymptomatic women with an intermediate risk with less than a 25% estimated lifetime risk of breast cancer. All of the women had a normal or benign mammogram and, if they had dense breasts, a normal or benign ultrasound result.

Courtesy of Dr. Christiane K. Kuhl

Acquiring the MIP and FAST images took less than 3 minutes with the patient on the MRI table. Reading the maximum intensity projection averaged 3 seconds, and reading the MIP plus FAST image averaged 28 seconds.

MRI screening identified 11 cancers, for an additional yield of 18 cancers per 1,000 examinations beyond what could be detected by mammography. Reading the MIP alone had a negative predictive value of 99%; the maximum intensity projection plus FAST readings and the full MRI protocol had negative predictive values just under 100%, Dr. Kuhl reported. The sensitivity of the MIP was close to 95% compared with 100% for MIP plus FAST or the full protocol. The specificity and positive predictive value could not be calculated for the MIP because the MIP reading detected only the presence or absence of significant enhancement. Evaluating the MIP plus FAST or the full MRI protocol produced similar specificities (in the mid-90% range) and positive predictive values (in the low 20% range).

All 11 breast cancers were intermediate- or high-grade cancers; 4 were ductal carcinoma in situ (DCIS) and 7 were invasive cancers. The median tumor size was 8 mm, and the mean age of the women with cancer was 51 years.

Conventional breast cancer screening using mammography picks up cancers that may be prognostically irrelevant, which add to potential overdiagnosis of breast cancer, she noted. In 11 studies that compared screening with breast MRI and mammography, MRI detected two to four times as many cancers as did mammography or ultrasound. Finding more DCIS and invasive cancers via MRI doesn’t necessarily add to the problem of overdiagnosis, she said, because the issue is as much underdiagnosis of prognostically relevant disease as it is overdiagnosis of relevant disease.

Courtesy Dr. Christiane K. Kohl

The technology of mammography favors detection of slowly growing cancers because of its focus on architectural distortions, spiculations, and calcifications that reflect regressive changes, while MRI technology detects angiogenic and protease activity that is biased toward biologically active disease, she said.

Previous data from her institution show that the sensitivity of MRI for detecting DCIS increases from 80% with low-grade DCIS to 98% with high-grade DCIS, but the sensitivity of mammography decreases as DCIS grade increases, dropping from 61% with low-grade DCIS to 35% with high-grade DCIS without necrosis*.

The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American Society for Radiation Oncology.

Dr. Kuhl has been a consultant to Bayer. She reported no other relevant financial disclosures.

*This story was updated 10/16/2013.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – A 3-minute MRI allowed a radiologist to rule out breast cancer with 99% accuracy in a prospective study of 443 women at a slightly increased or intermediate lifetime risk of breast cancer.

Extending the expert’s reading time to no more than 30 seconds to also interpret the first postcontrast subtracted (FAST) images provided the same sensitivity and specificity as a full diagnostic MRI protocol that had patients on the MRI table for 21 minutes on average, Dr. Christiane K. Kuhl reported at a breast cancer symposium sponsored by the American Society of Clinical Oncology.

Courtesy Dr. Christiane K. Kuhl

Conventional breast MRI protocols are time consuming and more expensive, because they are designed for diagnosis, not screening, said Dr. Kuhl, director of the department of diagnostic and interventional radiology at Rheinisch-Westfälische Technische Hochschule Aachen (Germany) University. The study aimed to trade some of the high sensitivity of MRI in detecting breast cancer for faster image acquisition and interpretation, perhaps eventually leading to lower cost and greater accessibility to MRI.

For the study, experienced breast radiologists were asked to review the maximum intensity projection (MIP) of the FAST images to determine whether there was significant enhancement. They then examined the FAST images for possible further categorization of any enhancement seen on the MIP, and analyzed the MRI under the full diagnostic protocol.

The prospective proof-of-concept study included patients who had imaging done between January 2009 and June 2010 and who were followed for 2 years to validate negative diagnoses. These were asymptomatic women with an intermediate risk with less than a 25% estimated lifetime risk of breast cancer. All of the women had a normal or benign mammogram and, if they had dense breasts, a normal or benign ultrasound result.

Courtesy of Dr. Christiane K. Kuhl

Acquiring the MIP and FAST images took less than 3 minutes with the patient on the MRI table. Reading the maximum intensity projection averaged 3 seconds, and reading the MIP plus FAST image averaged 28 seconds.

MRI screening identified 11 cancers, for an additional yield of 18 cancers per 1,000 examinations beyond what could be detected by mammography. Reading the MIP alone had a negative predictive value of 99%; the maximum intensity projection plus FAST readings and the full MRI protocol had negative predictive values just under 100%, Dr. Kuhl reported. The sensitivity of the MIP was close to 95% compared with 100% for MIP plus FAST or the full protocol. The specificity and positive predictive value could not be calculated for the MIP because the MIP reading detected only the presence or absence of significant enhancement. Evaluating the MIP plus FAST or the full MRI protocol produced similar specificities (in the mid-90% range) and positive predictive values (in the low 20% range).

All 11 breast cancers were intermediate- or high-grade cancers; 4 were ductal carcinoma in situ (DCIS) and 7 were invasive cancers. The median tumor size was 8 mm, and the mean age of the women with cancer was 51 years.

Conventional breast cancer screening using mammography picks up cancers that may be prognostically irrelevant, which add to potential overdiagnosis of breast cancer, she noted. In 11 studies that compared screening with breast MRI and mammography, MRI detected two to four times as many cancers as did mammography or ultrasound. Finding more DCIS and invasive cancers via MRI doesn’t necessarily add to the problem of overdiagnosis, she said, because the issue is as much underdiagnosis of prognostically relevant disease as it is overdiagnosis of relevant disease.

Courtesy Dr. Christiane K. Kohl

The technology of mammography favors detection of slowly growing cancers because of its focus on architectural distortions, spiculations, and calcifications that reflect regressive changes, while MRI technology detects angiogenic and protease activity that is biased toward biologically active disease, she said.

Previous data from her institution show that the sensitivity of MRI for detecting DCIS increases from 80% with low-grade DCIS to 98% with high-grade DCIS, but the sensitivity of mammography decreases as DCIS grade increases, dropping from 61% with low-grade DCIS to 35% with high-grade DCIS without necrosis*.

The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American Society for Radiation Oncology.

Dr. Kuhl has been a consultant to Bayer. She reported no other relevant financial disclosures.

*This story was updated 10/16/2013.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – A 3-minute MRI allowed a radiologist to rule out breast cancer with 99% accuracy in a prospective study of 443 women at a slightly increased or intermediate lifetime risk of breast cancer.

Extending the expert’s reading time to no more than 30 seconds to also interpret the first postcontrast subtracted (FAST) images provided the same sensitivity and specificity as a full diagnostic MRI protocol that had patients on the MRI table for 21 minutes on average, Dr. Christiane K. Kuhl reported at a breast cancer symposium sponsored by the American Society of Clinical Oncology.

Courtesy Dr. Christiane K. Kuhl

Conventional breast MRI protocols are time consuming and more expensive, because they are designed for diagnosis, not screening, said Dr. Kuhl, director of the department of diagnostic and interventional radiology at Rheinisch-Westfälische Technische Hochschule Aachen (Germany) University. The study aimed to trade some of the high sensitivity of MRI in detecting breast cancer for faster image acquisition and interpretation, perhaps eventually leading to lower cost and greater accessibility to MRI.

For the study, experienced breast radiologists were asked to review the maximum intensity projection (MIP) of the FAST images to determine whether there was significant enhancement. They then examined the FAST images for possible further categorization of any enhancement seen on the MIP, and analyzed the MRI under the full diagnostic protocol.

The prospective proof-of-concept study included patients who had imaging done between January 2009 and June 2010 and who were followed for 2 years to validate negative diagnoses. These were asymptomatic women with an intermediate risk with less than a 25% estimated lifetime risk of breast cancer. All of the women had a normal or benign mammogram and, if they had dense breasts, a normal or benign ultrasound result.

Courtesy of Dr. Christiane K. Kuhl

Acquiring the MIP and FAST images took less than 3 minutes with the patient on the MRI table. Reading the maximum intensity projection averaged 3 seconds, and reading the MIP plus FAST image averaged 28 seconds.

MRI screening identified 11 cancers, for an additional yield of 18 cancers per 1,000 examinations beyond what could be detected by mammography. Reading the MIP alone had a negative predictive value of 99%; the maximum intensity projection plus FAST readings and the full MRI protocol had negative predictive values just under 100%, Dr. Kuhl reported. The sensitivity of the MIP was close to 95% compared with 100% for MIP plus FAST or the full protocol. The specificity and positive predictive value could not be calculated for the MIP because the MIP reading detected only the presence or absence of significant enhancement. Evaluating the MIP plus FAST or the full MRI protocol produced similar specificities (in the mid-90% range) and positive predictive values (in the low 20% range).

All 11 breast cancers were intermediate- or high-grade cancers; 4 were ductal carcinoma in situ (DCIS) and 7 were invasive cancers. The median tumor size was 8 mm, and the mean age of the women with cancer was 51 years.

Conventional breast cancer screening using mammography picks up cancers that may be prognostically irrelevant, which add to potential overdiagnosis of breast cancer, she noted. In 11 studies that compared screening with breast MRI and mammography, MRI detected two to four times as many cancers as did mammography or ultrasound. Finding more DCIS and invasive cancers via MRI doesn’t necessarily add to the problem of overdiagnosis, she said, because the issue is as much underdiagnosis of prognostically relevant disease as it is overdiagnosis of relevant disease.

Courtesy Dr. Christiane K. Kohl

The technology of mammography favors detection of slowly growing cancers because of its focus on architectural distortions, spiculations, and calcifications that reflect regressive changes, while MRI technology detects angiogenic and protease activity that is biased toward biologically active disease, she said.

Previous data from her institution show that the sensitivity of MRI for detecting DCIS increases from 80% with low-grade DCIS to 98% with high-grade DCIS, but the sensitivity of mammography decreases as DCIS grade increases, dropping from 61% with low-grade DCIS to 35% with high-grade DCIS without necrosis*.

The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American Society for Radiation Oncology.

Dr. Kuhl has been a consultant to Bayer. She reported no other relevant financial disclosures.

*This story was updated 10/16/2013.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Five practice tips can help physicians consider systemic therapy for the subset of children with psoriasis who develop severe disease at some point, Dr. Kelly M. Cordoro said.

The key is to weigh the risks and benefits to decide which is worse, the treatment or the disease, in terms of how it affects the patient medically, psychosocially, and physically, she said at the annual meeting of the Pacific Dermatologic Association.

Approximately a quarter of the physicians in the audience had treated patients younger than 18 years with systemic therapy for psoriasis, an informal poll showed.*"

The exact approach varies per patient, and not all cases of severe pediatric psoriasis need systemic treatment. "It’s an art as much as it is a science," said Dr. Cordoro of the University of California, San Francisco.

It’s often a good idea to start with nonimmunosuppressive systemic agents for psoriasis in children, such as phototherapy or acitretin, before trying immunosuppressive treatments such as cyclosporine, methotrexate, or biologics, she suggested. Systemic therapy should be added to a multimodal care plan that includes identification and treatment of triggers and comorbidities, topical therapy, lifestyle modifications, education, and support. Keep in mind that no systemic medications are approved to treat psoriasis in children, and management is based on expert opinion, Dr. Cordoro noted.

Dr. Cordoro offered the following five pearls and principles to guide physicians managing severe pediatric psoriasis:

• Don’t just do something, stand there! Treat these children conservatively at first and observe the response, especially in patients with new-onset psoriasis and in particular if they have a family history of psoriasis, said Dr. Cordoro. It’s also a good approach in patients who’ve had a recent infection – group A streptococcal infection is a very common trigger of pediatric psoriasis, for example – or a recent viral illness or skin trauma.

"If you can find the trigger" and treat it, "you may be able to prevent the use of systemic therapy" for the psoriasis, she said. Conservative, yet aggressive, treatment might include a combination of topical therapy, wet wraps, itch control, and managing the triggers. Let the disease evolve for a few days to weeks before moving to systemic therapy, she suggested.

• Don’t just stand there, do something! The psychological impact of chronic disease can be as disabling as the physical impact, and uncontrolled inflammation can cause long-term health consequences, Dr. Cordoro said. No systemic therapies are approved for pediatric psoriasis because of a lack of studies, "but I encourage you to treat these kids" with severe disease who fail topical and other treatment strategies, she said.

Off-label use of methotrexate can help children with any form of psoriasis, in a dose range of 0.2-0.7 mg/kg per week, with a maximum of 25 mg/week, said Dr. Cordoro. Consider this a rescue phase, and then try to taper to the lowest effective dose or off of systemic therapy.

"Methotrexate doesn’t have to be forever," Dr. Cordoro emphasized. In children, methotrexate’s side effects commonly include GI symptoms and anorexia, and the drug very rarely causes pulmonary and hepatotoxicity. Dr. Cordoro recommended a supplemental folate dose of 1-5 mg every day, except methotrexate dose days, to ameliorate some of the GI side effects and the potential bone marrow toxicity. Monitoring is less intense than in adults, and involves frequent lab evaluations but no liver biopsies. Drug interactions with NSAIDs or trimethoprim/sulfamethoxazole can cause bone marrow toxicity, so be sure to send a letter to the child’s pediatrician and parents to alert them, she said.

For severe, diffuse plaque psoriasis in children, any of the conventional systemic or biologic treatments can be effective, and the choice depends on patient and clinical factors, Dr. Cordoro said. The goal is to gain control, taper the systemic treatment, and hold it at the lowest effective dose or transition to topical therapy or phototherapy.

• Don’t forget oral retinoids. Often a forgotten choice for therapy, short-term oral retinoids can be the best first systemic treatment for severe guttate psoriasis if phototherapy is not indicated or unavailable, or for palmoplantar psoriasis or pustular psoriasis, Dr. Cordoro said. In some cases, there can be synergistic effects from combining a low-dose retinoid with low-dose narrow-band UVB phototherapy.

Acitretin is not immunosuppressive but is teratogenic, so it should be avoided in girls older than 8 years, Dr. Cordoro noted. Reversible, dose-dependent side effects include mucocutaneous effects, dyslipidemia, or transaminitis. "Kids cannot tolerate high doses of retinoids, so 1 mg/kg per day or less is where you need to be," she said. Much-feared potential skeletal effects are very rare at doses that low when the medication is used for no more than a year or two, she added.

• When you need speed, try cyclosporine. Cyclosporine acts rapidly. An initial high dose of 5 mg/kg per day can take control of refractory plaque psoriasis, rapidly moving pustular psoriasis, or severe, rapidly progressive psoriasis. No more than a year of continuous use is the guideline, so you don’t want to start low and go slow. "Kids and typically tolerate and need higher doses" compared with adults, Dr. Cordoro said. Use the modified form (Neoral) for better oral bioavailability and better sustained drug levels, she suggested.

This, too, is a rescue treatment intended to control and stabilize the disease, followed by tapering and transitioning to other therapies. The most serious potential side effects include nephrotoxicity, hypertension, and immunosuppression. The most common side effects include nausea, vomiting and diarrhea, anorexia, and headache. Less often, cyclosporine can cause myalgia, arthralgia, paresthesia, gingival hyperplasia, or hypertrichosis. "My colleagues in oncology assure me that at the doses we’re using for psoriasis, we’re not at risk for giving these kids carcinomas down the road," she said.

• Biologics play an important role. Biologics are potent, but wouldn’t be the first choice for systemic therapy because they don’t have prolonged efficacy, said Dr. Cordoro. Their precise place in the therapeutic armamentarium is yet to be defined. "I like to reserve a biologic for when I don’t necessarily have a better choice, because I know I have a finite period of time for biologics," she said.

Nonetheless, anti–tumor necrosis factor agents can play a role in treating refractory plaque psoriasis, severe or refractory generalized pustular psoriasis, or psoriatic arthritis, Dr. Cordoro said. Anecdotal reports suggest that IL-12 and IL-23 inhibitors may help with pediatric psoriasis, but there are no study data yet.

The potential advantages of using biologics include less frequent dosing, less laboratory monitoring, and targeted treatment. On the other hand, biologics are expensive, require injection or infusion, have as-yet-unknown long-term risks, and are not approved for treating pediatric psoriasis (so insurance coverage is a battle), said Dr. Cordoro. Questions remain about standardized dosing and monitoring protocols, and about the endpoints of biologic therapy in this setting, although experience with biologics and evidence of their efficacy and safety in children are accumulating, she said.

Dr. Cordoro recommended two articles that she coauthored that provide expert consensus guidelines, tables, and charts for systemic treatment and monitoring of children with psoriasis (Dermatol. Clin. 2013;31:267-88 and Skin Therapy Lett. 2013;18:1-4).

Dr. Cordoro reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

*CORRECTION, 11/4/2013: An earlier version of this article imprecisely stated the results of the informal study.

SAN FRANCISCO – Five practice tips can help physicians consider systemic therapy for the subset of children with psoriasis who develop severe disease at some point, Dr. Kelly M. Cordoro said.

The key is to weigh the risks and benefits to decide which is worse, the treatment or the disease, in terms of how it affects the patient medically, psychosocially, and physically, she said at the annual meeting of the Pacific Dermatologic Association.

Approximately a quarter of the physicians in the audience had treated patients younger than 18 years with systemic therapy for psoriasis, an informal poll showed.*"

The exact approach varies per patient, and not all cases of severe pediatric psoriasis need systemic treatment. "It’s an art as much as it is a science," said Dr. Cordoro of the University of California, San Francisco.

It’s often a good idea to start with nonimmunosuppressive systemic agents for psoriasis in children, such as phototherapy or acitretin, before trying immunosuppressive treatments such as cyclosporine, methotrexate, or biologics, she suggested. Systemic therapy should be added to a multimodal care plan that includes identification and treatment of triggers and comorbidities, topical therapy, lifestyle modifications, education, and support. Keep in mind that no systemic medications are approved to treat psoriasis in children, and management is based on expert opinion, Dr. Cordoro noted.

Dr. Cordoro offered the following five pearls and principles to guide physicians managing severe pediatric psoriasis:

• Don’t just do something, stand there! Treat these children conservatively at first and observe the response, especially in patients with new-onset psoriasis and in particular if they have a family history of psoriasis, said Dr. Cordoro. It’s also a good approach in patients who’ve had a recent infection – group A streptococcal infection is a very common trigger of pediatric psoriasis, for example – or a recent viral illness or skin trauma.

"If you can find the trigger" and treat it, "you may be able to prevent the use of systemic therapy" for the psoriasis, she said. Conservative, yet aggressive, treatment might include a combination of topical therapy, wet wraps, itch control, and managing the triggers. Let the disease evolve for a few days to weeks before moving to systemic therapy, she suggested.

• Don’t just stand there, do something! The psychological impact of chronic disease can be as disabling as the physical impact, and uncontrolled inflammation can cause long-term health consequences, Dr. Cordoro said. No systemic therapies are approved for pediatric psoriasis because of a lack of studies, "but I encourage you to treat these kids" with severe disease who fail topical and other treatment strategies, she said.

Off-label use of methotrexate can help children with any form of psoriasis, in a dose range of 0.2-0.7 mg/kg per week, with a maximum of 25 mg/week, said Dr. Cordoro. Consider this a rescue phase, and then try to taper to the lowest effective dose or off of systemic therapy.

"Methotrexate doesn’t have to be forever," Dr. Cordoro emphasized. In children, methotrexate’s side effects commonly include GI symptoms and anorexia, and the drug very rarely causes pulmonary and hepatotoxicity. Dr. Cordoro recommended a supplemental folate dose of 1-5 mg every day, except methotrexate dose days, to ameliorate some of the GI side effects and the potential bone marrow toxicity. Monitoring is less intense than in adults, and involves frequent lab evaluations but no liver biopsies. Drug interactions with NSAIDs or trimethoprim/sulfamethoxazole can cause bone marrow toxicity, so be sure to send a letter to the child’s pediatrician and parents to alert them, she said.

For severe, diffuse plaque psoriasis in children, any of the conventional systemic or biologic treatments can be effective, and the choice depends on patient and clinical factors, Dr. Cordoro said. The goal is to gain control, taper the systemic treatment, and hold it at the lowest effective dose or transition to topical therapy or phototherapy.

• Don’t forget oral retinoids. Often a forgotten choice for therapy, short-term oral retinoids can be the best first systemic treatment for severe guttate psoriasis if phototherapy is not indicated or unavailable, or for palmoplantar psoriasis or pustular psoriasis, Dr. Cordoro said. In some cases, there can be synergistic effects from combining a low-dose retinoid with low-dose narrow-band UVB phototherapy.

Acitretin is not immunosuppressive but is teratogenic, so it should be avoided in girls older than 8 years, Dr. Cordoro noted. Reversible, dose-dependent side effects include mucocutaneous effects, dyslipidemia, or transaminitis. "Kids cannot tolerate high doses of retinoids, so 1 mg/kg per day or less is where you need to be," she said. Much-feared potential skeletal effects are very rare at doses that low when the medication is used for no more than a year or two, she added.

• When you need speed, try cyclosporine. Cyclosporine acts rapidly. An initial high dose of 5 mg/kg per day can take control of refractory plaque psoriasis, rapidly moving pustular psoriasis, or severe, rapidly progressive psoriasis. No more than a year of continuous use is the guideline, so you don’t want to start low and go slow. "Kids and typically tolerate and need higher doses" compared with adults, Dr. Cordoro said. Use the modified form (Neoral) for better oral bioavailability and better sustained drug levels, she suggested.

This, too, is a rescue treatment intended to control and stabilize the disease, followed by tapering and transitioning to other therapies. The most serious potential side effects include nephrotoxicity, hypertension, and immunosuppression. The most common side effects include nausea, vomiting and diarrhea, anorexia, and headache. Less often, cyclosporine can cause myalgia, arthralgia, paresthesia, gingival hyperplasia, or hypertrichosis. "My colleagues in oncology assure me that at the doses we’re using for psoriasis, we’re not at risk for giving these kids carcinomas down the road," she said.

• Biologics play an important role. Biologics are potent, but wouldn’t be the first choice for systemic therapy because they don’t have prolonged efficacy, said Dr. Cordoro. Their precise place in the therapeutic armamentarium is yet to be defined. "I like to reserve a biologic for when I don’t necessarily have a better choice, because I know I have a finite period of time for biologics," she said.

Nonetheless, anti–tumor necrosis factor agents can play a role in treating refractory plaque psoriasis, severe or refractory generalized pustular psoriasis, or psoriatic arthritis, Dr. Cordoro said. Anecdotal reports suggest that IL-12 and IL-23 inhibitors may help with pediatric psoriasis, but there are no study data yet.

The potential advantages of using biologics include less frequent dosing, less laboratory monitoring, and targeted treatment. On the other hand, biologics are expensive, require injection or infusion, have as-yet-unknown long-term risks, and are not approved for treating pediatric psoriasis (so insurance coverage is a battle), said Dr. Cordoro. Questions remain about standardized dosing and monitoring protocols, and about the endpoints of biologic therapy in this setting, although experience with biologics and evidence of their efficacy and safety in children are accumulating, she said.

Dr. Cordoro recommended two articles that she coauthored that provide expert consensus guidelines, tables, and charts for systemic treatment and monitoring of children with psoriasis (Dermatol. Clin. 2013;31:267-88 and Skin Therapy Lett. 2013;18:1-4).

Dr. Cordoro reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

*CORRECTION, 11/4/2013: An earlier version of this article imprecisely stated the results of the informal study.

SAN FRANCISCO – Five practice tips can help physicians consider systemic therapy for the subset of children with psoriasis who develop severe disease at some point, Dr. Kelly M. Cordoro said.

The key is to weigh the risks and benefits to decide which is worse, the treatment or the disease, in terms of how it affects the patient medically, psychosocially, and physically, she said at the annual meeting of the Pacific Dermatologic Association.

Approximately a quarter of the physicians in the audience had treated patients younger than 18 years with systemic therapy for psoriasis, an informal poll showed.*"

The exact approach varies per patient, and not all cases of severe pediatric psoriasis need systemic treatment. "It’s an art as much as it is a science," said Dr. Cordoro of the University of California, San Francisco.

It’s often a good idea to start with nonimmunosuppressive systemic agents for psoriasis in children, such as phototherapy or acitretin, before trying immunosuppressive treatments such as cyclosporine, methotrexate, or biologics, she suggested. Systemic therapy should be added to a multimodal care plan that includes identification and treatment of triggers and comorbidities, topical therapy, lifestyle modifications, education, and support. Keep in mind that no systemic medications are approved to treat psoriasis in children, and management is based on expert opinion, Dr. Cordoro noted.

Dr. Cordoro offered the following five pearls and principles to guide physicians managing severe pediatric psoriasis:

• Don’t just do something, stand there! Treat these children conservatively at first and observe the response, especially in patients with new-onset psoriasis and in particular if they have a family history of psoriasis, said Dr. Cordoro. It’s also a good approach in patients who’ve had a recent infection – group A streptococcal infection is a very common trigger of pediatric psoriasis, for example – or a recent viral illness or skin trauma.

"If you can find the trigger" and treat it, "you may be able to prevent the use of systemic therapy" for the psoriasis, she said. Conservative, yet aggressive, treatment might include a combination of topical therapy, wet wraps, itch control, and managing the triggers. Let the disease evolve for a few days to weeks before moving to systemic therapy, she suggested.

• Don’t just stand there, do something! The psychological impact of chronic disease can be as disabling as the physical impact, and uncontrolled inflammation can cause long-term health consequences, Dr. Cordoro said. No systemic therapies are approved for pediatric psoriasis because of a lack of studies, "but I encourage you to treat these kids" with severe disease who fail topical and other treatment strategies, she said.

Off-label use of methotrexate can help children with any form of psoriasis, in a dose range of 0.2-0.7 mg/kg per week, with a maximum of 25 mg/week, said Dr. Cordoro. Consider this a rescue phase, and then try to taper to the lowest effective dose or off of systemic therapy.

"Methotrexate doesn’t have to be forever," Dr. Cordoro emphasized. In children, methotrexate’s side effects commonly include GI symptoms and anorexia, and the drug very rarely causes pulmonary and hepatotoxicity. Dr. Cordoro recommended a supplemental folate dose of 1-5 mg every day, except methotrexate dose days, to ameliorate some of the GI side effects and the potential bone marrow toxicity. Monitoring is less intense than in adults, and involves frequent lab evaluations but no liver biopsies. Drug interactions with NSAIDs or trimethoprim/sulfamethoxazole can cause bone marrow toxicity, so be sure to send a letter to the child’s pediatrician and parents to alert them, she said.

For severe, diffuse plaque psoriasis in children, any of the conventional systemic or biologic treatments can be effective, and the choice depends on patient and clinical factors, Dr. Cordoro said. The goal is to gain control, taper the systemic treatment, and hold it at the lowest effective dose or transition to topical therapy or phototherapy.

• Don’t forget oral retinoids. Often a forgotten choice for therapy, short-term oral retinoids can be the best first systemic treatment for severe guttate psoriasis if phototherapy is not indicated or unavailable, or for palmoplantar psoriasis or pustular psoriasis, Dr. Cordoro said. In some cases, there can be synergistic effects from combining a low-dose retinoid with low-dose narrow-band UVB phototherapy.

Acitretin is not immunosuppressive but is teratogenic, so it should be avoided in girls older than 8 years, Dr. Cordoro noted. Reversible, dose-dependent side effects include mucocutaneous effects, dyslipidemia, or transaminitis. "Kids cannot tolerate high doses of retinoids, so 1 mg/kg per day or less is where you need to be," she said. Much-feared potential skeletal effects are very rare at doses that low when the medication is used for no more than a year or two, she added.

• When you need speed, try cyclosporine. Cyclosporine acts rapidly. An initial high dose of 5 mg/kg per day can take control of refractory plaque psoriasis, rapidly moving pustular psoriasis, or severe, rapidly progressive psoriasis. No more than a year of continuous use is the guideline, so you don’t want to start low and go slow. "Kids and typically tolerate and need higher doses" compared with adults, Dr. Cordoro said. Use the modified form (Neoral) for better oral bioavailability and better sustained drug levels, she suggested.

This, too, is a rescue treatment intended to control and stabilize the disease, followed by tapering and transitioning to other therapies. The most serious potential side effects include nephrotoxicity, hypertension, and immunosuppression. The most common side effects include nausea, vomiting and diarrhea, anorexia, and headache. Less often, cyclosporine can cause myalgia, arthralgia, paresthesia, gingival hyperplasia, or hypertrichosis. "My colleagues in oncology assure me that at the doses we’re using for psoriasis, we’re not at risk for giving these kids carcinomas down the road," she said.

• Biologics play an important role. Biologics are potent, but wouldn’t be the first choice for systemic therapy because they don’t have prolonged efficacy, said Dr. Cordoro. Their precise place in the therapeutic armamentarium is yet to be defined. "I like to reserve a biologic for when I don’t necessarily have a better choice, because I know I have a finite period of time for biologics," she said.

Nonetheless, anti–tumor necrosis factor agents can play a role in treating refractory plaque psoriasis, severe or refractory generalized pustular psoriasis, or psoriatic arthritis, Dr. Cordoro said. Anecdotal reports suggest that IL-12 and IL-23 inhibitors may help with pediatric psoriasis, but there are no study data yet.

The potential advantages of using biologics include less frequent dosing, less laboratory monitoring, and targeted treatment. On the other hand, biologics are expensive, require injection or infusion, have as-yet-unknown long-term risks, and are not approved for treating pediatric psoriasis (so insurance coverage is a battle), said Dr. Cordoro. Questions remain about standardized dosing and monitoring protocols, and about the endpoints of biologic therapy in this setting, although experience with biologics and evidence of their efficacy and safety in children are accumulating, she said.

Dr. Cordoro recommended two articles that she coauthored that provide expert consensus guidelines, tables, and charts for systemic treatment and monitoring of children with psoriasis (Dermatol. Clin. 2013;31:267-88 and Skin Therapy Lett. 2013;18:1-4).

Dr. Cordoro reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

*CORRECTION, 11/4/2013: An earlier version of this article imprecisely stated the results of the informal study.