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Doug Brunk is a San Diego-based award-winning reporter who began covering health care in 1991. Before joining the company, he wrote for the health sciences division of Columbia University and was an associate editor at Contemporary Long Term Care magazine when it won a Jesse H. Neal Award. His work has been syndicated by the Los Angeles Times and he is the author of two books related to the University of Kentucky Wildcats men's basketball program. Doug has a master’s degree in magazine journalism from the S.I. Newhouse School of Public Communications at Syracuse University. Follow him on Twitter @dougbrunk.
What should you tell your patients about the risks of ART?
CORONADO, CALIF. –
In addition, multiples conceived using ART – including twins – continue to be the biggest preventable risk factor for adverse pregnancy and fetal outcomes.
Those are key points that Joseph C. Gambone, DO, MPH, made during a wide-ranging talk about the adverse pregnancy and fetal outcomes related to ART at a meeting on in vitro fertilization (IVF) and embryo transfer sponsored by the University of California, San Diego.
In 2016, Barbara Luke, ScD, MPH, and her colleagues published results from the ongoing Massachusetts Outcomes Study of Reproductive Technologies (J Reprod Med. 2016 Mar-Apr;61[3-4]:114-27). They found that pregnancy plurality is the predominant risk factor for infants and mothers. Of 8,948 birth outcomes resulting from ART, risks for pregnancy-induced hypertension, cesarean delivery, gestational diabetes, preterm birth, birth defects, and small for gestational age were significantly increased among twins.
“Lowering the plurality rate, including twins, should substantially reduce morbidity with ART,” said Dr. Gambone, professor emeritus at the David Geffen School of Medicine at the University of California, Los Angeles, who was not affiliated with the study. Thawed embryos were associated with a higher risk for pregnancy-induced hypertension and large for gestational age offspring, but a lower risk for low birth weight and small for gestational age.
According to data from the Society for Assisted Reproductive Technology, elective singleton embryo transfer increased from 35% of all cycles in 2015 to 42% in 2016, while singleton births increased from 80.5% to 84% during the same time period. In addition, the proportion of twins born in 2015 was 19% and declined to 16% in 2016, while the percentage of triplets or greater born was the same in both years (0.4%).
Meanwhile, in an analysis of more than 1.1 million cycles between 2000 and 2011 drawn from Centers for Disease Control and Prevention surveillance data, researchers found that the most commonly reported patient complication was ovarian hyperstimulation syndrome (a peak of 154 per 10,000 autologous cycles) and hospitalization (a peak of 35 per 10,000 autologous cycles; JAMA. 2015 Jan 6;313[1]:88-90). Other complications remained below 10 per 10,000 cycles and included infection, hemorrhage with transfusion, adverse event from medication, adverse event to anesthesia, and patient death. In all, 58 deaths were reported: 18 because of stimulation and 40 during pregnancy. “Some deaths were due to potentially preventable complications because of unrecognized comorbidities or conditions,” said Dr. Gambone, who was not affiliated with the study. “Women with Turner syndrome who receive donor embryos could be an example.”
Today, the most feared maternal and pregnancy outcome from ART is breast and ovarian cancer from treatment, he said, while the most feared outcome in offspring is birth defects from treatment. On the breast cancer front, an analysis of nearly 2 million women provided some reassurance (Fertil Steril. 2017 Jul;108:137-44). It found no increased risk of breast cancer in women who have birth after ART, compared with women who gave birth after spontaneous conception (adjusted hazard ratio, 0.84). It also found no increased risk in women who received ovarian stimulation or other hormonal treatment for infertility (HRs, 0.86 and 0.79, respectively). A smaller study with a median follow-up of 21 years found no difference in the rate of invasive and in situ breast cancer between women who received IVF treatment and those who did not (JAMA. 2016 Jul 19;316[3]:300-12). However, a recent analysis from Great Britain found a slight increase for in situ breast cancer that was associated with women who had a higher number of treatment cycles (BMJ. 2018;362:k2644).
On the ovarian cancer front, a case-control analysis of 1,900 women conducted by researchers at Mayo Clinic found that infertile women who used fertility drugs were not at increased risk of developing ovarian tumors, compared with infertile women who did not use fertility drugs (adjusted odds ratio, 0.64; Fertil Steril. 2013;99[7]:2031-6). There also was no increased risk because of underlying infertility or any increase in borderline tumors. More recently, an abstract presented at the annual meeting of the European Society of Human Reproduction and Embryology, based on a large cohort study from Denmark, found a slightly higher overall risk of ovarian cancer among the ART women (0.11%), compared with non-ART controls (0.06%). However, the analysis also showed comparably higher rates of ovarian cancer in women who were nulliparous (a risk factor for ovarian cancer) and in the ART women who had a female cause of infertility. In an analysis from Great Britain, increased ovarian tumor risk was limited to women with endometriosis, low parity, or both (BMJ. 2018;362:k2644). Dr. Gambone noted that an article published online Oct. 23, 2017 in Nature Communication implicates the fallopian tube, rather than the ovaries, as a probable source of papillary serous cancers.
Women who are subfertile should be counseled about the increased risk of birth defects, irrespective of whether they undergo IVF or not, said Dr. Gambone, who also runs a private infertility practice in Durango, Colo. Studies consistently show an increased risk associated with subfertility. A large, retrospective cohort analysis of live and stillbirths from 2004 to 2010 in Massachusetts found that congenital anomalies were reported in 2% of ART births, 1.7% of subfertile births, and 1.4% of fertile births (Birth Defects Res. 2017 Aug 15;109[14]:1144-53). The adjusted prevalence ratios for birth defects were 1.5 for ART births and 1.3 for subfertile births, compared with fertile mother births. The researchers observed elevated rates of several birth defects with ART, including tetralogy of Fallot and hypospadias. Subfertility and multiple births affect these associations, with multiple births explaining 36% of the relative effect of ART on nonchromosomal birth defects.
“The absolute risk of birth defects is small with ART,” Dr. Gambone said. “A significant portion [but not all] is related to multiple births and underlying subfertility.” A more recent analysis found that subfertile women were 21% more likely to have babies born with birth defects, compared with fertile women (Pediatrics. 2018 Jul; e20174069).
In a study of the overall risk and etiology of major birth defects, researchers from Utah determined that they affect 1 in 33 babies in the United States at an annual direct cost of $2.6 billion per year (BMJ. 2017;357:j2249). Although major birth defects are the leading cause of infant mortality (20%), a known cause of the defect was established in only 20.2% of cases. “Of that percentage, the majority are chromosome or genetic causes,” Dr. Gambone said. “Interestingly, ART and/or subfertility were not listed in this analysis as causes of birth defects. However, the authors speculated that as genetic technology improves, both genetic and epigenetic causes will be identified.”
Dr. Gambone reported no relevant financial disclosures.
[email protected]
CORONADO, CALIF. –
In addition, multiples conceived using ART – including twins – continue to be the biggest preventable risk factor for adverse pregnancy and fetal outcomes.
Those are key points that Joseph C. Gambone, DO, MPH, made during a wide-ranging talk about the adverse pregnancy and fetal outcomes related to ART at a meeting on in vitro fertilization (IVF) and embryo transfer sponsored by the University of California, San Diego.
In 2016, Barbara Luke, ScD, MPH, and her colleagues published results from the ongoing Massachusetts Outcomes Study of Reproductive Technologies (J Reprod Med. 2016 Mar-Apr;61[3-4]:114-27). They found that pregnancy plurality is the predominant risk factor for infants and mothers. Of 8,948 birth outcomes resulting from ART, risks for pregnancy-induced hypertension, cesarean delivery, gestational diabetes, preterm birth, birth defects, and small for gestational age were significantly increased among twins.
“Lowering the plurality rate, including twins, should substantially reduce morbidity with ART,” said Dr. Gambone, professor emeritus at the David Geffen School of Medicine at the University of California, Los Angeles, who was not affiliated with the study. Thawed embryos were associated with a higher risk for pregnancy-induced hypertension and large for gestational age offspring, but a lower risk for low birth weight and small for gestational age.
According to data from the Society for Assisted Reproductive Technology, elective singleton embryo transfer increased from 35% of all cycles in 2015 to 42% in 2016, while singleton births increased from 80.5% to 84% during the same time period. In addition, the proportion of twins born in 2015 was 19% and declined to 16% in 2016, while the percentage of triplets or greater born was the same in both years (0.4%).
Meanwhile, in an analysis of more than 1.1 million cycles between 2000 and 2011 drawn from Centers for Disease Control and Prevention surveillance data, researchers found that the most commonly reported patient complication was ovarian hyperstimulation syndrome (a peak of 154 per 10,000 autologous cycles) and hospitalization (a peak of 35 per 10,000 autologous cycles; JAMA. 2015 Jan 6;313[1]:88-90). Other complications remained below 10 per 10,000 cycles and included infection, hemorrhage with transfusion, adverse event from medication, adverse event to anesthesia, and patient death. In all, 58 deaths were reported: 18 because of stimulation and 40 during pregnancy. “Some deaths were due to potentially preventable complications because of unrecognized comorbidities or conditions,” said Dr. Gambone, who was not affiliated with the study. “Women with Turner syndrome who receive donor embryos could be an example.”
Today, the most feared maternal and pregnancy outcome from ART is breast and ovarian cancer from treatment, he said, while the most feared outcome in offspring is birth defects from treatment. On the breast cancer front, an analysis of nearly 2 million women provided some reassurance (Fertil Steril. 2017 Jul;108:137-44). It found no increased risk of breast cancer in women who have birth after ART, compared with women who gave birth after spontaneous conception (adjusted hazard ratio, 0.84). It also found no increased risk in women who received ovarian stimulation or other hormonal treatment for infertility (HRs, 0.86 and 0.79, respectively). A smaller study with a median follow-up of 21 years found no difference in the rate of invasive and in situ breast cancer between women who received IVF treatment and those who did not (JAMA. 2016 Jul 19;316[3]:300-12). However, a recent analysis from Great Britain found a slight increase for in situ breast cancer that was associated with women who had a higher number of treatment cycles (BMJ. 2018;362:k2644).
On the ovarian cancer front, a case-control analysis of 1,900 women conducted by researchers at Mayo Clinic found that infertile women who used fertility drugs were not at increased risk of developing ovarian tumors, compared with infertile women who did not use fertility drugs (adjusted odds ratio, 0.64; Fertil Steril. 2013;99[7]:2031-6). There also was no increased risk because of underlying infertility or any increase in borderline tumors. More recently, an abstract presented at the annual meeting of the European Society of Human Reproduction and Embryology, based on a large cohort study from Denmark, found a slightly higher overall risk of ovarian cancer among the ART women (0.11%), compared with non-ART controls (0.06%). However, the analysis also showed comparably higher rates of ovarian cancer in women who were nulliparous (a risk factor for ovarian cancer) and in the ART women who had a female cause of infertility. In an analysis from Great Britain, increased ovarian tumor risk was limited to women with endometriosis, low parity, or both (BMJ. 2018;362:k2644). Dr. Gambone noted that an article published online Oct. 23, 2017 in Nature Communication implicates the fallopian tube, rather than the ovaries, as a probable source of papillary serous cancers.
Women who are subfertile should be counseled about the increased risk of birth defects, irrespective of whether they undergo IVF or not, said Dr. Gambone, who also runs a private infertility practice in Durango, Colo. Studies consistently show an increased risk associated with subfertility. A large, retrospective cohort analysis of live and stillbirths from 2004 to 2010 in Massachusetts found that congenital anomalies were reported in 2% of ART births, 1.7% of subfertile births, and 1.4% of fertile births (Birth Defects Res. 2017 Aug 15;109[14]:1144-53). The adjusted prevalence ratios for birth defects were 1.5 for ART births and 1.3 for subfertile births, compared with fertile mother births. The researchers observed elevated rates of several birth defects with ART, including tetralogy of Fallot and hypospadias. Subfertility and multiple births affect these associations, with multiple births explaining 36% of the relative effect of ART on nonchromosomal birth defects.
“The absolute risk of birth defects is small with ART,” Dr. Gambone said. “A significant portion [but not all] is related to multiple births and underlying subfertility.” A more recent analysis found that subfertile women were 21% more likely to have babies born with birth defects, compared with fertile women (Pediatrics. 2018 Jul; e20174069).
In a study of the overall risk and etiology of major birth defects, researchers from Utah determined that they affect 1 in 33 babies in the United States at an annual direct cost of $2.6 billion per year (BMJ. 2017;357:j2249). Although major birth defects are the leading cause of infant mortality (20%), a known cause of the defect was established in only 20.2% of cases. “Of that percentage, the majority are chromosome or genetic causes,” Dr. Gambone said. “Interestingly, ART and/or subfertility were not listed in this analysis as causes of birth defects. However, the authors speculated that as genetic technology improves, both genetic and epigenetic causes will be identified.”
Dr. Gambone reported no relevant financial disclosures.
[email protected]
CORONADO, CALIF. –
In addition, multiples conceived using ART – including twins – continue to be the biggest preventable risk factor for adverse pregnancy and fetal outcomes.
Those are key points that Joseph C. Gambone, DO, MPH, made during a wide-ranging talk about the adverse pregnancy and fetal outcomes related to ART at a meeting on in vitro fertilization (IVF) and embryo transfer sponsored by the University of California, San Diego.
In 2016, Barbara Luke, ScD, MPH, and her colleagues published results from the ongoing Massachusetts Outcomes Study of Reproductive Technologies (J Reprod Med. 2016 Mar-Apr;61[3-4]:114-27). They found that pregnancy plurality is the predominant risk factor for infants and mothers. Of 8,948 birth outcomes resulting from ART, risks for pregnancy-induced hypertension, cesarean delivery, gestational diabetes, preterm birth, birth defects, and small for gestational age were significantly increased among twins.
“Lowering the plurality rate, including twins, should substantially reduce morbidity with ART,” said Dr. Gambone, professor emeritus at the David Geffen School of Medicine at the University of California, Los Angeles, who was not affiliated with the study. Thawed embryos were associated with a higher risk for pregnancy-induced hypertension and large for gestational age offspring, but a lower risk for low birth weight and small for gestational age.
According to data from the Society for Assisted Reproductive Technology, elective singleton embryo transfer increased from 35% of all cycles in 2015 to 42% in 2016, while singleton births increased from 80.5% to 84% during the same time period. In addition, the proportion of twins born in 2015 was 19% and declined to 16% in 2016, while the percentage of triplets or greater born was the same in both years (0.4%).
Meanwhile, in an analysis of more than 1.1 million cycles between 2000 and 2011 drawn from Centers for Disease Control and Prevention surveillance data, researchers found that the most commonly reported patient complication was ovarian hyperstimulation syndrome (a peak of 154 per 10,000 autologous cycles) and hospitalization (a peak of 35 per 10,000 autologous cycles; JAMA. 2015 Jan 6;313[1]:88-90). Other complications remained below 10 per 10,000 cycles and included infection, hemorrhage with transfusion, adverse event from medication, adverse event to anesthesia, and patient death. In all, 58 deaths were reported: 18 because of stimulation and 40 during pregnancy. “Some deaths were due to potentially preventable complications because of unrecognized comorbidities or conditions,” said Dr. Gambone, who was not affiliated with the study. “Women with Turner syndrome who receive donor embryos could be an example.”
Today, the most feared maternal and pregnancy outcome from ART is breast and ovarian cancer from treatment, he said, while the most feared outcome in offspring is birth defects from treatment. On the breast cancer front, an analysis of nearly 2 million women provided some reassurance (Fertil Steril. 2017 Jul;108:137-44). It found no increased risk of breast cancer in women who have birth after ART, compared with women who gave birth after spontaneous conception (adjusted hazard ratio, 0.84). It also found no increased risk in women who received ovarian stimulation or other hormonal treatment for infertility (HRs, 0.86 and 0.79, respectively). A smaller study with a median follow-up of 21 years found no difference in the rate of invasive and in situ breast cancer between women who received IVF treatment and those who did not (JAMA. 2016 Jul 19;316[3]:300-12). However, a recent analysis from Great Britain found a slight increase for in situ breast cancer that was associated with women who had a higher number of treatment cycles (BMJ. 2018;362:k2644).
On the ovarian cancer front, a case-control analysis of 1,900 women conducted by researchers at Mayo Clinic found that infertile women who used fertility drugs were not at increased risk of developing ovarian tumors, compared with infertile women who did not use fertility drugs (adjusted odds ratio, 0.64; Fertil Steril. 2013;99[7]:2031-6). There also was no increased risk because of underlying infertility or any increase in borderline tumors. More recently, an abstract presented at the annual meeting of the European Society of Human Reproduction and Embryology, based on a large cohort study from Denmark, found a slightly higher overall risk of ovarian cancer among the ART women (0.11%), compared with non-ART controls (0.06%). However, the analysis also showed comparably higher rates of ovarian cancer in women who were nulliparous (a risk factor for ovarian cancer) and in the ART women who had a female cause of infertility. In an analysis from Great Britain, increased ovarian tumor risk was limited to women with endometriosis, low parity, or both (BMJ. 2018;362:k2644). Dr. Gambone noted that an article published online Oct. 23, 2017 in Nature Communication implicates the fallopian tube, rather than the ovaries, as a probable source of papillary serous cancers.
Women who are subfertile should be counseled about the increased risk of birth defects, irrespective of whether they undergo IVF or not, said Dr. Gambone, who also runs a private infertility practice in Durango, Colo. Studies consistently show an increased risk associated with subfertility. A large, retrospective cohort analysis of live and stillbirths from 2004 to 2010 in Massachusetts found that congenital anomalies were reported in 2% of ART births, 1.7% of subfertile births, and 1.4% of fertile births (Birth Defects Res. 2017 Aug 15;109[14]:1144-53). The adjusted prevalence ratios for birth defects were 1.5 for ART births and 1.3 for subfertile births, compared with fertile mother births. The researchers observed elevated rates of several birth defects with ART, including tetralogy of Fallot and hypospadias. Subfertility and multiple births affect these associations, with multiple births explaining 36% of the relative effect of ART on nonchromosomal birth defects.
“The absolute risk of birth defects is small with ART,” Dr. Gambone said. “A significant portion [but not all] is related to multiple births and underlying subfertility.” A more recent analysis found that subfertile women were 21% more likely to have babies born with birth defects, compared with fertile women (Pediatrics. 2018 Jul; e20174069).
In a study of the overall risk and etiology of major birth defects, researchers from Utah determined that they affect 1 in 33 babies in the United States at an annual direct cost of $2.6 billion per year (BMJ. 2017;357:j2249). Although major birth defects are the leading cause of infant mortality (20%), a known cause of the defect was established in only 20.2% of cases. “Of that percentage, the majority are chromosome or genetic causes,” Dr. Gambone said. “Interestingly, ART and/or subfertility were not listed in this analysis as causes of birth defects. However, the authors speculated that as genetic technology improves, both genetic and epigenetic causes will be identified.”
Dr. Gambone reported no relevant financial disclosures.
[email protected]
EXPERT ANALYSIS FROM A CME MEETING SPONSORED BY UCSD
Immunosuppression often triggers skin side effects
LAKE TAHOE, CALIF. – , and side effects of vemurafenib treatment.
In a presentation on the cutaneous sequelae of different immunosuppressive regimens at the annual meeting of the Society for Pediatric Dermatology, Carrie C. Coughlin, MD, opened with a discussion of AD triggered by the tumor necrosis factor (TNF) blocker infliximab, especially in the setting of therapy for Crohn’s disease. “In this patient population you often think of psoriasis as a consequence of infliximab and other TNF therapies,” said Dr. Coughlin, a pediatric dermatologist at Washington University, St. Louis. “But you can also get true atopic dermatitis with infliximab as well. Who’s more at risk for this? Patients with Crohn’s disease seem to be. Most of the literature is in adults, but there are a few series of children. In a series of children looking at cutaneous sequelae of infliximab therapy, about 20% of cutaneous eruptions were atopic dermatitis. I think it’s a great opportunity for us in dermatology to do a more research in this area.”
Some researchers have proposed that atopic disease could be a marker of over-suppression of TNF-alpha in young Crohn’s disease patients on infliximab (Inflamm Bowel Dis. 2014; 20[8]:1309-15). “One question you could ask is, could these patients actually tolerate a dose reduction?” Dr. Coughlin said. She promoted the role of dermatologists in working at managing side effects to keep patients on medications helping their GI disease, but acknowledged this is not always possible.
Atopic disease can also occur after a solid organ transplant. In fact, the incidence of new-onset food allergies after a liver transplant is 6%-30% of cases, mainly in young patients (Pediatr Transplant. 2009;13[1]:63-9, Pediatr Transplant 2013;17[3]:251-5). “There are some mechanisms, including liver presentation of antigens, that spread through portal veins that could potentially put people at risk who have liver dysfunction,” Dr. Coughlin explained. “They could potentially have a higher risk for food allergies and AD. There is also some thought that tacrolimus potentially predisposes patients to having atopic dermatitis and atopy after their transplant. When you look at the mechanism of action of tacrolimus, you see increased levels of IL-5, IL-13, and skewing of IgE levels.”
Dr. Coughlin also discussed the possibilities of development of AD after transplant being a delayed presentation of an allergic sensitization that patients already had. Younger patients are at higher risk for AD post transplant. The renal transplant population, meanwhile, generally receives the transplant at a later age, “so they may not have that delay in terms of presentation; they may have already had their allergies and grown out of them by the time they’re getting their transplant,” she said. “I think there’s more for us to investigate.”
Solid organ transplant recipients also face an increased risk of skin cancer as a long-term side effect of immunosuppressive therapy. Risk factors include fair skin, sun exposure, and remote time from transplant. “Time from transplant is a risk factor,” Dr. Coughlin said. “Longer time on immunosuppression could predispose you to a risk for skin cancer. Our patients are living longer post transplant than they used to, so they have more potential years to develop their skin cancers.” She focused on the importance of educating transplant recipients and families early about photoprotection. “It’s interesting to think about how we can continue to intervene early on to continue to decrease risk.”
Young patients exposed to voriconazole also face an increased risk for skin cancer. “We know that longer-term dosing and higher cumulative dosing puts you at higher risk,” she said. Lung transplant recipients, who are often more likely to be treated with voriconazole, are thus at higher risk.
Dr. Coughlin ended her presentation by noting that side effects of the BRAF inhibitor vemurafenib (Zelboraf) used to treat advanced melanoma in children are similar to, but not the same as, those in adults. “We see BRAF mutations in multiple different tumor types: Langerhans cell histiocytosis, gliomas, and melanoma,” she said. “Trials of vemurafenib and dabrafenib are under way in the pediatric population. Vemurafenib can cause keratosis pilaris, panniculitis, alopecia, and granulomatous dermatitis.” In her experience, she has seen more alopecia in the older teenage population, but younger patients may not be asked about this side effect as frequently.
She counsels patients to expect keratosis pilaris–like eruptions and to take sun protection seriously. “It’s important to emphasize that each time they come in,” Dr. Coughlin said. She also discussed the potential for changing nevi and treatment options for vemurafenib-associated panniculitis.
Dr. Coughlin disclosed that she is the recipient of active pilot grants from the Pediatric Dermatology Research Alliance and the SPD.
LAKE TAHOE, CALIF. – , and side effects of vemurafenib treatment.
In a presentation on the cutaneous sequelae of different immunosuppressive regimens at the annual meeting of the Society for Pediatric Dermatology, Carrie C. Coughlin, MD, opened with a discussion of AD triggered by the tumor necrosis factor (TNF) blocker infliximab, especially in the setting of therapy for Crohn’s disease. “In this patient population you often think of psoriasis as a consequence of infliximab and other TNF therapies,” said Dr. Coughlin, a pediatric dermatologist at Washington University, St. Louis. “But you can also get true atopic dermatitis with infliximab as well. Who’s more at risk for this? Patients with Crohn’s disease seem to be. Most of the literature is in adults, but there are a few series of children. In a series of children looking at cutaneous sequelae of infliximab therapy, about 20% of cutaneous eruptions were atopic dermatitis. I think it’s a great opportunity for us in dermatology to do a more research in this area.”
Some researchers have proposed that atopic disease could be a marker of over-suppression of TNF-alpha in young Crohn’s disease patients on infliximab (Inflamm Bowel Dis. 2014; 20[8]:1309-15). “One question you could ask is, could these patients actually tolerate a dose reduction?” Dr. Coughlin said. She promoted the role of dermatologists in working at managing side effects to keep patients on medications helping their GI disease, but acknowledged this is not always possible.
Atopic disease can also occur after a solid organ transplant. In fact, the incidence of new-onset food allergies after a liver transplant is 6%-30% of cases, mainly in young patients (Pediatr Transplant. 2009;13[1]:63-9, Pediatr Transplant 2013;17[3]:251-5). “There are some mechanisms, including liver presentation of antigens, that spread through portal veins that could potentially put people at risk who have liver dysfunction,” Dr. Coughlin explained. “They could potentially have a higher risk for food allergies and AD. There is also some thought that tacrolimus potentially predisposes patients to having atopic dermatitis and atopy after their transplant. When you look at the mechanism of action of tacrolimus, you see increased levels of IL-5, IL-13, and skewing of IgE levels.”
Dr. Coughlin also discussed the possibilities of development of AD after transplant being a delayed presentation of an allergic sensitization that patients already had. Younger patients are at higher risk for AD post transplant. The renal transplant population, meanwhile, generally receives the transplant at a later age, “so they may not have that delay in terms of presentation; they may have already had their allergies and grown out of them by the time they’re getting their transplant,” she said. “I think there’s more for us to investigate.”
Solid organ transplant recipients also face an increased risk of skin cancer as a long-term side effect of immunosuppressive therapy. Risk factors include fair skin, sun exposure, and remote time from transplant. “Time from transplant is a risk factor,” Dr. Coughlin said. “Longer time on immunosuppression could predispose you to a risk for skin cancer. Our patients are living longer post transplant than they used to, so they have more potential years to develop their skin cancers.” She focused on the importance of educating transplant recipients and families early about photoprotection. “It’s interesting to think about how we can continue to intervene early on to continue to decrease risk.”
Young patients exposed to voriconazole also face an increased risk for skin cancer. “We know that longer-term dosing and higher cumulative dosing puts you at higher risk,” she said. Lung transplant recipients, who are often more likely to be treated with voriconazole, are thus at higher risk.
Dr. Coughlin ended her presentation by noting that side effects of the BRAF inhibitor vemurafenib (Zelboraf) used to treat advanced melanoma in children are similar to, but not the same as, those in adults. “We see BRAF mutations in multiple different tumor types: Langerhans cell histiocytosis, gliomas, and melanoma,” she said. “Trials of vemurafenib and dabrafenib are under way in the pediatric population. Vemurafenib can cause keratosis pilaris, panniculitis, alopecia, and granulomatous dermatitis.” In her experience, she has seen more alopecia in the older teenage population, but younger patients may not be asked about this side effect as frequently.
She counsels patients to expect keratosis pilaris–like eruptions and to take sun protection seriously. “It’s important to emphasize that each time they come in,” Dr. Coughlin said. She also discussed the potential for changing nevi and treatment options for vemurafenib-associated panniculitis.
Dr. Coughlin disclosed that she is the recipient of active pilot grants from the Pediatric Dermatology Research Alliance and the SPD.
LAKE TAHOE, CALIF. – , and side effects of vemurafenib treatment.
In a presentation on the cutaneous sequelae of different immunosuppressive regimens at the annual meeting of the Society for Pediatric Dermatology, Carrie C. Coughlin, MD, opened with a discussion of AD triggered by the tumor necrosis factor (TNF) blocker infliximab, especially in the setting of therapy for Crohn’s disease. “In this patient population you often think of psoriasis as a consequence of infliximab and other TNF therapies,” said Dr. Coughlin, a pediatric dermatologist at Washington University, St. Louis. “But you can also get true atopic dermatitis with infliximab as well. Who’s more at risk for this? Patients with Crohn’s disease seem to be. Most of the literature is in adults, but there are a few series of children. In a series of children looking at cutaneous sequelae of infliximab therapy, about 20% of cutaneous eruptions were atopic dermatitis. I think it’s a great opportunity for us in dermatology to do a more research in this area.”
Some researchers have proposed that atopic disease could be a marker of over-suppression of TNF-alpha in young Crohn’s disease patients on infliximab (Inflamm Bowel Dis. 2014; 20[8]:1309-15). “One question you could ask is, could these patients actually tolerate a dose reduction?” Dr. Coughlin said. She promoted the role of dermatologists in working at managing side effects to keep patients on medications helping their GI disease, but acknowledged this is not always possible.
Atopic disease can also occur after a solid organ transplant. In fact, the incidence of new-onset food allergies after a liver transplant is 6%-30% of cases, mainly in young patients (Pediatr Transplant. 2009;13[1]:63-9, Pediatr Transplant 2013;17[3]:251-5). “There are some mechanisms, including liver presentation of antigens, that spread through portal veins that could potentially put people at risk who have liver dysfunction,” Dr. Coughlin explained. “They could potentially have a higher risk for food allergies and AD. There is also some thought that tacrolimus potentially predisposes patients to having atopic dermatitis and atopy after their transplant. When you look at the mechanism of action of tacrolimus, you see increased levels of IL-5, IL-13, and skewing of IgE levels.”
Dr. Coughlin also discussed the possibilities of development of AD after transplant being a delayed presentation of an allergic sensitization that patients already had. Younger patients are at higher risk for AD post transplant. The renal transplant population, meanwhile, generally receives the transplant at a later age, “so they may not have that delay in terms of presentation; they may have already had their allergies and grown out of them by the time they’re getting their transplant,” she said. “I think there’s more for us to investigate.”
Solid organ transplant recipients also face an increased risk of skin cancer as a long-term side effect of immunosuppressive therapy. Risk factors include fair skin, sun exposure, and remote time from transplant. “Time from transplant is a risk factor,” Dr. Coughlin said. “Longer time on immunosuppression could predispose you to a risk for skin cancer. Our patients are living longer post transplant than they used to, so they have more potential years to develop their skin cancers.” She focused on the importance of educating transplant recipients and families early about photoprotection. “It’s interesting to think about how we can continue to intervene early on to continue to decrease risk.”
Young patients exposed to voriconazole also face an increased risk for skin cancer. “We know that longer-term dosing and higher cumulative dosing puts you at higher risk,” she said. Lung transplant recipients, who are often more likely to be treated with voriconazole, are thus at higher risk.
Dr. Coughlin ended her presentation by noting that side effects of the BRAF inhibitor vemurafenib (Zelboraf) used to treat advanced melanoma in children are similar to, but not the same as, those in adults. “We see BRAF mutations in multiple different tumor types: Langerhans cell histiocytosis, gliomas, and melanoma,” she said. “Trials of vemurafenib and dabrafenib are under way in the pediatric population. Vemurafenib can cause keratosis pilaris, panniculitis, alopecia, and granulomatous dermatitis.” In her experience, she has seen more alopecia in the older teenage population, but younger patients may not be asked about this side effect as frequently.
She counsels patients to expect keratosis pilaris–like eruptions and to take sun protection seriously. “It’s important to emphasize that each time they come in,” Dr. Coughlin said. She also discussed the potential for changing nevi and treatment options for vemurafenib-associated panniculitis.
Dr. Coughlin disclosed that she is the recipient of active pilot grants from the Pediatric Dermatology Research Alliance and the SPD.
REPORTING FROM SPD 2018
Study offers snapshot of esophageal strictures in EB patients
LAKE TAHOE, CALIF. – and direct visualization of these strictures is the preferred method of diagnosis. Those are key findings from a multicenter study that lead author Elena Pope, MD, discussed at the annual meeting of the Society for Pediatric Dermatology.
According to Dr. Pope, who heads the section of dermatology at the Hospital for Sick Children, Toronto, an estimated 10%-17% of epidermolysis bullosa (EB) patients experience strictures, with an overrepresentation in the recessive dystrophic EB subtype in up to 80% of cases. The risk increases with age. “What remains unknown is the best short- and long-term intervention to manage the strictures and predictors/associations for stricture-free episodes,” Dr. Pope said. “The objectives of the current study were to determine the prevalence and predisposing factors for strictures in EB, management options, patient outcomes, and predictors for recurrences and stricture-free intervals.”
She and her associates at seven centers worldwide collected data on 125 EB patients who experienced at least one episode of esophageal stricture. Data was analyzed descriptively and with ANOVA regression analysis for associations/predictors for recurrences/episode-free intervals.
The researchers evaluated 497 stricture events in the 125 patients. A slight female predominance was noted (53%), and the mean age of the first episode was 12.7 years, “which is a little bit older” than the age found in previously published data, Dr. Pope said. As expected, dystrophic EB patients made up most of the sample (98.4%); of these 123 patients, recessive dystrophic EB severe generalized subtype – approaching 50% – was the most common, followed by the recessive dystrophic EB severe intermediate subtype (almost 21%), the dominant dystrophic EB generalized subtype (7%), and other types of dystrophic EB (almost 26%).
The median body mass index percentile for age was 6.3, “so these were patients who were severely malnourished, probably as a result of their strictures as well as their underlying disease,” Dr. Pope said.
As expected, dysphagia was a presenting symptom in most patients (85.5%), while 29.8% presented with inability to swallow solids. The preferred method of evaluation was video fluoroscopy (57.7%), and less commonly with barium swallow (22.3%) or with clinical symptoms alone (0.1%). The mean number of strictures was 1.69; 76.7% were located in the cervical area, 56.7% were located in the thoracic area, and 9.7% were located in the abdominal area. Most patients (76%) had lesions that were 1 cm or longer in size.
Fluoroscopy guidance was the most common method of dilatation (in 45.2% of cases), followed by retrograde endoscopy was (33%), antegrade endoscopy (19.1%), and bougienage (0.1%). General anesthesia was used in most cases (87.6%), and corticosteroids were used around the dilatation in 90.4% of patients. The mean duration of medication use was about 5 days.
As for outcomes after dilatation, 92.2% of strictures completely resolved, 3.8% were partially resolved, 3.9% were not resolved, and 2.7% had complications. The median interval between dilatations was 7 months. Fluoroscopy-guided balloon dilatation was associated with the longest esophageal stricture-free duration (mean of 13.83 months vs. 8.75 months; P less than .001), followed by retrograde endoscopy (mean of 13.10 months vs. 7.85 months; P less than .001), and antegrade endoscopy (mean of 7.63 months vs. 11.46 months; P = .024). “I think this is interesting,” said Dr. Pope, who is also a professor of pediatrics at the University of Toronto. “I think the difference occurs because if you use the endoscopy, which a rigid tube, you can potentially cause more damage, and more long-term scarring.”
Another predictor of esophageal stricture-free episodes was systemic corticosteroid use (a mean of 25.28 months vs. 10.24 months; P less than .001) around the time of the dilatation procedure. “By using systemic steroids, you’re actually decreasing some of the inflammation associated with the trauma of the procedure decreasing the chances of strictures formation,” she said.
Dr. Pope recommended that future studies evaluate the benefit of periprocedural medical interventions on increasing the intervals between esophageal stricture occurrences.
The study was supported by an unrestricted grant from the Epidermolysis Bullosa Research Foundation. She reported having no financial disclosures.
LAKE TAHOE, CALIF. – and direct visualization of these strictures is the preferred method of diagnosis. Those are key findings from a multicenter study that lead author Elena Pope, MD, discussed at the annual meeting of the Society for Pediatric Dermatology.
According to Dr. Pope, who heads the section of dermatology at the Hospital for Sick Children, Toronto, an estimated 10%-17% of epidermolysis bullosa (EB) patients experience strictures, with an overrepresentation in the recessive dystrophic EB subtype in up to 80% of cases. The risk increases with age. “What remains unknown is the best short- and long-term intervention to manage the strictures and predictors/associations for stricture-free episodes,” Dr. Pope said. “The objectives of the current study were to determine the prevalence and predisposing factors for strictures in EB, management options, patient outcomes, and predictors for recurrences and stricture-free intervals.”
She and her associates at seven centers worldwide collected data on 125 EB patients who experienced at least one episode of esophageal stricture. Data was analyzed descriptively and with ANOVA regression analysis for associations/predictors for recurrences/episode-free intervals.
The researchers evaluated 497 stricture events in the 125 patients. A slight female predominance was noted (53%), and the mean age of the first episode was 12.7 years, “which is a little bit older” than the age found in previously published data, Dr. Pope said. As expected, dystrophic EB patients made up most of the sample (98.4%); of these 123 patients, recessive dystrophic EB severe generalized subtype – approaching 50% – was the most common, followed by the recessive dystrophic EB severe intermediate subtype (almost 21%), the dominant dystrophic EB generalized subtype (7%), and other types of dystrophic EB (almost 26%).
The median body mass index percentile for age was 6.3, “so these were patients who were severely malnourished, probably as a result of their strictures as well as their underlying disease,” Dr. Pope said.
As expected, dysphagia was a presenting symptom in most patients (85.5%), while 29.8% presented with inability to swallow solids. The preferred method of evaluation was video fluoroscopy (57.7%), and less commonly with barium swallow (22.3%) or with clinical symptoms alone (0.1%). The mean number of strictures was 1.69; 76.7% were located in the cervical area, 56.7% were located in the thoracic area, and 9.7% were located in the abdominal area. Most patients (76%) had lesions that were 1 cm or longer in size.
Fluoroscopy guidance was the most common method of dilatation (in 45.2% of cases), followed by retrograde endoscopy was (33%), antegrade endoscopy (19.1%), and bougienage (0.1%). General anesthesia was used in most cases (87.6%), and corticosteroids were used around the dilatation in 90.4% of patients. The mean duration of medication use was about 5 days.
As for outcomes after dilatation, 92.2% of strictures completely resolved, 3.8% were partially resolved, 3.9% were not resolved, and 2.7% had complications. The median interval between dilatations was 7 months. Fluoroscopy-guided balloon dilatation was associated with the longest esophageal stricture-free duration (mean of 13.83 months vs. 8.75 months; P less than .001), followed by retrograde endoscopy (mean of 13.10 months vs. 7.85 months; P less than .001), and antegrade endoscopy (mean of 7.63 months vs. 11.46 months; P = .024). “I think this is interesting,” said Dr. Pope, who is also a professor of pediatrics at the University of Toronto. “I think the difference occurs because if you use the endoscopy, which a rigid tube, you can potentially cause more damage, and more long-term scarring.”
Another predictor of esophageal stricture-free episodes was systemic corticosteroid use (a mean of 25.28 months vs. 10.24 months; P less than .001) around the time of the dilatation procedure. “By using systemic steroids, you’re actually decreasing some of the inflammation associated with the trauma of the procedure decreasing the chances of strictures formation,” she said.
Dr. Pope recommended that future studies evaluate the benefit of periprocedural medical interventions on increasing the intervals between esophageal stricture occurrences.
The study was supported by an unrestricted grant from the Epidermolysis Bullosa Research Foundation. She reported having no financial disclosures.
LAKE TAHOE, CALIF. – and direct visualization of these strictures is the preferred method of diagnosis. Those are key findings from a multicenter study that lead author Elena Pope, MD, discussed at the annual meeting of the Society for Pediatric Dermatology.
According to Dr. Pope, who heads the section of dermatology at the Hospital for Sick Children, Toronto, an estimated 10%-17% of epidermolysis bullosa (EB) patients experience strictures, with an overrepresentation in the recessive dystrophic EB subtype in up to 80% of cases. The risk increases with age. “What remains unknown is the best short- and long-term intervention to manage the strictures and predictors/associations for stricture-free episodes,” Dr. Pope said. “The objectives of the current study were to determine the prevalence and predisposing factors for strictures in EB, management options, patient outcomes, and predictors for recurrences and stricture-free intervals.”
She and her associates at seven centers worldwide collected data on 125 EB patients who experienced at least one episode of esophageal stricture. Data was analyzed descriptively and with ANOVA regression analysis for associations/predictors for recurrences/episode-free intervals.
The researchers evaluated 497 stricture events in the 125 patients. A slight female predominance was noted (53%), and the mean age of the first episode was 12.7 years, “which is a little bit older” than the age found in previously published data, Dr. Pope said. As expected, dystrophic EB patients made up most of the sample (98.4%); of these 123 patients, recessive dystrophic EB severe generalized subtype – approaching 50% – was the most common, followed by the recessive dystrophic EB severe intermediate subtype (almost 21%), the dominant dystrophic EB generalized subtype (7%), and other types of dystrophic EB (almost 26%).
The median body mass index percentile for age was 6.3, “so these were patients who were severely malnourished, probably as a result of their strictures as well as their underlying disease,” Dr. Pope said.
As expected, dysphagia was a presenting symptom in most patients (85.5%), while 29.8% presented with inability to swallow solids. The preferred method of evaluation was video fluoroscopy (57.7%), and less commonly with barium swallow (22.3%) or with clinical symptoms alone (0.1%). The mean number of strictures was 1.69; 76.7% were located in the cervical area, 56.7% were located in the thoracic area, and 9.7% were located in the abdominal area. Most patients (76%) had lesions that were 1 cm or longer in size.
Fluoroscopy guidance was the most common method of dilatation (in 45.2% of cases), followed by retrograde endoscopy was (33%), antegrade endoscopy (19.1%), and bougienage (0.1%). General anesthesia was used in most cases (87.6%), and corticosteroids were used around the dilatation in 90.4% of patients. The mean duration of medication use was about 5 days.
As for outcomes after dilatation, 92.2% of strictures completely resolved, 3.8% were partially resolved, 3.9% were not resolved, and 2.7% had complications. The median interval between dilatations was 7 months. Fluoroscopy-guided balloon dilatation was associated with the longest esophageal stricture-free duration (mean of 13.83 months vs. 8.75 months; P less than .001), followed by retrograde endoscopy (mean of 13.10 months vs. 7.85 months; P less than .001), and antegrade endoscopy (mean of 7.63 months vs. 11.46 months; P = .024). “I think this is interesting,” said Dr. Pope, who is also a professor of pediatrics at the University of Toronto. “I think the difference occurs because if you use the endoscopy, which a rigid tube, you can potentially cause more damage, and more long-term scarring.”
Another predictor of esophageal stricture-free episodes was systemic corticosteroid use (a mean of 25.28 months vs. 10.24 months; P less than .001) around the time of the dilatation procedure. “By using systemic steroids, you’re actually decreasing some of the inflammation associated with the trauma of the procedure decreasing the chances of strictures formation,” she said.
Dr. Pope recommended that future studies evaluate the benefit of periprocedural medical interventions on increasing the intervals between esophageal stricture occurrences.
The study was supported by an unrestricted grant from the Epidermolysis Bullosa Research Foundation. She reported having no financial disclosures.
REPORTING FROM SPD 2018
Key clinical point: Esophageal strictures are common complications of patients with severe types of epidermolysis bullosa.
Major finding: Most epidermolysis bullosa patients (85.5%) presented with dysphagia, while the preferred method of evaluation was video fluoroscopy (57.7%).
Study details: A multicenter study of 497 stricture events in 125 patients with epidermolysis bullosa.
Disclosures: The study was supported by an unrestricted grant from the Epidermolysis Bullosa Research Foundation. Dr. Pope reported having no financial disclosures.
Foster cultural competence when examining hair, scalp of ethnic patients
LAKE TAHOE, CALIF. – The way Susan C. Taylor, MD, sees it,
At the annual meeting of the Society for Pediatric Dermatology, Dr. Taylor, a dermatologist at the University of Pennsylvania, Philadelphia, defined culturally competent care as a patient-centered approach in which clinicians establish a rapport with the patient and the caregiver. “It’s important that we ask the right questions,” she said. “In doing so, we have to be familiar with common hair care practices. It’s important that we respect our patients’ values, their goals, their health needs, and, of course, their cultural background. Finally, we have to engage in shared decision making. That’s where we can improve compliance and lead to an overall very satisfactory patient visit.”
To illustrate this point, she discussed the case of a four-year-old black female with a 9-month history of bad dandruff. The child’s mother reports thick flakes that never go away. She takes pride in caring for her daughter’s hair, and shampoos it every two weeks. “She tells me that during the 2.5 hours that it takes her on Saturdays to shampoo, detangle, and comb her daughter’s hair, which she then braids or cornrows and adorns with barrettes or balls, it is a great bonding experience for the two of them,” Dr. Taylor said. “The flakes are temporarily better after she ‘greases’ her daughter’s scalp, but after 2-3 days, they are back.”
In a case like this, Dr. Taylor recommends asking the parent or caregiver to join you while you examine the scalp. This way, the focus becomes the child’s scalp, and the parent is not just staring at your expressions. “The child also observes the pediatric dermatologist and parent/caregiver working together as a team,” she said. “You also want to ask the parent to remove the hair adornments. This makes the child feel more comfortable. It also allows you to observe how the hair is being managed. Are the adornments being removed gently? Is there aggressive pulling of the hair when they take out the braids? Is the child visibly wincing in pain? If the latter two happen this is a teachable moment. You can point out, ‘It looks like Susie is in pain. Let’s do it a little more gently. That might prevent further hair breakage.’ ”
The differential diagnosis of a scaly pediatric scalp includes infrequent shampooing, seborrheic dermatitis, tinea capitis, atopic dermatitis, psoriasis, and sebopsoriasis. The type of hairstyle also factors in. For example, cornrows are a popular hair styling option among ethnic patients. “These are very popular and very time consuming and may lead to infrequent shampooing,” she said. “If they’re put in very tightly or if they have beads or other adornments, it can lead to traction alopecia.” Twists, meanwhile, can create tension on the hair, while puffs can cause traction alopecia if they’re pulled too tightly. “Although dreadlocks are more common among adolescents, we’re seeing them more commonly in young children,” she said. “They can be very long and wavy and lead to traction alopecia.”
The time required to shampoo, detangle, and style tightly coiled African American hair can be significant. For example, in children with cornrows or braids with extensions, Dr. Taylor said that it might require 30 minutes to as long as 2 or 3 hours to remove their current hairstyle, followed by shampooing and conditioning. “Detangling can take at least 15 minutes. In tightly coiled African American hair, studies have demonstrated that detangling while the hair is wet is best, because you have fewer forces on that comb and the hair is less likely to break, as opposed to detangling when the hair is dry. After the wet hair is detangled and the conditioner is rinsed out, a leave-in conditioner is often applied. Then the hair is detangled again, which can take up to an hour, followed by styling, which can take 1-3 hours. That gives you some insight as to why there can often be infrequent shampooing.”
The recommended frequency of shampooing depends on the hairstyle selected. Many children with braids and extensions will have those braids and extensions taken out every six to 12 weeks, “but that doesn’t mean that the scalp can’t be shampooed,” Dr. Taylor said. “The scalp should be shampooed more often. Economics and socioeconomic status play into the frequency of shampooing. For example, if a parent or a caregiver sends a child to a hair stylist, that can range in price from $45 to $65 or more. Time also factors in. In the black community in particular, it’s a ritual on a Saturday to get your hair done. If the parent or caregiver works on weekends, that’s going to impact the frequency of shampooing.”
Dr. Taylor underscored the importance of framing the history-taking process to avoid common pitfall questions like “Do you wash the child’s hair every day or every other day?” or “Do you use dandruff shampoo every day?” It is important to remember that “the parent’s inherent perception is of a doctor who does not have my hair probably does not understand my hair or my child’s hair,” she said. “It’s unlikely that you’re going to find a parent who shampoos their child’s hair every day or every other day. Maybe once a week, probably biweekly. It’s important to ask culturally competent questions.”
She also advises against asking about shampooing when you’re examining the child’s hair, “because there’s going to be the perception that you may think the scalp is dirty,” Dr. Taylor explained. “You probably want to ask that when gathering the history of present illness. The culturally competent question is going to be, ‘Do you wash her/his hair weekly, every other week, monthly, or does it depend on the hair style?’ ”
Body language is also important. “Don’t lean in from afar when examining the patient,” she said. “Get up close and touch the child’s hair.” If you choose to wear surgical gloves for the exam “don’t hold your hands in the surgical scrub position,” she recommended. “Hold your hands in a more neutral position. I think it’s important to touch the hair.”
Referring back to the 4-year-old black child with bad dandruff, she said that a diagnosis of seborrheic dermatitis is unlikely since that condition usually occurs during puberty. “You should have a high index of suspicion for tinea capitis,” she said. “If the patient has occipital lymphadenopathy plus scaling of the scalp or alopecia, that’s enough to presumptively treat for tinea capitis. There are studies that support that.”
For established tinea capitis, Dr. Taylor advises parents to wash barrettes and other hair adornments in hot soapy water or in the dishwasher. She also recommends disposal of hair oil, pomade, and grease and shampooing the child’s hair with ketoconazole and use a conditioner to decrease household and patient spread, which decreases transmissible fungal spores. “There’s a misperception that the application of hair oils and grease can increase the rate of tinea capitis,” she noted. “That’s not true. However, if hair grease and hair oil is applied to the scalp within one week of culture, it could produce a false negative culture.”
For established seborrheic dermatitis, antifungal shampoos including ketoconazole, ciclopirox, and selenium sulfide may be too drying for ethnic hair, “which already has a propensity to break,” she said. “Instead, we recommend a 5-10 minute scalp contact time with the shampoo and avoid contact with strands of hair. Shampoo hair strands with a conditioning shampoo followed by a conditioner to limit hair breakage. We suggest once weekly or biweekly shampooing.”
Dr. Taylor disclosed that she has advisory board and/or investigator relationships with Aclaris Therapeutics, Allergan, Beiersdorf, Croma Pharmaceuticals, Galderma, Isdin, Johnson & Johnson, and Unilever. She also acknowledged Candrice R. Heath, MD, a dermatologist based in Newark, Delaware, for her assistance with the presentation content.
[email protected]
LAKE TAHOE, CALIF. – The way Susan C. Taylor, MD, sees it,
At the annual meeting of the Society for Pediatric Dermatology, Dr. Taylor, a dermatologist at the University of Pennsylvania, Philadelphia, defined culturally competent care as a patient-centered approach in which clinicians establish a rapport with the patient and the caregiver. “It’s important that we ask the right questions,” she said. “In doing so, we have to be familiar with common hair care practices. It’s important that we respect our patients’ values, their goals, their health needs, and, of course, their cultural background. Finally, we have to engage in shared decision making. That’s where we can improve compliance and lead to an overall very satisfactory patient visit.”
To illustrate this point, she discussed the case of a four-year-old black female with a 9-month history of bad dandruff. The child’s mother reports thick flakes that never go away. She takes pride in caring for her daughter’s hair, and shampoos it every two weeks. “She tells me that during the 2.5 hours that it takes her on Saturdays to shampoo, detangle, and comb her daughter’s hair, which she then braids or cornrows and adorns with barrettes or balls, it is a great bonding experience for the two of them,” Dr. Taylor said. “The flakes are temporarily better after she ‘greases’ her daughter’s scalp, but after 2-3 days, they are back.”
In a case like this, Dr. Taylor recommends asking the parent or caregiver to join you while you examine the scalp. This way, the focus becomes the child’s scalp, and the parent is not just staring at your expressions. “The child also observes the pediatric dermatologist and parent/caregiver working together as a team,” she said. “You also want to ask the parent to remove the hair adornments. This makes the child feel more comfortable. It also allows you to observe how the hair is being managed. Are the adornments being removed gently? Is there aggressive pulling of the hair when they take out the braids? Is the child visibly wincing in pain? If the latter two happen this is a teachable moment. You can point out, ‘It looks like Susie is in pain. Let’s do it a little more gently. That might prevent further hair breakage.’ ”
The differential diagnosis of a scaly pediatric scalp includes infrequent shampooing, seborrheic dermatitis, tinea capitis, atopic dermatitis, psoriasis, and sebopsoriasis. The type of hairstyle also factors in. For example, cornrows are a popular hair styling option among ethnic patients. “These are very popular and very time consuming and may lead to infrequent shampooing,” she said. “If they’re put in very tightly or if they have beads or other adornments, it can lead to traction alopecia.” Twists, meanwhile, can create tension on the hair, while puffs can cause traction alopecia if they’re pulled too tightly. “Although dreadlocks are more common among adolescents, we’re seeing them more commonly in young children,” she said. “They can be very long and wavy and lead to traction alopecia.”
The time required to shampoo, detangle, and style tightly coiled African American hair can be significant. For example, in children with cornrows or braids with extensions, Dr. Taylor said that it might require 30 minutes to as long as 2 or 3 hours to remove their current hairstyle, followed by shampooing and conditioning. “Detangling can take at least 15 minutes. In tightly coiled African American hair, studies have demonstrated that detangling while the hair is wet is best, because you have fewer forces on that comb and the hair is less likely to break, as opposed to detangling when the hair is dry. After the wet hair is detangled and the conditioner is rinsed out, a leave-in conditioner is often applied. Then the hair is detangled again, which can take up to an hour, followed by styling, which can take 1-3 hours. That gives you some insight as to why there can often be infrequent shampooing.”
The recommended frequency of shampooing depends on the hairstyle selected. Many children with braids and extensions will have those braids and extensions taken out every six to 12 weeks, “but that doesn’t mean that the scalp can’t be shampooed,” Dr. Taylor said. “The scalp should be shampooed more often. Economics and socioeconomic status play into the frequency of shampooing. For example, if a parent or a caregiver sends a child to a hair stylist, that can range in price from $45 to $65 or more. Time also factors in. In the black community in particular, it’s a ritual on a Saturday to get your hair done. If the parent or caregiver works on weekends, that’s going to impact the frequency of shampooing.”
Dr. Taylor underscored the importance of framing the history-taking process to avoid common pitfall questions like “Do you wash the child’s hair every day or every other day?” or “Do you use dandruff shampoo every day?” It is important to remember that “the parent’s inherent perception is of a doctor who does not have my hair probably does not understand my hair or my child’s hair,” she said. “It’s unlikely that you’re going to find a parent who shampoos their child’s hair every day or every other day. Maybe once a week, probably biweekly. It’s important to ask culturally competent questions.”
She also advises against asking about shampooing when you’re examining the child’s hair, “because there’s going to be the perception that you may think the scalp is dirty,” Dr. Taylor explained. “You probably want to ask that when gathering the history of present illness. The culturally competent question is going to be, ‘Do you wash her/his hair weekly, every other week, monthly, or does it depend on the hair style?’ ”
Body language is also important. “Don’t lean in from afar when examining the patient,” she said. “Get up close and touch the child’s hair.” If you choose to wear surgical gloves for the exam “don’t hold your hands in the surgical scrub position,” she recommended. “Hold your hands in a more neutral position. I think it’s important to touch the hair.”
Referring back to the 4-year-old black child with bad dandruff, she said that a diagnosis of seborrheic dermatitis is unlikely since that condition usually occurs during puberty. “You should have a high index of suspicion for tinea capitis,” she said. “If the patient has occipital lymphadenopathy plus scaling of the scalp or alopecia, that’s enough to presumptively treat for tinea capitis. There are studies that support that.”
For established tinea capitis, Dr. Taylor advises parents to wash barrettes and other hair adornments in hot soapy water or in the dishwasher. She also recommends disposal of hair oil, pomade, and grease and shampooing the child’s hair with ketoconazole and use a conditioner to decrease household and patient spread, which decreases transmissible fungal spores. “There’s a misperception that the application of hair oils and grease can increase the rate of tinea capitis,” she noted. “That’s not true. However, if hair grease and hair oil is applied to the scalp within one week of culture, it could produce a false negative culture.”
For established seborrheic dermatitis, antifungal shampoos including ketoconazole, ciclopirox, and selenium sulfide may be too drying for ethnic hair, “which already has a propensity to break,” she said. “Instead, we recommend a 5-10 minute scalp contact time with the shampoo and avoid contact with strands of hair. Shampoo hair strands with a conditioning shampoo followed by a conditioner to limit hair breakage. We suggest once weekly or biweekly shampooing.”
Dr. Taylor disclosed that she has advisory board and/or investigator relationships with Aclaris Therapeutics, Allergan, Beiersdorf, Croma Pharmaceuticals, Galderma, Isdin, Johnson & Johnson, and Unilever. She also acknowledged Candrice R. Heath, MD, a dermatologist based in Newark, Delaware, for her assistance with the presentation content.
[email protected]
LAKE TAHOE, CALIF. – The way Susan C. Taylor, MD, sees it,
At the annual meeting of the Society for Pediatric Dermatology, Dr. Taylor, a dermatologist at the University of Pennsylvania, Philadelphia, defined culturally competent care as a patient-centered approach in which clinicians establish a rapport with the patient and the caregiver. “It’s important that we ask the right questions,” she said. “In doing so, we have to be familiar with common hair care practices. It’s important that we respect our patients’ values, their goals, their health needs, and, of course, their cultural background. Finally, we have to engage in shared decision making. That’s where we can improve compliance and lead to an overall very satisfactory patient visit.”
To illustrate this point, she discussed the case of a four-year-old black female with a 9-month history of bad dandruff. The child’s mother reports thick flakes that never go away. She takes pride in caring for her daughter’s hair, and shampoos it every two weeks. “She tells me that during the 2.5 hours that it takes her on Saturdays to shampoo, detangle, and comb her daughter’s hair, which she then braids or cornrows and adorns with barrettes or balls, it is a great bonding experience for the two of them,” Dr. Taylor said. “The flakes are temporarily better after she ‘greases’ her daughter’s scalp, but after 2-3 days, they are back.”
In a case like this, Dr. Taylor recommends asking the parent or caregiver to join you while you examine the scalp. This way, the focus becomes the child’s scalp, and the parent is not just staring at your expressions. “The child also observes the pediatric dermatologist and parent/caregiver working together as a team,” she said. “You also want to ask the parent to remove the hair adornments. This makes the child feel more comfortable. It also allows you to observe how the hair is being managed. Are the adornments being removed gently? Is there aggressive pulling of the hair when they take out the braids? Is the child visibly wincing in pain? If the latter two happen this is a teachable moment. You can point out, ‘It looks like Susie is in pain. Let’s do it a little more gently. That might prevent further hair breakage.’ ”
The differential diagnosis of a scaly pediatric scalp includes infrequent shampooing, seborrheic dermatitis, tinea capitis, atopic dermatitis, psoriasis, and sebopsoriasis. The type of hairstyle also factors in. For example, cornrows are a popular hair styling option among ethnic patients. “These are very popular and very time consuming and may lead to infrequent shampooing,” she said. “If they’re put in very tightly or if they have beads or other adornments, it can lead to traction alopecia.” Twists, meanwhile, can create tension on the hair, while puffs can cause traction alopecia if they’re pulled too tightly. “Although dreadlocks are more common among adolescents, we’re seeing them more commonly in young children,” she said. “They can be very long and wavy and lead to traction alopecia.”
The time required to shampoo, detangle, and style tightly coiled African American hair can be significant. For example, in children with cornrows or braids with extensions, Dr. Taylor said that it might require 30 minutes to as long as 2 or 3 hours to remove their current hairstyle, followed by shampooing and conditioning. “Detangling can take at least 15 minutes. In tightly coiled African American hair, studies have demonstrated that detangling while the hair is wet is best, because you have fewer forces on that comb and the hair is less likely to break, as opposed to detangling when the hair is dry. After the wet hair is detangled and the conditioner is rinsed out, a leave-in conditioner is often applied. Then the hair is detangled again, which can take up to an hour, followed by styling, which can take 1-3 hours. That gives you some insight as to why there can often be infrequent shampooing.”
The recommended frequency of shampooing depends on the hairstyle selected. Many children with braids and extensions will have those braids and extensions taken out every six to 12 weeks, “but that doesn’t mean that the scalp can’t be shampooed,” Dr. Taylor said. “The scalp should be shampooed more often. Economics and socioeconomic status play into the frequency of shampooing. For example, if a parent or a caregiver sends a child to a hair stylist, that can range in price from $45 to $65 or more. Time also factors in. In the black community in particular, it’s a ritual on a Saturday to get your hair done. If the parent or caregiver works on weekends, that’s going to impact the frequency of shampooing.”
Dr. Taylor underscored the importance of framing the history-taking process to avoid common pitfall questions like “Do you wash the child’s hair every day or every other day?” or “Do you use dandruff shampoo every day?” It is important to remember that “the parent’s inherent perception is of a doctor who does not have my hair probably does not understand my hair or my child’s hair,” she said. “It’s unlikely that you’re going to find a parent who shampoos their child’s hair every day or every other day. Maybe once a week, probably biweekly. It’s important to ask culturally competent questions.”
She also advises against asking about shampooing when you’re examining the child’s hair, “because there’s going to be the perception that you may think the scalp is dirty,” Dr. Taylor explained. “You probably want to ask that when gathering the history of present illness. The culturally competent question is going to be, ‘Do you wash her/his hair weekly, every other week, monthly, or does it depend on the hair style?’ ”
Body language is also important. “Don’t lean in from afar when examining the patient,” she said. “Get up close and touch the child’s hair.” If you choose to wear surgical gloves for the exam “don’t hold your hands in the surgical scrub position,” she recommended. “Hold your hands in a more neutral position. I think it’s important to touch the hair.”
Referring back to the 4-year-old black child with bad dandruff, she said that a diagnosis of seborrheic dermatitis is unlikely since that condition usually occurs during puberty. “You should have a high index of suspicion for tinea capitis,” she said. “If the patient has occipital lymphadenopathy plus scaling of the scalp or alopecia, that’s enough to presumptively treat for tinea capitis. There are studies that support that.”
For established tinea capitis, Dr. Taylor advises parents to wash barrettes and other hair adornments in hot soapy water or in the dishwasher. She also recommends disposal of hair oil, pomade, and grease and shampooing the child’s hair with ketoconazole and use a conditioner to decrease household and patient spread, which decreases transmissible fungal spores. “There’s a misperception that the application of hair oils and grease can increase the rate of tinea capitis,” she noted. “That’s not true. However, if hair grease and hair oil is applied to the scalp within one week of culture, it could produce a false negative culture.”
For established seborrheic dermatitis, antifungal shampoos including ketoconazole, ciclopirox, and selenium sulfide may be too drying for ethnic hair, “which already has a propensity to break,” she said. “Instead, we recommend a 5-10 minute scalp contact time with the shampoo and avoid contact with strands of hair. Shampoo hair strands with a conditioning shampoo followed by a conditioner to limit hair breakage. We suggest once weekly or biweekly shampooing.”
Dr. Taylor disclosed that she has advisory board and/or investigator relationships with Aclaris Therapeutics, Allergan, Beiersdorf, Croma Pharmaceuticals, Galderma, Isdin, Johnson & Johnson, and Unilever. She also acknowledged Candrice R. Heath, MD, a dermatologist based in Newark, Delaware, for her assistance with the presentation content.
[email protected]
EXPERT ANALYSIS FROM THE SPD ANNUAL MEETING
Respect is key when treating dermatologic conditions in transgender youth
LAKE TAHOE, CALIF. – The way Stanley Vance Jr., MD, sees it, the No. 1 priority in the care of transgender youth is respecting their gender identity.
“This can really help with rapport and also help them continue to engage with your care,” he said at the annual meeting of the Society for Pediatric Dermatology.
One of the first steps is to establish the patient’s chosen name and pronouns. “Ask, use, and be consistent,” said Dr. Vance, an adolescent medicine specialist at the University of California, San Francisco. “Taking it to another level, you can implement system-level tools to ensure that all of your staff consistently use the chosen name and pronouns. and working with the IT department to have a place in our electronic medical record to put the chosen name and preferred pronouns.”
In a study published in the Journal of Adolescent Health, researchers found that the use of chosen names and pronouns for transgender use was associated with reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.
Dr. Vance, who also holds a staff position at the UCSF Child and Adolescent Clinic, went on to discuss dermatologic considerations for gender diverse youth. In transgender females, estrogens can reduce the quantity and density of body and facial hair, “but it doesn’t necessarily get rid of the hair, so we may refer to dermatology for hair removal or hair reduction. There can also be a decrease in sebum production, which can lead to dry skin for those who are at risk.”
Transgender females often seek laser hair removal or electrolysis to aid in “blendability,” or how they perceive as being female or feminine. “We know that this can help in psychosocial outcomes for these young people,” Dr. Vance said. “Another reason why hair reduction and removal may be important is preoperatively for vaginoplasty.”
In transgender males, testosterone increases male pattern hair growth and can increase male pattern hair loss. “Minoxidil does not interact with gender-affirming hormone treatment. If finasteride needs to be considered, it may interfere with the development of secondary sex characteristics.” Testosterone also increases sebum production and can increase acne, particularly in the first 6 months to 1 year after initiation, and with increased titration. “Some transmasculine youth may need oral isotretinoin, as stopping testosterone can be psychologically damaging,” Dr. Vance said.
“Unfortunately, the iPLEDGE program requirements can be perceived as gender nonaffirming, because patients must register by the sex assigned to them at birth, they must take pregnancy tests, and there can be provider assumptions about sexuality which does not equate with gender identity.”
He recommended having “open and honest” conversations with patients about the requirements and limitations of dispensing oral isotretinoin. “Assure the patient that you will be respectful and affirming of their gender identity while they’re in your office,” Dr. Vance advised. “If the patient has a mental health provider, you can strategize with them to reduce gender dysphoria around this process. Finally, advocating to change the system can not only be helpful for the patient in front of you, but for other patients who are in the same situation.”
He concluded his presentation by describing transgender youth as “some of the most resilient young people I’ve had the pleasure of working with.
“I think that we can all work to make sure they feel supported in who they are,” he said.
Dr. Vance reported having no relevant financial disclosures.
[email protected]
LAKE TAHOE, CALIF. – The way Stanley Vance Jr., MD, sees it, the No. 1 priority in the care of transgender youth is respecting their gender identity.
“This can really help with rapport and also help them continue to engage with your care,” he said at the annual meeting of the Society for Pediatric Dermatology.
One of the first steps is to establish the patient’s chosen name and pronouns. “Ask, use, and be consistent,” said Dr. Vance, an adolescent medicine specialist at the University of California, San Francisco. “Taking it to another level, you can implement system-level tools to ensure that all of your staff consistently use the chosen name and pronouns. and working with the IT department to have a place in our electronic medical record to put the chosen name and preferred pronouns.”
In a study published in the Journal of Adolescent Health, researchers found that the use of chosen names and pronouns for transgender use was associated with reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.
Dr. Vance, who also holds a staff position at the UCSF Child and Adolescent Clinic, went on to discuss dermatologic considerations for gender diverse youth. In transgender females, estrogens can reduce the quantity and density of body and facial hair, “but it doesn’t necessarily get rid of the hair, so we may refer to dermatology for hair removal or hair reduction. There can also be a decrease in sebum production, which can lead to dry skin for those who are at risk.”
Transgender females often seek laser hair removal or electrolysis to aid in “blendability,” or how they perceive as being female or feminine. “We know that this can help in psychosocial outcomes for these young people,” Dr. Vance said. “Another reason why hair reduction and removal may be important is preoperatively for vaginoplasty.”
In transgender males, testosterone increases male pattern hair growth and can increase male pattern hair loss. “Minoxidil does not interact with gender-affirming hormone treatment. If finasteride needs to be considered, it may interfere with the development of secondary sex characteristics.” Testosterone also increases sebum production and can increase acne, particularly in the first 6 months to 1 year after initiation, and with increased titration. “Some transmasculine youth may need oral isotretinoin, as stopping testosterone can be psychologically damaging,” Dr. Vance said.
“Unfortunately, the iPLEDGE program requirements can be perceived as gender nonaffirming, because patients must register by the sex assigned to them at birth, they must take pregnancy tests, and there can be provider assumptions about sexuality which does not equate with gender identity.”
He recommended having “open and honest” conversations with patients about the requirements and limitations of dispensing oral isotretinoin. “Assure the patient that you will be respectful and affirming of their gender identity while they’re in your office,” Dr. Vance advised. “If the patient has a mental health provider, you can strategize with them to reduce gender dysphoria around this process. Finally, advocating to change the system can not only be helpful for the patient in front of you, but for other patients who are in the same situation.”
He concluded his presentation by describing transgender youth as “some of the most resilient young people I’ve had the pleasure of working with.
“I think that we can all work to make sure they feel supported in who they are,” he said.
Dr. Vance reported having no relevant financial disclosures.
[email protected]
LAKE TAHOE, CALIF. – The way Stanley Vance Jr., MD, sees it, the No. 1 priority in the care of transgender youth is respecting their gender identity.
“This can really help with rapport and also help them continue to engage with your care,” he said at the annual meeting of the Society for Pediatric Dermatology.
One of the first steps is to establish the patient’s chosen name and pronouns. “Ask, use, and be consistent,” said Dr. Vance, an adolescent medicine specialist at the University of California, San Francisco. “Taking it to another level, you can implement system-level tools to ensure that all of your staff consistently use the chosen name and pronouns. and working with the IT department to have a place in our electronic medical record to put the chosen name and preferred pronouns.”
In a study published in the Journal of Adolescent Health, researchers found that the use of chosen names and pronouns for transgender use was associated with reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.
Dr. Vance, who also holds a staff position at the UCSF Child and Adolescent Clinic, went on to discuss dermatologic considerations for gender diverse youth. In transgender females, estrogens can reduce the quantity and density of body and facial hair, “but it doesn’t necessarily get rid of the hair, so we may refer to dermatology for hair removal or hair reduction. There can also be a decrease in sebum production, which can lead to dry skin for those who are at risk.”
Transgender females often seek laser hair removal or electrolysis to aid in “blendability,” or how they perceive as being female or feminine. “We know that this can help in psychosocial outcomes for these young people,” Dr. Vance said. “Another reason why hair reduction and removal may be important is preoperatively for vaginoplasty.”
In transgender males, testosterone increases male pattern hair growth and can increase male pattern hair loss. “Minoxidil does not interact with gender-affirming hormone treatment. If finasteride needs to be considered, it may interfere with the development of secondary sex characteristics.” Testosterone also increases sebum production and can increase acne, particularly in the first 6 months to 1 year after initiation, and with increased titration. “Some transmasculine youth may need oral isotretinoin, as stopping testosterone can be psychologically damaging,” Dr. Vance said.
“Unfortunately, the iPLEDGE program requirements can be perceived as gender nonaffirming, because patients must register by the sex assigned to them at birth, they must take pregnancy tests, and there can be provider assumptions about sexuality which does not equate with gender identity.”
He recommended having “open and honest” conversations with patients about the requirements and limitations of dispensing oral isotretinoin. “Assure the patient that you will be respectful and affirming of their gender identity while they’re in your office,” Dr. Vance advised. “If the patient has a mental health provider, you can strategize with them to reduce gender dysphoria around this process. Finally, advocating to change the system can not only be helpful for the patient in front of you, but for other patients who are in the same situation.”
He concluded his presentation by describing transgender youth as “some of the most resilient young people I’ve had the pleasure of working with.
“I think that we can all work to make sure they feel supported in who they are,” he said.
Dr. Vance reported having no relevant financial disclosures.
[email protected]
EXPERT ANALYSIS FROM SPD 2018
Pediatric vitiligo primarily affects those aged 10-17
LAKE TAHOE, CALIF. – Among children and adolescents, vitiligo appears to predominately affect nonwhite boys and girls between the ages of 10 and 17 years, results from a large cross-sectional analysis demonstrated.
During an interview at the annual meeting of the Society for Pediatric Dermatology, lead study author Jessica Haber, MD, said that, while it’s known vitiligo can have its onset in childhood, there have been no population-based analyses in the United States specific to children and adolescents with the condition.
“We wanted to examine disease burden in the U.S. specifically, because we have such a diverse population,” said Dr. Haber, a second-year resident in the department of dermatology at Northwell Health, New York.
For the study, she and her associates used IBM’s Explorys research analytics platform to conduct a cross-sectional analysis of more than 55 million unique patients across all census regions of the United States. There were 1,630 vitiligo cases identified from a total of 4,242,400 pediatric patients, for an overall standard prevalence of 0.04%, or 40.1 per 100,000 children and adolescents. The proportion of female and male patients with vitiligo was similar (49.1% and 50.9%, respectively), and nearly three-fourths (72.3%) were 10 years of age or older.
The researchers observed no significant difference in the prevalence of vitiligo between males and females (40.2 per 100,000 vs. 40 per 100,000, respectively). The standardized prevalence of vitiligo was greatest in pediatric patients who were of “other” races and ethnicities (including Asian, Hispanic, multiracial, and other; 69.1 per 100,000), followed by African Americans (51.5 per 100,000) and whites (37.9 per 100,000). There were too few vitiligo cases among biracial patients to determine standardized estimates, but the crude prevalence was greatest in this group (68.7 per 100,000).
Two factors could contribute to the increased prevalence of vitiligo observed in nonwhite children and adolescents, Dr. Haber said. One is selection bias.
“It has been reported that both children and adults with higher Fitzpatrick skin types tend to have increased morbidity of their vitiligo, so it may be a selection bias that these patients are seeking out treatment for their disease,” she said. (J Am Acad Dermatol. 2017;77[1]:1-13). That might explain some of our findings, as well.”
While the study findings “don’t necessarily change clinical practice, it is good for us to have a sense of the burden of disease in the pediatric patient population of vitiligo, and to be aware that this is a disease that predominately affects non-Caucasian children and adolescents,” Dr. Haber concluded.
She reported having no financial disclosures.
LAKE TAHOE, CALIF. – Among children and adolescents, vitiligo appears to predominately affect nonwhite boys and girls between the ages of 10 and 17 years, results from a large cross-sectional analysis demonstrated.
During an interview at the annual meeting of the Society for Pediatric Dermatology, lead study author Jessica Haber, MD, said that, while it’s known vitiligo can have its onset in childhood, there have been no population-based analyses in the United States specific to children and adolescents with the condition.
“We wanted to examine disease burden in the U.S. specifically, because we have such a diverse population,” said Dr. Haber, a second-year resident in the department of dermatology at Northwell Health, New York.
For the study, she and her associates used IBM’s Explorys research analytics platform to conduct a cross-sectional analysis of more than 55 million unique patients across all census regions of the United States. There were 1,630 vitiligo cases identified from a total of 4,242,400 pediatric patients, for an overall standard prevalence of 0.04%, or 40.1 per 100,000 children and adolescents. The proportion of female and male patients with vitiligo was similar (49.1% and 50.9%, respectively), and nearly three-fourths (72.3%) were 10 years of age or older.
The researchers observed no significant difference in the prevalence of vitiligo between males and females (40.2 per 100,000 vs. 40 per 100,000, respectively). The standardized prevalence of vitiligo was greatest in pediatric patients who were of “other” races and ethnicities (including Asian, Hispanic, multiracial, and other; 69.1 per 100,000), followed by African Americans (51.5 per 100,000) and whites (37.9 per 100,000). There were too few vitiligo cases among biracial patients to determine standardized estimates, but the crude prevalence was greatest in this group (68.7 per 100,000).
Two factors could contribute to the increased prevalence of vitiligo observed in nonwhite children and adolescents, Dr. Haber said. One is selection bias.
“It has been reported that both children and adults with higher Fitzpatrick skin types tend to have increased morbidity of their vitiligo, so it may be a selection bias that these patients are seeking out treatment for their disease,” she said. (J Am Acad Dermatol. 2017;77[1]:1-13). That might explain some of our findings, as well.”
While the study findings “don’t necessarily change clinical practice, it is good for us to have a sense of the burden of disease in the pediatric patient population of vitiligo, and to be aware that this is a disease that predominately affects non-Caucasian children and adolescents,” Dr. Haber concluded.
She reported having no financial disclosures.
LAKE TAHOE, CALIF. – Among children and adolescents, vitiligo appears to predominately affect nonwhite boys and girls between the ages of 10 and 17 years, results from a large cross-sectional analysis demonstrated.
During an interview at the annual meeting of the Society for Pediatric Dermatology, lead study author Jessica Haber, MD, said that, while it’s known vitiligo can have its onset in childhood, there have been no population-based analyses in the United States specific to children and adolescents with the condition.
“We wanted to examine disease burden in the U.S. specifically, because we have such a diverse population,” said Dr. Haber, a second-year resident in the department of dermatology at Northwell Health, New York.
For the study, she and her associates used IBM’s Explorys research analytics platform to conduct a cross-sectional analysis of more than 55 million unique patients across all census regions of the United States. There were 1,630 vitiligo cases identified from a total of 4,242,400 pediatric patients, for an overall standard prevalence of 0.04%, or 40.1 per 100,000 children and adolescents. The proportion of female and male patients with vitiligo was similar (49.1% and 50.9%, respectively), and nearly three-fourths (72.3%) were 10 years of age or older.
The researchers observed no significant difference in the prevalence of vitiligo between males and females (40.2 per 100,000 vs. 40 per 100,000, respectively). The standardized prevalence of vitiligo was greatest in pediatric patients who were of “other” races and ethnicities (including Asian, Hispanic, multiracial, and other; 69.1 per 100,000), followed by African Americans (51.5 per 100,000) and whites (37.9 per 100,000). There were too few vitiligo cases among biracial patients to determine standardized estimates, but the crude prevalence was greatest in this group (68.7 per 100,000).
Two factors could contribute to the increased prevalence of vitiligo observed in nonwhite children and adolescents, Dr. Haber said. One is selection bias.
“It has been reported that both children and adults with higher Fitzpatrick skin types tend to have increased morbidity of their vitiligo, so it may be a selection bias that these patients are seeking out treatment for their disease,” she said. (J Am Acad Dermatol. 2017;77[1]:1-13). That might explain some of our findings, as well.”
While the study findings “don’t necessarily change clinical practice, it is good for us to have a sense of the burden of disease in the pediatric patient population of vitiligo, and to be aware that this is a disease that predominately affects non-Caucasian children and adolescents,” Dr. Haber concluded.
She reported having no financial disclosures.
REPORTING FROM SPD 2018
Key clinical point: Vitiligo appears to predominately affect nonwhite boys and girls 10 years of age and older in the pediatric population.
Major finding: Of pediatric patients with vitiligo, 72.3% were 10 years of age or older.
Study details: A cross-sectional analysis of 1,630 vitiligo cases identified from a total of 4,242,400 pediatric patients.
Disclosures: Dr. Haber reported having no relevant financial disclosures.
Fatigue linked to increased risk of ACL injury
SAN DIEGO – Fatigue increases anterior cruciate ligament injury risk in adolescent athletes, results from a field-based drop-jump study demonstrate.
“The number of ACL reconstructions that occur annually are on the rise, particularly in high school and adolescent aged athletes,” lead study author Mohsin S. Fidai, MD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine. “About 70% of these are accounted for by noncontact injuries, the majority of which occur during jump landing. A number of risk factors that have previously been implicated in ACL injury include genetics and anatomy, but a modifiable risk factor is landing biomechanics.”
In 2005, researchers led by Timothy E. Hewett, PhD, determined biomechanical measures of neuromuscular control that might pose certain athletes to be at risk for ACL injury, particularly knee abduction and dynamic knee valgus during a drop-jump test (Am J Sports Med. 2005;33[4]:492-501). “Historically, these studies have required the use of sophisticated computer technology, which can be cumbersome from a time and cost perspective,” said Dr. Fidai, a third-year orthopedic surgery resident at Henry Ford Health System, Detroit.
In a more recent analysis, researchers validated a field-based drop vertical jump screening test for ACL injury (Phys Sportmed. 2016;44[1]:46-52). The sensitivity was 95%, the specificity was 46%, and it had a strong inter-rater reliability (k = 0.92; P less than .05).
The purpose of the current study was to evaluate the effect of fatigue on ACL injury risk using a field-based drop-jump test. “We hypothesized that fatigue would lead to greater dynamic knee valgus during a drop-jump test,” Dr. Fidai said. “We also wanted to identify individual characteristics which may place athletes at increased risk for ACL injury.”
The researchers recruited 85 athletes who competed in track and field, basketball, volleyball, and soccer. More than half (55%) were female, and the mean age was 15.4 years. They excluded athletes with any previous or current lower extremity injuries or neuromuscular deficits. Each athlete performed a maximum vertical jump, followed by a drop-jump test.
“We then fatigued all of our athletes with a standardized high-intensity fatigue protocol, and had each athlete perform another maximum vertical jump and drop-jump test,” Dr. Fidai said. “All drop-jumps were video recorded and sent to a number of orthopedic surgery residents, athletic trainers, and physical therapists for review.”
Of the 85 athletes, nearly half (45%) showed an increased risk for ACL injury after high-intensity aerobic activity. In addition, 68% of study participants were identified as having a medium or high risk for injury following the aerobic activity, compared with 44% at baseline. Dr. Fidai noted. “In the group of athletes with higher levels of fatigue, there is a significantly increased risk, compared with their counterparts with lower levels of fatigue.”
Specifically, 14 of the 22 athletes who demonstrated over 20% fatigue showed an increased ACL injury risk. Subgroup analysis revealed that female athletes and those older than age 15 were more likely to demonstrate an increased injury risk.
“The findings of this study advocate for changes to current neuromuscular training programs to incorporate fatigue resistance, as well as to raise awareness amongst physical therapists, athletic trainers, coaches, and athletes about the effect of fatigue on ACL injury risk,” Dr. Fidai concluded. “We can target vulnerable athletes, particularly female athletes, in an effort to negate some of those effects.”
The study’s principal investigator was Eric C. Makhni, MD. Dr. Makhni, an orthopedic surgeon in West Bloomfield, Mich., disclosed that he is a paid consultant for Smith & Nephew and that he receives publishing royalties from Springer. Dr. Fidai reported having no financial disclosures.
SAN DIEGO – Fatigue increases anterior cruciate ligament injury risk in adolescent athletes, results from a field-based drop-jump study demonstrate.
“The number of ACL reconstructions that occur annually are on the rise, particularly in high school and adolescent aged athletes,” lead study author Mohsin S. Fidai, MD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine. “About 70% of these are accounted for by noncontact injuries, the majority of which occur during jump landing. A number of risk factors that have previously been implicated in ACL injury include genetics and anatomy, but a modifiable risk factor is landing biomechanics.”
In 2005, researchers led by Timothy E. Hewett, PhD, determined biomechanical measures of neuromuscular control that might pose certain athletes to be at risk for ACL injury, particularly knee abduction and dynamic knee valgus during a drop-jump test (Am J Sports Med. 2005;33[4]:492-501). “Historically, these studies have required the use of sophisticated computer technology, which can be cumbersome from a time and cost perspective,” said Dr. Fidai, a third-year orthopedic surgery resident at Henry Ford Health System, Detroit.
In a more recent analysis, researchers validated a field-based drop vertical jump screening test for ACL injury (Phys Sportmed. 2016;44[1]:46-52). The sensitivity was 95%, the specificity was 46%, and it had a strong inter-rater reliability (k = 0.92; P less than .05).
The purpose of the current study was to evaluate the effect of fatigue on ACL injury risk using a field-based drop-jump test. “We hypothesized that fatigue would lead to greater dynamic knee valgus during a drop-jump test,” Dr. Fidai said. “We also wanted to identify individual characteristics which may place athletes at increased risk for ACL injury.”
The researchers recruited 85 athletes who competed in track and field, basketball, volleyball, and soccer. More than half (55%) were female, and the mean age was 15.4 years. They excluded athletes with any previous or current lower extremity injuries or neuromuscular deficits. Each athlete performed a maximum vertical jump, followed by a drop-jump test.
“We then fatigued all of our athletes with a standardized high-intensity fatigue protocol, and had each athlete perform another maximum vertical jump and drop-jump test,” Dr. Fidai said. “All drop-jumps were video recorded and sent to a number of orthopedic surgery residents, athletic trainers, and physical therapists for review.”
Of the 85 athletes, nearly half (45%) showed an increased risk for ACL injury after high-intensity aerobic activity. In addition, 68% of study participants were identified as having a medium or high risk for injury following the aerobic activity, compared with 44% at baseline. Dr. Fidai noted. “In the group of athletes with higher levels of fatigue, there is a significantly increased risk, compared with their counterparts with lower levels of fatigue.”
Specifically, 14 of the 22 athletes who demonstrated over 20% fatigue showed an increased ACL injury risk. Subgroup analysis revealed that female athletes and those older than age 15 were more likely to demonstrate an increased injury risk.
“The findings of this study advocate for changes to current neuromuscular training programs to incorporate fatigue resistance, as well as to raise awareness amongst physical therapists, athletic trainers, coaches, and athletes about the effect of fatigue on ACL injury risk,” Dr. Fidai concluded. “We can target vulnerable athletes, particularly female athletes, in an effort to negate some of those effects.”
The study’s principal investigator was Eric C. Makhni, MD. Dr. Makhni, an orthopedic surgeon in West Bloomfield, Mich., disclosed that he is a paid consultant for Smith & Nephew and that he receives publishing royalties from Springer. Dr. Fidai reported having no financial disclosures.
SAN DIEGO – Fatigue increases anterior cruciate ligament injury risk in adolescent athletes, results from a field-based drop-jump study demonstrate.
“The number of ACL reconstructions that occur annually are on the rise, particularly in high school and adolescent aged athletes,” lead study author Mohsin S. Fidai, MD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine. “About 70% of these are accounted for by noncontact injuries, the majority of which occur during jump landing. A number of risk factors that have previously been implicated in ACL injury include genetics and anatomy, but a modifiable risk factor is landing biomechanics.”
In 2005, researchers led by Timothy E. Hewett, PhD, determined biomechanical measures of neuromuscular control that might pose certain athletes to be at risk for ACL injury, particularly knee abduction and dynamic knee valgus during a drop-jump test (Am J Sports Med. 2005;33[4]:492-501). “Historically, these studies have required the use of sophisticated computer technology, which can be cumbersome from a time and cost perspective,” said Dr. Fidai, a third-year orthopedic surgery resident at Henry Ford Health System, Detroit.
In a more recent analysis, researchers validated a field-based drop vertical jump screening test for ACL injury (Phys Sportmed. 2016;44[1]:46-52). The sensitivity was 95%, the specificity was 46%, and it had a strong inter-rater reliability (k = 0.92; P less than .05).
The purpose of the current study was to evaluate the effect of fatigue on ACL injury risk using a field-based drop-jump test. “We hypothesized that fatigue would lead to greater dynamic knee valgus during a drop-jump test,” Dr. Fidai said. “We also wanted to identify individual characteristics which may place athletes at increased risk for ACL injury.”
The researchers recruited 85 athletes who competed in track and field, basketball, volleyball, and soccer. More than half (55%) were female, and the mean age was 15.4 years. They excluded athletes with any previous or current lower extremity injuries or neuromuscular deficits. Each athlete performed a maximum vertical jump, followed by a drop-jump test.
“We then fatigued all of our athletes with a standardized high-intensity fatigue protocol, and had each athlete perform another maximum vertical jump and drop-jump test,” Dr. Fidai said. “All drop-jumps were video recorded and sent to a number of orthopedic surgery residents, athletic trainers, and physical therapists for review.”
Of the 85 athletes, nearly half (45%) showed an increased risk for ACL injury after high-intensity aerobic activity. In addition, 68% of study participants were identified as having a medium or high risk for injury following the aerobic activity, compared with 44% at baseline. Dr. Fidai noted. “In the group of athletes with higher levels of fatigue, there is a significantly increased risk, compared with their counterparts with lower levels of fatigue.”
Specifically, 14 of the 22 athletes who demonstrated over 20% fatigue showed an increased ACL injury risk. Subgroup analysis revealed that female athletes and those older than age 15 were more likely to demonstrate an increased injury risk.
“The findings of this study advocate for changes to current neuromuscular training programs to incorporate fatigue resistance, as well as to raise awareness amongst physical therapists, athletic trainers, coaches, and athletes about the effect of fatigue on ACL injury risk,” Dr. Fidai concluded. “We can target vulnerable athletes, particularly female athletes, in an effort to negate some of those effects.”
The study’s principal investigator was Eric C. Makhni, MD. Dr. Makhni, an orthopedic surgeon in West Bloomfield, Mich., disclosed that he is a paid consultant for Smith & Nephew and that he receives publishing royalties from Springer. Dr. Fidai reported having no financial disclosures.
REPORTING FROM AOSSM 2018
Key clinical point: Athletes who experience fatigue as tested by a standardized assessment demonstrated increased risk of ACL injury.
Major finding: Nearly half of athletes (45%) showed an increased injury risk after high-intensity aerobic activity.
Study details: A field-based study of 85 athletes that used vertical and drop-jump assessments of each athlete, which were captured on video and reviewed by professional health observers.
Disclosures: Dr. Makhni disclosed that he is a paid consultant for Smith & Nephew and that he receives publishing royalties from Springer. Dr. Fidai reported having no financial disclosures.
Steroid injection prior to rotator cuff surgery elevates risk of revision repair
SAN DIEGO – Patients who received a corticosteroid injection within 6 months prior to rotator cuff repair were more likely to undergo a revision rotator cuff surgery within the following 3 years, results from a large database study show.
“Corticosteroid injections are frequently utilized in the nonoperative management of rotator cuff tears,” researchers led by Sophia A. Traven, MD, wrote in an abstract presented during a poster session at the annual meeting of the American Orthopaedic Society for Sports Medicine. “However, recent literature suggests that injections may reduce biomechanical strengths of tendons and ligaments in animal models.”
In an effort to examine the effect of preoperative shoulder injections on the rate of revision cuff repair following arthroscopic rotator cuff repair, the researchers retrospectively reviewed MarketScan claims data between 2010 and 2014 to identify 4,959 patients with an ICD-9 diagnosis of a rotator cuff tear with subsequent arthroscopic rotator cuff repair (CPT 29827).
They used multivariable logistic regression to compare the odds of reoperation between groups, while controlling for certain demographic and comorbid variables, including age and gender, tobacco use, diabetes, and the Charlson comorbidity index score.
Dr. Traven, an orthopedic surgeon at the Medical University of South Carolina, Charleston, and her associates reported that 392 of the 4,959 patients required rotator cuff repair revision within the following 3 years. Compared with those who did not require revision, those who did were older (a mean age of 53 vs. 49 years, respectively), more likely to be smokers (7% vs. 4%), and more likely to receive any injection prior to rotator cuff repair (36% vs 25%; P less than .0001 for all associations).
(odds ratio, 1.822), followed by those who received an injection 0-3 months before the primary repair (OR, 1.375), and those who received an injection 6-12 months before the primary repair (OR, 1.237).
“The risk of revision rotator cuff repair remains elevated for 6 months following a shoulder injection,” the researchers concluded in their poster. “Consideration should therefore be given to minimizing preoperative injections in patients who may require rotator cuff repair.”
They reported having no financial disclosures.
SAN DIEGO – Patients who received a corticosteroid injection within 6 months prior to rotator cuff repair were more likely to undergo a revision rotator cuff surgery within the following 3 years, results from a large database study show.
“Corticosteroid injections are frequently utilized in the nonoperative management of rotator cuff tears,” researchers led by Sophia A. Traven, MD, wrote in an abstract presented during a poster session at the annual meeting of the American Orthopaedic Society for Sports Medicine. “However, recent literature suggests that injections may reduce biomechanical strengths of tendons and ligaments in animal models.”
In an effort to examine the effect of preoperative shoulder injections on the rate of revision cuff repair following arthroscopic rotator cuff repair, the researchers retrospectively reviewed MarketScan claims data between 2010 and 2014 to identify 4,959 patients with an ICD-9 diagnosis of a rotator cuff tear with subsequent arthroscopic rotator cuff repair (CPT 29827).
They used multivariable logistic regression to compare the odds of reoperation between groups, while controlling for certain demographic and comorbid variables, including age and gender, tobacco use, diabetes, and the Charlson comorbidity index score.
Dr. Traven, an orthopedic surgeon at the Medical University of South Carolina, Charleston, and her associates reported that 392 of the 4,959 patients required rotator cuff repair revision within the following 3 years. Compared with those who did not require revision, those who did were older (a mean age of 53 vs. 49 years, respectively), more likely to be smokers (7% vs. 4%), and more likely to receive any injection prior to rotator cuff repair (36% vs 25%; P less than .0001 for all associations).
(odds ratio, 1.822), followed by those who received an injection 0-3 months before the primary repair (OR, 1.375), and those who received an injection 6-12 months before the primary repair (OR, 1.237).
“The risk of revision rotator cuff repair remains elevated for 6 months following a shoulder injection,” the researchers concluded in their poster. “Consideration should therefore be given to minimizing preoperative injections in patients who may require rotator cuff repair.”
They reported having no financial disclosures.
SAN DIEGO – Patients who received a corticosteroid injection within 6 months prior to rotator cuff repair were more likely to undergo a revision rotator cuff surgery within the following 3 years, results from a large database study show.
“Corticosteroid injections are frequently utilized in the nonoperative management of rotator cuff tears,” researchers led by Sophia A. Traven, MD, wrote in an abstract presented during a poster session at the annual meeting of the American Orthopaedic Society for Sports Medicine. “However, recent literature suggests that injections may reduce biomechanical strengths of tendons and ligaments in animal models.”
In an effort to examine the effect of preoperative shoulder injections on the rate of revision cuff repair following arthroscopic rotator cuff repair, the researchers retrospectively reviewed MarketScan claims data between 2010 and 2014 to identify 4,959 patients with an ICD-9 diagnosis of a rotator cuff tear with subsequent arthroscopic rotator cuff repair (CPT 29827).
They used multivariable logistic regression to compare the odds of reoperation between groups, while controlling for certain demographic and comorbid variables, including age and gender, tobacco use, diabetes, and the Charlson comorbidity index score.
Dr. Traven, an orthopedic surgeon at the Medical University of South Carolina, Charleston, and her associates reported that 392 of the 4,959 patients required rotator cuff repair revision within the following 3 years. Compared with those who did not require revision, those who did were older (a mean age of 53 vs. 49 years, respectively), more likely to be smokers (7% vs. 4%), and more likely to receive any injection prior to rotator cuff repair (36% vs 25%; P less than .0001 for all associations).
(odds ratio, 1.822), followed by those who received an injection 0-3 months before the primary repair (OR, 1.375), and those who received an injection 6-12 months before the primary repair (OR, 1.237).
“The risk of revision rotator cuff repair remains elevated for 6 months following a shoulder injection,” the researchers concluded in their poster. “Consideration should therefore be given to minimizing preoperative injections in patients who may require rotator cuff repair.”
They reported having no financial disclosures.
REPORTING FROM AOSSM 2018
Key clinical point: Consideration should be given to minimizing preoperative injections in patients who may require rotator cuff repair.
Major finding: The risk for revision rotator cuff repair was highest for patients who received an injection 3-6 months before the primary rotator cuff repair (odds ratio, 1.822).
Study details: A retrospective analysis of 4,959 patients with an ICD-9 diagnosis of a rotator cuff tear with subsequent arthroscopic rotator cuff repair.
Disclosures: The researchers reported having no financial disclosures.
Various soft tissue recovery methods get different results
SAN DIEGO – When it comes to soft tissue recovery modalities for elite athletes beyond rest, recovery, and retaining movement efficiency, not all options are created equal.
In fact, the science for most supplemental recovery modalities stems from cohort studies examining physiologic response – not high-level randomized clinical trials, Chuck Thigpen, PhD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine.
“We should be very careful when we discuss overtraining and overload,” said Dr. Thigpen, senior director of practice innovation and analytics for ATI Physical Therapy, Greenville, S.C. “In fact, we need training load to create an anabolic response, so then the question is, how do we manage that load? I would suggest that it’s not overtraining, but underrecovery after a load that results in increasing fatigue, decreased performance, and potential increased injury risk.”
One option for soft tissue recovery is whole body vibration, for which the athlete stands, sits, or lies on a machine with a vibrating platform, while he or she performs static or isotonic exercise. “With this modality, you get a rapid co-contraction of muscle, which increases muscle preactivation,” said Dr. Thigpen, who is also directs the program in observational clinical research in orthopedics at the Greenville, S.C.–based Center for Effectiveness Research in Orthopaedics. “It has demonstrated increased blood flow as well as increased motor neuron excitability. There seems to be some physiologic benefit coming potentially from muscle waste removal (lactate) and nutrient delivery, as well as decreasing subsequent inhibition.”
In terms of parameters, benefits have been observed when athletes perform one or two sets of a static stretch or contact massage on a body vibration machine for a minute or so at a frequency of 30-50 Hz. “The application is what becomes challenging,” Dr. Thigpen said. “Where are you going to work this in? Is it a pre or post activity? Recent evidence implicates use during halftime may maintain strength and power. However, most of the work that has been done with vibration has been as an adjunct to exercise and not really in terms of recovery.”
Massage is another popular recovery tool, and most elite sports team have a masseuse on staff. Soft tissue manipulation creates release of oxytocin and other neurotransmitters, some central nervous system response, and increased blood flow to the treated area, but it also influences the athlete’s general disposition.
“There’s something about laying hands on somebody that seems to affect a person’s mood state,” Dr. Thigpen said. “Some studies have reported better perceived recovery status, even though the physiologic markers are about the same. Therefore, I would classify body vibration and massage in the same bucket. They seem to work; they seem to have some perceived benefit.”
Another soft tissue recovery option, compression therapy, has been shown to increase the local pressure gradient of the impacted area, thereby increasing progressive venous return and creating some muscle splinting (or protective muscle spasms). “,” Dr. Thigpen said. “A couple of studies have looked at the ultrastructure of the muscle concurrently after using compression garments. The nice thing is that you can put them on right after the activity. They should be worn for 24 hours.”
Another way to get compression therapy is to use compression devices; it is recommended that they are worn for 15-minute intervals for up to 4 hours after intense physical activity, depending on the device. “You see some of the same benefits that you see with compression garments,” he said.
Dr. Thigpen went on to discuss cryotherapy such as cold-water immersion in a tub, which has a long history of use in muscle recovery. In fact, many basic science studies have demonstrated a reduction of inflammatory markers and other immunologic responses after its use. “Cryotherapy is thought to create an acute decrease in blood flow and a concurrent increase in blood flow after you remove it, which creates the release of these neurotransmitters and immunosuppressants that seem to be helpful in the healing process,” he explained.
“The thought is, because of the decreased pain reduction, the waste removal, and the change in oxidative stress, this would be beneficial.” For example, cold water immersion in a tub four times over a 72-hour period has been found to decrease soreness and increase athletic performance on the backside. “That seems to be helpful in recovery, as an adjunct to heavy resistance training or eccentric and plyometric training,” he said.
Neuromuscular electrical stimulation has been shown to provide some analgesic effect to sore muscles via afferent stimulation, but the primary mechanism is contractile via the motor unit. Typically, neuromuscular electrical stimulation consists of about a 20-minute application to affected muscles, “and you can do multiple applications per day interspersed with periods of high-intensity training to restore the neuromuscular profile during the recovery period,” Dr. Thigpen said.
He reported having no financial disclosures.
SAN DIEGO – When it comes to soft tissue recovery modalities for elite athletes beyond rest, recovery, and retaining movement efficiency, not all options are created equal.
In fact, the science for most supplemental recovery modalities stems from cohort studies examining physiologic response – not high-level randomized clinical trials, Chuck Thigpen, PhD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine.
“We should be very careful when we discuss overtraining and overload,” said Dr. Thigpen, senior director of practice innovation and analytics for ATI Physical Therapy, Greenville, S.C. “In fact, we need training load to create an anabolic response, so then the question is, how do we manage that load? I would suggest that it’s not overtraining, but underrecovery after a load that results in increasing fatigue, decreased performance, and potential increased injury risk.”
One option for soft tissue recovery is whole body vibration, for which the athlete stands, sits, or lies on a machine with a vibrating platform, while he or she performs static or isotonic exercise. “With this modality, you get a rapid co-contraction of muscle, which increases muscle preactivation,” said Dr. Thigpen, who is also directs the program in observational clinical research in orthopedics at the Greenville, S.C.–based Center for Effectiveness Research in Orthopaedics. “It has demonstrated increased blood flow as well as increased motor neuron excitability. There seems to be some physiologic benefit coming potentially from muscle waste removal (lactate) and nutrient delivery, as well as decreasing subsequent inhibition.”
In terms of parameters, benefits have been observed when athletes perform one or two sets of a static stretch or contact massage on a body vibration machine for a minute or so at a frequency of 30-50 Hz. “The application is what becomes challenging,” Dr. Thigpen said. “Where are you going to work this in? Is it a pre or post activity? Recent evidence implicates use during halftime may maintain strength and power. However, most of the work that has been done with vibration has been as an adjunct to exercise and not really in terms of recovery.”
Massage is another popular recovery tool, and most elite sports team have a masseuse on staff. Soft tissue manipulation creates release of oxytocin and other neurotransmitters, some central nervous system response, and increased blood flow to the treated area, but it also influences the athlete’s general disposition.
“There’s something about laying hands on somebody that seems to affect a person’s mood state,” Dr. Thigpen said. “Some studies have reported better perceived recovery status, even though the physiologic markers are about the same. Therefore, I would classify body vibration and massage in the same bucket. They seem to work; they seem to have some perceived benefit.”
Another soft tissue recovery option, compression therapy, has been shown to increase the local pressure gradient of the impacted area, thereby increasing progressive venous return and creating some muscle splinting (or protective muscle spasms). “,” Dr. Thigpen said. “A couple of studies have looked at the ultrastructure of the muscle concurrently after using compression garments. The nice thing is that you can put them on right after the activity. They should be worn for 24 hours.”
Another way to get compression therapy is to use compression devices; it is recommended that they are worn for 15-minute intervals for up to 4 hours after intense physical activity, depending on the device. “You see some of the same benefits that you see with compression garments,” he said.
Dr. Thigpen went on to discuss cryotherapy such as cold-water immersion in a tub, which has a long history of use in muscle recovery. In fact, many basic science studies have demonstrated a reduction of inflammatory markers and other immunologic responses after its use. “Cryotherapy is thought to create an acute decrease in blood flow and a concurrent increase in blood flow after you remove it, which creates the release of these neurotransmitters and immunosuppressants that seem to be helpful in the healing process,” he explained.
“The thought is, because of the decreased pain reduction, the waste removal, and the change in oxidative stress, this would be beneficial.” For example, cold water immersion in a tub four times over a 72-hour period has been found to decrease soreness and increase athletic performance on the backside. “That seems to be helpful in recovery, as an adjunct to heavy resistance training or eccentric and plyometric training,” he said.
Neuromuscular electrical stimulation has been shown to provide some analgesic effect to sore muscles via afferent stimulation, but the primary mechanism is contractile via the motor unit. Typically, neuromuscular electrical stimulation consists of about a 20-minute application to affected muscles, “and you can do multiple applications per day interspersed with periods of high-intensity training to restore the neuromuscular profile during the recovery period,” Dr. Thigpen said.
He reported having no financial disclosures.
SAN DIEGO – When it comes to soft tissue recovery modalities for elite athletes beyond rest, recovery, and retaining movement efficiency, not all options are created equal.
In fact, the science for most supplemental recovery modalities stems from cohort studies examining physiologic response – not high-level randomized clinical trials, Chuck Thigpen, PhD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine.
“We should be very careful when we discuss overtraining and overload,” said Dr. Thigpen, senior director of practice innovation and analytics for ATI Physical Therapy, Greenville, S.C. “In fact, we need training load to create an anabolic response, so then the question is, how do we manage that load? I would suggest that it’s not overtraining, but underrecovery after a load that results in increasing fatigue, decreased performance, and potential increased injury risk.”
One option for soft tissue recovery is whole body vibration, for which the athlete stands, sits, or lies on a machine with a vibrating platform, while he or she performs static or isotonic exercise. “With this modality, you get a rapid co-contraction of muscle, which increases muscle preactivation,” said Dr. Thigpen, who is also directs the program in observational clinical research in orthopedics at the Greenville, S.C.–based Center for Effectiveness Research in Orthopaedics. “It has demonstrated increased blood flow as well as increased motor neuron excitability. There seems to be some physiologic benefit coming potentially from muscle waste removal (lactate) and nutrient delivery, as well as decreasing subsequent inhibition.”
In terms of parameters, benefits have been observed when athletes perform one or two sets of a static stretch or contact massage on a body vibration machine for a minute or so at a frequency of 30-50 Hz. “The application is what becomes challenging,” Dr. Thigpen said. “Where are you going to work this in? Is it a pre or post activity? Recent evidence implicates use during halftime may maintain strength and power. However, most of the work that has been done with vibration has been as an adjunct to exercise and not really in terms of recovery.”
Massage is another popular recovery tool, and most elite sports team have a masseuse on staff. Soft tissue manipulation creates release of oxytocin and other neurotransmitters, some central nervous system response, and increased blood flow to the treated area, but it also influences the athlete’s general disposition.
“There’s something about laying hands on somebody that seems to affect a person’s mood state,” Dr. Thigpen said. “Some studies have reported better perceived recovery status, even though the physiologic markers are about the same. Therefore, I would classify body vibration and massage in the same bucket. They seem to work; they seem to have some perceived benefit.”
Another soft tissue recovery option, compression therapy, has been shown to increase the local pressure gradient of the impacted area, thereby increasing progressive venous return and creating some muscle splinting (or protective muscle spasms). “,” Dr. Thigpen said. “A couple of studies have looked at the ultrastructure of the muscle concurrently after using compression garments. The nice thing is that you can put them on right after the activity. They should be worn for 24 hours.”
Another way to get compression therapy is to use compression devices; it is recommended that they are worn for 15-minute intervals for up to 4 hours after intense physical activity, depending on the device. “You see some of the same benefits that you see with compression garments,” he said.
Dr. Thigpen went on to discuss cryotherapy such as cold-water immersion in a tub, which has a long history of use in muscle recovery. In fact, many basic science studies have demonstrated a reduction of inflammatory markers and other immunologic responses after its use. “Cryotherapy is thought to create an acute decrease in blood flow and a concurrent increase in blood flow after you remove it, which creates the release of these neurotransmitters and immunosuppressants that seem to be helpful in the healing process,” he explained.
“The thought is, because of the decreased pain reduction, the waste removal, and the change in oxidative stress, this would be beneficial.” For example, cold water immersion in a tub four times over a 72-hour period has been found to decrease soreness and increase athletic performance on the backside. “That seems to be helpful in recovery, as an adjunct to heavy resistance training or eccentric and plyometric training,” he said.
Neuromuscular electrical stimulation has been shown to provide some analgesic effect to sore muscles via afferent stimulation, but the primary mechanism is contractile via the motor unit. Typically, neuromuscular electrical stimulation consists of about a 20-minute application to affected muscles, “and you can do multiple applications per day interspersed with periods of high-intensity training to restore the neuromuscular profile during the recovery period,” Dr. Thigpen said.
He reported having no financial disclosures.
REPORTING FROM AOSSM 2018
Study explores adolescents’ views on their skin tone, pressure to tan
LAKE TAHOE, CALIF. –
During an interview at the annual meeting of the Society for Pediatric Dermatology, lead study author Shivani Patel, MD, said that prior research on skin color had focused mainly on adults and its impact on self-esteem and perceived attractiveness, yet little data are available on perceptions of skin color among adolescents.
“During puberty, adolescents receive pressure from friends, family, and social media to conform to a certain acceptable standard of skin tone,” said Dr. Patel, a chief resident in the department of dermatology at Johns Hopkins University, Baltimore. “They will often engage in risky behaviors such as tanning bed use, suntanning, and use of skin lightening creams.”
In an effort to characterize the attitudes of adolescents about their skin tone, she and her associates recruited 50 patients aged 12-19 years who were seen at the Johns Hopkins dermatology clinics. Slightly more than half (56%) were female. They were asked to complete surveys on their use of sunscreen, tanning beds, and skin-lightening creams, as well as to report any family or friends who have used these interventions.
Next, the researchers used Pantone’s Capsure device to record each subject’s skin tone according to a palate of 110 skin colors available from Pantone’s SkinTone Guide, which is intended to match and reproduce lifelike skin tones in a variety of industries. The adolescents were then given the palette and asked which skin tone they felt best represented their skin and which skin tone they wished they had. These differences were compared with their objective measurement by the study team.
Of all respondents, 20% indicated that they felt pressure to have tan skin and were likely to engage in suntanning (P less than .001), a feeling they said started around the age of 12 years and stemmed from perceived pressure from friends and celebrity figures. Those who suntanned were more likely to wear sunscreen (P less than .01), a finding “that was reassuring and showed that they are aware of sunscreen and sun safety,” Dr. Patel said. However, about half of the respondents reported never wearing sunscreen and only two reported wearing sunscreen daily. No one reported using tanning beds, but 8% reported that a family member used them. One adolescent reported using skin lightening creams, and three reported that their mothers used them.
The researchers also found that black and Asian study participants were significantly more likely to desire a skin tone lighter than what they perceived their skin tone to be, while white participants were significantly more likely to desire a darker skin tone (P less than .011 for both associations).
The findings suggest that sun safety initiatives should target prepubertal patients before they engage in risky behaviors, Dr. Patel said. She acknowledged that the small sample size is a limitation of the study, but said that she and her associates hope to conduct a larger-scale analysis.
She reported having no financial disclosures.
LAKE TAHOE, CALIF. –
During an interview at the annual meeting of the Society for Pediatric Dermatology, lead study author Shivani Patel, MD, said that prior research on skin color had focused mainly on adults and its impact on self-esteem and perceived attractiveness, yet little data are available on perceptions of skin color among adolescents.
“During puberty, adolescents receive pressure from friends, family, and social media to conform to a certain acceptable standard of skin tone,” said Dr. Patel, a chief resident in the department of dermatology at Johns Hopkins University, Baltimore. “They will often engage in risky behaviors such as tanning bed use, suntanning, and use of skin lightening creams.”
In an effort to characterize the attitudes of adolescents about their skin tone, she and her associates recruited 50 patients aged 12-19 years who were seen at the Johns Hopkins dermatology clinics. Slightly more than half (56%) were female. They were asked to complete surveys on their use of sunscreen, tanning beds, and skin-lightening creams, as well as to report any family or friends who have used these interventions.
Next, the researchers used Pantone’s Capsure device to record each subject’s skin tone according to a palate of 110 skin colors available from Pantone’s SkinTone Guide, which is intended to match and reproduce lifelike skin tones in a variety of industries. The adolescents were then given the palette and asked which skin tone they felt best represented their skin and which skin tone they wished they had. These differences were compared with their objective measurement by the study team.
Of all respondents, 20% indicated that they felt pressure to have tan skin and were likely to engage in suntanning (P less than .001), a feeling they said started around the age of 12 years and stemmed from perceived pressure from friends and celebrity figures. Those who suntanned were more likely to wear sunscreen (P less than .01), a finding “that was reassuring and showed that they are aware of sunscreen and sun safety,” Dr. Patel said. However, about half of the respondents reported never wearing sunscreen and only two reported wearing sunscreen daily. No one reported using tanning beds, but 8% reported that a family member used them. One adolescent reported using skin lightening creams, and three reported that their mothers used them.
The researchers also found that black and Asian study participants were significantly more likely to desire a skin tone lighter than what they perceived their skin tone to be, while white participants were significantly more likely to desire a darker skin tone (P less than .011 for both associations).
The findings suggest that sun safety initiatives should target prepubertal patients before they engage in risky behaviors, Dr. Patel said. She acknowledged that the small sample size is a limitation of the study, but said that she and her associates hope to conduct a larger-scale analysis.
She reported having no financial disclosures.
LAKE TAHOE, CALIF. –
During an interview at the annual meeting of the Society for Pediatric Dermatology, lead study author Shivani Patel, MD, said that prior research on skin color had focused mainly on adults and its impact on self-esteem and perceived attractiveness, yet little data are available on perceptions of skin color among adolescents.
“During puberty, adolescents receive pressure from friends, family, and social media to conform to a certain acceptable standard of skin tone,” said Dr. Patel, a chief resident in the department of dermatology at Johns Hopkins University, Baltimore. “They will often engage in risky behaviors such as tanning bed use, suntanning, and use of skin lightening creams.”
In an effort to characterize the attitudes of adolescents about their skin tone, she and her associates recruited 50 patients aged 12-19 years who were seen at the Johns Hopkins dermatology clinics. Slightly more than half (56%) were female. They were asked to complete surveys on their use of sunscreen, tanning beds, and skin-lightening creams, as well as to report any family or friends who have used these interventions.
Next, the researchers used Pantone’s Capsure device to record each subject’s skin tone according to a palate of 110 skin colors available from Pantone’s SkinTone Guide, which is intended to match and reproduce lifelike skin tones in a variety of industries. The adolescents were then given the palette and asked which skin tone they felt best represented their skin and which skin tone they wished they had. These differences were compared with their objective measurement by the study team.
Of all respondents, 20% indicated that they felt pressure to have tan skin and were likely to engage in suntanning (P less than .001), a feeling they said started around the age of 12 years and stemmed from perceived pressure from friends and celebrity figures. Those who suntanned were more likely to wear sunscreen (P less than .01), a finding “that was reassuring and showed that they are aware of sunscreen and sun safety,” Dr. Patel said. However, about half of the respondents reported never wearing sunscreen and only two reported wearing sunscreen daily. No one reported using tanning beds, but 8% reported that a family member used them. One adolescent reported using skin lightening creams, and three reported that their mothers used them.
The researchers also found that black and Asian study participants were significantly more likely to desire a skin tone lighter than what they perceived their skin tone to be, while white participants were significantly more likely to desire a darker skin tone (P less than .011 for both associations).
The findings suggest that sun safety initiatives should target prepubertal patients before they engage in risky behaviors, Dr. Patel said. She acknowledged that the small sample size is a limitation of the study, but said that she and her associates hope to conduct a larger-scale analysis.
She reported having no financial disclosures.
REPORTING FROM SPD 2018
Key clinical point: Sun safety initiatives should target prepubertal patients before they engage in risky behaviors.
Major finding: One in five adolescents indicated that they felt pressure to have tan skin and were likely to engage in suntanning (P less than .001).
Study details: A survey of 50 patients aged 12-19 years.
Disclosures: Dr. Patel reported having no financial disclosures.