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WCD: Smoking tied to worse occupational hand eczema
VANCOUVER, B.C. – Occupational hand eczema is worse and more persistent in smokers than nonsmokers, a large prospective cohort study found.
“Tobacco smoking is associated with work absenteeism and with not staying in the workforce due to occupational hand eczema. Smoking confers a worse prognosis and interferes with the outcome of prevention programs,” Dr. Richard Brans said at the World Congress of Dermatology.
Hand eczema is the most common occupational skin disease. Smoking might worsen signs and symptoms by inducing proinflammatory effects in the skin, said Dr. Brans, a dermatologist at the University of Osnabrück, Germany.
To better assess the link between smoking and hand eczema, he and his associates carried out a prospective 3-year study of 1,095 patients from throughout Germany. The patients initially had attended a 6-week residential treatment program for hand eczema that was followed by a 3-week outpatient program. Smokers comprised about half of the patients and resembled nonsmokers in terms of gender, general atopy, and degree of professional or occupational exposures, such as wetting or soiling the hands at work, Dr. Brans said. However, smokers were significantly younger than nonsmokers and were more likely to have allergic contact dermatitis, he noted.
The inpatient phase of the program markedly benefited both smokers and nonsmokers, but notably, smokers had significantly worse symptoms and signs of hand eczema at all time points assessed, Dr. Brans said. Furthermore, smokers missed an average of 37 days of work because of occupational hand eczema in the year before the program, compared with only 25 days for nonsmokers (P = .001), and smokers continued to miss more days of work because of hand eczema in the year after completing the program (P = .023), he reported. Significantly more smokers also left their professions because of their hand eczema, even after completing the prevention program (P = .021), he added.
The study found no link between number of cigarettes smoked per day and severity of hand eczema, Dr. Brans said. Smoking history was self-reported, and the study design excluded patients who changed their smoking behavior during follow-up, he noted. In addition, the researchers did not assess whether other factors associated with smoking might have confounded the association between smoking and severity of hand eczema, he said.
Dr. Brans reported no relevant disclosures.
VANCOUVER, B.C. – Occupational hand eczema is worse and more persistent in smokers than nonsmokers, a large prospective cohort study found.
“Tobacco smoking is associated with work absenteeism and with not staying in the workforce due to occupational hand eczema. Smoking confers a worse prognosis and interferes with the outcome of prevention programs,” Dr. Richard Brans said at the World Congress of Dermatology.
Hand eczema is the most common occupational skin disease. Smoking might worsen signs and symptoms by inducing proinflammatory effects in the skin, said Dr. Brans, a dermatologist at the University of Osnabrück, Germany.
To better assess the link between smoking and hand eczema, he and his associates carried out a prospective 3-year study of 1,095 patients from throughout Germany. The patients initially had attended a 6-week residential treatment program for hand eczema that was followed by a 3-week outpatient program. Smokers comprised about half of the patients and resembled nonsmokers in terms of gender, general atopy, and degree of professional or occupational exposures, such as wetting or soiling the hands at work, Dr. Brans said. However, smokers were significantly younger than nonsmokers and were more likely to have allergic contact dermatitis, he noted.
The inpatient phase of the program markedly benefited both smokers and nonsmokers, but notably, smokers had significantly worse symptoms and signs of hand eczema at all time points assessed, Dr. Brans said. Furthermore, smokers missed an average of 37 days of work because of occupational hand eczema in the year before the program, compared with only 25 days for nonsmokers (P = .001), and smokers continued to miss more days of work because of hand eczema in the year after completing the program (P = .023), he reported. Significantly more smokers also left their professions because of their hand eczema, even after completing the prevention program (P = .021), he added.
The study found no link between number of cigarettes smoked per day and severity of hand eczema, Dr. Brans said. Smoking history was self-reported, and the study design excluded patients who changed their smoking behavior during follow-up, he noted. In addition, the researchers did not assess whether other factors associated with smoking might have confounded the association between smoking and severity of hand eczema, he said.
Dr. Brans reported no relevant disclosures.
VANCOUVER, B.C. – Occupational hand eczema is worse and more persistent in smokers than nonsmokers, a large prospective cohort study found.
“Tobacco smoking is associated with work absenteeism and with not staying in the workforce due to occupational hand eczema. Smoking confers a worse prognosis and interferes with the outcome of prevention programs,” Dr. Richard Brans said at the World Congress of Dermatology.
Hand eczema is the most common occupational skin disease. Smoking might worsen signs and symptoms by inducing proinflammatory effects in the skin, said Dr. Brans, a dermatologist at the University of Osnabrück, Germany.
To better assess the link between smoking and hand eczema, he and his associates carried out a prospective 3-year study of 1,095 patients from throughout Germany. The patients initially had attended a 6-week residential treatment program for hand eczema that was followed by a 3-week outpatient program. Smokers comprised about half of the patients and resembled nonsmokers in terms of gender, general atopy, and degree of professional or occupational exposures, such as wetting or soiling the hands at work, Dr. Brans said. However, smokers were significantly younger than nonsmokers and were more likely to have allergic contact dermatitis, he noted.
The inpatient phase of the program markedly benefited both smokers and nonsmokers, but notably, smokers had significantly worse symptoms and signs of hand eczema at all time points assessed, Dr. Brans said. Furthermore, smokers missed an average of 37 days of work because of occupational hand eczema in the year before the program, compared with only 25 days for nonsmokers (P = .001), and smokers continued to miss more days of work because of hand eczema in the year after completing the program (P = .023), he reported. Significantly more smokers also left their professions because of their hand eczema, even after completing the prevention program (P = .021), he added.
The study found no link between number of cigarettes smoked per day and severity of hand eczema, Dr. Brans said. Smoking history was self-reported, and the study design excluded patients who changed their smoking behavior during follow-up, he noted. In addition, the researchers did not assess whether other factors associated with smoking might have confounded the association between smoking and severity of hand eczema, he said.
Dr. Brans reported no relevant disclosures.
AT WDC 2015
Key clinical point: Smoking might worsen the signs and symptoms of occupational hand eczema.
Major finding: Smokers had significantly worse symptoms and signs of hand eczema at all time points assessed.
Data source: Three-year prospective study of 1,095 smokers and nonsmokers with occupational hand eczema.
Disclosures: Dr. Brans reported no relevant conflicts of interest.
WCD: Restoring microbiome might ease atopic dermatitis
VANCOUVER, B.C. – Manipulating the skin microbiome might one day help control atopic dermatitis, Dr. Thomas Bieber said at the World Congress of Dermatology.
Scientists used to focus mainly on pathogens when considering how skin microbes affect atopic dermatitis (AD), said Dr. Bieber, professor of dermatology at the University of Bonn (Germany). But while Staphylococcus aureus is “the constant companion” of patients with AD, data from recent studies have shown that commensal microorganisms found on and within healthy skin undergo a “dialogue” with epithelial cells to help regulate antimicrobial peptides, which in turn inhibit pathogen growth, he said.
Flares in atopic dermatitis are marked by dramatic rises in S. aureus and corresponding decreases in commensal microbes, he noted. Whether an AD flare causes this microbial shift or results from it remains unclear, “but based on this knowledge, we are thinking about strategies to modulate and restore the microbiome. We have discovered a new kind of link to how the microbiome might affect atopic dermatitis,” Dr. Bieber explained.
In the future, such strategies might include formulating emollients to rebalance microbial diversity, he said, pointing to the landmark trial of fecal transplantation in patients with recurrent Clostridium difficile infections (N. Engl. J. Med. 2013;368:407-15). “That study was very impressive – the protocol was stopped due to the overwhelming benefits,” he said. “In terms of skin, could we imagine something similar?”
Restoring skin microbial diversity also might help prevent flares and worsening of AD, said Dr. Bieber. “We can control atopic dermatitis by controlling inflammation, dryness, improving the microbiota with appropriate emollients, and trying to hit early and efficiently,” he said. “We should not only think in terms of treatment, but in terms of prevention. Proactive management of atopic dermatitis does not restore or improve the diversity of the microbiome. It is probably not sufficient, and it’s just one part of the approach.”
Other future treatments for AD might target the dendritic cells that normally “bridge” the innate and adaptive immune systems, or the toll-like receptors of innate immune cells, which help regulate production of antimicrobial peptides by commensal microorganisms, Dr. Bieber said.
Recent research has shown that Th2 T cells inhibit antimicrobial peptide production in patients with atopic dermatitis, and that their dendritic cells have a “defective sensing mechanism toward staphylococcal-derived products,” he noted. “They are kind of neutralized or paralyzed, are not able to induce th17 immune response, and are not able to turn on antimicrobial production in the skin.” Restoring this sensing mechanism might one day help reestablish the normal, healthy diversity of the epidermal microbiome and prevent or alleviate AD, he said.
Dr. Bieber reported serving as a consultant, advisory board member, or speaker bureau member for L’Oreal, Galderma, Sanofi, Regeneron, Pfizer, and Novartis.
VANCOUVER, B.C. – Manipulating the skin microbiome might one day help control atopic dermatitis, Dr. Thomas Bieber said at the World Congress of Dermatology.
Scientists used to focus mainly on pathogens when considering how skin microbes affect atopic dermatitis (AD), said Dr. Bieber, professor of dermatology at the University of Bonn (Germany). But while Staphylococcus aureus is “the constant companion” of patients with AD, data from recent studies have shown that commensal microorganisms found on and within healthy skin undergo a “dialogue” with epithelial cells to help regulate antimicrobial peptides, which in turn inhibit pathogen growth, he said.
Flares in atopic dermatitis are marked by dramatic rises in S. aureus and corresponding decreases in commensal microbes, he noted. Whether an AD flare causes this microbial shift or results from it remains unclear, “but based on this knowledge, we are thinking about strategies to modulate and restore the microbiome. We have discovered a new kind of link to how the microbiome might affect atopic dermatitis,” Dr. Bieber explained.
In the future, such strategies might include formulating emollients to rebalance microbial diversity, he said, pointing to the landmark trial of fecal transplantation in patients with recurrent Clostridium difficile infections (N. Engl. J. Med. 2013;368:407-15). “That study was very impressive – the protocol was stopped due to the overwhelming benefits,” he said. “In terms of skin, could we imagine something similar?”
Restoring skin microbial diversity also might help prevent flares and worsening of AD, said Dr. Bieber. “We can control atopic dermatitis by controlling inflammation, dryness, improving the microbiota with appropriate emollients, and trying to hit early and efficiently,” he said. “We should not only think in terms of treatment, but in terms of prevention. Proactive management of atopic dermatitis does not restore or improve the diversity of the microbiome. It is probably not sufficient, and it’s just one part of the approach.”
Other future treatments for AD might target the dendritic cells that normally “bridge” the innate and adaptive immune systems, or the toll-like receptors of innate immune cells, which help regulate production of antimicrobial peptides by commensal microorganisms, Dr. Bieber said.
Recent research has shown that Th2 T cells inhibit antimicrobial peptide production in patients with atopic dermatitis, and that their dendritic cells have a “defective sensing mechanism toward staphylococcal-derived products,” he noted. “They are kind of neutralized or paralyzed, are not able to induce th17 immune response, and are not able to turn on antimicrobial production in the skin.” Restoring this sensing mechanism might one day help reestablish the normal, healthy diversity of the epidermal microbiome and prevent or alleviate AD, he said.
Dr. Bieber reported serving as a consultant, advisory board member, or speaker bureau member for L’Oreal, Galderma, Sanofi, Regeneron, Pfizer, and Novartis.
VANCOUVER, B.C. – Manipulating the skin microbiome might one day help control atopic dermatitis, Dr. Thomas Bieber said at the World Congress of Dermatology.
Scientists used to focus mainly on pathogens when considering how skin microbes affect atopic dermatitis (AD), said Dr. Bieber, professor of dermatology at the University of Bonn (Germany). But while Staphylococcus aureus is “the constant companion” of patients with AD, data from recent studies have shown that commensal microorganisms found on and within healthy skin undergo a “dialogue” with epithelial cells to help regulate antimicrobial peptides, which in turn inhibit pathogen growth, he said.
Flares in atopic dermatitis are marked by dramatic rises in S. aureus and corresponding decreases in commensal microbes, he noted. Whether an AD flare causes this microbial shift or results from it remains unclear, “but based on this knowledge, we are thinking about strategies to modulate and restore the microbiome. We have discovered a new kind of link to how the microbiome might affect atopic dermatitis,” Dr. Bieber explained.
In the future, such strategies might include formulating emollients to rebalance microbial diversity, he said, pointing to the landmark trial of fecal transplantation in patients with recurrent Clostridium difficile infections (N. Engl. J. Med. 2013;368:407-15). “That study was very impressive – the protocol was stopped due to the overwhelming benefits,” he said. “In terms of skin, could we imagine something similar?”
Restoring skin microbial diversity also might help prevent flares and worsening of AD, said Dr. Bieber. “We can control atopic dermatitis by controlling inflammation, dryness, improving the microbiota with appropriate emollients, and trying to hit early and efficiently,” he said. “We should not only think in terms of treatment, but in terms of prevention. Proactive management of atopic dermatitis does not restore or improve the diversity of the microbiome. It is probably not sufficient, and it’s just one part of the approach.”
Other future treatments for AD might target the dendritic cells that normally “bridge” the innate and adaptive immune systems, or the toll-like receptors of innate immune cells, which help regulate production of antimicrobial peptides by commensal microorganisms, Dr. Bieber said.
Recent research has shown that Th2 T cells inhibit antimicrobial peptide production in patients with atopic dermatitis, and that their dendritic cells have a “defective sensing mechanism toward staphylococcal-derived products,” he noted. “They are kind of neutralized or paralyzed, are not able to induce th17 immune response, and are not able to turn on antimicrobial production in the skin.” Restoring this sensing mechanism might one day help reestablish the normal, healthy diversity of the epidermal microbiome and prevent or alleviate AD, he said.
Dr. Bieber reported serving as a consultant, advisory board member, or speaker bureau member for L’Oreal, Galderma, Sanofi, Regeneron, Pfizer, and Novartis.
EXPERT ANALYSIS FROM WCD 2015
Regular, outcomes-based treatment effective in vulvar lichen sclerosus
VANCOUVER, B.C. – Women with vulvar lichen sclerosus (VLS) who consistently used topical corticosteroids that had been titrated to normalize skin color and texture had significantly better outcomes than patients who sometimes skipped treatment, a prospective single-center cohort study found.
Most notably, none of the treatment-compliant patients developed vulvar carcinoma during an average of almost 5 years of follow-up, compared with 4.7% of the partially compliant group (P < .001), reported Dr. Jason Lee, a dermatologist with the University of Sydney, Australia.
“We are proposing a paradigm shift to change the way we manage this condition,” Dr. Lee said at the World Congress of Dermatology. “Clinicians should aim for individual regular treatment of patients with vulvar lichen sclerosus. The treatment is safe, and the course of the disease can be altered by treatment.”
The report appeared simultaneously in JAMA Dermatology (2015 June 12 [doi:10.1001/jamadermatol.2015.0643]).
Vulvar lichen sclerosus is an uncommon disease that causes vulvar itching, pain, and sexual dysfunction, and can significantly alter the vulvar architecture. Before clinicians began treating VLS with superpotent topical corticosteroids, about 5% of cases were thought to progress to vulvar intraepithelial neoplasia or invasive squamous cell carcinoma.
Furthermore, even fairly mild cases can become cancerous, Dr. Lee noted. “Until now, it was thought that cancer was inevitable in some women with VLS,” he added. “Short-term control is easy, but long-term management lacks data, and research has not addressed whether treatment can prevent scarring or cancer.”
To assess the impact of individualized topical corticosteroid therapy with regular follow-up, Dr. Lee and his associates studied 507 women with biopsy-proven VLS during 2008-2014. Patients averaged 55 years of age at presentation and had an average symptom history of 5 years.
The investigators graded cases as mild, moderate, severe, or very severe depending on degree of hyperkeratosis, and titrated treatment with the goal of normalizing skin color and texture. They classified patients as treatment-compliant if they said they followed treatment directions most or all of the time, and as partially compliant if they said they followed directions some, little, or none of the time. They saw patients at least once a year for follow-up.
Most patients initially needed superpotent or ultrapotent topical corticosteroids to control their disease and then switched to moderate or mild strength formulations to maintain results, Dr. Lee and his associates reported.
About 30% of patients were only partially compliant with treatment. These patients were significantly less likely to achieve symptom resolution (58% vs. 93%) and resolution of dyspareunia (66% vs. 94%), and were more likely to develop adhesions and scars during follow-up (40% vs. 3%), compared with fully compliant patients (P < .001 for all), the researchers said. Rates of steroid dermatitis and reversible steroid-induced cutaneous atrophy were similar between the fully and partially compliant groups (2.2% vs. 4%, and 1.1% vs. 2%, respectively).
Based on the findings, clinicians would need to treat 21 cases of VLS to prevent 1 case of vulvar cancer and 2.7 cases to prevent scarring, said Dr. Lee.
“This is the first study adequately powered to demonstrate that cancer and scarring can be prevented by regular treatment according to clinical outcome, not symptoms,” he added.
But Dr. Lee acknowledged that selection bias could have affected the results. “We did find that patients who were not complying with treatment were more likely to have severe disease at the start of the study,” he said. “They probably were at increased risk of cancer to start with.”
The dermatology department of Royal North Shore Hospital partially funded the work. The investigators reported having no relevant conflicts of interest.
We congratulate the authors on an article that has profound implications for patients with vulvar lichen sclerosus and their physicians worldwide. Until now, suppression of the disease has concerned physicians and has often been inadequate. The reduction in cancer among patients with VLS who were treated with [topical corticosteroids] is no longer speculative. This focus of concern can effectively communicate the message that long-term use of a TCS likely prevents the progression of VLS and the development of squamous cell carcinoma.
In the study, cohort treatment was tailored to the severity of disease, using the presence or absence and degree of hyperkeratosis as the principal marker of severity. The most severe cases with extensive hyperkeratosis were treated twice daily with a superpotent TCS and less severe cases with a reduced-potency TCS for the initial treatment period.
This use is in contrast to the recommendations of guidelines. Starting with a superpotent corticosteroid has been advocated for all patients either as an initial 3-month once-daily regimen or a tapered regimen for 3 months. Signs at presentation vary considerably, with some women displaying severe widespread genital pallor, hyperkeratosis, fissures, and erosions, whereas others show subtle pallor; there are yet others who are asymptomatic. Hyperkeratosis alone may not be a sufficient marker of active disease, because ecchymoses and erosions may also be important. Tailoring treatment to the severity of the disease makes sense, because in other inflammatory diseases, such as atopic eczema, dermatologists routinely tailor the potency of the corticosteroid used to the severity of the disease.
This article is an important contribution to our knowledge, providing the first evidence in women of the association between malignant neoplasms and poor compliance with treatment. This information will allow us to better inform our patients and encourage those who find it difficult to comply for various reasons.
Dr. Susan M. Cooper is with the department of dermatology, Oxford University Hospitals Trust, Oxford, England. Dr. Nina Madnani is with the department of dermatology, P.D. Hinduja National Hospital and Medical Research Center, Mumbai. Dr. Lynnette Margesson is with the Geisel School of Medicine, Dartmouth College, Hanover, N.H. They disclosed no conflicts of interest. These comments were excerpted from their accompanying editorial (JAMA Dermatol. 2015 June 12 [doi:10.1001/jamadermatol.2015.0644]).
We congratulate the authors on an article that has profound implications for patients with vulvar lichen sclerosus and their physicians worldwide. Until now, suppression of the disease has concerned physicians and has often been inadequate. The reduction in cancer among patients with VLS who were treated with [topical corticosteroids] is no longer speculative. This focus of concern can effectively communicate the message that long-term use of a TCS likely prevents the progression of VLS and the development of squamous cell carcinoma.
In the study, cohort treatment was tailored to the severity of disease, using the presence or absence and degree of hyperkeratosis as the principal marker of severity. The most severe cases with extensive hyperkeratosis were treated twice daily with a superpotent TCS and less severe cases with a reduced-potency TCS for the initial treatment period.
This use is in contrast to the recommendations of guidelines. Starting with a superpotent corticosteroid has been advocated for all patients either as an initial 3-month once-daily regimen or a tapered regimen for 3 months. Signs at presentation vary considerably, with some women displaying severe widespread genital pallor, hyperkeratosis, fissures, and erosions, whereas others show subtle pallor; there are yet others who are asymptomatic. Hyperkeratosis alone may not be a sufficient marker of active disease, because ecchymoses and erosions may also be important. Tailoring treatment to the severity of the disease makes sense, because in other inflammatory diseases, such as atopic eczema, dermatologists routinely tailor the potency of the corticosteroid used to the severity of the disease.
This article is an important contribution to our knowledge, providing the first evidence in women of the association between malignant neoplasms and poor compliance with treatment. This information will allow us to better inform our patients and encourage those who find it difficult to comply for various reasons.
Dr. Susan M. Cooper is with the department of dermatology, Oxford University Hospitals Trust, Oxford, England. Dr. Nina Madnani is with the department of dermatology, P.D. Hinduja National Hospital and Medical Research Center, Mumbai. Dr. Lynnette Margesson is with the Geisel School of Medicine, Dartmouth College, Hanover, N.H. They disclosed no conflicts of interest. These comments were excerpted from their accompanying editorial (JAMA Dermatol. 2015 June 12 [doi:10.1001/jamadermatol.2015.0644]).
We congratulate the authors on an article that has profound implications for patients with vulvar lichen sclerosus and their physicians worldwide. Until now, suppression of the disease has concerned physicians and has often been inadequate. The reduction in cancer among patients with VLS who were treated with [topical corticosteroids] is no longer speculative. This focus of concern can effectively communicate the message that long-term use of a TCS likely prevents the progression of VLS and the development of squamous cell carcinoma.
In the study, cohort treatment was tailored to the severity of disease, using the presence or absence and degree of hyperkeratosis as the principal marker of severity. The most severe cases with extensive hyperkeratosis were treated twice daily with a superpotent TCS and less severe cases with a reduced-potency TCS for the initial treatment period.
This use is in contrast to the recommendations of guidelines. Starting with a superpotent corticosteroid has been advocated for all patients either as an initial 3-month once-daily regimen or a tapered regimen for 3 months. Signs at presentation vary considerably, with some women displaying severe widespread genital pallor, hyperkeratosis, fissures, and erosions, whereas others show subtle pallor; there are yet others who are asymptomatic. Hyperkeratosis alone may not be a sufficient marker of active disease, because ecchymoses and erosions may also be important. Tailoring treatment to the severity of the disease makes sense, because in other inflammatory diseases, such as atopic eczema, dermatologists routinely tailor the potency of the corticosteroid used to the severity of the disease.
This article is an important contribution to our knowledge, providing the first evidence in women of the association between malignant neoplasms and poor compliance with treatment. This information will allow us to better inform our patients and encourage those who find it difficult to comply for various reasons.
Dr. Susan M. Cooper is with the department of dermatology, Oxford University Hospitals Trust, Oxford, England. Dr. Nina Madnani is with the department of dermatology, P.D. Hinduja National Hospital and Medical Research Center, Mumbai. Dr. Lynnette Margesson is with the Geisel School of Medicine, Dartmouth College, Hanover, N.H. They disclosed no conflicts of interest. These comments were excerpted from their accompanying editorial (JAMA Dermatol. 2015 June 12 [doi:10.1001/jamadermatol.2015.0644]).
VANCOUVER, B.C. – Women with vulvar lichen sclerosus (VLS) who consistently used topical corticosteroids that had been titrated to normalize skin color and texture had significantly better outcomes than patients who sometimes skipped treatment, a prospective single-center cohort study found.
Most notably, none of the treatment-compliant patients developed vulvar carcinoma during an average of almost 5 years of follow-up, compared with 4.7% of the partially compliant group (P < .001), reported Dr. Jason Lee, a dermatologist with the University of Sydney, Australia.
“We are proposing a paradigm shift to change the way we manage this condition,” Dr. Lee said at the World Congress of Dermatology. “Clinicians should aim for individual regular treatment of patients with vulvar lichen sclerosus. The treatment is safe, and the course of the disease can be altered by treatment.”
The report appeared simultaneously in JAMA Dermatology (2015 June 12 [doi:10.1001/jamadermatol.2015.0643]).
Vulvar lichen sclerosus is an uncommon disease that causes vulvar itching, pain, and sexual dysfunction, and can significantly alter the vulvar architecture. Before clinicians began treating VLS with superpotent topical corticosteroids, about 5% of cases were thought to progress to vulvar intraepithelial neoplasia or invasive squamous cell carcinoma.
Furthermore, even fairly mild cases can become cancerous, Dr. Lee noted. “Until now, it was thought that cancer was inevitable in some women with VLS,” he added. “Short-term control is easy, but long-term management lacks data, and research has not addressed whether treatment can prevent scarring or cancer.”
To assess the impact of individualized topical corticosteroid therapy with regular follow-up, Dr. Lee and his associates studied 507 women with biopsy-proven VLS during 2008-2014. Patients averaged 55 years of age at presentation and had an average symptom history of 5 years.
The investigators graded cases as mild, moderate, severe, or very severe depending on degree of hyperkeratosis, and titrated treatment with the goal of normalizing skin color and texture. They classified patients as treatment-compliant if they said they followed treatment directions most or all of the time, and as partially compliant if they said they followed directions some, little, or none of the time. They saw patients at least once a year for follow-up.
Most patients initially needed superpotent or ultrapotent topical corticosteroids to control their disease and then switched to moderate or mild strength formulations to maintain results, Dr. Lee and his associates reported.
About 30% of patients were only partially compliant with treatment. These patients were significantly less likely to achieve symptom resolution (58% vs. 93%) and resolution of dyspareunia (66% vs. 94%), and were more likely to develop adhesions and scars during follow-up (40% vs. 3%), compared with fully compliant patients (P < .001 for all), the researchers said. Rates of steroid dermatitis and reversible steroid-induced cutaneous atrophy were similar between the fully and partially compliant groups (2.2% vs. 4%, and 1.1% vs. 2%, respectively).
Based on the findings, clinicians would need to treat 21 cases of VLS to prevent 1 case of vulvar cancer and 2.7 cases to prevent scarring, said Dr. Lee.
“This is the first study adequately powered to demonstrate that cancer and scarring can be prevented by regular treatment according to clinical outcome, not symptoms,” he added.
But Dr. Lee acknowledged that selection bias could have affected the results. “We did find that patients who were not complying with treatment were more likely to have severe disease at the start of the study,” he said. “They probably were at increased risk of cancer to start with.”
The dermatology department of Royal North Shore Hospital partially funded the work. The investigators reported having no relevant conflicts of interest.
VANCOUVER, B.C. – Women with vulvar lichen sclerosus (VLS) who consistently used topical corticosteroids that had been titrated to normalize skin color and texture had significantly better outcomes than patients who sometimes skipped treatment, a prospective single-center cohort study found.
Most notably, none of the treatment-compliant patients developed vulvar carcinoma during an average of almost 5 years of follow-up, compared with 4.7% of the partially compliant group (P < .001), reported Dr. Jason Lee, a dermatologist with the University of Sydney, Australia.
“We are proposing a paradigm shift to change the way we manage this condition,” Dr. Lee said at the World Congress of Dermatology. “Clinicians should aim for individual regular treatment of patients with vulvar lichen sclerosus. The treatment is safe, and the course of the disease can be altered by treatment.”
The report appeared simultaneously in JAMA Dermatology (2015 June 12 [doi:10.1001/jamadermatol.2015.0643]).
Vulvar lichen sclerosus is an uncommon disease that causes vulvar itching, pain, and sexual dysfunction, and can significantly alter the vulvar architecture. Before clinicians began treating VLS with superpotent topical corticosteroids, about 5% of cases were thought to progress to vulvar intraepithelial neoplasia or invasive squamous cell carcinoma.
Furthermore, even fairly mild cases can become cancerous, Dr. Lee noted. “Until now, it was thought that cancer was inevitable in some women with VLS,” he added. “Short-term control is easy, but long-term management lacks data, and research has not addressed whether treatment can prevent scarring or cancer.”
To assess the impact of individualized topical corticosteroid therapy with regular follow-up, Dr. Lee and his associates studied 507 women with biopsy-proven VLS during 2008-2014. Patients averaged 55 years of age at presentation and had an average symptom history of 5 years.
The investigators graded cases as mild, moderate, severe, or very severe depending on degree of hyperkeratosis, and titrated treatment with the goal of normalizing skin color and texture. They classified patients as treatment-compliant if they said they followed treatment directions most or all of the time, and as partially compliant if they said they followed directions some, little, or none of the time. They saw patients at least once a year for follow-up.
Most patients initially needed superpotent or ultrapotent topical corticosteroids to control their disease and then switched to moderate or mild strength formulations to maintain results, Dr. Lee and his associates reported.
About 30% of patients were only partially compliant with treatment. These patients were significantly less likely to achieve symptom resolution (58% vs. 93%) and resolution of dyspareunia (66% vs. 94%), and were more likely to develop adhesions and scars during follow-up (40% vs. 3%), compared with fully compliant patients (P < .001 for all), the researchers said. Rates of steroid dermatitis and reversible steroid-induced cutaneous atrophy were similar between the fully and partially compliant groups (2.2% vs. 4%, and 1.1% vs. 2%, respectively).
Based on the findings, clinicians would need to treat 21 cases of VLS to prevent 1 case of vulvar cancer and 2.7 cases to prevent scarring, said Dr. Lee.
“This is the first study adequately powered to demonstrate that cancer and scarring can be prevented by regular treatment according to clinical outcome, not symptoms,” he added.
But Dr. Lee acknowledged that selection bias could have affected the results. “We did find that patients who were not complying with treatment were more likely to have severe disease at the start of the study,” he said. “They probably were at increased risk of cancer to start with.”
The dermatology department of Royal North Shore Hospital partially funded the work. The investigators reported having no relevant conflicts of interest.
AT WCD 2015
Key clinical point: Women with vulvar lichen sclerosus who consistently used topical corticosteroids titrated to normalize skin color and texture had significantly better symptoms, scarring, and rates of vulvar cancer compared with partially compliant patients.
Major finding: None of the women who consistently followed their individualized treatment plan developed vulvar carcinoma, compared with 4.7% of partially compliant patients (P < .001).
Data source: Single-center prospective, observational cohort study of 507 women with biopsy-proven vulvar lichen sclerosus.
Disclosures: The dermatology department of Royal North Shore Hospital partially funded the work. Dr. Lee reported having no relevant conflicts of interest.
Expert critiques isotretinoin controversies
VANCOUVER – Controversies surrounding isotretinoin are mostly unfounded, Dr. Neil Shear said at the World Congress of Dermatology.
“Isotretinoin is the most effective treatment for all grades of acne vulgaris,” added Dr. Shear, professor and chief of dermatology at the University of Toronto Medical School. “Isotretinoin causes fetal malformations, and most preventative strategies around pregnancy have not been completely successful. Isotretinoin does not cause inflammatory disease, nor irritable bowel, but it can, rarely, cause depression,” he said. “If you agree with all those things, I don’t find it very controversial.”
In fact, there exists “a very good argument” for using isotretinoin as a first-line therapy for some patients with acne, said Dr. Shear. “I would be for it,” he said. “It has its issues, and they do have to be managed, but we know the issues behind systemic antibiotics might be larger than the issues behind isotretinoin.”
Safety concerns about isotretinoin have spurred dozens of lawsuits in the United States, many of which allege that the medication caused inflammatory bowel disease (IBD). But despite split verdicts and millions of dollars awarded to some plaintiffs, the best available evidence does not support a causal association between isotretinoin and IBD, Dr. Shear asserted. He pointed to a large population-based cohort study that found no association between isotretinoin and IBD in its primary analysis, although prespecified secondary analyses linked IBD with both isotretinoin and topical acne medications. “The conclusion could only be that if there is increased IBD, it is associated with acne, not with the therapy,” Dr. Shear said. “The arrow has been pointing us in this direction for over a decade now, and I am hoping there will be bigger studies to show the blame is with acne, not isotretinoin.”
Isotretinoin has been associated with clinical depression, which is sometimes preceded by onset of new headache, Dr. Shear said. He has seen some patients become depressed on the medication, he added. “But untreated acne is associated with depression and even suicidal ideation sometimes. I think it’s quite manageable, personally,” he said. “It’s all part of the risk management of using a medication like isotretinoin. Patients who are depressed with acne, even when they have dry lips and other side effects, are so much happier with isotretinoin.”
In fact, Dr. Shear would not rule out isotretinoin for acne patients who have a history of clinical depression, although he would first consider other options such as decreasing dietary glycemic load or retrying “failed” treatments to ensure that patients gave them an adequate trial, he said.
Because of its high risk of severe fetal malformations, dermatologists who prescribe isotretinoin need to ensure that female patients have a specific plan for using effective birth control, Dr. Shear emphasized. But the risk of birth defects does not negate the need for the drug, he said. “Companies have tried hard to make a similar retinoid that does not affect the fetus and cause birth defects and have not been successful.”
The hypothesis that isotretinoin adversely affects pediatric bone growth has been debunked, Dr. Shear said, in response to a question from the audience, citing a study published in the journal Osteoporosis International.
Dr. Shear reported having no relevant conflicts of interest except having worked with Roche on rituximab. Roche formerly manufactured and marketed isotretinoin (Accutane) in the United States, but no longer does so.
VANCOUVER – Controversies surrounding isotretinoin are mostly unfounded, Dr. Neil Shear said at the World Congress of Dermatology.
“Isotretinoin is the most effective treatment for all grades of acne vulgaris,” added Dr. Shear, professor and chief of dermatology at the University of Toronto Medical School. “Isotretinoin causes fetal malformations, and most preventative strategies around pregnancy have not been completely successful. Isotretinoin does not cause inflammatory disease, nor irritable bowel, but it can, rarely, cause depression,” he said. “If you agree with all those things, I don’t find it very controversial.”
In fact, there exists “a very good argument” for using isotretinoin as a first-line therapy for some patients with acne, said Dr. Shear. “I would be for it,” he said. “It has its issues, and they do have to be managed, but we know the issues behind systemic antibiotics might be larger than the issues behind isotretinoin.”
Safety concerns about isotretinoin have spurred dozens of lawsuits in the United States, many of which allege that the medication caused inflammatory bowel disease (IBD). But despite split verdicts and millions of dollars awarded to some plaintiffs, the best available evidence does not support a causal association between isotretinoin and IBD, Dr. Shear asserted. He pointed to a large population-based cohort study that found no association between isotretinoin and IBD in its primary analysis, although prespecified secondary analyses linked IBD with both isotretinoin and topical acne medications. “The conclusion could only be that if there is increased IBD, it is associated with acne, not with the therapy,” Dr. Shear said. “The arrow has been pointing us in this direction for over a decade now, and I am hoping there will be bigger studies to show the blame is with acne, not isotretinoin.”
Isotretinoin has been associated with clinical depression, which is sometimes preceded by onset of new headache, Dr. Shear said. He has seen some patients become depressed on the medication, he added. “But untreated acne is associated with depression and even suicidal ideation sometimes. I think it’s quite manageable, personally,” he said. “It’s all part of the risk management of using a medication like isotretinoin. Patients who are depressed with acne, even when they have dry lips and other side effects, are so much happier with isotretinoin.”
In fact, Dr. Shear would not rule out isotretinoin for acne patients who have a history of clinical depression, although he would first consider other options such as decreasing dietary glycemic load or retrying “failed” treatments to ensure that patients gave them an adequate trial, he said.
Because of its high risk of severe fetal malformations, dermatologists who prescribe isotretinoin need to ensure that female patients have a specific plan for using effective birth control, Dr. Shear emphasized. But the risk of birth defects does not negate the need for the drug, he said. “Companies have tried hard to make a similar retinoid that does not affect the fetus and cause birth defects and have not been successful.”
The hypothesis that isotretinoin adversely affects pediatric bone growth has been debunked, Dr. Shear said, in response to a question from the audience, citing a study published in the journal Osteoporosis International.
Dr. Shear reported having no relevant conflicts of interest except having worked with Roche on rituximab. Roche formerly manufactured and marketed isotretinoin (Accutane) in the United States, but no longer does so.
VANCOUVER – Controversies surrounding isotretinoin are mostly unfounded, Dr. Neil Shear said at the World Congress of Dermatology.
“Isotretinoin is the most effective treatment for all grades of acne vulgaris,” added Dr. Shear, professor and chief of dermatology at the University of Toronto Medical School. “Isotretinoin causes fetal malformations, and most preventative strategies around pregnancy have not been completely successful. Isotretinoin does not cause inflammatory disease, nor irritable bowel, but it can, rarely, cause depression,” he said. “If you agree with all those things, I don’t find it very controversial.”
In fact, there exists “a very good argument” for using isotretinoin as a first-line therapy for some patients with acne, said Dr. Shear. “I would be for it,” he said. “It has its issues, and they do have to be managed, but we know the issues behind systemic antibiotics might be larger than the issues behind isotretinoin.”
Safety concerns about isotretinoin have spurred dozens of lawsuits in the United States, many of which allege that the medication caused inflammatory bowel disease (IBD). But despite split verdicts and millions of dollars awarded to some plaintiffs, the best available evidence does not support a causal association between isotretinoin and IBD, Dr. Shear asserted. He pointed to a large population-based cohort study that found no association between isotretinoin and IBD in its primary analysis, although prespecified secondary analyses linked IBD with both isotretinoin and topical acne medications. “The conclusion could only be that if there is increased IBD, it is associated with acne, not with the therapy,” Dr. Shear said. “The arrow has been pointing us in this direction for over a decade now, and I am hoping there will be bigger studies to show the blame is with acne, not isotretinoin.”
Isotretinoin has been associated with clinical depression, which is sometimes preceded by onset of new headache, Dr. Shear said. He has seen some patients become depressed on the medication, he added. “But untreated acne is associated with depression and even suicidal ideation sometimes. I think it’s quite manageable, personally,” he said. “It’s all part of the risk management of using a medication like isotretinoin. Patients who are depressed with acne, even when they have dry lips and other side effects, are so much happier with isotretinoin.”
In fact, Dr. Shear would not rule out isotretinoin for acne patients who have a history of clinical depression, although he would first consider other options such as decreasing dietary glycemic load or retrying “failed” treatments to ensure that patients gave them an adequate trial, he said.
Because of its high risk of severe fetal malformations, dermatologists who prescribe isotretinoin need to ensure that female patients have a specific plan for using effective birth control, Dr. Shear emphasized. But the risk of birth defects does not negate the need for the drug, he said. “Companies have tried hard to make a similar retinoid that does not affect the fetus and cause birth defects and have not been successful.”
The hypothesis that isotretinoin adversely affects pediatric bone growth has been debunked, Dr. Shear said, in response to a question from the audience, citing a study published in the journal Osteoporosis International.
Dr. Shear reported having no relevant conflicts of interest except having worked with Roche on rituximab. Roche formerly manufactured and marketed isotretinoin (Accutane) in the United States, but no longer does so.
AT WCD 2015
WCD: Cut Simple Carbs to Clear Acne
VANCOUVER, B.C. – Mounting evidence suggests that consuming a low glycemic index diet can substantially improve acne, according to Dr. Hyuck Hoon Kwon.
The approach has held up in several small-scale randomized clinical trials, earning it a grade of 1B last year from the American Academy of Dermatology, noted Dr. Kwon of Seoul National University in South Korea.
“Dermatologists can recommend dietary modification to patients, and can advise them to avoid foods that they believe worsen their acne,” Dr. Kwon said at the World Congress of Dermatology. He said he has seen clinically meaningful reductions in acne lesions as soon as 4 weeks after patients cut their intake of refined carbohydrates and other high glycemic index (GI) foods, although results can take up to 12 weeks, and more studies of time to effect are needed.
Scientists and clinicians have long debated the role of diet in the pathogenesis of acne, and until recently, there were no randomized, controlled trials or meta-analyses of the topic. But observational studies have repeatedly documented “astonishingly” low rates of acne in cultures with “traditional” diets that are lower in refined carbohydrates and fat than typical Western fare, said Dr. Kwon.
In one study of 1,285 individuals in Korea, those who did not have acne reported consuming significantly higher amounts of fish and yellow, leafy green, and cruciferous vegetables, while those with acne ate significantly more instant noodles, processed cheeses, and “junk” foods, he noted (Eur. J. Dermatol. 2010;20:768-72).
In another trial, Dr. Kwon and colleagues randomized 32 individuals with mild to moderate acne to either a low-GI diet that emphasized beans, barley, vegetables, fish, and whole-grain breads, or to a high-GI control diet (Acta Derm. Venereol. 2012;92:241-6). The low-GI group ate more protein to replace calories lost from cutting carbohydrates. At 10 weeks, the groups had similar mean calorie intakes and body mass indices, but the low-GI group had reduced its dietary glycemic load from baseline and had significantly fewer inflammatory and noninflammatory acne lesions compared with baseline and with the high-GI group, Dr. Kwon said. The low-GI group also had significant decreases in total average area of sebaceous glands, and decreased expression of sterol response element-binding protein-1 (SREBP-1), which stimulates lipogenesis in sebocytes.
Most recently, scientists have explored the molecular mechanisms linking diet to acne, Dr. Kwon noted. High GI diets trigger chronic hyperinsulinemia, which impairs the ability of FoxO1 transcription factor to mediate androgen receptor signaling, oxidative stress, lipogenesis, and sebaceous gland homeostasis. Importantly, FoxO1 inhibition also is associated with activation of mTORC1, which promotes lipid and protein synthesis, sebaceous gland hyperplasia, and sebaceous lipogenesis, he said.
Dr. Kwon reported having no relevant conflicts of interest.
VANCOUVER, B.C. – Mounting evidence suggests that consuming a low glycemic index diet can substantially improve acne, according to Dr. Hyuck Hoon Kwon.
The approach has held up in several small-scale randomized clinical trials, earning it a grade of 1B last year from the American Academy of Dermatology, noted Dr. Kwon of Seoul National University in South Korea.
“Dermatologists can recommend dietary modification to patients, and can advise them to avoid foods that they believe worsen their acne,” Dr. Kwon said at the World Congress of Dermatology. He said he has seen clinically meaningful reductions in acne lesions as soon as 4 weeks after patients cut their intake of refined carbohydrates and other high glycemic index (GI) foods, although results can take up to 12 weeks, and more studies of time to effect are needed.
Scientists and clinicians have long debated the role of diet in the pathogenesis of acne, and until recently, there were no randomized, controlled trials or meta-analyses of the topic. But observational studies have repeatedly documented “astonishingly” low rates of acne in cultures with “traditional” diets that are lower in refined carbohydrates and fat than typical Western fare, said Dr. Kwon.
In one study of 1,285 individuals in Korea, those who did not have acne reported consuming significantly higher amounts of fish and yellow, leafy green, and cruciferous vegetables, while those with acne ate significantly more instant noodles, processed cheeses, and “junk” foods, he noted (Eur. J. Dermatol. 2010;20:768-72).
In another trial, Dr. Kwon and colleagues randomized 32 individuals with mild to moderate acne to either a low-GI diet that emphasized beans, barley, vegetables, fish, and whole-grain breads, or to a high-GI control diet (Acta Derm. Venereol. 2012;92:241-6). The low-GI group ate more protein to replace calories lost from cutting carbohydrates. At 10 weeks, the groups had similar mean calorie intakes and body mass indices, but the low-GI group had reduced its dietary glycemic load from baseline and had significantly fewer inflammatory and noninflammatory acne lesions compared with baseline and with the high-GI group, Dr. Kwon said. The low-GI group also had significant decreases in total average area of sebaceous glands, and decreased expression of sterol response element-binding protein-1 (SREBP-1), which stimulates lipogenesis in sebocytes.
Most recently, scientists have explored the molecular mechanisms linking diet to acne, Dr. Kwon noted. High GI diets trigger chronic hyperinsulinemia, which impairs the ability of FoxO1 transcription factor to mediate androgen receptor signaling, oxidative stress, lipogenesis, and sebaceous gland homeostasis. Importantly, FoxO1 inhibition also is associated with activation of mTORC1, which promotes lipid and protein synthesis, sebaceous gland hyperplasia, and sebaceous lipogenesis, he said.
Dr. Kwon reported having no relevant conflicts of interest.
VANCOUVER, B.C. – Mounting evidence suggests that consuming a low glycemic index diet can substantially improve acne, according to Dr. Hyuck Hoon Kwon.
The approach has held up in several small-scale randomized clinical trials, earning it a grade of 1B last year from the American Academy of Dermatology, noted Dr. Kwon of Seoul National University in South Korea.
“Dermatologists can recommend dietary modification to patients, and can advise them to avoid foods that they believe worsen their acne,” Dr. Kwon said at the World Congress of Dermatology. He said he has seen clinically meaningful reductions in acne lesions as soon as 4 weeks after patients cut their intake of refined carbohydrates and other high glycemic index (GI) foods, although results can take up to 12 weeks, and more studies of time to effect are needed.
Scientists and clinicians have long debated the role of diet in the pathogenesis of acne, and until recently, there were no randomized, controlled trials or meta-analyses of the topic. But observational studies have repeatedly documented “astonishingly” low rates of acne in cultures with “traditional” diets that are lower in refined carbohydrates and fat than typical Western fare, said Dr. Kwon.
In one study of 1,285 individuals in Korea, those who did not have acne reported consuming significantly higher amounts of fish and yellow, leafy green, and cruciferous vegetables, while those with acne ate significantly more instant noodles, processed cheeses, and “junk” foods, he noted (Eur. J. Dermatol. 2010;20:768-72).
In another trial, Dr. Kwon and colleagues randomized 32 individuals with mild to moderate acne to either a low-GI diet that emphasized beans, barley, vegetables, fish, and whole-grain breads, or to a high-GI control diet (Acta Derm. Venereol. 2012;92:241-6). The low-GI group ate more protein to replace calories lost from cutting carbohydrates. At 10 weeks, the groups had similar mean calorie intakes and body mass indices, but the low-GI group had reduced its dietary glycemic load from baseline and had significantly fewer inflammatory and noninflammatory acne lesions compared with baseline and with the high-GI group, Dr. Kwon said. The low-GI group also had significant decreases in total average area of sebaceous glands, and decreased expression of sterol response element-binding protein-1 (SREBP-1), which stimulates lipogenesis in sebocytes.
Most recently, scientists have explored the molecular mechanisms linking diet to acne, Dr. Kwon noted. High GI diets trigger chronic hyperinsulinemia, which impairs the ability of FoxO1 transcription factor to mediate androgen receptor signaling, oxidative stress, lipogenesis, and sebaceous gland homeostasis. Importantly, FoxO1 inhibition also is associated with activation of mTORC1, which promotes lipid and protein synthesis, sebaceous gland hyperplasia, and sebaceous lipogenesis, he said.
Dr. Kwon reported having no relevant conflicts of interest.
AT WCD 2015
WCD: Cut simple carbs to clear acne
VANCOUVER, B.C. – Mounting evidence suggests that consuming a low glycemic index diet can substantially improve acne, according to Dr. Hyuck Hoon Kwon.
The approach has held up in several small-scale randomized clinical trials, earning it a grade of 1B last year from the American Academy of Dermatology, noted Dr. Kwon of Seoul National University in South Korea.
“Dermatologists can recommend dietary modification to patients, and can advise them to avoid foods that they believe worsen their acne,” Dr. Kwon said at the World Congress of Dermatology. He said he has seen clinically meaningful reductions in acne lesions as soon as 4 weeks after patients cut their intake of refined carbohydrates and other high glycemic index (GI) foods, although results can take up to 12 weeks, and more studies of time to effect are needed.
Scientists and clinicians have long debated the role of diet in the pathogenesis of acne, and until recently, there were no randomized, controlled trials or meta-analyses of the topic. But observational studies have repeatedly documented “astonishingly” low rates of acne in cultures with “traditional” diets that are lower in refined carbohydrates and fat than typical Western fare, said Dr. Kwon.
In one study of 1,285 individuals in Korea, those who did not have acne reported consuming significantly higher amounts of fish and yellow, leafy green, and cruciferous vegetables, while those with acne ate significantly more instant noodles, processed cheeses, and “junk” foods, he noted (Eur. J. Dermatol. 2010;20:768-72).
In another trial, Dr. Kwon and colleagues randomized 32 individuals with mild to moderate acne to either a low-GI diet that emphasized beans, barley, vegetables, fish, and whole-grain breads, or to a high-GI control diet (Acta Derm. Venereol. 2012;92:241-6). The low-GI group ate more protein to replace calories lost from cutting carbohydrates. At 10 weeks, the groups had similar mean calorie intakes and body mass indices, but the low-GI group had reduced its dietary glycemic load from baseline and had significantly fewer inflammatory and noninflammatory acne lesions compared with baseline and with the high-GI group, Dr. Kwon said. The low-GI group also had significant decreases in total average area of sebaceous glands, and decreased expression of sterol response element-binding protein-1 (SREBP-1), which stimulates lipogenesis in sebocytes.
Most recently, scientists have explored the molecular mechanisms linking diet to acne, Dr. Kwon noted. High GI diets trigger chronic hyperinsulinemia, which impairs the ability of FoxO1 transcription factor to mediate androgen receptor signaling, oxidative stress, lipogenesis, and sebaceous gland homeostasis. Importantly, FoxO1 inhibition also is associated with activation of mTORC1, which promotes lipid and protein synthesis, sebaceous gland hyperplasia, and sebaceous lipogenesis, he said.
Dr. Kwon reported having no relevant conflicts of interest.
VANCOUVER, B.C. – Mounting evidence suggests that consuming a low glycemic index diet can substantially improve acne, according to Dr. Hyuck Hoon Kwon.
The approach has held up in several small-scale randomized clinical trials, earning it a grade of 1B last year from the American Academy of Dermatology, noted Dr. Kwon of Seoul National University in South Korea.
“Dermatologists can recommend dietary modification to patients, and can advise them to avoid foods that they believe worsen their acne,” Dr. Kwon said at the World Congress of Dermatology. He said he has seen clinically meaningful reductions in acne lesions as soon as 4 weeks after patients cut their intake of refined carbohydrates and other high glycemic index (GI) foods, although results can take up to 12 weeks, and more studies of time to effect are needed.
Scientists and clinicians have long debated the role of diet in the pathogenesis of acne, and until recently, there were no randomized, controlled trials or meta-analyses of the topic. But observational studies have repeatedly documented “astonishingly” low rates of acne in cultures with “traditional” diets that are lower in refined carbohydrates and fat than typical Western fare, said Dr. Kwon.
In one study of 1,285 individuals in Korea, those who did not have acne reported consuming significantly higher amounts of fish and yellow, leafy green, and cruciferous vegetables, while those with acne ate significantly more instant noodles, processed cheeses, and “junk” foods, he noted (Eur. J. Dermatol. 2010;20:768-72).
In another trial, Dr. Kwon and colleagues randomized 32 individuals with mild to moderate acne to either a low-GI diet that emphasized beans, barley, vegetables, fish, and whole-grain breads, or to a high-GI control diet (Acta Derm. Venereol. 2012;92:241-6). The low-GI group ate more protein to replace calories lost from cutting carbohydrates. At 10 weeks, the groups had similar mean calorie intakes and body mass indices, but the low-GI group had reduced its dietary glycemic load from baseline and had significantly fewer inflammatory and noninflammatory acne lesions compared with baseline and with the high-GI group, Dr. Kwon said. The low-GI group also had significant decreases in total average area of sebaceous glands, and decreased expression of sterol response element-binding protein-1 (SREBP-1), which stimulates lipogenesis in sebocytes.
Most recently, scientists have explored the molecular mechanisms linking diet to acne, Dr. Kwon noted. High GI diets trigger chronic hyperinsulinemia, which impairs the ability of FoxO1 transcription factor to mediate androgen receptor signaling, oxidative stress, lipogenesis, and sebaceous gland homeostasis. Importantly, FoxO1 inhibition also is associated with activation of mTORC1, which promotes lipid and protein synthesis, sebaceous gland hyperplasia, and sebaceous lipogenesis, he said.
Dr. Kwon reported having no relevant conflicts of interest.
VANCOUVER, B.C. – Mounting evidence suggests that consuming a low glycemic index diet can substantially improve acne, according to Dr. Hyuck Hoon Kwon.
The approach has held up in several small-scale randomized clinical trials, earning it a grade of 1B last year from the American Academy of Dermatology, noted Dr. Kwon of Seoul National University in South Korea.
“Dermatologists can recommend dietary modification to patients, and can advise them to avoid foods that they believe worsen their acne,” Dr. Kwon said at the World Congress of Dermatology. He said he has seen clinically meaningful reductions in acne lesions as soon as 4 weeks after patients cut their intake of refined carbohydrates and other high glycemic index (GI) foods, although results can take up to 12 weeks, and more studies of time to effect are needed.
Scientists and clinicians have long debated the role of diet in the pathogenesis of acne, and until recently, there were no randomized, controlled trials or meta-analyses of the topic. But observational studies have repeatedly documented “astonishingly” low rates of acne in cultures with “traditional” diets that are lower in refined carbohydrates and fat than typical Western fare, said Dr. Kwon.
In one study of 1,285 individuals in Korea, those who did not have acne reported consuming significantly higher amounts of fish and yellow, leafy green, and cruciferous vegetables, while those with acne ate significantly more instant noodles, processed cheeses, and “junk” foods, he noted (Eur. J. Dermatol. 2010;20:768-72).
In another trial, Dr. Kwon and colleagues randomized 32 individuals with mild to moderate acne to either a low-GI diet that emphasized beans, barley, vegetables, fish, and whole-grain breads, or to a high-GI control diet (Acta Derm. Venereol. 2012;92:241-6). The low-GI group ate more protein to replace calories lost from cutting carbohydrates. At 10 weeks, the groups had similar mean calorie intakes and body mass indices, but the low-GI group had reduced its dietary glycemic load from baseline and had significantly fewer inflammatory and noninflammatory acne lesions compared with baseline and with the high-GI group, Dr. Kwon said. The low-GI group also had significant decreases in total average area of sebaceous glands, and decreased expression of sterol response element-binding protein-1 (SREBP-1), which stimulates lipogenesis in sebocytes.
Most recently, scientists have explored the molecular mechanisms linking diet to acne, Dr. Kwon noted. High GI diets trigger chronic hyperinsulinemia, which impairs the ability of FoxO1 transcription factor to mediate androgen receptor signaling, oxidative stress, lipogenesis, and sebaceous gland homeostasis. Importantly, FoxO1 inhibition also is associated with activation of mTORC1, which promotes lipid and protein synthesis, sebaceous gland hyperplasia, and sebaceous lipogenesis, he said.
Dr. Kwon reported having no relevant conflicts of interest.
AT WCD 2015
Expert advises on filling the forehead and temples
VANCOUVER – Fillers can greatly improve the age-related effects of atrophy of subcutaneous fat of the central forehead and temples, where volume loss can create an unhealthy or even skeletal appearance, according to Dr. Tatjana Pavicic.
However, dermatologists in Western countries often neglect to use fillers in the forehead and temples, said Dr. Pavicic, whose private practice in Munich specializes in cosmetic surgery and aesthetic procedures. They can learn from their colleagues in eastern Asia, where a “high, gently curved, round, or even slightly protruding forehead” is traditionally a sign of wealth, and the forehead and temples are among the most popular sites for fillers, she noted in a presentation at the World Congress of Dermatology.
Restoring volume to the central forehead and temples can shave years off patients’ appearance, but clinicians should be mindful of anatomy and use proper tools and techniques when filling these areas, Dr. Pavicic emphasized. Otherwise patients can suffer serious adverse effects, including tissue necrosis or even permanent blindness as a result of filler entering the vasculature, she said. Likewise, because the bone at the temples is thin, clinicians must be especially careful not to penetrate it. Dr. Pavicic noted that there has been at least one case in Europe of intracranial injection of filler associated with treatment of the temples.
Dr. Pavicic offered several tips for optimizing cosmetic results and keeping patients safe when filling the temples and forehead. For white patients, the cosmetic goal is to neutralize age-related concavities, while for Asian patients, it is to restore lost convexity, particularly of the forehead, she noted.
When treating the forehead, Dr. Pavicic said she places filler above the frontal bone at the subfascial level. For deep injections, the needle should be “really on the bone,” she noted. Inject small boluses of filler instead of a single large bolus, and aspirate back before injecting filler to ensure that needles are not intravascular, she said.
If using the blunt cannula technique, the cannula must be stiff enough to achieve good control – Dr. Pavicic recommends using a 22-gauge – and it should be placed into the medial and central fat pads of the forehead.
For superficial filler injections of the temples, Dr. Pavicic introduces the cannula at the zygomatic arch instead of trying to clean behind the hairline. She also recommended warning patients that the superficial veins in their temples might be more prominent for about a week after treatment. “Otherwise, they will call you in shock,” she said.
Regardless of the filler technique or the site in question, always use a high-quality product that exhibits good moldability, Dr. Pavicic concluded.
She reported having advisory or consulting relationships with Merz Pharmaceuticals, Dermaceutica, Eucerin, Galderma, and Ulthera, and receiving research support from Bayer and Ipsen.
VANCOUVER – Fillers can greatly improve the age-related effects of atrophy of subcutaneous fat of the central forehead and temples, where volume loss can create an unhealthy or even skeletal appearance, according to Dr. Tatjana Pavicic.
However, dermatologists in Western countries often neglect to use fillers in the forehead and temples, said Dr. Pavicic, whose private practice in Munich specializes in cosmetic surgery and aesthetic procedures. They can learn from their colleagues in eastern Asia, where a “high, gently curved, round, or even slightly protruding forehead” is traditionally a sign of wealth, and the forehead and temples are among the most popular sites for fillers, she noted in a presentation at the World Congress of Dermatology.
Restoring volume to the central forehead and temples can shave years off patients’ appearance, but clinicians should be mindful of anatomy and use proper tools and techniques when filling these areas, Dr. Pavicic emphasized. Otherwise patients can suffer serious adverse effects, including tissue necrosis or even permanent blindness as a result of filler entering the vasculature, she said. Likewise, because the bone at the temples is thin, clinicians must be especially careful not to penetrate it. Dr. Pavicic noted that there has been at least one case in Europe of intracranial injection of filler associated with treatment of the temples.
Dr. Pavicic offered several tips for optimizing cosmetic results and keeping patients safe when filling the temples and forehead. For white patients, the cosmetic goal is to neutralize age-related concavities, while for Asian patients, it is to restore lost convexity, particularly of the forehead, she noted.
When treating the forehead, Dr. Pavicic said she places filler above the frontal bone at the subfascial level. For deep injections, the needle should be “really on the bone,” she noted. Inject small boluses of filler instead of a single large bolus, and aspirate back before injecting filler to ensure that needles are not intravascular, she said.
If using the blunt cannula technique, the cannula must be stiff enough to achieve good control – Dr. Pavicic recommends using a 22-gauge – and it should be placed into the medial and central fat pads of the forehead.
For superficial filler injections of the temples, Dr. Pavicic introduces the cannula at the zygomatic arch instead of trying to clean behind the hairline. She also recommended warning patients that the superficial veins in their temples might be more prominent for about a week after treatment. “Otherwise, they will call you in shock,” she said.
Regardless of the filler technique or the site in question, always use a high-quality product that exhibits good moldability, Dr. Pavicic concluded.
She reported having advisory or consulting relationships with Merz Pharmaceuticals, Dermaceutica, Eucerin, Galderma, and Ulthera, and receiving research support from Bayer and Ipsen.
VANCOUVER – Fillers can greatly improve the age-related effects of atrophy of subcutaneous fat of the central forehead and temples, where volume loss can create an unhealthy or even skeletal appearance, according to Dr. Tatjana Pavicic.
However, dermatologists in Western countries often neglect to use fillers in the forehead and temples, said Dr. Pavicic, whose private practice in Munich specializes in cosmetic surgery and aesthetic procedures. They can learn from their colleagues in eastern Asia, where a “high, gently curved, round, or even slightly protruding forehead” is traditionally a sign of wealth, and the forehead and temples are among the most popular sites for fillers, she noted in a presentation at the World Congress of Dermatology.
Restoring volume to the central forehead and temples can shave years off patients’ appearance, but clinicians should be mindful of anatomy and use proper tools and techniques when filling these areas, Dr. Pavicic emphasized. Otherwise patients can suffer serious adverse effects, including tissue necrosis or even permanent blindness as a result of filler entering the vasculature, she said. Likewise, because the bone at the temples is thin, clinicians must be especially careful not to penetrate it. Dr. Pavicic noted that there has been at least one case in Europe of intracranial injection of filler associated with treatment of the temples.
Dr. Pavicic offered several tips for optimizing cosmetic results and keeping patients safe when filling the temples and forehead. For white patients, the cosmetic goal is to neutralize age-related concavities, while for Asian patients, it is to restore lost convexity, particularly of the forehead, she noted.
When treating the forehead, Dr. Pavicic said she places filler above the frontal bone at the subfascial level. For deep injections, the needle should be “really on the bone,” she noted. Inject small boluses of filler instead of a single large bolus, and aspirate back before injecting filler to ensure that needles are not intravascular, she said.
If using the blunt cannula technique, the cannula must be stiff enough to achieve good control – Dr. Pavicic recommends using a 22-gauge – and it should be placed into the medial and central fat pads of the forehead.
For superficial filler injections of the temples, Dr. Pavicic introduces the cannula at the zygomatic arch instead of trying to clean behind the hairline. She also recommended warning patients that the superficial veins in their temples might be more prominent for about a week after treatment. “Otherwise, they will call you in shock,” she said.
Regardless of the filler technique or the site in question, always use a high-quality product that exhibits good moldability, Dr. Pavicic concluded.
She reported having advisory or consulting relationships with Merz Pharmaceuticals, Dermaceutica, Eucerin, Galderma, and Ulthera, and receiving research support from Bayer and Ipsen.
AT WDC 2015
Amplified pain in knee osteoarthritis linked to insomnia, catastrophizing
Patients with knee osteoarthritis and poor sleep habits suffered greater central sensitization to pain than other individuals, especially if they tended to ruminate about their pain, a case-control study found.
The study is the largest to date to examine sleep, catastrophizing, and central sensitization in knee osteoarthritis, said Claudia Campbell, Ph.D., of Johns Hopkins University, Baltimore. “While we were underpowered to fully examine all possible data described, we hope that these data serve as a platform for future studies to adequately power themselves and explore potential differences.”
Patients with osteoarthritis often report poor sleep, and studies show that many of these patients also have central sensitization, or hyperexcitability of nociceptive nerve pathways, a phenomenon that tends to amplify and prolong pain. Catastrophizing – a “persistently negative cognitive affective style” in which patients feel helpless, and magnify and ruminate about their pain – predicts worse pain outcomes in osteoarthritis and other painful conditions, the investigators noted (Arthritis Care Res. 2015 June 4 [doi: 10.1002/acr.22609]).Dr. Campbell and her colleagues categorized 208 adults into four groups: those with insomnia and knee osteoarthritis, those with one or the other of the disorders, and those with neither condition (healthy controls). More than 70% of participants were female, and individuals with knee osteoarthritis were significantly older than the rest. The investigators matched the groups with knee osteoarthritis based on radiographic severity.
Quantitative sensory testing showed that patients with knee osteoarthritis and insomnia had significantly greater central sensitization, compared with healthy controls, the researchers reported. Low sleep efficiency (a measure of self-perceived sleep quality) was linked to heightened central sensitization, but only when patients scored more 7.4 on the 13-item Pain Catastrophizing Scale, they added. In all 56% of the sample met that threshold, as did 77% of participants who had both insomnia and knee osteoarthritis.
Central sensitization also correlated positively with clinical pain. “Clinical implications of these findings suggest that treatment options for osteoarthritis patients could include sleep and/or intervention for catastrophizing, both modifiable risk factors, [which] may aid in reducing central sensitization and decrease clinical pain,” the researchers noted.
The study was the first part of a randomized trial that is examining cognitive behavioral therapy for insomnia in patients with osteoarthritis.
The National Institutes of Arthritis and Musculoskeletal and Skin Disease and the National Institutes of Health supported the study. The investigators reported having no relevant conflicts of interest.
Patients with knee osteoarthritis and poor sleep habits suffered greater central sensitization to pain than other individuals, especially if they tended to ruminate about their pain, a case-control study found.
The study is the largest to date to examine sleep, catastrophizing, and central sensitization in knee osteoarthritis, said Claudia Campbell, Ph.D., of Johns Hopkins University, Baltimore. “While we were underpowered to fully examine all possible data described, we hope that these data serve as a platform for future studies to adequately power themselves and explore potential differences.”
Patients with osteoarthritis often report poor sleep, and studies show that many of these patients also have central sensitization, or hyperexcitability of nociceptive nerve pathways, a phenomenon that tends to amplify and prolong pain. Catastrophizing – a “persistently negative cognitive affective style” in which patients feel helpless, and magnify and ruminate about their pain – predicts worse pain outcomes in osteoarthritis and other painful conditions, the investigators noted (Arthritis Care Res. 2015 June 4 [doi: 10.1002/acr.22609]).Dr. Campbell and her colleagues categorized 208 adults into four groups: those with insomnia and knee osteoarthritis, those with one or the other of the disorders, and those with neither condition (healthy controls). More than 70% of participants were female, and individuals with knee osteoarthritis were significantly older than the rest. The investigators matched the groups with knee osteoarthritis based on radiographic severity.
Quantitative sensory testing showed that patients with knee osteoarthritis and insomnia had significantly greater central sensitization, compared with healthy controls, the researchers reported. Low sleep efficiency (a measure of self-perceived sleep quality) was linked to heightened central sensitization, but only when patients scored more 7.4 on the 13-item Pain Catastrophizing Scale, they added. In all 56% of the sample met that threshold, as did 77% of participants who had both insomnia and knee osteoarthritis.
Central sensitization also correlated positively with clinical pain. “Clinical implications of these findings suggest that treatment options for osteoarthritis patients could include sleep and/or intervention for catastrophizing, both modifiable risk factors, [which] may aid in reducing central sensitization and decrease clinical pain,” the researchers noted.
The study was the first part of a randomized trial that is examining cognitive behavioral therapy for insomnia in patients with osteoarthritis.
The National Institutes of Arthritis and Musculoskeletal and Skin Disease and the National Institutes of Health supported the study. The investigators reported having no relevant conflicts of interest.
Patients with knee osteoarthritis and poor sleep habits suffered greater central sensitization to pain than other individuals, especially if they tended to ruminate about their pain, a case-control study found.
The study is the largest to date to examine sleep, catastrophizing, and central sensitization in knee osteoarthritis, said Claudia Campbell, Ph.D., of Johns Hopkins University, Baltimore. “While we were underpowered to fully examine all possible data described, we hope that these data serve as a platform for future studies to adequately power themselves and explore potential differences.”
Patients with osteoarthritis often report poor sleep, and studies show that many of these patients also have central sensitization, or hyperexcitability of nociceptive nerve pathways, a phenomenon that tends to amplify and prolong pain. Catastrophizing – a “persistently negative cognitive affective style” in which patients feel helpless, and magnify and ruminate about their pain – predicts worse pain outcomes in osteoarthritis and other painful conditions, the investigators noted (Arthritis Care Res. 2015 June 4 [doi: 10.1002/acr.22609]).Dr. Campbell and her colleagues categorized 208 adults into four groups: those with insomnia and knee osteoarthritis, those with one or the other of the disorders, and those with neither condition (healthy controls). More than 70% of participants were female, and individuals with knee osteoarthritis were significantly older than the rest. The investigators matched the groups with knee osteoarthritis based on radiographic severity.
Quantitative sensory testing showed that patients with knee osteoarthritis and insomnia had significantly greater central sensitization, compared with healthy controls, the researchers reported. Low sleep efficiency (a measure of self-perceived sleep quality) was linked to heightened central sensitization, but only when patients scored more 7.4 on the 13-item Pain Catastrophizing Scale, they added. In all 56% of the sample met that threshold, as did 77% of participants who had both insomnia and knee osteoarthritis.
Central sensitization also correlated positively with clinical pain. “Clinical implications of these findings suggest that treatment options for osteoarthritis patients could include sleep and/or intervention for catastrophizing, both modifiable risk factors, [which] may aid in reducing central sensitization and decrease clinical pain,” the researchers noted.
The study was the first part of a randomized trial that is examining cognitive behavioral therapy for insomnia in patients with osteoarthritis.
The National Institutes of Arthritis and Musculoskeletal and Skin Disease and the National Institutes of Health supported the study. The investigators reported having no relevant conflicts of interest.
Key clinical point: Patients with knee osteoarthritis and insomnia suffered greater central sensitization, especially if they tended to ruminate about their pain.
Major finding: Patients with knee osteoarthritis and insomnia had significantly greater central sensitization compared with controls.
Data source: Case-control study of 208 adults.
Disclosures: The National Institutes of Health supported the research. The investigators reported having no relevant conflicts of interest.
Reserve thrombophilia testing for select subgroups
Clinicians should avoid routinely screening venous thromboembolism patients for thrombophilias, and should instead weigh the risks of recurrent thrombosis against the chances of bleeding with prolonged anticoagulation, according to a review article published in the April issue of the Journal of Vascular Surgery: Venous and Lymphatic Disorders.
“These laboratory tests are costly, and surprisingly, there is little evidence showing that testing leads to improved clinical outcomes,” said Dr. Elna Masuda at Straub Clinic and Hospital, Honolulu, and her associates. “Until data from well-designed, controlled trials are available comparing different durations of anticoagulation with specific thrombophilic states, treatment should be based on clinical risk factors and less on laboratory abnormalities.”
More than half of patients with an initial venous thromboembolism (VTE) episode had a positive thrombophilia screen in one study (Ann. Intern. Med. 2001;135:367-73), the reviewers noted. Testing, however, usually does not affect clinical management or prevent VTE recurrence, and it can cost more than $3,000 per patient, they said.
For these reasons, the American Society of Hematology, the National Institute for Health Care and Excellence, and the Society for Vascular Medicine discourage screening after an initial VTE episode if patients have a known cause or transient risk factor for thrombosis.
Testing also is unlikely to benefit patients with first-time unprovoked (or idiopathic) VTE, patients with a permanent risk factor for thrombosis such as cancer, or patients with arterial thrombosis or thrombosis of the retina or upper-arm veins, Dr. Masuda and her associates said. And because recurrent VTE generally merits long-term anticoagulation, affected patients should be screened only if they are considering stopping treatment and test results could inform that decision, they added (J. Vasc. Surg. Venous Lymphat. Disord. 2015;3:228-35).
Some subgroups of patients, however, could benefit from targeted thrombophilia testing. The reviewers recommended antiphospholipid antibody testing if patients have a history of several unexplained pregnancy losses or another reason to suspect antiphospholipid syndrome. Patients with heparin resistance should be tested for antithrombin deficiency, and patients with warfarin necrosis or neonatal purpura fulminans should be tested for protein C and S deficiencies, they added.
Clinicians also should consider screening women with a personal or family history of VTE if they are pregnant and are considering anticoagulation or are considering oral contraceptives or hormone replacement therapy, Dr. Masuda and her associates said.
“In the subgroup of those pregnant or planning pregnancy, history of prior VTE and strong family history of thrombosis are two factors that appear to play a clinically important role in identifying those who may benefit from screening,” they said.
Patients who want to pursue testing need to understand that management is mainly based on clinical risk and that test results usually will not change treatment recommendations.
“If testing will change management, it may be appropriate to proceed,” they added. “If long-term anticoagulation is preferred on the basis of positive test results, the risk of bleeding should be considered.”
Dr. Masuda reported that she has served on the speakers bureau for Janssen Pharmaceuticals.
Clinical utility of thrombophilia testing is determined by the cost-benefit ratio to each patient. Testing can range from factor V Leiden and homocystine levels to lupus anticoagulant and an isolated factor, or it can include panels of both fibrinolytic and thrombotic pathways as well as genetic testing. Duration of therapy and risk of recurrence can be influenced by the results. The real cost of underestimating the risk of recurrence is the sequela of recurrent thrombosis, such as the increased risk of valvular damage or obstruction, pulmonary embolism, and the development of the postthrombotic syndrome.
Even patients who have a provoked thrombus have been shown to have an increased incidence of thrombophilia. A positive test result can impact the patient’s treatment or potentially prevent events in families who have an unrecognized thrombophilic issue. Those outcomes matter to the patient and the family. In the past we ligated the saphenofemoral junction for patients with an isolated superficial vein thrombosis encroaching on the junction only to find out that many of these patients have an underlying undiagnosed thrombophilia, which had progressed to deep vein thrombosis.
Many people who have an underlying thrombophilia have a minor change in their baseline that then starts a cascade to promote a thrombotic event. Knowledge is power and testing to help identify risk is warranted.
Treatments are based on risk factor assessment, which includes laboratory analysis, residual thrombus, and clinical risk. Understanding the fibrinolytic balance may further explain why some patients recanalize completely while other patients never recanalize and have a significant amount of residual thrombus.
Once a thrombophilia has been identified, family members can be tested for a specific defect, potentially avoiding any thrombotic events and preventing miscarriages in those of reproductive years. Further testing and identification of subgroups is needed to clearly define those who would benefit most. Research can identify additional defects and help to further understand the thrombotic and fibrinolytic pathways.
Dr. Joann Lohr is director of the John J. Cranley Vascular Laboratory at Good Samaritan Hospital, both in Cincinnati. She had no relevant financial disclosures.
Clinical utility of thrombophilia testing is determined by the cost-benefit ratio to each patient. Testing can range from factor V Leiden and homocystine levels to lupus anticoagulant and an isolated factor, or it can include panels of both fibrinolytic and thrombotic pathways as well as genetic testing. Duration of therapy and risk of recurrence can be influenced by the results. The real cost of underestimating the risk of recurrence is the sequela of recurrent thrombosis, such as the increased risk of valvular damage or obstruction, pulmonary embolism, and the development of the postthrombotic syndrome.
Even patients who have a provoked thrombus have been shown to have an increased incidence of thrombophilia. A positive test result can impact the patient’s treatment or potentially prevent events in families who have an unrecognized thrombophilic issue. Those outcomes matter to the patient and the family. In the past we ligated the saphenofemoral junction for patients with an isolated superficial vein thrombosis encroaching on the junction only to find out that many of these patients have an underlying undiagnosed thrombophilia, which had progressed to deep vein thrombosis.
Many people who have an underlying thrombophilia have a minor change in their baseline that then starts a cascade to promote a thrombotic event. Knowledge is power and testing to help identify risk is warranted.
Treatments are based on risk factor assessment, which includes laboratory analysis, residual thrombus, and clinical risk. Understanding the fibrinolytic balance may further explain why some patients recanalize completely while other patients never recanalize and have a significant amount of residual thrombus.
Once a thrombophilia has been identified, family members can be tested for a specific defect, potentially avoiding any thrombotic events and preventing miscarriages in those of reproductive years. Further testing and identification of subgroups is needed to clearly define those who would benefit most. Research can identify additional defects and help to further understand the thrombotic and fibrinolytic pathways.
Dr. Joann Lohr is director of the John J. Cranley Vascular Laboratory at Good Samaritan Hospital, both in Cincinnati. She had no relevant financial disclosures.
Clinical utility of thrombophilia testing is determined by the cost-benefit ratio to each patient. Testing can range from factor V Leiden and homocystine levels to lupus anticoagulant and an isolated factor, or it can include panels of both fibrinolytic and thrombotic pathways as well as genetic testing. Duration of therapy and risk of recurrence can be influenced by the results. The real cost of underestimating the risk of recurrence is the sequela of recurrent thrombosis, such as the increased risk of valvular damage or obstruction, pulmonary embolism, and the development of the postthrombotic syndrome.
Even patients who have a provoked thrombus have been shown to have an increased incidence of thrombophilia. A positive test result can impact the patient’s treatment or potentially prevent events in families who have an unrecognized thrombophilic issue. Those outcomes matter to the patient and the family. In the past we ligated the saphenofemoral junction for patients with an isolated superficial vein thrombosis encroaching on the junction only to find out that many of these patients have an underlying undiagnosed thrombophilia, which had progressed to deep vein thrombosis.
Many people who have an underlying thrombophilia have a minor change in their baseline that then starts a cascade to promote a thrombotic event. Knowledge is power and testing to help identify risk is warranted.
Treatments are based on risk factor assessment, which includes laboratory analysis, residual thrombus, and clinical risk. Understanding the fibrinolytic balance may further explain why some patients recanalize completely while other patients never recanalize and have a significant amount of residual thrombus.
Once a thrombophilia has been identified, family members can be tested for a specific defect, potentially avoiding any thrombotic events and preventing miscarriages in those of reproductive years. Further testing and identification of subgroups is needed to clearly define those who would benefit most. Research can identify additional defects and help to further understand the thrombotic and fibrinolytic pathways.
Dr. Joann Lohr is director of the John J. Cranley Vascular Laboratory at Good Samaritan Hospital, both in Cincinnati. She had no relevant financial disclosures.
Clinicians should avoid routinely screening venous thromboembolism patients for thrombophilias, and should instead weigh the risks of recurrent thrombosis against the chances of bleeding with prolonged anticoagulation, according to a review article published in the April issue of the Journal of Vascular Surgery: Venous and Lymphatic Disorders.
“These laboratory tests are costly, and surprisingly, there is little evidence showing that testing leads to improved clinical outcomes,” said Dr. Elna Masuda at Straub Clinic and Hospital, Honolulu, and her associates. “Until data from well-designed, controlled trials are available comparing different durations of anticoagulation with specific thrombophilic states, treatment should be based on clinical risk factors and less on laboratory abnormalities.”
More than half of patients with an initial venous thromboembolism (VTE) episode had a positive thrombophilia screen in one study (Ann. Intern. Med. 2001;135:367-73), the reviewers noted. Testing, however, usually does not affect clinical management or prevent VTE recurrence, and it can cost more than $3,000 per patient, they said.
For these reasons, the American Society of Hematology, the National Institute for Health Care and Excellence, and the Society for Vascular Medicine discourage screening after an initial VTE episode if patients have a known cause or transient risk factor for thrombosis.
Testing also is unlikely to benefit patients with first-time unprovoked (or idiopathic) VTE, patients with a permanent risk factor for thrombosis such as cancer, or patients with arterial thrombosis or thrombosis of the retina or upper-arm veins, Dr. Masuda and her associates said. And because recurrent VTE generally merits long-term anticoagulation, affected patients should be screened only if they are considering stopping treatment and test results could inform that decision, they added (J. Vasc. Surg. Venous Lymphat. Disord. 2015;3:228-35).
Some subgroups of patients, however, could benefit from targeted thrombophilia testing. The reviewers recommended antiphospholipid antibody testing if patients have a history of several unexplained pregnancy losses or another reason to suspect antiphospholipid syndrome. Patients with heparin resistance should be tested for antithrombin deficiency, and patients with warfarin necrosis or neonatal purpura fulminans should be tested for protein C and S deficiencies, they added.
Clinicians also should consider screening women with a personal or family history of VTE if they are pregnant and are considering anticoagulation or are considering oral contraceptives or hormone replacement therapy, Dr. Masuda and her associates said.
“In the subgroup of those pregnant or planning pregnancy, history of prior VTE and strong family history of thrombosis are two factors that appear to play a clinically important role in identifying those who may benefit from screening,” they said.
Patients who want to pursue testing need to understand that management is mainly based on clinical risk and that test results usually will not change treatment recommendations.
“If testing will change management, it may be appropriate to proceed,” they added. “If long-term anticoagulation is preferred on the basis of positive test results, the risk of bleeding should be considered.”
Dr. Masuda reported that she has served on the speakers bureau for Janssen Pharmaceuticals.
Clinicians should avoid routinely screening venous thromboembolism patients for thrombophilias, and should instead weigh the risks of recurrent thrombosis against the chances of bleeding with prolonged anticoagulation, according to a review article published in the April issue of the Journal of Vascular Surgery: Venous and Lymphatic Disorders.
“These laboratory tests are costly, and surprisingly, there is little evidence showing that testing leads to improved clinical outcomes,” said Dr. Elna Masuda at Straub Clinic and Hospital, Honolulu, and her associates. “Until data from well-designed, controlled trials are available comparing different durations of anticoagulation with specific thrombophilic states, treatment should be based on clinical risk factors and less on laboratory abnormalities.”
More than half of patients with an initial venous thromboembolism (VTE) episode had a positive thrombophilia screen in one study (Ann. Intern. Med. 2001;135:367-73), the reviewers noted. Testing, however, usually does not affect clinical management or prevent VTE recurrence, and it can cost more than $3,000 per patient, they said.
For these reasons, the American Society of Hematology, the National Institute for Health Care and Excellence, and the Society for Vascular Medicine discourage screening after an initial VTE episode if patients have a known cause or transient risk factor for thrombosis.
Testing also is unlikely to benefit patients with first-time unprovoked (or idiopathic) VTE, patients with a permanent risk factor for thrombosis such as cancer, or patients with arterial thrombosis or thrombosis of the retina or upper-arm veins, Dr. Masuda and her associates said. And because recurrent VTE generally merits long-term anticoagulation, affected patients should be screened only if they are considering stopping treatment and test results could inform that decision, they added (J. Vasc. Surg. Venous Lymphat. Disord. 2015;3:228-35).
Some subgroups of patients, however, could benefit from targeted thrombophilia testing. The reviewers recommended antiphospholipid antibody testing if patients have a history of several unexplained pregnancy losses or another reason to suspect antiphospholipid syndrome. Patients with heparin resistance should be tested for antithrombin deficiency, and patients with warfarin necrosis or neonatal purpura fulminans should be tested for protein C and S deficiencies, they added.
Clinicians also should consider screening women with a personal or family history of VTE if they are pregnant and are considering anticoagulation or are considering oral contraceptives or hormone replacement therapy, Dr. Masuda and her associates said.
“In the subgroup of those pregnant or planning pregnancy, history of prior VTE and strong family history of thrombosis are two factors that appear to play a clinically important role in identifying those who may benefit from screening,” they said.
Patients who want to pursue testing need to understand that management is mainly based on clinical risk and that test results usually will not change treatment recommendations.
“If testing will change management, it may be appropriate to proceed,” they added. “If long-term anticoagulation is preferred on the basis of positive test results, the risk of bleeding should be considered.”
Dr. Masuda reported that she has served on the speakers bureau for Janssen Pharmaceuticals.
June 2015: Click for Credit
Here are 6 articles in the June issue of Clinician Reviews (accreditation valid until January 1, 2016):
1. ACCP and CTS Issue Joint Guideline on COPD Exacerbations
To take the posttest, go to: http://bit.ly/1EIadmv
VITALS
Key clinical point: The American College of Chest Physicians and the Canadian Thoracic Society have issued a guideline for prevention of acute exacerbations of COPD.
Major finding: COPD exacerbations are acute, trajectory changing, and often deadly manifestations of a chronic disease.
Data source: A comprehensive literature review on prevention of acute COPD exacerbations and a compilation of 33 recommendations and suggestions for clinicians in clinical practice.
Disclosures: The American College of Chest Physicians, the Canadian Thoracic Society, and the American Thoracic Society supported the project. Dr Criner reported having no relevant financial disclosures; his associates reported ties to numerous industry sources.
2. GI Symptoms Common in Parkinson Disease and Related Disorders
To take the posttest, go to: http://bit.ly/1AZSaXA
VITALS
Key clinical point: GI symptoms were linked with specific motor and nonmotor features of Parkinson disease and related disorders.
Major finding: Constipation was the most common symptom among all three parkinsonian disorders.
Data source: Multicenter, cross-sectional survey of 473 patients with Parkinson disease, atypical parkinsonism, or vascular parkinsonism.
Disclosures: The Collaborative Clinical Research Fund of Boramae Medical Center partially funded the work. The authors declared no relevant conflicts of interest.
3. Aerosolized Measles Vaccine Inferior to Subcutaneous
To take the posttest, go to: http://bit.ly/1RKJizC
VITALS
Key clinical point: An aerosolized measles vaccine was immunogenic but inferior to the subcutaneous vaccine at inducing seropositivity among babies residing in rural India.
Major finding: The primary endpoint—seropositivity for antibodies against measles at 91 days after vaccination—was 85.4% for aerosolized vaccine and 94.6% for subcutaneous.
Data source: An open-label, randomized noninferiority trial comparing aerosolized vs subcutaneous measles vaccination in 2,004 infants ages 9 to 11.9 months in villages in India.
Disclosures: This study was funded by the Bill and Melinda Gates Foundation. The Serum Institute of India provided vaccines free of charge, and Aerogen provided the delivery devices free of charge. Dr Low reported several grants plus monies paid to her institution from the World Health Organization for projects about vaccines and sexually transmitted infections; her associates reported ties to the Serum Institute of India, Aerogen, and Dance Biopharm. One associate has a patent pending on an aerosol device licensed to Novartis and another has a patent pending related to vaccine nebulizers.
4. Unrecognized Diabetes Common in Acute MI
To take the posttest, go to: http://bit.ly/1IB9sC8
VITALS
Key clinical point: Many patients presenting with acute MI had unrecognized diabetes, which, in most cases, remained undiagnosed, untreated, and unrecorded.
Major finding: Of 2,854 (10%) patients enrolled in an MI registry, 287 had A1C levels of 6.5% or higher on routine laboratory testing during hospitalization for acute MI, but treating physicians recognized only 101 of these cases of diabetes (35%).
Data source: A retrospective cohort study involving 2,854 adults presenting with acute MI to 24 US medical centers in a 3.5-year period.
Disclosures: This study was sponsored by the National Heart, Lung, and Blood Institute and supported by a research grant from Genentech. Dr Arnold reported receiving honoraria from Novartis; her associates reported ties to numerous industry sources.
5. Methotrexate and Biologics Linked to Higher Zoster Risk in Psoriasis
To take the posttest, go to: http://bit.ly/1AZScyF
VITALS
Key clinical point: The combination of methotrexate and biologics for the treatment of psoriasis may increase risk for herpes zoster.
Major finding: Combination therapy with both biologic medications and methotrexate was associated with a significant 66% increase in the incidence of herpes zoster over more than 11 years of follow-up.
Data source: Analysis of medical records for 95,941 patients with psoriasis.
Disclosures: One author reported consultancies and research grants from a range of pharmaceutical companies. There were no other disclosures.
6. ACP: Avoid ECG, MPI Cardiac Screening in Low-risk Patients
To take the posttest, go to: http://bit.ly/1e3NLha
Here are 6 articles in the June issue of Clinician Reviews (accreditation valid until January 1, 2016):
1. ACCP and CTS Issue Joint Guideline on COPD Exacerbations
To take the posttest, go to: http://bit.ly/1EIadmv
VITALS
Key clinical point: The American College of Chest Physicians and the Canadian Thoracic Society have issued a guideline for prevention of acute exacerbations of COPD.
Major finding: COPD exacerbations are acute, trajectory changing, and often deadly manifestations of a chronic disease.
Data source: A comprehensive literature review on prevention of acute COPD exacerbations and a compilation of 33 recommendations and suggestions for clinicians in clinical practice.
Disclosures: The American College of Chest Physicians, the Canadian Thoracic Society, and the American Thoracic Society supported the project. Dr Criner reported having no relevant financial disclosures; his associates reported ties to numerous industry sources.
2. GI Symptoms Common in Parkinson Disease and Related Disorders
To take the posttest, go to: http://bit.ly/1AZSaXA
VITALS
Key clinical point: GI symptoms were linked with specific motor and nonmotor features of Parkinson disease and related disorders.
Major finding: Constipation was the most common symptom among all three parkinsonian disorders.
Data source: Multicenter, cross-sectional survey of 473 patients with Parkinson disease, atypical parkinsonism, or vascular parkinsonism.
Disclosures: The Collaborative Clinical Research Fund of Boramae Medical Center partially funded the work. The authors declared no relevant conflicts of interest.
3. Aerosolized Measles Vaccine Inferior to Subcutaneous
To take the posttest, go to: http://bit.ly/1RKJizC
VITALS
Key clinical point: An aerosolized measles vaccine was immunogenic but inferior to the subcutaneous vaccine at inducing seropositivity among babies residing in rural India.
Major finding: The primary endpoint—seropositivity for antibodies against measles at 91 days after vaccination—was 85.4% for aerosolized vaccine and 94.6% for subcutaneous.
Data source: An open-label, randomized noninferiority trial comparing aerosolized vs subcutaneous measles vaccination in 2,004 infants ages 9 to 11.9 months in villages in India.
Disclosures: This study was funded by the Bill and Melinda Gates Foundation. The Serum Institute of India provided vaccines free of charge, and Aerogen provided the delivery devices free of charge. Dr Low reported several grants plus monies paid to her institution from the World Health Organization for projects about vaccines and sexually transmitted infections; her associates reported ties to the Serum Institute of India, Aerogen, and Dance Biopharm. One associate has a patent pending on an aerosol device licensed to Novartis and another has a patent pending related to vaccine nebulizers.
4. Unrecognized Diabetes Common in Acute MI
To take the posttest, go to: http://bit.ly/1IB9sC8
VITALS
Key clinical point: Many patients presenting with acute MI had unrecognized diabetes, which, in most cases, remained undiagnosed, untreated, and unrecorded.
Major finding: Of 2,854 (10%) patients enrolled in an MI registry, 287 had A1C levels of 6.5% or higher on routine laboratory testing during hospitalization for acute MI, but treating physicians recognized only 101 of these cases of diabetes (35%).
Data source: A retrospective cohort study involving 2,854 adults presenting with acute MI to 24 US medical centers in a 3.5-year period.
Disclosures: This study was sponsored by the National Heart, Lung, and Blood Institute and supported by a research grant from Genentech. Dr Arnold reported receiving honoraria from Novartis; her associates reported ties to numerous industry sources.
5. Methotrexate and Biologics Linked to Higher Zoster Risk in Psoriasis
To take the posttest, go to: http://bit.ly/1AZScyF
VITALS
Key clinical point: The combination of methotrexate and biologics for the treatment of psoriasis may increase risk for herpes zoster.
Major finding: Combination therapy with both biologic medications and methotrexate was associated with a significant 66% increase in the incidence of herpes zoster over more than 11 years of follow-up.
Data source: Analysis of medical records for 95,941 patients with psoriasis.
Disclosures: One author reported consultancies and research grants from a range of pharmaceutical companies. There were no other disclosures.
6. ACP: Avoid ECG, MPI Cardiac Screening in Low-risk Patients
To take the posttest, go to: http://bit.ly/1e3NLha
Here are 6 articles in the June issue of Clinician Reviews (accreditation valid until January 1, 2016):
1. ACCP and CTS Issue Joint Guideline on COPD Exacerbations
To take the posttest, go to: http://bit.ly/1EIadmv
VITALS
Key clinical point: The American College of Chest Physicians and the Canadian Thoracic Society have issued a guideline for prevention of acute exacerbations of COPD.
Major finding: COPD exacerbations are acute, trajectory changing, and often deadly manifestations of a chronic disease.
Data source: A comprehensive literature review on prevention of acute COPD exacerbations and a compilation of 33 recommendations and suggestions for clinicians in clinical practice.
Disclosures: The American College of Chest Physicians, the Canadian Thoracic Society, and the American Thoracic Society supported the project. Dr Criner reported having no relevant financial disclosures; his associates reported ties to numerous industry sources.
2. GI Symptoms Common in Parkinson Disease and Related Disorders
To take the posttest, go to: http://bit.ly/1AZSaXA
VITALS
Key clinical point: GI symptoms were linked with specific motor and nonmotor features of Parkinson disease and related disorders.
Major finding: Constipation was the most common symptom among all three parkinsonian disorders.
Data source: Multicenter, cross-sectional survey of 473 patients with Parkinson disease, atypical parkinsonism, or vascular parkinsonism.
Disclosures: The Collaborative Clinical Research Fund of Boramae Medical Center partially funded the work. The authors declared no relevant conflicts of interest.
3. Aerosolized Measles Vaccine Inferior to Subcutaneous
To take the posttest, go to: http://bit.ly/1RKJizC
VITALS
Key clinical point: An aerosolized measles vaccine was immunogenic but inferior to the subcutaneous vaccine at inducing seropositivity among babies residing in rural India.
Major finding: The primary endpoint—seropositivity for antibodies against measles at 91 days after vaccination—was 85.4% for aerosolized vaccine and 94.6% for subcutaneous.
Data source: An open-label, randomized noninferiority trial comparing aerosolized vs subcutaneous measles vaccination in 2,004 infants ages 9 to 11.9 months in villages in India.
Disclosures: This study was funded by the Bill and Melinda Gates Foundation. The Serum Institute of India provided vaccines free of charge, and Aerogen provided the delivery devices free of charge. Dr Low reported several grants plus monies paid to her institution from the World Health Organization for projects about vaccines and sexually transmitted infections; her associates reported ties to the Serum Institute of India, Aerogen, and Dance Biopharm. One associate has a patent pending on an aerosol device licensed to Novartis and another has a patent pending related to vaccine nebulizers.
4. Unrecognized Diabetes Common in Acute MI
To take the posttest, go to: http://bit.ly/1IB9sC8
VITALS
Key clinical point: Many patients presenting with acute MI had unrecognized diabetes, which, in most cases, remained undiagnosed, untreated, and unrecorded.
Major finding: Of 2,854 (10%) patients enrolled in an MI registry, 287 had A1C levels of 6.5% or higher on routine laboratory testing during hospitalization for acute MI, but treating physicians recognized only 101 of these cases of diabetes (35%).
Data source: A retrospective cohort study involving 2,854 adults presenting with acute MI to 24 US medical centers in a 3.5-year period.
Disclosures: This study was sponsored by the National Heart, Lung, and Blood Institute and supported by a research grant from Genentech. Dr Arnold reported receiving honoraria from Novartis; her associates reported ties to numerous industry sources.
5. Methotrexate and Biologics Linked to Higher Zoster Risk in Psoriasis
To take the posttest, go to: http://bit.ly/1AZScyF
VITALS
Key clinical point: The combination of methotrexate and biologics for the treatment of psoriasis may increase risk for herpes zoster.
Major finding: Combination therapy with both biologic medications and methotrexate was associated with a significant 66% increase in the incidence of herpes zoster over more than 11 years of follow-up.
Data source: Analysis of medical records for 95,941 patients with psoriasis.
Disclosures: One author reported consultancies and research grants from a range of pharmaceutical companies. There were no other disclosures.
6. ACP: Avoid ECG, MPI Cardiac Screening in Low-risk Patients
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