Doug Brunk

SAN DIEGO – In the opinion of Kimberly J. Butterwick, MD, there are at least three reasons why dermatologists should consider incorporating cosmeceuticals into their aesthetic practice

First, if you don’t, patients will buy products elsewhere. “There’s good data showing that 80% of patients will purchase a product within 24 hours of an office visit,” Dr. Butterwick said at the annual Masters of Aesthetics Symposium.

“You should be the one giving them unbiased advice, because patients waste a lot of money on products which aren’t that effective. Female patients spend an average of $2,000 per year on cosmetics. The average woman uses 15 different cosmetics per day,” according to Dr. Butterwick.

A second reason to consider selling cosmeceuticals is that patients visit dermatologists in order to have healthy, beautiful skin. “Patients want and need your expertise,” said Dr. Butterwick, one of five board-certified dermatologists who practices at the San Diego-based Cosmetic Laser Dermatology. “Patients who are educated and are given advice have better compliance and outcomes. You also want to care for patients for life, to show that you have an interest in treating them beyond what they come to see you for. That will make them come back to you. They’ll get refills and visits and more advice.”

A third reason to consider selling moisturizers, bleaching agents, and other cosmeceuticals is that it’s good for business. “It can be profitable, not just to you, but it’s an opportunity for employees to be creative and earn more with a product sales incentive,” Dr. Butterwick said. “Some of them are great sellers.” She and her colleagues at Cosmetic Laser Dermatology hit more than $1 million in gross revenue from cosmeceutical sales in 2016, 2017, and 2018. In 2018 alone, they sold 167 different products across 27 skin care lines. Six product lines brought in 84% of total sales: SkinMedica, Calecim, SkinCeuticals, Neocutis, Colorescience, and Topix. “Antiaging products are always going to be the number one seller,” she said, including antioxidants, peptides, growth factors, retinoids, hydroxyacids, botanicals, nutriceuticals, teeth-whitening agents, and supplements. New serums with solid science behind them, she continued, include Multi-Action Cream, a product from Calecim that contains a cytokine and growth factor blend from umbilical cord stem cells of red deer to stimulate collagen production and healing after procedures. In 2020, Dr. Butterwick said that SkinMedica’s TNS Essential Serum will contain human fibroblasts grown at low oxygen levels. These are designed to behave as embryonic fibroblasts with more effective growth factors, resulting in better collagen production.

“You want to take the high road when selling cosmeceuticals,” said Dr. Butterwick, who also was a co-founder of SkinMedica. “Provide guidance and education to steer your patients toward products that have proven efficacy, safety, are well tolerated, and are tested and approved by office staff and patients.”

Her tips for effective dispensing include selecting products that target your patient base and the climate in your area, and starting with a specific product line such as SkinMedica, Obagi, SkinCeuticals, Colorescience, Alastin, or Skin Better. “When you choose a company, make sure they have good return policies,” she said. “Get that in writing. Make sure they’ll educate your staff, and make sure they have some system in place to monitor unauthorized sales online. A lot of companies have this now. At trade shows, I’ve learned that some companies will dump expired products, which people buy at a discount and sell online. You don’t want to be competing with that kind of situation.”

She recommends setting aside a dedicated area in your office to display products, “whether it’s the checkout counter in your waiting room or a separate room that resembles a store,” she said. “For effective dispensing, physician-directed products are best. Explain the science: why you are recommending a product and why it is effective. Staff can review the regimen and try products with the patient. A written regimen assures compliance. You also want to offer patients discounts for multiple products or a featured brand of the month. Offer free shipping for refills, and consider linking products with procedures for a discount.”

Citing independent research conducted for a major cosmetics company, Dr. Butterwick said that patients are initially excited to purchase a cosmeceutical product, but once they get home compliance wanes. Only 30% buy the product a second time, and only 12% buy it a third time. “Reasons why so many drop off include that they find it inconvenient to buy, they forgot how to use the product, they become demotivated or distracted, or they shop around for a lower price,” she explained. “Remind your patients not to buy products online. Many of these products are expired or counterfeit. There’s so much information available online, but why not be a source of truth and tell them what’s really going to help? That’s going to assure your patient of the best outcome. It will also keep your patient loyal to you and your practice.”

In addition to co-founding SkinMedica, Dr. Butterwick disclosed that she has received grants/research support from Allergan, Galderma, and Histogen, and consulting fees from Allergan, Colorescience, Evolus, Galderma, Merz, and Sinclair. She is also a member of the speakers’ bureau for Allergan and Merz.

[email protected]

SAN DIEGO – In the opinion of Kimberly J. Butterwick, MD, there are at least three reasons why dermatologists should consider incorporating cosmeceuticals into their aesthetic practice

First, if you don’t, patients will buy products elsewhere. “There’s good data showing that 80% of patients will purchase a product within 24 hours of an office visit,” Dr. Butterwick said at the annual Masters of Aesthetics Symposium.

“You should be the one giving them unbiased advice, because patients waste a lot of money on products which aren’t that effective. Female patients spend an average of $2,000 per year on cosmetics. The average woman uses 15 different cosmetics per day,” according to Dr. Butterwick.

A second reason to consider selling cosmeceuticals is that patients visit dermatologists in order to have healthy, beautiful skin. “Patients want and need your expertise,” said Dr. Butterwick, one of five board-certified dermatologists who practices at the San Diego-based Cosmetic Laser Dermatology. “Patients who are educated and are given advice have better compliance and outcomes. You also want to care for patients for life, to show that you have an interest in treating them beyond what they come to see you for. That will make them come back to you. They’ll get refills and visits and more advice.”

A third reason to consider selling moisturizers, bleaching agents, and other cosmeceuticals is that it’s good for business. “It can be profitable, not just to you, but it’s an opportunity for employees to be creative and earn more with a product sales incentive,” Dr. Butterwick said. “Some of them are great sellers.” She and her colleagues at Cosmetic Laser Dermatology hit more than $1 million in gross revenue from cosmeceutical sales in 2016, 2017, and 2018. In 2018 alone, they sold 167 different products across 27 skin care lines. Six product lines brought in 84% of total sales: SkinMedica, Calecim, SkinCeuticals, Neocutis, Colorescience, and Topix. “Antiaging products are always going to be the number one seller,” she said, including antioxidants, peptides, growth factors, retinoids, hydroxyacids, botanicals, nutriceuticals, teeth-whitening agents, and supplements. New serums with solid science behind them, she continued, include Multi-Action Cream, a product from Calecim that contains a cytokine and growth factor blend from umbilical cord stem cells of red deer to stimulate collagen production and healing after procedures. In 2020, Dr. Butterwick said that SkinMedica’s TNS Essential Serum will contain human fibroblasts grown at low oxygen levels. These are designed to behave as embryonic fibroblasts with more effective growth factors, resulting in better collagen production.

“You want to take the high road when selling cosmeceuticals,” said Dr. Butterwick, who also was a co-founder of SkinMedica. “Provide guidance and education to steer your patients toward products that have proven efficacy, safety, are well tolerated, and are tested and approved by office staff and patients.”

Her tips for effective dispensing include selecting products that target your patient base and the climate in your area, and starting with a specific product line such as SkinMedica, Obagi, SkinCeuticals, Colorescience, Alastin, or Skin Better. “When you choose a company, make sure they have good return policies,” she said. “Get that in writing. Make sure they’ll educate your staff, and make sure they have some system in place to monitor unauthorized sales online. A lot of companies have this now. At trade shows, I’ve learned that some companies will dump expired products, which people buy at a discount and sell online. You don’t want to be competing with that kind of situation.”

She recommends setting aside a dedicated area in your office to display products, “whether it’s the checkout counter in your waiting room or a separate room that resembles a store,” she said. “For effective dispensing, physician-directed products are best. Explain the science: why you are recommending a product and why it is effective. Staff can review the regimen and try products with the patient. A written regimen assures compliance. You also want to offer patients discounts for multiple products or a featured brand of the month. Offer free shipping for refills, and consider linking products with procedures for a discount.”

Citing independent research conducted for a major cosmetics company, Dr. Butterwick said that patients are initially excited to purchase a cosmeceutical product, but once they get home compliance wanes. Only 30% buy the product a second time, and only 12% buy it a third time. “Reasons why so many drop off include that they find it inconvenient to buy, they forgot how to use the product, they become demotivated or distracted, or they shop around for a lower price,” she explained. “Remind your patients not to buy products online. Many of these products are expired or counterfeit. There’s so much information available online, but why not be a source of truth and tell them what’s really going to help? That’s going to assure your patient of the best outcome. It will also keep your patient loyal to you and your practice.”

In addition to co-founding SkinMedica, Dr. Butterwick disclosed that she has received grants/research support from Allergan, Galderma, and Histogen, and consulting fees from Allergan, Colorescience, Evolus, Galderma, Merz, and Sinclair. She is also a member of the speakers’ bureau for Allergan and Merz.

[email protected]

SAN DIEGO – In the opinion of Kimberly J. Butterwick, MD, there are at least three reasons why dermatologists should consider incorporating cosmeceuticals into their aesthetic practice

First, if you don’t, patients will buy products elsewhere. “There’s good data showing that 80% of patients will purchase a product within 24 hours of an office visit,” Dr. Butterwick said at the annual Masters of Aesthetics Symposium.

“You should be the one giving them unbiased advice, because patients waste a lot of money on products which aren’t that effective. Female patients spend an average of $2,000 per year on cosmetics. The average woman uses 15 different cosmetics per day,” according to Dr. Butterwick.

A second reason to consider selling cosmeceuticals is that patients visit dermatologists in order to have healthy, beautiful skin. “Patients want and need your expertise,” said Dr. Butterwick, one of five board-certified dermatologists who practices at the San Diego-based Cosmetic Laser Dermatology. “Patients who are educated and are given advice have better compliance and outcomes. You also want to care for patients for life, to show that you have an interest in treating them beyond what they come to see you for. That will make them come back to you. They’ll get refills and visits and more advice.”

A third reason to consider selling moisturizers, bleaching agents, and other cosmeceuticals is that it’s good for business. “It can be profitable, not just to you, but it’s an opportunity for employees to be creative and earn more with a product sales incentive,” Dr. Butterwick said. “Some of them are great sellers.” She and her colleagues at Cosmetic Laser Dermatology hit more than $1 million in gross revenue from cosmeceutical sales in 2016, 2017, and 2018. In 2018 alone, they sold 167 different products across 27 skin care lines. Six product lines brought in 84% of total sales: SkinMedica, Calecim, SkinCeuticals, Neocutis, Colorescience, and Topix. “Antiaging products are always going to be the number one seller,” she said, including antioxidants, peptides, growth factors, retinoids, hydroxyacids, botanicals, nutriceuticals, teeth-whitening agents, and supplements. New serums with solid science behind them, she continued, include Multi-Action Cream, a product from Calecim that contains a cytokine and growth factor blend from umbilical cord stem cells of red deer to stimulate collagen production and healing after procedures. In 2020, Dr. Butterwick said that SkinMedica’s TNS Essential Serum will contain human fibroblasts grown at low oxygen levels. These are designed to behave as embryonic fibroblasts with more effective growth factors, resulting in better collagen production.

“You want to take the high road when selling cosmeceuticals,” said Dr. Butterwick, who also was a co-founder of SkinMedica. “Provide guidance and education to steer your patients toward products that have proven efficacy, safety, are well tolerated, and are tested and approved by office staff and patients.”

Her tips for effective dispensing include selecting products that target your patient base and the climate in your area, and starting with a specific product line such as SkinMedica, Obagi, SkinCeuticals, Colorescience, Alastin, or Skin Better. “When you choose a company, make sure they have good return policies,” she said. “Get that in writing. Make sure they’ll educate your staff, and make sure they have some system in place to monitor unauthorized sales online. A lot of companies have this now. At trade shows, I’ve learned that some companies will dump expired products, which people buy at a discount and sell online. You don’t want to be competing with that kind of situation.”

She recommends setting aside a dedicated area in your office to display products, “whether it’s the checkout counter in your waiting room or a separate room that resembles a store,” she said. “For effective dispensing, physician-directed products are best. Explain the science: why you are recommending a product and why it is effective. Staff can review the regimen and try products with the patient. A written regimen assures compliance. You also want to offer patients discounts for multiple products or a featured brand of the month. Offer free shipping for refills, and consider linking products with procedures for a discount.”

Citing independent research conducted for a major cosmetics company, Dr. Butterwick said that patients are initially excited to purchase a cosmeceutical product, but once they get home compliance wanes. Only 30% buy the product a second time, and only 12% buy it a third time. “Reasons why so many drop off include that they find it inconvenient to buy, they forgot how to use the product, they become demotivated or distracted, or they shop around for a lower price,” she explained. “Remind your patients not to buy products online. Many of these products are expired or counterfeit. There’s so much information available online, but why not be a source of truth and tell them what’s really going to help? That’s going to assure your patient of the best outcome. It will also keep your patient loyal to you and your practice.”

In addition to co-founding SkinMedica, Dr. Butterwick disclosed that she has received grants/research support from Allergan, Galderma, and Histogen, and consulting fees from Allergan, Colorescience, Evolus, Galderma, Merz, and Sinclair. She is also a member of the speakers’ bureau for Allergan and Merz.

[email protected]

SAN DIEGO – If the idea of marketing your aesthetic dermatology services to Millennials is an afterthought, Brian Biesman, MD, recommends that you reconsider that outlook. At the annual Masters of Aesthetics Symposium, Dr. Biesman told attendees that the age group dubbed as the “Me Me Me Generation” by Joel Stein of Time Magazine is slowly overtaking Baby Boomers as the largest shopping generation in history.

A large consumer survey conducted by Accenture found that by 2020, spending by Millennials will account for $1.4 trillion in U.S. retail sales. This segment of the population, which the Pew Research Center defines as those born from 1981 to 1996, also spends more online than any other generation. According to data from the consulting firm Bain & Company, 25% of luxury goods will be purchased online by 2025, up from 8% in 2016. “Millennials are going to be a huge economic driving force,” Dr. Biesman said.

Dr. Biesman, an oculofacial plastic surgeon who practices in Nashville, Tenn., said Millennials were born into a digital age. “They are very socially connected, sometimes to their detriment,” said Dr. Biesman, who is a past president of the American Society for Laser Medicine and Surgery. “They’re definitely in debt ... but they’re comfortable with that and don’t mind spending. Their priorities are different. They tend to put off marriage and having kids, and they’re driven by social media.

They also hold a strong interest in appearance, said Dr, Biesman, who noted that the average Millennial woman is more likely to be aware of beauty issues by a factor of 10 years younger than her mother’s generation. “At age 25, Millennial women are getting interested in aesthetics, whereas the older generation didn’t start until about 35,” he said. Millennials “are educated, and they use the Internet to read up on procedures.” In his clinical experience, Millennials seek aesthetic treatments to resolve specific issues such as acne scars, to try noninvasive aesthetic treatments for “prejuvenation,” to beautify or to address dissatisfaction with their appearance, and to keep up with the latest trends endorsed or promoted by the media or by celebrities. The most popular procedures include neuromodulators, fillers (especially in the lips and in the infraorbital hollow), minimally invasive laser hair removal, superficial laser resurfacing, and prescription skin care and cosmeceuticals.

According to a 2018 survey of 500 Millennials conducted by the aesthetics site Zalea, 32% were considering a cosmetic procedure and 6.6% had undergone one. Of the 149 Millennials who completed all of the survey questions, 65% indicated that they relied on Google search for information about cosmetic treatments, which was a higher proportion than for physicians (63%), friends and family (60%), and social networks such as Instagram, Facebook, and Twitter (25%). Dr. Biesman said that a paradigm shift is under way in aesthetic dermatology, in which the traditional means of achieving a strong reputation amongst patients by excellent training, publications, and research can be replaced by building a visible social media presence/personality.

“The social media influencer factor is a real phenomenon, and can carry tremendous weight due to their perceived relationship with their audience/followers,” Dr. Biesman said. “Some physicians are influencers, while others collaborate with influencers.” He emphasized that the decision to work with social media influencers depends on your preference, your comfort level/trust, the professionalism of the influencer, and your overall social media strategy. “The more you share about yourself, the more successful your social media account will be,” he said. “You need to determine your comfort zone, such as how much of your life you want to share.”

He advises aesthetic dermatologists to develop a strategy for reaching out to and incorporating Millennials into their practice. “Be deliberate in assessing the profile of your practice demographics, and determine which patient groups you want to serve, and to what extent,” he said. “If your practice is focused on minimally invasive aesthetics, it’s important to understand the Millennial mindset, because this is the largest group of consumers.”

Dr. Biesman reported having no relevant disclosures related to his presentation.

[email protected]

SAN DIEGO – If the idea of marketing your aesthetic dermatology services to Millennials is an afterthought, Brian Biesman, MD, recommends that you reconsider that outlook. At the annual Masters of Aesthetics Symposium, Dr. Biesman told attendees that the age group dubbed as the “Me Me Me Generation” by Joel Stein of Time Magazine is slowly overtaking Baby Boomers as the largest shopping generation in history.

A large consumer survey conducted by Accenture found that by 2020, spending by Millennials will account for $1.4 trillion in U.S. retail sales. This segment of the population, which the Pew Research Center defines as those born from 1981 to 1996, also spends more online than any other generation. According to data from the consulting firm Bain & Company, 25% of luxury goods will be purchased online by 2025, up from 8% in 2016. “Millennials are going to be a huge economic driving force,” Dr. Biesman said.

Dr. Biesman, an oculofacial plastic surgeon who practices in Nashville, Tenn., said Millennials were born into a digital age. “They are very socially connected, sometimes to their detriment,” said Dr. Biesman, who is a past president of the American Society for Laser Medicine and Surgery. “They’re definitely in debt ... but they’re comfortable with that and don’t mind spending. Their priorities are different. They tend to put off marriage and having kids, and they’re driven by social media.

They also hold a strong interest in appearance, said Dr, Biesman, who noted that the average Millennial woman is more likely to be aware of beauty issues by a factor of 10 years younger than her mother’s generation. “At age 25, Millennial women are getting interested in aesthetics, whereas the older generation didn’t start until about 35,” he said. Millennials “are educated, and they use the Internet to read up on procedures.” In his clinical experience, Millennials seek aesthetic treatments to resolve specific issues such as acne scars, to try noninvasive aesthetic treatments for “prejuvenation,” to beautify or to address dissatisfaction with their appearance, and to keep up with the latest trends endorsed or promoted by the media or by celebrities. The most popular procedures include neuromodulators, fillers (especially in the lips and in the infraorbital hollow), minimally invasive laser hair removal, superficial laser resurfacing, and prescription skin care and cosmeceuticals.

According to a 2018 survey of 500 Millennials conducted by the aesthetics site Zalea, 32% were considering a cosmetic procedure and 6.6% had undergone one. Of the 149 Millennials who completed all of the survey questions, 65% indicated that they relied on Google search for information about cosmetic treatments, which was a higher proportion than for physicians (63%), friends and family (60%), and social networks such as Instagram, Facebook, and Twitter (25%). Dr. Biesman said that a paradigm shift is under way in aesthetic dermatology, in which the traditional means of achieving a strong reputation amongst patients by excellent training, publications, and research can be replaced by building a visible social media presence/personality.

“The social media influencer factor is a real phenomenon, and can carry tremendous weight due to their perceived relationship with their audience/followers,” Dr. Biesman said. “Some physicians are influencers, while others collaborate with influencers.” He emphasized that the decision to work with social media influencers depends on your preference, your comfort level/trust, the professionalism of the influencer, and your overall social media strategy. “The more you share about yourself, the more successful your social media account will be,” he said. “You need to determine your comfort zone, such as how much of your life you want to share.”

He advises aesthetic dermatologists to develop a strategy for reaching out to and incorporating Millennials into their practice. “Be deliberate in assessing the profile of your practice demographics, and determine which patient groups you want to serve, and to what extent,” he said. “If your practice is focused on minimally invasive aesthetics, it’s important to understand the Millennial mindset, because this is the largest group of consumers.”

Dr. Biesman reported having no relevant disclosures related to his presentation.

[email protected]

SAN DIEGO – If the idea of marketing your aesthetic dermatology services to Millennials is an afterthought, Brian Biesman, MD, recommends that you reconsider that outlook. At the annual Masters of Aesthetics Symposium, Dr. Biesman told attendees that the age group dubbed as the “Me Me Me Generation” by Joel Stein of Time Magazine is slowly overtaking Baby Boomers as the largest shopping generation in history.

A large consumer survey conducted by Accenture found that by 2020, spending by Millennials will account for $1.4 trillion in U.S. retail sales. This segment of the population, which the Pew Research Center defines as those born from 1981 to 1996, also spends more online than any other generation. According to data from the consulting firm Bain & Company, 25% of luxury goods will be purchased online by 2025, up from 8% in 2016. “Millennials are going to be a huge economic driving force,” Dr. Biesman said.

Dr. Biesman, an oculofacial plastic surgeon who practices in Nashville, Tenn., said Millennials were born into a digital age. “They are very socially connected, sometimes to their detriment,” said Dr. Biesman, who is a past president of the American Society for Laser Medicine and Surgery. “They’re definitely in debt ... but they’re comfortable with that and don’t mind spending. Their priorities are different. They tend to put off marriage and having kids, and they’re driven by social media.

They also hold a strong interest in appearance, said Dr, Biesman, who noted that the average Millennial woman is more likely to be aware of beauty issues by a factor of 10 years younger than her mother’s generation. “At age 25, Millennial women are getting interested in aesthetics, whereas the older generation didn’t start until about 35,” he said. Millennials “are educated, and they use the Internet to read up on procedures.” In his clinical experience, Millennials seek aesthetic treatments to resolve specific issues such as acne scars, to try noninvasive aesthetic treatments for “prejuvenation,” to beautify or to address dissatisfaction with their appearance, and to keep up with the latest trends endorsed or promoted by the media or by celebrities. The most popular procedures include neuromodulators, fillers (especially in the lips and in the infraorbital hollow), minimally invasive laser hair removal, superficial laser resurfacing, and prescription skin care and cosmeceuticals.

According to a 2018 survey of 500 Millennials conducted by the aesthetics site Zalea, 32% were considering a cosmetic procedure and 6.6% had undergone one. Of the 149 Millennials who completed all of the survey questions, 65% indicated that they relied on Google search for information about cosmetic treatments, which was a higher proportion than for physicians (63%), friends and family (60%), and social networks such as Instagram, Facebook, and Twitter (25%). Dr. Biesman said that a paradigm shift is under way in aesthetic dermatology, in which the traditional means of achieving a strong reputation amongst patients by excellent training, publications, and research can be replaced by building a visible social media presence/personality.

“The social media influencer factor is a real phenomenon, and can carry tremendous weight due to their perceived relationship with their audience/followers,” Dr. Biesman said. “Some physicians are influencers, while others collaborate with influencers.” He emphasized that the decision to work with social media influencers depends on your preference, your comfort level/trust, the professionalism of the influencer, and your overall social media strategy. “The more you share about yourself, the more successful your social media account will be,” he said. “You need to determine your comfort zone, such as how much of your life you want to share.”

He advises aesthetic dermatologists to develop a strategy for reaching out to and incorporating Millennials into their practice. “Be deliberate in assessing the profile of your practice demographics, and determine which patient groups you want to serve, and to what extent,” he said. “If your practice is focused on minimally invasive aesthetics, it’s important to understand the Millennial mindset, because this is the largest group of consumers.”

Dr. Biesman reported having no relevant disclosures related to his presentation.

[email protected]

AUSTIN, TEX. – For children and adolescents with severe, refractory atopic dermatitis, Peter A. Lio, MD, often turns to cyclosporine as his systemic treatment of choice.

Doug Brunk/MDedge News

Cyclosporine “works quickly, and it’s very reliable,” Dr. Lio said at the annual meeting of the Society for Pediatric Dermatology. “In my experience, more than 90% of patients will see significant improvement, but there are real risks, including hypertension, kidney damage, monthly blood work, tremor, hypertrichosis, gum hypertrophy, and cancer/infection risk.”

To mitigate those risks, Dr. Lio, of the departments of dermatology and pediatrics at Northwestern University, Chicago, prescribes cyclosporine for 3-6 months at a dose of 5 mg/kg per day with a cap of 300 mg per day to “to cool things down.” He then transitions patients to phototherapy or mycophenolate right away. “Those are my two favorites,” he said. “Methotrexate can also be used, but I rarely use azathioprine.

“If you do this, you avoid most of the major risks and you can put people in a remission. More than half of the time, maybe two-thirds of the time, I get them into at least a relative remission,” Dr. Lio said.

While patients are on cyclosporine, blood pressure should be monitored each week for 4 weeks, and then monthly, he said. Draws for complete blood count, liver function tests, comprehensive metabolic panel, uric acid, and lipids should be performed monthly for 3 months, then every 8 weeks, he advised. Dr. Lio typically maintains the cyclosporine for 3 months, then tapers patients off the drug.

Patients who continue to struggle for relief might try taking cyclosporine on weekends only, a concept reported by Spanish investigators in 2015 (Pediatr Dermatol 2015 32[4]:551-2). “This involves twice-daily full dosing just on Saturdays and Sundays,” Dr. Lio said. “I now have quite a few patients doing well with this approach.”

Dr. Lio disclosed having financial ties to numerous pharmaceutical companies but none related to cyclosporine.

[email protected]

AUSTIN, TEX. – For children and adolescents with severe, refractory atopic dermatitis, Peter A. Lio, MD, often turns to cyclosporine as his systemic treatment of choice.

Doug Brunk/MDedge News

Cyclosporine “works quickly, and it’s very reliable,” Dr. Lio said at the annual meeting of the Society for Pediatric Dermatology. “In my experience, more than 90% of patients will see significant improvement, but there are real risks, including hypertension, kidney damage, monthly blood work, tremor, hypertrichosis, gum hypertrophy, and cancer/infection risk.”

To mitigate those risks, Dr. Lio, of the departments of dermatology and pediatrics at Northwestern University, Chicago, prescribes cyclosporine for 3-6 months at a dose of 5 mg/kg per day with a cap of 300 mg per day to “to cool things down.” He then transitions patients to phototherapy or mycophenolate right away. “Those are my two favorites,” he said. “Methotrexate can also be used, but I rarely use azathioprine.

“If you do this, you avoid most of the major risks and you can put people in a remission. More than half of the time, maybe two-thirds of the time, I get them into at least a relative remission,” Dr. Lio said.

While patients are on cyclosporine, blood pressure should be monitored each week for 4 weeks, and then monthly, he said. Draws for complete blood count, liver function tests, comprehensive metabolic panel, uric acid, and lipids should be performed monthly for 3 months, then every 8 weeks, he advised. Dr. Lio typically maintains the cyclosporine for 3 months, then tapers patients off the drug.

Patients who continue to struggle for relief might try taking cyclosporine on weekends only, a concept reported by Spanish investigators in 2015 (Pediatr Dermatol 2015 32[4]:551-2). “This involves twice-daily full dosing just on Saturdays and Sundays,” Dr. Lio said. “I now have quite a few patients doing well with this approach.”

Dr. Lio disclosed having financial ties to numerous pharmaceutical companies but none related to cyclosporine.

[email protected]

AUSTIN, TEX. – For children and adolescents with severe, refractory atopic dermatitis, Peter A. Lio, MD, often turns to cyclosporine as his systemic treatment of choice.

Doug Brunk/MDedge News

Cyclosporine “works quickly, and it’s very reliable,” Dr. Lio said at the annual meeting of the Society for Pediatric Dermatology. “In my experience, more than 90% of patients will see significant improvement, but there are real risks, including hypertension, kidney damage, monthly blood work, tremor, hypertrichosis, gum hypertrophy, and cancer/infection risk.”

To mitigate those risks, Dr. Lio, of the departments of dermatology and pediatrics at Northwestern University, Chicago, prescribes cyclosporine for 3-6 months at a dose of 5 mg/kg per day with a cap of 300 mg per day to “to cool things down.” He then transitions patients to phototherapy or mycophenolate right away. “Those are my two favorites,” he said. “Methotrexate can also be used, but I rarely use azathioprine.

“If you do this, you avoid most of the major risks and you can put people in a remission. More than half of the time, maybe two-thirds of the time, I get them into at least a relative remission,” Dr. Lio said.

While patients are on cyclosporine, blood pressure should be monitored each week for 4 weeks, and then monthly, he said. Draws for complete blood count, liver function tests, comprehensive metabolic panel, uric acid, and lipids should be performed monthly for 3 months, then every 8 weeks, he advised. Dr. Lio typically maintains the cyclosporine for 3 months, then tapers patients off the drug.

Patients who continue to struggle for relief might try taking cyclosporine on weekends only, a concept reported by Spanish investigators in 2015 (Pediatr Dermatol 2015 32[4]:551-2). “This involves twice-daily full dosing just on Saturdays and Sundays,” Dr. Lio said. “I now have quite a few patients doing well with this approach.”

Dr. Lio disclosed having financial ties to numerous pharmaceutical companies but none related to cyclosporine.

[email protected]

ORANGE, CALIF. – When Shannon Suo, MD, reached her family medicine rotation as a medical student at the University of Cincinnati, she recalls that the faculty “seemed a little lost” when they encountered patients who presented with psychiatric issues.

“If it were diabetes, high blood pressure, or back pain, they knew what to do; they had a plan,” said Dr. Suo, who is now training director for the combined family medicine/psychiatry residency at the University of California, Davis. “But when it came to depression, anxiety, maybe even some psychosis, they kind of looked a little nervous. Maybe they prescribed an antidepressant, but then they were like, ‘I don’t know what else to do for you.’ I felt uncomfortable with that.”

Eric Eschweiler, DNP, can identify with that sentiment. After he assumed the medical directorship of a federally qualified health center that opened 4 years ago in San Bernardino, Calif., nearly every person who presented for treatment had an underlying psychiatric disorder, from depression and anxiety to bipolar disorder and substance abuse stemming from childhood trauma.

“I really felt unprepared to take care of that population because with those mental health disorders, we would get a lot of concomitant chronic medical conditions,” Dr. Eschweiler said. “But they were not adherent, not compliant because they couldn’t control the mental health aspects, or we couldn’t get a handle on those issues.

“In [nurse practitioner] training, we really don’t get a whole lot of education related to the psychiatric component of health care,” he said. “I have a doctorate, but even with that, we didn’t get very much.”

When Dr. Eschweiler learned about a yearlong clinical fellowship designed for primary care–oriented trainees and clinicians who wish to receive advanced training in primary care psychiatry, he applied, “hoping I’d be first in line,” he said. He earned a spot in the 2018 class.

The program, known as the UC Irvine/UC Davis Train New Trainers (TNT) Primary Care Psychiatry (PCP) Fellowship, launched in 2016 as a way to train primary care clinicians to diagnose and treat the most common psychiatric conditions found in the primary care setting. The fellowship is aimed at educating not only MDs and DOs, but physician assistants, nurse practitioners, and pharmacists as well.

Doug Brunk/MDedge News

“We want to give high-quality training to as many people as we can in order to optimize and expand the psychiatric workforce,” said Robert M. McCarron, DO, founding codirector of the fellowship program, and professor and vice chair of education and integrated care at the University of California, Irvine. “That’s really what we’re trying to do here.”

According to Dr. McCarron, who founded the fellowship with seed money during his tenure as a faculty member at UC Davis, up to 60% of all behavioral health care is provided in the busy primary setting, and as many as 80% of antidepressants are prescribed by nonpsychiatrists. Couple that with the current psychiatric workforce shortage “and you have a perfect storm,” he said.

“The toughest part is the volume of patients primary care providers have to see, comingled with a high frequency of comorbid mental illness. Added on to that, they didn’t get the training for much of the conditions they’re trying to address or treat. A primary care provider can refer to a psychiatrist, but there is not a large referral base. In addition, plenty of studies show that about half of those patients don’t end up seeing a mental health provider. Resources are limited in many areas of the country.”

TNT PCP fellows participate in the year-long program during nonclinic hours and accrue more than 45 CME units. Much of the training involves online courses framed around the textbook Primary Care Psychiatry (Wolters Kluwer, 2019), but fellows also are required to attend two intensive weekend sessions where they drill down on core topics, such as how to conduct an effective psychiatric interview, techniques, and how to screen and treat for psychiatric disorders.

“It’s not just about medicine options,” said Jaesu Han, MD, a fellowship faculty member who is board certified in psychiatry and family medicine. “For example, we try to focus on basic principles of cognitive-behavioral therapy, the role of psychotherapy, and the role of motivational interviewing. We try to help the providers recognize that there are other tools available [besides medication]. Those principles are going to help them engage with their patients more and have a larger impact.”

During one of the intensive weekend sessions, fellows are required to give a PowerPoint lecture on a topic of their choosing, with the idea of getting them comfortable with training their primary care colleagues on principles they learn.

“Some fellows are training their staff on their lunch breaks, or they’re implementing different tools they learned in our program to their organization,” said Wendy Cant, MBA, who is TNT PCP’s administrative director.

During a PowerPoint presentation a few years ago, one fellow chose to lecture about how to administer long-term antipsychotic medication in the primary care setting, a topic that the TNT PCP faculty had not thought to recommend. “We thought that was something a primary care provider would punt on,” said Dr. Suo, who is codirector of the fellowship program. “The fellow said, ‘No. This makes absolute sense. Our offices are equipped to do IM injections; our medical staff are trained to do that. It’s something that improves adherence and outcomes. It stabilizes people, and it makes us better able to take care of that population and not have to punt.’ That was unexpected and gratifying to know that we increased his comfort level to that point.”

Fellows also participate in two interactive learning sessions per month with faculty members, and each is paired with a faculty mentor, with whom they meet monthly in person or by video call or phone call.

“One of my fellows is feeling overwhelmed because she’s been tasked with taking care of the general psychiatric population, to do initial triage before she refers off to one of very few psychiatrists,” said Matthew Reed, MD, MSPH, one of the faculty mentors who serves as director of education for TNT PCP. “Her biggest concern is, ‘How do I not hate what I’m doing with my job because it’s so stressful and all patients want are opioid analgesics, or all they want are some benzodiazepines? They always want something, and I can’t get them to do what I want them to do.’ ” Together, they discuss various tools that might help her situation, such as using motivational interviewing to foster a sense of collaboration with patients.

Dr. Reed used the analogy of skeet shooting to illustrate the point that, without inviting patients to share in decision making, they are more likely to “shoot down” interventions that clinicians suggest to them.

Currently, about 80% of the program’s 118 fellows practice in California, there is a similar proportion of men and women, and their experience levels range from trainees to seasoned clinicians.

“They have 10, 15, and in some cases 25 years of experience, and they’re saying, ‘I‘ve been practicing for years and have been struggling when it comes to psychiatric issues. I want to do better,’ ” Dr. Suo noted.

Tuition is $15,500, and it usually is covered by outside funding sources. Last year, the program received a $1 million grant from California’s Office of Statewide Health Planning and Development, which was enough to fund tuition for 62 fellows. TNT PCP administrators and faculty also formed sponsor partnerships with several health plans and counties, including Inland Empire Health Plan, LA Care, Alameda Health Consortium, and Fresno County.

Employers also have stepped up. Cedars-Sinai Medical Center recently supplied a grant to fund tuition for 30 affiliated clinicians from different service planning areas. Other organizations that support funding for the fellowship include the American Academy of Pediatrics, the California Academy of Family Physicians, the California Behavioral Health Directors Association, and the California Psychiatric Association.

Meanwhile, word about the TNT PCP program is spreading to clinicians in other states. “By far, the hardest part is helping fellows from out of state find funding in their area,” Ms. Cant said. “That’s new territory we are starting to look into, but typically it’s not out of pocket. We only had three people pay out of pocket last year.”

Program faculty hope to not only improve the fellows’ knowledge in psychiatry and better treatment for depression, anxiety, and substance abuse, but also decrease prescription of opioids and decrease the stigma that some clinicians might perceive in mental illness. “People come to our fellowship feeling like there’s a void in their training,” Dr. Suo said. “We’re able to fill that void. In the first year, we had a fellow who said that, after completing the program, she felt physically less tired at the end of the day, because she had been so anxious about what to do for her patients who came in with mental health complaints.

“Now she knows what to do, so she can relax and listen to them – and be more connected.”

In the spirit of paying his TNT PCP education forward, last year Dr. Eschweiler secured a Song Brown grant to implement a 2-day psychiatric course for family medicine NP students at Western University of Health Sciences in Pomona, Calif., where he holds a faculty post. After they completed the course, students spent 80 hours with Dr. Eschweiler or with a designated clinician in the clinic, where they applied what they learned.

“By the time we shared information with students who I received in the TNT PCP fellowship, their comfort level went up by 80%-90%,” he said. “Now, they’re able to move into practice and take care of a lot of these patients without having to punt.”

Such stories are heartening to TNT PCP faculty. “We simply do not have enough psychiatrists in the country to provide mental health care for everybody who needs it,” Dr. Suo said. “Unfortunately, that means primary care will have to take up the slack. We want to prepare people to be able to do that.”

For information about the 2020 TNT PCP Fellowship, visit www.psychiatry.uci.edu/tnt.

[email protected]

ORANGE, CALIF. – When Shannon Suo, MD, reached her family medicine rotation as a medical student at the University of Cincinnati, she recalls that the faculty “seemed a little lost” when they encountered patients who presented with psychiatric issues.

“If it were diabetes, high blood pressure, or back pain, they knew what to do; they had a plan,” said Dr. Suo, who is now training director for the combined family medicine/psychiatry residency at the University of California, Davis. “But when it came to depression, anxiety, maybe even some psychosis, they kind of looked a little nervous. Maybe they prescribed an antidepressant, but then they were like, ‘I don’t know what else to do for you.’ I felt uncomfortable with that.”

Eric Eschweiler, DNP, can identify with that sentiment. After he assumed the medical directorship of a federally qualified health center that opened 4 years ago in San Bernardino, Calif., nearly every person who presented for treatment had an underlying psychiatric disorder, from depression and anxiety to bipolar disorder and substance abuse stemming from childhood trauma.

“I really felt unprepared to take care of that population because with those mental health disorders, we would get a lot of concomitant chronic medical conditions,” Dr. Eschweiler said. “But they were not adherent, not compliant because they couldn’t control the mental health aspects, or we couldn’t get a handle on those issues.

“In [nurse practitioner] training, we really don’t get a whole lot of education related to the psychiatric component of health care,” he said. “I have a doctorate, but even with that, we didn’t get very much.”

When Dr. Eschweiler learned about a yearlong clinical fellowship designed for primary care–oriented trainees and clinicians who wish to receive advanced training in primary care psychiatry, he applied, “hoping I’d be first in line,” he said. He earned a spot in the 2018 class.

The program, known as the UC Irvine/UC Davis Train New Trainers (TNT) Primary Care Psychiatry (PCP) Fellowship, launched in 2016 as a way to train primary care clinicians to diagnose and treat the most common psychiatric conditions found in the primary care setting. The fellowship is aimed at educating not only MDs and DOs, but physician assistants, nurse practitioners, and pharmacists as well.

Doug Brunk/MDedge News

“We want to give high-quality training to as many people as we can in order to optimize and expand the psychiatric workforce,” said Robert M. McCarron, DO, founding codirector of the fellowship program, and professor and vice chair of education and integrated care at the University of California, Irvine. “That’s really what we’re trying to do here.”

According to Dr. McCarron, who founded the fellowship with seed money during his tenure as a faculty member at UC Davis, up to 60% of all behavioral health care is provided in the busy primary setting, and as many as 80% of antidepressants are prescribed by nonpsychiatrists. Couple that with the current psychiatric workforce shortage “and you have a perfect storm,” he said.

“The toughest part is the volume of patients primary care providers have to see, comingled with a high frequency of comorbid mental illness. Added on to that, they didn’t get the training for much of the conditions they’re trying to address or treat. A primary care provider can refer to a psychiatrist, but there is not a large referral base. In addition, plenty of studies show that about half of those patients don’t end up seeing a mental health provider. Resources are limited in many areas of the country.”

TNT PCP fellows participate in the year-long program during nonclinic hours and accrue more than 45 CME units. Much of the training involves online courses framed around the textbook Primary Care Psychiatry (Wolters Kluwer, 2019), but fellows also are required to attend two intensive weekend sessions where they drill down on core topics, such as how to conduct an effective psychiatric interview, techniques, and how to screen and treat for psychiatric disorders.

“It’s not just about medicine options,” said Jaesu Han, MD, a fellowship faculty member who is board certified in psychiatry and family medicine. “For example, we try to focus on basic principles of cognitive-behavioral therapy, the role of psychotherapy, and the role of motivational interviewing. We try to help the providers recognize that there are other tools available [besides medication]. Those principles are going to help them engage with their patients more and have a larger impact.”

During one of the intensive weekend sessions, fellows are required to give a PowerPoint lecture on a topic of their choosing, with the idea of getting them comfortable with training their primary care colleagues on principles they learn.

“Some fellows are training their staff on their lunch breaks, or they’re implementing different tools they learned in our program to their organization,” said Wendy Cant, MBA, who is TNT PCP’s administrative director.

During a PowerPoint presentation a few years ago, one fellow chose to lecture about how to administer long-term antipsychotic medication in the primary care setting, a topic that the TNT PCP faculty had not thought to recommend. “We thought that was something a primary care provider would punt on,” said Dr. Suo, who is codirector of the fellowship program. “The fellow said, ‘No. This makes absolute sense. Our offices are equipped to do IM injections; our medical staff are trained to do that. It’s something that improves adherence and outcomes. It stabilizes people, and it makes us better able to take care of that population and not have to punt.’ That was unexpected and gratifying to know that we increased his comfort level to that point.”

Fellows also participate in two interactive learning sessions per month with faculty members, and each is paired with a faculty mentor, with whom they meet monthly in person or by video call or phone call.

“One of my fellows is feeling overwhelmed because she’s been tasked with taking care of the general psychiatric population, to do initial triage before she refers off to one of very few psychiatrists,” said Matthew Reed, MD, MSPH, one of the faculty mentors who serves as director of education for TNT PCP. “Her biggest concern is, ‘How do I not hate what I’m doing with my job because it’s so stressful and all patients want are opioid analgesics, or all they want are some benzodiazepines? They always want something, and I can’t get them to do what I want them to do.’ ” Together, they discuss various tools that might help her situation, such as using motivational interviewing to foster a sense of collaboration with patients.

Dr. Reed used the analogy of skeet shooting to illustrate the point that, without inviting patients to share in decision making, they are more likely to “shoot down” interventions that clinicians suggest to them.

Currently, about 80% of the program’s 118 fellows practice in California, there is a similar proportion of men and women, and their experience levels range from trainees to seasoned clinicians.

“They have 10, 15, and in some cases 25 years of experience, and they’re saying, ‘I‘ve been practicing for years and have been struggling when it comes to psychiatric issues. I want to do better,’ ” Dr. Suo noted.

Tuition is $15,500, and it usually is covered by outside funding sources. Last year, the program received a $1 million grant from California’s Office of Statewide Health Planning and Development, which was enough to fund tuition for 62 fellows. TNT PCP administrators and faculty also formed sponsor partnerships with several health plans and counties, including Inland Empire Health Plan, LA Care, Alameda Health Consortium, and Fresno County.

Employers also have stepped up. Cedars-Sinai Medical Center recently supplied a grant to fund tuition for 30 affiliated clinicians from different service planning areas. Other organizations that support funding for the fellowship include the American Academy of Pediatrics, the California Academy of Family Physicians, the California Behavioral Health Directors Association, and the California Psychiatric Association.

Meanwhile, word about the TNT PCP program is spreading to clinicians in other states. “By far, the hardest part is helping fellows from out of state find funding in their area,” Ms. Cant said. “That’s new territory we are starting to look into, but typically it’s not out of pocket. We only had three people pay out of pocket last year.”

Program faculty hope to not only improve the fellows’ knowledge in psychiatry and better treatment for depression, anxiety, and substance abuse, but also decrease prescription of opioids and decrease the stigma that some clinicians might perceive in mental illness. “People come to our fellowship feeling like there’s a void in their training,” Dr. Suo said. “We’re able to fill that void. In the first year, we had a fellow who said that, after completing the program, she felt physically less tired at the end of the day, because she had been so anxious about what to do for her patients who came in with mental health complaints.

“Now she knows what to do, so she can relax and listen to them – and be more connected.”

In the spirit of paying his TNT PCP education forward, last year Dr. Eschweiler secured a Song Brown grant to implement a 2-day psychiatric course for family medicine NP students at Western University of Health Sciences in Pomona, Calif., where he holds a faculty post. After they completed the course, students spent 80 hours with Dr. Eschweiler or with a designated clinician in the clinic, where they applied what they learned.

“By the time we shared information with students who I received in the TNT PCP fellowship, their comfort level went up by 80%-90%,” he said. “Now, they’re able to move into practice and take care of a lot of these patients without having to punt.”

Such stories are heartening to TNT PCP faculty. “We simply do not have enough psychiatrists in the country to provide mental health care for everybody who needs it,” Dr. Suo said. “Unfortunately, that means primary care will have to take up the slack. We want to prepare people to be able to do that.”

For information about the 2020 TNT PCP Fellowship, visit www.psychiatry.uci.edu/tnt.

[email protected]

ORANGE, CALIF. – When Shannon Suo, MD, reached her family medicine rotation as a medical student at the University of Cincinnati, she recalls that the faculty “seemed a little lost” when they encountered patients who presented with psychiatric issues.

“If it were diabetes, high blood pressure, or back pain, they knew what to do; they had a plan,” said Dr. Suo, who is now training director for the combined family medicine/psychiatry residency at the University of California, Davis. “But when it came to depression, anxiety, maybe even some psychosis, they kind of looked a little nervous. Maybe they prescribed an antidepressant, but then they were like, ‘I don’t know what else to do for you.’ I felt uncomfortable with that.”

Eric Eschweiler, DNP, can identify with that sentiment. After he assumed the medical directorship of a federally qualified health center that opened 4 years ago in San Bernardino, Calif., nearly every person who presented for treatment had an underlying psychiatric disorder, from depression and anxiety to bipolar disorder and substance abuse stemming from childhood trauma.

“I really felt unprepared to take care of that population because with those mental health disorders, we would get a lot of concomitant chronic medical conditions,” Dr. Eschweiler said. “But they were not adherent, not compliant because they couldn’t control the mental health aspects, or we couldn’t get a handle on those issues.

“In [nurse practitioner] training, we really don’t get a whole lot of education related to the psychiatric component of health care,” he said. “I have a doctorate, but even with that, we didn’t get very much.”

When Dr. Eschweiler learned about a yearlong clinical fellowship designed for primary care–oriented trainees and clinicians who wish to receive advanced training in primary care psychiatry, he applied, “hoping I’d be first in line,” he said. He earned a spot in the 2018 class.

The program, known as the UC Irvine/UC Davis Train New Trainers (TNT) Primary Care Psychiatry (PCP) Fellowship, launched in 2016 as a way to train primary care clinicians to diagnose and treat the most common psychiatric conditions found in the primary care setting. The fellowship is aimed at educating not only MDs and DOs, but physician assistants, nurse practitioners, and pharmacists as well.

Doug Brunk/MDedge News

“We want to give high-quality training to as many people as we can in order to optimize and expand the psychiatric workforce,” said Robert M. McCarron, DO, founding codirector of the fellowship program, and professor and vice chair of education and integrated care at the University of California, Irvine. “That’s really what we’re trying to do here.”

According to Dr. McCarron, who founded the fellowship with seed money during his tenure as a faculty member at UC Davis, up to 60% of all behavioral health care is provided in the busy primary setting, and as many as 80% of antidepressants are prescribed by nonpsychiatrists. Couple that with the current psychiatric workforce shortage “and you have a perfect storm,” he said.

“The toughest part is the volume of patients primary care providers have to see, comingled with a high frequency of comorbid mental illness. Added on to that, they didn’t get the training for much of the conditions they’re trying to address or treat. A primary care provider can refer to a psychiatrist, but there is not a large referral base. In addition, plenty of studies show that about half of those patients don’t end up seeing a mental health provider. Resources are limited in many areas of the country.”

TNT PCP fellows participate in the year-long program during nonclinic hours and accrue more than 45 CME units. Much of the training involves online courses framed around the textbook Primary Care Psychiatry (Wolters Kluwer, 2019), but fellows also are required to attend two intensive weekend sessions where they drill down on core topics, such as how to conduct an effective psychiatric interview, techniques, and how to screen and treat for psychiatric disorders.

“It’s not just about medicine options,” said Jaesu Han, MD, a fellowship faculty member who is board certified in psychiatry and family medicine. “For example, we try to focus on basic principles of cognitive-behavioral therapy, the role of psychotherapy, and the role of motivational interviewing. We try to help the providers recognize that there are other tools available [besides medication]. Those principles are going to help them engage with their patients more and have a larger impact.”

During one of the intensive weekend sessions, fellows are required to give a PowerPoint lecture on a topic of their choosing, with the idea of getting them comfortable with training their primary care colleagues on principles they learn.

“Some fellows are training their staff on their lunch breaks, or they’re implementing different tools they learned in our program to their organization,” said Wendy Cant, MBA, who is TNT PCP’s administrative director.

During a PowerPoint presentation a few years ago, one fellow chose to lecture about how to administer long-term antipsychotic medication in the primary care setting, a topic that the TNT PCP faculty had not thought to recommend. “We thought that was something a primary care provider would punt on,” said Dr. Suo, who is codirector of the fellowship program. “The fellow said, ‘No. This makes absolute sense. Our offices are equipped to do IM injections; our medical staff are trained to do that. It’s something that improves adherence and outcomes. It stabilizes people, and it makes us better able to take care of that population and not have to punt.’ That was unexpected and gratifying to know that we increased his comfort level to that point.”

Fellows also participate in two interactive learning sessions per month with faculty members, and each is paired with a faculty mentor, with whom they meet monthly in person or by video call or phone call.

“One of my fellows is feeling overwhelmed because she’s been tasked with taking care of the general psychiatric population, to do initial triage before she refers off to one of very few psychiatrists,” said Matthew Reed, MD, MSPH, one of the faculty mentors who serves as director of education for TNT PCP. “Her biggest concern is, ‘How do I not hate what I’m doing with my job because it’s so stressful and all patients want are opioid analgesics, or all they want are some benzodiazepines? They always want something, and I can’t get them to do what I want them to do.’ ” Together, they discuss various tools that might help her situation, such as using motivational interviewing to foster a sense of collaboration with patients.

Dr. Reed used the analogy of skeet shooting to illustrate the point that, without inviting patients to share in decision making, they are more likely to “shoot down” interventions that clinicians suggest to them.

Currently, about 80% of the program’s 118 fellows practice in California, there is a similar proportion of men and women, and their experience levels range from trainees to seasoned clinicians.

“They have 10, 15, and in some cases 25 years of experience, and they’re saying, ‘I‘ve been practicing for years and have been struggling when it comes to psychiatric issues. I want to do better,’ ” Dr. Suo noted.

Tuition is $15,500, and it usually is covered by outside funding sources. Last year, the program received a $1 million grant from California’s Office of Statewide Health Planning and Development, which was enough to fund tuition for 62 fellows. TNT PCP administrators and faculty also formed sponsor partnerships with several health plans and counties, including Inland Empire Health Plan, LA Care, Alameda Health Consortium, and Fresno County.

Employers also have stepped up. Cedars-Sinai Medical Center recently supplied a grant to fund tuition for 30 affiliated clinicians from different service planning areas. Other organizations that support funding for the fellowship include the American Academy of Pediatrics, the California Academy of Family Physicians, the California Behavioral Health Directors Association, and the California Psychiatric Association.

Meanwhile, word about the TNT PCP program is spreading to clinicians in other states. “By far, the hardest part is helping fellows from out of state find funding in their area,” Ms. Cant said. “That’s new territory we are starting to look into, but typically it’s not out of pocket. We only had three people pay out of pocket last year.”

Program faculty hope to not only improve the fellows’ knowledge in psychiatry and better treatment for depression, anxiety, and substance abuse, but also decrease prescription of opioids and decrease the stigma that some clinicians might perceive in mental illness. “People come to our fellowship feeling like there’s a void in their training,” Dr. Suo said. “We’re able to fill that void. In the first year, we had a fellow who said that, after completing the program, she felt physically less tired at the end of the day, because she had been so anxious about what to do for her patients who came in with mental health complaints.

“Now she knows what to do, so she can relax and listen to them – and be more connected.”

In the spirit of paying his TNT PCP education forward, last year Dr. Eschweiler secured a Song Brown grant to implement a 2-day psychiatric course for family medicine NP students at Western University of Health Sciences in Pomona, Calif., where he holds a faculty post. After they completed the course, students spent 80 hours with Dr. Eschweiler or with a designated clinician in the clinic, where they applied what they learned.

“By the time we shared information with students who I received in the TNT PCP fellowship, their comfort level went up by 80%-90%,” he said. “Now, they’re able to move into practice and take care of a lot of these patients without having to punt.”

Such stories are heartening to TNT PCP faculty. “We simply do not have enough psychiatrists in the country to provide mental health care for everybody who needs it,” Dr. Suo said. “Unfortunately, that means primary care will have to take up the slack. We want to prepare people to be able to do that.”

For information about the 2020 TNT PCP Fellowship, visit www.psychiatry.uci.edu/tnt.

[email protected]

AUSTIN, TEX. – Adolescents with moderate to severe atopic dermatitis who used dupilumab experienced significant improvements in signs and symptoms of the condition, with minimal safety concerns, according to results of a phase 3 study.

Doug Brunk/MDedge News

“Dupilumab works as effectively in adolescents as in adults,” Randy Prescilla, MD, one of the study authors, said in an interview at the annual meeting of the Society for Pediatric Dermatology. “It gives us promise that we could go into other age groups with the same optimism. We are enrolling patients in even younger age groups.”

The double-blind, placebo-controlled study analyzed the efficacy and safety of dupilumab monotherapy in patients between the ages of 12 and 17 years with moderate to severe atopic dermatitis (AD) inadequately controlled with topical therapies. In the United States, dupilumab is approved for those aged 12 years and older with moderate to severe disease inadequately controlled by topical prescription treatments or when those therapies are not advisable.

For the 16-week study, Dr. Prescilla, global medical affairs director of pediatric dermatology for Sanofi Genzyme, and colleagues randomized 251 patients to one of three groups: dupilumab every 2 weeks (200 mg if baseline weight was less than 60 kg; 300 mg if that weight was 60 kg or more); 300 mg dupilumab every 4 weeks; or placebo every 2 weeks.

At week 16, a significantly higher proportion of patients in the two drug treatment groups had Investigator’s Global Assessment scores of 0/1, compared with those in the placebo group (24.4%, 17.9%, and 2.4%) as well as a significantly higher percentage of patients who achieved at least a 75% improvement in the Eczema Area and Severity Index (EASI-75) score (41.5%, 38.1%, and 8.2%).

In addition, patients in the two drug treatment groups experienced improved percent change in least square-means on the EASI from baseline to week 16, compared with those in the placebo group (–65.9%, –64.8%, and –23.6%), the Peak Pruritus Numerical Rating Scale (–47.9%, –45.5%, and –19.0%), body surface area affected by AD (–30.1%, –33.4%, and –11.7%), and in the SCORing AD clinical tool (P less than .001 for all comparisons).


Between baseline and week 16, scores on the Children’s Dermatology Life Quality Index and Patient-Oriented Eczema Measure improved significantly in the two dupilumab groups, compared with the placebo group. The rate of skin infection was higher in the placebo group (20%), compared with 11% in the group that received dupilumab every 2 weeks and 13.3% in the group receiving the drug every 4 weeks.

Conjunctivitis occurred more frequently with dupilumab treatment (9.8% in the every-2-weeks dupilumab group, 10.8% in the every-4-weeks dupilumab group, and 4.7% in the placebo group) as did injection site reactions (8.5%, 6.0%, and 3.5%). Two adverse events, one of which was serious, occurred in the placebo group.

Dr. Prescilla acknowledged certain limitations of the study, including its small sample size and the fact that it was limited to 16 weeks. “However, smaller sample size and duration are typical for this type of study and in line with the study design of the SOLO 1 and SOLO 2 studies in adults,” he said.

On Aug. 6, the European Commission extended the marketing authorization for dupilumab in the European Union to include adolescents 12-17 years of age with moderate to severe atopic dermatitis who are candidates for systemic therapy. On the same day, Sanofi Genzyme and Regeneron announced positive topline results in a phase 3 trial in children aged 6-11 years with severe AD.

The study’s principal investigator was Amy S. Paller, MD. The study was funded by Sanofi Genzyme and Regeneron. Dr. Prescilla is an employee of Sanofi Genzyme.

[email protected]

AUSTIN, TEX. – Adolescents with moderate to severe atopic dermatitis who used dupilumab experienced significant improvements in signs and symptoms of the condition, with minimal safety concerns, according to results of a phase 3 study.

Doug Brunk/MDedge News

“Dupilumab works as effectively in adolescents as in adults,” Randy Prescilla, MD, one of the study authors, said in an interview at the annual meeting of the Society for Pediatric Dermatology. “It gives us promise that we could go into other age groups with the same optimism. We are enrolling patients in even younger age groups.”

The double-blind, placebo-controlled study analyzed the efficacy and safety of dupilumab monotherapy in patients between the ages of 12 and 17 years with moderate to severe atopic dermatitis (AD) inadequately controlled with topical therapies. In the United States, dupilumab is approved for those aged 12 years and older with moderate to severe disease inadequately controlled by topical prescription treatments or when those therapies are not advisable.

For the 16-week study, Dr. Prescilla, global medical affairs director of pediatric dermatology for Sanofi Genzyme, and colleagues randomized 251 patients to one of three groups: dupilumab every 2 weeks (200 mg if baseline weight was less than 60 kg; 300 mg if that weight was 60 kg or more); 300 mg dupilumab every 4 weeks; or placebo every 2 weeks.

At week 16, a significantly higher proportion of patients in the two drug treatment groups had Investigator’s Global Assessment scores of 0/1, compared with those in the placebo group (24.4%, 17.9%, and 2.4%) as well as a significantly higher percentage of patients who achieved at least a 75% improvement in the Eczema Area and Severity Index (EASI-75) score (41.5%, 38.1%, and 8.2%).

In addition, patients in the two drug treatment groups experienced improved percent change in least square-means on the EASI from baseline to week 16, compared with those in the placebo group (–65.9%, –64.8%, and –23.6%), the Peak Pruritus Numerical Rating Scale (–47.9%, –45.5%, and –19.0%), body surface area affected by AD (–30.1%, –33.4%, and –11.7%), and in the SCORing AD clinical tool (P less than .001 for all comparisons).


Between baseline and week 16, scores on the Children’s Dermatology Life Quality Index and Patient-Oriented Eczema Measure improved significantly in the two dupilumab groups, compared with the placebo group. The rate of skin infection was higher in the placebo group (20%), compared with 11% in the group that received dupilumab every 2 weeks and 13.3% in the group receiving the drug every 4 weeks.

Conjunctivitis occurred more frequently with dupilumab treatment (9.8% in the every-2-weeks dupilumab group, 10.8% in the every-4-weeks dupilumab group, and 4.7% in the placebo group) as did injection site reactions (8.5%, 6.0%, and 3.5%). Two adverse events, one of which was serious, occurred in the placebo group.

Dr. Prescilla acknowledged certain limitations of the study, including its small sample size and the fact that it was limited to 16 weeks. “However, smaller sample size and duration are typical for this type of study and in line with the study design of the SOLO 1 and SOLO 2 studies in adults,” he said.

On Aug. 6, the European Commission extended the marketing authorization for dupilumab in the European Union to include adolescents 12-17 years of age with moderate to severe atopic dermatitis who are candidates for systemic therapy. On the same day, Sanofi Genzyme and Regeneron announced positive topline results in a phase 3 trial in children aged 6-11 years with severe AD.

The study’s principal investigator was Amy S. Paller, MD. The study was funded by Sanofi Genzyme and Regeneron. Dr. Prescilla is an employee of Sanofi Genzyme.

[email protected]

AUSTIN, TEX. – Adolescents with moderate to severe atopic dermatitis who used dupilumab experienced significant improvements in signs and symptoms of the condition, with minimal safety concerns, according to results of a phase 3 study.

Doug Brunk/MDedge News

“Dupilumab works as effectively in adolescents as in adults,” Randy Prescilla, MD, one of the study authors, said in an interview at the annual meeting of the Society for Pediatric Dermatology. “It gives us promise that we could go into other age groups with the same optimism. We are enrolling patients in even younger age groups.”

The double-blind, placebo-controlled study analyzed the efficacy and safety of dupilumab monotherapy in patients between the ages of 12 and 17 years with moderate to severe atopic dermatitis (AD) inadequately controlled with topical therapies. In the United States, dupilumab is approved for those aged 12 years and older with moderate to severe disease inadequately controlled by topical prescription treatments or when those therapies are not advisable.

For the 16-week study, Dr. Prescilla, global medical affairs director of pediatric dermatology for Sanofi Genzyme, and colleagues randomized 251 patients to one of three groups: dupilumab every 2 weeks (200 mg if baseline weight was less than 60 kg; 300 mg if that weight was 60 kg or more); 300 mg dupilumab every 4 weeks; or placebo every 2 weeks.

At week 16, a significantly higher proportion of patients in the two drug treatment groups had Investigator’s Global Assessment scores of 0/1, compared with those in the placebo group (24.4%, 17.9%, and 2.4%) as well as a significantly higher percentage of patients who achieved at least a 75% improvement in the Eczema Area and Severity Index (EASI-75) score (41.5%, 38.1%, and 8.2%).

In addition, patients in the two drug treatment groups experienced improved percent change in least square-means on the EASI from baseline to week 16, compared with those in the placebo group (–65.9%, –64.8%, and –23.6%), the Peak Pruritus Numerical Rating Scale (–47.9%, –45.5%, and –19.0%), body surface area affected by AD (–30.1%, –33.4%, and –11.7%), and in the SCORing AD clinical tool (P less than .001 for all comparisons).


Between baseline and week 16, scores on the Children’s Dermatology Life Quality Index and Patient-Oriented Eczema Measure improved significantly in the two dupilumab groups, compared with the placebo group. The rate of skin infection was higher in the placebo group (20%), compared with 11% in the group that received dupilumab every 2 weeks and 13.3% in the group receiving the drug every 4 weeks.

Conjunctivitis occurred more frequently with dupilumab treatment (9.8% in the every-2-weeks dupilumab group, 10.8% in the every-4-weeks dupilumab group, and 4.7% in the placebo group) as did injection site reactions (8.5%, 6.0%, and 3.5%). Two adverse events, one of which was serious, occurred in the placebo group.

Dr. Prescilla acknowledged certain limitations of the study, including its small sample size and the fact that it was limited to 16 weeks. “However, smaller sample size and duration are typical for this type of study and in line with the study design of the SOLO 1 and SOLO 2 studies in adults,” he said.

On Aug. 6, the European Commission extended the marketing authorization for dupilumab in the European Union to include adolescents 12-17 years of age with moderate to severe atopic dermatitis who are candidates for systemic therapy. On the same day, Sanofi Genzyme and Regeneron announced positive topline results in a phase 3 trial in children aged 6-11 years with severe AD.

The study’s principal investigator was Amy S. Paller, MD. The study was funded by Sanofi Genzyme and Regeneron. Dr. Prescilla is an employee of Sanofi Genzyme.

[email protected]

Among patients with suboptimally controlled type 2 diabetes who use oral glucose-lowering medication, endoscopic duodenal mucosal resection (DMR) can be implemented safely and effectively, results from a multicenter, international, phase 2 study demonstrated.

“DMR elicited a substantial improvement in parameters of glycemia as well as a decrease in liver transaminase levels at 24 weeks, which was sustained at 12 months post procedure,” researchers led by Annieke C.G. van Baar, MD, wrote in a study published online in Gut. “These findings were also associated with an improvement in patients’ diabetes treatment satisfaction.”

For the study, Dr. van Baar, of the department of gastroenterology and hepatology at Amsterdam University Medical Center, and colleagues at seven clinical sites enrolled 46 patients with type 2 diabetes who were on stable glucose-lowering medication to undergo DMR. The procedure “involves circumferential hydrothermal ablation of the duodenal mucosa resulting in subsequent regeneration of the mucosa,” they wrote. “Before ablation, the mucosa is lifted with saline to protect the outer layers of the duodenum.” DMR was performed under either general anesthesia or deep sedation with propofol by a single endoscopist at each site with extensive experience in therapeutic upper GI endoscopy and guidewire management.

The mean age of the study participants was 55 years and 63% were male. Of the 46 patients, 37 (80%) underwent complete DMR and results were reported for 36 of them. A total of 24 patients had at least one adverse event related to DMR (52%), mostly GI symptoms such as diarrhea, abdominal pain, nausea, and oropharyngeal pain. Of these, 81% were mild. One serious adverse event was considered to be related to the procedure. “This concerned a patient with general malaise, mild fever, and increased C-reactive protein level on the first day after DMR,” the researchers wrote. “The mild fever resolved within 24 hours and [C-reactive protein] level normalized within 3 days.” No unanticipated adverse events were reported.

During follow-up measures taken 24 weeks after their DMR, hemoglobin A_1c fell by a mean of 10 mmol/mol (P less than .001), fasting plasma glucose by 1.7 mmol/L (P less than .001), and the Homeostatic Model Assessment of Insulin Resistance improved significantly (P less than .001). In addition, the procedure conferred a moderate reduction in weight (a mean loss of 2.5 kg) and a decrease in hepatic transaminase levels. The effects were sustained at 12 months.

“While the majority of patients showed a durable glycemic response over 12 months, a minority exhibited less benefit from DMR and required additional glucose-lowering medication at 24 weeks,” the researchers wrote. “Of note, approximately two-thirds of the patients who required addition of antidiabetic medication in the latter phase of study had undergone insulin secretagogue medication withdrawal at screening. For future study, it may not be necessary to discontinue these medications before DMR, and this will allow an even more precise measure of DMR effect.”


Dr. van Baar and colleagues acknowledged certain limitations of the phase 2 study, including its open-label, uncontrolled design. “The results of this multicenter study need to be confirmed in a proper controlled study. Nevertheless, this study forms the requisite solid foundation for further research, and controlled studies are currently underway.”

The study was funded by Fractyl Laboratories. Dr. van Baar reported having no financial disclosures. Four of the study authors reported having financial relationships with numerous pharmaceutical and device companies.

[email protected]

SOURCE: van Baar ACG et al. Gut. 2019 Jul 22. doi: 10.1136/gutjnl-2019-318349.

Among patients with suboptimally controlled type 2 diabetes who use oral glucose-lowering medication, endoscopic duodenal mucosal resection (DMR) can be implemented safely and effectively, results from a multicenter, international, phase 2 study demonstrated.

“DMR elicited a substantial improvement in parameters of glycemia as well as a decrease in liver transaminase levels at 24 weeks, which was sustained at 12 months post procedure,” researchers led by Annieke C.G. van Baar, MD, wrote in a study published online in Gut. “These findings were also associated with an improvement in patients’ diabetes treatment satisfaction.”

For the study, Dr. van Baar, of the department of gastroenterology and hepatology at Amsterdam University Medical Center, and colleagues at seven clinical sites enrolled 46 patients with type 2 diabetes who were on stable glucose-lowering medication to undergo DMR. The procedure “involves circumferential hydrothermal ablation of the duodenal mucosa resulting in subsequent regeneration of the mucosa,” they wrote. “Before ablation, the mucosa is lifted with saline to protect the outer layers of the duodenum.” DMR was performed under either general anesthesia or deep sedation with propofol by a single endoscopist at each site with extensive experience in therapeutic upper GI endoscopy and guidewire management.

The mean age of the study participants was 55 years and 63% were male. Of the 46 patients, 37 (80%) underwent complete DMR and results were reported for 36 of them. A total of 24 patients had at least one adverse event related to DMR (52%), mostly GI symptoms such as diarrhea, abdominal pain, nausea, and oropharyngeal pain. Of these, 81% were mild. One serious adverse event was considered to be related to the procedure. “This concerned a patient with general malaise, mild fever, and increased C-reactive protein level on the first day after DMR,” the researchers wrote. “The mild fever resolved within 24 hours and [C-reactive protein] level normalized within 3 days.” No unanticipated adverse events were reported.

During follow-up measures taken 24 weeks after their DMR, hemoglobin A_1c fell by a mean of 10 mmol/mol (P less than .001), fasting plasma glucose by 1.7 mmol/L (P less than .001), and the Homeostatic Model Assessment of Insulin Resistance improved significantly (P less than .001). In addition, the procedure conferred a moderate reduction in weight (a mean loss of 2.5 kg) and a decrease in hepatic transaminase levels. The effects were sustained at 12 months.

“While the majority of patients showed a durable glycemic response over 12 months, a minority exhibited less benefit from DMR and required additional glucose-lowering medication at 24 weeks,” the researchers wrote. “Of note, approximately two-thirds of the patients who required addition of antidiabetic medication in the latter phase of study had undergone insulin secretagogue medication withdrawal at screening. For future study, it may not be necessary to discontinue these medications before DMR, and this will allow an even more precise measure of DMR effect.”


Dr. van Baar and colleagues acknowledged certain limitations of the phase 2 study, including its open-label, uncontrolled design. “The results of this multicenter study need to be confirmed in a proper controlled study. Nevertheless, this study forms the requisite solid foundation for further research, and controlled studies are currently underway.”

The study was funded by Fractyl Laboratories. Dr. van Baar reported having no financial disclosures. Four of the study authors reported having financial relationships with numerous pharmaceutical and device companies.

[email protected]

SOURCE: van Baar ACG et al. Gut. 2019 Jul 22. doi: 10.1136/gutjnl-2019-318349.

Among patients with suboptimally controlled type 2 diabetes who use oral glucose-lowering medication, endoscopic duodenal mucosal resection (DMR) can be implemented safely and effectively, results from a multicenter, international, phase 2 study demonstrated.

“DMR elicited a substantial improvement in parameters of glycemia as well as a decrease in liver transaminase levels at 24 weeks, which was sustained at 12 months post procedure,” researchers led by Annieke C.G. van Baar, MD, wrote in a study published online in Gut. “These findings were also associated with an improvement in patients’ diabetes treatment satisfaction.”

For the study, Dr. van Baar, of the department of gastroenterology and hepatology at Amsterdam University Medical Center, and colleagues at seven clinical sites enrolled 46 patients with type 2 diabetes who were on stable glucose-lowering medication to undergo DMR. The procedure “involves circumferential hydrothermal ablation of the duodenal mucosa resulting in subsequent regeneration of the mucosa,” they wrote. “Before ablation, the mucosa is lifted with saline to protect the outer layers of the duodenum.” DMR was performed under either general anesthesia or deep sedation with propofol by a single endoscopist at each site with extensive experience in therapeutic upper GI endoscopy and guidewire management.

The mean age of the study participants was 55 years and 63% were male. Of the 46 patients, 37 (80%) underwent complete DMR and results were reported for 36 of them. A total of 24 patients had at least one adverse event related to DMR (52%), mostly GI symptoms such as diarrhea, abdominal pain, nausea, and oropharyngeal pain. Of these, 81% were mild. One serious adverse event was considered to be related to the procedure. “This concerned a patient with general malaise, mild fever, and increased C-reactive protein level on the first day after DMR,” the researchers wrote. “The mild fever resolved within 24 hours and [C-reactive protein] level normalized within 3 days.” No unanticipated adverse events were reported.

During follow-up measures taken 24 weeks after their DMR, hemoglobin A_1c fell by a mean of 10 mmol/mol (P less than .001), fasting plasma glucose by 1.7 mmol/L (P less than .001), and the Homeostatic Model Assessment of Insulin Resistance improved significantly (P less than .001). In addition, the procedure conferred a moderate reduction in weight (a mean loss of 2.5 kg) and a decrease in hepatic transaminase levels. The effects were sustained at 12 months.

“While the majority of patients showed a durable glycemic response over 12 months, a minority exhibited less benefit from DMR and required additional glucose-lowering medication at 24 weeks,” the researchers wrote. “Of note, approximately two-thirds of the patients who required addition of antidiabetic medication in the latter phase of study had undergone insulin secretagogue medication withdrawal at screening. For future study, it may not be necessary to discontinue these medications before DMR, and this will allow an even more precise measure of DMR effect.”


Dr. van Baar and colleagues acknowledged certain limitations of the phase 2 study, including its open-label, uncontrolled design. “The results of this multicenter study need to be confirmed in a proper controlled study. Nevertheless, this study forms the requisite solid foundation for further research, and controlled studies are currently underway.”

The study was funded by Fractyl Laboratories. Dr. van Baar reported having no financial disclosures. Four of the study authors reported having financial relationships with numerous pharmaceutical and device companies.

[email protected]

SOURCE: van Baar ACG et al. Gut. 2019 Jul 22. doi: 10.1136/gutjnl-2019-318349.

AUSTIN, TEX. – All too often, children and adolescents stumble on their way to adult health care – if they make it at all.

In fact, data from an ongoing survey by the Department of Health & Human Services and the Health Resources and Services Administration indicate that only 40% of children with special health care needs aged 12-17 years receive the services necessary to make transitions to adult health care.

“Most fall off the proverbial cliff and do not engage with adult providers,” Cynthia Peacock, MD, said at the annual meeting of the Society for Pediatric Dermatology. She recalled meeting with one individual who, after being a patient at the children’s hospital for 13 years, was told over the phone to transition to an adult provider with not so much as a promised letter of introduction being sent on. “She did not know about the adult health care culture, which is fractured in care, relies on the patient to be their own advocate, and wants patients to be able to do their visit in 10-15 minutes.”

Dr. Peacock, medical director of the Transition Medicine Clinic at Baylor College of Medicine, Houston, described transition health care as a purposeful, planned migration from child-oriented to adult-oriented health care, a process that should start as early as possible. “Starting at age 12 is not too early,” she said. “It gives you time so that you can keep introducing the concept when that individual keeps coming back to see you, especially if it’s a chronic condition.”

She recommended that clinicians ask several questions to assess transition readiness of pediatric patients to adult care, including, Do you know your medications? Do you know how to take them? Do you know how to refill them? Do you know how to discuss them? Can you discuss your medical condition with the adult doctor? Can you call for a doctor’s appointment or get a prescription filled? “Adolescents are notorious for calling [the doctor’s office], and if they’re told they can’t make an appointment, that’s it; they stop right there,” Dr. Peacock said. “They don’t tend to problem solve. They don’t engage.”

Studies have suggested that the transfer of care is more likely to be successful if a formal transition program is in place to prepare the patient and to facilitate the change in health care providers. “There is a growing evidence base in the literature that skills training for young people with chronic illnesses can be associated with positive outcomes,” she said. “This can be as easy as telling the individual, ‘Do a book report about your condition. Talk to a friend. Tell a friend what your condition is. Or, do school science fair project and talk to your class about what you have.’ Get them past that uncomfortable feeling of having to talk about it.”

The earlier this happens, the better. “We know from research that if you get them to be their own [health care] advocate, that’s one less thing they have to do in the adult health care system,” she said. “They will move on to other things, such as getting a job or going to college.”

Dr. Peacock, who is board certified in pediatrics and internal medicine, added that providing adolescents with the option of being seen by professionals without their parents is considered best practice. “You could start by introducing the concept at age 12, but say at age 13, ‘I want to spend a minute with you alone without your parent. I want you to bring in questions that you want to ask me that you may not want to ask in front of your parents,’” she said. “I guarantee you that on that third visit the adolescent will ask you a question.”

Optimistic messaging is another component of effective planning. “You may see someone in your office with a disease that you know has high mortality and high morbidity, and you’re trying to help the family cope,” Dr. Peacock said. “That young person needs to be asked, ‘What are your plans for your future?’ Think about it: In 10 or 20 years when you’re transitioning that individual out of your health care system, what medical miracles have happened?” She recalled visiting with the mother of a patient with Down syndrome who had significant congenital heart disease. He was in his 30s and struggled to keep his behavior in check. “We were trying to develop a behavior plan, but his past care team had never put one in place for him,” Dr. Peacock said. “The mother looked at me and said, accusingly, ‘It’s your fault. It’s all of your doctors’ faults because they never told me that this would happen. They told me to take him home and spoil him because he would not be around at this age.’”

Effective transition handoffs are collaborative, she continued, with care plans built around what is likely to happen with the patient over time. “At Baylor College of Medicine, pediatric dermatologists follow patients for life, but I take over everything else adult care related,” Dr. Peacock said. “The pediatric dermatologist has me come over to the hospital when we’re talking about quality-of-life issues – about advance care, advanced directives, those types of things.”


She recommends not transferring care to an adult provider during pregnancy, hospitalization, during active disease, or during changes to a patient’s medical therapy. “When pediatricians call me from the hospital and they want an urgent transfer, I tell them, ‘Your emergency is not my urgency. Get everything ready; get them discharged. Get them followed up and back on their chronic care management, and I’ll be happy to do that transition for you,’ ” she said. “It’s also good to leave that door open for the adult provider to call you. Give them your cell phone number because it may be just one question, like, ‘Can you tell me why his liver enzymes are elevated? We can’t figure it out.’ ”

Dr. Peacock advises pediatric providers to develop processes within their own practice that facilitates transfer, “even if it just means sharing information with the adult provider at the end of the time you’re seeing that young adult. Know your systems and your resources. Get that medical summary done, even if it’s making the patient do the medical summary.” More information for clinicians and for patients and their families can be found at www.gottransition.org.

She reported having no relevant financial disclosures.

[email protected]

AUSTIN, TEX. – All too often, children and adolescents stumble on their way to adult health care – if they make it at all.

In fact, data from an ongoing survey by the Department of Health & Human Services and the Health Resources and Services Administration indicate that only 40% of children with special health care needs aged 12-17 years receive the services necessary to make transitions to adult health care.

“Most fall off the proverbial cliff and do not engage with adult providers,” Cynthia Peacock, MD, said at the annual meeting of the Society for Pediatric Dermatology. She recalled meeting with one individual who, after being a patient at the children’s hospital for 13 years, was told over the phone to transition to an adult provider with not so much as a promised letter of introduction being sent on. “She did not know about the adult health care culture, which is fractured in care, relies on the patient to be their own advocate, and wants patients to be able to do their visit in 10-15 minutes.”

Dr. Peacock, medical director of the Transition Medicine Clinic at Baylor College of Medicine, Houston, described transition health care as a purposeful, planned migration from child-oriented to adult-oriented health care, a process that should start as early as possible. “Starting at age 12 is not too early,” she said. “It gives you time so that you can keep introducing the concept when that individual keeps coming back to see you, especially if it’s a chronic condition.”

She recommended that clinicians ask several questions to assess transition readiness of pediatric patients to adult care, including, Do you know your medications? Do you know how to take them? Do you know how to refill them? Do you know how to discuss them? Can you discuss your medical condition with the adult doctor? Can you call for a doctor’s appointment or get a prescription filled? “Adolescents are notorious for calling [the doctor’s office], and if they’re told they can’t make an appointment, that’s it; they stop right there,” Dr. Peacock said. “They don’t tend to problem solve. They don’t engage.”

Studies have suggested that the transfer of care is more likely to be successful if a formal transition program is in place to prepare the patient and to facilitate the change in health care providers. “There is a growing evidence base in the literature that skills training for young people with chronic illnesses can be associated with positive outcomes,” she said. “This can be as easy as telling the individual, ‘Do a book report about your condition. Talk to a friend. Tell a friend what your condition is. Or, do school science fair project and talk to your class about what you have.’ Get them past that uncomfortable feeling of having to talk about it.”

The earlier this happens, the better. “We know from research that if you get them to be their own [health care] advocate, that’s one less thing they have to do in the adult health care system,” she said. “They will move on to other things, such as getting a job or going to college.”

Dr. Peacock, who is board certified in pediatrics and internal medicine, added that providing adolescents with the option of being seen by professionals without their parents is considered best practice. “You could start by introducing the concept at age 12, but say at age 13, ‘I want to spend a minute with you alone without your parent. I want you to bring in questions that you want to ask me that you may not want to ask in front of your parents,’” she said. “I guarantee you that on that third visit the adolescent will ask you a question.”

Optimistic messaging is another component of effective planning. “You may see someone in your office with a disease that you know has high mortality and high morbidity, and you’re trying to help the family cope,” Dr. Peacock said. “That young person needs to be asked, ‘What are your plans for your future?’ Think about it: In 10 or 20 years when you’re transitioning that individual out of your health care system, what medical miracles have happened?” She recalled visiting with the mother of a patient with Down syndrome who had significant congenital heart disease. He was in his 30s and struggled to keep his behavior in check. “We were trying to develop a behavior plan, but his past care team had never put one in place for him,” Dr. Peacock said. “The mother looked at me and said, accusingly, ‘It’s your fault. It’s all of your doctors’ faults because they never told me that this would happen. They told me to take him home and spoil him because he would not be around at this age.’”

Effective transition handoffs are collaborative, she continued, with care plans built around what is likely to happen with the patient over time. “At Baylor College of Medicine, pediatric dermatologists follow patients for life, but I take over everything else adult care related,” Dr. Peacock said. “The pediatric dermatologist has me come over to the hospital when we’re talking about quality-of-life issues – about advance care, advanced directives, those types of things.”


She recommends not transferring care to an adult provider during pregnancy, hospitalization, during active disease, or during changes to a patient’s medical therapy. “When pediatricians call me from the hospital and they want an urgent transfer, I tell them, ‘Your emergency is not my urgency. Get everything ready; get them discharged. Get them followed up and back on their chronic care management, and I’ll be happy to do that transition for you,’ ” she said. “It’s also good to leave that door open for the adult provider to call you. Give them your cell phone number because it may be just one question, like, ‘Can you tell me why his liver enzymes are elevated? We can’t figure it out.’ ”

Dr. Peacock advises pediatric providers to develop processes within their own practice that facilitates transfer, “even if it just means sharing information with the adult provider at the end of the time you’re seeing that young adult. Know your systems and your resources. Get that medical summary done, even if it’s making the patient do the medical summary.” More information for clinicians and for patients and their families can be found at www.gottransition.org.

She reported having no relevant financial disclosures.

[email protected]

AUSTIN, TEX. – All too often, children and adolescents stumble on their way to adult health care – if they make it at all.

In fact, data from an ongoing survey by the Department of Health & Human Services and the Health Resources and Services Administration indicate that only 40% of children with special health care needs aged 12-17 years receive the services necessary to make transitions to adult health care.

“Most fall off the proverbial cliff and do not engage with adult providers,” Cynthia Peacock, MD, said at the annual meeting of the Society for Pediatric Dermatology. She recalled meeting with one individual who, after being a patient at the children’s hospital for 13 years, was told over the phone to transition to an adult provider with not so much as a promised letter of introduction being sent on. “She did not know about the adult health care culture, which is fractured in care, relies on the patient to be their own advocate, and wants patients to be able to do their visit in 10-15 minutes.”

Dr. Peacock, medical director of the Transition Medicine Clinic at Baylor College of Medicine, Houston, described transition health care as a purposeful, planned migration from child-oriented to adult-oriented health care, a process that should start as early as possible. “Starting at age 12 is not too early,” she said. “It gives you time so that you can keep introducing the concept when that individual keeps coming back to see you, especially if it’s a chronic condition.”

She recommended that clinicians ask several questions to assess transition readiness of pediatric patients to adult care, including, Do you know your medications? Do you know how to take them? Do you know how to refill them? Do you know how to discuss them? Can you discuss your medical condition with the adult doctor? Can you call for a doctor’s appointment or get a prescription filled? “Adolescents are notorious for calling [the doctor’s office], and if they’re told they can’t make an appointment, that’s it; they stop right there,” Dr. Peacock said. “They don’t tend to problem solve. They don’t engage.”

Studies have suggested that the transfer of care is more likely to be successful if a formal transition program is in place to prepare the patient and to facilitate the change in health care providers. “There is a growing evidence base in the literature that skills training for young people with chronic illnesses can be associated with positive outcomes,” she said. “This can be as easy as telling the individual, ‘Do a book report about your condition. Talk to a friend. Tell a friend what your condition is. Or, do school science fair project and talk to your class about what you have.’ Get them past that uncomfortable feeling of having to talk about it.”

The earlier this happens, the better. “We know from research that if you get them to be their own [health care] advocate, that’s one less thing they have to do in the adult health care system,” she said. “They will move on to other things, such as getting a job or going to college.”

Dr. Peacock, who is board certified in pediatrics and internal medicine, added that providing adolescents with the option of being seen by professionals without their parents is considered best practice. “You could start by introducing the concept at age 12, but say at age 13, ‘I want to spend a minute with you alone without your parent. I want you to bring in questions that you want to ask me that you may not want to ask in front of your parents,’” she said. “I guarantee you that on that third visit the adolescent will ask you a question.”

Optimistic messaging is another component of effective planning. “You may see someone in your office with a disease that you know has high mortality and high morbidity, and you’re trying to help the family cope,” Dr. Peacock said. “That young person needs to be asked, ‘What are your plans for your future?’ Think about it: In 10 or 20 years when you’re transitioning that individual out of your health care system, what medical miracles have happened?” She recalled visiting with the mother of a patient with Down syndrome who had significant congenital heart disease. He was in his 30s and struggled to keep his behavior in check. “We were trying to develop a behavior plan, but his past care team had never put one in place for him,” Dr. Peacock said. “The mother looked at me and said, accusingly, ‘It’s your fault. It’s all of your doctors’ faults because they never told me that this would happen. They told me to take him home and spoil him because he would not be around at this age.’”

Effective transition handoffs are collaborative, she continued, with care plans built around what is likely to happen with the patient over time. “At Baylor College of Medicine, pediatric dermatologists follow patients for life, but I take over everything else adult care related,” Dr. Peacock said. “The pediatric dermatologist has me come over to the hospital when we’re talking about quality-of-life issues – about advance care, advanced directives, those types of things.”


She recommends not transferring care to an adult provider during pregnancy, hospitalization, during active disease, or during changes to a patient’s medical therapy. “When pediatricians call me from the hospital and they want an urgent transfer, I tell them, ‘Your emergency is not my urgency. Get everything ready; get them discharged. Get them followed up and back on their chronic care management, and I’ll be happy to do that transition for you,’ ” she said. “It’s also good to leave that door open for the adult provider to call you. Give them your cell phone number because it may be just one question, like, ‘Can you tell me why his liver enzymes are elevated? We can’t figure it out.’ ”

Dr. Peacock advises pediatric providers to develop processes within their own practice that facilitates transfer, “even if it just means sharing information with the adult provider at the end of the time you’re seeing that young adult. Know your systems and your resources. Get that medical summary done, even if it’s making the patient do the medical summary.” More information for clinicians and for patients and their families can be found at www.gottransition.org.

She reported having no relevant financial disclosures.

[email protected]

AUSTIN, TEX. – The way Adelaide A. Hebert, MD, sees it, the decision to add clinical research to your existing dermatology practice requires some soul searching, because not everyone is cut out for it.

“This is not something you take lightly,” Dr. Hebert, chief of pediatric dermatology at the University of Texas Health Science Center, Houston, said at the annual meeting of the Society for Pediatric Dermatology. “There will be days when you feel like you are going into combat. If you are not prepared for that, maybe stick to clinical practice. That plan might be a bit simpler.”

For more than 30 years, Dr. Hebert has been engaged in dermatology clinical research, with a focus on atopic dermatitis, psoriasis, and hyperhidrosis. Her team includes a full-time research fellow, a full-time nurse practitioner, and a part-time clinical trials coordinator. “We work very hard, and I am responsible for their salaries,” she said. “There is considerable pressure from year to year, but they work hard and are very loyal. They represent a great portion of the success that we have in clinical research. You need a team, and you have to be a team leader in order to undertake this.”

Dr. Hebert offered the following tips for incorporating clinical research into your practice:

• Set aside allocated time. “This is not a side job within your current occupation,” she emphasized. “You really need allocated time to do research, and you need protected academic time if you work in that environment. You also need protected academic time for your staff to conduct research.”

• Get to know the players involved. This includes forming professional relationships with internal and external review boards, and understanding contract and grants. “This collaboration is a lot like getting into a sport,” she explained. “You have to know the rules, you have to know how to play with strategy, and you have to be very effective.”

Review boards that work with academic centers include the Western Institutional Review Board (WIRB) and Advarra. “You also need to understand time lines, what it takes to go from submission to implementation,” Dr. Hebert said. “That time cannot be too long, or you will be off the list of desired investigators because you cannot get up and running in a timely fashion. Your team has to be behind you in order to make this happen.” [She recommended the National Association of Healthcare Revenue Integrity publication, “The Practical Guide to Clinical Trials Billing.”]

• Consider space and equipment needs. This includes space for patient charts, cameras, scales, electronic devices for data capture, computer equipment, and other instruments you may need to carry out your work. Dr. Hebert’s clinic houses about a half-dozen EKG machines dedicated to research projects. “You also need a lot of storage,” she added. “Our university requires us to save every piece of paper, every communication for 15 years. Our university does allocate that space.”

Sponsored research opportunities include working with the National Institutes of Health, Department of Defense, pharmaceutical companies, and over-the-counter product companies. “You can also initiate your own research,” she said. “One way to get started is to partner with an established researcher. That could be someone in your department, in a different department, or in a clinical research unit within your institution. They can help you with infrastructure and they can sometimes do your research submissions for you.”

Other ways to explore research opportunities include reaching out to medical science liaisons and clinical trial research organizations, and hiring fellows with research experience. “The bottom line is, talk to a lot of people you do not know,” Dr. Hebert said. “That is the real secret to getting research studies.”

There is another player in the field to become familiar with: contract research organizations (CROs), which provide support to pharmaceutical industries in the form of research services outsourced on a contract basis. They receive payment from the sponsor to conduct clinical research operations. “Many times the sponsor does not entirely know what the CRO is doing with regard to the interface with you as an investigator,” said Dr. Hebert, who has conducted more than 160 trials, including 65 in atopic dermatitis alone. “Sometimes you have to go over the head of the CRO to address issues that come up. The reality is, if the sponsor does not know you are not getting paid or having obstacles put in front of you that may not be in your contract, that constitutes a problem. You have to learn to be a bit shrewd in this game of research.”

She added that clinicians who choose to conduct clinical research come to learn “a whole new language,” such as what a confidential disclosure agreement is. “You also have to undergo CITI [Collaborative Institutional Training Initiative] training to meet the principles of good clinical practice,” she said. Other specifics include infectious substance shipping training per International Air Transport Association shipping guidelines, protocol training in arenas such as Eczema Area and Severity Index scoring and Psoriasis Area Severity Index scoring, and electronic case report form/electronic data–capture report training. “We also have a lot of equipment training because we are constantly getting new tablets for recording patient data and so forth,” she said. “This is something that has helped me become more technically equipped to handle all of this data capture.”

Dr. Hebert closed her remarks by noting that conducting clinical research can be a rewarding endeavor. “You really do address unmet needs, and you give a lot of education to residents, students, and fellows,” she said. “Clinical research provides research opportunities for those interested in dermatology. You have those moments when you see patients get better, and this represents the best patient encounter you could ever hope for.”

She reported having no relevant financial disclosures.

[email protected]

AUSTIN, TEX. – The way Adelaide A. Hebert, MD, sees it, the decision to add clinical research to your existing dermatology practice requires some soul searching, because not everyone is cut out for it.

“This is not something you take lightly,” Dr. Hebert, chief of pediatric dermatology at the University of Texas Health Science Center, Houston, said at the annual meeting of the Society for Pediatric Dermatology. “There will be days when you feel like you are going into combat. If you are not prepared for that, maybe stick to clinical practice. That plan might be a bit simpler.”

For more than 30 years, Dr. Hebert has been engaged in dermatology clinical research, with a focus on atopic dermatitis, psoriasis, and hyperhidrosis. Her team includes a full-time research fellow, a full-time nurse practitioner, and a part-time clinical trials coordinator. “We work very hard, and I am responsible for their salaries,” she said. “There is considerable pressure from year to year, but they work hard and are very loyal. They represent a great portion of the success that we have in clinical research. You need a team, and you have to be a team leader in order to undertake this.”

Dr. Hebert offered the following tips for incorporating clinical research into your practice:

• Set aside allocated time. “This is not a side job within your current occupation,” she emphasized. “You really need allocated time to do research, and you need protected academic time if you work in that environment. You also need protected academic time for your staff to conduct research.”

• Get to know the players involved. This includes forming professional relationships with internal and external review boards, and understanding contract and grants. “This collaboration is a lot like getting into a sport,” she explained. “You have to know the rules, you have to know how to play with strategy, and you have to be very effective.”

Review boards that work with academic centers include the Western Institutional Review Board (WIRB) and Advarra. “You also need to understand time lines, what it takes to go from submission to implementation,” Dr. Hebert said. “That time cannot be too long, or you will be off the list of desired investigators because you cannot get up and running in a timely fashion. Your team has to be behind you in order to make this happen.” [She recommended the National Association of Healthcare Revenue Integrity publication, “The Practical Guide to Clinical Trials Billing.”]

• Consider space and equipment needs. This includes space for patient charts, cameras, scales, electronic devices for data capture, computer equipment, and other instruments you may need to carry out your work. Dr. Hebert’s clinic houses about a half-dozen EKG machines dedicated to research projects. “You also need a lot of storage,” she added. “Our university requires us to save every piece of paper, every communication for 15 years. Our university does allocate that space.”

Sponsored research opportunities include working with the National Institutes of Health, Department of Defense, pharmaceutical companies, and over-the-counter product companies. “You can also initiate your own research,” she said. “One way to get started is to partner with an established researcher. That could be someone in your department, in a different department, or in a clinical research unit within your institution. They can help you with infrastructure and they can sometimes do your research submissions for you.”

Other ways to explore research opportunities include reaching out to medical science liaisons and clinical trial research organizations, and hiring fellows with research experience. “The bottom line is, talk to a lot of people you do not know,” Dr. Hebert said. “That is the real secret to getting research studies.”

There is another player in the field to become familiar with: contract research organizations (CROs), which provide support to pharmaceutical industries in the form of research services outsourced on a contract basis. They receive payment from the sponsor to conduct clinical research operations. “Many times the sponsor does not entirely know what the CRO is doing with regard to the interface with you as an investigator,” said Dr. Hebert, who has conducted more than 160 trials, including 65 in atopic dermatitis alone. “Sometimes you have to go over the head of the CRO to address issues that come up. The reality is, if the sponsor does not know you are not getting paid or having obstacles put in front of you that may not be in your contract, that constitutes a problem. You have to learn to be a bit shrewd in this game of research.”

She added that clinicians who choose to conduct clinical research come to learn “a whole new language,” such as what a confidential disclosure agreement is. “You also have to undergo CITI [Collaborative Institutional Training Initiative] training to meet the principles of good clinical practice,” she said. Other specifics include infectious substance shipping training per International Air Transport Association shipping guidelines, protocol training in arenas such as Eczema Area and Severity Index scoring and Psoriasis Area Severity Index scoring, and electronic case report form/electronic data–capture report training. “We also have a lot of equipment training because we are constantly getting new tablets for recording patient data and so forth,” she said. “This is something that has helped me become more technically equipped to handle all of this data capture.”

Dr. Hebert closed her remarks by noting that conducting clinical research can be a rewarding endeavor. “You really do address unmet needs, and you give a lot of education to residents, students, and fellows,” she said. “Clinical research provides research opportunities for those interested in dermatology. You have those moments when you see patients get better, and this represents the best patient encounter you could ever hope for.”

She reported having no relevant financial disclosures.

[email protected]

AUSTIN, TEX. – The way Adelaide A. Hebert, MD, sees it, the decision to add clinical research to your existing dermatology practice requires some soul searching, because not everyone is cut out for it.

“This is not something you take lightly,” Dr. Hebert, chief of pediatric dermatology at the University of Texas Health Science Center, Houston, said at the annual meeting of the Society for Pediatric Dermatology. “There will be days when you feel like you are going into combat. If you are not prepared for that, maybe stick to clinical practice. That plan might be a bit simpler.”

For more than 30 years, Dr. Hebert has been engaged in dermatology clinical research, with a focus on atopic dermatitis, psoriasis, and hyperhidrosis. Her team includes a full-time research fellow, a full-time nurse practitioner, and a part-time clinical trials coordinator. “We work very hard, and I am responsible for their salaries,” she said. “There is considerable pressure from year to year, but they work hard and are very loyal. They represent a great portion of the success that we have in clinical research. You need a team, and you have to be a team leader in order to undertake this.”

Dr. Hebert offered the following tips for incorporating clinical research into your practice:

• Set aside allocated time. “This is not a side job within your current occupation,” she emphasized. “You really need allocated time to do research, and you need protected academic time if you work in that environment. You also need protected academic time for your staff to conduct research.”

• Get to know the players involved. This includes forming professional relationships with internal and external review boards, and understanding contract and grants. “This collaboration is a lot like getting into a sport,” she explained. “You have to know the rules, you have to know how to play with strategy, and you have to be very effective.”

Review boards that work with academic centers include the Western Institutional Review Board (WIRB) and Advarra. “You also need to understand time lines, what it takes to go from submission to implementation,” Dr. Hebert said. “That time cannot be too long, or you will be off the list of desired investigators because you cannot get up and running in a timely fashion. Your team has to be behind you in order to make this happen.” [She recommended the National Association of Healthcare Revenue Integrity publication, “The Practical Guide to Clinical Trials Billing.”]

• Consider space and equipment needs. This includes space for patient charts, cameras, scales, electronic devices for data capture, computer equipment, and other instruments you may need to carry out your work. Dr. Hebert’s clinic houses about a half-dozen EKG machines dedicated to research projects. “You also need a lot of storage,” she added. “Our university requires us to save every piece of paper, every communication for 15 years. Our university does allocate that space.”

Sponsored research opportunities include working with the National Institutes of Health, Department of Defense, pharmaceutical companies, and over-the-counter product companies. “You can also initiate your own research,” she said. “One way to get started is to partner with an established researcher. That could be someone in your department, in a different department, or in a clinical research unit within your institution. They can help you with infrastructure and they can sometimes do your research submissions for you.”

Other ways to explore research opportunities include reaching out to medical science liaisons and clinical trial research organizations, and hiring fellows with research experience. “The bottom line is, talk to a lot of people you do not know,” Dr. Hebert said. “That is the real secret to getting research studies.”

There is another player in the field to become familiar with: contract research organizations (CROs), which provide support to pharmaceutical industries in the form of research services outsourced on a contract basis. They receive payment from the sponsor to conduct clinical research operations. “Many times the sponsor does not entirely know what the CRO is doing with regard to the interface with you as an investigator,” said Dr. Hebert, who has conducted more than 160 trials, including 65 in atopic dermatitis alone. “Sometimes you have to go over the head of the CRO to address issues that come up. The reality is, if the sponsor does not know you are not getting paid or having obstacles put in front of you that may not be in your contract, that constitutes a problem. You have to learn to be a bit shrewd in this game of research.”

She added that clinicians who choose to conduct clinical research come to learn “a whole new language,” such as what a confidential disclosure agreement is. “You also have to undergo CITI [Collaborative Institutional Training Initiative] training to meet the principles of good clinical practice,” she said. Other specifics include infectious substance shipping training per International Air Transport Association shipping guidelines, protocol training in arenas such as Eczema Area and Severity Index scoring and Psoriasis Area Severity Index scoring, and electronic case report form/electronic data–capture report training. “We also have a lot of equipment training because we are constantly getting new tablets for recording patient data and so forth,” she said. “This is something that has helped me become more technically equipped to handle all of this data capture.”

Dr. Hebert closed her remarks by noting that conducting clinical research can be a rewarding endeavor. “You really do address unmet needs, and you give a lot of education to residents, students, and fellows,” she said. “Clinical research provides research opportunities for those interested in dermatology. You have those moments when you see patients get better, and this represents the best patient encounter you could ever hope for.”

She reported having no relevant financial disclosures.

[email protected]

AUSTIN, TEX. – One day each week, Sasha D. Jaquez, PhD, visits with patients in the dermatology clinic at Dell Children’s Medical Center of Central Texas who wrestle with some aspect of their skin condition, from noncompliance to a recommended treatment regimen to fear of needles when an injection of medicine is required to keep them well.

“Our goal is to help promote the health and development of children, adolescents, and families through the use of evidence-based methods like cognitive-behavioral therapy,” said Dr. Jaquez, who is a pediatric psychologist at the University of Texas, Austin. “We do assessment and treatment of behavioral and emotional difficulties related to their skin condition or medical condition. So if they’re depressed but it’s not related to their skin condition, we will likely refer the patient to a community mental health system.”

During 1-hour visits at the dermatology clinic, Dr. Jaquez uses a mixed approach that includes cognitive-behavioral therapy and motivational interviewing to help patients and family members cope with their problematic behavior or negative thought patterns related to their skin conditions. “We do not have magic wands; we focus on the here and now,” she explained. “We focus on how to move forward in the most efficient way possible by teaching skills, practicing those skills with them in the office, and sending them home to use those skills. I don’t have 100% compliance on this, so if I notice that they’re not doing what I asked of them, we’ll have a conversation about what the barrier is. ‘What is getting in the way?’ I’ll ask. ‘Is this something you’re really wanting, or do you want a magic pill? If you want a magic pill, then our office isn’t where that’s going to come from.’ Sometimes patients aren’t ready to work on feeling better, and that is good for us to know.”

During consultations, she often talks with children and adolescents about how thoughts, feelings, and behaviors are related. She’ll use phrasing like, “The way that you think about something changes the way that you feel, and it changes the way that you act. We have control over our thoughts and behaviors, so if we think it’s going to be a bad day, it’s going to be a bad day. If we think it’s going to be a good day, then we’re going to find the positive aspects in the day and we might let those bad aspects go away. If I do something different [for my skin condition], then I’m going to feel different.”

She recalled the case of a 3-year-old boy with atopic dermatitis who was referred for excessive scratching. His mom stays at home, while dad works and travels frequently. “The parents had differing views on how to treat his medical condition. Mom wanted to do wet wraps while dad wanted to do bleach baths. Their son was getting no treatment because the parents couldn’t agree on anything. Mom noticed that her son scratches when he wants attention and when he’s angry.”

When Dr. Jaquez met with his parents, she encouraged them to agree on a plan to implement at home so that their son would gain some relief. She also advised them to ignore when their son scratches or when he gets angry. “Give him something else to do besides scratch, because if those hands are busy, he won’t be scratching. Let’s change the way this behavior happens. Let’s give him attention all the time instead of just when he’s scratching. That will work very quickly. And it did.”

She makes it a point to talk with patients and their families about living with the stress of a chronic illness like psoriasis or atopic dermatitis. “Let’s figure out, ‘How do we accept that this is how it is, and that they’re going to have to find their own ‘normal?’ ” she said. “I don’t know how many times someone comes into my office and says, ‘I just want to be normal.’ I like to ask patients, ‘what is your normal?’ These kids might have a lower quality of life than a child without a chronic illness, but we want to make sure that they’re living their lives to the fullest. You want to monitor not only adherence [to medication] but also quality of life. Sleep concerns are big. A lot of our kids might not being going to school, or they’re afraid to go to school because they get picked on because people don’t understand their skin condition.”

Dr. Jaquez acknowledged that not all dermatologists have a psychologist on staff or in their referral network, but all are capable of destigmatizing psychological and mental health issues for their patients. “Psychological comorbidities such as depression and anxiety can be associated with certain skin conditions,” she said. “Let them know that this is stressful stuff. Have discussions early, so if the time comes for a referral they won’t think you’re giving up on them. Don’t be afraid to say you have a psychologist that you want to refer to. Say, ‘I have an added team member I would love for you to meet. She’s our psychologist. She works with patients who are having difficulties.’ ”

Giving patients perceived control of their care could also help improve the behavior of concern. For example, when patients with needle phobia require an injection, ask if they would like to lay down, or sit down for the injection. “Giving them this tiny bit of control is going to help them feel more empowered,” she said.

Dr. Jaquez also recommends that clinicians pay attention to nonverbal cues and steer clear of using scare tactics to change their behavior. “Use positive behavioral strategies and try to avoid punishment. Children don’t want to hear ‘stop’ all the time. Parents are tired of saying it, and kids are tired of hearing it. We focus on praising the things that are going well. I advise parents all the time: ‘Catch them being good.’ ”

Dr. Jaquez reported having no financial disclosures.

[email protected]

AUSTIN, TEX. – One day each week, Sasha D. Jaquez, PhD, visits with patients in the dermatology clinic at Dell Children’s Medical Center of Central Texas who wrestle with some aspect of their skin condition, from noncompliance to a recommended treatment regimen to fear of needles when an injection of medicine is required to keep them well.

“Our goal is to help promote the health and development of children, adolescents, and families through the use of evidence-based methods like cognitive-behavioral therapy,” said Dr. Jaquez, who is a pediatric psychologist at the University of Texas, Austin. “We do assessment and treatment of behavioral and emotional difficulties related to their skin condition or medical condition. So if they’re depressed but it’s not related to their skin condition, we will likely refer the patient to a community mental health system.”

During 1-hour visits at the dermatology clinic, Dr. Jaquez uses a mixed approach that includes cognitive-behavioral therapy and motivational interviewing to help patients and family members cope with their problematic behavior or negative thought patterns related to their skin conditions. “We do not have magic wands; we focus on the here and now,” she explained. “We focus on how to move forward in the most efficient way possible by teaching skills, practicing those skills with them in the office, and sending them home to use those skills. I don’t have 100% compliance on this, so if I notice that they’re not doing what I asked of them, we’ll have a conversation about what the barrier is. ‘What is getting in the way?’ I’ll ask. ‘Is this something you’re really wanting, or do you want a magic pill? If you want a magic pill, then our office isn’t where that’s going to come from.’ Sometimes patients aren’t ready to work on feeling better, and that is good for us to know.”

During consultations, she often talks with children and adolescents about how thoughts, feelings, and behaviors are related. She’ll use phrasing like, “The way that you think about something changes the way that you feel, and it changes the way that you act. We have control over our thoughts and behaviors, so if we think it’s going to be a bad day, it’s going to be a bad day. If we think it’s going to be a good day, then we’re going to find the positive aspects in the day and we might let those bad aspects go away. If I do something different [for my skin condition], then I’m going to feel different.”

She recalled the case of a 3-year-old boy with atopic dermatitis who was referred for excessive scratching. His mom stays at home, while dad works and travels frequently. “The parents had differing views on how to treat his medical condition. Mom wanted to do wet wraps while dad wanted to do bleach baths. Their son was getting no treatment because the parents couldn’t agree on anything. Mom noticed that her son scratches when he wants attention and when he’s angry.”

When Dr. Jaquez met with his parents, she encouraged them to agree on a plan to implement at home so that their son would gain some relief. She also advised them to ignore when their son scratches or when he gets angry. “Give him something else to do besides scratch, because if those hands are busy, he won’t be scratching. Let’s change the way this behavior happens. Let’s give him attention all the time instead of just when he’s scratching. That will work very quickly. And it did.”

She makes it a point to talk with patients and their families about living with the stress of a chronic illness like psoriasis or atopic dermatitis. “Let’s figure out, ‘How do we accept that this is how it is, and that they’re going to have to find their own ‘normal?’ ” she said. “I don’t know how many times someone comes into my office and says, ‘I just want to be normal.’ I like to ask patients, ‘what is your normal?’ These kids might have a lower quality of life than a child without a chronic illness, but we want to make sure that they’re living their lives to the fullest. You want to monitor not only adherence [to medication] but also quality of life. Sleep concerns are big. A lot of our kids might not being going to school, or they’re afraid to go to school because they get picked on because people don’t understand their skin condition.”

Dr. Jaquez acknowledged that not all dermatologists have a psychologist on staff or in their referral network, but all are capable of destigmatizing psychological and mental health issues for their patients. “Psychological comorbidities such as depression and anxiety can be associated with certain skin conditions,” she said. “Let them know that this is stressful stuff. Have discussions early, so if the time comes for a referral they won’t think you’re giving up on them. Don’t be afraid to say you have a psychologist that you want to refer to. Say, ‘I have an added team member I would love for you to meet. She’s our psychologist. She works with patients who are having difficulties.’ ”

Giving patients perceived control of their care could also help improve the behavior of concern. For example, when patients with needle phobia require an injection, ask if they would like to lay down, or sit down for the injection. “Giving them this tiny bit of control is going to help them feel more empowered,” she said.

Dr. Jaquez also recommends that clinicians pay attention to nonverbal cues and steer clear of using scare tactics to change their behavior. “Use positive behavioral strategies and try to avoid punishment. Children don’t want to hear ‘stop’ all the time. Parents are tired of saying it, and kids are tired of hearing it. We focus on praising the things that are going well. I advise parents all the time: ‘Catch them being good.’ ”

Dr. Jaquez reported having no financial disclosures.

[email protected]

AUSTIN, TEX. – One day each week, Sasha D. Jaquez, PhD, visits with patients in the dermatology clinic at Dell Children’s Medical Center of Central Texas who wrestle with some aspect of their skin condition, from noncompliance to a recommended treatment regimen to fear of needles when an injection of medicine is required to keep them well.

“Our goal is to help promote the health and development of children, adolescents, and families through the use of evidence-based methods like cognitive-behavioral therapy,” said Dr. Jaquez, who is a pediatric psychologist at the University of Texas, Austin. “We do assessment and treatment of behavioral and emotional difficulties related to their skin condition or medical condition. So if they’re depressed but it’s not related to their skin condition, we will likely refer the patient to a community mental health system.”

During 1-hour visits at the dermatology clinic, Dr. Jaquez uses a mixed approach that includes cognitive-behavioral therapy and motivational interviewing to help patients and family members cope with their problematic behavior or negative thought patterns related to their skin conditions. “We do not have magic wands; we focus on the here and now,” she explained. “We focus on how to move forward in the most efficient way possible by teaching skills, practicing those skills with them in the office, and sending them home to use those skills. I don’t have 100% compliance on this, so if I notice that they’re not doing what I asked of them, we’ll have a conversation about what the barrier is. ‘What is getting in the way?’ I’ll ask. ‘Is this something you’re really wanting, or do you want a magic pill? If you want a magic pill, then our office isn’t where that’s going to come from.’ Sometimes patients aren’t ready to work on feeling better, and that is good for us to know.”

During consultations, she often talks with children and adolescents about how thoughts, feelings, and behaviors are related. She’ll use phrasing like, “The way that you think about something changes the way that you feel, and it changes the way that you act. We have control over our thoughts and behaviors, so if we think it’s going to be a bad day, it’s going to be a bad day. If we think it’s going to be a good day, then we’re going to find the positive aspects in the day and we might let those bad aspects go away. If I do something different [for my skin condition], then I’m going to feel different.”

She recalled the case of a 3-year-old boy with atopic dermatitis who was referred for excessive scratching. His mom stays at home, while dad works and travels frequently. “The parents had differing views on how to treat his medical condition. Mom wanted to do wet wraps while dad wanted to do bleach baths. Their son was getting no treatment because the parents couldn’t agree on anything. Mom noticed that her son scratches when he wants attention and when he’s angry.”

When Dr. Jaquez met with his parents, she encouraged them to agree on a plan to implement at home so that their son would gain some relief. She also advised them to ignore when their son scratches or when he gets angry. “Give him something else to do besides scratch, because if those hands are busy, he won’t be scratching. Let’s change the way this behavior happens. Let’s give him attention all the time instead of just when he’s scratching. That will work very quickly. And it did.”

She makes it a point to talk with patients and their families about living with the stress of a chronic illness like psoriasis or atopic dermatitis. “Let’s figure out, ‘How do we accept that this is how it is, and that they’re going to have to find their own ‘normal?’ ” she said. “I don’t know how many times someone comes into my office and says, ‘I just want to be normal.’ I like to ask patients, ‘what is your normal?’ These kids might have a lower quality of life than a child without a chronic illness, but we want to make sure that they’re living their lives to the fullest. You want to monitor not only adherence [to medication] but also quality of life. Sleep concerns are big. A lot of our kids might not being going to school, or they’re afraid to go to school because they get picked on because people don’t understand their skin condition.”

Dr. Jaquez acknowledged that not all dermatologists have a psychologist on staff or in their referral network, but all are capable of destigmatizing psychological and mental health issues for their patients. “Psychological comorbidities such as depression and anxiety can be associated with certain skin conditions,” she said. “Let them know that this is stressful stuff. Have discussions early, so if the time comes for a referral they won’t think you’re giving up on them. Don’t be afraid to say you have a psychologist that you want to refer to. Say, ‘I have an added team member I would love for you to meet. She’s our psychologist. She works with patients who are having difficulties.’ ”

Giving patients perceived control of their care could also help improve the behavior of concern. For example, when patients with needle phobia require an injection, ask if they would like to lay down, or sit down for the injection. “Giving them this tiny bit of control is going to help them feel more empowered,” she said.

Dr. Jaquez also recommends that clinicians pay attention to nonverbal cues and steer clear of using scare tactics to change their behavior. “Use positive behavioral strategies and try to avoid punishment. Children don’t want to hear ‘stop’ all the time. Parents are tired of saying it, and kids are tired of hearing it. We focus on praising the things that are going well. I advise parents all the time: ‘Catch them being good.’ ”

Dr. Jaquez reported having no financial disclosures.

[email protected]

AUSTIN, TEX. – Among children with psoriasis, there appears to be no strong evidence that biologic immunomodulating drugs increase the 6-month risk of serious infections, compared with systemic nonbiologics or phototherapy, according to results from the largest population-based study of its kind to date.

However, children with psoriasis face a 64% increased risk of infection, compared with risk-matched pediatric patients without the disease.

“We know that pediatric psoriasis affects up to 1.3% of children, and we know that is associated with multiple potential comorbidities and that it has a significant impact on quality of life for children affected,” lead study author Maria Schneeweiss, MD, said at the annual meeting of the Society for Pediatric Dermatology. “Increasingly, we see that biologic and nonbiologic systemic agents are used to treat moderate to severe pediatric psoriasis. While we have a lot of experience in adult psoriasis and a lot of comparative safety studies of these drugs in adult psoriasis, there are very few population-based studies on the safety of these systemic agents for treating pediatric psoriasis.”

In an effort to evaluate the 6-month risk of serious bacterial and opportunistic infections in children with psoriasis treated with systemic immunomodulatory medications, Dr. Schneeweiss and Joseph F. Merola, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and Jennifer Huang, MD, of Boston Children’s Hospital drew from longitudinal, patient-level U.S. claims data in the MarketScan database between 2003 and 2017. They limited the analysis to patients younger than age 18; those who had a recorded diagnosis of psoriasis; and those who were treated with biologics, nonbiologic immunomodulatory agents, or phototherapy. The researchers used hospital discharge diagnoses to compute the risk of serious bacterial and opportunistic infections, and propensity score matching to determine relative risks.

A total of 54,355 children with psoriasis were identified in the database. Before propensity score matching, 635 patients initiated biologic therapy, 919 initiated nonbiologic systemic agents, and 2,537 initiated phototherapy. Their mean age was 12-14 years and slightly more than half were female. In nonbiologic initiators, the 6-month risk of serious infections was 4.75 per 1,000 patients, while in biologic initiators it was 5.44 per 1,000 patients, resulting in a propensity score–matched ratio of 0.60. There was no statistically significant increased risk when the use of nonbiologics was compared with the use of phototherapy.

Independent of treatment, the risk of infection among psoriasis patients was 1.1 per 1,000 patients, which was 60% higher than matched pediatric patients without psoriasis (risk ratio, 1.64).

“When treating pediatric patients with psoriasis, clinicians should remain mindful that the presence of psoriasis itself may increase the risk of infection in children and adolescents, independent of treatment, but that biologic immunomodulatory agents do not further increase that risk,” Dr. Schneeweiss said in an interview. “Our findings suggest that, while there may be an increased risk of certain infections based on the presence of psoriasis alone, all appropriate treatment options should be discussed with patients in shared decision making with their physician. Patients should understand the risks, benefits, and alternatives to any treatment option but not necessarily be restricted as such and have access to newer, targeted and highly effective therapy as appropriate to each individual case.”

She added that, based on the National Psoriasis Foundation guidance of treat-to-target strategies, “our pediatric patients should be offered the same level of disease control as all psoriasis patients.”

She acknowledged certain limitations of the analysis, including the inability to stratify by disease severity and to determine specific doses of medication used.

The study was funded by the Brigham and Women’s Hospital departments of dermatology and medicine. Dr. Schneeweiss and Dr. Huang reported having no financial disclosures. Dr. Merola reported that he has served as a consultant and/or investigator for numerous pharmaceutical companies.

[email protected]

AUSTIN, TEX. – Among children with psoriasis, there appears to be no strong evidence that biologic immunomodulating drugs increase the 6-month risk of serious infections, compared with systemic nonbiologics or phototherapy, according to results from the largest population-based study of its kind to date.

However, children with psoriasis face a 64% increased risk of infection, compared with risk-matched pediatric patients without the disease.

“We know that pediatric psoriasis affects up to 1.3% of children, and we know that is associated with multiple potential comorbidities and that it has a significant impact on quality of life for children affected,” lead study author Maria Schneeweiss, MD, said at the annual meeting of the Society for Pediatric Dermatology. “Increasingly, we see that biologic and nonbiologic systemic agents are used to treat moderate to severe pediatric psoriasis. While we have a lot of experience in adult psoriasis and a lot of comparative safety studies of these drugs in adult psoriasis, there are very few population-based studies on the safety of these systemic agents for treating pediatric psoriasis.”

In an effort to evaluate the 6-month risk of serious bacterial and opportunistic infections in children with psoriasis treated with systemic immunomodulatory medications, Dr. Schneeweiss and Joseph F. Merola, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and Jennifer Huang, MD, of Boston Children’s Hospital drew from longitudinal, patient-level U.S. claims data in the MarketScan database between 2003 and 2017. They limited the analysis to patients younger than age 18; those who had a recorded diagnosis of psoriasis; and those who were treated with biologics, nonbiologic immunomodulatory agents, or phototherapy. The researchers used hospital discharge diagnoses to compute the risk of serious bacterial and opportunistic infections, and propensity score matching to determine relative risks.

A total of 54,355 children with psoriasis were identified in the database. Before propensity score matching, 635 patients initiated biologic therapy, 919 initiated nonbiologic systemic agents, and 2,537 initiated phototherapy. Their mean age was 12-14 years and slightly more than half were female. In nonbiologic initiators, the 6-month risk of serious infections was 4.75 per 1,000 patients, while in biologic initiators it was 5.44 per 1,000 patients, resulting in a propensity score–matched ratio of 0.60. There was no statistically significant increased risk when the use of nonbiologics was compared with the use of phototherapy.

Independent of treatment, the risk of infection among psoriasis patients was 1.1 per 1,000 patients, which was 60% higher than matched pediatric patients without psoriasis (risk ratio, 1.64).

“When treating pediatric patients with psoriasis, clinicians should remain mindful that the presence of psoriasis itself may increase the risk of infection in children and adolescents, independent of treatment, but that biologic immunomodulatory agents do not further increase that risk,” Dr. Schneeweiss said in an interview. “Our findings suggest that, while there may be an increased risk of certain infections based on the presence of psoriasis alone, all appropriate treatment options should be discussed with patients in shared decision making with their physician. Patients should understand the risks, benefits, and alternatives to any treatment option but not necessarily be restricted as such and have access to newer, targeted and highly effective therapy as appropriate to each individual case.”

She added that, based on the National Psoriasis Foundation guidance of treat-to-target strategies, “our pediatric patients should be offered the same level of disease control as all psoriasis patients.”

She acknowledged certain limitations of the analysis, including the inability to stratify by disease severity and to determine specific doses of medication used.

The study was funded by the Brigham and Women’s Hospital departments of dermatology and medicine. Dr. Schneeweiss and Dr. Huang reported having no financial disclosures. Dr. Merola reported that he has served as a consultant and/or investigator for numerous pharmaceutical companies.

[email protected]

AUSTIN, TEX. – Among children with psoriasis, there appears to be no strong evidence that biologic immunomodulating drugs increase the 6-month risk of serious infections, compared with systemic nonbiologics or phototherapy, according to results from the largest population-based study of its kind to date.

However, children with psoriasis face a 64% increased risk of infection, compared with risk-matched pediatric patients without the disease.

“We know that pediatric psoriasis affects up to 1.3% of children, and we know that is associated with multiple potential comorbidities and that it has a significant impact on quality of life for children affected,” lead study author Maria Schneeweiss, MD, said at the annual meeting of the Society for Pediatric Dermatology. “Increasingly, we see that biologic and nonbiologic systemic agents are used to treat moderate to severe pediatric psoriasis. While we have a lot of experience in adult psoriasis and a lot of comparative safety studies of these drugs in adult psoriasis, there are very few population-based studies on the safety of these systemic agents for treating pediatric psoriasis.”

In an effort to evaluate the 6-month risk of serious bacterial and opportunistic infections in children with psoriasis treated with systemic immunomodulatory medications, Dr. Schneeweiss and Joseph F. Merola, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and Jennifer Huang, MD, of Boston Children’s Hospital drew from longitudinal, patient-level U.S. claims data in the MarketScan database between 2003 and 2017. They limited the analysis to patients younger than age 18; those who had a recorded diagnosis of psoriasis; and those who were treated with biologics, nonbiologic immunomodulatory agents, or phototherapy. The researchers used hospital discharge diagnoses to compute the risk of serious bacterial and opportunistic infections, and propensity score matching to determine relative risks.

A total of 54,355 children with psoriasis were identified in the database. Before propensity score matching, 635 patients initiated biologic therapy, 919 initiated nonbiologic systemic agents, and 2,537 initiated phototherapy. Their mean age was 12-14 years and slightly more than half were female. In nonbiologic initiators, the 6-month risk of serious infections was 4.75 per 1,000 patients, while in biologic initiators it was 5.44 per 1,000 patients, resulting in a propensity score–matched ratio of 0.60. There was no statistically significant increased risk when the use of nonbiologics was compared with the use of phototherapy.

Independent of treatment, the risk of infection among psoriasis patients was 1.1 per 1,000 patients, which was 60% higher than matched pediatric patients without psoriasis (risk ratio, 1.64).

“When treating pediatric patients with psoriasis, clinicians should remain mindful that the presence of psoriasis itself may increase the risk of infection in children and adolescents, independent of treatment, but that biologic immunomodulatory agents do not further increase that risk,” Dr. Schneeweiss said in an interview. “Our findings suggest that, while there may be an increased risk of certain infections based on the presence of psoriasis alone, all appropriate treatment options should be discussed with patients in shared decision making with their physician. Patients should understand the risks, benefits, and alternatives to any treatment option but not necessarily be restricted as such and have access to newer, targeted and highly effective therapy as appropriate to each individual case.”

She added that, based on the National Psoriasis Foundation guidance of treat-to-target strategies, “our pediatric patients should be offered the same level of disease control as all psoriasis patients.”

She acknowledged certain limitations of the analysis, including the inability to stratify by disease severity and to determine specific doses of medication used.

The study was funded by the Brigham and Women’s Hospital departments of dermatology and medicine. Dr. Schneeweiss and Dr. Huang reported having no financial disclosures. Dr. Merola reported that he has served as a consultant and/or investigator for numerous pharmaceutical companies.

[email protected]