Ted Bosworth

NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.

"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.

An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.

The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.

"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."

Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.

Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.

Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.

The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.

"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.

However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.

Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.

Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.

NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.

"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.

An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.

The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.

"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."

Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.

Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.

Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.

The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.

"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.

However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.

Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.

Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.

NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.

"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.

An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.

The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.

"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."

Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.

Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.

Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.

The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.

"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.

However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.

Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.

Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.

NEW YORK – Unexpectedly and conflicting with previous reports, a careful analysis of a relatively large series of patients with psoriatic arthritis mutilans found that most had axial involvement.

In a series of 56 patients with psoriatic arthritis (PsA) mutilans drawn from 610 consecutive patients with PsA, 65% had evidence of axial disease on the most recent radiograph. Of these, 57% had radiographic sacroiliitis, which was bilateral in 80%.

"This proportion far exceeds the typical 25% incidence of axial disease reported in the literature," according to Dr. Deepak Jadon, a specialist registrar in rheumatology at the Royal National Hospital for Rheumatic Diseases, Bath, England.

The proportion of confirmed PsA mutilans cases, at 9%, was also higher than the 5% typically reported, according to Dr. Jadon, who presented these findings at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Referral to a specialty clinic may explain the higher rate, but PsA mutilans could only be ruled out, because of inadequate radiographs, in 483 of the 610 patients, so the actual proportion could be even higher.

In 35 of the patients with PsA mutilans, defined as osteolysis involving at least 50% of the visualized articular surface on both sides of the joints, serial radiographs confirmed that this disease is progressive. In this series, 37% of the patients had PsA mutilans at the time of the first radiograph, but the rest developed PsA mutilans over the course of follow-up.

Of this second group, 84% had received a disease-modifying antirheumatic drug (DMARD) prior to developing PsA mutilans, an observation that "suggests DMARDs may not prevent the onset of this condition," Dr. Jadon reported, cautioning that there are other potential explanations.

Using a random-effects model, "different patterns of progression were observed in the feet and hands," Dr. Jadon reported. In both groups, the most common pattern was an initial surge of activity followed by a tapering of rate of progression. However, a second surge of activity in the hands was not observed in the feet.

When compared to unaffected PsA patients, those with PsA mutilans were on average younger (33 vs. 40 years; P = .039) and more likely to have nail dystrophy (83% vs. 45%; P = .0002). The severity of nail dystrophy appeared to correlate with the severity of joint involvement.

The most commonly affected joints in this series were the metatarsophalangeal joint of the big toe, the proximal interphalangeal joint of the thumb, and the metacarpophalangeal joint of the index finger. While many patients had monoarticular involvement at the time of diagnosis, 80% of patients in this series had polyarticular disease on the most recent radiograph.

Not surprisingly, functional limitations were significantly greater for patients with PsA mutilans on standardized health assessment questionnaire (HAQ) when compared with patients with PsA (P = .048). The differences involved functions affecting both the hands, such as those relevant to grip strength, and the feet.

Data from this series did not provide any insight on treatment efficacy. Biologic use in those with serial radiographs, which included a sizeable number of patients managed before the biologic era, was too infrequent to infer effect on disease progression. However, the frequent exposure to DMARDs in patients with documented progression suggests benefits may be limited.

Dr. Jadon suggested that prospective data for PsA mutilans, which is widely regarded as the least common but most severe form of PsA, are now needed to determine which treatments have the greatest potential to improve long-term outcome.

Dr. Jadon reported no potential conflicts of interest.

NEW YORK – Unexpectedly and conflicting with previous reports, a careful analysis of a relatively large series of patients with psoriatic arthritis mutilans found that most had axial involvement.

In a series of 56 patients with psoriatic arthritis (PsA) mutilans drawn from 610 consecutive patients with PsA, 65% had evidence of axial disease on the most recent radiograph. Of these, 57% had radiographic sacroiliitis, which was bilateral in 80%.

"This proportion far exceeds the typical 25% incidence of axial disease reported in the literature," according to Dr. Deepak Jadon, a specialist registrar in rheumatology at the Royal National Hospital for Rheumatic Diseases, Bath, England.

The proportion of confirmed PsA mutilans cases, at 9%, was also higher than the 5% typically reported, according to Dr. Jadon, who presented these findings at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Referral to a specialty clinic may explain the higher rate, but PsA mutilans could only be ruled out, because of inadequate radiographs, in 483 of the 610 patients, so the actual proportion could be even higher.

In 35 of the patients with PsA mutilans, defined as osteolysis involving at least 50% of the visualized articular surface on both sides of the joints, serial radiographs confirmed that this disease is progressive. In this series, 37% of the patients had PsA mutilans at the time of the first radiograph, but the rest developed PsA mutilans over the course of follow-up.

Of this second group, 84% had received a disease-modifying antirheumatic drug (DMARD) prior to developing PsA mutilans, an observation that "suggests DMARDs may not prevent the onset of this condition," Dr. Jadon reported, cautioning that there are other potential explanations.

Using a random-effects model, "different patterns of progression were observed in the feet and hands," Dr. Jadon reported. In both groups, the most common pattern was an initial surge of activity followed by a tapering of rate of progression. However, a second surge of activity in the hands was not observed in the feet.

When compared to unaffected PsA patients, those with PsA mutilans were on average younger (33 vs. 40 years; P = .039) and more likely to have nail dystrophy (83% vs. 45%; P = .0002). The severity of nail dystrophy appeared to correlate with the severity of joint involvement.

The most commonly affected joints in this series were the metatarsophalangeal joint of the big toe, the proximal interphalangeal joint of the thumb, and the metacarpophalangeal joint of the index finger. While many patients had monoarticular involvement at the time of diagnosis, 80% of patients in this series had polyarticular disease on the most recent radiograph.

Not surprisingly, functional limitations were significantly greater for patients with PsA mutilans on standardized health assessment questionnaire (HAQ) when compared with patients with PsA (P = .048). The differences involved functions affecting both the hands, such as those relevant to grip strength, and the feet.

Data from this series did not provide any insight on treatment efficacy. Biologic use in those with serial radiographs, which included a sizeable number of patients managed before the biologic era, was too infrequent to infer effect on disease progression. However, the frequent exposure to DMARDs in patients with documented progression suggests benefits may be limited.

Dr. Jadon suggested that prospective data for PsA mutilans, which is widely regarded as the least common but most severe form of PsA, are now needed to determine which treatments have the greatest potential to improve long-term outcome.

Dr. Jadon reported no potential conflicts of interest.

NEW YORK – Unexpectedly and conflicting with previous reports, a careful analysis of a relatively large series of patients with psoriatic arthritis mutilans found that most had axial involvement.

In a series of 56 patients with psoriatic arthritis (PsA) mutilans drawn from 610 consecutive patients with PsA, 65% had evidence of axial disease on the most recent radiograph. Of these, 57% had radiographic sacroiliitis, which was bilateral in 80%.

"This proportion far exceeds the typical 25% incidence of axial disease reported in the literature," according to Dr. Deepak Jadon, a specialist registrar in rheumatology at the Royal National Hospital for Rheumatic Diseases, Bath, England.

The proportion of confirmed PsA mutilans cases, at 9%, was also higher than the 5% typically reported, according to Dr. Jadon, who presented these findings at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Referral to a specialty clinic may explain the higher rate, but PsA mutilans could only be ruled out, because of inadequate radiographs, in 483 of the 610 patients, so the actual proportion could be even higher.

In 35 of the patients with PsA mutilans, defined as osteolysis involving at least 50% of the visualized articular surface on both sides of the joints, serial radiographs confirmed that this disease is progressive. In this series, 37% of the patients had PsA mutilans at the time of the first radiograph, but the rest developed PsA mutilans over the course of follow-up.

Of this second group, 84% had received a disease-modifying antirheumatic drug (DMARD) prior to developing PsA mutilans, an observation that "suggests DMARDs may not prevent the onset of this condition," Dr. Jadon reported, cautioning that there are other potential explanations.

Using a random-effects model, "different patterns of progression were observed in the feet and hands," Dr. Jadon reported. In both groups, the most common pattern was an initial surge of activity followed by a tapering of rate of progression. However, a second surge of activity in the hands was not observed in the feet.

When compared to unaffected PsA patients, those with PsA mutilans were on average younger (33 vs. 40 years; P = .039) and more likely to have nail dystrophy (83% vs. 45%; P = .0002). The severity of nail dystrophy appeared to correlate with the severity of joint involvement.

The most commonly affected joints in this series were the metatarsophalangeal joint of the big toe, the proximal interphalangeal joint of the thumb, and the metacarpophalangeal joint of the index finger. While many patients had monoarticular involvement at the time of diagnosis, 80% of patients in this series had polyarticular disease on the most recent radiograph.

Not surprisingly, functional limitations were significantly greater for patients with PsA mutilans on standardized health assessment questionnaire (HAQ) when compared with patients with PsA (P = .048). The differences involved functions affecting both the hands, such as those relevant to grip strength, and the feet.

Data from this series did not provide any insight on treatment efficacy. Biologic use in those with serial radiographs, which included a sizeable number of patients managed before the biologic era, was too infrequent to infer effect on disease progression. However, the frequent exposure to DMARDs in patients with documented progression suggests benefits may be limited.

Dr. Jadon suggested that prospective data for PsA mutilans, which is widely regarded as the least common but most severe form of PsA, are now needed to determine which treatments have the greatest potential to improve long-term outcome.

Dr. Jadon reported no potential conflicts of interest.

NEW YORK – Improvements in clinical trial design for psoriasis, psoriatic arthritis, and other inflammatory diseases are being credited to a decision to enlist patients as full partners, not just advisors or consultants, in research initiatives.

"Rheumatologists, I think, have been leaders is recognizing that patients can bring an expertise to clinical research that is unique and ensure that study endpoints are relevant to outcomes important to them," reported Dr. William Tillett, a research fellow in the department of rheumatology at the Royal National Hospital for Rheumatic Diseases in Bath, England.

The value of patient research partners (PRP) was a recurring theme at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network. GRAPPA, in particular, has been fostering research collaborations with patients since 2006.

"It has been an evolution. Patients were initially enlisted to sit in when trial designs were being discussed. Now, we are talking about full partnership so that they are involved at the inception with equal partnership that includes veto power and author credit," Dr. Tillett explained.

At the GRAPPA meeting, an afternoon symposium was devoted to optimal strategies for fostering collaboration with PRPs, which builds on work already initiated with a group called Patient Involvement for Outcome Measures in PsA (PIOMPsA). In turn, PIOMPsA, formed 2 years ago, was largely modeled on PRP initiatives led by OMERACT (Outcomes Measurement in Rheumatology).

"OMERACT has been involving patients in clinical research design for about 10 years," reported Dr. Philip J. Mease, director of rheumatology research at Swedish Medical Center, Seattle. "The idea of making patients full-blown partners is more recent, but I think there is increasing appreciation for what the right patients can contribute to improve study design."

The initiatives are spreading through rheumatology and other inflammatory diseases. At the GRAPPA meeting, updates on patient initiatives to influence clinical research were presented not only from the work of PIOMPsA and OMERACT but also from the International Dermatology Outcomes Measures (IDEOM) consortium. Created in collaboration with the National Psoriasis Foundation (NPF), IDEOM is bringing clinicians and patients together to define standard outcome measures.

"There are no really good measures to evaluate relative severity of psoriasis from the patient’s perspective," reported Dr. Alice Gottlieb, professor of dermatology at Tufts Medical Center, Boston. Tools traditionally used in clinical trials, such as the Psoriasis Area Severity Index (PASI) "are not practical in the clinic" and do not necessarily reflect the impact of psoriasis on quality of life when used as a study endpoint, she said.

PIOMPsA has now conducted several meetings, including one held in conjunction with OMERACT in Budapest, Hungary, in early May 2014. Like IDEOM, PIOMPsA has been focused on developing consensus on core symptoms of its target inflammatory disease. This is critical because the ability of clinical trials to generate relevant data is dependent on first defining meaningful endpoints, according to Dr. Tillett, who presented the PIOMPsA deliberations at the GRAPPA meeting.

In Budapest, for example, a vote was taken on whether to add fatigue to a list of core symptoms for PsA that includes impaired physical function, skin lesions, and joint pain. Fatigue was added to the list by a vote in which 70% supported it as a core PsA symptom, said Dr. Tillett, who recently published on the goals and underlying concepts of PIOMPsA (Curr. Rheumatol. Rep. 2014;16:418).

According to Dr. Tillett and Dr. Mease, PRPs are an answer to the repeatedly reported disconnect between physicians and patients in rating disease severity. By involving patients with interest in clinical research and collaborative skills, treatment trials have the potential to generate data more useful to practical patient management.

"It will be very difficult to show objectively that patient-aided trial design leads to better studies, but this is a reasonable expectation. I think that the contributions we have already seen from these collaborations bear this out," said Dr. Tillett, who expects the concept to spread to other fields of medicine.

Dr. Tillett reported financial relationships with AbbVie and Amgen. Dr. Mease reported financial relationships with AbbVie, Amgen, Biogen Idec, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, Janssen Pharmaceuticals, Lilly, Merck & Co, Novartis, Pfizer, UCB Pharma, and Vertex. Dr. Gottlieb reported financial relationships with Abbott, Actelion, Amgen, Bristol-Myers Squibb, Celgene, Centocor, Novo Nordisk, Teva, and UCB.

NEW YORK – Improvements in clinical trial design for psoriasis, psoriatic arthritis, and other inflammatory diseases are being credited to a decision to enlist patients as full partners, not just advisors or consultants, in research initiatives.

"Rheumatologists, I think, have been leaders is recognizing that patients can bring an expertise to clinical research that is unique and ensure that study endpoints are relevant to outcomes important to them," reported Dr. William Tillett, a research fellow in the department of rheumatology at the Royal National Hospital for Rheumatic Diseases in Bath, England.

The value of patient research partners (PRP) was a recurring theme at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network. GRAPPA, in particular, has been fostering research collaborations with patients since 2006.

"It has been an evolution. Patients were initially enlisted to sit in when trial designs were being discussed. Now, we are talking about full partnership so that they are involved at the inception with equal partnership that includes veto power and author credit," Dr. Tillett explained.

At the GRAPPA meeting, an afternoon symposium was devoted to optimal strategies for fostering collaboration with PRPs, which builds on work already initiated with a group called Patient Involvement for Outcome Measures in PsA (PIOMPsA). In turn, PIOMPsA, formed 2 years ago, was largely modeled on PRP initiatives led by OMERACT (Outcomes Measurement in Rheumatology).

"OMERACT has been involving patients in clinical research design for about 10 years," reported Dr. Philip J. Mease, director of rheumatology research at Swedish Medical Center, Seattle. "The idea of making patients full-blown partners is more recent, but I think there is increasing appreciation for what the right patients can contribute to improve study design."

The initiatives are spreading through rheumatology and other inflammatory diseases. At the GRAPPA meeting, updates on patient initiatives to influence clinical research were presented not only from the work of PIOMPsA and OMERACT but also from the International Dermatology Outcomes Measures (IDEOM) consortium. Created in collaboration with the National Psoriasis Foundation (NPF), IDEOM is bringing clinicians and patients together to define standard outcome measures.

"There are no really good measures to evaluate relative severity of psoriasis from the patient’s perspective," reported Dr. Alice Gottlieb, professor of dermatology at Tufts Medical Center, Boston. Tools traditionally used in clinical trials, such as the Psoriasis Area Severity Index (PASI) "are not practical in the clinic" and do not necessarily reflect the impact of psoriasis on quality of life when used as a study endpoint, she said.

PIOMPsA has now conducted several meetings, including one held in conjunction with OMERACT in Budapest, Hungary, in early May 2014. Like IDEOM, PIOMPsA has been focused on developing consensus on core symptoms of its target inflammatory disease. This is critical because the ability of clinical trials to generate relevant data is dependent on first defining meaningful endpoints, according to Dr. Tillett, who presented the PIOMPsA deliberations at the GRAPPA meeting.

In Budapest, for example, a vote was taken on whether to add fatigue to a list of core symptoms for PsA that includes impaired physical function, skin lesions, and joint pain. Fatigue was added to the list by a vote in which 70% supported it as a core PsA symptom, said Dr. Tillett, who recently published on the goals and underlying concepts of PIOMPsA (Curr. Rheumatol. Rep. 2014;16:418).

According to Dr. Tillett and Dr. Mease, PRPs are an answer to the repeatedly reported disconnect between physicians and patients in rating disease severity. By involving patients with interest in clinical research and collaborative skills, treatment trials have the potential to generate data more useful to practical patient management.

"It will be very difficult to show objectively that patient-aided trial design leads to better studies, but this is a reasonable expectation. I think that the contributions we have already seen from these collaborations bear this out," said Dr. Tillett, who expects the concept to spread to other fields of medicine.

Dr. Tillett reported financial relationships with AbbVie and Amgen. Dr. Mease reported financial relationships with AbbVie, Amgen, Biogen Idec, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, Janssen Pharmaceuticals, Lilly, Merck & Co, Novartis, Pfizer, UCB Pharma, and Vertex. Dr. Gottlieb reported financial relationships with Abbott, Actelion, Amgen, Bristol-Myers Squibb, Celgene, Centocor, Novo Nordisk, Teva, and UCB.

NEW YORK – Improvements in clinical trial design for psoriasis, psoriatic arthritis, and other inflammatory diseases are being credited to a decision to enlist patients as full partners, not just advisors or consultants, in research initiatives.

"Rheumatologists, I think, have been leaders is recognizing that patients can bring an expertise to clinical research that is unique and ensure that study endpoints are relevant to outcomes important to them," reported Dr. William Tillett, a research fellow in the department of rheumatology at the Royal National Hospital for Rheumatic Diseases in Bath, England.

The value of patient research partners (PRP) was a recurring theme at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network. GRAPPA, in particular, has been fostering research collaborations with patients since 2006.

"It has been an evolution. Patients were initially enlisted to sit in when trial designs were being discussed. Now, we are talking about full partnership so that they are involved at the inception with equal partnership that includes veto power and author credit," Dr. Tillett explained.

At the GRAPPA meeting, an afternoon symposium was devoted to optimal strategies for fostering collaboration with PRPs, which builds on work already initiated with a group called Patient Involvement for Outcome Measures in PsA (PIOMPsA). In turn, PIOMPsA, formed 2 years ago, was largely modeled on PRP initiatives led by OMERACT (Outcomes Measurement in Rheumatology).

"OMERACT has been involving patients in clinical research design for about 10 years," reported Dr. Philip J. Mease, director of rheumatology research at Swedish Medical Center, Seattle. "The idea of making patients full-blown partners is more recent, but I think there is increasing appreciation for what the right patients can contribute to improve study design."

The initiatives are spreading through rheumatology and other inflammatory diseases. At the GRAPPA meeting, updates on patient initiatives to influence clinical research were presented not only from the work of PIOMPsA and OMERACT but also from the International Dermatology Outcomes Measures (IDEOM) consortium. Created in collaboration with the National Psoriasis Foundation (NPF), IDEOM is bringing clinicians and patients together to define standard outcome measures.

"There are no really good measures to evaluate relative severity of psoriasis from the patient’s perspective," reported Dr. Alice Gottlieb, professor of dermatology at Tufts Medical Center, Boston. Tools traditionally used in clinical trials, such as the Psoriasis Area Severity Index (PASI) "are not practical in the clinic" and do not necessarily reflect the impact of psoriasis on quality of life when used as a study endpoint, she said.

PIOMPsA has now conducted several meetings, including one held in conjunction with OMERACT in Budapest, Hungary, in early May 2014. Like IDEOM, PIOMPsA has been focused on developing consensus on core symptoms of its target inflammatory disease. This is critical because the ability of clinical trials to generate relevant data is dependent on first defining meaningful endpoints, according to Dr. Tillett, who presented the PIOMPsA deliberations at the GRAPPA meeting.

In Budapest, for example, a vote was taken on whether to add fatigue to a list of core symptoms for PsA that includes impaired physical function, skin lesions, and joint pain. Fatigue was added to the list by a vote in which 70% supported it as a core PsA symptom, said Dr. Tillett, who recently published on the goals and underlying concepts of PIOMPsA (Curr. Rheumatol. Rep. 2014;16:418).

According to Dr. Tillett and Dr. Mease, PRPs are an answer to the repeatedly reported disconnect between physicians and patients in rating disease severity. By involving patients with interest in clinical research and collaborative skills, treatment trials have the potential to generate data more useful to practical patient management.

"It will be very difficult to show objectively that patient-aided trial design leads to better studies, but this is a reasonable expectation. I think that the contributions we have already seen from these collaborations bear this out," said Dr. Tillett, who expects the concept to spread to other fields of medicine.

Dr. Tillett reported financial relationships with AbbVie and Amgen. Dr. Mease reported financial relationships with AbbVie, Amgen, Biogen Idec, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, Janssen Pharmaceuticals, Lilly, Merck & Co, Novartis, Pfizer, UCB Pharma, and Vertex. Dr. Gottlieb reported financial relationships with Abbott, Actelion, Amgen, Bristol-Myers Squibb, Celgene, Centocor, Novo Nordisk, Teva, and UCB.

NEW YORK – For the skin component of psoriatic arthritis, consensus about how high to set the bar for disease control continues to elude experts, judging from a debate about the value of "clear" or "almost clear" as the most acceptable treatment endpoints.

Current therapies in psoriatic arthritis (PsA) are sufficiently effective to support a treat-to-target approach for both skin lesions and joint inflammation, but there is lack of consensus about which metrics should be employed to define any specific target for skin lesions, according to Dr. Joel Gelfand, medical director of the clinical studies unit in the department of dermatology at the University of Pennsylvania, Philadelphia. He noted that even if the goal is the absence of skin involvement, no one agrees on what method should be used to document this endpoint.

"No one in clinical practice uses PASI," maintained Dr. Gelfand, referring to the Psoriasis and Area and Severity Index, which is one of the most widely accepted standards for judging efficacy in treatment trials. Speaking at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network, Dr. Gelfand said most objective scoring systems, such as PASI, are too labor intensive. Clinicians tend to use their own system for documenting relative control of skin lesions in the medical record.

Evaluating disease control without applying a reproducible, broadly used metric has numerous potential problems, according to Dr. Gelfand. Most importantly, it prevents objective evaluation of whether treatment targets are being met. This obscures efforts to document benefit relative to either clinical goals or optimal care. Dr. Gelfand made the analogy to the treatment goals created for blood pressure, blood glucose, or cholesterol, where the targets are clear and a change in treatment is warranted if the target is not reached.

This point of view resonated with the audience of dermatologists, rheumatologists, and PsA patients attending the meeting. In an electronic audience poll, there was nearly 100% agreement that a treat-to-target approach is appropriate for skin lesions but no strong consensus on what the target should be. In the poll attempting to define consensus, 32% agreed with a target of less than 3% body surface area (BSA) while 48% agreed the BSA target should be less than 1%. It is notable that dermatologists were more likely to accept a less rigorous BSA than rheumatologists. The majority of patients agreed the target should be less than 1% BSA, although this group represented less than 10% of the audience.

Not surprisingly, health-related quality of life studies show measurable differences between "clear" and "almost clear" skin lesions in PsA patients whether measured by PASI, BSA, or other measures, according to Dr. Gelfand, but he cautioned that it is important to be realistic about goals. He suggested that a target that exposes patients to unacceptable side effects is the wrong target, and this may be the source of dissension among experts.

Asked for a comment, Dr. Wolf-Henning Boehncke, professor and chair of the department of dermatology at the University of Geneva agreed in principle with the treat-to-target approach. However, Dr. Boehncke, who is the current president of GRAPPA, also emphasized simple and practical assessment tools and achievable endpoints.

"We must define targets that are reasonable," Dr. Boehncke said. While complex patient assessment tools are not likely to be widely used by clinicians, unrealistic targets can be counterproductive if they are not considered in the overall context of tolerability and patient satisfaction.

Dr. Gelfand has or has had financial relationships with AbbVie, Amgen, Celgene, Eli Lilly, Genentech, Janssen, Merck, Novartis, and Pfizer.

NEW YORK – For the skin component of psoriatic arthritis, consensus about how high to set the bar for disease control continues to elude experts, judging from a debate about the value of "clear" or "almost clear" as the most acceptable treatment endpoints.

Current therapies in psoriatic arthritis (PsA) are sufficiently effective to support a treat-to-target approach for both skin lesions and joint inflammation, but there is lack of consensus about which metrics should be employed to define any specific target for skin lesions, according to Dr. Joel Gelfand, medical director of the clinical studies unit in the department of dermatology at the University of Pennsylvania, Philadelphia. He noted that even if the goal is the absence of skin involvement, no one agrees on what method should be used to document this endpoint.

"No one in clinical practice uses PASI," maintained Dr. Gelfand, referring to the Psoriasis and Area and Severity Index, which is one of the most widely accepted standards for judging efficacy in treatment trials. Speaking at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network, Dr. Gelfand said most objective scoring systems, such as PASI, are too labor intensive. Clinicians tend to use their own system for documenting relative control of skin lesions in the medical record.

Evaluating disease control without applying a reproducible, broadly used metric has numerous potential problems, according to Dr. Gelfand. Most importantly, it prevents objective evaluation of whether treatment targets are being met. This obscures efforts to document benefit relative to either clinical goals or optimal care. Dr. Gelfand made the analogy to the treatment goals created for blood pressure, blood glucose, or cholesterol, where the targets are clear and a change in treatment is warranted if the target is not reached.

This point of view resonated with the audience of dermatologists, rheumatologists, and PsA patients attending the meeting. In an electronic audience poll, there was nearly 100% agreement that a treat-to-target approach is appropriate for skin lesions but no strong consensus on what the target should be. In the poll attempting to define consensus, 32% agreed with a target of less than 3% body surface area (BSA) while 48% agreed the BSA target should be less than 1%. It is notable that dermatologists were more likely to accept a less rigorous BSA than rheumatologists. The majority of patients agreed the target should be less than 1% BSA, although this group represented less than 10% of the audience.

Not surprisingly, health-related quality of life studies show measurable differences between "clear" and "almost clear" skin lesions in PsA patients whether measured by PASI, BSA, or other measures, according to Dr. Gelfand, but he cautioned that it is important to be realistic about goals. He suggested that a target that exposes patients to unacceptable side effects is the wrong target, and this may be the source of dissension among experts.

Asked for a comment, Dr. Wolf-Henning Boehncke, professor and chair of the department of dermatology at the University of Geneva agreed in principle with the treat-to-target approach. However, Dr. Boehncke, who is the current president of GRAPPA, also emphasized simple and practical assessment tools and achievable endpoints.

"We must define targets that are reasonable," Dr. Boehncke said. While complex patient assessment tools are not likely to be widely used by clinicians, unrealistic targets can be counterproductive if they are not considered in the overall context of tolerability and patient satisfaction.

Dr. Gelfand has or has had financial relationships with AbbVie, Amgen, Celgene, Eli Lilly, Genentech, Janssen, Merck, Novartis, and Pfizer.

NEW YORK – For the skin component of psoriatic arthritis, consensus about how high to set the bar for disease control continues to elude experts, judging from a debate about the value of "clear" or "almost clear" as the most acceptable treatment endpoints.

Current therapies in psoriatic arthritis (PsA) are sufficiently effective to support a treat-to-target approach for both skin lesions and joint inflammation, but there is lack of consensus about which metrics should be employed to define any specific target for skin lesions, according to Dr. Joel Gelfand, medical director of the clinical studies unit in the department of dermatology at the University of Pennsylvania, Philadelphia. He noted that even if the goal is the absence of skin involvement, no one agrees on what method should be used to document this endpoint.

"No one in clinical practice uses PASI," maintained Dr. Gelfand, referring to the Psoriasis and Area and Severity Index, which is one of the most widely accepted standards for judging efficacy in treatment trials. Speaking at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network, Dr. Gelfand said most objective scoring systems, such as PASI, are too labor intensive. Clinicians tend to use their own system for documenting relative control of skin lesions in the medical record.

Evaluating disease control without applying a reproducible, broadly used metric has numerous potential problems, according to Dr. Gelfand. Most importantly, it prevents objective evaluation of whether treatment targets are being met. This obscures efforts to document benefit relative to either clinical goals or optimal care. Dr. Gelfand made the analogy to the treatment goals created for blood pressure, blood glucose, or cholesterol, where the targets are clear and a change in treatment is warranted if the target is not reached.

This point of view resonated with the audience of dermatologists, rheumatologists, and PsA patients attending the meeting. In an electronic audience poll, there was nearly 100% agreement that a treat-to-target approach is appropriate for skin lesions but no strong consensus on what the target should be. In the poll attempting to define consensus, 32% agreed with a target of less than 3% body surface area (BSA) while 48% agreed the BSA target should be less than 1%. It is notable that dermatologists were more likely to accept a less rigorous BSA than rheumatologists. The majority of patients agreed the target should be less than 1% BSA, although this group represented less than 10% of the audience.

Not surprisingly, health-related quality of life studies show measurable differences between "clear" and "almost clear" skin lesions in PsA patients whether measured by PASI, BSA, or other measures, according to Dr. Gelfand, but he cautioned that it is important to be realistic about goals. He suggested that a target that exposes patients to unacceptable side effects is the wrong target, and this may be the source of dissension among experts.

Asked for a comment, Dr. Wolf-Henning Boehncke, professor and chair of the department of dermatology at the University of Geneva agreed in principle with the treat-to-target approach. However, Dr. Boehncke, who is the current president of GRAPPA, also emphasized simple and practical assessment tools and achievable endpoints.

"We must define targets that are reasonable," Dr. Boehncke said. While complex patient assessment tools are not likely to be widely used by clinicians, unrealistic targets can be counterproductive if they are not considered in the overall context of tolerability and patient satisfaction.

Dr. Gelfand has or has had financial relationships with AbbVie, Amgen, Celgene, Eli Lilly, Genentech, Janssen, Merck, Novartis, and Pfizer.

NEW YORK – Clinicians, think about how to eliminate – not just reduce – the risk of exposure to bloodborne pathogens in your practice, said Dr. Joseph F. Sobanko of the University of Pennsylvania, Philadelphia.

"Dermatology, with its balance of medical and surgical procedures, is a specialty with unique risks," Dr. Sobanko said in a presentation at the American Academy of Dermatology summer meeting. While the risk of exposure to bloodborne pathogens is broadly shared in health-care delivery, Dr. Sobanko cited data from a recent survey of dermatology residents showing that confirmed rates of inadvertent exposure to patient blood remain high in this population (J. Am. Acad. Dermatol. 2011;65:648-50). Most instances of exposure were needle sticks.

"The majority of those surveyed considered themselves responsible for the exposure," said Dr. Sobanko. The list of safety procedures on how to avoid exposure to bloodborne pathogens is long, and includes never recapping needles and avoiding hand-to-hand transfer of sharps, he said.

However, Dr. Sobanko condensed his "zero-risk" recommendations into three principles: mental preparedness, physical protection, and motor repetition.

The violation of any of the three principles, and especially all three simultaneously, likely explains the evidence that injury risk is highest in individuals with the least training, he said.

One example of mental preparedness is detailed preoperative planning, such as placing the instrument tray in a convenient and neutral spot so that anyone involved in the procedure can access the tools, Dr. Sobanko said. In his own center, the nurses have been supplied with photos of proper setup of the instrument tray for each procedure so that all the tools are always placed in the same spot.

For physical protection, Dr. Sobanko emphasized the importance of using shields and goggles instead of glasses. He cited a study in which shields were tested for blood after asking clinicians if there had been blood splatter. The presence of blood was only correctly predicted 10% of the time. Dr. Sobanko also cited data supporting the safety of double-gloving. Although he acknowledged that some clinicians report reduced dexterity, he said that this relative disadvantage can probably be overcome with practice.

Performing the procedure repeatedly provides its own protection, according to Dr. Sobanko, who cited data of an inverse relationship between risk of exposure to a bloodborne pathogen and experience. These data suggests the need for greatly increased vigilance during procedures with which one is less familiar, he said.

Creating a culture of safety is also important, with emphasis on safety over speed. In the survey of dermatology residents, the sense of feeling rushed was identified as an important factor in needle stick injuries, Dr. Sobanko said.

Dr. Sobanko, who is preparing an atlas of procedural safety in dermatology with Dr. Jacob Levitt of Mount Sinai School of Medicine, N.Y., added that this culture shift to an emphasis on safety falls under his category of mental preparedness.

When asked for additional perspective on safety, Dr. William K. Andersen, a dermatologist in private practice in Lancaster, Penn., agreed with Dr. Sobanko’s points, but he suggested that it is not enough to post a list of safety procedures. All health-care personnel involved in a given procedure must function together.

"Everybody has to be on board even when you have the protocols in place," Dr. Anderson noted. When everyone is cooperating, there is less risk in the face of unexpected events, he said.

Dr. Sobanko had no relevant financial conflicts to disclose.

NEW YORK – Clinicians, think about how to eliminate – not just reduce – the risk of exposure to bloodborne pathogens in your practice, said Dr. Joseph F. Sobanko of the University of Pennsylvania, Philadelphia.

"Dermatology, with its balance of medical and surgical procedures, is a specialty with unique risks," Dr. Sobanko said in a presentation at the American Academy of Dermatology summer meeting. While the risk of exposure to bloodborne pathogens is broadly shared in health-care delivery, Dr. Sobanko cited data from a recent survey of dermatology residents showing that confirmed rates of inadvertent exposure to patient blood remain high in this population (J. Am. Acad. Dermatol. 2011;65:648-50). Most instances of exposure were needle sticks.

"The majority of those surveyed considered themselves responsible for the exposure," said Dr. Sobanko. The list of safety procedures on how to avoid exposure to bloodborne pathogens is long, and includes never recapping needles and avoiding hand-to-hand transfer of sharps, he said.

However, Dr. Sobanko condensed his "zero-risk" recommendations into three principles: mental preparedness, physical protection, and motor repetition.

The violation of any of the three principles, and especially all three simultaneously, likely explains the evidence that injury risk is highest in individuals with the least training, he said.

One example of mental preparedness is detailed preoperative planning, such as placing the instrument tray in a convenient and neutral spot so that anyone involved in the procedure can access the tools, Dr. Sobanko said. In his own center, the nurses have been supplied with photos of proper setup of the instrument tray for each procedure so that all the tools are always placed in the same spot.

For physical protection, Dr. Sobanko emphasized the importance of using shields and goggles instead of glasses. He cited a study in which shields were tested for blood after asking clinicians if there had been blood splatter. The presence of blood was only correctly predicted 10% of the time. Dr. Sobanko also cited data supporting the safety of double-gloving. Although he acknowledged that some clinicians report reduced dexterity, he said that this relative disadvantage can probably be overcome with practice.

Performing the procedure repeatedly provides its own protection, according to Dr. Sobanko, who cited data of an inverse relationship between risk of exposure to a bloodborne pathogen and experience. These data suggests the need for greatly increased vigilance during procedures with which one is less familiar, he said.

Creating a culture of safety is also important, with emphasis on safety over speed. In the survey of dermatology residents, the sense of feeling rushed was identified as an important factor in needle stick injuries, Dr. Sobanko said.

Dr. Sobanko, who is preparing an atlas of procedural safety in dermatology with Dr. Jacob Levitt of Mount Sinai School of Medicine, N.Y., added that this culture shift to an emphasis on safety falls under his category of mental preparedness.

When asked for additional perspective on safety, Dr. William K. Andersen, a dermatologist in private practice in Lancaster, Penn., agreed with Dr. Sobanko’s points, but he suggested that it is not enough to post a list of safety procedures. All health-care personnel involved in a given procedure must function together.

"Everybody has to be on board even when you have the protocols in place," Dr. Anderson noted. When everyone is cooperating, there is less risk in the face of unexpected events, he said.

Dr. Sobanko had no relevant financial conflicts to disclose.

NEW YORK – Clinicians, think about how to eliminate – not just reduce – the risk of exposure to bloodborne pathogens in your practice, said Dr. Joseph F. Sobanko of the University of Pennsylvania, Philadelphia.

"Dermatology, with its balance of medical and surgical procedures, is a specialty with unique risks," Dr. Sobanko said in a presentation at the American Academy of Dermatology summer meeting. While the risk of exposure to bloodborne pathogens is broadly shared in health-care delivery, Dr. Sobanko cited data from a recent survey of dermatology residents showing that confirmed rates of inadvertent exposure to patient blood remain high in this population (J. Am. Acad. Dermatol. 2011;65:648-50). Most instances of exposure were needle sticks.

"The majority of those surveyed considered themselves responsible for the exposure," said Dr. Sobanko. The list of safety procedures on how to avoid exposure to bloodborne pathogens is long, and includes never recapping needles and avoiding hand-to-hand transfer of sharps, he said.

However, Dr. Sobanko condensed his "zero-risk" recommendations into three principles: mental preparedness, physical protection, and motor repetition.

The violation of any of the three principles, and especially all three simultaneously, likely explains the evidence that injury risk is highest in individuals with the least training, he said.

One example of mental preparedness is detailed preoperative planning, such as placing the instrument tray in a convenient and neutral spot so that anyone involved in the procedure can access the tools, Dr. Sobanko said. In his own center, the nurses have been supplied with photos of proper setup of the instrument tray for each procedure so that all the tools are always placed in the same spot.

For physical protection, Dr. Sobanko emphasized the importance of using shields and goggles instead of glasses. He cited a study in which shields were tested for blood after asking clinicians if there had been blood splatter. The presence of blood was only correctly predicted 10% of the time. Dr. Sobanko also cited data supporting the safety of double-gloving. Although he acknowledged that some clinicians report reduced dexterity, he said that this relative disadvantage can probably be overcome with practice.

Performing the procedure repeatedly provides its own protection, according to Dr. Sobanko, who cited data of an inverse relationship between risk of exposure to a bloodborne pathogen and experience. These data suggests the need for greatly increased vigilance during procedures with which one is less familiar, he said.

Creating a culture of safety is also important, with emphasis on safety over speed. In the survey of dermatology residents, the sense of feeling rushed was identified as an important factor in needle stick injuries, Dr. Sobanko said.

Dr. Sobanko, who is preparing an atlas of procedural safety in dermatology with Dr. Jacob Levitt of Mount Sinai School of Medicine, N.Y., added that this culture shift to an emphasis on safety falls under his category of mental preparedness.

When asked for additional perspective on safety, Dr. William K. Andersen, a dermatologist in private practice in Lancaster, Penn., agreed with Dr. Sobanko’s points, but he suggested that it is not enough to post a list of safety procedures. All health-care personnel involved in a given procedure must function together.

"Everybody has to be on board even when you have the protocols in place," Dr. Anderson noted. When everyone is cooperating, there is less risk in the face of unexpected events, he said.

Dr. Sobanko had no relevant financial conflicts to disclose.

NEW YORK – One expert has characterized para-tertiary-butylphenol formaldehyde resin as a suitable candidate for the next pediatric contact allergen of the year, based on a growing number of case reports.

Para-tertiary-butylphenol (PTPB) formaldehyde resin is found in shin guards, push-up bras, and numerous other products used by children and adolescents.

Published case reports of contact allergies caused by PTPB formaldehyde resin date back several years, but use of this resin as an adhesive in a broad range of products – particularly leather goods, such as shoes, purses, and watch straps – appears to be increasing, according to Dr. Nanette B. Silverberg.

Dr. Silverberg presented a review of new trends in pediatric contact dermatitis at the American Academy of Dermatology summer meeting.

The causes of contact allergies in children evolve constantly because of the introduction of new products, and this should influence the order in which patch testing of specific allergens is performed, said Dr. Silverberg, a dermatologist at St. Luke’s–Roosevelt Hospital Center, New York.

In her update, she cited several recently designated "allergens of the year" from the American Contact Dermatitis Society (ACDS) and added some of her own.

Dr. Silverberg also emphasized tricks she has devised to increase the likelihood of a successful patch test, not least of which is enlisting parent cooperation. "It is important to convince parents that they are guilt free," she advised. In parents who begin to blame themselves for exposures, a sense of denial can interfere with efforts to cooperate with patch testing. To avoid this problem, she suggested a proactive effort to establish they are fault free. "Blame it on marketing if you must."

In light of the potential for lack of compliance, patch testing should be made as effortless as possible. For one approach, Dr. Silverberg suggested timing testing so it is not an excuse to miss school. Another tip was to use "heaps of tape and more tape" to keep the patch tests in place, and then provide patients with a roll of tape when they leave the office. She also recommended thinking in advance of strategies to reduce the risk of patch tests being inadvertently or intentionally removed by children, such as gauze wrap around the abdomen.

"The number one way to make patch tests work in young children is to keep your patch test panel streamlined and focused," Dr. Silverberg said. Particularly in young children, she suggested just one or two panels rather than three or four. While bribes such as lollipops and stickers "should be used judiciously," Dr. Silverberg said it is very helpful to outline each patch with highlighters that glow under Wood’s lamp to make results easier to assess.

Contact allergies are extremely common, and it is often possible to control the contact dermatitis before or even without confirming the allergen. For example, dialkyl thiourea, the ACDS allergen of the year in 2009, is another source of contact dermatitis to shin guards as well as other products, but reactions to this or PTPB formaldehyde resin can often be prevented simply by putting a layer of clothing in front of the skin. By the same principle, contact dermatitis from car seats is often caused by dimethyl fumerate, the ACDS allergen of the year in 2011, but can be prevented simply by laying fabric or creating some other barrier to prevent contact.

Methylisothiazolinone, a preservative and antifungal agent often found in moist towels and wipes, was recognized as the most recent (2013) ACDS allergen of the year. Dr. Silverberg noted that these wipes have surprisingly broad applications. While dermatitis on the hands and buttocks would be expected, she cautioned that patients use these to clean other skin surfaces, so a broad index of suspicion is needed.

The most common contact allergens, such as nickel, cobalt, and neomycin, remain relatively unchanged from year to year, but many of these products are used less frequently in children’s products in appreciation of the risks that they pose. The challenge is keeping abreast of evolving trends. While patch testing is an effective tool for identifying the source of a contact dermatitis to alert parents and patients of the products they should avoid, she said that technique is critical to patch test success.

Dr. Silverberg said she had no financial disclosures.

NEW YORK – One expert has characterized para-tertiary-butylphenol formaldehyde resin as a suitable candidate for the next pediatric contact allergen of the year, based on a growing number of case reports.

Para-tertiary-butylphenol (PTPB) formaldehyde resin is found in shin guards, push-up bras, and numerous other products used by children and adolescents.

Published case reports of contact allergies caused by PTPB formaldehyde resin date back several years, but use of this resin as an adhesive in a broad range of products – particularly leather goods, such as shoes, purses, and watch straps – appears to be increasing, according to Dr. Nanette B. Silverberg.

Dr. Silverberg presented a review of new trends in pediatric contact dermatitis at the American Academy of Dermatology summer meeting.

The causes of contact allergies in children evolve constantly because of the introduction of new products, and this should influence the order in which patch testing of specific allergens is performed, said Dr. Silverberg, a dermatologist at St. Luke’s–Roosevelt Hospital Center, New York.

In her update, she cited several recently designated "allergens of the year" from the American Contact Dermatitis Society (ACDS) and added some of her own.

Dr. Silverberg also emphasized tricks she has devised to increase the likelihood of a successful patch test, not least of which is enlisting parent cooperation. "It is important to convince parents that they are guilt free," she advised. In parents who begin to blame themselves for exposures, a sense of denial can interfere with efforts to cooperate with patch testing. To avoid this problem, she suggested a proactive effort to establish they are fault free. "Blame it on marketing if you must."

In light of the potential for lack of compliance, patch testing should be made as effortless as possible. For one approach, Dr. Silverberg suggested timing testing so it is not an excuse to miss school. Another tip was to use "heaps of tape and more tape" to keep the patch tests in place, and then provide patients with a roll of tape when they leave the office. She also recommended thinking in advance of strategies to reduce the risk of patch tests being inadvertently or intentionally removed by children, such as gauze wrap around the abdomen.

"The number one way to make patch tests work in young children is to keep your patch test panel streamlined and focused," Dr. Silverberg said. Particularly in young children, she suggested just one or two panels rather than three or four. While bribes such as lollipops and stickers "should be used judiciously," Dr. Silverberg said it is very helpful to outline each patch with highlighters that glow under Wood’s lamp to make results easier to assess.

Contact allergies are extremely common, and it is often possible to control the contact dermatitis before or even without confirming the allergen. For example, dialkyl thiourea, the ACDS allergen of the year in 2009, is another source of contact dermatitis to shin guards as well as other products, but reactions to this or PTPB formaldehyde resin can often be prevented simply by putting a layer of clothing in front of the skin. By the same principle, contact dermatitis from car seats is often caused by dimethyl fumerate, the ACDS allergen of the year in 2011, but can be prevented simply by laying fabric or creating some other barrier to prevent contact.

Methylisothiazolinone, a preservative and antifungal agent often found in moist towels and wipes, was recognized as the most recent (2013) ACDS allergen of the year. Dr. Silverberg noted that these wipes have surprisingly broad applications. While dermatitis on the hands and buttocks would be expected, she cautioned that patients use these to clean other skin surfaces, so a broad index of suspicion is needed.

The most common contact allergens, such as nickel, cobalt, and neomycin, remain relatively unchanged from year to year, but many of these products are used less frequently in children’s products in appreciation of the risks that they pose. The challenge is keeping abreast of evolving trends. While patch testing is an effective tool for identifying the source of a contact dermatitis to alert parents and patients of the products they should avoid, she said that technique is critical to patch test success.

Dr. Silverberg said she had no financial disclosures.

NEW YORK – One expert has characterized para-tertiary-butylphenol formaldehyde resin as a suitable candidate for the next pediatric contact allergen of the year, based on a growing number of case reports.

Para-tertiary-butylphenol (PTPB) formaldehyde resin is found in shin guards, push-up bras, and numerous other products used by children and adolescents.

Published case reports of contact allergies caused by PTPB formaldehyde resin date back several years, but use of this resin as an adhesive in a broad range of products – particularly leather goods, such as shoes, purses, and watch straps – appears to be increasing, according to Dr. Nanette B. Silverberg.

Dr. Silverberg presented a review of new trends in pediatric contact dermatitis at the American Academy of Dermatology summer meeting.

The causes of contact allergies in children evolve constantly because of the introduction of new products, and this should influence the order in which patch testing of specific allergens is performed, said Dr. Silverberg, a dermatologist at St. Luke’s–Roosevelt Hospital Center, New York.

In her update, she cited several recently designated "allergens of the year" from the American Contact Dermatitis Society (ACDS) and added some of her own.

Dr. Silverberg also emphasized tricks she has devised to increase the likelihood of a successful patch test, not least of which is enlisting parent cooperation. "It is important to convince parents that they are guilt free," she advised. In parents who begin to blame themselves for exposures, a sense of denial can interfere with efforts to cooperate with patch testing. To avoid this problem, she suggested a proactive effort to establish they are fault free. "Blame it on marketing if you must."

In light of the potential for lack of compliance, patch testing should be made as effortless as possible. For one approach, Dr. Silverberg suggested timing testing so it is not an excuse to miss school. Another tip was to use "heaps of tape and more tape" to keep the patch tests in place, and then provide patients with a roll of tape when they leave the office. She also recommended thinking in advance of strategies to reduce the risk of patch tests being inadvertently or intentionally removed by children, such as gauze wrap around the abdomen.

"The number one way to make patch tests work in young children is to keep your patch test panel streamlined and focused," Dr. Silverberg said. Particularly in young children, she suggested just one or two panels rather than three or four. While bribes such as lollipops and stickers "should be used judiciously," Dr. Silverberg said it is very helpful to outline each patch with highlighters that glow under Wood’s lamp to make results easier to assess.

Contact allergies are extremely common, and it is often possible to control the contact dermatitis before or even without confirming the allergen. For example, dialkyl thiourea, the ACDS allergen of the year in 2009, is another source of contact dermatitis to shin guards as well as other products, but reactions to this or PTPB formaldehyde resin can often be prevented simply by putting a layer of clothing in front of the skin. By the same principle, contact dermatitis from car seats is often caused by dimethyl fumerate, the ACDS allergen of the year in 2011, but can be prevented simply by laying fabric or creating some other barrier to prevent contact.

Methylisothiazolinone, a preservative and antifungal agent often found in moist towels and wipes, was recognized as the most recent (2013) ACDS allergen of the year. Dr. Silverberg noted that these wipes have surprisingly broad applications. While dermatitis on the hands and buttocks would be expected, she cautioned that patients use these to clean other skin surfaces, so a broad index of suspicion is needed.

The most common contact allergens, such as nickel, cobalt, and neomycin, remain relatively unchanged from year to year, but many of these products are used less frequently in children’s products in appreciation of the risks that they pose. The challenge is keeping abreast of evolving trends. While patch testing is an effective tool for identifying the source of a contact dermatitis to alert parents and patients of the products they should avoid, she said that technique is critical to patch test success.

Dr. Silverberg said she had no financial disclosures.

NEW YORK – One expert has characterized para-tertiary-butylphenol formaldehyde resin as a suitable candidate for the next pediatric contact allergen of the year, based on a growing number of case reports.

Para-tertiary-butylphenol (PTPB) formaldehyde resin is found in shin guards, push-up bras, and numerous other products used by children and adolescents.

Published case reports of contact allergies caused by PTPB formaldehyde resin date back several years, but use of this resin as an adhesive in a broad range of products – particularly leather goods, such as shoes, purses, and watch straps – appears to be increasing, according to Dr. Nanette B. Silverberg.

Dr. Silverberg presented a review of new trends in pediatric contact dermatitis at the American Academy of Dermatology summer meeting.

The causes of contact allergies in children evolve constantly because of the introduction of new products, and this should influence the order in which patch testing of specific allergens is performed, said Dr. Silverberg, a dermatologist at St. Luke’s–Roosevelt Hospital Center, New York.

In her update, she cited several recently designated "allergens of the year" from the American Contact Dermatitis Society (ACDS) and added some of her own.

Dr. Silverberg also emphasized tricks she has devised to increase the likelihood of a successful patch test, not least of which is enlisting parent cooperation. "It is important to convince parents that they are guilt free," she advised. In parents who begin to blame themselves for exposures, a sense of denial can interfere with efforts to cooperate with patch testing. To avoid this problem, she suggested a proactive effort to establish they are fault free. "Blame it on marketing if you must."

In light of the potential for lack of compliance, patch testing should be made as effortless as possible. For one approach, Dr. Silverberg suggested timing testing so it is not an excuse to miss school. Another tip was to use "heaps of tape and more tape" to keep the patch tests in place, and then provide patients with a roll of tape when they leave the office. She also recommended thinking in advance of strategies to reduce the risk of patch tests being inadvertently or intentionally removed by children, such as gauze wrap around the abdomen.

"The number one way to make patch tests work in young children is to keep your patch test panel streamlined and focused," Dr. Silverberg said. Particularly in young children, she suggested just one or two panels rather than three or four. While bribes such as lollipops and stickers "should be used judiciously," Dr. Silverberg said it is very helpful to outline each patch with highlighters that glow under Wood’s lamp to make results easier to assess.

Contact allergies are extremely common, and it is often possible to control the contact dermatitis before or even without confirming the allergen. For example, dialkyl thiourea, the ACDS allergen of the year in 2009, is another source of contact dermatitis to shin guards as well as other products, but reactions to this or PTPB formaldehyde resin can often be prevented simply by putting a layer of clothing in front of the skin. By the same principle, contact dermatitis from car seats is often caused by dimethyl fumerate, the ACDS allergen of the year in 2011, but can be prevented simply by laying fabric or creating some other barrier to prevent contact.

Methylisothiazolinone, a preservative and antifungal agent often found in moist towels and wipes, was recognized as the most recent (2013) ACDS allergen of the year. Dr. Silverberg noted that these wipes have surprisingly broad applications. While dermatitis on the hands and buttocks would be expected, she cautioned that patients use these to clean other skin surfaces, so a broad index of suspicion is needed.

The most common contact allergens, such as nickel, cobalt, and neomycin, remain relatively unchanged from year to year, but many of these products are used less frequently in children’s products in appreciation of the risks that they pose. The challenge is keeping abreast of evolving trends. While patch testing is an effective tool for identifying the source of a contact dermatitis to alert parents and patients of the products they should avoid, she said that technique is critical to patch test success.

Dr. Silverberg said she had no financial disclosures.

NEW YORK – One expert has characterized para-tertiary-butylphenol formaldehyde resin as a suitable candidate for the next pediatric contact allergen of the year, based on a growing number of case reports.

Para-tertiary-butylphenol (PTPB) formaldehyde resin is found in shin guards, push-up bras, and numerous other products used by children and adolescents.

Published case reports of contact allergies caused by PTPB formaldehyde resin date back several years, but use of this resin as an adhesive in a broad range of products – particularly leather goods, such as shoes, purses, and watch straps – appears to be increasing, according to Dr. Nanette B. Silverberg.

Dr. Silverberg presented a review of new trends in pediatric contact dermatitis at the American Academy of Dermatology summer meeting.

The causes of contact allergies in children evolve constantly because of the introduction of new products, and this should influence the order in which patch testing of specific allergens is performed, said Dr. Silverberg, a dermatologist at St. Luke’s–Roosevelt Hospital Center, New York.

In her update, she cited several recently designated "allergens of the year" from the American Contact Dermatitis Society (ACDS) and added some of her own.

Dr. Silverberg also emphasized tricks she has devised to increase the likelihood of a successful patch test, not least of which is enlisting parent cooperation. "It is important to convince parents that they are guilt free," she advised. In parents who begin to blame themselves for exposures, a sense of denial can interfere with efforts to cooperate with patch testing. To avoid this problem, she suggested a proactive effort to establish they are fault free. "Blame it on marketing if you must."

In light of the potential for lack of compliance, patch testing should be made as effortless as possible. For one approach, Dr. Silverberg suggested timing testing so it is not an excuse to miss school. Another tip was to use "heaps of tape and more tape" to keep the patch tests in place, and then provide patients with a roll of tape when they leave the office. She also recommended thinking in advance of strategies to reduce the risk of patch tests being inadvertently or intentionally removed by children, such as gauze wrap around the abdomen.

"The number one way to make patch tests work in young children is to keep your patch test panel streamlined and focused," Dr. Silverberg said. Particularly in young children, she suggested just one or two panels rather than three or four. While bribes such as lollipops and stickers "should be used judiciously," Dr. Silverberg said it is very helpful to outline each patch with highlighters that glow under Wood’s lamp to make results easier to assess.

Contact allergies are extremely common, and it is often possible to control the contact dermatitis before or even without confirming the allergen. For example, dialkyl thiourea, the ACDS allergen of the year in 2009, is another source of contact dermatitis to shin guards as well as other products, but reactions to this or PTPB formaldehyde resin can often be prevented simply by putting a layer of clothing in front of the skin. By the same principle, contact dermatitis from car seats is often caused by dimethyl fumerate, the ACDS allergen of the year in 2011, but can be prevented simply by laying fabric or creating some other barrier to prevent contact.

Methylisothiazolinone, a preservative and antifungal agent often found in moist towels and wipes, was recognized as the most recent (2013) ACDS allergen of the year. Dr. Silverberg noted that these wipes have surprisingly broad applications. While dermatitis on the hands and buttocks would be expected, she cautioned that patients use these to clean other skin surfaces, so a broad index of suspicion is needed.

The most common contact allergens, such as nickel, cobalt, and neomycin, remain relatively unchanged from year to year, but many of these products are used less frequently in children’s products in appreciation of the risks that they pose. The challenge is keeping abreast of evolving trends. While patch testing is an effective tool for identifying the source of a contact dermatitis to alert parents and patients of the products they should avoid, she said that technique is critical to patch test success.

Dr. Silverberg said she had no financial disclosures.

NEW YORK – One expert has characterized para-tertiary-butylphenol formaldehyde resin as a suitable candidate for the next pediatric contact allergen of the year, based on a growing number of case reports.

Para-tertiary-butylphenol (PTPB) formaldehyde resin is found in shin guards, push-up bras, and numerous other products used by children and adolescents.

Published case reports of contact allergies caused by PTPB formaldehyde resin date back several years, but use of this resin as an adhesive in a broad range of products – particularly leather goods, such as shoes, purses, and watch straps – appears to be increasing, according to Dr. Nanette B. Silverberg.

Dr. Silverberg presented a review of new trends in pediatric contact dermatitis at the American Academy of Dermatology summer meeting.

The causes of contact allergies in children evolve constantly because of the introduction of new products, and this should influence the order in which patch testing of specific allergens is performed, said Dr. Silverberg, a dermatologist at St. Luke’s–Roosevelt Hospital Center, New York.

In her update, she cited several recently designated "allergens of the year" from the American Contact Dermatitis Society (ACDS) and added some of her own.

Dr. Silverberg also emphasized tricks she has devised to increase the likelihood of a successful patch test, not least of which is enlisting parent cooperation. "It is important to convince parents that they are guilt free," she advised. In parents who begin to blame themselves for exposures, a sense of denial can interfere with efforts to cooperate with patch testing. To avoid this problem, she suggested a proactive effort to establish they are fault free. "Blame it on marketing if you must."

In light of the potential for lack of compliance, patch testing should be made as effortless as possible. For one approach, Dr. Silverberg suggested timing testing so it is not an excuse to miss school. Another tip was to use "heaps of tape and more tape" to keep the patch tests in place, and then provide patients with a roll of tape when they leave the office. She also recommended thinking in advance of strategies to reduce the risk of patch tests being inadvertently or intentionally removed by children, such as gauze wrap around the abdomen.

"The number one way to make patch tests work in young children is to keep your patch test panel streamlined and focused," Dr. Silverberg said. Particularly in young children, she suggested just one or two panels rather than three or four. While bribes such as lollipops and stickers "should be used judiciously," Dr. Silverberg said it is very helpful to outline each patch with highlighters that glow under Wood’s lamp to make results easier to assess.

Contact allergies are extremely common, and it is often possible to control the contact dermatitis before or even without confirming the allergen. For example, dialkyl thiourea, the ACDS allergen of the year in 2009, is another source of contact dermatitis to shin guards as well as other products, but reactions to this or PTPB formaldehyde resin can often be prevented simply by putting a layer of clothing in front of the skin. By the same principle, contact dermatitis from car seats is often caused by dimethyl fumerate, the ACDS allergen of the year in 2011, but can be prevented simply by laying fabric or creating some other barrier to prevent contact.

Methylisothiazolinone, a preservative and antifungal agent often found in moist towels and wipes, was recognized as the most recent (2013) ACDS allergen of the year. Dr. Silverberg noted that these wipes have surprisingly broad applications. While dermatitis on the hands and buttocks would be expected, she cautioned that patients use these to clean other skin surfaces, so a broad index of suspicion is needed.

The most common contact allergens, such as nickel, cobalt, and neomycin, remain relatively unchanged from year to year, but many of these products are used less frequently in children’s products in appreciation of the risks that they pose. The challenge is keeping abreast of evolving trends. While patch testing is an effective tool for identifying the source of a contact dermatitis to alert parents and patients of the products they should avoid, she said that technique is critical to patch test success.

Dr. Silverberg said she had no financial disclosures.

NEW YORK – Too many parents are incorrectly reassured that their child’s hemangioma will spontaneously resolve, and that no immediate treatment is needed, according to Dr. Francine Blei, medical director of the Vascular Birthmark Institute of New York at Roosevelt Hospital.

"I cannot stress enough the importance of early referral," Dr. Blei said.

Although some hemangiomas will resolve with time, those that require treatment will have the lowest risk for functional defects and the best cosmetic outcome if intervention occurs early, Dr. Blei said at the American Academy of Dermatology summer meeting.

For clinicians with experience managing these lesions, early examination can help separate those at risk of permanent disability or disfigurement from those whose lesions will resolve with an acceptable result, she said.

Infantile hemangiomas are part of an array of vascular anomalies, of which the most serious can involve internal organs and be life-threatening. Based on emerging information regarding the etiology and histopathology of vascular anomalies, the International Society for the Study of Vascular Abnormalities (ISSVA) has updated its classification system several times. Given recent progress, particularly related to the role of genetics in the pathophysiology of these lesions, new terminology is "in the works" and will be a topic of discussion at the ISSVA Workshop on Vascular Anomalies in April 2014 in Melbourne, Dr. Blei said. The two broad categories in the current terminology separate vascular tumors (such as infantile hemangiomas, which occur in up to 10% of infants) from vascular malformations, which are not necessarily congenital.

"The inconsistent terminology has been a problem," noted Dr. Blei, citing a study from the Vascular Anomalies Center at Boston Children’s Hospital. Data from this study showed that only 53% of 5,621 cases reviewed had a correct referral diagnosis (J. Pediatr. Surg. 2011;46:1784-9). Although referral diagnoses were correct for 77.8% of infantile hemangiomas, the rate was only 45.6% for vascular malformations.

For infantile hemangiomas, Dr. Blei offered a series of simple questions for clinicians to ask to help determine the risk of an adverse outcome. Although size and location are important, she emphasized looking for associated symptoms, such as stridor, ptosis, ulceration, and bleeding. While some parents may seek a conservative approach in the hope that the lesions will resolve without an invasive procedure, Dr. Blei said that she is "dogmatic" in regard to urging aggressive intervention when there is a risk of persistent functional impairment.

Other questions useful in understanding the prognosis and guiding the therapy of infantile hemangiomas include whether the lesion has subcutaneous involvement, whether there are multiple lesions, and whether the lesion is focal or segmental. For segmental lesions, a particular concern is whether the hemangioma is a manifestation of a larger syndrome, such as PHACE, a condition that includes cardiac abnormalities, and LUMBAR, which includes spinal and urogenital complications.

The age of the child at the time of evaluation is also relevant, particularly for differentiating infantile from congenital hemangiomas, Dr. Blei noted. Infantile hemangiomas begin proliferation soon after birth and, on average, reach their peak proliferation at 8-10 months of age before involuting slowly. By contrast, congenital hemangiomas are fully developed at birth and, unlike infantile hemangiomas, are negative for the immunohistochemical marker GLUT1. One kind of congenital hemangioma, called RICH (rapidly involuting congenital hemangioma), reaches an advanced stage of spontaneous resolution within the first several months of life. The other major form, called NICH (noninvoluting congenital hemangioma) persists through childhood.

If infantile hemangiomas are identified early, their treatment may be more effective and less invasive, said Dr. Blei. She noted that an adequate response can be achieved with topical beta-blockers in some cases. Oral beta-blockers and other systemic therapies also may allow for a relatively conservative resolution. Pulse dye lasers have a greater likelihood of efficacy if used early rather than after the hemangioma has become bulky, she added.

"If you treat early, you limit the size," Dr. Blei said. If you wait, the opportunity for complete or near-complete resolution may be lost, she added.

Dr. Blei had no financial conflicts to disclose.

NEW YORK – Too many parents are incorrectly reassured that their child’s hemangioma will spontaneously resolve, and that no immediate treatment is needed, according to Dr. Francine Blei, medical director of the Vascular Birthmark Institute of New York at Roosevelt Hospital.

"I cannot stress enough the importance of early referral," Dr. Blei said.

Although some hemangiomas will resolve with time, those that require treatment will have the lowest risk for functional defects and the best cosmetic outcome if intervention occurs early, Dr. Blei said at the American Academy of Dermatology summer meeting.

For clinicians with experience managing these lesions, early examination can help separate those at risk of permanent disability or disfigurement from those whose lesions will resolve with an acceptable result, she said.

Infantile hemangiomas are part of an array of vascular anomalies, of which the most serious can involve internal organs and be life-threatening. Based on emerging information regarding the etiology and histopathology of vascular anomalies, the International Society for the Study of Vascular Abnormalities (ISSVA) has updated its classification system several times. Given recent progress, particularly related to the role of genetics in the pathophysiology of these lesions, new terminology is "in the works" and will be a topic of discussion at the ISSVA Workshop on Vascular Anomalies in April 2014 in Melbourne, Dr. Blei said. The two broad categories in the current terminology separate vascular tumors (such as infantile hemangiomas, which occur in up to 10% of infants) from vascular malformations, which are not necessarily congenital.

"The inconsistent terminology has been a problem," noted Dr. Blei, citing a study from the Vascular Anomalies Center at Boston Children’s Hospital. Data from this study showed that only 53% of 5,621 cases reviewed had a correct referral diagnosis (J. Pediatr. Surg. 2011;46:1784-9). Although referral diagnoses were correct for 77.8% of infantile hemangiomas, the rate was only 45.6% for vascular malformations.

For infantile hemangiomas, Dr. Blei offered a series of simple questions for clinicians to ask to help determine the risk of an adverse outcome. Although size and location are important, she emphasized looking for associated symptoms, such as stridor, ptosis, ulceration, and bleeding. While some parents may seek a conservative approach in the hope that the lesions will resolve without an invasive procedure, Dr. Blei said that she is "dogmatic" in regard to urging aggressive intervention when there is a risk of persistent functional impairment.

Other questions useful in understanding the prognosis and guiding the therapy of infantile hemangiomas include whether the lesion has subcutaneous involvement, whether there are multiple lesions, and whether the lesion is focal or segmental. For segmental lesions, a particular concern is whether the hemangioma is a manifestation of a larger syndrome, such as PHACE, a condition that includes cardiac abnormalities, and LUMBAR, which includes spinal and urogenital complications.

The age of the child at the time of evaluation is also relevant, particularly for differentiating infantile from congenital hemangiomas, Dr. Blei noted. Infantile hemangiomas begin proliferation soon after birth and, on average, reach their peak proliferation at 8-10 months of age before involuting slowly. By contrast, congenital hemangiomas are fully developed at birth and, unlike infantile hemangiomas, are negative for the immunohistochemical marker GLUT1. One kind of congenital hemangioma, called RICH (rapidly involuting congenital hemangioma), reaches an advanced stage of spontaneous resolution within the first several months of life. The other major form, called NICH (noninvoluting congenital hemangioma) persists through childhood.

If infantile hemangiomas are identified early, their treatment may be more effective and less invasive, said Dr. Blei. She noted that an adequate response can be achieved with topical beta-blockers in some cases. Oral beta-blockers and other systemic therapies also may allow for a relatively conservative resolution. Pulse dye lasers have a greater likelihood of efficacy if used early rather than after the hemangioma has become bulky, she added.

"If you treat early, you limit the size," Dr. Blei said. If you wait, the opportunity for complete or near-complete resolution may be lost, she added.

Dr. Blei had no financial conflicts to disclose.

NEW YORK – Too many parents are incorrectly reassured that their child’s hemangioma will spontaneously resolve, and that no immediate treatment is needed, according to Dr. Francine Blei, medical director of the Vascular Birthmark Institute of New York at Roosevelt Hospital.

"I cannot stress enough the importance of early referral," Dr. Blei said.

Although some hemangiomas will resolve with time, those that require treatment will have the lowest risk for functional defects and the best cosmetic outcome if intervention occurs early, Dr. Blei said at the American Academy of Dermatology summer meeting.

For clinicians with experience managing these lesions, early examination can help separate those at risk of permanent disability or disfigurement from those whose lesions will resolve with an acceptable result, she said.

Infantile hemangiomas are part of an array of vascular anomalies, of which the most serious can involve internal organs and be life-threatening. Based on emerging information regarding the etiology and histopathology of vascular anomalies, the International Society for the Study of Vascular Abnormalities (ISSVA) has updated its classification system several times. Given recent progress, particularly related to the role of genetics in the pathophysiology of these lesions, new terminology is "in the works" and will be a topic of discussion at the ISSVA Workshop on Vascular Anomalies in April 2014 in Melbourne, Dr. Blei said. The two broad categories in the current terminology separate vascular tumors (such as infantile hemangiomas, which occur in up to 10% of infants) from vascular malformations, which are not necessarily congenital.

"The inconsistent terminology has been a problem," noted Dr. Blei, citing a study from the Vascular Anomalies Center at Boston Children’s Hospital. Data from this study showed that only 53% of 5,621 cases reviewed had a correct referral diagnosis (J. Pediatr. Surg. 2011;46:1784-9). Although referral diagnoses were correct for 77.8% of infantile hemangiomas, the rate was only 45.6% for vascular malformations.

For infantile hemangiomas, Dr. Blei offered a series of simple questions for clinicians to ask to help determine the risk of an adverse outcome. Although size and location are important, she emphasized looking for associated symptoms, such as stridor, ptosis, ulceration, and bleeding. While some parents may seek a conservative approach in the hope that the lesions will resolve without an invasive procedure, Dr. Blei said that she is "dogmatic" in regard to urging aggressive intervention when there is a risk of persistent functional impairment.

Other questions useful in understanding the prognosis and guiding the therapy of infantile hemangiomas include whether the lesion has subcutaneous involvement, whether there are multiple lesions, and whether the lesion is focal or segmental. For segmental lesions, a particular concern is whether the hemangioma is a manifestation of a larger syndrome, such as PHACE, a condition that includes cardiac abnormalities, and LUMBAR, which includes spinal and urogenital complications.

The age of the child at the time of evaluation is also relevant, particularly for differentiating infantile from congenital hemangiomas, Dr. Blei noted. Infantile hemangiomas begin proliferation soon after birth and, on average, reach their peak proliferation at 8-10 months of age before involuting slowly. By contrast, congenital hemangiomas are fully developed at birth and, unlike infantile hemangiomas, are negative for the immunohistochemical marker GLUT1. One kind of congenital hemangioma, called RICH (rapidly involuting congenital hemangioma), reaches an advanced stage of spontaneous resolution within the first several months of life. The other major form, called NICH (noninvoluting congenital hemangioma) persists through childhood.

If infantile hemangiomas are identified early, their treatment may be more effective and less invasive, said Dr. Blei. She noted that an adequate response can be achieved with topical beta-blockers in some cases. Oral beta-blockers and other systemic therapies also may allow for a relatively conservative resolution. Pulse dye lasers have a greater likelihood of efficacy if used early rather than after the hemangioma has become bulky, she added.

"If you treat early, you limit the size," Dr. Blei said. If you wait, the opportunity for complete or near-complete resolution may be lost, she added.

Dr. Blei had no financial conflicts to disclose.

NEW YORK – Nail complications are increasingly recognized as a problematic side effect of chemotherapies and biologic therapies for cancer patients.

In some cases these are cosmetic issues, but the side effects really do interfere with activities of daily living for many cancer patients, Dr. Patricia S. Myskowski, an attending dermatologist at Memorial Sloan Kettering Cancer Center, New York, reported at the American Academy of Dermatology summer meeting.

In a list of toxicities provided by the National Cancer Institute in 2006, only three categories of nail toxicities were listed, and these employed relatively vague descriptions, according to Dr. Myskowski. More recent summaries, including a literature review (J. Oncol. Pharm. Pract. 2009;15:143-55), have helped to classify and quantify nail complications as well as provide therapeutic guidance.

Taxanes, and specifically docetaxel, are "the worst offenders" of chemotherapies resulting in nails disorders, she said. More than 80% of patients treated with multiple cycles of docetaxel will develop some nail changes. Most are cosmetic reactions, such as depigmentation, but nearly one-third of patients have reactions that interfere with activities of daily living.

One of the most bothersome of these complications is subungual hematomas with hemopurulent discharge. In patients with nail infection, antibiotics may accelerate drainage and healing, but Dr. Myskowski suggested that this complication can be avoided by keeping the nails trimmed as short as possible.

Short nails are associated with a reduced risk of secondary infection, said Dr. Myskowski, who advised bacterial and fungal cultures when infection is suspected.

Biological therapies, particularly epidermal growth factor receptor (EGFR) inhibitors and tyrosine kinase inhibitors (TKIs), also are associated with a high rate of nail disorders, including paronychia, pyogenic granuloma, and infection. Although nail disorders are far less common than the characteristic rash associated with these agents, she cited one study suggesting a 12% incidence of symptomatic paronychia on EGFR inhibitors. Typically, nail complications emerge about 2 months after treatment is initiated.

To prevent paronychia associated with EGFR inhibitors, Dr. Myskowksi recommended following guidelines issued by the National Comprehensive Cancer Network (J. Natl. Compr. Canc. Netw. 2009;75:S5-S21).

Recommendations include avoiding frequent water immersion as well as contact with harsh chemicals. Applying petroleum jelly to the periungual soft tissue may be protective. In the event of nail infection, augmenting antibiotic therapy with topical therapies such as silver nitrate solution or white vinegar soaks may speed healing. In patients who have reinfections of toenails, disposing of shoes that may harbor bacteria sometimes resolves the problem.

Dr. Myskowski reported no financial disclosures relevant to her presentation.

NEW YORK – Nail complications are increasingly recognized as a problematic side effect of chemotherapies and biologic therapies for cancer patients.

In some cases these are cosmetic issues, but the side effects really do interfere with activities of daily living for many cancer patients, Dr. Patricia S. Myskowski, an attending dermatologist at Memorial Sloan Kettering Cancer Center, New York, reported at the American Academy of Dermatology summer meeting.

In a list of toxicities provided by the National Cancer Institute in 2006, only three categories of nail toxicities were listed, and these employed relatively vague descriptions, according to Dr. Myskowski. More recent summaries, including a literature review (J. Oncol. Pharm. Pract. 2009;15:143-55), have helped to classify and quantify nail complications as well as provide therapeutic guidance.

Taxanes, and specifically docetaxel, are "the worst offenders" of chemotherapies resulting in nails disorders, she said. More than 80% of patients treated with multiple cycles of docetaxel will develop some nail changes. Most are cosmetic reactions, such as depigmentation, but nearly one-third of patients have reactions that interfere with activities of daily living.

One of the most bothersome of these complications is subungual hematomas with hemopurulent discharge. In patients with nail infection, antibiotics may accelerate drainage and healing, but Dr. Myskowski suggested that this complication can be avoided by keeping the nails trimmed as short as possible.

Short nails are associated with a reduced risk of secondary infection, said Dr. Myskowski, who advised bacterial and fungal cultures when infection is suspected.

Biological therapies, particularly epidermal growth factor receptor (EGFR) inhibitors and tyrosine kinase inhibitors (TKIs), also are associated with a high rate of nail disorders, including paronychia, pyogenic granuloma, and infection. Although nail disorders are far less common than the characteristic rash associated with these agents, she cited one study suggesting a 12% incidence of symptomatic paronychia on EGFR inhibitors. Typically, nail complications emerge about 2 months after treatment is initiated.

To prevent paronychia associated with EGFR inhibitors, Dr. Myskowksi recommended following guidelines issued by the National Comprehensive Cancer Network (J. Natl. Compr. Canc. Netw. 2009;75:S5-S21).

Recommendations include avoiding frequent water immersion as well as contact with harsh chemicals. Applying petroleum jelly to the periungual soft tissue may be protective. In the event of nail infection, augmenting antibiotic therapy with topical therapies such as silver nitrate solution or white vinegar soaks may speed healing. In patients who have reinfections of toenails, disposing of shoes that may harbor bacteria sometimes resolves the problem.

Dr. Myskowski reported no financial disclosures relevant to her presentation.

NEW YORK – Nail complications are increasingly recognized as a problematic side effect of chemotherapies and biologic therapies for cancer patients.

In some cases these are cosmetic issues, but the side effects really do interfere with activities of daily living for many cancer patients, Dr. Patricia S. Myskowski, an attending dermatologist at Memorial Sloan Kettering Cancer Center, New York, reported at the American Academy of Dermatology summer meeting.

In a list of toxicities provided by the National Cancer Institute in 2006, only three categories of nail toxicities were listed, and these employed relatively vague descriptions, according to Dr. Myskowski. More recent summaries, including a literature review (J. Oncol. Pharm. Pract. 2009;15:143-55), have helped to classify and quantify nail complications as well as provide therapeutic guidance.

Taxanes, and specifically docetaxel, are "the worst offenders" of chemotherapies resulting in nails disorders, she said. More than 80% of patients treated with multiple cycles of docetaxel will develop some nail changes. Most are cosmetic reactions, such as depigmentation, but nearly one-third of patients have reactions that interfere with activities of daily living.

One of the most bothersome of these complications is subungual hematomas with hemopurulent discharge. In patients with nail infection, antibiotics may accelerate drainage and healing, but Dr. Myskowski suggested that this complication can be avoided by keeping the nails trimmed as short as possible.

Short nails are associated with a reduced risk of secondary infection, said Dr. Myskowski, who advised bacterial and fungal cultures when infection is suspected.

Biological therapies, particularly epidermal growth factor receptor (EGFR) inhibitors and tyrosine kinase inhibitors (TKIs), also are associated with a high rate of nail disorders, including paronychia, pyogenic granuloma, and infection. Although nail disorders are far less common than the characteristic rash associated with these agents, she cited one study suggesting a 12% incidence of symptomatic paronychia on EGFR inhibitors. Typically, nail complications emerge about 2 months after treatment is initiated.

To prevent paronychia associated with EGFR inhibitors, Dr. Myskowksi recommended following guidelines issued by the National Comprehensive Cancer Network (J. Natl. Compr. Canc. Netw. 2009;75:S5-S21).

Recommendations include avoiding frequent water immersion as well as contact with harsh chemicals. Applying petroleum jelly to the periungual soft tissue may be protective. In the event of nail infection, augmenting antibiotic therapy with topical therapies such as silver nitrate solution or white vinegar soaks may speed healing. In patients who have reinfections of toenails, disposing of shoes that may harbor bacteria sometimes resolves the problem.

Dr. Myskowski reported no financial disclosures relevant to her presentation.