Doug Brunk

SAN DIEGO – The way Doris Day, MD, sees it, before establishing a professional presence on Facebook, Twitter, YouTube, or any other social media channel, the first question to ask yourself is why.

“Why are you doing this, and why does it matter?” she asked attendees at the annual Masters of Aesthetics Symposium. “If you know why, then you can answer a lot of questions.”

Dr. Day of the department of dermatology at New York University, said there are at least four quadrants of personal branding. The first is personal (who you are, where you live, family, hobbies, interests, education), and the second is professional (where you work, training, important skills and experience, and what sets you apart). The last two are thought leadership and legacy, “which is not your image,” she said. “It’s what you do for others; it’s the teaching you do from day to day.”

She noted that 74% of people look to social media networks for advice on buying decisions, and 40% of people purchased an item based on seeing it promoted by an influencer via Instagram or Twitter. This extends to aesthetics as well. “We need to become the influencers,” Dr. Day said. However, social media “is not all always about you; it’s the message, so knowing your medium is important. Each medium has its own velocity, its own type of follower, its own best practice to attract the best amount of viewers. Consistency is important. You have to reach your target generation.”

According to Dr. Day, Millennials (those aged 20-35 years) spend an average of 8 hours per day online; 70% use Facebook, 63% use YouTube, and 43% want brands to reach them via e-mail. “They’re a little more concerned about their financial future than other generations,” she said. Meanwhile, 76% of the demographic Generation X (those aged 36-49) access some form of social media. They have an annual buying power of $200 million, and 68% make decisions based on reviews like those on Yelp. “Reviews matter,” she said. “It’s only the people who are unhappy with you who are happy to go out and talk about it. People who are happy with you are going to need more encouragement to write a review.” On average, baby boomers (those aged 50-65 years) spend 27 hours per week online, and nearly 16% spend at least 11 hours on Facebook. Nearly half (48%) rely on credit cards for their purchases, and 13% use LinkedIn.

[email protected]

SAN DIEGO – The way Doris Day, MD, sees it, before establishing a professional presence on Facebook, Twitter, YouTube, or any other social media channel, the first question to ask yourself is why.

“Why are you doing this, and why does it matter?” she asked attendees at the annual Masters of Aesthetics Symposium. “If you know why, then you can answer a lot of questions.”

Dr. Day of the department of dermatology at New York University, said there are at least four quadrants of personal branding. The first is personal (who you are, where you live, family, hobbies, interests, education), and the second is professional (where you work, training, important skills and experience, and what sets you apart). The last two are thought leadership and legacy, “which is not your image,” she said. “It’s what you do for others; it’s the teaching you do from day to day.”

She noted that 74% of people look to social media networks for advice on buying decisions, and 40% of people purchased an item based on seeing it promoted by an influencer via Instagram or Twitter. This extends to aesthetics as well. “We need to become the influencers,” Dr. Day said. However, social media “is not all always about you; it’s the message, so knowing your medium is important. Each medium has its own velocity, its own type of follower, its own best practice to attract the best amount of viewers. Consistency is important. You have to reach your target generation.”

According to Dr. Day, Millennials (those aged 20-35 years) spend an average of 8 hours per day online; 70% use Facebook, 63% use YouTube, and 43% want brands to reach them via e-mail. “They’re a little more concerned about their financial future than other generations,” she said. Meanwhile, 76% of the demographic Generation X (those aged 36-49) access some form of social media. They have an annual buying power of $200 million, and 68% make decisions based on reviews like those on Yelp. “Reviews matter,” she said. “It’s only the people who are unhappy with you who are happy to go out and talk about it. People who are happy with you are going to need more encouragement to write a review.” On average, baby boomers (those aged 50-65 years) spend 27 hours per week online, and nearly 16% spend at least 11 hours on Facebook. Nearly half (48%) rely on credit cards for their purchases, and 13% use LinkedIn.

[email protected]

SAN DIEGO – The way Doris Day, MD, sees it, before establishing a professional presence on Facebook, Twitter, YouTube, or any other social media channel, the first question to ask yourself is why.

“Why are you doing this, and why does it matter?” she asked attendees at the annual Masters of Aesthetics Symposium. “If you know why, then you can answer a lot of questions.”

Dr. Day of the department of dermatology at New York University, said there are at least four quadrants of personal branding. The first is personal (who you are, where you live, family, hobbies, interests, education), and the second is professional (where you work, training, important skills and experience, and what sets you apart). The last two are thought leadership and legacy, “which is not your image,” she said. “It’s what you do for others; it’s the teaching you do from day to day.”

She noted that 74% of people look to social media networks for advice on buying decisions, and 40% of people purchased an item based on seeing it promoted by an influencer via Instagram or Twitter. This extends to aesthetics as well. “We need to become the influencers,” Dr. Day said. However, social media “is not all always about you; it’s the message, so knowing your medium is important. Each medium has its own velocity, its own type of follower, its own best practice to attract the best amount of viewers. Consistency is important. You have to reach your target generation.”

According to Dr. Day, Millennials (those aged 20-35 years) spend an average of 8 hours per day online; 70% use Facebook, 63% use YouTube, and 43% want brands to reach them via e-mail. “They’re a little more concerned about their financial future than other generations,” she said. Meanwhile, 76% of the demographic Generation X (those aged 36-49) access some form of social media. They have an annual buying power of $200 million, and 68% make decisions based on reviews like those on Yelp. “Reviews matter,” she said. “It’s only the people who are unhappy with you who are happy to go out and talk about it. People who are happy with you are going to need more encouragement to write a review.” On average, baby boomers (those aged 50-65 years) spend 27 hours per week online, and nearly 16% spend at least 11 hours on Facebook. Nearly half (48%) rely on credit cards for their purchases, and 13% use LinkedIn.

[email protected]

About 15 years ago, rheumatologists at the University of Colorado School of Medicine, Aurora, implemented a preappointment consult triage system as a way to identify rheumatology patients who require timely evaluation and treatment.

Over time, the endeavor caused some soul searching. They wondered how effective their consult triage system was in identifying all patients with inflammatory rheumatic diseases and in ensuring they were seen promptly. They also wondered about the revenue implications of routine outpatient care of autoimmune and inflammatory rheumatic disease (AIRD) patients, compared with that of non-AIRD patients.

“Hospital leadership is very interested in making sure that all patients have access to specialty care in a timely manner,” said Sterling G. West, MD, one of the study authors who is also professor of medicine at the university. “However, there are not enough rheumatologists to see all patients with rheumatic complaints, and this deficit is likely to get worse. Although all patients with a rheumatic complaint would likely benefit from a rheumatology consultation, it is clear that timely access to rheumatologic care is most beneficial for patients with inflammatory rheumatic diseases to prevent future morbidity and disability.”
 

Year-long follow-up finds high sensitivity, more revenue

What started out as a quality improvement project morphed into a robust study that was published online July 12, 2018, in Arthritis Care & Research. Using data recorded in the electronic medical record, Dr. West and his colleagues retrospectively reviewed 961 new outpatient rheumatology consults sent during a 9-month period for final diagnosis and revenue generation for routine outpatient care over 1 year following consult review or initial evaluation. The first step of the consult management involves an intake access coordinator, Ryan Goecker, obtaining information about the patient from the referring clinician. Next, one of three experienced rheumatologists at the university – Duane W. Pearson, MD, Christopher C. Striebich, MD, or Jason R. Kolfenbach, MD – reviews the information about the case. “We do request that labs and x-rays be done ahead of time, depending on what the consult question is, so that we have the data to be able to decide whether a patient likely has an inflammatory process that we need to see or not,” Dr. West explained. “It takes somewhere between 5 and 20 minutes per consult. In total, it takes our rheumatologists about 5 hours a week to do the consults. However, even after subtracting the physician time spent screening consults, the time saved by the consult triage system enabled over 200 more time slots per year to be available to see new AIRD patients than would have been possible without the triage system.”

Following review of the data supplied about the case, patients who may have acute inflammatory monoarticular arthritis or some other rheumatologic emergency are seen within 24-48 hours, while consults with a possible AIRD are approved and seen within 1-4 weeks. Priority is given to those with suspected vasculitis, systemic lupus erythematosus, myositis, and disabling inflammatory arthritis. Patients with probable noninflammatory conditions such as osteoarthritis, fibromyalgia, and mechanical low back pain are not scheduled for an in-person visit. “Instead of simply declining the consult, we try to give some direction, or we say, ‘Why don’t you try this, this, and this, sort of a miniconsult,” Dr. West noted. “One of the potential adverse reactions to doing consult triage would be that the referring provider would be upset if we decline their consult. We acknowledge that. But over time we’ve been able to convince them that this is best for all concerned, so that the inflammatory disease group gets in to see us in an appropriate amount of time.”

Of the 961 consults, 673 were scheduled for an in-person AIRD evaluation and 288 consults were not scheduled. Patients were seen an average of 13 days after consult review. Of the 673 approved consults, 597 (89%) came for evaluation. Of these, 357 were diagnosed as having an AIRD, while 240 were diagnosed as having a non-AIRD. Among the patients not scheduled for a rheumatology visit, 128 had 1-year follow-up data, with 6 patients eventually diagnosed as having an AIRD. This translated into a consult triage sensitivity of 98% and a positive predictive value of 60%. “There’s a fair number of people with noninflammatory disease who do get into see us,” Dr. West said. “That has to do with our desire to not be overly rigid. The sensitivity, specificity, and positive predictive value were not quite as high as some people would like to see, but we really weren’t missing people who really needed to be seen.”

In their conservative cost analysis, revenue data for outpatient care was available for 318 of the 357 AIRD patients and 192 of 240 non-AIRD patients. It demonstrated that care of AIRD patients generates 44 times more revenue, compared with non-AIRD patients ($5,877 vs. $134 per patient, respectively; P less than .001).

“Our consult triage protocol appears to be an effective method to assure that patients with inflammatory rheumatic diseases get expedited access to appropriate rheumatologic care,” Dr. West concluded. “Using conservative measures, caring for patients with inflammatory rheumatic diseases results in significantly more revenue generation.” Generalizability of such a protocol to other practice settings depends on the time rheumatologists are willing to commit to it. “That’s the big thing,” he said. “The question comes up, could a nurse or a nurse practitioner learn the skills over time to be able to do efficient consult triage, to free up the doc from that? Yes. I think that’s absolutely possible.”

Going forward, Dr. Pearson and Dr. Kolfenbach, who are authors on the paper, have launched a pilot project in which the rheumatologist is compensated for doing a record review and e-consult on patients not recommended to be seen in the rheumatology clinic. “For consults who do not have inflammatory disease, we can say [to the referring clinician], ‘If we did see them, this is what we would be doing,’ ” Dr. West said. “Sometimes if there are still questions, we’ll say something like, ‘Once you get the results back, let us know and we can look at it again.’ That way they are getting similar compensation as telemedicine and other forms of consultation.”

At the Zuckerberg San Francisco General Hospital (ZSFG), use of a novel electronic consultation and referral system that was implemented in 2007 by University of California, San Francisco, providers continues to thrive for rheumatology and other specialty services. With this electronic system, previously called e-referral, all provider communication is captured in real time and recorded within the electronic health record. In a 2015 article from Arthritis Care & Research, researchers led by Jinoos Yazdany, MD, MPH, reviewed 2,105 e-referrals made between 2008 and 2012 (Arthritis Care Res. 2015;67[8]:1158-63). The main outcome of interest was use of preconsultation exchange, defined as back-and-forth communication between referring and specialty care providers, facilitating triage of referrals, requests for more information, or resolution of questions without a visit. The researchers found that about 25% of e-consults were resolved without a clinic visit, and that the proportion of e-consults undergoing preconsultation exchange increased over time, from 55% in 2008 to 74% in 2011.

“We’ve had situations in which somebody within our hospital system has requested a rheumatology referral but did not realize the urgency of the patients’ clinical signs and symptoms,” Dr. Yazdany, a rheumatologist and health services researcher at UCSF, said in an interview. “E-referrals are often responded to within that day. When we see an e-consult for a young woman with a rash and protein in her urine, a rheumatologist will recognize that is very concerning for a serious diagnosis like lupus of the kidney or systemic vasculitis. In that situation, we would pick up the phone and sometimes even call the patient and have them come to the emergency room for an urgent evaluation. Over the years, there have been many situations in which we’ve been able to intervene much earlier than we otherwise would have. In some cases that early intervention was lifesaving, or at least organ-preserving for the patient.”

Two studies from the early 2000s examined the use of preappointment management in rheumatology (see Arthritis Care Res. 2001;45:295-300 and Arthritis Rheum. 2004;51:253-7), but this is among the first to incorporate use of an electronic medical record to provide real-time exchange between the specialist and the referring provider. Clinicians at UCSF are reimbursed for reviewing e-consults in one of two ways. Those at ZSFG have protected and compensated time for the task, “so it’s basically part of their job to spend a half day a week on e-consults,” Dr. Yazdany said. “The department of public health and our health care system fold that into operational costs. That’s absolutely critical for success. To be done well and thoughtfully, managing consults and referrals takes time. It takes a lot of expertise.” Meanwhile, clinicians at UCSF’s main university hospital receive a small payment for each e-consult they review. “If it’s a complex consult it’s a higher reimbursement,” she said. “If it’s a simple one, it’s slightly less reimbursement, so it’s a fee-for-service model. It’s something that the health system funds, because it creates efficiencies and access for patients.”
 

Gaining popularity across specialties

Delphine S. Tuot, MD, a nephrologist who directs the ZSFG e-consult system, said that the notion of preconsult triage is gaining popularity in all medical specialties. For example, the Blue Shield of California Foundation is funding implementation of e-consult systems across many of California’s safety net health care delivery systems. “We have many health care plans that are interested in this process as well, because it improves access to specialty care, particularly in rural areas or in areas where the specialist workforce is limited,” said Dr. Tuot, who is codirector of the UCSF Center for Innovation in Access and Quality at ZSFG. Such efforts are also being promoted by the Public Hospital Redesign and Incentives in Medi-Cal Program (PRIME), which is part of California’s Medicaid waiver. PRIME “is encouraging health systems to look at innovative ways to deliver specialty care,” Dr. Tuot said. “E-consults and other non–face-to-face ways to deliver specialty care, including telemedicine encounters, count toward that metric for the Medicaid waiver.”

At the national level, the Association of American Medical Colleges has collaborated with more than 20 academic medical centers in 14 states, including Dartmouth-Hitchcock and Yale University, to implement tools built into the electronic medical record system through a program known as Project CORE (Coordinating Optimal Referral Experiences). According to Scott Shipman, MD, MPH, director of clinical innovations for the AAMC, nearly all of the current CORE sites have either gone live with the model in rheumatology or are planning to do so. “Better communication and coordination between primary care providers and specialists is important for all specialties, but because of the complexity of evaluation and management of problems in rheumatology, there is a tremendous opportunity for the CORE model to help get providers on the same page,” Dr. Shipman said in an interview. “We do this through simple decision support that we build into the referral order in the EMR, available at the point of care. Additionally, given the workforce challenges facing rheumatology in most regions of the country and consequent access barriers, offloading some of the demand via e-consults holds great promise.” Current focus areas for Project CORE, he said, include continued support of current CORE sites in their implementation and scaling efforts to maximize impact, advocacy to promote payer engagement in support of e-consult reimbursements, and working to extend the model to additional academic medical centers.

Dr. Tuot emphasized that performing e-consults “takes time and effort on behalf of specialists, so if you’re by yourself in solo practice it probably does not make sense to implement,” she said. “You need to spend your time seeing patients as much as possible. For primary care providers who are asking for curbside consults, it’s probably best to have things in writing from the specialist, such as in an e-consult, to make sure there’s no misunderstanding.”

As demand for rheumatology services increases, clinicians “have to figure out a way to see patients in most urgent need of our services,” Dr. Yazdany said. “That requires that we use technology like the e-consult system to prioritize the patients that we’re seeing. As we look at the rheumatology workforce shortage, especially in some geographic regions, it’s going to be absolutely critical. There are some diseases that no other specialists have experience caring for. In those situations, those patients need to get in to see rheumatologists in a timely fashion.”
 

Paper-based preconsult triage system

At Essentia Health, an integrated health care system with facilities in Minnesota, Wisconsin, and North Dakota, Meghan Scheibe, MD, a rheumatologist, is currently working with a rheumatologist colleague and a registered nurse to implement a paper-based preconsult triage system, “because our wait times have unfortunately skyrocketed,” she said. “We receive a lot of outside referrals from other health care groups and large health care systems that don’t have access to rheumatology.” Currently, the triage system is comprised of a referral note which includes the reason for consultation. Dr. Scheibe and her colleague rank the referral as expedited, intermediate concern, or low priority based on information provided by the referring clinician. “We mark those for our nurse to help schedule, and we let the referring provider know what the wait time is,” Dr. Scheibe said. “Then they have an opportunity to communicate back to us or say, ‘Yes, that’s fine,’ or, ‘I’m really worried about this patient. Could you get her in sooner?’ ”

It’s early in the process, but so far, implementation of the preconsult triage protocol “is allowing us to focus on the consultations on which we can be most impactful and not overwhelm the rheumatology workforce that we have,” she said.

Research reported in the UCSF study was supported by the American College of Rheumatology’s Ephraim P. Engleman Endowed Resident Research Preceptorship and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. None of the sources interviewed for this story reported having relevant financial disclosures.

[email protected]

About 15 years ago, rheumatologists at the University of Colorado School of Medicine, Aurora, implemented a preappointment consult triage system as a way to identify rheumatology patients who require timely evaluation and treatment.

Over time, the endeavor caused some soul searching. They wondered how effective their consult triage system was in identifying all patients with inflammatory rheumatic diseases and in ensuring they were seen promptly. They also wondered about the revenue implications of routine outpatient care of autoimmune and inflammatory rheumatic disease (AIRD) patients, compared with that of non-AIRD patients.

“Hospital leadership is very interested in making sure that all patients have access to specialty care in a timely manner,” said Sterling G. West, MD, one of the study authors who is also professor of medicine at the university. “However, there are not enough rheumatologists to see all patients with rheumatic complaints, and this deficit is likely to get worse. Although all patients with a rheumatic complaint would likely benefit from a rheumatology consultation, it is clear that timely access to rheumatologic care is most beneficial for patients with inflammatory rheumatic diseases to prevent future morbidity and disability.”
 

Year-long follow-up finds high sensitivity, more revenue

What started out as a quality improvement project morphed into a robust study that was published online July 12, 2018, in Arthritis Care & Research. Using data recorded in the electronic medical record, Dr. West and his colleagues retrospectively reviewed 961 new outpatient rheumatology consults sent during a 9-month period for final diagnosis and revenue generation for routine outpatient care over 1 year following consult review or initial evaluation. The first step of the consult management involves an intake access coordinator, Ryan Goecker, obtaining information about the patient from the referring clinician. Next, one of three experienced rheumatologists at the university – Duane W. Pearson, MD, Christopher C. Striebich, MD, or Jason R. Kolfenbach, MD – reviews the information about the case. “We do request that labs and x-rays be done ahead of time, depending on what the consult question is, so that we have the data to be able to decide whether a patient likely has an inflammatory process that we need to see or not,” Dr. West explained. “It takes somewhere between 5 and 20 minutes per consult. In total, it takes our rheumatologists about 5 hours a week to do the consults. However, even after subtracting the physician time spent screening consults, the time saved by the consult triage system enabled over 200 more time slots per year to be available to see new AIRD patients than would have been possible without the triage system.”

Following review of the data supplied about the case, patients who may have acute inflammatory monoarticular arthritis or some other rheumatologic emergency are seen within 24-48 hours, while consults with a possible AIRD are approved and seen within 1-4 weeks. Priority is given to those with suspected vasculitis, systemic lupus erythematosus, myositis, and disabling inflammatory arthritis. Patients with probable noninflammatory conditions such as osteoarthritis, fibromyalgia, and mechanical low back pain are not scheduled for an in-person visit. “Instead of simply declining the consult, we try to give some direction, or we say, ‘Why don’t you try this, this, and this, sort of a miniconsult,” Dr. West noted. “One of the potential adverse reactions to doing consult triage would be that the referring provider would be upset if we decline their consult. We acknowledge that. But over time we’ve been able to convince them that this is best for all concerned, so that the inflammatory disease group gets in to see us in an appropriate amount of time.”

Of the 961 consults, 673 were scheduled for an in-person AIRD evaluation and 288 consults were not scheduled. Patients were seen an average of 13 days after consult review. Of the 673 approved consults, 597 (89%) came for evaluation. Of these, 357 were diagnosed as having an AIRD, while 240 were diagnosed as having a non-AIRD. Among the patients not scheduled for a rheumatology visit, 128 had 1-year follow-up data, with 6 patients eventually diagnosed as having an AIRD. This translated into a consult triage sensitivity of 98% and a positive predictive value of 60%. “There’s a fair number of people with noninflammatory disease who do get into see us,” Dr. West said. “That has to do with our desire to not be overly rigid. The sensitivity, specificity, and positive predictive value were not quite as high as some people would like to see, but we really weren’t missing people who really needed to be seen.”

In their conservative cost analysis, revenue data for outpatient care was available for 318 of the 357 AIRD patients and 192 of 240 non-AIRD patients. It demonstrated that care of AIRD patients generates 44 times more revenue, compared with non-AIRD patients ($5,877 vs. $134 per patient, respectively; P less than .001).

“Our consult triage protocol appears to be an effective method to assure that patients with inflammatory rheumatic diseases get expedited access to appropriate rheumatologic care,” Dr. West concluded. “Using conservative measures, caring for patients with inflammatory rheumatic diseases results in significantly more revenue generation.” Generalizability of such a protocol to other practice settings depends on the time rheumatologists are willing to commit to it. “That’s the big thing,” he said. “The question comes up, could a nurse or a nurse practitioner learn the skills over time to be able to do efficient consult triage, to free up the doc from that? Yes. I think that’s absolutely possible.”

Going forward, Dr. Pearson and Dr. Kolfenbach, who are authors on the paper, have launched a pilot project in which the rheumatologist is compensated for doing a record review and e-consult on patients not recommended to be seen in the rheumatology clinic. “For consults who do not have inflammatory disease, we can say [to the referring clinician], ‘If we did see them, this is what we would be doing,’ ” Dr. West said. “Sometimes if there are still questions, we’ll say something like, ‘Once you get the results back, let us know and we can look at it again.’ That way they are getting similar compensation as telemedicine and other forms of consultation.”

At the Zuckerberg San Francisco General Hospital (ZSFG), use of a novel electronic consultation and referral system that was implemented in 2007 by University of California, San Francisco, providers continues to thrive for rheumatology and other specialty services. With this electronic system, previously called e-referral, all provider communication is captured in real time and recorded within the electronic health record. In a 2015 article from Arthritis Care & Research, researchers led by Jinoos Yazdany, MD, MPH, reviewed 2,105 e-referrals made between 2008 and 2012 (Arthritis Care Res. 2015;67[8]:1158-63). The main outcome of interest was use of preconsultation exchange, defined as back-and-forth communication between referring and specialty care providers, facilitating triage of referrals, requests for more information, or resolution of questions without a visit. The researchers found that about 25% of e-consults were resolved without a clinic visit, and that the proportion of e-consults undergoing preconsultation exchange increased over time, from 55% in 2008 to 74% in 2011.

“We’ve had situations in which somebody within our hospital system has requested a rheumatology referral but did not realize the urgency of the patients’ clinical signs and symptoms,” Dr. Yazdany, a rheumatologist and health services researcher at UCSF, said in an interview. “E-referrals are often responded to within that day. When we see an e-consult for a young woman with a rash and protein in her urine, a rheumatologist will recognize that is very concerning for a serious diagnosis like lupus of the kidney or systemic vasculitis. In that situation, we would pick up the phone and sometimes even call the patient and have them come to the emergency room for an urgent evaluation. Over the years, there have been many situations in which we’ve been able to intervene much earlier than we otherwise would have. In some cases that early intervention was lifesaving, or at least organ-preserving for the patient.”

Two studies from the early 2000s examined the use of preappointment management in rheumatology (see Arthritis Care Res. 2001;45:295-300 and Arthritis Rheum. 2004;51:253-7), but this is among the first to incorporate use of an electronic medical record to provide real-time exchange between the specialist and the referring provider. Clinicians at UCSF are reimbursed for reviewing e-consults in one of two ways. Those at ZSFG have protected and compensated time for the task, “so it’s basically part of their job to spend a half day a week on e-consults,” Dr. Yazdany said. “The department of public health and our health care system fold that into operational costs. That’s absolutely critical for success. To be done well and thoughtfully, managing consults and referrals takes time. It takes a lot of expertise.” Meanwhile, clinicians at UCSF’s main university hospital receive a small payment for each e-consult they review. “If it’s a complex consult it’s a higher reimbursement,” she said. “If it’s a simple one, it’s slightly less reimbursement, so it’s a fee-for-service model. It’s something that the health system funds, because it creates efficiencies and access for patients.”
 

Gaining popularity across specialties

Delphine S. Tuot, MD, a nephrologist who directs the ZSFG e-consult system, said that the notion of preconsult triage is gaining popularity in all medical specialties. For example, the Blue Shield of California Foundation is funding implementation of e-consult systems across many of California’s safety net health care delivery systems. “We have many health care plans that are interested in this process as well, because it improves access to specialty care, particularly in rural areas or in areas where the specialist workforce is limited,” said Dr. Tuot, who is codirector of the UCSF Center for Innovation in Access and Quality at ZSFG. Such efforts are also being promoted by the Public Hospital Redesign and Incentives in Medi-Cal Program (PRIME), which is part of California’s Medicaid waiver. PRIME “is encouraging health systems to look at innovative ways to deliver specialty care,” Dr. Tuot said. “E-consults and other non–face-to-face ways to deliver specialty care, including telemedicine encounters, count toward that metric for the Medicaid waiver.”

At the national level, the Association of American Medical Colleges has collaborated with more than 20 academic medical centers in 14 states, including Dartmouth-Hitchcock and Yale University, to implement tools built into the electronic medical record system through a program known as Project CORE (Coordinating Optimal Referral Experiences). According to Scott Shipman, MD, MPH, director of clinical innovations for the AAMC, nearly all of the current CORE sites have either gone live with the model in rheumatology or are planning to do so. “Better communication and coordination between primary care providers and specialists is important for all specialties, but because of the complexity of evaluation and management of problems in rheumatology, there is a tremendous opportunity for the CORE model to help get providers on the same page,” Dr. Shipman said in an interview. “We do this through simple decision support that we build into the referral order in the EMR, available at the point of care. Additionally, given the workforce challenges facing rheumatology in most regions of the country and consequent access barriers, offloading some of the demand via e-consults holds great promise.” Current focus areas for Project CORE, he said, include continued support of current CORE sites in their implementation and scaling efforts to maximize impact, advocacy to promote payer engagement in support of e-consult reimbursements, and working to extend the model to additional academic medical centers.

Dr. Tuot emphasized that performing e-consults “takes time and effort on behalf of specialists, so if you’re by yourself in solo practice it probably does not make sense to implement,” she said. “You need to spend your time seeing patients as much as possible. For primary care providers who are asking for curbside consults, it’s probably best to have things in writing from the specialist, such as in an e-consult, to make sure there’s no misunderstanding.”

As demand for rheumatology services increases, clinicians “have to figure out a way to see patients in most urgent need of our services,” Dr. Yazdany said. “That requires that we use technology like the e-consult system to prioritize the patients that we’re seeing. As we look at the rheumatology workforce shortage, especially in some geographic regions, it’s going to be absolutely critical. There are some diseases that no other specialists have experience caring for. In those situations, those patients need to get in to see rheumatologists in a timely fashion.”
 

Paper-based preconsult triage system

At Essentia Health, an integrated health care system with facilities in Minnesota, Wisconsin, and North Dakota, Meghan Scheibe, MD, a rheumatologist, is currently working with a rheumatologist colleague and a registered nurse to implement a paper-based preconsult triage system, “because our wait times have unfortunately skyrocketed,” she said. “We receive a lot of outside referrals from other health care groups and large health care systems that don’t have access to rheumatology.” Currently, the triage system is comprised of a referral note which includes the reason for consultation. Dr. Scheibe and her colleague rank the referral as expedited, intermediate concern, or low priority based on information provided by the referring clinician. “We mark those for our nurse to help schedule, and we let the referring provider know what the wait time is,” Dr. Scheibe said. “Then they have an opportunity to communicate back to us or say, ‘Yes, that’s fine,’ or, ‘I’m really worried about this patient. Could you get her in sooner?’ ”

It’s early in the process, but so far, implementation of the preconsult triage protocol “is allowing us to focus on the consultations on which we can be most impactful and not overwhelm the rheumatology workforce that we have,” she said.

Research reported in the UCSF study was supported by the American College of Rheumatology’s Ephraim P. Engleman Endowed Resident Research Preceptorship and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. None of the sources interviewed for this story reported having relevant financial disclosures.

[email protected]

About 15 years ago, rheumatologists at the University of Colorado School of Medicine, Aurora, implemented a preappointment consult triage system as a way to identify rheumatology patients who require timely evaluation and treatment.

Over time, the endeavor caused some soul searching. They wondered how effective their consult triage system was in identifying all patients with inflammatory rheumatic diseases and in ensuring they were seen promptly. They also wondered about the revenue implications of routine outpatient care of autoimmune and inflammatory rheumatic disease (AIRD) patients, compared with that of non-AIRD patients.

“Hospital leadership is very interested in making sure that all patients have access to specialty care in a timely manner,” said Sterling G. West, MD, one of the study authors who is also professor of medicine at the university. “However, there are not enough rheumatologists to see all patients with rheumatic complaints, and this deficit is likely to get worse. Although all patients with a rheumatic complaint would likely benefit from a rheumatology consultation, it is clear that timely access to rheumatologic care is most beneficial for patients with inflammatory rheumatic diseases to prevent future morbidity and disability.”
 

Year-long follow-up finds high sensitivity, more revenue

What started out as a quality improvement project morphed into a robust study that was published online July 12, 2018, in Arthritis Care & Research. Using data recorded in the electronic medical record, Dr. West and his colleagues retrospectively reviewed 961 new outpatient rheumatology consults sent during a 9-month period for final diagnosis and revenue generation for routine outpatient care over 1 year following consult review or initial evaluation. The first step of the consult management involves an intake access coordinator, Ryan Goecker, obtaining information about the patient from the referring clinician. Next, one of three experienced rheumatologists at the university – Duane W. Pearson, MD, Christopher C. Striebich, MD, or Jason R. Kolfenbach, MD – reviews the information about the case. “We do request that labs and x-rays be done ahead of time, depending on what the consult question is, so that we have the data to be able to decide whether a patient likely has an inflammatory process that we need to see or not,” Dr. West explained. “It takes somewhere between 5 and 20 minutes per consult. In total, it takes our rheumatologists about 5 hours a week to do the consults. However, even after subtracting the physician time spent screening consults, the time saved by the consult triage system enabled over 200 more time slots per year to be available to see new AIRD patients than would have been possible without the triage system.”

Following review of the data supplied about the case, patients who may have acute inflammatory monoarticular arthritis or some other rheumatologic emergency are seen within 24-48 hours, while consults with a possible AIRD are approved and seen within 1-4 weeks. Priority is given to those with suspected vasculitis, systemic lupus erythematosus, myositis, and disabling inflammatory arthritis. Patients with probable noninflammatory conditions such as osteoarthritis, fibromyalgia, and mechanical low back pain are not scheduled for an in-person visit. “Instead of simply declining the consult, we try to give some direction, or we say, ‘Why don’t you try this, this, and this, sort of a miniconsult,” Dr. West noted. “One of the potential adverse reactions to doing consult triage would be that the referring provider would be upset if we decline their consult. We acknowledge that. But over time we’ve been able to convince them that this is best for all concerned, so that the inflammatory disease group gets in to see us in an appropriate amount of time.”

Of the 961 consults, 673 were scheduled for an in-person AIRD evaluation and 288 consults were not scheduled. Patients were seen an average of 13 days after consult review. Of the 673 approved consults, 597 (89%) came for evaluation. Of these, 357 were diagnosed as having an AIRD, while 240 were diagnosed as having a non-AIRD. Among the patients not scheduled for a rheumatology visit, 128 had 1-year follow-up data, with 6 patients eventually diagnosed as having an AIRD. This translated into a consult triage sensitivity of 98% and a positive predictive value of 60%. “There’s a fair number of people with noninflammatory disease who do get into see us,” Dr. West said. “That has to do with our desire to not be overly rigid. The sensitivity, specificity, and positive predictive value were not quite as high as some people would like to see, but we really weren’t missing people who really needed to be seen.”

In their conservative cost analysis, revenue data for outpatient care was available for 318 of the 357 AIRD patients and 192 of 240 non-AIRD patients. It demonstrated that care of AIRD patients generates 44 times more revenue, compared with non-AIRD patients ($5,877 vs. $134 per patient, respectively; P less than .001).

“Our consult triage protocol appears to be an effective method to assure that patients with inflammatory rheumatic diseases get expedited access to appropriate rheumatologic care,” Dr. West concluded. “Using conservative measures, caring for patients with inflammatory rheumatic diseases results in significantly more revenue generation.” Generalizability of such a protocol to other practice settings depends on the time rheumatologists are willing to commit to it. “That’s the big thing,” he said. “The question comes up, could a nurse or a nurse practitioner learn the skills over time to be able to do efficient consult triage, to free up the doc from that? Yes. I think that’s absolutely possible.”

Going forward, Dr. Pearson and Dr. Kolfenbach, who are authors on the paper, have launched a pilot project in which the rheumatologist is compensated for doing a record review and e-consult on patients not recommended to be seen in the rheumatology clinic. “For consults who do not have inflammatory disease, we can say [to the referring clinician], ‘If we did see them, this is what we would be doing,’ ” Dr. West said. “Sometimes if there are still questions, we’ll say something like, ‘Once you get the results back, let us know and we can look at it again.’ That way they are getting similar compensation as telemedicine and other forms of consultation.”

At the Zuckerberg San Francisco General Hospital (ZSFG), use of a novel electronic consultation and referral system that was implemented in 2007 by University of California, San Francisco, providers continues to thrive for rheumatology and other specialty services. With this electronic system, previously called e-referral, all provider communication is captured in real time and recorded within the electronic health record. In a 2015 article from Arthritis Care & Research, researchers led by Jinoos Yazdany, MD, MPH, reviewed 2,105 e-referrals made between 2008 and 2012 (Arthritis Care Res. 2015;67[8]:1158-63). The main outcome of interest was use of preconsultation exchange, defined as back-and-forth communication between referring and specialty care providers, facilitating triage of referrals, requests for more information, or resolution of questions without a visit. The researchers found that about 25% of e-consults were resolved without a clinic visit, and that the proportion of e-consults undergoing preconsultation exchange increased over time, from 55% in 2008 to 74% in 2011.

“We’ve had situations in which somebody within our hospital system has requested a rheumatology referral but did not realize the urgency of the patients’ clinical signs and symptoms,” Dr. Yazdany, a rheumatologist and health services researcher at UCSF, said in an interview. “E-referrals are often responded to within that day. When we see an e-consult for a young woman with a rash and protein in her urine, a rheumatologist will recognize that is very concerning for a serious diagnosis like lupus of the kidney or systemic vasculitis. In that situation, we would pick up the phone and sometimes even call the patient and have them come to the emergency room for an urgent evaluation. Over the years, there have been many situations in which we’ve been able to intervene much earlier than we otherwise would have. In some cases that early intervention was lifesaving, or at least organ-preserving for the patient.”

Two studies from the early 2000s examined the use of preappointment management in rheumatology (see Arthritis Care Res. 2001;45:295-300 and Arthritis Rheum. 2004;51:253-7), but this is among the first to incorporate use of an electronic medical record to provide real-time exchange between the specialist and the referring provider. Clinicians at UCSF are reimbursed for reviewing e-consults in one of two ways. Those at ZSFG have protected and compensated time for the task, “so it’s basically part of their job to spend a half day a week on e-consults,” Dr. Yazdany said. “The department of public health and our health care system fold that into operational costs. That’s absolutely critical for success. To be done well and thoughtfully, managing consults and referrals takes time. It takes a lot of expertise.” Meanwhile, clinicians at UCSF’s main university hospital receive a small payment for each e-consult they review. “If it’s a complex consult it’s a higher reimbursement,” she said. “If it’s a simple one, it’s slightly less reimbursement, so it’s a fee-for-service model. It’s something that the health system funds, because it creates efficiencies and access for patients.”
 

Gaining popularity across specialties

Delphine S. Tuot, MD, a nephrologist who directs the ZSFG e-consult system, said that the notion of preconsult triage is gaining popularity in all medical specialties. For example, the Blue Shield of California Foundation is funding implementation of e-consult systems across many of California’s safety net health care delivery systems. “We have many health care plans that are interested in this process as well, because it improves access to specialty care, particularly in rural areas or in areas where the specialist workforce is limited,” said Dr. Tuot, who is codirector of the UCSF Center for Innovation in Access and Quality at ZSFG. Such efforts are also being promoted by the Public Hospital Redesign and Incentives in Medi-Cal Program (PRIME), which is part of California’s Medicaid waiver. PRIME “is encouraging health systems to look at innovative ways to deliver specialty care,” Dr. Tuot said. “E-consults and other non–face-to-face ways to deliver specialty care, including telemedicine encounters, count toward that metric for the Medicaid waiver.”

At the national level, the Association of American Medical Colleges has collaborated with more than 20 academic medical centers in 14 states, including Dartmouth-Hitchcock and Yale University, to implement tools built into the electronic medical record system through a program known as Project CORE (Coordinating Optimal Referral Experiences). According to Scott Shipman, MD, MPH, director of clinical innovations for the AAMC, nearly all of the current CORE sites have either gone live with the model in rheumatology or are planning to do so. “Better communication and coordination between primary care providers and specialists is important for all specialties, but because of the complexity of evaluation and management of problems in rheumatology, there is a tremendous opportunity for the CORE model to help get providers on the same page,” Dr. Shipman said in an interview. “We do this through simple decision support that we build into the referral order in the EMR, available at the point of care. Additionally, given the workforce challenges facing rheumatology in most regions of the country and consequent access barriers, offloading some of the demand via e-consults holds great promise.” Current focus areas for Project CORE, he said, include continued support of current CORE sites in their implementation and scaling efforts to maximize impact, advocacy to promote payer engagement in support of e-consult reimbursements, and working to extend the model to additional academic medical centers.

Dr. Tuot emphasized that performing e-consults “takes time and effort on behalf of specialists, so if you’re by yourself in solo practice it probably does not make sense to implement,” she said. “You need to spend your time seeing patients as much as possible. For primary care providers who are asking for curbside consults, it’s probably best to have things in writing from the specialist, such as in an e-consult, to make sure there’s no misunderstanding.”

As demand for rheumatology services increases, clinicians “have to figure out a way to see patients in most urgent need of our services,” Dr. Yazdany said. “That requires that we use technology like the e-consult system to prioritize the patients that we’re seeing. As we look at the rheumatology workforce shortage, especially in some geographic regions, it’s going to be absolutely critical. There are some diseases that no other specialists have experience caring for. In those situations, those patients need to get in to see rheumatologists in a timely fashion.”
 

Paper-based preconsult triage system

At Essentia Health, an integrated health care system with facilities in Minnesota, Wisconsin, and North Dakota, Meghan Scheibe, MD, a rheumatologist, is currently working with a rheumatologist colleague and a registered nurse to implement a paper-based preconsult triage system, “because our wait times have unfortunately skyrocketed,” she said. “We receive a lot of outside referrals from other health care groups and large health care systems that don’t have access to rheumatology.” Currently, the triage system is comprised of a referral note which includes the reason for consultation. Dr. Scheibe and her colleague rank the referral as expedited, intermediate concern, or low priority based on information provided by the referring clinician. “We mark those for our nurse to help schedule, and we let the referring provider know what the wait time is,” Dr. Scheibe said. “Then they have an opportunity to communicate back to us or say, ‘Yes, that’s fine,’ or, ‘I’m really worried about this patient. Could you get her in sooner?’ ”

It’s early in the process, but so far, implementation of the preconsult triage protocol “is allowing us to focus on the consultations on which we can be most impactful and not overwhelm the rheumatology workforce that we have,” she said.

Research reported in the UCSF study was supported by the American College of Rheumatology’s Ephraim P. Engleman Endowed Resident Research Preceptorship and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. None of the sources interviewed for this story reported having relevant financial disclosures.

[email protected]

LAKE TAHOE, CALIF. – Dermatologists prescribe more antibiotics than any other physician group, a statistic that George G. Zhanel, PhD, would like to see go by the wayside.

After all, the World Health Organization projects that the number of annual deaths in North America attributable to antibiotic resistance will reach 317,000 by the year 2050.

“It doesn’t really matter where you are in the world – we’re going to have a lot of deaths due to infections caused by antibiotic-resistant organisms,” Dr. Zhanel, a microbiologist at the College of Medicine, University of Manitoba, Winnipeg, Canada, said at the annual meeting of the Society for Pediatric Dermatology. “Many of us are very concerned about this. Countries have put together an optimal action plan. What are we going to do about this? The plans are quite similar from country to country. They talk about surveillance, finding where these pathogens are. They talk about infection control such as washing your hands in the clinic so you’re not moving antibiotic-resistant organisms around. They talk about diagnostic and treatment guidelines, new antibiotic therapies, probiotics, and vaccination strategies. My own group is doing research on all of these areas, but today I’m going to focus on antibiotic stewardship: Using antibiotics wisely, trying to optimize efficacy while trying to minimize the development of resistant organisms.”

Dr. Zhanel, who is also director of the Canadian Antimicrobial Resistance Alliance (CARA) at the College of Medicine, University of Manitoba, described dermatologists as “big players” when it comes to antibiotic use. According to a 2016 report from the Scientific Panel on Antibiotic Use in Dermatology, dermatologists order 8.2 million oral antibiotic prescriptions each year, which is more common than any other physician group based on the prescribing rate per clinician (J Clin Aesthet Dermatol. 2016;9[4]:18-24). In addition, the prescribed duration of antibiotic therapy is often markedly longer with therapies treated by dermatologists, especially acne and rosacea. One study of general practitioners in the United Kingdom found that the mean duration of oral antibiotic use for treating acne was 175 days (J Am Acad Dermatol 2016;75:1142-50). “For some patients it went on much longer,” said Dr. Zhanel, who was not affiliated with the study.

“You are important players when it comes to antibiotics. How you use them and if you use them wisely impacts not only your patients, but the world.”

The correlation between antibiotic use and resistance is widely established, he continued. “We have known for 30 to 40 years that if you treat patients with tetracyclines, the Staphylococcus epidermidis that we all have on our skin develop tetracycline resistance,” he said. “The tetracycline resistance genes from S. epidermidis can then transfer to putative pathogens such as Staphylococcus aureus, and potentially [methicillin-resistant S. aureus]. That’s why we need to try to minimize oral tetracycline exposure on the normal microbiome.” In addition, tetracycline use can help create multidrug resistant organisms.

Next, Dr. Zhanel discussed potential solutions to antimicrobial usage/resistance in dermatology. According to recent guidelines on the care for the management of acne vulgaris, systemic antibiotic use should be limited to the shortest possible duration, typically 90 days (J Am Acad Dermatol. 2016;74[5]:945-73). A common treatment for moderate to-severe acne is to combine a topical retinoid with an oral or topical antimicrobial (J Am Acad Dermatol. 2009;60(5 suppl):S1-S50). If the addition of an oral antibiotic is required, limit its use to 3 or 4 months and co-prescribe with a product that contains benzoyl peroxide (BPO), or use as a washout. “Ideally, that’s your exit strategy,” he said. “Once you finish the oral antibiotic, in about 3 months if possible, continue with the topical retinoids plus BPO to maintain that particular remission.”

Why add benzoyl peroxide to topical retinoids for maintenance therapy? “Benzoyl peroxide and topical retinoids affect multiple targets in your acne strategy, and when you use them together they are powerful,” Dr. Zhanel said. He advises dermatologists not to prescribe oral or topical clindamycin unless they have to, because that drug is one of the main drivers of Clostridium difficile infection.

Dr. Zhanel’s stewardship tips for topical antibiotics involve not using topical tetracyclines/clindamycin/macrolides, in favor of using a topical antimicrobial such as BPO. “We think that benzoyl peroxide is less likely to drive resistance than are the traditional topical antibiotics like tetracyclines and clindamycin,” he said. “Use topical retinoids and benzoyl peroxide, if possible.”

Subtherapeutic oral doses of tetracyclines such as doxycycline 40 mg modified release “look very powerful for treating rosacea and do not affect the normal microbiome or select for resistance,” he said. In the meantime, Dr. Zhanel and other researchers are working to develop narrow spectrum tetracyclines with less impact on the GI flora, such as sarecycline. “So there is the potential for more eco-friendly tetracyclines,” he said.

Going forward, many questions remain about optimal antibiotic stewardship in dermatology, Dr. Zhanel said. For example, if you combine a topical antibiotic with benzoyl peroxide, are you less likely to get resistance to that topical antibiotic? “I think the answer is yes, but the literature isn’t very strong on that,” he said. “Also, is benzoyl peroxide plus a topical retinoid better than benzoyl peroxide plus a topical antibiotic in terms of resistance? I think the answer is yes, but again there is very little data on this.”

Dr. Zhanel disclosed having numerous financial ties to the pharmaceutical industry.

[email protected]

LAKE TAHOE, CALIF. – Dermatologists prescribe more antibiotics than any other physician group, a statistic that George G. Zhanel, PhD, would like to see go by the wayside.

After all, the World Health Organization projects that the number of annual deaths in North America attributable to antibiotic resistance will reach 317,000 by the year 2050.

“It doesn’t really matter where you are in the world – we’re going to have a lot of deaths due to infections caused by antibiotic-resistant organisms,” Dr. Zhanel, a microbiologist at the College of Medicine, University of Manitoba, Winnipeg, Canada, said at the annual meeting of the Society for Pediatric Dermatology. “Many of us are very concerned about this. Countries have put together an optimal action plan. What are we going to do about this? The plans are quite similar from country to country. They talk about surveillance, finding where these pathogens are. They talk about infection control such as washing your hands in the clinic so you’re not moving antibiotic-resistant organisms around. They talk about diagnostic and treatment guidelines, new antibiotic therapies, probiotics, and vaccination strategies. My own group is doing research on all of these areas, but today I’m going to focus on antibiotic stewardship: Using antibiotics wisely, trying to optimize efficacy while trying to minimize the development of resistant organisms.”

Dr. Zhanel, who is also director of the Canadian Antimicrobial Resistance Alliance (CARA) at the College of Medicine, University of Manitoba, described dermatologists as “big players” when it comes to antibiotic use. According to a 2016 report from the Scientific Panel on Antibiotic Use in Dermatology, dermatologists order 8.2 million oral antibiotic prescriptions each year, which is more common than any other physician group based on the prescribing rate per clinician (J Clin Aesthet Dermatol. 2016;9[4]:18-24). In addition, the prescribed duration of antibiotic therapy is often markedly longer with therapies treated by dermatologists, especially acne and rosacea. One study of general practitioners in the United Kingdom found that the mean duration of oral antibiotic use for treating acne was 175 days (J Am Acad Dermatol 2016;75:1142-50). “For some patients it went on much longer,” said Dr. Zhanel, who was not affiliated with the study.

“You are important players when it comes to antibiotics. How you use them and if you use them wisely impacts not only your patients, but the world.”

The correlation between antibiotic use and resistance is widely established, he continued. “We have known for 30 to 40 years that if you treat patients with tetracyclines, the Staphylococcus epidermidis that we all have on our skin develop tetracycline resistance,” he said. “The tetracycline resistance genes from S. epidermidis can then transfer to putative pathogens such as Staphylococcus aureus, and potentially [methicillin-resistant S. aureus]. That’s why we need to try to minimize oral tetracycline exposure on the normal microbiome.” In addition, tetracycline use can help create multidrug resistant organisms.

Next, Dr. Zhanel discussed potential solutions to antimicrobial usage/resistance in dermatology. According to recent guidelines on the care for the management of acne vulgaris, systemic antibiotic use should be limited to the shortest possible duration, typically 90 days (J Am Acad Dermatol. 2016;74[5]:945-73). A common treatment for moderate to-severe acne is to combine a topical retinoid with an oral or topical antimicrobial (J Am Acad Dermatol. 2009;60(5 suppl):S1-S50). If the addition of an oral antibiotic is required, limit its use to 3 or 4 months and co-prescribe with a product that contains benzoyl peroxide (BPO), or use as a washout. “Ideally, that’s your exit strategy,” he said. “Once you finish the oral antibiotic, in about 3 months if possible, continue with the topical retinoids plus BPO to maintain that particular remission.”

Why add benzoyl peroxide to topical retinoids for maintenance therapy? “Benzoyl peroxide and topical retinoids affect multiple targets in your acne strategy, and when you use them together they are powerful,” Dr. Zhanel said. He advises dermatologists not to prescribe oral or topical clindamycin unless they have to, because that drug is one of the main drivers of Clostridium difficile infection.

Dr. Zhanel’s stewardship tips for topical antibiotics involve not using topical tetracyclines/clindamycin/macrolides, in favor of using a topical antimicrobial such as BPO. “We think that benzoyl peroxide is less likely to drive resistance than are the traditional topical antibiotics like tetracyclines and clindamycin,” he said. “Use topical retinoids and benzoyl peroxide, if possible.”

Subtherapeutic oral doses of tetracyclines such as doxycycline 40 mg modified release “look very powerful for treating rosacea and do not affect the normal microbiome or select for resistance,” he said. In the meantime, Dr. Zhanel and other researchers are working to develop narrow spectrum tetracyclines with less impact on the GI flora, such as sarecycline. “So there is the potential for more eco-friendly tetracyclines,” he said.

Going forward, many questions remain about optimal antibiotic stewardship in dermatology, Dr. Zhanel said. For example, if you combine a topical antibiotic with benzoyl peroxide, are you less likely to get resistance to that topical antibiotic? “I think the answer is yes, but the literature isn’t very strong on that,” he said. “Also, is benzoyl peroxide plus a topical retinoid better than benzoyl peroxide plus a topical antibiotic in terms of resistance? I think the answer is yes, but again there is very little data on this.”

Dr. Zhanel disclosed having numerous financial ties to the pharmaceutical industry.

[email protected]

LAKE TAHOE, CALIF. – Dermatologists prescribe more antibiotics than any other physician group, a statistic that George G. Zhanel, PhD, would like to see go by the wayside.

After all, the World Health Organization projects that the number of annual deaths in North America attributable to antibiotic resistance will reach 317,000 by the year 2050.

“It doesn’t really matter where you are in the world – we’re going to have a lot of deaths due to infections caused by antibiotic-resistant organisms,” Dr. Zhanel, a microbiologist at the College of Medicine, University of Manitoba, Winnipeg, Canada, said at the annual meeting of the Society for Pediatric Dermatology. “Many of us are very concerned about this. Countries have put together an optimal action plan. What are we going to do about this? The plans are quite similar from country to country. They talk about surveillance, finding where these pathogens are. They talk about infection control such as washing your hands in the clinic so you’re not moving antibiotic-resistant organisms around. They talk about diagnostic and treatment guidelines, new antibiotic therapies, probiotics, and vaccination strategies. My own group is doing research on all of these areas, but today I’m going to focus on antibiotic stewardship: Using antibiotics wisely, trying to optimize efficacy while trying to minimize the development of resistant organisms.”

Dr. Zhanel, who is also director of the Canadian Antimicrobial Resistance Alliance (CARA) at the College of Medicine, University of Manitoba, described dermatologists as “big players” when it comes to antibiotic use. According to a 2016 report from the Scientific Panel on Antibiotic Use in Dermatology, dermatologists order 8.2 million oral antibiotic prescriptions each year, which is more common than any other physician group based on the prescribing rate per clinician (J Clin Aesthet Dermatol. 2016;9[4]:18-24). In addition, the prescribed duration of antibiotic therapy is often markedly longer with therapies treated by dermatologists, especially acne and rosacea. One study of general practitioners in the United Kingdom found that the mean duration of oral antibiotic use for treating acne was 175 days (J Am Acad Dermatol 2016;75:1142-50). “For some patients it went on much longer,” said Dr. Zhanel, who was not affiliated with the study.

“You are important players when it comes to antibiotics. How you use them and if you use them wisely impacts not only your patients, but the world.”

The correlation between antibiotic use and resistance is widely established, he continued. “We have known for 30 to 40 years that if you treat patients with tetracyclines, the Staphylococcus epidermidis that we all have on our skin develop tetracycline resistance,” he said. “The tetracycline resistance genes from S. epidermidis can then transfer to putative pathogens such as Staphylococcus aureus, and potentially [methicillin-resistant S. aureus]. That’s why we need to try to minimize oral tetracycline exposure on the normal microbiome.” In addition, tetracycline use can help create multidrug resistant organisms.

Next, Dr. Zhanel discussed potential solutions to antimicrobial usage/resistance in dermatology. According to recent guidelines on the care for the management of acne vulgaris, systemic antibiotic use should be limited to the shortest possible duration, typically 90 days (J Am Acad Dermatol. 2016;74[5]:945-73). A common treatment for moderate to-severe acne is to combine a topical retinoid with an oral or topical antimicrobial (J Am Acad Dermatol. 2009;60(5 suppl):S1-S50). If the addition of an oral antibiotic is required, limit its use to 3 or 4 months and co-prescribe with a product that contains benzoyl peroxide (BPO), or use as a washout. “Ideally, that’s your exit strategy,” he said. “Once you finish the oral antibiotic, in about 3 months if possible, continue with the topical retinoids plus BPO to maintain that particular remission.”

Why add benzoyl peroxide to topical retinoids for maintenance therapy? “Benzoyl peroxide and topical retinoids affect multiple targets in your acne strategy, and when you use them together they are powerful,” Dr. Zhanel said. He advises dermatologists not to prescribe oral or topical clindamycin unless they have to, because that drug is one of the main drivers of Clostridium difficile infection.

Dr. Zhanel’s stewardship tips for topical antibiotics involve not using topical tetracyclines/clindamycin/macrolides, in favor of using a topical antimicrobial such as BPO. “We think that benzoyl peroxide is less likely to drive resistance than are the traditional topical antibiotics like tetracyclines and clindamycin,” he said. “Use topical retinoids and benzoyl peroxide, if possible.”

Subtherapeutic oral doses of tetracyclines such as doxycycline 40 mg modified release “look very powerful for treating rosacea and do not affect the normal microbiome or select for resistance,” he said. In the meantime, Dr. Zhanel and other researchers are working to develop narrow spectrum tetracyclines with less impact on the GI flora, such as sarecycline. “So there is the potential for more eco-friendly tetracyclines,” he said.

Going forward, many questions remain about optimal antibiotic stewardship in dermatology, Dr. Zhanel said. For example, if you combine a topical antibiotic with benzoyl peroxide, are you less likely to get resistance to that topical antibiotic? “I think the answer is yes, but the literature isn’t very strong on that,” he said. “Also, is benzoyl peroxide plus a topical retinoid better than benzoyl peroxide plus a topical antibiotic in terms of resistance? I think the answer is yes, but again there is very little data on this.”

Dr. Zhanel disclosed having numerous financial ties to the pharmaceutical industry.

[email protected]

LAKE TAHOE, CALIF. – Mosaicism makes everything in genetics more challenging, but it also enables researchers to understand how genes and cell pathways work in cancer and during human development, Leslie G. Biesecker, MD said at the annual meeting of the Society for Pediatric Dermatology.

Dr. Biesecker, senior investigator and head of the clinical genomics section of the National Human Genome Research Institute’s Medical Genomics and Metabolic Genetics Branch, discussed mosaicism and a number of overgrowth syndromes that he and his associates have been studying that have clinical relevance for pediatric dermatologists. He noted that mosaicism can affect any tissue, anywhere, in any pattern. “If an affected cell cannot survive gametogenesis, fertilization, or survive early development, this generates Happle-type mosaicism,” explained Dr. Biesecker, who is trained in pediatrics and in clinical and molecular genetics.

“This is characterized by patchy manifestations, and no parent-to-child transmission or recurrence. You must always be careful here, though, because Mother Nature does what she wants to. Mosaic mutations can happen more than once, but it’s a very unlikely outcome. Happle-type mosaicism is also characterized by discordant monozygotic twins,” he noted.

The prototype for Happle-type mosaicism is Proteus syndrome, formerly known as Elephant Man disease, which is caused by a mutation in the AKT1 gene. Patients with Proteus syndrome undergo severe, relentless overgrowth, and about 25% of them die during childhood. “If you see one of these patients, you have a serious clinical problem on your hands,” he said. “There is enormous individual variability, but it is ultra rare.”

Dermatologic lesions that are characteristic of Proteus syndrome include cerebriform connective tissue nevus, which typically presents on the hands and feet. “A wide range of vascular malformations have also been associated with this, even patients with arteriovenous malformations,” Dr. Biesecker said. “They are a serious problem.” Linear verrucous epidermal nevus is another characteristic lesion of Proteus syndrome. It can present in a number of ways and in various body sites. “The natural history of these lesions is important,” he commented. “Over time, are they stable, or do they spread and expand over time? These lesions do not ever spontaneously regress. This does enable molecular diagnosis, but don’t bother sampling their blood, because it will be negative. You have to have a biopsy sample.”

Overgrowth syndromes that do not meet criteria for Proteus syndrome fall into a category known as PIK3CA-related overgrowth spectrum, which Dr. Biesecker characterized as “a bunch of clinical designations all caused by the same underlying somatic mutation in a gene called PIK3CA. There is an enormous variability in these patients, ranging from those who have profound overgrowth, including malformations, truncal overgrowth, and vascular malformations, and digital overgrowth in all sorts of patterns. We designate this as PIK3CA-related overgrowth spectrum (PROS), because we can’t clinically separate these things from one another.”

These conditions include what used to be called CLOVES syndrome (congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and scoliosis/skeletal/spinal anomalies), facial infiltrating lipomatosis, and megalencephaly-capillary malformation syndrome. PROS is about 100 times more common than Proteus syndrome. “There are no rational boundaries to distinguish these entities,” Dr. Biesecker said. “They are rationalized under a combined clinical-molecular PROS framework, meaning that the molecular diagnosis is absolutely key to correctly diagnosing these patients.”

In this way, mosaicism challenges the traditional concept of diagnosing overgrowth disorders. “What we thought were separate disorders are in fact many manifestations of a single disorder,” he continued. “When I was doing my genetics training, we were taught that it would turn out that there was one gene for every disease, and one disease for every gene. That is completely wrong; it’s much more complicated than that. Mosaicism is also important for us as biologists, because it gives us a window into biology we otherwise would not see. Without a mosaicism, Proteus syndrome cannot exist biologically. So if I want to understand that gene product, I have to study patients who are mosaics. Mosaicism can happen in any tissue, whether it’s visible or not.”

Dr. Biesecker, who has been elected to serve as president of the American Society of Human Genetics for 2019, noted that most of the gene mutations that cause overgrowth disorders are the same ones implicated in cancer. “It makes sense, because cancer is a disorder of uncontrolled proliferation and differentiation,” he said. “These overgrowth disorders are similar but less severe manifestations of the same problem. It turns out that these mosaic patients are single gene model systems of cancer biology.” Therefore, when a drug company develops an anti-cancer drug, he continued, it also can be useful for PROS or Proteus syndrome. It’s much easier to inhibit a protein that’s overactive than it is to replace the activity of a gene that has lost its function.

But in PROS and Proteus, “we have very different treatment objectives than oncologists do,” he said. “Our goal is to reduce the signaling caused by these mutations; we do not want to kill the cells. Some of my patients with these disorders have pretty close to 50% of cells in their body carrying these mutations. If I were thinking like an oncologist, the oncologist wants to kill cancer cells; that’s their objective. If I were to kill all of the mutant cells in my patients, I’m certain that would kill them.”

One promising development is the investigational oral agent ARQ 092, which is an inhibitor of AKT1. Dr. Biesecker and his colleagues at the NIH have been working to figure out what dosing should be used in humans based on mouse data, lab data, and data from cancer patients. They started with about one-twelvth the dose that oncologists use. After treating the first patient with overgrowth syndrome, on day 15 that person’s AKT1 level dropped to about 20% of normal, while on day 75 it moved to around 60% of normal. “We are right in that zone where we want to drive the activity of that protein to about half of what it should be,” Dr. Biesecker said. He and his colleagues also have observed regression of lesions in a patient with cerebriform connective tissue nevus who was treated with ARQ 092. “We’ve never seen this before.”

Dr. Biesecker disclosed that he is a member of the Illumina medical ethics board. He has received royalties from Genentech and in-kind research support from ArQule and Pfizer.

[email protected]

 

LAKE TAHOE, CALIF. – Mosaicism makes everything in genetics more challenging, but it also enables researchers to understand how genes and cell pathways work in cancer and during human development, Leslie G. Biesecker, MD said at the annual meeting of the Society for Pediatric Dermatology.

Dr. Biesecker, senior investigator and head of the clinical genomics section of the National Human Genome Research Institute’s Medical Genomics and Metabolic Genetics Branch, discussed mosaicism and a number of overgrowth syndromes that he and his associates have been studying that have clinical relevance for pediatric dermatologists. He noted that mosaicism can affect any tissue, anywhere, in any pattern. “If an affected cell cannot survive gametogenesis, fertilization, or survive early development, this generates Happle-type mosaicism,” explained Dr. Biesecker, who is trained in pediatrics and in clinical and molecular genetics.

“This is characterized by patchy manifestations, and no parent-to-child transmission or recurrence. You must always be careful here, though, because Mother Nature does what she wants to. Mosaic mutations can happen more than once, but it’s a very unlikely outcome. Happle-type mosaicism is also characterized by discordant monozygotic twins,” he noted.

The prototype for Happle-type mosaicism is Proteus syndrome, formerly known as Elephant Man disease, which is caused by a mutation in the AKT1 gene. Patients with Proteus syndrome undergo severe, relentless overgrowth, and about 25% of them die during childhood. “If you see one of these patients, you have a serious clinical problem on your hands,” he said. “There is enormous individual variability, but it is ultra rare.”

Dermatologic lesions that are characteristic of Proteus syndrome include cerebriform connective tissue nevus, which typically presents on the hands and feet. “A wide range of vascular malformations have also been associated with this, even patients with arteriovenous malformations,” Dr. Biesecker said. “They are a serious problem.” Linear verrucous epidermal nevus is another characteristic lesion of Proteus syndrome. It can present in a number of ways and in various body sites. “The natural history of these lesions is important,” he commented. “Over time, are they stable, or do they spread and expand over time? These lesions do not ever spontaneously regress. This does enable molecular diagnosis, but don’t bother sampling their blood, because it will be negative. You have to have a biopsy sample.”

Overgrowth syndromes that do not meet criteria for Proteus syndrome fall into a category known as PIK3CA-related overgrowth spectrum, which Dr. Biesecker characterized as “a bunch of clinical designations all caused by the same underlying somatic mutation in a gene called PIK3CA. There is an enormous variability in these patients, ranging from those who have profound overgrowth, including malformations, truncal overgrowth, and vascular malformations, and digital overgrowth in all sorts of patterns. We designate this as PIK3CA-related overgrowth spectrum (PROS), because we can’t clinically separate these things from one another.”

These conditions include what used to be called CLOVES syndrome (congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and scoliosis/skeletal/spinal anomalies), facial infiltrating lipomatosis, and megalencephaly-capillary malformation syndrome. PROS is about 100 times more common than Proteus syndrome. “There are no rational boundaries to distinguish these entities,” Dr. Biesecker said. “They are rationalized under a combined clinical-molecular PROS framework, meaning that the molecular diagnosis is absolutely key to correctly diagnosing these patients.”

In this way, mosaicism challenges the traditional concept of diagnosing overgrowth disorders. “What we thought were separate disorders are in fact many manifestations of a single disorder,” he continued. “When I was doing my genetics training, we were taught that it would turn out that there was one gene for every disease, and one disease for every gene. That is completely wrong; it’s much more complicated than that. Mosaicism is also important for us as biologists, because it gives us a window into biology we otherwise would not see. Without a mosaicism, Proteus syndrome cannot exist biologically. So if I want to understand that gene product, I have to study patients who are mosaics. Mosaicism can happen in any tissue, whether it’s visible or not.”

Dr. Biesecker, who has been elected to serve as president of the American Society of Human Genetics for 2019, noted that most of the gene mutations that cause overgrowth disorders are the same ones implicated in cancer. “It makes sense, because cancer is a disorder of uncontrolled proliferation and differentiation,” he said. “These overgrowth disorders are similar but less severe manifestations of the same problem. It turns out that these mosaic patients are single gene model systems of cancer biology.” Therefore, when a drug company develops an anti-cancer drug, he continued, it also can be useful for PROS or Proteus syndrome. It’s much easier to inhibit a protein that’s overactive than it is to replace the activity of a gene that has lost its function.

But in PROS and Proteus, “we have very different treatment objectives than oncologists do,” he said. “Our goal is to reduce the signaling caused by these mutations; we do not want to kill the cells. Some of my patients with these disorders have pretty close to 50% of cells in their body carrying these mutations. If I were thinking like an oncologist, the oncologist wants to kill cancer cells; that’s their objective. If I were to kill all of the mutant cells in my patients, I’m certain that would kill them.”

One promising development is the investigational oral agent ARQ 092, which is an inhibitor of AKT1. Dr. Biesecker and his colleagues at the NIH have been working to figure out what dosing should be used in humans based on mouse data, lab data, and data from cancer patients. They started with about one-twelvth the dose that oncologists use. After treating the first patient with overgrowth syndrome, on day 15 that person’s AKT1 level dropped to about 20% of normal, while on day 75 it moved to around 60% of normal. “We are right in that zone where we want to drive the activity of that protein to about half of what it should be,” Dr. Biesecker said. He and his colleagues also have observed regression of lesions in a patient with cerebriform connective tissue nevus who was treated with ARQ 092. “We’ve never seen this before.”

Dr. Biesecker disclosed that he is a member of the Illumina medical ethics board. He has received royalties from Genentech and in-kind research support from ArQule and Pfizer.

[email protected]

 

LAKE TAHOE, CALIF. – Mosaicism makes everything in genetics more challenging, but it also enables researchers to understand how genes and cell pathways work in cancer and during human development, Leslie G. Biesecker, MD said at the annual meeting of the Society for Pediatric Dermatology.

Dr. Biesecker, senior investigator and head of the clinical genomics section of the National Human Genome Research Institute’s Medical Genomics and Metabolic Genetics Branch, discussed mosaicism and a number of overgrowth syndromes that he and his associates have been studying that have clinical relevance for pediatric dermatologists. He noted that mosaicism can affect any tissue, anywhere, in any pattern. “If an affected cell cannot survive gametogenesis, fertilization, or survive early development, this generates Happle-type mosaicism,” explained Dr. Biesecker, who is trained in pediatrics and in clinical and molecular genetics.

“This is characterized by patchy manifestations, and no parent-to-child transmission or recurrence. You must always be careful here, though, because Mother Nature does what she wants to. Mosaic mutations can happen more than once, but it’s a very unlikely outcome. Happle-type mosaicism is also characterized by discordant monozygotic twins,” he noted.

The prototype for Happle-type mosaicism is Proteus syndrome, formerly known as Elephant Man disease, which is caused by a mutation in the AKT1 gene. Patients with Proteus syndrome undergo severe, relentless overgrowth, and about 25% of them die during childhood. “If you see one of these patients, you have a serious clinical problem on your hands,” he said. “There is enormous individual variability, but it is ultra rare.”

Dermatologic lesions that are characteristic of Proteus syndrome include cerebriform connective tissue nevus, which typically presents on the hands and feet. “A wide range of vascular malformations have also been associated with this, even patients with arteriovenous malformations,” Dr. Biesecker said. “They are a serious problem.” Linear verrucous epidermal nevus is another characteristic lesion of Proteus syndrome. It can present in a number of ways and in various body sites. “The natural history of these lesions is important,” he commented. “Over time, are they stable, or do they spread and expand over time? These lesions do not ever spontaneously regress. This does enable molecular diagnosis, but don’t bother sampling their blood, because it will be negative. You have to have a biopsy sample.”

Overgrowth syndromes that do not meet criteria for Proteus syndrome fall into a category known as PIK3CA-related overgrowth spectrum, which Dr. Biesecker characterized as “a bunch of clinical designations all caused by the same underlying somatic mutation in a gene called PIK3CA. There is an enormous variability in these patients, ranging from those who have profound overgrowth, including malformations, truncal overgrowth, and vascular malformations, and digital overgrowth in all sorts of patterns. We designate this as PIK3CA-related overgrowth spectrum (PROS), because we can’t clinically separate these things from one another.”

These conditions include what used to be called CLOVES syndrome (congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and scoliosis/skeletal/spinal anomalies), facial infiltrating lipomatosis, and megalencephaly-capillary malformation syndrome. PROS is about 100 times more common than Proteus syndrome. “There are no rational boundaries to distinguish these entities,” Dr. Biesecker said. “They are rationalized under a combined clinical-molecular PROS framework, meaning that the molecular diagnosis is absolutely key to correctly diagnosing these patients.”

In this way, mosaicism challenges the traditional concept of diagnosing overgrowth disorders. “What we thought were separate disorders are in fact many manifestations of a single disorder,” he continued. “When I was doing my genetics training, we were taught that it would turn out that there was one gene for every disease, and one disease for every gene. That is completely wrong; it’s much more complicated than that. Mosaicism is also important for us as biologists, because it gives us a window into biology we otherwise would not see. Without a mosaicism, Proteus syndrome cannot exist biologically. So if I want to understand that gene product, I have to study patients who are mosaics. Mosaicism can happen in any tissue, whether it’s visible or not.”

Dr. Biesecker, who has been elected to serve as president of the American Society of Human Genetics for 2019, noted that most of the gene mutations that cause overgrowth disorders are the same ones implicated in cancer. “It makes sense, because cancer is a disorder of uncontrolled proliferation and differentiation,” he said. “These overgrowth disorders are similar but less severe manifestations of the same problem. It turns out that these mosaic patients are single gene model systems of cancer biology.” Therefore, when a drug company develops an anti-cancer drug, he continued, it also can be useful for PROS or Proteus syndrome. It’s much easier to inhibit a protein that’s overactive than it is to replace the activity of a gene that has lost its function.

But in PROS and Proteus, “we have very different treatment objectives than oncologists do,” he said. “Our goal is to reduce the signaling caused by these mutations; we do not want to kill the cells. Some of my patients with these disorders have pretty close to 50% of cells in their body carrying these mutations. If I were thinking like an oncologist, the oncologist wants to kill cancer cells; that’s their objective. If I were to kill all of the mutant cells in my patients, I’m certain that would kill them.”

One promising development is the investigational oral agent ARQ 092, which is an inhibitor of AKT1. Dr. Biesecker and his colleagues at the NIH have been working to figure out what dosing should be used in humans based on mouse data, lab data, and data from cancer patients. They started with about one-twelvth the dose that oncologists use. After treating the first patient with overgrowth syndrome, on day 15 that person’s AKT1 level dropped to about 20% of normal, while on day 75 it moved to around 60% of normal. “We are right in that zone where we want to drive the activity of that protein to about half of what it should be,” Dr. Biesecker said. He and his colleagues also have observed regression of lesions in a patient with cerebriform connective tissue nevus who was treated with ARQ 092. “We’ve never seen this before.”

Dr. Biesecker disclosed that he is a member of the Illumina medical ethics board. He has received royalties from Genentech and in-kind research support from ArQule and Pfizer.

[email protected]

 

LAKE TAHOE, CALIF. – After Brett King, MD, PhD, and his wife and collaborator, Brittany G. Craiglow, MD, published an index case of oral tofacitinib reversing alopecia universalis in a 25-year-old male patient back in 2014 (J Invest Dermatol. 2014;134:2988-90), they received hundreds of e-mails and phone calls from clinicians and patients.

“We also received quite a bit of media attention from around the world,” Dr. King recalled at the annual meeting of the Society for Pediatric Dermatology.

After all, alopecia areata and its variants affect 1%-2% of the population and have a marked impact on health-related quality of life, with high rates of concomitant generalized anxiety disorder and major depressive disorder. “The health-related quality of life is similar to that of atopic dermatitis and psoriasis, and there are no reliably effective therapies, especially for severe disease,” he said. “If treating atopic dermatitis and psoriasis with systemic agents is appropriate, then certainly treating alopecia areata is, too.”

Currently available Janus kinase (JAK) inhibitors include tofacitinib (Xeljanz), ruxolitinib (Jakafi), and baricitinib (Olumiant). “These medicines are not [Food and Drug Administration] approved for alopecia areata, though tofacitinib was recently approved for psoriatic arthritis, and so we have formal entry of this medicine into dermatology for the first time,” said Dr. King, who is a dermatologist at Yale University, New Haven, Conn.

Potential adverse effects of JAKs include nasopharyngitis, headache, diarrhea, elevated cholesterol, uncommonly herpes zoster, cytopenias, transaminitis, and rarely non-melanoma skin cancer, solid organ malignancy and lymphoma, and GI perforation. Tofacitinib has an FDA black box warning regarding serious infections and malignancies, and baricitinib has these plus an additional warning about thrombosis.

In an open label, two-center trial that followed the index patient report, Dr. King and his associates enrolled 66 patients aged 19-35 years who had greater than 50% scalp hair loss for at least 6 months to receive tofacitinib 5 mg twice daily for 3 months (JCI Insight. 2016; 1[15]:e89776). A primary outcome of interest was regrowth of hair as measured by the percent change in Severity of Alopecia Tool (SALT) score. A SALT score of 100 indicates baldness, while a score of zero indicates no hair loss. Following 3 months of treatment, 32% of patients had a greater than 50% change in their SALT score, 32% had a change in the range of 5%-50%, while 36% had a change that was less than 5%.

“One of the interesting findings was that long duration of current episode of complete scalp hair loss was a negative predictor of treatment response, especially for those who have had hair loss greater than 10 years,” Dr. King said. Adverse events were “pretty bland,” with the most common being upper respiratory infection (17%), headache (8%), abdominal pain (8%), and acne (8%). Weight gain occurred in 1.5% of patients.

Next, Dr. King and colleagues reviewed the records of 90 patients aged 18 years or older who were treated with tofacitinib for at least 4 months (J Am Acad Dermatol. 2017;76[1]:22-8). Patients had greater than 40% scalp hair loss, and the tofacitinib dose was up to 10 mg per day at the discretion of the physician. “About 43% of patients were treated with tofacitinib 5 mg” twice daily, Dr. King said. “Other patients had higher doses or the addition of prednisone for three doses to see if that would help.”

After treatment, 20% of patients had a greater than 90% change in their SALT score (complete scalp hair regrowth), while 38.4% had a change that ranged from 51%-90%. At the same time, 18% had a change in their SALT score that ranged from 6%-50%, while 23% had a change that was 5% or less. As observed in the earlier trial, researchers saw a negative correlation between duration of current episode of hair loss and latest percent change in SALT score.

“We believe that you have to catch people before they get to more than 10 years of complete scalp hair loss,” Dr. King said. “This is important for the pediatric age group. I just saw somebody who’s 13, and they’ve been bald for 8 years. You might make the argument that this person deserves treatment, at least for a period of time long enough to regrow their hair in order to reset the clock.”

The most common adverse events were acne and weight gain.

In a separate analysis, Dr. King, Dr. Craiglow, and Lucy Y. Liu, evaluated the use of tofacitinib for at least 2 months in 13 alopecia areata patients aged 12-17 years (J Am Acad Dermatol. 2017;76[1]:29-32). They limited the analysis to those who had greater than 20% scalp hair loss, alopecia totalis, or alopecia universalis that was stable or worsening for 6 months or longer. Of the 13 patients, 9 (69%) were responders. Of the four non-responders, one had a very long duration of baldness. The percent change in SALT score was 93% overall, including 100% in the responder group over a median of 5 months and just 1% in the non-responder group over a median of 4 months. “This does not work every time,” Dr. King said.

While some preliminary studies of topical JAK inhibitors for alopecia areata show promise, it remains unclear if this approach will translate in a clinically meaningful way, he said. Clinical trials are currently under way.

Dr. King disclosed that he has received honoraria or consulting fees from Aclaris Therapeutics, Celgene, Concert Pharmaceuticals, Eli Lilly, Pfizer, Regeneron Pharmaceuticals, and Dermavant Sciences. He has also received funding support from The Ranjini and Ajay Poddar Resource Fund for Dermatologic Diseases Research.

[email protected]

LAKE TAHOE, CALIF. – After Brett King, MD, PhD, and his wife and collaborator, Brittany G. Craiglow, MD, published an index case of oral tofacitinib reversing alopecia universalis in a 25-year-old male patient back in 2014 (J Invest Dermatol. 2014;134:2988-90), they received hundreds of e-mails and phone calls from clinicians and patients.

“We also received quite a bit of media attention from around the world,” Dr. King recalled at the annual meeting of the Society for Pediatric Dermatology.

After all, alopecia areata and its variants affect 1%-2% of the population and have a marked impact on health-related quality of life, with high rates of concomitant generalized anxiety disorder and major depressive disorder. “The health-related quality of life is similar to that of atopic dermatitis and psoriasis, and there are no reliably effective therapies, especially for severe disease,” he said. “If treating atopic dermatitis and psoriasis with systemic agents is appropriate, then certainly treating alopecia areata is, too.”

Currently available Janus kinase (JAK) inhibitors include tofacitinib (Xeljanz), ruxolitinib (Jakafi), and baricitinib (Olumiant). “These medicines are not [Food and Drug Administration] approved for alopecia areata, though tofacitinib was recently approved for psoriatic arthritis, and so we have formal entry of this medicine into dermatology for the first time,” said Dr. King, who is a dermatologist at Yale University, New Haven, Conn.

Potential adverse effects of JAKs include nasopharyngitis, headache, diarrhea, elevated cholesterol, uncommonly herpes zoster, cytopenias, transaminitis, and rarely non-melanoma skin cancer, solid organ malignancy and lymphoma, and GI perforation. Tofacitinib has an FDA black box warning regarding serious infections and malignancies, and baricitinib has these plus an additional warning about thrombosis.

In an open label, two-center trial that followed the index patient report, Dr. King and his associates enrolled 66 patients aged 19-35 years who had greater than 50% scalp hair loss for at least 6 months to receive tofacitinib 5 mg twice daily for 3 months (JCI Insight. 2016; 1[15]:e89776). A primary outcome of interest was regrowth of hair as measured by the percent change in Severity of Alopecia Tool (SALT) score. A SALT score of 100 indicates baldness, while a score of zero indicates no hair loss. Following 3 months of treatment, 32% of patients had a greater than 50% change in their SALT score, 32% had a change in the range of 5%-50%, while 36% had a change that was less than 5%.

“One of the interesting findings was that long duration of current episode of complete scalp hair loss was a negative predictor of treatment response, especially for those who have had hair loss greater than 10 years,” Dr. King said. Adverse events were “pretty bland,” with the most common being upper respiratory infection (17%), headache (8%), abdominal pain (8%), and acne (8%). Weight gain occurred in 1.5% of patients.

Next, Dr. King and colleagues reviewed the records of 90 patients aged 18 years or older who were treated with tofacitinib for at least 4 months (J Am Acad Dermatol. 2017;76[1]:22-8). Patients had greater than 40% scalp hair loss, and the tofacitinib dose was up to 10 mg per day at the discretion of the physician. “About 43% of patients were treated with tofacitinib 5 mg” twice daily, Dr. King said. “Other patients had higher doses or the addition of prednisone for three doses to see if that would help.”

After treatment, 20% of patients had a greater than 90% change in their SALT score (complete scalp hair regrowth), while 38.4% had a change that ranged from 51%-90%. At the same time, 18% had a change in their SALT score that ranged from 6%-50%, while 23% had a change that was 5% or less. As observed in the earlier trial, researchers saw a negative correlation between duration of current episode of hair loss and latest percent change in SALT score.

“We believe that you have to catch people before they get to more than 10 years of complete scalp hair loss,” Dr. King said. “This is important for the pediatric age group. I just saw somebody who’s 13, and they’ve been bald for 8 years. You might make the argument that this person deserves treatment, at least for a period of time long enough to regrow their hair in order to reset the clock.”

The most common adverse events were acne and weight gain.

In a separate analysis, Dr. King, Dr. Craiglow, and Lucy Y. Liu, evaluated the use of tofacitinib for at least 2 months in 13 alopecia areata patients aged 12-17 years (J Am Acad Dermatol. 2017;76[1]:29-32). They limited the analysis to those who had greater than 20% scalp hair loss, alopecia totalis, or alopecia universalis that was stable or worsening for 6 months or longer. Of the 13 patients, 9 (69%) were responders. Of the four non-responders, one had a very long duration of baldness. The percent change in SALT score was 93% overall, including 100% in the responder group over a median of 5 months and just 1% in the non-responder group over a median of 4 months. “This does not work every time,” Dr. King said.

While some preliminary studies of topical JAK inhibitors for alopecia areata show promise, it remains unclear if this approach will translate in a clinically meaningful way, he said. Clinical trials are currently under way.

Dr. King disclosed that he has received honoraria or consulting fees from Aclaris Therapeutics, Celgene, Concert Pharmaceuticals, Eli Lilly, Pfizer, Regeneron Pharmaceuticals, and Dermavant Sciences. He has also received funding support from The Ranjini and Ajay Poddar Resource Fund for Dermatologic Diseases Research.

[email protected]

LAKE TAHOE, CALIF. – After Brett King, MD, PhD, and his wife and collaborator, Brittany G. Craiglow, MD, published an index case of oral tofacitinib reversing alopecia universalis in a 25-year-old male patient back in 2014 (J Invest Dermatol. 2014;134:2988-90), they received hundreds of e-mails and phone calls from clinicians and patients.

“We also received quite a bit of media attention from around the world,” Dr. King recalled at the annual meeting of the Society for Pediatric Dermatology.

After all, alopecia areata and its variants affect 1%-2% of the population and have a marked impact on health-related quality of life, with high rates of concomitant generalized anxiety disorder and major depressive disorder. “The health-related quality of life is similar to that of atopic dermatitis and psoriasis, and there are no reliably effective therapies, especially for severe disease,” he said. “If treating atopic dermatitis and psoriasis with systemic agents is appropriate, then certainly treating alopecia areata is, too.”

Currently available Janus kinase (JAK) inhibitors include tofacitinib (Xeljanz), ruxolitinib (Jakafi), and baricitinib (Olumiant). “These medicines are not [Food and Drug Administration] approved for alopecia areata, though tofacitinib was recently approved for psoriatic arthritis, and so we have formal entry of this medicine into dermatology for the first time,” said Dr. King, who is a dermatologist at Yale University, New Haven, Conn.

Potential adverse effects of JAKs include nasopharyngitis, headache, diarrhea, elevated cholesterol, uncommonly herpes zoster, cytopenias, transaminitis, and rarely non-melanoma skin cancer, solid organ malignancy and lymphoma, and GI perforation. Tofacitinib has an FDA black box warning regarding serious infections and malignancies, and baricitinib has these plus an additional warning about thrombosis.

In an open label, two-center trial that followed the index patient report, Dr. King and his associates enrolled 66 patients aged 19-35 years who had greater than 50% scalp hair loss for at least 6 months to receive tofacitinib 5 mg twice daily for 3 months (JCI Insight. 2016; 1[15]:e89776). A primary outcome of interest was regrowth of hair as measured by the percent change in Severity of Alopecia Tool (SALT) score. A SALT score of 100 indicates baldness, while a score of zero indicates no hair loss. Following 3 months of treatment, 32% of patients had a greater than 50% change in their SALT score, 32% had a change in the range of 5%-50%, while 36% had a change that was less than 5%.

“One of the interesting findings was that long duration of current episode of complete scalp hair loss was a negative predictor of treatment response, especially for those who have had hair loss greater than 10 years,” Dr. King said. Adverse events were “pretty bland,” with the most common being upper respiratory infection (17%), headache (8%), abdominal pain (8%), and acne (8%). Weight gain occurred in 1.5% of patients.

Next, Dr. King and colleagues reviewed the records of 90 patients aged 18 years or older who were treated with tofacitinib for at least 4 months (J Am Acad Dermatol. 2017;76[1]:22-8). Patients had greater than 40% scalp hair loss, and the tofacitinib dose was up to 10 mg per day at the discretion of the physician. “About 43% of patients were treated with tofacitinib 5 mg” twice daily, Dr. King said. “Other patients had higher doses or the addition of prednisone for three doses to see if that would help.”

After treatment, 20% of patients had a greater than 90% change in their SALT score (complete scalp hair regrowth), while 38.4% had a change that ranged from 51%-90%. At the same time, 18% had a change in their SALT score that ranged from 6%-50%, while 23% had a change that was 5% or less. As observed in the earlier trial, researchers saw a negative correlation between duration of current episode of hair loss and latest percent change in SALT score.

“We believe that you have to catch people before they get to more than 10 years of complete scalp hair loss,” Dr. King said. “This is important for the pediatric age group. I just saw somebody who’s 13, and they’ve been bald for 8 years. You might make the argument that this person deserves treatment, at least for a period of time long enough to regrow their hair in order to reset the clock.”

The most common adverse events were acne and weight gain.

In a separate analysis, Dr. King, Dr. Craiglow, and Lucy Y. Liu, evaluated the use of tofacitinib for at least 2 months in 13 alopecia areata patients aged 12-17 years (J Am Acad Dermatol. 2017;76[1]:29-32). They limited the analysis to those who had greater than 20% scalp hair loss, alopecia totalis, or alopecia universalis that was stable or worsening for 6 months or longer. Of the 13 patients, 9 (69%) were responders. Of the four non-responders, one had a very long duration of baldness. The percent change in SALT score was 93% overall, including 100% in the responder group over a median of 5 months and just 1% in the non-responder group over a median of 4 months. “This does not work every time,” Dr. King said.

While some preliminary studies of topical JAK inhibitors for alopecia areata show promise, it remains unclear if this approach will translate in a clinically meaningful way, he said. Clinical trials are currently under way.

Dr. King disclosed that he has received honoraria or consulting fees from Aclaris Therapeutics, Celgene, Concert Pharmaceuticals, Eli Lilly, Pfizer, Regeneron Pharmaceuticals, and Dermavant Sciences. He has also received funding support from The Ranjini and Ajay Poddar Resource Fund for Dermatologic Diseases Research.

[email protected]

LAKE TAHOE, CALIF. – Strong associations exist between intestinal dysbiosis and a wide variety of gut and systemic diseases, according to Mark A. Underwood, MD.

Doug Brunk/MDedge News

“Antibiotic exposure changes the composition of the intestinal microbiota,” he said at the annual meeting of the Society for Pediatric Dermatology. “That clearly causes both antibiotic-associated diarrhea and Clostridium difficile colitis. The bigger question is, is it possible that intestinal dysbiosis is related to a whole bunch of other systemic diseases? In other words, does an insult during a critical window of development cause changes in the intestinal microbiota that can lead to systemic diseases in the brain, the lung, the liver, or the immune system?”

According Dr. Underwood, a pediatrician who is chief of the division of neonatology at the University of California, Davis, the prevalence of dysbiosis is increasing worldwide, particularly in developed countries, where Bifidobacteria are decreasing and Enterobacteriaceae are increasing. “Those changes are associated with gut permeability and alterations in both local and systemic inflammation, and the risk for a number of diseases, including atopic dermatitis,” he said. Key reasons for the increasing prevalence of dysbiosis, he continued, include the use of antibiotics, cesarean section delivery, formula feeding, changes in hygiene that alter the intestinal biota, the high-fat, high-sugar Western diet, and a loss of vertical and horizontal transmission over generations.

In an effort to evaluate the association between early childhood antibiotic use with allergic diseases in later childhood, Japanese researchers followed 1,200 infants to the age of 5 years (Ann Allergy Asthma Immunol. 2017;119:54-8). They found that antibiotic exposure within the first 2 years of life was associated with an increased risk of asthma (adjusted odds ratio 1.72), allergic rhinitis (adjusted OR 1.65), and atopic dermatitis (adjusted OR 1.40). In a more recent, smaller prospective study, 436 Dutch infants were followed to 1 year of age (Pediatr Allergy Immunol. 2018;29[2]:151-8). The researchers found that antibiotic exposure within the first week of life was associated with allergic sensitization (adjusted OR 3.26), colic (adjusted OR 1.66), and wheezing (adjusted OR 1.56).

In a study of 44 term infants with a family history of allergy, changes in the fecal microbiota, especially colonization with Ruminococcus gnavus, preceded the onset of allergic symptoms (Gastroenterol. 2018;154[1]:154-67). The same researchers observed similar findings in an animal model.

One potential mechanism by which intestinal dysbiosis causes systemic disease is stimulation of toll-like receptor 4 (TLR4), “which is a receptor on a variety of mucosal cells that senses the presence of a microbial pathogen-associated patterns, particularly those of Gram-negative Enterobacteriaceae,” Dr. Underwood explained. Other potential mechanisms include increased intestinal permeability, an increase in the pH and decreases in short-chain fatty acids within the gut lumen, and a loss of intraluminal hypoxia. “Think of the colon as an anaerobic chamber,” he said. “The colon lumen should be very low in oxygen. It should be dominated by obligate anaerobes.”

Efforts to prevent or treat dysbiosis-related diseases include the use of probiotics and fecal transplantation. A recent Cochrane review of 8,672 patients found “moderate certainty evidence” that probiotics are effective for preventing C. difficile-associated diarrhea. The analysis included 31 randomized, controlled trials of adults who were treated either with a probiotic or with a placebo. When pooled, the risk ratio was 0.40, which represented a significant protection. In addition, a summary of 7 randomized controlled trials and 30 case series suggests that fecal microbial transplantation is superior to vancomycin for adults with recurrent C. difficile colitis (relative risk 0.23) (Aliment Pharmacol Ther. 2017;46[5]:470-93).

To date, the effect of giving probiotics to pregnant women who have a family history of allergy is less clear. One pooled analysis of such studies put the overall risk ratio at 0.74 (Mil Med. 2014;179[6]:580-92). “While I think the jury’s still out on how to best prevent atopic dermatitis in these families, it looks like there is some potential benefit in treating these moms during pregnancy with probiotics and treating the infant during the first few months of life,” Dr. Underwood said. The most effective were mixtures including one or more Lactobacillus species or L. rhamnosus, mixtures including one or more Bifidobacterium species, or B. lactis by itself. The use of probiotics also has been found to prevent necrotizing enterocolitis, sepsis, and death in premature infants (Semin Pediatr Surg. 2018;27[1]:39-46).

Dr. Underwood disclosed that he has received honoraria from Abbott and that he was a member of the scientific review board for Avexegen. He also chaired the data safety and monitoring board for Infant Bacterial Therapeutics and has received support from Evolve BioSystems to perform a clinical trial.

[email protected]

LAKE TAHOE, CALIF. – Strong associations exist between intestinal dysbiosis and a wide variety of gut and systemic diseases, according to Mark A. Underwood, MD.

Doug Brunk/MDedge News

“Antibiotic exposure changes the composition of the intestinal microbiota,” he said at the annual meeting of the Society for Pediatric Dermatology. “That clearly causes both antibiotic-associated diarrhea and Clostridium difficile colitis. The bigger question is, is it possible that intestinal dysbiosis is related to a whole bunch of other systemic diseases? In other words, does an insult during a critical window of development cause changes in the intestinal microbiota that can lead to systemic diseases in the brain, the lung, the liver, or the immune system?”

According Dr. Underwood, a pediatrician who is chief of the division of neonatology at the University of California, Davis, the prevalence of dysbiosis is increasing worldwide, particularly in developed countries, where Bifidobacteria are decreasing and Enterobacteriaceae are increasing. “Those changes are associated with gut permeability and alterations in both local and systemic inflammation, and the risk for a number of diseases, including atopic dermatitis,” he said. Key reasons for the increasing prevalence of dysbiosis, he continued, include the use of antibiotics, cesarean section delivery, formula feeding, changes in hygiene that alter the intestinal biota, the high-fat, high-sugar Western diet, and a loss of vertical and horizontal transmission over generations.

In an effort to evaluate the association between early childhood antibiotic use with allergic diseases in later childhood, Japanese researchers followed 1,200 infants to the age of 5 years (Ann Allergy Asthma Immunol. 2017;119:54-8). They found that antibiotic exposure within the first 2 years of life was associated with an increased risk of asthma (adjusted odds ratio 1.72), allergic rhinitis (adjusted OR 1.65), and atopic dermatitis (adjusted OR 1.40). In a more recent, smaller prospective study, 436 Dutch infants were followed to 1 year of age (Pediatr Allergy Immunol. 2018;29[2]:151-8). The researchers found that antibiotic exposure within the first week of life was associated with allergic sensitization (adjusted OR 3.26), colic (adjusted OR 1.66), and wheezing (adjusted OR 1.56).

In a study of 44 term infants with a family history of allergy, changes in the fecal microbiota, especially colonization with Ruminococcus gnavus, preceded the onset of allergic symptoms (Gastroenterol. 2018;154[1]:154-67). The same researchers observed similar findings in an animal model.

One potential mechanism by which intestinal dysbiosis causes systemic disease is stimulation of toll-like receptor 4 (TLR4), “which is a receptor on a variety of mucosal cells that senses the presence of a microbial pathogen-associated patterns, particularly those of Gram-negative Enterobacteriaceae,” Dr. Underwood explained. Other potential mechanisms include increased intestinal permeability, an increase in the pH and decreases in short-chain fatty acids within the gut lumen, and a loss of intraluminal hypoxia. “Think of the colon as an anaerobic chamber,” he said. “The colon lumen should be very low in oxygen. It should be dominated by obligate anaerobes.”

Efforts to prevent or treat dysbiosis-related diseases include the use of probiotics and fecal transplantation. A recent Cochrane review of 8,672 patients found “moderate certainty evidence” that probiotics are effective for preventing C. difficile-associated diarrhea. The analysis included 31 randomized, controlled trials of adults who were treated either with a probiotic or with a placebo. When pooled, the risk ratio was 0.40, which represented a significant protection. In addition, a summary of 7 randomized controlled trials and 30 case series suggests that fecal microbial transplantation is superior to vancomycin for adults with recurrent C. difficile colitis (relative risk 0.23) (Aliment Pharmacol Ther. 2017;46[5]:470-93).

To date, the effect of giving probiotics to pregnant women who have a family history of allergy is less clear. One pooled analysis of such studies put the overall risk ratio at 0.74 (Mil Med. 2014;179[6]:580-92). “While I think the jury’s still out on how to best prevent atopic dermatitis in these families, it looks like there is some potential benefit in treating these moms during pregnancy with probiotics and treating the infant during the first few months of life,” Dr. Underwood said. The most effective were mixtures including one or more Lactobacillus species or L. rhamnosus, mixtures including one or more Bifidobacterium species, or B. lactis by itself. The use of probiotics also has been found to prevent necrotizing enterocolitis, sepsis, and death in premature infants (Semin Pediatr Surg. 2018;27[1]:39-46).

Dr. Underwood disclosed that he has received honoraria from Abbott and that he was a member of the scientific review board for Avexegen. He also chaired the data safety and monitoring board for Infant Bacterial Therapeutics and has received support from Evolve BioSystems to perform a clinical trial.

[email protected]

LAKE TAHOE, CALIF. – Strong associations exist between intestinal dysbiosis and a wide variety of gut and systemic diseases, according to Mark A. Underwood, MD.

Doug Brunk/MDedge News

“Antibiotic exposure changes the composition of the intestinal microbiota,” he said at the annual meeting of the Society for Pediatric Dermatology. “That clearly causes both antibiotic-associated diarrhea and Clostridium difficile colitis. The bigger question is, is it possible that intestinal dysbiosis is related to a whole bunch of other systemic diseases? In other words, does an insult during a critical window of development cause changes in the intestinal microbiota that can lead to systemic diseases in the brain, the lung, the liver, or the immune system?”

According Dr. Underwood, a pediatrician who is chief of the division of neonatology at the University of California, Davis, the prevalence of dysbiosis is increasing worldwide, particularly in developed countries, where Bifidobacteria are decreasing and Enterobacteriaceae are increasing. “Those changes are associated with gut permeability and alterations in both local and systemic inflammation, and the risk for a number of diseases, including atopic dermatitis,” he said. Key reasons for the increasing prevalence of dysbiosis, he continued, include the use of antibiotics, cesarean section delivery, formula feeding, changes in hygiene that alter the intestinal biota, the high-fat, high-sugar Western diet, and a loss of vertical and horizontal transmission over generations.

In an effort to evaluate the association between early childhood antibiotic use with allergic diseases in later childhood, Japanese researchers followed 1,200 infants to the age of 5 years (Ann Allergy Asthma Immunol. 2017;119:54-8). They found that antibiotic exposure within the first 2 years of life was associated with an increased risk of asthma (adjusted odds ratio 1.72), allergic rhinitis (adjusted OR 1.65), and atopic dermatitis (adjusted OR 1.40). In a more recent, smaller prospective study, 436 Dutch infants were followed to 1 year of age (Pediatr Allergy Immunol. 2018;29[2]:151-8). The researchers found that antibiotic exposure within the first week of life was associated with allergic sensitization (adjusted OR 3.26), colic (adjusted OR 1.66), and wheezing (adjusted OR 1.56).

In a study of 44 term infants with a family history of allergy, changes in the fecal microbiota, especially colonization with Ruminococcus gnavus, preceded the onset of allergic symptoms (Gastroenterol. 2018;154[1]:154-67). The same researchers observed similar findings in an animal model.

One potential mechanism by which intestinal dysbiosis causes systemic disease is stimulation of toll-like receptor 4 (TLR4), “which is a receptor on a variety of mucosal cells that senses the presence of a microbial pathogen-associated patterns, particularly those of Gram-negative Enterobacteriaceae,” Dr. Underwood explained. Other potential mechanisms include increased intestinal permeability, an increase in the pH and decreases in short-chain fatty acids within the gut lumen, and a loss of intraluminal hypoxia. “Think of the colon as an anaerobic chamber,” he said. “The colon lumen should be very low in oxygen. It should be dominated by obligate anaerobes.”

Efforts to prevent or treat dysbiosis-related diseases include the use of probiotics and fecal transplantation. A recent Cochrane review of 8,672 patients found “moderate certainty evidence” that probiotics are effective for preventing C. difficile-associated diarrhea. The analysis included 31 randomized, controlled trials of adults who were treated either with a probiotic or with a placebo. When pooled, the risk ratio was 0.40, which represented a significant protection. In addition, a summary of 7 randomized controlled trials and 30 case series suggests that fecal microbial transplantation is superior to vancomycin for adults with recurrent C. difficile colitis (relative risk 0.23) (Aliment Pharmacol Ther. 2017;46[5]:470-93).

To date, the effect of giving probiotics to pregnant women who have a family history of allergy is less clear. One pooled analysis of such studies put the overall risk ratio at 0.74 (Mil Med. 2014;179[6]:580-92). “While I think the jury’s still out on how to best prevent atopic dermatitis in these families, it looks like there is some potential benefit in treating these moms during pregnancy with probiotics and treating the infant during the first few months of life,” Dr. Underwood said. The most effective were mixtures including one or more Lactobacillus species or L. rhamnosus, mixtures including one or more Bifidobacterium species, or B. lactis by itself. The use of probiotics also has been found to prevent necrotizing enterocolitis, sepsis, and death in premature infants (Semin Pediatr Surg. 2018;27[1]:39-46).

Dr. Underwood disclosed that he has received honoraria from Abbott and that he was a member of the scientific review board for Avexegen. He also chaired the data safety and monitoring board for Infant Bacterial Therapeutics and has received support from Evolve BioSystems to perform a clinical trial.

[email protected]

SAN DIEGO – Picosecond lasers have surpassed Q-switched lasers as the treatment of choice for tattoo removal, delivering high energies in trillionths of a second.

Dr. Amanda Champlain

“A picosecond is to a second as 1 second is to 37,000 years,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “That’s equivalent to the total energy of the city of San Diego for 300-750 trillionths of a second.”

According to Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, picosecond lasers produce extreme cavitation and cell rupture, with a desired clinical endpoint of immediate dermal whitening of tattooed skin. The process causes transdermal elimination of the tattoo ink. Some of the ink flows into the lymphatic system, while the rest undergoes rephagocytosis by dermal scavenger cells.

Commercially available picosecond lasers include devices with wavelengths of 532 nm, 755 nm, and 1,064 nm that deliver energy in a range of 300-750 picoseconds. Nd:YAG lasers work best for red and black ink, while alexandrite lasers work best for green and blue ink. In Dr. Avram’s experience, picosecond lasers are generally more effective for tattoo removal, compared with nanosecond lasers. “There is some nonselective targeting of other pigments, and they’re particularly effective for faded tattoos, but the devices are more expensive,” he said.

Dr. Avram, who is also the faculty director for laser and cosmetic dermatology training at Harvard Medical School, also in Boston, advises against promising a certain number of laser treatments during initial patient consultations. “You will regret it,” he said. “Tattoos are notoriously unpredictable in how they respond. I often hear people say they get rid of these in three to five treatments. That isn’t my experience with these lasers. Often, all you’re going to be able to do is get significant clearing rather than tattoo removal. Professional tattoos are the most difficult to treat because they are the deepest and they have the most amount of ink.”

On the other hand, amateur tattoos, traumatic tattoos, and radiation tattoos require far fewer treatments. “The color is important,” he said. “Multicolored tattoos, regardless of the colors, are always going to be more difficult to clear than a single-color tattoo.” Black and dark-blue tattoos respond best to laser light; light-blue and green also respond well. Red responds well, while purple can be challenging. Yellow and orange do not respond very well, but they do respond partially.

According to a trial that analyzed variables influencing the outcome of tattoos treated by Q-switched lasers, 47% were cleared after 10 sessions, while 75% were cleared after 15 sessions (Arch Dermatol 2012;148[12]:1364-9). “It’s very important to message to your patients how many treatments this might take, because there is going to be an annuity of patients who are unhappy because they have to keep coming back,” said Dr. Avram, who is the immediate past president of the American Society for Laser Medicine and Surgery. Skin type and pigmentation also affect treatment outcomes. “For darker skin types or tanned individuals, hyper- or hypopigmentation is a greater concern than in patients with lighter skin types,” he said. “A test spot may be beneficial. The 1,064-nm Q-switched Nd:YAG laser is least likely to affect skin pigment; it’s safest for skin types IV-VI . This is great if it’s a black tattoo. But if it’s a green, blue, or red tattoo, you have a problem because you’re not going to target it very effectively.”

Some degree of posttreatment hypopigmentation is likely to occur, regardless of skin type. “Let patients know this is going to happen, but over time, this usually resolves, because you’re not destroying the melanocytes, unless you’re going too strong,” Dr. Avram said. “It may take a few months. It may take a year or 2, but the pigment should recur.”

He emphasized that the key variable during laser treatment of tattoos is the clinical endpoint, not the energy setting of the device. “What you want to see is immediate whitening of the treated area,” he said. “With the 1,064-nm Nd:YAG, you may get a little pinpoint bleeding in addition to whitening. Do not memorize treatment settings. Many Q-switched lasers are not externally calibrated. Thus, energy levels may change day to day or before and after servicing [of the device]. Trust your eyes; trust your clinical skills.” If you see epidermal disruption and bleeding during treatment, you’re probably being too aggressive. If that happens, “decrease your fluence,” he recommended. “You also want to decrease fluences when treating tattoos that are placed over other tattoos.”

Another rule of thumb is to use larger spot sizes during treatment sessions. “The larger the spot size, the more efficient the energy is going to get more deeply, and less is going to be at the dermal-epidermal junction,” Dr. Avram said. “So you’re going to get less hypopigmentation and less hyperpigmentation. Follow your endpoints and you are less likely to get pigmentation changes.”

Posttreatment care typically includes the application of topical petroleum jelly and a Telfa dressing. “Wait about a week to heal, counsel patients to keep out of the sun, and avoid friction to the treated area during healing,” he said. Patients can be rescheduled for retreatment 6-8 weeks later.

Common adverse events during laser treatment of tattoos include erythema, blistering, hyperpigmentation, hypopigmentation, and scarring, which occurs in about 5% of cases. Less common adverse events include allergic reaction, darkening of cosmetic tattoos, immune reaction, and chrysiasis, which is a dark-blue pigmentation caused by Q-switched laser treatment in patients with a history of gold salt ingestion. “Any history of gold salt ingestion will produce this characteristic finding, even if they took it when they were 5 years old and they come to you when they’re 85,” Dr. Avram said. “All of our intake forms include a question about this, and before I treat patients I always ask if they have a history of gold ingestion, because it’s very difficult to treat.”

Surgical excision may be an alternative for smaller tattoos. “Another option is ablative fractional resurfacing as a solo treatment or in combination with the Q-switched or picosecond laser, which has better efficacy,” he said. “The ablative fractional laser also may help with fibrosis after multiple treatments in a recalcitrant tattoo.” He noted that cosmetic tattoos such as lip liner and blush tattoos might darken because of oxidation of ferric oxide or titanium oxide pigment. The best approach to such cases is to perform an inconspicuous test spot prior to treatment.

Clinicians continue to explore the optimal interval between treatments. For example, the “R20” method consists of four consecutive treatment passes separated by 20 minutes. The initial study found that this approach led to better outcomes, compared with conventional, single-pass laser treatment (J Am Acad Dermatol 2012;66[2]:271-7). A follow-up study by Dr. Avram and his colleagues contradicted these findings, while another follow-up study was supportive.

Another technology playing a role in such repeat treatments is a perfluorodecalin-infused silicone patch, which is placed over the treatment area. According to Dr. Avram, the FDA-cleared patch helps reduce scatter during treatment and likely improves efficacy. It also allows for performing consecutive repeat laser treatments at the same visit. In one study, 11 of 17 patients had more rapid clearance on the side treated with the perfluorodecalin patch, compared with the side treated without the patch (Laser Surg Med 2015;47[8]:613-8).

Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.

[email protected]





 

SAN DIEGO – Picosecond lasers have surpassed Q-switched lasers as the treatment of choice for tattoo removal, delivering high energies in trillionths of a second.

Dr. Amanda Champlain

“A picosecond is to a second as 1 second is to 37,000 years,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “That’s equivalent to the total energy of the city of San Diego for 300-750 trillionths of a second.”

According to Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, picosecond lasers produce extreme cavitation and cell rupture, with a desired clinical endpoint of immediate dermal whitening of tattooed skin. The process causes transdermal elimination of the tattoo ink. Some of the ink flows into the lymphatic system, while the rest undergoes rephagocytosis by dermal scavenger cells.

Commercially available picosecond lasers include devices with wavelengths of 532 nm, 755 nm, and 1,064 nm that deliver energy in a range of 300-750 picoseconds. Nd:YAG lasers work best for red and black ink, while alexandrite lasers work best for green and blue ink. In Dr. Avram’s experience, picosecond lasers are generally more effective for tattoo removal, compared with nanosecond lasers. “There is some nonselective targeting of other pigments, and they’re particularly effective for faded tattoos, but the devices are more expensive,” he said.

Dr. Avram, who is also the faculty director for laser and cosmetic dermatology training at Harvard Medical School, also in Boston, advises against promising a certain number of laser treatments during initial patient consultations. “You will regret it,” he said. “Tattoos are notoriously unpredictable in how they respond. I often hear people say they get rid of these in three to five treatments. That isn’t my experience with these lasers. Often, all you’re going to be able to do is get significant clearing rather than tattoo removal. Professional tattoos are the most difficult to treat because they are the deepest and they have the most amount of ink.”

On the other hand, amateur tattoos, traumatic tattoos, and radiation tattoos require far fewer treatments. “The color is important,” he said. “Multicolored tattoos, regardless of the colors, are always going to be more difficult to clear than a single-color tattoo.” Black and dark-blue tattoos respond best to laser light; light-blue and green also respond well. Red responds well, while purple can be challenging. Yellow and orange do not respond very well, but they do respond partially.

According to a trial that analyzed variables influencing the outcome of tattoos treated by Q-switched lasers, 47% were cleared after 10 sessions, while 75% were cleared after 15 sessions (Arch Dermatol 2012;148[12]:1364-9). “It’s very important to message to your patients how many treatments this might take, because there is going to be an annuity of patients who are unhappy because they have to keep coming back,” said Dr. Avram, who is the immediate past president of the American Society for Laser Medicine and Surgery. Skin type and pigmentation also affect treatment outcomes. “For darker skin types or tanned individuals, hyper- or hypopigmentation is a greater concern than in patients with lighter skin types,” he said. “A test spot may be beneficial. The 1,064-nm Q-switched Nd:YAG laser is least likely to affect skin pigment; it’s safest for skin types IV-VI . This is great if it’s a black tattoo. But if it’s a green, blue, or red tattoo, you have a problem because you’re not going to target it very effectively.”

Some degree of posttreatment hypopigmentation is likely to occur, regardless of skin type. “Let patients know this is going to happen, but over time, this usually resolves, because you’re not destroying the melanocytes, unless you’re going too strong,” Dr. Avram said. “It may take a few months. It may take a year or 2, but the pigment should recur.”

He emphasized that the key variable during laser treatment of tattoos is the clinical endpoint, not the energy setting of the device. “What you want to see is immediate whitening of the treated area,” he said. “With the 1,064-nm Nd:YAG, you may get a little pinpoint bleeding in addition to whitening. Do not memorize treatment settings. Many Q-switched lasers are not externally calibrated. Thus, energy levels may change day to day or before and after servicing [of the device]. Trust your eyes; trust your clinical skills.” If you see epidermal disruption and bleeding during treatment, you’re probably being too aggressive. If that happens, “decrease your fluence,” he recommended. “You also want to decrease fluences when treating tattoos that are placed over other tattoos.”

Another rule of thumb is to use larger spot sizes during treatment sessions. “The larger the spot size, the more efficient the energy is going to get more deeply, and less is going to be at the dermal-epidermal junction,” Dr. Avram said. “So you’re going to get less hypopigmentation and less hyperpigmentation. Follow your endpoints and you are less likely to get pigmentation changes.”

Posttreatment care typically includes the application of topical petroleum jelly and a Telfa dressing. “Wait about a week to heal, counsel patients to keep out of the sun, and avoid friction to the treated area during healing,” he said. Patients can be rescheduled for retreatment 6-8 weeks later.

Common adverse events during laser treatment of tattoos include erythema, blistering, hyperpigmentation, hypopigmentation, and scarring, which occurs in about 5% of cases. Less common adverse events include allergic reaction, darkening of cosmetic tattoos, immune reaction, and chrysiasis, which is a dark-blue pigmentation caused by Q-switched laser treatment in patients with a history of gold salt ingestion. “Any history of gold salt ingestion will produce this characteristic finding, even if they took it when they were 5 years old and they come to you when they’re 85,” Dr. Avram said. “All of our intake forms include a question about this, and before I treat patients I always ask if they have a history of gold ingestion, because it’s very difficult to treat.”

Surgical excision may be an alternative for smaller tattoos. “Another option is ablative fractional resurfacing as a solo treatment or in combination with the Q-switched or picosecond laser, which has better efficacy,” he said. “The ablative fractional laser also may help with fibrosis after multiple treatments in a recalcitrant tattoo.” He noted that cosmetic tattoos such as lip liner and blush tattoos might darken because of oxidation of ferric oxide or titanium oxide pigment. The best approach to such cases is to perform an inconspicuous test spot prior to treatment.

Clinicians continue to explore the optimal interval between treatments. For example, the “R20” method consists of four consecutive treatment passes separated by 20 minutes. The initial study found that this approach led to better outcomes, compared with conventional, single-pass laser treatment (J Am Acad Dermatol 2012;66[2]:271-7). A follow-up study by Dr. Avram and his colleagues contradicted these findings, while another follow-up study was supportive.

Another technology playing a role in such repeat treatments is a perfluorodecalin-infused silicone patch, which is placed over the treatment area. According to Dr. Avram, the FDA-cleared patch helps reduce scatter during treatment and likely improves efficacy. It also allows for performing consecutive repeat laser treatments at the same visit. In one study, 11 of 17 patients had more rapid clearance on the side treated with the perfluorodecalin patch, compared with the side treated without the patch (Laser Surg Med 2015;47[8]:613-8).

Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.

[email protected]





 

SAN DIEGO – Picosecond lasers have surpassed Q-switched lasers as the treatment of choice for tattoo removal, delivering high energies in trillionths of a second.

Dr. Amanda Champlain

“A picosecond is to a second as 1 second is to 37,000 years,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “That’s equivalent to the total energy of the city of San Diego for 300-750 trillionths of a second.”

According to Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, picosecond lasers produce extreme cavitation and cell rupture, with a desired clinical endpoint of immediate dermal whitening of tattooed skin. The process causes transdermal elimination of the tattoo ink. Some of the ink flows into the lymphatic system, while the rest undergoes rephagocytosis by dermal scavenger cells.

Commercially available picosecond lasers include devices with wavelengths of 532 nm, 755 nm, and 1,064 nm that deliver energy in a range of 300-750 picoseconds. Nd:YAG lasers work best for red and black ink, while alexandrite lasers work best for green and blue ink. In Dr. Avram’s experience, picosecond lasers are generally more effective for tattoo removal, compared with nanosecond lasers. “There is some nonselective targeting of other pigments, and they’re particularly effective for faded tattoos, but the devices are more expensive,” he said.

Dr. Avram, who is also the faculty director for laser and cosmetic dermatology training at Harvard Medical School, also in Boston, advises against promising a certain number of laser treatments during initial patient consultations. “You will regret it,” he said. “Tattoos are notoriously unpredictable in how they respond. I often hear people say they get rid of these in three to five treatments. That isn’t my experience with these lasers. Often, all you’re going to be able to do is get significant clearing rather than tattoo removal. Professional tattoos are the most difficult to treat because they are the deepest and they have the most amount of ink.”

On the other hand, amateur tattoos, traumatic tattoos, and radiation tattoos require far fewer treatments. “The color is important,” he said. “Multicolored tattoos, regardless of the colors, are always going to be more difficult to clear than a single-color tattoo.” Black and dark-blue tattoos respond best to laser light; light-blue and green also respond well. Red responds well, while purple can be challenging. Yellow and orange do not respond very well, but they do respond partially.

According to a trial that analyzed variables influencing the outcome of tattoos treated by Q-switched lasers, 47% were cleared after 10 sessions, while 75% were cleared after 15 sessions (Arch Dermatol 2012;148[12]:1364-9). “It’s very important to message to your patients how many treatments this might take, because there is going to be an annuity of patients who are unhappy because they have to keep coming back,” said Dr. Avram, who is the immediate past president of the American Society for Laser Medicine and Surgery. Skin type and pigmentation also affect treatment outcomes. “For darker skin types or tanned individuals, hyper- or hypopigmentation is a greater concern than in patients with lighter skin types,” he said. “A test spot may be beneficial. The 1,064-nm Q-switched Nd:YAG laser is least likely to affect skin pigment; it’s safest for skin types IV-VI . This is great if it’s a black tattoo. But if it’s a green, blue, or red tattoo, you have a problem because you’re not going to target it very effectively.”

Some degree of posttreatment hypopigmentation is likely to occur, regardless of skin type. “Let patients know this is going to happen, but over time, this usually resolves, because you’re not destroying the melanocytes, unless you’re going too strong,” Dr. Avram said. “It may take a few months. It may take a year or 2, but the pigment should recur.”

He emphasized that the key variable during laser treatment of tattoos is the clinical endpoint, not the energy setting of the device. “What you want to see is immediate whitening of the treated area,” he said. “With the 1,064-nm Nd:YAG, you may get a little pinpoint bleeding in addition to whitening. Do not memorize treatment settings. Many Q-switched lasers are not externally calibrated. Thus, energy levels may change day to day or before and after servicing [of the device]. Trust your eyes; trust your clinical skills.” If you see epidermal disruption and bleeding during treatment, you’re probably being too aggressive. If that happens, “decrease your fluence,” he recommended. “You also want to decrease fluences when treating tattoos that are placed over other tattoos.”

Another rule of thumb is to use larger spot sizes during treatment sessions. “The larger the spot size, the more efficient the energy is going to get more deeply, and less is going to be at the dermal-epidermal junction,” Dr. Avram said. “So you’re going to get less hypopigmentation and less hyperpigmentation. Follow your endpoints and you are less likely to get pigmentation changes.”

Posttreatment care typically includes the application of topical petroleum jelly and a Telfa dressing. “Wait about a week to heal, counsel patients to keep out of the sun, and avoid friction to the treated area during healing,” he said. Patients can be rescheduled for retreatment 6-8 weeks later.

Common adverse events during laser treatment of tattoos include erythema, blistering, hyperpigmentation, hypopigmentation, and scarring, which occurs in about 5% of cases. Less common adverse events include allergic reaction, darkening of cosmetic tattoos, immune reaction, and chrysiasis, which is a dark-blue pigmentation caused by Q-switched laser treatment in patients with a history of gold salt ingestion. “Any history of gold salt ingestion will produce this characteristic finding, even if they took it when they were 5 years old and they come to you when they’re 85,” Dr. Avram said. “All of our intake forms include a question about this, and before I treat patients I always ask if they have a history of gold ingestion, because it’s very difficult to treat.”

Surgical excision may be an alternative for smaller tattoos. “Another option is ablative fractional resurfacing as a solo treatment or in combination with the Q-switched or picosecond laser, which has better efficacy,” he said. “The ablative fractional laser also may help with fibrosis after multiple treatments in a recalcitrant tattoo.” He noted that cosmetic tattoos such as lip liner and blush tattoos might darken because of oxidation of ferric oxide or titanium oxide pigment. The best approach to such cases is to perform an inconspicuous test spot prior to treatment.

Clinicians continue to explore the optimal interval between treatments. For example, the “R20” method consists of four consecutive treatment passes separated by 20 minutes. The initial study found that this approach led to better outcomes, compared with conventional, single-pass laser treatment (J Am Acad Dermatol 2012;66[2]:271-7). A follow-up study by Dr. Avram and his colleagues contradicted these findings, while another follow-up study was supportive.

Another technology playing a role in such repeat treatments is a perfluorodecalin-infused silicone patch, which is placed over the treatment area. According to Dr. Avram, the FDA-cleared patch helps reduce scatter during treatment and likely improves efficacy. It also allows for performing consecutive repeat laser treatments at the same visit. In one study, 11 of 17 patients had more rapid clearance on the side treated with the perfluorodecalin patch, compared with the side treated without the patch (Laser Surg Med 2015;47[8]:613-8).

Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.

[email protected]





 

LAKE TAHOE, CALIF. – Several years ago, David H. Darrow, MD, DDS, began to notice a pattern in the conversation threads on websites dedicated to support for parents of children with facial port-wine stains (PWS).

Parents were reporting that dental problems arose earlier on their child’s side of face with the PWS, and that the alveolar ridge was lower on the side of the face that harbored the lesion. “Most importantly, parents were concerned that dentists were not touching their children because they were concerned about bleeding,” Dr. Darrow said at the annual meeting of the Society for Pediatric Dermatology. A search in the medical literature for port-wine stains and oral cavity changes, did not turn up much except for a few articles on bleeding. “One said that port-wine stains or capillary malformations rarely present major problems for the oral and maxillofacial surgeon. The other said that periodontal probing should not be done, as even gentle probing can result in uncontrolled bleeding,” he noted.

This prompted Dr. Darrow, who directs the Center for Hemangiomas and Vascular Birthmarks at the Eastern Virginia Medical School, Norfolk, and coinvestigators, Megan B. Dowling, MD, and Yueqin Zhao, PhD, to characterize manifestations of PWS in the oral cavity via an anonymous paired survey of volunteers with facial PWS and their dentists who were recruited from birthmarks.com and 10 collaborating physician practices (J Am Acad Dermatol 2012;67:687-93). Volunteers ranged in age from 1 to 62 years; mean age was 29 years. A total of 30 patients participated, and most (67%) were female.

The five most common oral manifestations reported by the patients were lip hyperplasia (53%), stained gingiva (47%), malocclusion (30%), bleeding gingiva (27%), and spacing between teeth (23%). Only 3% reported bleeding from dental procedures. When the researchers evaluated the orodental findings in the paired patient-physician responses, “most of the time there was good agreement between the patient and the dentist,” Dr. Darrow said. “The only one that fell out of agreement was lip hyperplasia. That’s probably because most dentists look right past the lips and into the oral cavity.”

When the researchers examined patients who had stained gingiva versus those who did not, they found that early-stage lesions demonstrated a reddish blush of the oral mucosa and gingiva, while late-stage lesions demonstrated increased blush of the oral tissues, as well as hyperplasia of the soft tissue or bone in the affected area. “Based on our review of the literature, bleeding of gums is rarely prolonged and dental procedures are safe,” Dr. Darrow said.

The findings are important, he continued, because capillary malformations of the oral cavity may result in periodontal disease associated with gingival overgrowth. The depth of the gingival pocket should be no more than 2-3 mm. “When you have areas of inflammation and deep-pocket formation, plaque and bacteria slowly erode the connection between the tooth and the soft tissue,” he explained. “At some point, that pocket becomes so deep that it reaches down into the bone in which the tooth is anchored. As that bone is eroded, the teeth loosen and begin to fall out. The goals of therapy are prevention of periodontal disease with meticulous oral hygiene.”

Soft tissue hyperplasia may be exacerbated by medications such as calcium channel blockers, cyclosporine, and phenytoin and phenobarbital, which are sometimes used by patients with Sturge-Weber syndrome, he said.

Dr. Darrow reported having no financial disclosures.

[email protected]

LAKE TAHOE, CALIF. – Several years ago, David H. Darrow, MD, DDS, began to notice a pattern in the conversation threads on websites dedicated to support for parents of children with facial port-wine stains (PWS).

Parents were reporting that dental problems arose earlier on their child’s side of face with the PWS, and that the alveolar ridge was lower on the side of the face that harbored the lesion. “Most importantly, parents were concerned that dentists were not touching their children because they were concerned about bleeding,” Dr. Darrow said at the annual meeting of the Society for Pediatric Dermatology. A search in the medical literature for port-wine stains and oral cavity changes, did not turn up much except for a few articles on bleeding. “One said that port-wine stains or capillary malformations rarely present major problems for the oral and maxillofacial surgeon. The other said that periodontal probing should not be done, as even gentle probing can result in uncontrolled bleeding,” he noted.

This prompted Dr. Darrow, who directs the Center for Hemangiomas and Vascular Birthmarks at the Eastern Virginia Medical School, Norfolk, and coinvestigators, Megan B. Dowling, MD, and Yueqin Zhao, PhD, to characterize manifestations of PWS in the oral cavity via an anonymous paired survey of volunteers with facial PWS and their dentists who were recruited from birthmarks.com and 10 collaborating physician practices (J Am Acad Dermatol 2012;67:687-93). Volunteers ranged in age from 1 to 62 years; mean age was 29 years. A total of 30 patients participated, and most (67%) were female.

The five most common oral manifestations reported by the patients were lip hyperplasia (53%), stained gingiva (47%), malocclusion (30%), bleeding gingiva (27%), and spacing between teeth (23%). Only 3% reported bleeding from dental procedures. When the researchers evaluated the orodental findings in the paired patient-physician responses, “most of the time there was good agreement between the patient and the dentist,” Dr. Darrow said. “The only one that fell out of agreement was lip hyperplasia. That’s probably because most dentists look right past the lips and into the oral cavity.”

When the researchers examined patients who had stained gingiva versus those who did not, they found that early-stage lesions demonstrated a reddish blush of the oral mucosa and gingiva, while late-stage lesions demonstrated increased blush of the oral tissues, as well as hyperplasia of the soft tissue or bone in the affected area. “Based on our review of the literature, bleeding of gums is rarely prolonged and dental procedures are safe,” Dr. Darrow said.

The findings are important, he continued, because capillary malformations of the oral cavity may result in periodontal disease associated with gingival overgrowth. The depth of the gingival pocket should be no more than 2-3 mm. “When you have areas of inflammation and deep-pocket formation, plaque and bacteria slowly erode the connection between the tooth and the soft tissue,” he explained. “At some point, that pocket becomes so deep that it reaches down into the bone in which the tooth is anchored. As that bone is eroded, the teeth loosen and begin to fall out. The goals of therapy are prevention of periodontal disease with meticulous oral hygiene.”

Soft tissue hyperplasia may be exacerbated by medications such as calcium channel blockers, cyclosporine, and phenytoin and phenobarbital, which are sometimes used by patients with Sturge-Weber syndrome, he said.

Dr. Darrow reported having no financial disclosures.

[email protected]

LAKE TAHOE, CALIF. – Several years ago, David H. Darrow, MD, DDS, began to notice a pattern in the conversation threads on websites dedicated to support for parents of children with facial port-wine stains (PWS).

Parents were reporting that dental problems arose earlier on their child’s side of face with the PWS, and that the alveolar ridge was lower on the side of the face that harbored the lesion. “Most importantly, parents were concerned that dentists were not touching their children because they were concerned about bleeding,” Dr. Darrow said at the annual meeting of the Society for Pediatric Dermatology. A search in the medical literature for port-wine stains and oral cavity changes, did not turn up much except for a few articles on bleeding. “One said that port-wine stains or capillary malformations rarely present major problems for the oral and maxillofacial surgeon. The other said that periodontal probing should not be done, as even gentle probing can result in uncontrolled bleeding,” he noted.

This prompted Dr. Darrow, who directs the Center for Hemangiomas and Vascular Birthmarks at the Eastern Virginia Medical School, Norfolk, and coinvestigators, Megan B. Dowling, MD, and Yueqin Zhao, PhD, to characterize manifestations of PWS in the oral cavity via an anonymous paired survey of volunteers with facial PWS and their dentists who were recruited from birthmarks.com and 10 collaborating physician practices (J Am Acad Dermatol 2012;67:687-93). Volunteers ranged in age from 1 to 62 years; mean age was 29 years. A total of 30 patients participated, and most (67%) were female.

The five most common oral manifestations reported by the patients were lip hyperplasia (53%), stained gingiva (47%), malocclusion (30%), bleeding gingiva (27%), and spacing between teeth (23%). Only 3% reported bleeding from dental procedures. When the researchers evaluated the orodental findings in the paired patient-physician responses, “most of the time there was good agreement between the patient and the dentist,” Dr. Darrow said. “The only one that fell out of agreement was lip hyperplasia. That’s probably because most dentists look right past the lips and into the oral cavity.”

When the researchers examined patients who had stained gingiva versus those who did not, they found that early-stage lesions demonstrated a reddish blush of the oral mucosa and gingiva, while late-stage lesions demonstrated increased blush of the oral tissues, as well as hyperplasia of the soft tissue or bone in the affected area. “Based on our review of the literature, bleeding of gums is rarely prolonged and dental procedures are safe,” Dr. Darrow said.

The findings are important, he continued, because capillary malformations of the oral cavity may result in periodontal disease associated with gingival overgrowth. The depth of the gingival pocket should be no more than 2-3 mm. “When you have areas of inflammation and deep-pocket formation, plaque and bacteria slowly erode the connection between the tooth and the soft tissue,” he explained. “At some point, that pocket becomes so deep that it reaches down into the bone in which the tooth is anchored. As that bone is eroded, the teeth loosen and begin to fall out. The goals of therapy are prevention of periodontal disease with meticulous oral hygiene.”

Soft tissue hyperplasia may be exacerbated by medications such as calcium channel blockers, cyclosporine, and phenytoin and phenobarbital, which are sometimes used by patients with Sturge-Weber syndrome, he said.

Dr. Darrow reported having no financial disclosures.

[email protected]

CORONADO, CALIF. – Atraumatic embryo transfer is essential to success of in vitro fertilization (IVF), and ultrasound guidance maximizes the chance for this to occur, according to William Schoolcraft, MD, HCLD.

At a meeting on IVF and embryo transfer sponsored by the University of California, San Diego, Dr. Schoolcraft said that ultrasound-guided embryo transfer helps clinicians avoid difficult transfers, minimizes contamination with blood, facilitates proper placement of the catheter tip, and minimizes the stimulation of uterine contractions. “We know that contaminating the catheter either with blood or mucous or endometrial tissue lowers clinical pregnancy rates, compared to a clean catheter,” said Dr. Schoolcraft, founder and medical director of the Colorado Center for Reproductive Medicine, Denver.

“Ultrasound guidance can help you follow the contour of the cervix and avoid touching the fundus. Your catheter should be free of blood, mucous, or endometrial cells when the embryologist examines it,” he said. In his clinical opinion, it’s hard to argue against using ultrasound guidance for embryo transfer. “It’s also very popular with IVF patients, because they get to visualize the transfer and have some reassurance that the embryo is delivered to their uterus,” he said.

The potential benefit of using three-dimensional ultrasound for embryo transfer is less clear. “It does require more expensive equipment and it’s a little more skill dependent, but in a randomized trial it didn’t lead to any difference in outcomes,” Dr. Schoolcraft said. “I think if you’re good with two-dimensional ultrasound, three-dimensional ultrasound doesn’t seem to have much benefit in terms of pregnancy outcomes.”

In a study published in 2017, researchers from Barcelona analyzed 7,714 embryo transfers to determine the impact of maneuvers during embryo transfers on the pregnancy rate (Fertil Steril. 2017 Mar;107[3]:657-63.e1). Using the direct embryo transfer as a reference, each instrumentation needed to successfully deposit the embryos in the fundus served as an index of the difficulty of transfer. A difficult transfer occurred in 7.7% of cycles, and the researchers found that the clinical pregnancy rate decreased progressively with the use of additional maneuvers during embryo transfer. Specifically, the clinical pregnancy rate was 39.4% when no additional maneuvers were required, 36.9% when an outer catheter sheath was used (odds ratio, 0.89), 31.7% when a Wallace stylet was used (OR, 0.71), and 26.1% when a tenaculum was used (OR, 0.54). “I think without question, avoiding a difficult transfer is important and certainly a key to our success,” said Dr. Schoolcraft, who was not involved with the study.

The ideal depth of embryo transfer is “a bit complicated,” he said, but according to the best available evidence, a depth of 15-20 mm from the fundus by ultrasound guidance appears to optimize implantation by avoiding the lower cavity where implantation is compromised. This range of depth also avoids problems with upper cavity transfers, including trauma, contractions, and tubal pregnancy. “I think that transfers which are close to the fundus, and possibly in some cases touching the fundus, may lead to uterine contractions, plugging the catheter with endometrium and generating bleeding,” Dr. Schoolcraft said. He pointed out that during natural pregnancies, embryos implant in the upper fundus nearly 90% of the time, compared with 66% of the time during IVF pregnancies. “To mimic Mother Nature we don’t want to be too low, either,” he said. “We all know that placenta previa is increased with IVF. This may be due to placing the embryos too low.”

According to Dr. Schoolcraft, many published studies have found that significantly higher pregnancy rates occur with routine bladder distension prior to embryo transfer, probably because of the smooth and easy insertion of the embryo transfer. A Scandinavian meta-analysis found that the odds ratio favoring ultrasound guidance and a full bladder for ongoing pregnancy was 1.44 and clinical pregnancy was 1.55, which is similar to that seen during an earlier review from The Cochrane Collaborative, with an OR of 1.47 for ongoing pregnancy and OR 1.53 for live birth (Cochrane Database Syst Rev. 2016 Mar 17. doi: 10.1002/14651858.CD006107.pub4).

Dr. Schoolcraft reported having no financial disclosures.

[email protected]

CORONADO, CALIF. – Atraumatic embryo transfer is essential to success of in vitro fertilization (IVF), and ultrasound guidance maximizes the chance for this to occur, according to William Schoolcraft, MD, HCLD.

At a meeting on IVF and embryo transfer sponsored by the University of California, San Diego, Dr. Schoolcraft said that ultrasound-guided embryo transfer helps clinicians avoid difficult transfers, minimizes contamination with blood, facilitates proper placement of the catheter tip, and minimizes the stimulation of uterine contractions. “We know that contaminating the catheter either with blood or mucous or endometrial tissue lowers clinical pregnancy rates, compared to a clean catheter,” said Dr. Schoolcraft, founder and medical director of the Colorado Center for Reproductive Medicine, Denver.

“Ultrasound guidance can help you follow the contour of the cervix and avoid touching the fundus. Your catheter should be free of blood, mucous, or endometrial cells when the embryologist examines it,” he said. In his clinical opinion, it’s hard to argue against using ultrasound guidance for embryo transfer. “It’s also very popular with IVF patients, because they get to visualize the transfer and have some reassurance that the embryo is delivered to their uterus,” he said.

The potential benefit of using three-dimensional ultrasound for embryo transfer is less clear. “It does require more expensive equipment and it’s a little more skill dependent, but in a randomized trial it didn’t lead to any difference in outcomes,” Dr. Schoolcraft said. “I think if you’re good with two-dimensional ultrasound, three-dimensional ultrasound doesn’t seem to have much benefit in terms of pregnancy outcomes.”

In a study published in 2017, researchers from Barcelona analyzed 7,714 embryo transfers to determine the impact of maneuvers during embryo transfers on the pregnancy rate (Fertil Steril. 2017 Mar;107[3]:657-63.e1). Using the direct embryo transfer as a reference, each instrumentation needed to successfully deposit the embryos in the fundus served as an index of the difficulty of transfer. A difficult transfer occurred in 7.7% of cycles, and the researchers found that the clinical pregnancy rate decreased progressively with the use of additional maneuvers during embryo transfer. Specifically, the clinical pregnancy rate was 39.4% when no additional maneuvers were required, 36.9% when an outer catheter sheath was used (odds ratio, 0.89), 31.7% when a Wallace stylet was used (OR, 0.71), and 26.1% when a tenaculum was used (OR, 0.54). “I think without question, avoiding a difficult transfer is important and certainly a key to our success,” said Dr. Schoolcraft, who was not involved with the study.

The ideal depth of embryo transfer is “a bit complicated,” he said, but according to the best available evidence, a depth of 15-20 mm from the fundus by ultrasound guidance appears to optimize implantation by avoiding the lower cavity where implantation is compromised. This range of depth also avoids problems with upper cavity transfers, including trauma, contractions, and tubal pregnancy. “I think that transfers which are close to the fundus, and possibly in some cases touching the fundus, may lead to uterine contractions, plugging the catheter with endometrium and generating bleeding,” Dr. Schoolcraft said. He pointed out that during natural pregnancies, embryos implant in the upper fundus nearly 90% of the time, compared with 66% of the time during IVF pregnancies. “To mimic Mother Nature we don’t want to be too low, either,” he said. “We all know that placenta previa is increased with IVF. This may be due to placing the embryos too low.”

According to Dr. Schoolcraft, many published studies have found that significantly higher pregnancy rates occur with routine bladder distension prior to embryo transfer, probably because of the smooth and easy insertion of the embryo transfer. A Scandinavian meta-analysis found that the odds ratio favoring ultrasound guidance and a full bladder for ongoing pregnancy was 1.44 and clinical pregnancy was 1.55, which is similar to that seen during an earlier review from The Cochrane Collaborative, with an OR of 1.47 for ongoing pregnancy and OR 1.53 for live birth (Cochrane Database Syst Rev. 2016 Mar 17. doi: 10.1002/14651858.CD006107.pub4).

Dr. Schoolcraft reported having no financial disclosures.

[email protected]

CORONADO, CALIF. – Atraumatic embryo transfer is essential to success of in vitro fertilization (IVF), and ultrasound guidance maximizes the chance for this to occur, according to William Schoolcraft, MD, HCLD.

At a meeting on IVF and embryo transfer sponsored by the University of California, San Diego, Dr. Schoolcraft said that ultrasound-guided embryo transfer helps clinicians avoid difficult transfers, minimizes contamination with blood, facilitates proper placement of the catheter tip, and minimizes the stimulation of uterine contractions. “We know that contaminating the catheter either with blood or mucous or endometrial tissue lowers clinical pregnancy rates, compared to a clean catheter,” said Dr. Schoolcraft, founder and medical director of the Colorado Center for Reproductive Medicine, Denver.

“Ultrasound guidance can help you follow the contour of the cervix and avoid touching the fundus. Your catheter should be free of blood, mucous, or endometrial cells when the embryologist examines it,” he said. In his clinical opinion, it’s hard to argue against using ultrasound guidance for embryo transfer. “It’s also very popular with IVF patients, because they get to visualize the transfer and have some reassurance that the embryo is delivered to their uterus,” he said.

The potential benefit of using three-dimensional ultrasound for embryo transfer is less clear. “It does require more expensive equipment and it’s a little more skill dependent, but in a randomized trial it didn’t lead to any difference in outcomes,” Dr. Schoolcraft said. “I think if you’re good with two-dimensional ultrasound, three-dimensional ultrasound doesn’t seem to have much benefit in terms of pregnancy outcomes.”

In a study published in 2017, researchers from Barcelona analyzed 7,714 embryo transfers to determine the impact of maneuvers during embryo transfers on the pregnancy rate (Fertil Steril. 2017 Mar;107[3]:657-63.e1). Using the direct embryo transfer as a reference, each instrumentation needed to successfully deposit the embryos in the fundus served as an index of the difficulty of transfer. A difficult transfer occurred in 7.7% of cycles, and the researchers found that the clinical pregnancy rate decreased progressively with the use of additional maneuvers during embryo transfer. Specifically, the clinical pregnancy rate was 39.4% when no additional maneuvers were required, 36.9% when an outer catheter sheath was used (odds ratio, 0.89), 31.7% when a Wallace stylet was used (OR, 0.71), and 26.1% when a tenaculum was used (OR, 0.54). “I think without question, avoiding a difficult transfer is important and certainly a key to our success,” said Dr. Schoolcraft, who was not involved with the study.

The ideal depth of embryo transfer is “a bit complicated,” he said, but according to the best available evidence, a depth of 15-20 mm from the fundus by ultrasound guidance appears to optimize implantation by avoiding the lower cavity where implantation is compromised. This range of depth also avoids problems with upper cavity transfers, including trauma, contractions, and tubal pregnancy. “I think that transfers which are close to the fundus, and possibly in some cases touching the fundus, may lead to uterine contractions, plugging the catheter with endometrium and generating bleeding,” Dr. Schoolcraft said. He pointed out that during natural pregnancies, embryos implant in the upper fundus nearly 90% of the time, compared with 66% of the time during IVF pregnancies. “To mimic Mother Nature we don’t want to be too low, either,” he said. “We all know that placenta previa is increased with IVF. This may be due to placing the embryos too low.”

According to Dr. Schoolcraft, many published studies have found that significantly higher pregnancy rates occur with routine bladder distension prior to embryo transfer, probably because of the smooth and easy insertion of the embryo transfer. A Scandinavian meta-analysis found that the odds ratio favoring ultrasound guidance and a full bladder for ongoing pregnancy was 1.44 and clinical pregnancy was 1.55, which is similar to that seen during an earlier review from The Cochrane Collaborative, with an OR of 1.47 for ongoing pregnancy and OR 1.53 for live birth (Cochrane Database Syst Rev. 2016 Mar 17. doi: 10.1002/14651858.CD006107.pub4).

Dr. Schoolcraft reported having no financial disclosures.

[email protected]

LAKE TAHOE, CALIF. – Evaluation of an infant with a vesiculopustular lesion entails a pragmatic approach, with three assessment steps, according to pediatric dermatologist Lawrence A. Schachner, MD.

At the annual meeting of the Society for Pediatric Dermatology, Dr. Schachner noted that the differential diagnosis of noninfectious, usually benign neonatal vesiculopustular lesions includes acropustulosis of infancy; eosinophilic pustular folliculitis; erythema toxicum neonatorum; miliaria crystallina, rubra, or profunda; transient neonatal pustular melanosis; and neonatal sucking blisters. Noninfectious lesions that can be potentially serious include acrodermatitis enteropathica, bullous pemphigoid, epidermolysis bullosa, epidermolytic hyperkeratosis, incontinentia pigmenti, Langerhans cell histiocytosis, pemphigus vulgaris, pustular psoriasis, and urticarial pigmentosa.

Step 1 for evaluating vesiculopustular lesions involves drawing out the fluid for bacterial cultures and sensitivity, Gram stains, viral culture and/or serology, said Dr. Schachner, who directs the division of pediatric dermatology at the University of Miami.

Step 2 involves snipping off the lesion’s roof for a potassium hydroxide test to send for dermatopathology or frozen pathology.

Step 3 involves scraping the lesion’s base for viral cytology and cell identification. “If we can see a predominant cell type, that’s where the action is,” said Dr. Schachner, professor of pediatrics at the university. If cytology reveals polymorphic neutrophils, differential diagnoses include transient neonatal pustular melanosis, infantile acropustulosis, bullous impetigo, and pustular psoriasis. If cytology reveals eosinophils, differential diagnoses include eosinophilic pustular folliculitis of infancy, erythema toxicum neonatorum, incontinentia pigmenti, bullous pemphigoid, drug reactions, and arthropod bites. The presence of lymphocytes on cytology, meanwhile, may suggest a differential diagnosis miliaria or acrodermatitis enteropathica.

“When in doubt about the diagnosis, biopsy,” Dr. Schachner said. “This, to me, is a pragmatic approach.”

Dr. Schachner disclosed that he is an investigator for Astellas, Ferndale Labs, Novartis, Organogenesis, Stiefel Laboratories, Berg Pharma, Medimetrics, and Lilly. He is a consultant to Beiersdorf, Lexington, TopMD, Cutanea, Hoth Therapeutics, and Mustela.

[email protected]

LAKE TAHOE, CALIF. – Evaluation of an infant with a vesiculopustular lesion entails a pragmatic approach, with three assessment steps, according to pediatric dermatologist Lawrence A. Schachner, MD.

At the annual meeting of the Society for Pediatric Dermatology, Dr. Schachner noted that the differential diagnosis of noninfectious, usually benign neonatal vesiculopustular lesions includes acropustulosis of infancy; eosinophilic pustular folliculitis; erythema toxicum neonatorum; miliaria crystallina, rubra, or profunda; transient neonatal pustular melanosis; and neonatal sucking blisters. Noninfectious lesions that can be potentially serious include acrodermatitis enteropathica, bullous pemphigoid, epidermolysis bullosa, epidermolytic hyperkeratosis, incontinentia pigmenti, Langerhans cell histiocytosis, pemphigus vulgaris, pustular psoriasis, and urticarial pigmentosa.

Step 1 for evaluating vesiculopustular lesions involves drawing out the fluid for bacterial cultures and sensitivity, Gram stains, viral culture and/or serology, said Dr. Schachner, who directs the division of pediatric dermatology at the University of Miami.

Step 2 involves snipping off the lesion’s roof for a potassium hydroxide test to send for dermatopathology or frozen pathology.

Step 3 involves scraping the lesion’s base for viral cytology and cell identification. “If we can see a predominant cell type, that’s where the action is,” said Dr. Schachner, professor of pediatrics at the university. If cytology reveals polymorphic neutrophils, differential diagnoses include transient neonatal pustular melanosis, infantile acropustulosis, bullous impetigo, and pustular psoriasis. If cytology reveals eosinophils, differential diagnoses include eosinophilic pustular folliculitis of infancy, erythema toxicum neonatorum, incontinentia pigmenti, bullous pemphigoid, drug reactions, and arthropod bites. The presence of lymphocytes on cytology, meanwhile, may suggest a differential diagnosis miliaria or acrodermatitis enteropathica.

“When in doubt about the diagnosis, biopsy,” Dr. Schachner said. “This, to me, is a pragmatic approach.”

Dr. Schachner disclosed that he is an investigator for Astellas, Ferndale Labs, Novartis, Organogenesis, Stiefel Laboratories, Berg Pharma, Medimetrics, and Lilly. He is a consultant to Beiersdorf, Lexington, TopMD, Cutanea, Hoth Therapeutics, and Mustela.

[email protected]

LAKE TAHOE, CALIF. – Evaluation of an infant with a vesiculopustular lesion entails a pragmatic approach, with three assessment steps, according to pediatric dermatologist Lawrence A. Schachner, MD.

At the annual meeting of the Society for Pediatric Dermatology, Dr. Schachner noted that the differential diagnosis of noninfectious, usually benign neonatal vesiculopustular lesions includes acropustulosis of infancy; eosinophilic pustular folliculitis; erythema toxicum neonatorum; miliaria crystallina, rubra, or profunda; transient neonatal pustular melanosis; and neonatal sucking blisters. Noninfectious lesions that can be potentially serious include acrodermatitis enteropathica, bullous pemphigoid, epidermolysis bullosa, epidermolytic hyperkeratosis, incontinentia pigmenti, Langerhans cell histiocytosis, pemphigus vulgaris, pustular psoriasis, and urticarial pigmentosa.

Step 1 for evaluating vesiculopustular lesions involves drawing out the fluid for bacterial cultures and sensitivity, Gram stains, viral culture and/or serology, said Dr. Schachner, who directs the division of pediatric dermatology at the University of Miami.

Step 2 involves snipping off the lesion’s roof for a potassium hydroxide test to send for dermatopathology or frozen pathology.

Step 3 involves scraping the lesion’s base for viral cytology and cell identification. “If we can see a predominant cell type, that’s where the action is,” said Dr. Schachner, professor of pediatrics at the university. If cytology reveals polymorphic neutrophils, differential diagnoses include transient neonatal pustular melanosis, infantile acropustulosis, bullous impetigo, and pustular psoriasis. If cytology reveals eosinophils, differential diagnoses include eosinophilic pustular folliculitis of infancy, erythema toxicum neonatorum, incontinentia pigmenti, bullous pemphigoid, drug reactions, and arthropod bites. The presence of lymphocytes on cytology, meanwhile, may suggest a differential diagnosis miliaria or acrodermatitis enteropathica.

“When in doubt about the diagnosis, biopsy,” Dr. Schachner said. “This, to me, is a pragmatic approach.”

Dr. Schachner disclosed that he is an investigator for Astellas, Ferndale Labs, Novartis, Organogenesis, Stiefel Laboratories, Berg Pharma, Medimetrics, and Lilly. He is a consultant to Beiersdorf, Lexington, TopMD, Cutanea, Hoth Therapeutics, and Mustela.

[email protected]