Kate Johnson

MONTREAL — Suicide screening can be done quickly and easily for veterans attending routine primary care visits, according to Hani Shabana, Ph.D., of the Veterans Affairs Medical Center in Salem, Va.

“Primary care is a largely untapped resource” for suicide prevention in this population, he said, noting evidence that many suicides are completed within days of a primary care visit.

“Many veterans are prone to things like chronic pain, posttraumatic stress syndrome, and depression, and there is a push within Veterans Affairs to get mental health providers integrated into the primary care setting,” he said at the annual meeting of the Society of Behavioral Medicine.

Evidence from the Centers for Disease Control and Prevention suggests that up to 20% of all suicides are completed by veterans, a group that is highly trained with guns and that has access to other lethal weapons, he said.

A review of 40 published studies confirms that contact with a primary care provider is much more common than contact with mental health services prior to completed suicide. About 45% of people in the study had visited a primary care provider within 1 month of their suicide; 20% had seen a mental health specialist. Older individuals had higher rates of contact with a primary care provider, compared with younger people (Am. J. Psychiatry 2002;159:909–16).

An increase in suicide rates among veterans prompted Dr. Shabana's hospital to establish a primary care screening program that captures every veteran at the institution who has not been seen by primary care within the previous 2 weeks.

At intake, nursing staff ask one simple question: “In the past 2 weeks, have you had urges to harm yourself or others?” A positive answer triggers a thorough assessment with either a primary care or mental health provider at the hospital. “We assess risk factors, social/demographic factors, current life stressors, and protective factors to come up with an overall assessment of whether they are at low, moderate, or high risk for suicide,” he said.

Among a group of veterans who screened positive for the initial intake question, 177 were being seen by a mental health provider, 62 had received mental health treatment previously, and 159 had never been treated.

Data on these veterans showed that 110 were prescribed mental health treatment, 118 were referred to specialty treatment for things such as substance abuse or posttraumatic stress syndrome, 29 were followed by a primary care physician, 31 were followed by a mental health expert, 43 declined help, and 7 were hospitalized. Among the 118 referred for specialty treatment, 63% had never been offered help before, Dr. Shabana said.

“We are pretty excited about this last group because we are always looking for people who are floating around the system who need help but haven't been getting it,” he said. The beauty of the screening model is that it is simple and effective, he explained.

There are reduced barriers to access because of the simple handoff from the intake nurse to a primary care or mental health provider, and there is no obligation to see a mental health expert.

“Some veterans get squeamish about mental health and so for them to have a relationship with their primary care provider is easier, and sometimes helps ease them over to [receiving care from] a mental health expert.

MONTREAL — Suicide screening can be done quickly and easily for veterans attending routine primary care visits, according to Hani Shabana, Ph.D., of the Veterans Affairs Medical Center in Salem, Va.

“Primary care is a largely untapped resource” for suicide prevention in this population, he said, noting evidence that many suicides are completed within days of a primary care visit.

“Many veterans are prone to things like chronic pain, posttraumatic stress syndrome, and depression, and there is a push within Veterans Affairs to get mental health providers integrated into the primary care setting,” he said at the annual meeting of the Society of Behavioral Medicine.

Evidence from the Centers for Disease Control and Prevention suggests that up to 20% of all suicides are completed by veterans, a group that is highly trained with guns and that has access to other lethal weapons, he said.

A review of 40 published studies confirms that contact with a primary care provider is much more common than contact with mental health services prior to completed suicide. About 45% of people in the study had visited a primary care provider within 1 month of their suicide; 20% had seen a mental health specialist. Older individuals had higher rates of contact with a primary care provider, compared with younger people (Am. J. Psychiatry 2002;159:909–16).

An increase in suicide rates among veterans prompted Dr. Shabana's hospital to establish a primary care screening program that captures every veteran at the institution who has not been seen by primary care within the previous 2 weeks.

At intake, nursing staff ask one simple question: “In the past 2 weeks, have you had urges to harm yourself or others?” A positive answer triggers a thorough assessment with either a primary care or mental health provider at the hospital. “We assess risk factors, social/demographic factors, current life stressors, and protective factors to come up with an overall assessment of whether they are at low, moderate, or high risk for suicide,” he said.

Among a group of veterans who screened positive for the initial intake question, 177 were being seen by a mental health provider, 62 had received mental health treatment previously, and 159 had never been treated.

Data on these veterans showed that 110 were prescribed mental health treatment, 118 were referred to specialty treatment for things such as substance abuse or posttraumatic stress syndrome, 29 were followed by a primary care physician, 31 were followed by a mental health expert, 43 declined help, and 7 were hospitalized. Among the 118 referred for specialty treatment, 63% had never been offered help before, Dr. Shabana said.

“We are pretty excited about this last group because we are always looking for people who are floating around the system who need help but haven't been getting it,” he said. The beauty of the screening model is that it is simple and effective, he explained.

There are reduced barriers to access because of the simple handoff from the intake nurse to a primary care or mental health provider, and there is no obligation to see a mental health expert.

“Some veterans get squeamish about mental health and so for them to have a relationship with their primary care provider is easier, and sometimes helps ease them over to [receiving care from] a mental health expert.

MONTREAL — Suicide screening can be done quickly and easily for veterans attending routine primary care visits, according to Hani Shabana, Ph.D., of the Veterans Affairs Medical Center in Salem, Va.

“Primary care is a largely untapped resource” for suicide prevention in this population, he said, noting evidence that many suicides are completed within days of a primary care visit.

“Many veterans are prone to things like chronic pain, posttraumatic stress syndrome, and depression, and there is a push within Veterans Affairs to get mental health providers integrated into the primary care setting,” he said at the annual meeting of the Society of Behavioral Medicine.

Evidence from the Centers for Disease Control and Prevention suggests that up to 20% of all suicides are completed by veterans, a group that is highly trained with guns and that has access to other lethal weapons, he said.

A review of 40 published studies confirms that contact with a primary care provider is much more common than contact with mental health services prior to completed suicide. About 45% of people in the study had visited a primary care provider within 1 month of their suicide; 20% had seen a mental health specialist. Older individuals had higher rates of contact with a primary care provider, compared with younger people (Am. J. Psychiatry 2002;159:909–16).

An increase in suicide rates among veterans prompted Dr. Shabana's hospital to establish a primary care screening program that captures every veteran at the institution who has not been seen by primary care within the previous 2 weeks.

At intake, nursing staff ask one simple question: “In the past 2 weeks, have you had urges to harm yourself or others?” A positive answer triggers a thorough assessment with either a primary care or mental health provider at the hospital. “We assess risk factors, social/demographic factors, current life stressors, and protective factors to come up with an overall assessment of whether they are at low, moderate, or high risk for suicide,” he said.

Among a group of veterans who screened positive for the initial intake question, 177 were being seen by a mental health provider, 62 had received mental health treatment previously, and 159 had never been treated.

Data on these veterans showed that 110 were prescribed mental health treatment, 118 were referred to specialty treatment for things such as substance abuse or posttraumatic stress syndrome, 29 were followed by a primary care physician, 31 were followed by a mental health expert, 43 declined help, and 7 were hospitalized. Among the 118 referred for specialty treatment, 63% had never been offered help before, Dr. Shabana said.

“We are pretty excited about this last group because we are always looking for people who are floating around the system who need help but haven't been getting it,” he said. The beauty of the screening model is that it is simple and effective, he explained.

There are reduced barriers to access because of the simple handoff from the intake nurse to a primary care or mental health provider, and there is no obligation to see a mental health expert.

“Some veterans get squeamish about mental health and so for them to have a relationship with their primary care provider is easier, and sometimes helps ease them over to [receiving care from] a mental health expert.

MONTREAL — Major depression is associated with a twofold increase in the risk of incident diabetic foot ulcers, according to the results of a large, prospective, population-based cohort study.

The findings suggest strong benefits in screening for and treating depression to prevent this complication, said Dr. Lisa Williams, of the department of dermatology at the University of Washington, Seattle.

“Depression is twice as common in patients with diabetes,” she said at the annual meeting of the Society for Investigative Dermatology. “At any one time, 11%-12% of patients with diabetes have major depression, and 31% have significant depressive symptoms.”

Until now, it has not been known whether depression increases the incidence of diabetic foot ulcers. However, it is known that “depression is associated with more severe and larger diabetic foot ulcers, and poor healing and recurrence. Depression is also associated with a threefold increase in mortality rate among patients with their first foot ulcer,” she said.

Her study, funded by the National Institute of Mental Health, included 3,474 patients from the Pathways Epidemiologic Study, a prospective cohort of primary care diabetes patients from nine clinics in western Washington State.

Major and minor depression were assessed using the Patient Health Questionnaire (PHQ-9), and there was a mean follow-up of about 4 years. New-onset foot ulcers were assessed during the course of the study, using ICD-9 codes.

There were 401 diagnoses of major and 290 diagnoses of minor depression in the cohort, and 121 incident foot ulcers, said Dr. Williams, who reported no conflicts of interest.

Compared with patients with no depression, Dr. Williams and her coinvestigators found a significant increase in the risk of foot ulcers in patients with major, but not minor, depression (hazard ratios, 2.0 and 1.3, respectively).

There was no difference between depressed and nondepressed patients in foot self-care. However, previous research has shown that depression in patients with diabetes is associated with poor self-care, as well as hyperglycemia, smoking, and obesity, she said. “In our study, we found that compared with nondepressed patients, depressed patients were older, unmarried, had [a higher BMI], were more likely to smoke, and had more diabetes complications.

MONTREAL — Major depression is associated with a twofold increase in the risk of incident diabetic foot ulcers, according to the results of a large, prospective, population-based cohort study.

The findings suggest strong benefits in screening for and treating depression to prevent this complication, said Dr. Lisa Williams, of the department of dermatology at the University of Washington, Seattle.

“Depression is twice as common in patients with diabetes,” she said at the annual meeting of the Society for Investigative Dermatology. “At any one time, 11%-12% of patients with diabetes have major depression, and 31% have significant depressive symptoms.”

Until now, it has not been known whether depression increases the incidence of diabetic foot ulcers. However, it is known that “depression is associated with more severe and larger diabetic foot ulcers, and poor healing and recurrence. Depression is also associated with a threefold increase in mortality rate among patients with their first foot ulcer,” she said.

Her study, funded by the National Institute of Mental Health, included 3,474 patients from the Pathways Epidemiologic Study, a prospective cohort of primary care diabetes patients from nine clinics in western Washington State.

Major and minor depression were assessed using the Patient Health Questionnaire (PHQ-9), and there was a mean follow-up of about 4 years. New-onset foot ulcers were assessed during the course of the study, using ICD-9 codes.

There were 401 diagnoses of major and 290 diagnoses of minor depression in the cohort, and 121 incident foot ulcers, said Dr. Williams, who reported no conflicts of interest.

Compared with patients with no depression, Dr. Williams and her coinvestigators found a significant increase in the risk of foot ulcers in patients with major, but not minor, depression (hazard ratios, 2.0 and 1.3, respectively).

There was no difference between depressed and nondepressed patients in foot self-care. However, previous research has shown that depression in patients with diabetes is associated with poor self-care, as well as hyperglycemia, smoking, and obesity, she said. “In our study, we found that compared with nondepressed patients, depressed patients were older, unmarried, had [a higher BMI], were more likely to smoke, and had more diabetes complications.

MONTREAL — Major depression is associated with a twofold increase in the risk of incident diabetic foot ulcers, according to the results of a large, prospective, population-based cohort study.

The findings suggest strong benefits in screening for and treating depression to prevent this complication, said Dr. Lisa Williams, of the department of dermatology at the University of Washington, Seattle.

“Depression is twice as common in patients with diabetes,” she said at the annual meeting of the Society for Investigative Dermatology. “At any one time, 11%-12% of patients with diabetes have major depression, and 31% have significant depressive symptoms.”

Until now, it has not been known whether depression increases the incidence of diabetic foot ulcers. However, it is known that “depression is associated with more severe and larger diabetic foot ulcers, and poor healing and recurrence. Depression is also associated with a threefold increase in mortality rate among patients with their first foot ulcer,” she said.

Her study, funded by the National Institute of Mental Health, included 3,474 patients from the Pathways Epidemiologic Study, a prospective cohort of primary care diabetes patients from nine clinics in western Washington State.

Major and minor depression were assessed using the Patient Health Questionnaire (PHQ-9), and there was a mean follow-up of about 4 years. New-onset foot ulcers were assessed during the course of the study, using ICD-9 codes.

There were 401 diagnoses of major and 290 diagnoses of minor depression in the cohort, and 121 incident foot ulcers, said Dr. Williams, who reported no conflicts of interest.

Compared with patients with no depression, Dr. Williams and her coinvestigators found a significant increase in the risk of foot ulcers in patients with major, but not minor, depression (hazard ratios, 2.0 and 1.3, respectively).

There was no difference between depressed and nondepressed patients in foot self-care. However, previous research has shown that depression in patients with diabetes is associated with poor self-care, as well as hyperglycemia, smoking, and obesity, she said. “In our study, we found that compared with nondepressed patients, depressed patients were older, unmarried, had [a higher BMI], were more likely to smoke, and had more diabetes complications.

MONTREAL — Suicide screening can be done quickly and easily for veterans attending routine primary care visits, according to Hani Shabana, Ph.D., from the Veterans Affairs Medical Center, Salem, Va.

“Primary care is a largely untapped resource” for suicide prevention in this population, he said, noting evidence that many suicides are completed within days of a primary care visit.

“Many veterans are prone to things like chronic pain, post-traumatic stress syndrome, and depression, and there is a push within Veterans Affairs to get mental health providers integrated into the primary care setting,” he said at the annual meeting of the Society of Behavioral Medicine.

Evidence from the Centers for Disease Control and Prevention suggest that up to 20% of all suicides are completed by veterans, a group that is highly trained with guns and that has access to other lethal weapons, he said.

A review of 40 published studies confirms that contact with a primary care provider is much more common than contact with mental health services prior to completed suicide. About 45% of people in the study had visited a primary care provider within one month of their suicide; 20% had seen a mental health specialist.

Older individuals had higher rates of contact with a primary care provider than younger people (Am. J Psychiatry 2002;159:909–16).

An increase in suicide rates among veterans prompted Dr. Shabana's hospital to establish a primary care screening program that captures every veteran at the institution who has not been seen by primary care within the previous two weeks.

At intake, nursing staff ask one simple question: “In the past two weeks have you had urges to harm yourself or others?” A positive answer triggers a thorough assessment with either a primary care or mental health provider at the hospital.

“We assess risk factors, social/demographic factors, current life stressors and protective factors to come up with an overall assessment of whether they are at low, moderate, or high risk for suicide,” he said.

Among a group of veterans who screened positive for the initial intake question, 177 were currently already being seen by a mental health provider, 62 had received mental health treatment previously, and 159 had never been treated.

Data on these veterans showed that 110 were prescribed mental health treatment, 118 were referred to specialty treatment for things such as substance abuse or post-traumatic stress syndrome, 29 were followed by a primary care physician, 31 were followed by a mental health expert, 43 declined help, and 7 were hospitalized.

Among the 118 referred for specialty treatment, 63% had never been offered help before, said Dr. Shabana.

“We are pretty excited about this last group because we are always looking for people who are floating around the system who need help but haven't been getting it.”

The beauty of the screening model is that it is simple and effective, he explained.

There are reduced barriers to access because of the simple hand-off from the intake nurse to a primary care or mental health provider, and there is no obligation to see a mental health expert.

“Some veterans get squeamish about mental health and so for them to have a relationship with their primary care provider is easier, and sometimes helps ease them over to a mental health expert.”

MONTREAL — Suicide screening can be done quickly and easily for veterans attending routine primary care visits, according to Hani Shabana, Ph.D., from the Veterans Affairs Medical Center, Salem, Va.

“Primary care is a largely untapped resource” for suicide prevention in this population, he said, noting evidence that many suicides are completed within days of a primary care visit.

“Many veterans are prone to things like chronic pain, post-traumatic stress syndrome, and depression, and there is a push within Veterans Affairs to get mental health providers integrated into the primary care setting,” he said at the annual meeting of the Society of Behavioral Medicine.

Evidence from the Centers for Disease Control and Prevention suggest that up to 20% of all suicides are completed by veterans, a group that is highly trained with guns and that has access to other lethal weapons, he said.

A review of 40 published studies confirms that contact with a primary care provider is much more common than contact with mental health services prior to completed suicide. About 45% of people in the study had visited a primary care provider within one month of their suicide; 20% had seen a mental health specialist.

Older individuals had higher rates of contact with a primary care provider than younger people (Am. J Psychiatry 2002;159:909–16).

An increase in suicide rates among veterans prompted Dr. Shabana's hospital to establish a primary care screening program that captures every veteran at the institution who has not been seen by primary care within the previous two weeks.

At intake, nursing staff ask one simple question: “In the past two weeks have you had urges to harm yourself or others?” A positive answer triggers a thorough assessment with either a primary care or mental health provider at the hospital.

“We assess risk factors, social/demographic factors, current life stressors and protective factors to come up with an overall assessment of whether they are at low, moderate, or high risk for suicide,” he said.

Among a group of veterans who screened positive for the initial intake question, 177 were currently already being seen by a mental health provider, 62 had received mental health treatment previously, and 159 had never been treated.

Data on these veterans showed that 110 were prescribed mental health treatment, 118 were referred to specialty treatment for things such as substance abuse or post-traumatic stress syndrome, 29 were followed by a primary care physician, 31 were followed by a mental health expert, 43 declined help, and 7 were hospitalized.

Among the 118 referred for specialty treatment, 63% had never been offered help before, said Dr. Shabana.

“We are pretty excited about this last group because we are always looking for people who are floating around the system who need help but haven't been getting it.”

The beauty of the screening model is that it is simple and effective, he explained.

There are reduced barriers to access because of the simple hand-off from the intake nurse to a primary care or mental health provider, and there is no obligation to see a mental health expert.

“Some veterans get squeamish about mental health and so for them to have a relationship with their primary care provider is easier, and sometimes helps ease them over to a mental health expert.”

MONTREAL — Suicide screening can be done quickly and easily for veterans attending routine primary care visits, according to Hani Shabana, Ph.D., from the Veterans Affairs Medical Center, Salem, Va.

“Primary care is a largely untapped resource” for suicide prevention in this population, he said, noting evidence that many suicides are completed within days of a primary care visit.

“Many veterans are prone to things like chronic pain, post-traumatic stress syndrome, and depression, and there is a push within Veterans Affairs to get mental health providers integrated into the primary care setting,” he said at the annual meeting of the Society of Behavioral Medicine.

Evidence from the Centers for Disease Control and Prevention suggest that up to 20% of all suicides are completed by veterans, a group that is highly trained with guns and that has access to other lethal weapons, he said.

A review of 40 published studies confirms that contact with a primary care provider is much more common than contact with mental health services prior to completed suicide. About 45% of people in the study had visited a primary care provider within one month of their suicide; 20% had seen a mental health specialist.

Older individuals had higher rates of contact with a primary care provider than younger people (Am. J Psychiatry 2002;159:909–16).

An increase in suicide rates among veterans prompted Dr. Shabana's hospital to establish a primary care screening program that captures every veteran at the institution who has not been seen by primary care within the previous two weeks.

At intake, nursing staff ask one simple question: “In the past two weeks have you had urges to harm yourself or others?” A positive answer triggers a thorough assessment with either a primary care or mental health provider at the hospital.

“We assess risk factors, social/demographic factors, current life stressors and protective factors to come up with an overall assessment of whether they are at low, moderate, or high risk for suicide,” he said.

Among a group of veterans who screened positive for the initial intake question, 177 were currently already being seen by a mental health provider, 62 had received mental health treatment previously, and 159 had never been treated.

Data on these veterans showed that 110 were prescribed mental health treatment, 118 were referred to specialty treatment for things such as substance abuse or post-traumatic stress syndrome, 29 were followed by a primary care physician, 31 were followed by a mental health expert, 43 declined help, and 7 were hospitalized.

Among the 118 referred for specialty treatment, 63% had never been offered help before, said Dr. Shabana.

“We are pretty excited about this last group because we are always looking for people who are floating around the system who need help but haven't been getting it.”

The beauty of the screening model is that it is simple and effective, he explained.

There are reduced barriers to access because of the simple hand-off from the intake nurse to a primary care or mental health provider, and there is no obligation to see a mental health expert.

“Some veterans get squeamish about mental health and so for them to have a relationship with their primary care provider is easier, and sometimes helps ease them over to a mental health expert.”

MONTREAL — Women who drank alcohol, especially those who consumed at least five beers per week, were at increased risk of developing psoriasis, based on an analysis of the Nurses' Health Study.

Compared with abstainers, women who drank alcohol (defined as consumption of at least 30 g, or roughly two drinks, per week) had a significantly increased risk of developing psoriasis, with a relative risk (RR) of 1.59, said Dr. Patrick Dominguez, who presented his findings at the annual meeting of the Society for Investigative Dermatology.

When type of alcohol was examined, however, only regular beer consumption of more than five drinks per week was a significant predictor (RR 1.83) for the development of psoriasis. “For any amount of light beer, wine, or liquor consumed, the relative risks were not significant.”

At study entry in 1989, women in the Nurses' Health Study were asked about their level of alcohol consumption in grams per week. According to the Centers for Disease Control and Prevention, a standard drink contains 13.7 g of alcohol and is defined as 12 ounces of regular beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.

Over a 14-year period, biennial questionnaires were used to monitor both the amount as well as the type of alcohol consumed (regular beer, light beer, wine, or liquor), said Dr. Dominguez, who is a research fellow in the department of dermatology at Brigham and Women's Hospital in Boston.

In 2005, participants were asked if they had psoriasis. A total of 2,169 reported a diagnosis of psoriasis; 1,162 were prevalent cases and the remaining 1,007 were incident cases, said Dr. Dominguez, who declared no conflicts of interest. After excluding incident cases for which there was incomplete information on alcohol consumption, 955 participants with new onset psoriasis were included for analysis.

The abstainers and women who drank alcohol did not differ significantly in age. Abstainers had slightly higher body mass indices. Drinkers were more physically active, and a higher percentage of drinkers also reported current or past smoking.

“We also measured dietary folate, which may be a modifier for alcohol's effect in psoriasis, and folate intake was higher in the drinkers, but not significantly higher,” Dr. Dominguez said.

One possible explanation for the study's findings is that gluten, a nonalcoholic ingredient found in beer, might trigger the onset of psoriasis, he speculated.

“There are multiple case series in which patients with gluten sensitivity, or celiac disease, and psoriasis go on a gluten-free diet, and their psoriasis clears up,” he said in an interview. “Beer is the only alcoholic drink that contains gluten. Light beer has some gluten but much less.”

MONTREAL — Women who drank alcohol, especially those who consumed at least five beers per week, were at increased risk of developing psoriasis, based on an analysis of the Nurses' Health Study.

Compared with abstainers, women who drank alcohol (defined as consumption of at least 30 g, or roughly two drinks, per week) had a significantly increased risk of developing psoriasis, with a relative risk (RR) of 1.59, said Dr. Patrick Dominguez, who presented his findings at the annual meeting of the Society for Investigative Dermatology.

When type of alcohol was examined, however, only regular beer consumption of more than five drinks per week was a significant predictor (RR 1.83) for the development of psoriasis. “For any amount of light beer, wine, or liquor consumed, the relative risks were not significant.”

At study entry in 1989, women in the Nurses' Health Study were asked about their level of alcohol consumption in grams per week. According to the Centers for Disease Control and Prevention, a standard drink contains 13.7 g of alcohol and is defined as 12 ounces of regular beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.

Over a 14-year period, biennial questionnaires were used to monitor both the amount as well as the type of alcohol consumed (regular beer, light beer, wine, or liquor), said Dr. Dominguez, who is a research fellow in the department of dermatology at Brigham and Women's Hospital in Boston.

In 2005, participants were asked if they had psoriasis. A total of 2,169 reported a diagnosis of psoriasis; 1,162 were prevalent cases and the remaining 1,007 were incident cases, said Dr. Dominguez, who declared no conflicts of interest. After excluding incident cases for which there was incomplete information on alcohol consumption, 955 participants with new onset psoriasis were included for analysis.

The abstainers and women who drank alcohol did not differ significantly in age. Abstainers had slightly higher body mass indices. Drinkers were more physically active, and a higher percentage of drinkers also reported current or past smoking.

“We also measured dietary folate, which may be a modifier for alcohol's effect in psoriasis, and folate intake was higher in the drinkers, but not significantly higher,” Dr. Dominguez said.

One possible explanation for the study's findings is that gluten, a nonalcoholic ingredient found in beer, might trigger the onset of psoriasis, he speculated.

“There are multiple case series in which patients with gluten sensitivity, or celiac disease, and psoriasis go on a gluten-free diet, and their psoriasis clears up,” he said in an interview. “Beer is the only alcoholic drink that contains gluten. Light beer has some gluten but much less.”

MONTREAL — Women who drank alcohol, especially those who consumed at least five beers per week, were at increased risk of developing psoriasis, based on an analysis of the Nurses' Health Study.

Compared with abstainers, women who drank alcohol (defined as consumption of at least 30 g, or roughly two drinks, per week) had a significantly increased risk of developing psoriasis, with a relative risk (RR) of 1.59, said Dr. Patrick Dominguez, who presented his findings at the annual meeting of the Society for Investigative Dermatology.

When type of alcohol was examined, however, only regular beer consumption of more than five drinks per week was a significant predictor (RR 1.83) for the development of psoriasis. “For any amount of light beer, wine, or liquor consumed, the relative risks were not significant.”

At study entry in 1989, women in the Nurses' Health Study were asked about their level of alcohol consumption in grams per week. According to the Centers for Disease Control and Prevention, a standard drink contains 13.7 g of alcohol and is defined as 12 ounces of regular beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.

Over a 14-year period, biennial questionnaires were used to monitor both the amount as well as the type of alcohol consumed (regular beer, light beer, wine, or liquor), said Dr. Dominguez, who is a research fellow in the department of dermatology at Brigham and Women's Hospital in Boston.

In 2005, participants were asked if they had psoriasis. A total of 2,169 reported a diagnosis of psoriasis; 1,162 were prevalent cases and the remaining 1,007 were incident cases, said Dr. Dominguez, who declared no conflicts of interest. After excluding incident cases for which there was incomplete information on alcohol consumption, 955 participants with new onset psoriasis were included for analysis.

The abstainers and women who drank alcohol did not differ significantly in age. Abstainers had slightly higher body mass indices. Drinkers were more physically active, and a higher percentage of drinkers also reported current or past smoking.

“We also measured dietary folate, which may be a modifier for alcohol's effect in psoriasis, and folate intake was higher in the drinkers, but not significantly higher,” Dr. Dominguez said.

One possible explanation for the study's findings is that gluten, a nonalcoholic ingredient found in beer, might trigger the onset of psoriasis, he speculated.

“There are multiple case series in which patients with gluten sensitivity, or celiac disease, and psoriasis go on a gluten-free diet, and their psoriasis clears up,” he said in an interview. “Beer is the only alcoholic drink that contains gluten. Light beer has some gluten but much less.”

MONTREAL — Mortality rates are significantly increased in patients with severe psoriasis compared with the general population, according to two new studies.

But the studies have conflicting results regarding cause of death, researchers reported at the annual meeting of the Society for Investigative Dermatology. A study by Dr. Rahat Azfar showed an age-dependent, significantly increased risk of cardiovascular death with severe psoriasis, compared with patients without it.

“Severe psoriasis may be an independent risk factor for cardiovascular mortality,” noted Dr. Azfar of the University of Pennsylvania, Philadelphia, whose study showed a 50% increase in cardiovascular death.

Her findings are in direct contrast to another study presented in the same session and conflict with a growing body of evidence. Dr. Robert Stern presented results from the 30-year PUVA Follow-Up Study, which showed no increase in cardiovascular death risk in severe psoriasis patients, all of whom had undergone PUVA.

“In patients with extremely severe psoriasis, there is an increased risk of death from noncardiovascular, but not cardiovascular causes,” said Dr. Stern, professor of dermatology at Harvard Medical School and vice chair of dermatology at Beth Israel Deaconess Medical Center in Boston.

“Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done,” commented Dr. Azfar, who declared no conflicts of interest.

Her study, which she presented at the meeting, was funded by the National Institutes of Health and a grant from Centocor. It examined more than 3,000 patients with severe psoriasis, matched to more than 14,000 controls.

Compared with controls, patients with severe psoriasis had a significantly increased risk of all-cause mortality (odds ratio [OR] 1.78), she said.

After researchers controlled for traditional cardiovascular risk factors, psoriasis patients had a clinically significant increased risk of cardiovascular death (hazard ratio [HR] 1.55). This risk was modified by age, with patients aged 40 and younger being at greater risk (HR 2.65) than patients aged 41–60 (HR 1.90). This translated to an excess of 5.78 cardiovascular deaths per 10,000 person-years at age 40 and 58.9 per 10,000 person-years at age 60, she said.

Dr. Stern, who declared no conflicts of interest, agreed that cardiovascular risk factors are important, but his data suggest they are no more important than other risk factors.

The data show “that liver disease and nonmelanoma skin cancer accounted for more than half the approximately 70 excess deaths we observed,” he said. His prospective study followed 1,376 patients from the PUVA Follow-Up for 28 years, from 1976 to 2004.

Comparing the observed and expected mortality rates among patients and controls, the researchers found an increased all-cause mortality rate among only those patients with the most severe psoriasis. When cause of death was examined in this group, noncardiovascular reasons explained the increased risk, and there was a nonsignificant increase in the rate of cardiovascular deaths, compared with controls, Dr. Stern said.

'Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done.' DR. AZFAR

MONTREAL — Mortality rates are significantly increased in patients with severe psoriasis compared with the general population, according to two new studies.

But the studies have conflicting results regarding cause of death, researchers reported at the annual meeting of the Society for Investigative Dermatology. A study by Dr. Rahat Azfar showed an age-dependent, significantly increased risk of cardiovascular death with severe psoriasis, compared with patients without it.

“Severe psoriasis may be an independent risk factor for cardiovascular mortality,” noted Dr. Azfar of the University of Pennsylvania, Philadelphia, whose study showed a 50% increase in cardiovascular death.

Her findings are in direct contrast to another study presented in the same session and conflict with a growing body of evidence. Dr. Robert Stern presented results from the 30-year PUVA Follow-Up Study, which showed no increase in cardiovascular death risk in severe psoriasis patients, all of whom had undergone PUVA.

“In patients with extremely severe psoriasis, there is an increased risk of death from noncardiovascular, but not cardiovascular causes,” said Dr. Stern, professor of dermatology at Harvard Medical School and vice chair of dermatology at Beth Israel Deaconess Medical Center in Boston.

“Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done,” commented Dr. Azfar, who declared no conflicts of interest.

Her study, which she presented at the meeting, was funded by the National Institutes of Health and a grant from Centocor. It examined more than 3,000 patients with severe psoriasis, matched to more than 14,000 controls.

Compared with controls, patients with severe psoriasis had a significantly increased risk of all-cause mortality (odds ratio [OR] 1.78), she said.

After researchers controlled for traditional cardiovascular risk factors, psoriasis patients had a clinically significant increased risk of cardiovascular death (hazard ratio [HR] 1.55). This risk was modified by age, with patients aged 40 and younger being at greater risk (HR 2.65) than patients aged 41–60 (HR 1.90). This translated to an excess of 5.78 cardiovascular deaths per 10,000 person-years at age 40 and 58.9 per 10,000 person-years at age 60, she said.

Dr. Stern, who declared no conflicts of interest, agreed that cardiovascular risk factors are important, but his data suggest they are no more important than other risk factors.

The data show “that liver disease and nonmelanoma skin cancer accounted for more than half the approximately 70 excess deaths we observed,” he said. His prospective study followed 1,376 patients from the PUVA Follow-Up for 28 years, from 1976 to 2004.

Comparing the observed and expected mortality rates among patients and controls, the researchers found an increased all-cause mortality rate among only those patients with the most severe psoriasis. When cause of death was examined in this group, noncardiovascular reasons explained the increased risk, and there was a nonsignificant increase in the rate of cardiovascular deaths, compared with controls, Dr. Stern said.

'Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done.' DR. AZFAR

MONTREAL — Mortality rates are significantly increased in patients with severe psoriasis compared with the general population, according to two new studies.

But the studies have conflicting results regarding cause of death, researchers reported at the annual meeting of the Society for Investigative Dermatology. A study by Dr. Rahat Azfar showed an age-dependent, significantly increased risk of cardiovascular death with severe psoriasis, compared with patients without it.

“Severe psoriasis may be an independent risk factor for cardiovascular mortality,” noted Dr. Azfar of the University of Pennsylvania, Philadelphia, whose study showed a 50% increase in cardiovascular death.

Her findings are in direct contrast to another study presented in the same session and conflict with a growing body of evidence. Dr. Robert Stern presented results from the 30-year PUVA Follow-Up Study, which showed no increase in cardiovascular death risk in severe psoriasis patients, all of whom had undergone PUVA.

“In patients with extremely severe psoriasis, there is an increased risk of death from noncardiovascular, but not cardiovascular causes,” said Dr. Stern, professor of dermatology at Harvard Medical School and vice chair of dermatology at Beth Israel Deaconess Medical Center in Boston.

“Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done,” commented Dr. Azfar, who declared no conflicts of interest.

Her study, which she presented at the meeting, was funded by the National Institutes of Health and a grant from Centocor. It examined more than 3,000 patients with severe psoriasis, matched to more than 14,000 controls.

Compared with controls, patients with severe psoriasis had a significantly increased risk of all-cause mortality (odds ratio [OR] 1.78), she said.

After researchers controlled for traditional cardiovascular risk factors, psoriasis patients had a clinically significant increased risk of cardiovascular death (hazard ratio [HR] 1.55). This risk was modified by age, with patients aged 40 and younger being at greater risk (HR 2.65) than patients aged 41–60 (HR 1.90). This translated to an excess of 5.78 cardiovascular deaths per 10,000 person-years at age 40 and 58.9 per 10,000 person-years at age 60, she said.

Dr. Stern, who declared no conflicts of interest, agreed that cardiovascular risk factors are important, but his data suggest they are no more important than other risk factors.

The data show “that liver disease and nonmelanoma skin cancer accounted for more than half the approximately 70 excess deaths we observed,” he said. His prospective study followed 1,376 patients from the PUVA Follow-Up for 28 years, from 1976 to 2004.

Comparing the observed and expected mortality rates among patients and controls, the researchers found an increased all-cause mortality rate among only those patients with the most severe psoriasis. When cause of death was examined in this group, noncardiovascular reasons explained the increased risk, and there was a nonsignificant increase in the rate of cardiovascular deaths, compared with controls, Dr. Stern said.

'Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done.' DR. AZFAR

MONTREAL — Women who drank alcohol, especially those consuming at least five beers per week, were at increased risk of developing psoriasis, based on an analysis of the Nurses' Health Study.

Compared to abstainers, women who drank alcohol (defined as consumption of at least 30 grams, or roughly two drinks, per week) had a significantly increased risk of developing psoriasis, with a relative risk (RR) of 1.6, said Dr. Patrick Dominguez, who presented his findings at the annual meeting of the Society for Investigative Dermatology

When type of alcohol was examined, however, only regular beer consumption of more than 5 drinks per week was a significant predictor (RR 1.8) for the development of psoriasis. “For any amount of light beer, wine, or liquor consumed, the relative risks were not significant.”

At study entry in 1989, women in the Nurses' Health Study were asked about their level of alcohol consumption in grams per week. According to the Centers for Disease Control and Prevention, a standard drink contains 13.7 grams of alcohol and is defined as 12 ounces of regular beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.

Over a 14-year period, biennial questionnaires were used to monitor both the amount as well as the type of alcohol consumed (regular beer, light beer, wine, or liquor), said Dr. Dominguez, who is a research fellow in the department of dermatology at Brigham and Women's Hospital in Boston.

In 2005, participants were asked if they had psoriasis. A total of 2,169 reported a diagnosis of psoriasis; 1,162 were prevalent cases and the remaining 1,007 were incident cases, said Dr. Dominguez, who declared no conflicts of interest. After excluding incident cases for which there was incomplete information on alcohol consumption, 955 participants with new onset psoriasis were included for analysis.

The abstainers and women who drank alcohol did not differ significantly in age. Abstainers had slightly higher body mass indices. Drinkers were more physically active, and a higher percentage of drinkers also reported current or past smoking.

One possible explanation for the study's findings is that gluten, a non-alcoholic ingredient found in beer, might trigger the onset of psoriasis, Dr. Dominguez speculated.

“There are multiple case series in which patients with gluten sensitivity, or celiac disease, and psoriasis go on a gluten-free diet, and their psoriasis clears up,” he said in an interview. “Beer is the only alcoholic drink that contains gluten. Light beer has some gluten but much less.”

Gluten, which is found in beer but not other forms of alcohol, may be a trigger. Courtesy Len Rizzi/National Cancer Institute

MONTREAL — Women who drank alcohol, especially those consuming at least five beers per week, were at increased risk of developing psoriasis, based on an analysis of the Nurses' Health Study.

Compared to abstainers, women who drank alcohol (defined as consumption of at least 30 grams, or roughly two drinks, per week) had a significantly increased risk of developing psoriasis, with a relative risk (RR) of 1.6, said Dr. Patrick Dominguez, who presented his findings at the annual meeting of the Society for Investigative Dermatology

When type of alcohol was examined, however, only regular beer consumption of more than 5 drinks per week was a significant predictor (RR 1.8) for the development of psoriasis. “For any amount of light beer, wine, or liquor consumed, the relative risks were not significant.”

At study entry in 1989, women in the Nurses' Health Study were asked about their level of alcohol consumption in grams per week. According to the Centers for Disease Control and Prevention, a standard drink contains 13.7 grams of alcohol and is defined as 12 ounces of regular beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.

Over a 14-year period, biennial questionnaires were used to monitor both the amount as well as the type of alcohol consumed (regular beer, light beer, wine, or liquor), said Dr. Dominguez, who is a research fellow in the department of dermatology at Brigham and Women's Hospital in Boston.

In 2005, participants were asked if they had psoriasis. A total of 2,169 reported a diagnosis of psoriasis; 1,162 were prevalent cases and the remaining 1,007 were incident cases, said Dr. Dominguez, who declared no conflicts of interest. After excluding incident cases for which there was incomplete information on alcohol consumption, 955 participants with new onset psoriasis were included for analysis.

The abstainers and women who drank alcohol did not differ significantly in age. Abstainers had slightly higher body mass indices. Drinkers were more physically active, and a higher percentage of drinkers also reported current or past smoking.

One possible explanation for the study's findings is that gluten, a non-alcoholic ingredient found in beer, might trigger the onset of psoriasis, Dr. Dominguez speculated.

“There are multiple case series in which patients with gluten sensitivity, or celiac disease, and psoriasis go on a gluten-free diet, and their psoriasis clears up,” he said in an interview. “Beer is the only alcoholic drink that contains gluten. Light beer has some gluten but much less.”

Gluten, which is found in beer but not other forms of alcohol, may be a trigger. Courtesy Len Rizzi/National Cancer Institute

MONTREAL — Women who drank alcohol, especially those consuming at least five beers per week, were at increased risk of developing psoriasis, based on an analysis of the Nurses' Health Study.

Compared to abstainers, women who drank alcohol (defined as consumption of at least 30 grams, or roughly two drinks, per week) had a significantly increased risk of developing psoriasis, with a relative risk (RR) of 1.6, said Dr. Patrick Dominguez, who presented his findings at the annual meeting of the Society for Investigative Dermatology

When type of alcohol was examined, however, only regular beer consumption of more than 5 drinks per week was a significant predictor (RR 1.8) for the development of psoriasis. “For any amount of light beer, wine, or liquor consumed, the relative risks were not significant.”

At study entry in 1989, women in the Nurses' Health Study were asked about their level of alcohol consumption in grams per week. According to the Centers for Disease Control and Prevention, a standard drink contains 13.7 grams of alcohol and is defined as 12 ounces of regular beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.

Over a 14-year period, biennial questionnaires were used to monitor both the amount as well as the type of alcohol consumed (regular beer, light beer, wine, or liquor), said Dr. Dominguez, who is a research fellow in the department of dermatology at Brigham and Women's Hospital in Boston.

In 2005, participants were asked if they had psoriasis. A total of 2,169 reported a diagnosis of psoriasis; 1,162 were prevalent cases and the remaining 1,007 were incident cases, said Dr. Dominguez, who declared no conflicts of interest. After excluding incident cases for which there was incomplete information on alcohol consumption, 955 participants with new onset psoriasis were included for analysis.

The abstainers and women who drank alcohol did not differ significantly in age. Abstainers had slightly higher body mass indices. Drinkers were more physically active, and a higher percentage of drinkers also reported current or past smoking.

One possible explanation for the study's findings is that gluten, a non-alcoholic ingredient found in beer, might trigger the onset of psoriasis, Dr. Dominguez speculated.

“There are multiple case series in which patients with gluten sensitivity, or celiac disease, and psoriasis go on a gluten-free diet, and their psoriasis clears up,” he said in an interview. “Beer is the only alcoholic drink that contains gluten. Light beer has some gluten but much less.”

Gluten, which is found in beer but not other forms of alcohol, may be a trigger. Courtesy Len Rizzi/National Cancer Institute

MONTREAL — Topical 5-fluorouracil used for the treatment of actinic keratosis can also promote dermal remodeling in photoaged skin, according to a small study.

For years, clinicians and patients have noted that, in addition to treating actinic keratosis (AK), topical 5-fluorouracil (5-FU) treatment can result in skin softening and smoothing, Dr. Sewon Kang of Johns Hopkins University, Baltimore, said at the annual meeting of the Society for Investigative Dermatology.

"We knew this anecdotally, but it had never been documented or studied at a molecular level," he said in an interview. "We did this study to confirm people's clinical observation that this happens, and added a few lab measurements to support how it might be happening."

The nonrandomized, non-vehicle-controlled study was funded by Valeant Pharmaceuticals, and Dr. Kang did not disclose any conflicts of interest.

The study included 21 subjects, aged 56–85 years, who received 5% topical 5-FU cream twice daily for 2 weeks for the treatment of facial AK. In addition to AK lesions, all patients had moderate to severe photodamage.

The subjects underwent a baseline clinical skin examination, which was repeated 1 day after the last treatment application and again at 4, 10, and 24 weeks post treatment.

Photographic evaluation was performed, and photoaging parameters were assessed according to a photonumeric scale that included wrinkling, roughness, lentigines, hyperpigmentation, and sallowness. Biopsies were also taken at the same time points.

At the end of the study, the number of AKs was reduced from almost 12 to less than 2 per patient. In addition, photoaging scores dropped from slightly less than 5.5 to about 4.6, he reported.

Biopsies were used to examine the molecular end points of epidermal injury, inflammation, dermal matrix degradation, and collagen, Dr. Kang said.

"Epidermal injury causes an inflammatory reaction in the skin, which triggers collagen repair, and we believe this is the mechanism by which topical 5-FU might improve wrinkles," he explained at the meeting.

Biopsies taken at the end of the study showed a seven-fold increase from baseline in keratin 16, a marker of epidermal injury, and a two-fold increase in inflammatory cytokine expression. Additionally, there was a statistically significant increase in the induction of collagenase (MMP-1) and stromelysin (MMP-3), markers of dermal matrix degradation, he said.

Finally, procollagen protein levels increased significantly from baseline, indicating collagen repair.

"Topical 5-FU induces epidermal wounding by a mechanism similar to microdermabrasion and certain lasers used for the treatment of photoaging. Agents that produce irritation could improve photoaging," Dr. Kang concluded.

MONTREAL — Topical 5-fluorouracil used for the treatment of actinic keratosis can also promote dermal remodeling in photoaged skin, according to a small study.

For years, clinicians and patients have noted that, in addition to treating actinic keratosis (AK), topical 5-fluorouracil (5-FU) treatment can result in skin softening and smoothing, Dr. Sewon Kang of Johns Hopkins University, Baltimore, said at the annual meeting of the Society for Investigative Dermatology.

"We knew this anecdotally, but it had never been documented or studied at a molecular level," he said in an interview. "We did this study to confirm people's clinical observation that this happens, and added a few lab measurements to support how it might be happening."

The nonrandomized, non-vehicle-controlled study was funded by Valeant Pharmaceuticals, and Dr. Kang did not disclose any conflicts of interest.

The study included 21 subjects, aged 56–85 years, who received 5% topical 5-FU cream twice daily for 2 weeks for the treatment of facial AK. In addition to AK lesions, all patients had moderate to severe photodamage.

The subjects underwent a baseline clinical skin examination, which was repeated 1 day after the last treatment application and again at 4, 10, and 24 weeks post treatment.

Photographic evaluation was performed, and photoaging parameters were assessed according to a photonumeric scale that included wrinkling, roughness, lentigines, hyperpigmentation, and sallowness. Biopsies were also taken at the same time points.

At the end of the study, the number of AKs was reduced from almost 12 to less than 2 per patient. In addition, photoaging scores dropped from slightly less than 5.5 to about 4.6, he reported.

Biopsies were used to examine the molecular end points of epidermal injury, inflammation, dermal matrix degradation, and collagen, Dr. Kang said.

"Epidermal injury causes an inflammatory reaction in the skin, which triggers collagen repair, and we believe this is the mechanism by which topical 5-FU might improve wrinkles," he explained at the meeting.

Biopsies taken at the end of the study showed a seven-fold increase from baseline in keratin 16, a marker of epidermal injury, and a two-fold increase in inflammatory cytokine expression. Additionally, there was a statistically significant increase in the induction of collagenase (MMP-1) and stromelysin (MMP-3), markers of dermal matrix degradation, he said.

Finally, procollagen protein levels increased significantly from baseline, indicating collagen repair.

"Topical 5-FU induces epidermal wounding by a mechanism similar to microdermabrasion and certain lasers used for the treatment of photoaging. Agents that produce irritation could improve photoaging," Dr. Kang concluded.

MONTREAL — Topical 5-fluorouracil used for the treatment of actinic keratosis can also promote dermal remodeling in photoaged skin, according to a small study.

For years, clinicians and patients have noted that, in addition to treating actinic keratosis (AK), topical 5-fluorouracil (5-FU) treatment can result in skin softening and smoothing, Dr. Sewon Kang of Johns Hopkins University, Baltimore, said at the annual meeting of the Society for Investigative Dermatology.

"We knew this anecdotally, but it had never been documented or studied at a molecular level," he said in an interview. "We did this study to confirm people's clinical observation that this happens, and added a few lab measurements to support how it might be happening."

The nonrandomized, non-vehicle-controlled study was funded by Valeant Pharmaceuticals, and Dr. Kang did not disclose any conflicts of interest.

The study included 21 subjects, aged 56–85 years, who received 5% topical 5-FU cream twice daily for 2 weeks for the treatment of facial AK. In addition to AK lesions, all patients had moderate to severe photodamage.

The subjects underwent a baseline clinical skin examination, which was repeated 1 day after the last treatment application and again at 4, 10, and 24 weeks post treatment.

Photographic evaluation was performed, and photoaging parameters were assessed according to a photonumeric scale that included wrinkling, roughness, lentigines, hyperpigmentation, and sallowness. Biopsies were also taken at the same time points.

At the end of the study, the number of AKs was reduced from almost 12 to less than 2 per patient. In addition, photoaging scores dropped from slightly less than 5.5 to about 4.6, he reported.

Biopsies were used to examine the molecular end points of epidermal injury, inflammation, dermal matrix degradation, and collagen, Dr. Kang said.

"Epidermal injury causes an inflammatory reaction in the skin, which triggers collagen repair, and we believe this is the mechanism by which topical 5-FU might improve wrinkles," he explained at the meeting.

Biopsies taken at the end of the study showed a seven-fold increase from baseline in keratin 16, a marker of epidermal injury, and a two-fold increase in inflammatory cytokine expression. Additionally, there was a statistically significant increase in the induction of collagenase (MMP-1) and stromelysin (MMP-3), markers of dermal matrix degradation, he said.

Finally, procollagen protein levels increased significantly from baseline, indicating collagen repair.

"Topical 5-FU induces epidermal wounding by a mechanism similar to microdermabrasion and certain lasers used for the treatment of photoaging. Agents that produce irritation could improve photoaging," Dr. Kang concluded.

MONTREAL — The incidence of melanoma in the United States increased rapidly over a 10-year period, regardless of tumor thickness and socioeconomic status, reported Dr. Eleni Linos.

"This has implications for preventive screening and primary care," she said at the annual meeting of the Society for Investigative Dermatology.

Dr. Linos and her coinvestigators examined data from the Surveillance, Epidemiology, and End Results (SEER) registry between 1992 and 2004 (J. Invest. Derm. 2009 Jan. 8 [doi:10.1038/jid.2008.423

During the study period, the incidence of melanoma of all thicknesses increased from 18 per 100,000 in 1992 to 26 per 100,000 in 2004—an annual increase of 3%, said Dr. Linos of Stanford (Calif.) University. The steepest increase was seen in men aged 65 years and older, in whom the incidence rose from 73 to 126 new cases per 100,000. "The vast majority of melanomas that are diagnosed are thin, and that is why we have not seen such a dramatic increase in mortality rates," she explained. Overall mortality rose by 0.4% annually.

Melanoma trends were examined according to socioeconomic status to determine whether the findings could be explained by better screening in those with a higher status. Similarly, tumor thickness was examined to determine whether the increased incidence could be explained by more diagnoses of thin, clinically insignificant tumors.

"We found parallel increases across all socioeconomic groups and thicknesses, representing a true increase in clinically significant tumors," she said.

MONTREAL — The incidence of melanoma in the United States increased rapidly over a 10-year period, regardless of tumor thickness and socioeconomic status, reported Dr. Eleni Linos.

"This has implications for preventive screening and primary care," she said at the annual meeting of the Society for Investigative Dermatology.

Dr. Linos and her coinvestigators examined data from the Surveillance, Epidemiology, and End Results (SEER) registry between 1992 and 2004 (J. Invest. Derm. 2009 Jan. 8 [doi:10.1038/jid.2008.423

During the study period, the incidence of melanoma of all thicknesses increased from 18 per 100,000 in 1992 to 26 per 100,000 in 2004—an annual increase of 3%, said Dr. Linos of Stanford (Calif.) University. The steepest increase was seen in men aged 65 years and older, in whom the incidence rose from 73 to 126 new cases per 100,000. "The vast majority of melanomas that are diagnosed are thin, and that is why we have not seen such a dramatic increase in mortality rates," she explained. Overall mortality rose by 0.4% annually.

Melanoma trends were examined according to socioeconomic status to determine whether the findings could be explained by better screening in those with a higher status. Similarly, tumor thickness was examined to determine whether the increased incidence could be explained by more diagnoses of thin, clinically insignificant tumors.

"We found parallel increases across all socioeconomic groups and thicknesses, representing a true increase in clinically significant tumors," she said.

MONTREAL — The incidence of melanoma in the United States increased rapidly over a 10-year period, regardless of tumor thickness and socioeconomic status, reported Dr. Eleni Linos.

"This has implications for preventive screening and primary care," she said at the annual meeting of the Society for Investigative Dermatology.

Dr. Linos and her coinvestigators examined data from the Surveillance, Epidemiology, and End Results (SEER) registry between 1992 and 2004 (J. Invest. Derm. 2009 Jan. 8 [doi:10.1038/jid.2008.423

During the study period, the incidence of melanoma of all thicknesses increased from 18 per 100,000 in 1992 to 26 per 100,000 in 2004—an annual increase of 3%, said Dr. Linos of Stanford (Calif.) University. The steepest increase was seen in men aged 65 years and older, in whom the incidence rose from 73 to 126 new cases per 100,000. "The vast majority of melanomas that are diagnosed are thin, and that is why we have not seen such a dramatic increase in mortality rates," she explained. Overall mortality rose by 0.4% annually.

Melanoma trends were examined according to socioeconomic status to determine whether the findings could be explained by better screening in those with a higher status. Similarly, tumor thickness was examined to determine whether the increased incidence could be explained by more diagnoses of thin, clinically insignificant tumors.

"We found parallel increases across all socioeconomic groups and thicknesses, representing a true increase in clinically significant tumors," she said.

MONTREAL — Actinic keratoses are dynamic lesions and their expression varies over time, based on the results of an 11-month study of the natural course of the lesions in people with extensive actinic damage.

"At any one time, less than half of the lesions are evident clinically," said Dr. Craig Elmets, who reported his findings at the annual meeting of the Society for Investigative Dermatology.

The pattern of regression and recurrence of actinic keratoses (AK) has implications for the treatment of the lesions, said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham.

"If one is going to treat individual lesions, then they need to be treated aggressively because at any one time only a minority of the [visible] AKs are present," he said. "In patients with extensive actinic damage, peel treatment may be a very good approach to treating these lesions."

Dr. Elmets did not disclose any conflicts of interest in regard to this study, but he serves on the advisory boards of several pharmaceutical companies.

The study followed AK lesions for 11 months in 26 individuals with extensive actinic damage.

At baseline, the subjects had 10–40 actinic lesions and at least one prior histological diagnosis of an AK or a nonmelanoma skin cancer.

The subjects' AKs were mapped at baseline and again at 3, 6, 9, and 11 months.

The lesions also were biopsied at baseline and the end of the study. "If a lesion that had been selected for biopsy was no longer present clinically, the site where it had been was still biopsied," Dr. Elmets explained.

At baseline, there were a total of 610 AKs in the study group (mean 23.5 per individual). At the end of the study, this number was not significantly different despite the development of 973 new lesions over the 11-month period.

About 40% of the lesions present at baseline had regressed by month 11, and nearly 200 of the lesions that were present at baseline regressed and then recurred, he said. "A total of 51 of the lesions regressed twice."

Using a histologic grading scheme that was based on a cervical dysplasia model, Dr. Elmets noted little progression in the severity of lesions in terms of proliferation, atypia, or both features. "The histologic appearance seems to accurately correlate with the clinical appearance, and over the course of 11 months there was little evidence of histologic progression."

AKs have been thought to be precursors to squamous cell carcinomas in some cases.

The presence of AKs is strongly predictive of individuals who are at increased risk for basal cell and squamous cell carcinomas, noted Dr. Elmets.

The pattern of regression and recurrence of actinic keratoses may have implications for the treatment of the lesions. Courtesy Dr. Roger I. Ceilley

MONTREAL — Actinic keratoses are dynamic lesions and their expression varies over time, based on the results of an 11-month study of the natural course of the lesions in people with extensive actinic damage.

"At any one time, less than half of the lesions are evident clinically," said Dr. Craig Elmets, who reported his findings at the annual meeting of the Society for Investigative Dermatology.

The pattern of regression and recurrence of actinic keratoses (AK) has implications for the treatment of the lesions, said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham.

"If one is going to treat individual lesions, then they need to be treated aggressively because at any one time only a minority of the [visible] AKs are present," he said. "In patients with extensive actinic damage, peel treatment may be a very good approach to treating these lesions."

Dr. Elmets did not disclose any conflicts of interest in regard to this study, but he serves on the advisory boards of several pharmaceutical companies.

The study followed AK lesions for 11 months in 26 individuals with extensive actinic damage.

At baseline, the subjects had 10–40 actinic lesions and at least one prior histological diagnosis of an AK or a nonmelanoma skin cancer.

The subjects' AKs were mapped at baseline and again at 3, 6, 9, and 11 months.

The lesions also were biopsied at baseline and the end of the study. "If a lesion that had been selected for biopsy was no longer present clinically, the site where it had been was still biopsied," Dr. Elmets explained.

At baseline, there were a total of 610 AKs in the study group (mean 23.5 per individual). At the end of the study, this number was not significantly different despite the development of 973 new lesions over the 11-month period.

About 40% of the lesions present at baseline had regressed by month 11, and nearly 200 of the lesions that were present at baseline regressed and then recurred, he said. "A total of 51 of the lesions regressed twice."

Using a histologic grading scheme that was based on a cervical dysplasia model, Dr. Elmets noted little progression in the severity of lesions in terms of proliferation, atypia, or both features. "The histologic appearance seems to accurately correlate with the clinical appearance, and over the course of 11 months there was little evidence of histologic progression."

AKs have been thought to be precursors to squamous cell carcinomas in some cases.

The presence of AKs is strongly predictive of individuals who are at increased risk for basal cell and squamous cell carcinomas, noted Dr. Elmets.

The pattern of regression and recurrence of actinic keratoses may have implications for the treatment of the lesions. Courtesy Dr. Roger I. Ceilley

MONTREAL — Actinic keratoses are dynamic lesions and their expression varies over time, based on the results of an 11-month study of the natural course of the lesions in people with extensive actinic damage.

"At any one time, less than half of the lesions are evident clinically," said Dr. Craig Elmets, who reported his findings at the annual meeting of the Society for Investigative Dermatology.

The pattern of regression and recurrence of actinic keratoses (AK) has implications for the treatment of the lesions, said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham.

"If one is going to treat individual lesions, then they need to be treated aggressively because at any one time only a minority of the [visible] AKs are present," he said. "In patients with extensive actinic damage, peel treatment may be a very good approach to treating these lesions."

Dr. Elmets did not disclose any conflicts of interest in regard to this study, but he serves on the advisory boards of several pharmaceutical companies.

The study followed AK lesions for 11 months in 26 individuals with extensive actinic damage.

At baseline, the subjects had 10–40 actinic lesions and at least one prior histological diagnosis of an AK or a nonmelanoma skin cancer.

The subjects' AKs were mapped at baseline and again at 3, 6, 9, and 11 months.

The lesions also were biopsied at baseline and the end of the study. "If a lesion that had been selected for biopsy was no longer present clinically, the site where it had been was still biopsied," Dr. Elmets explained.

At baseline, there were a total of 610 AKs in the study group (mean 23.5 per individual). At the end of the study, this number was not significantly different despite the development of 973 new lesions over the 11-month period.

About 40% of the lesions present at baseline had regressed by month 11, and nearly 200 of the lesions that were present at baseline regressed and then recurred, he said. "A total of 51 of the lesions regressed twice."

Using a histologic grading scheme that was based on a cervical dysplasia model, Dr. Elmets noted little progression in the severity of lesions in terms of proliferation, atypia, or both features. "The histologic appearance seems to accurately correlate with the clinical appearance, and over the course of 11 months there was little evidence of histologic progression."

AKs have been thought to be precursors to squamous cell carcinomas in some cases.

The presence of AKs is strongly predictive of individuals who are at increased risk for basal cell and squamous cell carcinomas, noted Dr. Elmets.

The pattern of regression and recurrence of actinic keratoses may have implications for the treatment of the lesions. Courtesy Dr. Roger I. Ceilley

MONTREAL — Mortality rates are significantly increased in patients with severe psoriasis compared with the general population, according to two new studies.

But studies have conflicting results regarding the cause of death, researchers reported at the annual meeting of the Society for Investigative Dermatology. A study by Dr. Rahat Azfar showed an age-dependent, significantly increased risk of cardiovascular death with severe psoriasis, compared with patients without psoriasis.

“Severe psoriasis may be an independent risk factor for cardiovascular mortality,” noted Dr. Azfar of the University of Pennsylvania, Philadelphia, whose study showed a 50% increase in cardiovascular death.

Her findings are in direct contrast to another study presented in the same session and conflict with a growing body of evidence. Dr. Robert Stern presented results from the 30-year PUVA Follow-Up Study, which showed no increase in cardiovascular death risk in severe psoriasis patients, all of whom had undergone PUVA.

“In patients with extremely severe psoriasis, there is an increased risk of death from noncardiovascular, but not cardiovascular causes,” said Dr. Stern, professor of dermatology at Harvard Medical School and vice chair of dermatology at Beth Israel Deaconess Medical Center in Boston.

“Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done,” commented Dr. Azfar, who declared no conflicts of interest.

Her study, which she presented at the meeting, was funded by the National Institutes of Health and a grant from Centocor. It examined more than 3,000 patients with severe psoriasis, matched to more than 14,000 controls from the United Kingdom's General Practice Research Database.

Compared with controls, patients with severe psoriasis had a significantly increased risk of all-cause mortality (odds ratio 1.78), she said. After the researchers controlled for traditional cardiovascular risk factors, psoriasis patients had a clinically significant increased risk of cardiovascular death (hazard ratio [HR] 1.55). This risk was modified by age, with patients aged 40 and younger being at greater risk (HR 2.65) than patients aged between 41 and 60 (HR 1.90). This translated to an excess risk of 5.78 cardiovascular deaths per 10,000 person-years at age 40, and 58.9 per 10,000 person-years at age 60, she said.

Dr. Stern, who declared no conflicts of interest, agreed that cardiovascular risk factors are important, but his data suggest they are no more important than other risk factors.

The data show “that liver disease and nonmelanoma skin cancer accounted for more than half the approximately 70 excess deaths we observed,” he said. His prospective study followed 1,376 patients from the PUVA Follow-Up for 28 years, from 1976 to 2004. The patients had participated in a therapeutic PUVA study in 1975–1976 in 16 tertiary care academic centers across the United States.

Comparing the observed and expected mortality rates among patients and controls, the researchers found an increased all-cause mortality rate (HR 1.51) among only those patients with the most severe psoriasis. When cause of death was examined in this group, noncardiovascular reasons explained the increased risk (HR 1.74), and there was a nonsignificant increase in the rate of cardiovascular deaths, compared with controls (HR 1.29), Dr. Stern said.

“Dr. Stern's study results need to be interpreted with extreme caution due to the inherent bias in his study design,” warned Dr. Joel Gelfand, also of the University of Pennsylvania, and principal investigator on Dr. Azfar's study.

Dr. Stern's study design compares apples to oranges, commented Dr. Gelfand. “Patients who participate in psoriasis clinical trials at tertiary care medical centers may be healthier, better educated, and have better access to medical care than the general U.S. population,” he noted. “Our study … was population based.”

'Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done.' DR. AZFAR

MONTREAL — Mortality rates are significantly increased in patients with severe psoriasis compared with the general population, according to two new studies.

But studies have conflicting results regarding the cause of death, researchers reported at the annual meeting of the Society for Investigative Dermatology. A study by Dr. Rahat Azfar showed an age-dependent, significantly increased risk of cardiovascular death with severe psoriasis, compared with patients without psoriasis.

“Severe psoriasis may be an independent risk factor for cardiovascular mortality,” noted Dr. Azfar of the University of Pennsylvania, Philadelphia, whose study showed a 50% increase in cardiovascular death.

Her findings are in direct contrast to another study presented in the same session and conflict with a growing body of evidence. Dr. Robert Stern presented results from the 30-year PUVA Follow-Up Study, which showed no increase in cardiovascular death risk in severe psoriasis patients, all of whom had undergone PUVA.

“In patients with extremely severe psoriasis, there is an increased risk of death from noncardiovascular, but not cardiovascular causes,” said Dr. Stern, professor of dermatology at Harvard Medical School and vice chair of dermatology at Beth Israel Deaconess Medical Center in Boston.

“Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done,” commented Dr. Azfar, who declared no conflicts of interest.

Her study, which she presented at the meeting, was funded by the National Institutes of Health and a grant from Centocor. It examined more than 3,000 patients with severe psoriasis, matched to more than 14,000 controls from the United Kingdom's General Practice Research Database.

Compared with controls, patients with severe psoriasis had a significantly increased risk of all-cause mortality (odds ratio 1.78), she said. After the researchers controlled for traditional cardiovascular risk factors, psoriasis patients had a clinically significant increased risk of cardiovascular death (hazard ratio [HR] 1.55). This risk was modified by age, with patients aged 40 and younger being at greater risk (HR 2.65) than patients aged between 41 and 60 (HR 1.90). This translated to an excess risk of 5.78 cardiovascular deaths per 10,000 person-years at age 40, and 58.9 per 10,000 person-years at age 60, she said.

Dr. Stern, who declared no conflicts of interest, agreed that cardiovascular risk factors are important, but his data suggest they are no more important than other risk factors.

The data show “that liver disease and nonmelanoma skin cancer accounted for more than half the approximately 70 excess deaths we observed,” he said. His prospective study followed 1,376 patients from the PUVA Follow-Up for 28 years, from 1976 to 2004. The patients had participated in a therapeutic PUVA study in 1975–1976 in 16 tertiary care academic centers across the United States.

Comparing the observed and expected mortality rates among patients and controls, the researchers found an increased all-cause mortality rate (HR 1.51) among only those patients with the most severe psoriasis. When cause of death was examined in this group, noncardiovascular reasons explained the increased risk (HR 1.74), and there was a nonsignificant increase in the rate of cardiovascular deaths, compared with controls (HR 1.29), Dr. Stern said.

“Dr. Stern's study results need to be interpreted with extreme caution due to the inherent bias in his study design,” warned Dr. Joel Gelfand, also of the University of Pennsylvania, and principal investigator on Dr. Azfar's study.

Dr. Stern's study design compares apples to oranges, commented Dr. Gelfand. “Patients who participate in psoriasis clinical trials at tertiary care medical centers may be healthier, better educated, and have better access to medical care than the general U.S. population,” he noted. “Our study … was population based.”

'Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done.' DR. AZFAR

MONTREAL — Mortality rates are significantly increased in patients with severe psoriasis compared with the general population, according to two new studies.

But studies have conflicting results regarding the cause of death, researchers reported at the annual meeting of the Society for Investigative Dermatology. A study by Dr. Rahat Azfar showed an age-dependent, significantly increased risk of cardiovascular death with severe psoriasis, compared with patients without psoriasis.

“Severe psoriasis may be an independent risk factor for cardiovascular mortality,” noted Dr. Azfar of the University of Pennsylvania, Philadelphia, whose study showed a 50% increase in cardiovascular death.

Her findings are in direct contrast to another study presented in the same session and conflict with a growing body of evidence. Dr. Robert Stern presented results from the 30-year PUVA Follow-Up Study, which showed no increase in cardiovascular death risk in severe psoriasis patients, all of whom had undergone PUVA.

“In patients with extremely severe psoriasis, there is an increased risk of death from noncardiovascular, but not cardiovascular causes,” said Dr. Stern, professor of dermatology at Harvard Medical School and vice chair of dermatology at Beth Israel Deaconess Medical Center in Boston.

“Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done,” commented Dr. Azfar, who declared no conflicts of interest.

Her study, which she presented at the meeting, was funded by the National Institutes of Health and a grant from Centocor. It examined more than 3,000 patients with severe psoriasis, matched to more than 14,000 controls from the United Kingdom's General Practice Research Database.

Compared with controls, patients with severe psoriasis had a significantly increased risk of all-cause mortality (odds ratio 1.78), she said. After the researchers controlled for traditional cardiovascular risk factors, psoriasis patients had a clinically significant increased risk of cardiovascular death (hazard ratio [HR] 1.55). This risk was modified by age, with patients aged 40 and younger being at greater risk (HR 2.65) than patients aged between 41 and 60 (HR 1.90). This translated to an excess risk of 5.78 cardiovascular deaths per 10,000 person-years at age 40, and 58.9 per 10,000 person-years at age 60, she said.

Dr. Stern, who declared no conflicts of interest, agreed that cardiovascular risk factors are important, but his data suggest they are no more important than other risk factors.

The data show “that liver disease and nonmelanoma skin cancer accounted for more than half the approximately 70 excess deaths we observed,” he said. His prospective study followed 1,376 patients from the PUVA Follow-Up for 28 years, from 1976 to 2004. The patients had participated in a therapeutic PUVA study in 1975–1976 in 16 tertiary care academic centers across the United States.

Comparing the observed and expected mortality rates among patients and controls, the researchers found an increased all-cause mortality rate (HR 1.51) among only those patients with the most severe psoriasis. When cause of death was examined in this group, noncardiovascular reasons explained the increased risk (HR 1.74), and there was a nonsignificant increase in the rate of cardiovascular deaths, compared with controls (HR 1.29), Dr. Stern said.

“Dr. Stern's study results need to be interpreted with extreme caution due to the inherent bias in his study design,” warned Dr. Joel Gelfand, also of the University of Pennsylvania, and principal investigator on Dr. Azfar's study.

Dr. Stern's study design compares apples to oranges, commented Dr. Gelfand. “Patients who participate in psoriasis clinical trials at tertiary care medical centers may be healthier, better educated, and have better access to medical care than the general U.S. population,” he noted. “Our study … was population based.”

'Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done.' DR. AZFAR