Recent findings, new classification criteria and treatment guidelines, and concerted efforts by various organizations to provide educational resources are among a number of factors improving the outlook for patients with primary Sjögren’s syndrome, according to Judith James, MD, PhD.

Additionally, the number of studies of primary Sjögren’s syndrome (pSS) is increasing, albeit slowly, and ongoing studies of biologics are showing promise, Dr. James said during a clinical update at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
 

Classification criteria

The ACR in conjunction with the European League Against Rheumatism (EULAR) published new criteria for pSS classification in 2016 based on the available evidence and expert consensus. Inclusion criteria include daily, persistent, troublesome dry eyes for more than 3 months, recurrent sensation of sand or gravel in the eyes, use of tear substitutes more than three times each day, frequent drinking of liquids to aid in swallowing dry food, or at least one EULAR Sjögren’s syndrome disease activity index (ESSDAI) domain with a positive item. Exclusion criteria include prior head and neck radiation treatment, polymerase chain reaction–confirmed active hepatitis C infection, AIDS, sarcoidosis, amyloidosis, graft-versus-host disease, or IgG4-related disease, said Dr. James, professor and chair of the arthritis and clinical immunology research program at the University of Oklahoma, Oklahoma City (Arthritis Rheumatol. Jan 2017;69[1]:35-45).

• A score of 4 or higher in patients who meet the inclusion criteria and do not have any of the exclusion criteria leads to classification with pSS, based on the following findings:
• Labial salivary gland with focal lymphocytic sialadenitis and focus score of at least 1 foci/4 mm² (weight/score = 3).
• Anti-SSA/Ro-positivity (weight/score = 3).
• Ocular Staining Score of at least 5, or van Bijsterveld score of at least 4, in at least one eye (weight/score = 1).
• Schirmer’s test of no more than 5 mm/5 min in at least one eye (weight/score = 1).
• Unstimulated whole saliva flow rate of no more than 0.1 mL/min (weight/score = 1).

Clinical pearls for detection and management

In Dr. James’ experience, the three symptoms (taken together) with the highest predictive value for diagnosing pSS are dry mouth, sore mouth/tongue, and dry eyes. About 25% of Sjögren’s patients may have no detectable salivary flow, she said.

Dry, cracked skin that can lead to secondary infections is another common issue affecting about 55% of patients.

“So we always have to talk to our Sjögren’s patients about skin,” she said. “We also have recurrent sinusitis, chronic cough, dyspepsia, constipation, and other symptoms.”

Concurrent autoimmune diseases are another concern in Sjögren’s patients, she said. One to particularly keep in mind, in addition to lupus and rheumatoid arthritis, is autoimmune thyroid disease.

Data suggest that up to 45% of Sjögren’s patients have thyroid dysfunction, and if you look at just those with autoimmune thyroiditis, their risk of Sjögren’s is increased 10-fold vs. those without autoimmune thyroiditis, she said.

Other conditions to keep in mind when it comes to diagnosing and managing patients, as has been shown in numerous studies over the years, include Raynaud’s phenomenon, which affects at least 13% of patients, and subclinical muscle inflammation, which affects more than 50% of patients, Dr. James said.

“Depression ... as well as anxiety, is quite common in Sjögren’s patients, and fatigue is profound,” she added, noting that fatigue is “the No. 1 issue” for many patients.

Another area of particular concern in Sjögren’s is the increased risk of lymphoma, she said.

Studies show varying rates of lymphoma in Sjögren’s, with one suggesting a 44-fold increased risk, but this is likely only among those at very high risk. Other studies suggest the increase is risk overall is in the range of 4- to 10-fold, she said.

Mortality in Sjögren’s patients

A 2015 study by Soledad Retamozo et al. showed that the presence of cryoglobulinemic vasculitis (CV) at diagnosis is associated with increased mortality risk.

Of 515 consecutive pSS patients with a mean follow-up of 110 months, 65 (12%) had cryoglobulins detected, and 21 of those (32%) fulfilled CV criteria. The patients with cryoglobulins had higher cumulative mean disease activity, 45 (9%) developed B-cell lymphoma, and 33 (6%) died (Arthritis Rheumatol. 2015;67[suppl 10]. Abstract 628).

Additionally, both CV-positive and CV-negative patients had higher risk of B-cell lymphoma, but the risk was greatest in the CV-positive group (hazard ratios, 7.47 and 2.56, respectively), and the CV-positive patients had a higher risk of death (HR, 11.68).

“This actually has changed practice in our Sjögren’s clinic because we didn’t used to do cryos on everybody unless they had leukocytoclastic vasculitis, because they also have a higher risk of death,” Dr. James said.

Systemic activity also predicts pSS mortality, according to findings published in 2016 by Pilar Brito-Zerón et al. Of 1,045 patients who were part of the Spanish Group of Autoimmune Disease-SS Study Group and who were followed for a mean of 117 months, mortality was 11%. Survival was 96% at 5 years, 90% at 10 years, 81% at 20 years, and 60% at 30 years (Ann Rheum Dis. 2016;75:348-55).

Baseline factors associated with increased mortality on multivariate analysis included male gender, cryoglobulins, and low complement levels; the strongest model for death included high activity in at least one ESSDAI domain, baseline ESSDAI of at least 14, more than one laboratory predictive marker such as lymphopenia, anti-La, monoclonal gammopathy, low C3, low C4, and/or cryoglobulins.
 

Predicting progression to pSS

Progress has also been made with respect to predicting progression to pSS among patients who present with some related symptoms but don’t meet Sjögren’s criteria, Dr. James noted.

A 2017 study by Caroline Shiboski et al. looked at 771 patients from the Sjögren’s International Collaborative Clinical Alliance (SICCA) registry who had previously had objective measures of salivary hypofunction, dry eyes, focal lymphocytic sialadenitis or anti-Ro/anti-La. When these patients were recalled 2-3 years after their baseline evaluation, 28 (9%) of 308 patients who did not meet pSS criteria at baseline had then progressed to pSS (Arthritis Care Res. 2017;70[2]:284-94).

Those with baseline hypergammaglobulinemia were four times more likely to progress, and those with baseline low complement levels were six times more likely to progress.

Many patients will present with symptoms, but won’t ever develop Sjögren’s, but the subset of patients with these baseline characteristics may be at greater risk, she said.
 

Autoantibodies and pathogenesis

Up to 90% of pSS patients will have one or more of anti-Ro, anti-La, or rheumatoid factor, and many will have a positive antinuclear antibody (ANA) level of at least 1:320, Dr. James said, adding that anti-Ro and anti-La are linked with earlier disease onset, increased disease severity, longer disease duration, and extraglandular involvement.

Ro52, a target of Sjögren’s autoantibodies, may also confer more severe disease, and autoantibodies to muscarinic acetylcholine receptors appear to contribute to pathogenesis in Sjögren’s patients “above and beyond what we see with lymphocytic infiltrates and other things that are happening in the salivary gland,” she said.

Other exciting progress with respect to disease pathogenesis includes an increased focus on genetics and genetic predisposition beyond human leukocyte antigen associations.

Mutations in genes that overlap with Sjögren’s and lupus or Sjögren’s and RA, such as IRF5, Blk, and STAT4 appear to contribute to Sjögren’s syndrome development.

“And then there’s also some new genetics looking at Sjögren’s-specific genes, and these may help us as we think about new targetable pathways in this disorder,” she said.

Genomics and gene-environment interactions, such as interactions with viral infections or “other things that lead to molecular mimicry that get the disease process started,” are also getting increased attention; gene-expression profiling has shown overlap between Sjögren’s and lupus (shared genetics, autoantibodies, and similarly strong interferon signatures, for example), which isn’t surprising.

“But we’re also seeing NF-kB [NF-kappa B] activation, antigen presentation, and migration pathways that are being found in Sjögren’s that aren’t necessarily the ones that we see in lupus,” she added.
 

Clinical practice guidelines

A number of practice guidelines addressing various symptoms and issues associated with pSS have been released in the last few years, including several from EULAR, the United States, Brazil, and the United Kingdom, are summarized and reviewed in a recent paper by Vasco Romão et al. (RMD Open. 2018;4:e000789. doi: 10.1136/rmdopen-2018-000789).

The British Society of Rheumatology guideline, which came out about a year ago, has particularly practical guidance on the management of dryness and systemic disease, she said (Rheumatology. 2017;56[10]:1643-7).

The increasing focus on pSS research has important implications both for trial design and patient care, especially in light of the new classification criteria, practice guidelines, and educational resources provided by organizations such as the Sjögren’s Syndrome Foundation (including videos, health care provider information, and downloadable brochures and resource sheets) and the European Research Network’s ReCONNET Disease Info Toolbox for Sjögren’s, Dr. James concluded.

Dr. James reported having no disclosures.

[email protected]

Recent findings, new classification criteria and treatment guidelines, and concerted efforts by various organizations to provide educational resources are among a number of factors improving the outlook for patients with primary Sjögren’s syndrome, according to Judith James, MD, PhD.

Additionally, the number of studies of primary Sjögren’s syndrome (pSS) is increasing, albeit slowly, and ongoing studies of biologics are showing promise, Dr. James said during a clinical update at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
 

Classification criteria

The ACR in conjunction with the European League Against Rheumatism (EULAR) published new criteria for pSS classification in 2016 based on the available evidence and expert consensus. Inclusion criteria include daily, persistent, troublesome dry eyes for more than 3 months, recurrent sensation of sand or gravel in the eyes, use of tear substitutes more than three times each day, frequent drinking of liquids to aid in swallowing dry food, or at least one EULAR Sjögren’s syndrome disease activity index (ESSDAI) domain with a positive item. Exclusion criteria include prior head and neck radiation treatment, polymerase chain reaction–confirmed active hepatitis C infection, AIDS, sarcoidosis, amyloidosis, graft-versus-host disease, or IgG4-related disease, said Dr. James, professor and chair of the arthritis and clinical immunology research program at the University of Oklahoma, Oklahoma City (Arthritis Rheumatol. Jan 2017;69[1]:35-45).

• A score of 4 or higher in patients who meet the inclusion criteria and do not have any of the exclusion criteria leads to classification with pSS, based on the following findings:
• Labial salivary gland with focal lymphocytic sialadenitis and focus score of at least 1 foci/4 mm² (weight/score = 3).
• Anti-SSA/Ro-positivity (weight/score = 3).
• Ocular Staining Score of at least 5, or van Bijsterveld score of at least 4, in at least one eye (weight/score = 1).
• Schirmer’s test of no more than 5 mm/5 min in at least one eye (weight/score = 1).
• Unstimulated whole saliva flow rate of no more than 0.1 mL/min (weight/score = 1).

Clinical pearls for detection and management

In Dr. James’ experience, the three symptoms (taken together) with the highest predictive value for diagnosing pSS are dry mouth, sore mouth/tongue, and dry eyes. About 25% of Sjögren’s patients may have no detectable salivary flow, she said.

Dry, cracked skin that can lead to secondary infections is another common issue affecting about 55% of patients.

“So we always have to talk to our Sjögren’s patients about skin,” she said. “We also have recurrent sinusitis, chronic cough, dyspepsia, constipation, and other symptoms.”

Concurrent autoimmune diseases are another concern in Sjögren’s patients, she said. One to particularly keep in mind, in addition to lupus and rheumatoid arthritis, is autoimmune thyroid disease.

Data suggest that up to 45% of Sjögren’s patients have thyroid dysfunction, and if you look at just those with autoimmune thyroiditis, their risk of Sjögren’s is increased 10-fold vs. those without autoimmune thyroiditis, she said.

Other conditions to keep in mind when it comes to diagnosing and managing patients, as has been shown in numerous studies over the years, include Raynaud’s phenomenon, which affects at least 13% of patients, and subclinical muscle inflammation, which affects more than 50% of patients, Dr. James said.

“Depression ... as well as anxiety, is quite common in Sjögren’s patients, and fatigue is profound,” she added, noting that fatigue is “the No. 1 issue” for many patients.

Another area of particular concern in Sjögren’s is the increased risk of lymphoma, she said.

Studies show varying rates of lymphoma in Sjögren’s, with one suggesting a 44-fold increased risk, but this is likely only among those at very high risk. Other studies suggest the increase is risk overall is in the range of 4- to 10-fold, she said.

Mortality in Sjögren’s patients

A 2015 study by Soledad Retamozo et al. showed that the presence of cryoglobulinemic vasculitis (CV) at diagnosis is associated with increased mortality risk.

Of 515 consecutive pSS patients with a mean follow-up of 110 months, 65 (12%) had cryoglobulins detected, and 21 of those (32%) fulfilled CV criteria. The patients with cryoglobulins had higher cumulative mean disease activity, 45 (9%) developed B-cell lymphoma, and 33 (6%) died (Arthritis Rheumatol. 2015;67[suppl 10]. Abstract 628).

Additionally, both CV-positive and CV-negative patients had higher risk of B-cell lymphoma, but the risk was greatest in the CV-positive group (hazard ratios, 7.47 and 2.56, respectively), and the CV-positive patients had a higher risk of death (HR, 11.68).

“This actually has changed practice in our Sjögren’s clinic because we didn’t used to do cryos on everybody unless they had leukocytoclastic vasculitis, because they also have a higher risk of death,” Dr. James said.

Systemic activity also predicts pSS mortality, according to findings published in 2016 by Pilar Brito-Zerón et al. Of 1,045 patients who were part of the Spanish Group of Autoimmune Disease-SS Study Group and who were followed for a mean of 117 months, mortality was 11%. Survival was 96% at 5 years, 90% at 10 years, 81% at 20 years, and 60% at 30 years (Ann Rheum Dis. 2016;75:348-55).

Baseline factors associated with increased mortality on multivariate analysis included male gender, cryoglobulins, and low complement levels; the strongest model for death included high activity in at least one ESSDAI domain, baseline ESSDAI of at least 14, more than one laboratory predictive marker such as lymphopenia, anti-La, monoclonal gammopathy, low C3, low C4, and/or cryoglobulins.
 

Predicting progression to pSS

Progress has also been made with respect to predicting progression to pSS among patients who present with some related symptoms but don’t meet Sjögren’s criteria, Dr. James noted.

A 2017 study by Caroline Shiboski et al. looked at 771 patients from the Sjögren’s International Collaborative Clinical Alliance (SICCA) registry who had previously had objective measures of salivary hypofunction, dry eyes, focal lymphocytic sialadenitis or anti-Ro/anti-La. When these patients were recalled 2-3 years after their baseline evaluation, 28 (9%) of 308 patients who did not meet pSS criteria at baseline had then progressed to pSS (Arthritis Care Res. 2017;70[2]:284-94).

Those with baseline hypergammaglobulinemia were four times more likely to progress, and those with baseline low complement levels were six times more likely to progress.

Many patients will present with symptoms, but won’t ever develop Sjögren’s, but the subset of patients with these baseline characteristics may be at greater risk, she said.
 

Autoantibodies and pathogenesis

Up to 90% of pSS patients will have one or more of anti-Ro, anti-La, or rheumatoid factor, and many will have a positive antinuclear antibody (ANA) level of at least 1:320, Dr. James said, adding that anti-Ro and anti-La are linked with earlier disease onset, increased disease severity, longer disease duration, and extraglandular involvement.

Ro52, a target of Sjögren’s autoantibodies, may also confer more severe disease, and autoantibodies to muscarinic acetylcholine receptors appear to contribute to pathogenesis in Sjögren’s patients “above and beyond what we see with lymphocytic infiltrates and other things that are happening in the salivary gland,” she said.

Other exciting progress with respect to disease pathogenesis includes an increased focus on genetics and genetic predisposition beyond human leukocyte antigen associations.

Mutations in genes that overlap with Sjögren’s and lupus or Sjögren’s and RA, such as IRF5, Blk, and STAT4 appear to contribute to Sjögren’s syndrome development.

“And then there’s also some new genetics looking at Sjögren’s-specific genes, and these may help us as we think about new targetable pathways in this disorder,” she said.

Genomics and gene-environment interactions, such as interactions with viral infections or “other things that lead to molecular mimicry that get the disease process started,” are also getting increased attention; gene-expression profiling has shown overlap between Sjögren’s and lupus (shared genetics, autoantibodies, and similarly strong interferon signatures, for example), which isn’t surprising.

“But we’re also seeing NF-kB [NF-kappa B] activation, antigen presentation, and migration pathways that are being found in Sjögren’s that aren’t necessarily the ones that we see in lupus,” she added.
 

Clinical practice guidelines

A number of practice guidelines addressing various symptoms and issues associated with pSS have been released in the last few years, including several from EULAR, the United States, Brazil, and the United Kingdom, are summarized and reviewed in a recent paper by Vasco Romão et al. (RMD Open. 2018;4:e000789. doi: 10.1136/rmdopen-2018-000789).

The British Society of Rheumatology guideline, which came out about a year ago, has particularly practical guidance on the management of dryness and systemic disease, she said (Rheumatology. 2017;56[10]:1643-7).

The increasing focus on pSS research has important implications both for trial design and patient care, especially in light of the new classification criteria, practice guidelines, and educational resources provided by organizations such as the Sjögren’s Syndrome Foundation (including videos, health care provider information, and downloadable brochures and resource sheets) and the European Research Network’s ReCONNET Disease Info Toolbox for Sjögren’s, Dr. James concluded.

Dr. James reported having no disclosures.

[email protected]

Recent findings, new classification criteria and treatment guidelines, and concerted efforts by various organizations to provide educational resources are among a number of factors improving the outlook for patients with primary Sjögren’s syndrome, according to Judith James, MD, PhD.

Additionally, the number of studies of primary Sjögren’s syndrome (pSS) is increasing, albeit slowly, and ongoing studies of biologics are showing promise, Dr. James said during a clinical update at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
 

Classification criteria

The ACR in conjunction with the European League Against Rheumatism (EULAR) published new criteria for pSS classification in 2016 based on the available evidence and expert consensus. Inclusion criteria include daily, persistent, troublesome dry eyes for more than 3 months, recurrent sensation of sand or gravel in the eyes, use of tear substitutes more than three times each day, frequent drinking of liquids to aid in swallowing dry food, or at least one EULAR Sjögren’s syndrome disease activity index (ESSDAI) domain with a positive item. Exclusion criteria include prior head and neck radiation treatment, polymerase chain reaction–confirmed active hepatitis C infection, AIDS, sarcoidosis, amyloidosis, graft-versus-host disease, or IgG4-related disease, said Dr. James, professor and chair of the arthritis and clinical immunology research program at the University of Oklahoma, Oklahoma City (Arthritis Rheumatol. Jan 2017;69[1]:35-45).

• A score of 4 or higher in patients who meet the inclusion criteria and do not have any of the exclusion criteria leads to classification with pSS, based on the following findings:
• Labial salivary gland with focal lymphocytic sialadenitis and focus score of at least 1 foci/4 mm² (weight/score = 3).
• Anti-SSA/Ro-positivity (weight/score = 3).
• Ocular Staining Score of at least 5, or van Bijsterveld score of at least 4, in at least one eye (weight/score = 1).
• Schirmer’s test of no more than 5 mm/5 min in at least one eye (weight/score = 1).
• Unstimulated whole saliva flow rate of no more than 0.1 mL/min (weight/score = 1).

Clinical pearls for detection and management

In Dr. James’ experience, the three symptoms (taken together) with the highest predictive value for diagnosing pSS are dry mouth, sore mouth/tongue, and dry eyes. About 25% of Sjögren’s patients may have no detectable salivary flow, she said.

Dry, cracked skin that can lead to secondary infections is another common issue affecting about 55% of patients.

“So we always have to talk to our Sjögren’s patients about skin,” she said. “We also have recurrent sinusitis, chronic cough, dyspepsia, constipation, and other symptoms.”

Concurrent autoimmune diseases are another concern in Sjögren’s patients, she said. One to particularly keep in mind, in addition to lupus and rheumatoid arthritis, is autoimmune thyroid disease.

Data suggest that up to 45% of Sjögren’s patients have thyroid dysfunction, and if you look at just those with autoimmune thyroiditis, their risk of Sjögren’s is increased 10-fold vs. those without autoimmune thyroiditis, she said.

Other conditions to keep in mind when it comes to diagnosing and managing patients, as has been shown in numerous studies over the years, include Raynaud’s phenomenon, which affects at least 13% of patients, and subclinical muscle inflammation, which affects more than 50% of patients, Dr. James said.

“Depression ... as well as anxiety, is quite common in Sjögren’s patients, and fatigue is profound,” she added, noting that fatigue is “the No. 1 issue” for many patients.

Another area of particular concern in Sjögren’s is the increased risk of lymphoma, she said.

Studies show varying rates of lymphoma in Sjögren’s, with one suggesting a 44-fold increased risk, but this is likely only among those at very high risk. Other studies suggest the increase is risk overall is in the range of 4- to 10-fold, she said.

Mortality in Sjögren’s patients

A 2015 study by Soledad Retamozo et al. showed that the presence of cryoglobulinemic vasculitis (CV) at diagnosis is associated with increased mortality risk.

Of 515 consecutive pSS patients with a mean follow-up of 110 months, 65 (12%) had cryoglobulins detected, and 21 of those (32%) fulfilled CV criteria. The patients with cryoglobulins had higher cumulative mean disease activity, 45 (9%) developed B-cell lymphoma, and 33 (6%) died (Arthritis Rheumatol. 2015;67[suppl 10]. Abstract 628).

Additionally, both CV-positive and CV-negative patients had higher risk of B-cell lymphoma, but the risk was greatest in the CV-positive group (hazard ratios, 7.47 and 2.56, respectively), and the CV-positive patients had a higher risk of death (HR, 11.68).

“This actually has changed practice in our Sjögren’s clinic because we didn’t used to do cryos on everybody unless they had leukocytoclastic vasculitis, because they also have a higher risk of death,” Dr. James said.

Systemic activity also predicts pSS mortality, according to findings published in 2016 by Pilar Brito-Zerón et al. Of 1,045 patients who were part of the Spanish Group of Autoimmune Disease-SS Study Group and who were followed for a mean of 117 months, mortality was 11%. Survival was 96% at 5 years, 90% at 10 years, 81% at 20 years, and 60% at 30 years (Ann Rheum Dis. 2016;75:348-55).

Baseline factors associated with increased mortality on multivariate analysis included male gender, cryoglobulins, and low complement levels; the strongest model for death included high activity in at least one ESSDAI domain, baseline ESSDAI of at least 14, more than one laboratory predictive marker such as lymphopenia, anti-La, monoclonal gammopathy, low C3, low C4, and/or cryoglobulins.
 

Predicting progression to pSS

Progress has also been made with respect to predicting progression to pSS among patients who present with some related symptoms but don’t meet Sjögren’s criteria, Dr. James noted.

A 2017 study by Caroline Shiboski et al. looked at 771 patients from the Sjögren’s International Collaborative Clinical Alliance (SICCA) registry who had previously had objective measures of salivary hypofunction, dry eyes, focal lymphocytic sialadenitis or anti-Ro/anti-La. When these patients were recalled 2-3 years after their baseline evaluation, 28 (9%) of 308 patients who did not meet pSS criteria at baseline had then progressed to pSS (Arthritis Care Res. 2017;70[2]:284-94).

Those with baseline hypergammaglobulinemia were four times more likely to progress, and those with baseline low complement levels were six times more likely to progress.

Many patients will present with symptoms, but won’t ever develop Sjögren’s, but the subset of patients with these baseline characteristics may be at greater risk, she said.
 

Autoantibodies and pathogenesis

Up to 90% of pSS patients will have one or more of anti-Ro, anti-La, or rheumatoid factor, and many will have a positive antinuclear antibody (ANA) level of at least 1:320, Dr. James said, adding that anti-Ro and anti-La are linked with earlier disease onset, increased disease severity, longer disease duration, and extraglandular involvement.

Ro52, a target of Sjögren’s autoantibodies, may also confer more severe disease, and autoantibodies to muscarinic acetylcholine receptors appear to contribute to pathogenesis in Sjögren’s patients “above and beyond what we see with lymphocytic infiltrates and other things that are happening in the salivary gland,” she said.

Other exciting progress with respect to disease pathogenesis includes an increased focus on genetics and genetic predisposition beyond human leukocyte antigen associations.

Mutations in genes that overlap with Sjögren’s and lupus or Sjögren’s and RA, such as IRF5, Blk, and STAT4 appear to contribute to Sjögren’s syndrome development.

“And then there’s also some new genetics looking at Sjögren’s-specific genes, and these may help us as we think about new targetable pathways in this disorder,” she said.

Genomics and gene-environment interactions, such as interactions with viral infections or “other things that lead to molecular mimicry that get the disease process started,” are also getting increased attention; gene-expression profiling has shown overlap between Sjögren’s and lupus (shared genetics, autoantibodies, and similarly strong interferon signatures, for example), which isn’t surprising.

“But we’re also seeing NF-kB [NF-kappa B] activation, antigen presentation, and migration pathways that are being found in Sjögren’s that aren’t necessarily the ones that we see in lupus,” she added.
 

Clinical practice guidelines

A number of practice guidelines addressing various symptoms and issues associated with pSS have been released in the last few years, including several from EULAR, the United States, Brazil, and the United Kingdom, are summarized and reviewed in a recent paper by Vasco Romão et al. (RMD Open. 2018;4:e000789. doi: 10.1136/rmdopen-2018-000789).

The British Society of Rheumatology guideline, which came out about a year ago, has particularly practical guidance on the management of dryness and systemic disease, she said (Rheumatology. 2017;56[10]:1643-7).

The increasing focus on pSS research has important implications both for trial design and patient care, especially in light of the new classification criteria, practice guidelines, and educational resources provided by organizations such as the Sjögren’s Syndrome Foundation (including videos, health care provider information, and downloadable brochures and resource sheets) and the European Research Network’s ReCONNET Disease Info Toolbox for Sjögren’s, Dr. James concluded.

Dr. James reported having no disclosures.

[email protected]

GRAND CAYMAN, CAYMAN ISLANDS – Guselkumab bested secukinumab in a 48-week-long study of plaque psoriasis, with 84.5% of patients on the interleukin (IL)-23 blocker hitting at least a 90% improvement in their Psoriasis Area Severity Index (PASI), compared with 70% of those taking secukinumab, which blocks IL-17.

The difference in the PASI 90 response, the primary endpoint, was guselkumab’s largest effect over the comparator in the phase 3 trial, which also had six secondary endpoints. The drug was numerically, but not significantly, better than secukinumab in the PASI 75 response at weeks 12 and 48 (84.6% for guselkumab at both time points vs. 80.2% for secukinumab at both time points). This finding on the primary secondary endpoint knocked the P values of the other five into “nominally significant” ranges. But the responses were still good enough for researchers to tag guselkumab as noninferior to its competitor, Jeffrey M. Sobell, MD, said at the meeting provided by Global Academy for Medical Education.

The difference also speaks to the difference in the drugs’ onset of action and its peak efficacy, said Dr. Sobell, of the department of dermatology at Tufts University, Boston.

“In both groups, the PASI 90 increased similarly in the first month,” to about 20%, he commented. “But at week 12 and after, it was consistently higher in guselkumab, peaking around week 28. Secukinumab peaked around weeks 16 to 20 and then slowly declined.”

Despite not being statistically significant, the other secondary efficacy endpoints were certainly enough to pique the audience’s attention. At week 48, guselkumab topped secukinumab in both PASI 100 (58.2% vs. 48.4%, respectively) and Investigator’s Global Assessment (IGA) scores of 0 (62.2% vs. 50.4%) and 0-1 (85% vs. 74.9%).

ECLIPSE randomized 1,048 patients with moderate to severe plaque psoriasis to 100-mg subcutaneous guselkumab at weeks 0, 4, and 12, followed by dosing every 8 weeks, or to 300-mg subcutaneous secukinumab administered by two subcutaneous injections of 150 mg at weeks 0, 1, 2, 3, and 4, followed by dosing every 4 weeks. The primary endpoint of the study was the proportion of patients achieving a PASI 90 response at week 48. Secondary endpoints were assessed at weeks 12 and 48, with safety monitoring through week 56.

The mean baseline Body Surface Area score was 24, and the mean PASI score was 20. Patients had already been treated with phototherapy (51.8%), nonbiologic systemic medications (53.7%), and biologics (29%). About 37% were naive to both nonbiologics and biologics.

Both drugs were well tolerated, with no unanticipated adverse events. Through week 44, the discontinuation rates were 5% for guselkumab and 9% for secukinumab. Adverse events were common in both arms (77.9% and 81.6%, respectively). Serious adverse events occurred in 6.2% and 7.2%, respectively. These included serious infections in six patients taking guselkumab and five taking secukinumab. Superficial Candida infections occurred in 2% of the guselkumab group and 5.7% of the secukinumab group; Tinea infections occurred in 1.7% and 4.5%, respectively.

The session was sponsored by Janssen, the manufacturer of guselkumab (Tremfya). Dr. Sobell is a consultant for Janssen and also disclosed relationships with AbbVie, Amgen, Celgene, Eli Lilly, Merck, Novartis, Regeneron, and Sun Pharma. Secukinumab is marketed as Cosentyx.

Global Academy and this news organization are owned by the same parent company.

This article was updated 2/1/19.

[email protected]

GRAND CAYMAN, CAYMAN ISLANDS – Guselkumab bested secukinumab in a 48-week-long study of plaque psoriasis, with 84.5% of patients on the interleukin (IL)-23 blocker hitting at least a 90% improvement in their Psoriasis Area Severity Index (PASI), compared with 70% of those taking secukinumab, which blocks IL-17.

The difference in the PASI 90 response, the primary endpoint, was guselkumab’s largest effect over the comparator in the phase 3 trial, which also had six secondary endpoints. The drug was numerically, but not significantly, better than secukinumab in the PASI 75 response at weeks 12 and 48 (84.6% for guselkumab at both time points vs. 80.2% for secukinumab at both time points). This finding on the primary secondary endpoint knocked the P values of the other five into “nominally significant” ranges. But the responses were still good enough for researchers to tag guselkumab as noninferior to its competitor, Jeffrey M. Sobell, MD, said at the meeting provided by Global Academy for Medical Education.

The difference also speaks to the difference in the drugs’ onset of action and its peak efficacy, said Dr. Sobell, of the department of dermatology at Tufts University, Boston.

“In both groups, the PASI 90 increased similarly in the first month,” to about 20%, he commented. “But at week 12 and after, it was consistently higher in guselkumab, peaking around week 28. Secukinumab peaked around weeks 16 to 20 and then slowly declined.”

Despite not being statistically significant, the other secondary efficacy endpoints were certainly enough to pique the audience’s attention. At week 48, guselkumab topped secukinumab in both PASI 100 (58.2% vs. 48.4%, respectively) and Investigator’s Global Assessment (IGA) scores of 0 (62.2% vs. 50.4%) and 0-1 (85% vs. 74.9%).

ECLIPSE randomized 1,048 patients with moderate to severe plaque psoriasis to 100-mg subcutaneous guselkumab at weeks 0, 4, and 12, followed by dosing every 8 weeks, or to 300-mg subcutaneous secukinumab administered by two subcutaneous injections of 150 mg at weeks 0, 1, 2, 3, and 4, followed by dosing every 4 weeks. The primary endpoint of the study was the proportion of patients achieving a PASI 90 response at week 48. Secondary endpoints were assessed at weeks 12 and 48, with safety monitoring through week 56.

The mean baseline Body Surface Area score was 24, and the mean PASI score was 20. Patients had already been treated with phototherapy (51.8%), nonbiologic systemic medications (53.7%), and biologics (29%). About 37% were naive to both nonbiologics and biologics.

Both drugs were well tolerated, with no unanticipated adverse events. Through week 44, the discontinuation rates were 5% for guselkumab and 9% for secukinumab. Adverse events were common in both arms (77.9% and 81.6%, respectively). Serious adverse events occurred in 6.2% and 7.2%, respectively. These included serious infections in six patients taking guselkumab and five taking secukinumab. Superficial Candida infections occurred in 2% of the guselkumab group and 5.7% of the secukinumab group; Tinea infections occurred in 1.7% and 4.5%, respectively.

The session was sponsored by Janssen, the manufacturer of guselkumab (Tremfya). Dr. Sobell is a consultant for Janssen and also disclosed relationships with AbbVie, Amgen, Celgene, Eli Lilly, Merck, Novartis, Regeneron, and Sun Pharma. Secukinumab is marketed as Cosentyx.

Global Academy and this news organization are owned by the same parent company.

This article was updated 2/1/19.

[email protected]

GRAND CAYMAN, CAYMAN ISLANDS – Guselkumab bested secukinumab in a 48-week-long study of plaque psoriasis, with 84.5% of patients on the interleukin (IL)-23 blocker hitting at least a 90% improvement in their Psoriasis Area Severity Index (PASI), compared with 70% of those taking secukinumab, which blocks IL-17.

The difference in the PASI 90 response, the primary endpoint, was guselkumab’s largest effect over the comparator in the phase 3 trial, which also had six secondary endpoints. The drug was numerically, but not significantly, better than secukinumab in the PASI 75 response at weeks 12 and 48 (84.6% for guselkumab at both time points vs. 80.2% for secukinumab at both time points). This finding on the primary secondary endpoint knocked the P values of the other five into “nominally significant” ranges. But the responses were still good enough for researchers to tag guselkumab as noninferior to its competitor, Jeffrey M. Sobell, MD, said at the meeting provided by Global Academy for Medical Education.

The difference also speaks to the difference in the drugs’ onset of action and its peak efficacy, said Dr. Sobell, of the department of dermatology at Tufts University, Boston.

“In both groups, the PASI 90 increased similarly in the first month,” to about 20%, he commented. “But at week 12 and after, it was consistently higher in guselkumab, peaking around week 28. Secukinumab peaked around weeks 16 to 20 and then slowly declined.”

Despite not being statistically significant, the other secondary efficacy endpoints were certainly enough to pique the audience’s attention. At week 48, guselkumab topped secukinumab in both PASI 100 (58.2% vs. 48.4%, respectively) and Investigator’s Global Assessment (IGA) scores of 0 (62.2% vs. 50.4%) and 0-1 (85% vs. 74.9%).

ECLIPSE randomized 1,048 patients with moderate to severe plaque psoriasis to 100-mg subcutaneous guselkumab at weeks 0, 4, and 12, followed by dosing every 8 weeks, or to 300-mg subcutaneous secukinumab administered by two subcutaneous injections of 150 mg at weeks 0, 1, 2, 3, and 4, followed by dosing every 4 weeks. The primary endpoint of the study was the proportion of patients achieving a PASI 90 response at week 48. Secondary endpoints were assessed at weeks 12 and 48, with safety monitoring through week 56.

The mean baseline Body Surface Area score was 24, and the mean PASI score was 20. Patients had already been treated with phototherapy (51.8%), nonbiologic systemic medications (53.7%), and biologics (29%). About 37% were naive to both nonbiologics and biologics.

Both drugs were well tolerated, with no unanticipated adverse events. Through week 44, the discontinuation rates were 5% for guselkumab and 9% for secukinumab. Adverse events were common in both arms (77.9% and 81.6%, respectively). Serious adverse events occurred in 6.2% and 7.2%, respectively. These included serious infections in six patients taking guselkumab and five taking secukinumab. Superficial Candida infections occurred in 2% of the guselkumab group and 5.7% of the secukinumab group; Tinea infections occurred in 1.7% and 4.5%, respectively.

The session was sponsored by Janssen, the manufacturer of guselkumab (Tremfya). Dr. Sobell is a consultant for Janssen and also disclosed relationships with AbbVie, Amgen, Celgene, Eli Lilly, Merck, Novartis, Regeneron, and Sun Pharma. Secukinumab is marketed as Cosentyx.

Global Academy and this news organization are owned by the same parent company.

This article was updated 2/1/19.

[email protected]

BROOKLYN, N.Y. – Intervening effectively for children and adolescents at suicide risk involves watching for triggers such as personal loss, sleep disturbances, or interpersonal conflict, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

It is important to distinguish the distal risks, which are factors known to increase suicidal ideation, and proximal risk factors, which predict attempts, according to Tina R. Goldstein, PhD, associate professor of psychiatry and psychology at the University of Pittsburgh. “We know that the optimal targets for preventing suicidal behavior are proximal,” Dr. Goldstein said. Treatment of distal risks, such as depression or substance use, is a foundation for risk management, but suicidal events are driven by acute crises that appear to require individualized intervention.

Dr. Goldstein said she had just “one sad slide” to summarize drug treatments aimed at controlling suicidal behavior. That slide included citations for studies associating neuroleptics and antidepressants with a reduction in aggressive or impulsive behavior in children. The only study associating a drug with a reduction in suicide attempts was performed with lithium in adults.

However, intensive cognitive and dialectical behavior interventions involving the family have been shown to reduce suicide attempts in randomized controlled trials, said Dr. Goldstein, who also is affiliated with the university’s Child and Adolescent Bipolar Spectrum Services Research Program. Those trials underscore the messages that personalizing therapy is essential, as are addressing specific triggers and helping patients develop defenses against suicidal thoughts.

Dr. Goldstein described a recently published, National Institutes of Health–funded study that focused on suicide reduction. The study was conducted in adolescents who were being discharged from a brief hospitalization for acute suicidal ideation or a suicide attempt (J Adolesc Health. 2018 Nov. 8. doi: 10.1016/j.jadohealth.2018.09.015). “We know that there is this really high-risk period after discharge from the hospital for which we could potentially do things better,” said Dr. Goldstein, whose center was involved in the study.

The tested intervention, called As Safe As Possible (ASAP), involved “front-loading some coping skills and giving [the patients] a good safety plan even before they are discharged,” Dr. Goldstein said. For risk management after discharge, the adolescents were provided with a smartphone app called BRITE that contained the safety plan as well as a summary of personalized coping skills, including reminders that the patients themselves had provided for reasons for living. The app was augmented as appropriate with favorite songs, photos of the patients’ pet, or other customized aids to provide support during the typical delay between the time of discharge and the next step in care.

In 6 months of follow-up, the rate of suicide attempts was 8.7% of those enrolled in the intensive outpatient program, compared with 27.3% (P = .08) for those who received treatment as usual. Dr. Goldstein called this trend promising, particularly in the context of other favorable results, including a significantly longer (P = .03) time to a suicide attempt in the ASAP group.

In patients at imminent risk of a suicide attempt, it is logical to assume that treatment must be personalized to the issues behind increased suicidal ideation. However, a study published by Dr. Goldstein and her associates several years ago suggested that evidence of deteriorating mental health can signal a need for intensification of suicide risk management (Arch Gen Psychiatry. 2012;69:1113-22). In one part of that study, risk factors for suicide were evaluated in the 8 weeks before a suicide attempt in 413 children with bipolar disorder. During that time, depression scores increased as did substance use, but, surprisingly, so did use of mental health services.

“The way we have come to think of these data is that the kids, their parents, and their providers were recognizing that things were getting worse and they needed more services,” Dr. Goldstein said. “The bad news is that the services we were giving them were not particularly effective.”

Those data underscore some of the challenges facing clinicians who treat pediatric patients with mental illness. “Our field has not yet developed ... gold standard treatments for preventing suicidal behavior in kids with mood disorder,” Dr. Goldstein said. However, she thinks that some progress has been made and that some of the personalized approaches are demonstrating efficacy – particularly in children and adolescents who exhibit signs of imminent risk.

BROOKLYN, N.Y. – Intervening effectively for children and adolescents at suicide risk involves watching for triggers such as personal loss, sleep disturbances, or interpersonal conflict, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

It is important to distinguish the distal risks, which are factors known to increase suicidal ideation, and proximal risk factors, which predict attempts, according to Tina R. Goldstein, PhD, associate professor of psychiatry and psychology at the University of Pittsburgh. “We know that the optimal targets for preventing suicidal behavior are proximal,” Dr. Goldstein said. Treatment of distal risks, such as depression or substance use, is a foundation for risk management, but suicidal events are driven by acute crises that appear to require individualized intervention.

Dr. Goldstein said she had just “one sad slide” to summarize drug treatments aimed at controlling suicidal behavior. That slide included citations for studies associating neuroleptics and antidepressants with a reduction in aggressive or impulsive behavior in children. The only study associating a drug with a reduction in suicide attempts was performed with lithium in adults.

However, intensive cognitive and dialectical behavior interventions involving the family have been shown to reduce suicide attempts in randomized controlled trials, said Dr. Goldstein, who also is affiliated with the university’s Child and Adolescent Bipolar Spectrum Services Research Program. Those trials underscore the messages that personalizing therapy is essential, as are addressing specific triggers and helping patients develop defenses against suicidal thoughts.

Dr. Goldstein described a recently published, National Institutes of Health–funded study that focused on suicide reduction. The study was conducted in adolescents who were being discharged from a brief hospitalization for acute suicidal ideation or a suicide attempt (J Adolesc Health. 2018 Nov. 8. doi: 10.1016/j.jadohealth.2018.09.015). “We know that there is this really high-risk period after discharge from the hospital for which we could potentially do things better,” said Dr. Goldstein, whose center was involved in the study.

The tested intervention, called As Safe As Possible (ASAP), involved “front-loading some coping skills and giving [the patients] a good safety plan even before they are discharged,” Dr. Goldstein said. For risk management after discharge, the adolescents were provided with a smartphone app called BRITE that contained the safety plan as well as a summary of personalized coping skills, including reminders that the patients themselves had provided for reasons for living. The app was augmented as appropriate with favorite songs, photos of the patients’ pet, or other customized aids to provide support during the typical delay between the time of discharge and the next step in care.

In 6 months of follow-up, the rate of suicide attempts was 8.7% of those enrolled in the intensive outpatient program, compared with 27.3% (P = .08) for those who received treatment as usual. Dr. Goldstein called this trend promising, particularly in the context of other favorable results, including a significantly longer (P = .03) time to a suicide attempt in the ASAP group.

In patients at imminent risk of a suicide attempt, it is logical to assume that treatment must be personalized to the issues behind increased suicidal ideation. However, a study published by Dr. Goldstein and her associates several years ago suggested that evidence of deteriorating mental health can signal a need for intensification of suicide risk management (Arch Gen Psychiatry. 2012;69:1113-22). In one part of that study, risk factors for suicide were evaluated in the 8 weeks before a suicide attempt in 413 children with bipolar disorder. During that time, depression scores increased as did substance use, but, surprisingly, so did use of mental health services.

“The way we have come to think of these data is that the kids, their parents, and their providers were recognizing that things were getting worse and they needed more services,” Dr. Goldstein said. “The bad news is that the services we were giving them were not particularly effective.”

Those data underscore some of the challenges facing clinicians who treat pediatric patients with mental illness. “Our field has not yet developed ... gold standard treatments for preventing suicidal behavior in kids with mood disorder,” Dr. Goldstein said. However, she thinks that some progress has been made and that some of the personalized approaches are demonstrating efficacy – particularly in children and adolescents who exhibit signs of imminent risk.

BROOKLYN, N.Y. – Intervening effectively for children and adolescents at suicide risk involves watching for triggers such as personal loss, sleep disturbances, or interpersonal conflict, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

It is important to distinguish the distal risks, which are factors known to increase suicidal ideation, and proximal risk factors, which predict attempts, according to Tina R. Goldstein, PhD, associate professor of psychiatry and psychology at the University of Pittsburgh. “We know that the optimal targets for preventing suicidal behavior are proximal,” Dr. Goldstein said. Treatment of distal risks, such as depression or substance use, is a foundation for risk management, but suicidal events are driven by acute crises that appear to require individualized intervention.

Dr. Goldstein said she had just “one sad slide” to summarize drug treatments aimed at controlling suicidal behavior. That slide included citations for studies associating neuroleptics and antidepressants with a reduction in aggressive or impulsive behavior in children. The only study associating a drug with a reduction in suicide attempts was performed with lithium in adults.

However, intensive cognitive and dialectical behavior interventions involving the family have been shown to reduce suicide attempts in randomized controlled trials, said Dr. Goldstein, who also is affiliated with the university’s Child and Adolescent Bipolar Spectrum Services Research Program. Those trials underscore the messages that personalizing therapy is essential, as are addressing specific triggers and helping patients develop defenses against suicidal thoughts.

Dr. Goldstein described a recently published, National Institutes of Health–funded study that focused on suicide reduction. The study was conducted in adolescents who were being discharged from a brief hospitalization for acute suicidal ideation or a suicide attempt (J Adolesc Health. 2018 Nov. 8. doi: 10.1016/j.jadohealth.2018.09.015). “We know that there is this really high-risk period after discharge from the hospital for which we could potentially do things better,” said Dr. Goldstein, whose center was involved in the study.

The tested intervention, called As Safe As Possible (ASAP), involved “front-loading some coping skills and giving [the patients] a good safety plan even before they are discharged,” Dr. Goldstein said. For risk management after discharge, the adolescents were provided with a smartphone app called BRITE that contained the safety plan as well as a summary of personalized coping skills, including reminders that the patients themselves had provided for reasons for living. The app was augmented as appropriate with favorite songs, photos of the patients’ pet, or other customized aids to provide support during the typical delay between the time of discharge and the next step in care.

In 6 months of follow-up, the rate of suicide attempts was 8.7% of those enrolled in the intensive outpatient program, compared with 27.3% (P = .08) for those who received treatment as usual. Dr. Goldstein called this trend promising, particularly in the context of other favorable results, including a significantly longer (P = .03) time to a suicide attempt in the ASAP group.

In patients at imminent risk of a suicide attempt, it is logical to assume that treatment must be personalized to the issues behind increased suicidal ideation. However, a study published by Dr. Goldstein and her associates several years ago suggested that evidence of deteriorating mental health can signal a need for intensification of suicide risk management (Arch Gen Psychiatry. 2012;69:1113-22). In one part of that study, risk factors for suicide were evaluated in the 8 weeks before a suicide attempt in 413 children with bipolar disorder. During that time, depression scores increased as did substance use, but, surprisingly, so did use of mental health services.

“The way we have come to think of these data is that the kids, their parents, and their providers were recognizing that things were getting worse and they needed more services,” Dr. Goldstein said. “The bad news is that the services we were giving them were not particularly effective.”

Those data underscore some of the challenges facing clinicians who treat pediatric patients with mental illness. “Our field has not yet developed ... gold standard treatments for preventing suicidal behavior in kids with mood disorder,” Dr. Goldstein said. However, she thinks that some progress has been made and that some of the personalized approaches are demonstrating efficacy – particularly in children and adolescents who exhibit signs of imminent risk.

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Contrary to recent reports, resting core temperature is not elevated in patients with relapsing-remitting multiple sclerosis (RRMS) compared to healthy controls when measured using precision thermometry, according to a recent study. Furthermore, no association was observed between resting rectal temperature (T_re) and any subjective measures of fatigue in a subset of participants with MS. Across 2 international data collection sites (Sydney and Dallas), 28 RRMS patients and 27 aged-matched controls (CON) were exposed to either 30°C, 30% relative humidity (RH) (Sydney) or 25°C, 30% RH (Dallas). Resting T_re and esophageal (T_eso) temperature and resting oxygen consumption (VO₂) was measured in MS (n=28) and CON (n=27) groups who completed the 25°C and 30°C trials. Tympanic membrane (T_tym) temperature was measured in MS (n=16) and CON (n=15) groups in the 30°C condition. A modified fatigue impact scale (MFIS) questionnaire was used to assess subjective measures of psychosocial, physical, and cognitive fatigue in the 30°C condition. Researchers found:

• Irrespective of ambient temperature, no group differences were observed for T_re, T_eso, or resting VO₂.
• Similarly, no group differences were observed for T_tym in the 30°C condition.

Chaseling GK, Allen DR, Vucic S, et al. Core temperature is not elevated at rest in people with relapsing-remitting multiple sclerosis. [Published online ahead of print January 3, 2019]. Mult Scler Relat Disord. doi:10.1016/j.msard.2019.01.013.

Contrary to recent reports, resting core temperature is not elevated in patients with relapsing-remitting multiple sclerosis (RRMS) compared to healthy controls when measured using precision thermometry, according to a recent study. Furthermore, no association was observed between resting rectal temperature (T_re) and any subjective measures of fatigue in a subset of participants with MS. Across 2 international data collection sites (Sydney and Dallas), 28 RRMS patients and 27 aged-matched controls (CON) were exposed to either 30°C, 30% relative humidity (RH) (Sydney) or 25°C, 30% RH (Dallas). Resting T_re and esophageal (T_eso) temperature and resting oxygen consumption (VO₂) was measured in MS (n=28) and CON (n=27) groups who completed the 25°C and 30°C trials. Tympanic membrane (T_tym) temperature was measured in MS (n=16) and CON (n=15) groups in the 30°C condition. A modified fatigue impact scale (MFIS) questionnaire was used to assess subjective measures of psychosocial, physical, and cognitive fatigue in the 30°C condition. Researchers found:

• Irrespective of ambient temperature, no group differences were observed for T_re, T_eso, or resting VO₂.
• Similarly, no group differences were observed for T_tym in the 30°C condition.

Chaseling GK, Allen DR, Vucic S, et al. Core temperature is not elevated at rest in people with relapsing-remitting multiple sclerosis. [Published online ahead of print January 3, 2019]. Mult Scler Relat Disord. doi:10.1016/j.msard.2019.01.013.

Contrary to recent reports, resting core temperature is not elevated in patients with relapsing-remitting multiple sclerosis (RRMS) compared to healthy controls when measured using precision thermometry, according to a recent study. Furthermore, no association was observed between resting rectal temperature (T_re) and any subjective measures of fatigue in a subset of participants with MS. Across 2 international data collection sites (Sydney and Dallas), 28 RRMS patients and 27 aged-matched controls (CON) were exposed to either 30°C, 30% relative humidity (RH) (Sydney) or 25°C, 30% RH (Dallas). Resting T_re and esophageal (T_eso) temperature and resting oxygen consumption (VO₂) was measured in MS (n=28) and CON (n=27) groups who completed the 25°C and 30°C trials. Tympanic membrane (T_tym) temperature was measured in MS (n=16) and CON (n=15) groups in the 30°C condition. A modified fatigue impact scale (MFIS) questionnaire was used to assess subjective measures of psychosocial, physical, and cognitive fatigue in the 30°C condition. Researchers found:

• Irrespective of ambient temperature, no group differences were observed for T_re, T_eso, or resting VO₂.
• Similarly, no group differences were observed for T_tym in the 30°C condition.

Chaseling GK, Allen DR, Vucic S, et al. Core temperature is not elevated at rest in people with relapsing-remitting multiple sclerosis. [Published online ahead of print January 3, 2019]. Mult Scler Relat Disord. doi:10.1016/j.msard.2019.01.013.

Persons with multiple sclerosis (MS) who have greater disability exhibit higher body fat and lower bone tissue content and density than those with mild disability, a recent study found. Researchers conducted a cross-sectional investigation of 47 ambulatory persons with relapsing remitting MS who were grouped by Expanded Disability Status Scale (EDSS) scores as having mild (1.0‒4.0; n=26) or moderate (4.5‒6.5; n=21) disability. Main outcome measures were whole-body and regional soft tissue composition (%body fat [BF], fat mass [FM], and fat-free soft tissue mass [FFM]), bone mineral content (BMC), and bone mineral density (BMD). Other outcomes included physical fitness, mobility, cognitive processing speed, symptoms, and health-related quality of life (HRQOL). They found:

• Whole-body and regional %BF and FM were significantly higher, and whole-body and appendicular BMC and BMD were significantly lower in participants with moderate disability than those with mild disability.
• There were no significant differences in whole-body or regional FFM by disability status.
• In the overall sample, body fat correlated significantly with cardiorespiratory fitness, pain symptoms, and psychological HRQOL.
• FFM and BMC correlated primarily with measures of muscular strength.

Pilutti LA, Motl RW. Body composition and disability in people with multiple sclerosis: A dual-energy x-ray absorptiometry study. [Published online ahead of print January 3, 2019]. Mult Scler Relat Disord. doi:10.1016/j.msard.2019.01.009.

Persons with multiple sclerosis (MS) who have greater disability exhibit higher body fat and lower bone tissue content and density than those with mild disability, a recent study found. Researchers conducted a cross-sectional investigation of 47 ambulatory persons with relapsing remitting MS who were grouped by Expanded Disability Status Scale (EDSS) scores as having mild (1.0‒4.0; n=26) or moderate (4.5‒6.5; n=21) disability. Main outcome measures were whole-body and regional soft tissue composition (%body fat [BF], fat mass [FM], and fat-free soft tissue mass [FFM]), bone mineral content (BMC), and bone mineral density (BMD). Other outcomes included physical fitness, mobility, cognitive processing speed, symptoms, and health-related quality of life (HRQOL). They found:

• Whole-body and regional %BF and FM were significantly higher, and whole-body and appendicular BMC and BMD were significantly lower in participants with moderate disability than those with mild disability.
• There were no significant differences in whole-body or regional FFM by disability status.
• In the overall sample, body fat correlated significantly with cardiorespiratory fitness, pain symptoms, and psychological HRQOL.
• FFM and BMC correlated primarily with measures of muscular strength.

Pilutti LA, Motl RW. Body composition and disability in people with multiple sclerosis: A dual-energy x-ray absorptiometry study. [Published online ahead of print January 3, 2019]. Mult Scler Relat Disord. doi:10.1016/j.msard.2019.01.009.

Persons with multiple sclerosis (MS) who have greater disability exhibit higher body fat and lower bone tissue content and density than those with mild disability, a recent study found. Researchers conducted a cross-sectional investigation of 47 ambulatory persons with relapsing remitting MS who were grouped by Expanded Disability Status Scale (EDSS) scores as having mild (1.0‒4.0; n=26) or moderate (4.5‒6.5; n=21) disability. Main outcome measures were whole-body and regional soft tissue composition (%body fat [BF], fat mass [FM], and fat-free soft tissue mass [FFM]), bone mineral content (BMC), and bone mineral density (BMD). Other outcomes included physical fitness, mobility, cognitive processing speed, symptoms, and health-related quality of life (HRQOL). They found:

• Whole-body and regional %BF and FM were significantly higher, and whole-body and appendicular BMC and BMD were significantly lower in participants with moderate disability than those with mild disability.
• There were no significant differences in whole-body or regional FFM by disability status.
• In the overall sample, body fat correlated significantly with cardiorespiratory fitness, pain symptoms, and psychological HRQOL.
• FFM and BMC correlated primarily with measures of muscular strength.

Pilutti LA, Motl RW. Body composition and disability in people with multiple sclerosis: A dual-energy x-ray absorptiometry study. [Published online ahead of print January 3, 2019]. Mult Scler Relat Disord. doi:10.1016/j.msard.2019.01.009.

The prevalence of pseudobulbar affect (PBA) in multiple sclerosis (MS) is low, according to a recent study, but similar symptoms may co-occur or overlap with depression, highlighting the importance of concomitant assessment of mood when evaluating potential PBA. Furthermore, PBA may be associated with cognitive impairment in people with MS. North American Research Committee on MS (NARCOMS) registry participants completed the Center for Neurologic Study-Lability Scale (CNS-LS), a validated 7-question self-report measure of PBA. Researchers categorized individuals as PBA-positive (PBA[+]) if they had a composite score ≥17 without current depression. Participants also reported their demographic characteristics and their clinical characteristics using Patient-Determined Disease Steps and Performance Scales. They found:

• Of the 8,136 responders, 574 (7%) had scores ≥17 on the CNS-LS; however, only 200 (2.5%) individuals had scores ≥17 without comorbid depression, of whom only 22 (11%) reported a diagnosis of PBA.
• PBA(+) individuals tended to be younger (mean [SD] 53.4 [11.0] vs 57.2 [10.3] years), non-white (13% vs 9%), and have lower socioeconomic status (≤$30,000 annual income: 28% vs 22%).
• In multivariable models, PBA(+) was associated with increased odds of more severe cognitive impairment.

Fitzgerald KC, Salter A, Tyry T, Fox RJ, Cutter G, Marrie RA. Pseudobulbar affect.

Prevalence and association with symptoms in multiple sclerosis. Neurol Clin Pract. 2018;8(6):472-481. doi:10.1212/CPJ.0000000000000523.

The prevalence of pseudobulbar affect (PBA) in multiple sclerosis (MS) is low, according to a recent study, but similar symptoms may co-occur or overlap with depression, highlighting the importance of concomitant assessment of mood when evaluating potential PBA. Furthermore, PBA may be associated with cognitive impairment in people with MS. North American Research Committee on MS (NARCOMS) registry participants completed the Center for Neurologic Study-Lability Scale (CNS-LS), a validated 7-question self-report measure of PBA. Researchers categorized individuals as PBA-positive (PBA[+]) if they had a composite score ≥17 without current depression. Participants also reported their demographic characteristics and their clinical characteristics using Patient-Determined Disease Steps and Performance Scales. They found:

• Of the 8,136 responders, 574 (7%) had scores ≥17 on the CNS-LS; however, only 200 (2.5%) individuals had scores ≥17 without comorbid depression, of whom only 22 (11%) reported a diagnosis of PBA.
• PBA(+) individuals tended to be younger (mean [SD] 53.4 [11.0] vs 57.2 [10.3] years), non-white (13% vs 9%), and have lower socioeconomic status (≤$30,000 annual income: 28% vs 22%).
• In multivariable models, PBA(+) was associated with increased odds of more severe cognitive impairment.

Fitzgerald KC, Salter A, Tyry T, Fox RJ, Cutter G, Marrie RA. Pseudobulbar affect.

Prevalence and association with symptoms in multiple sclerosis. Neurol Clin Pract. 2018;8(6):472-481. doi:10.1212/CPJ.0000000000000523.

The prevalence of pseudobulbar affect (PBA) in multiple sclerosis (MS) is low, according to a recent study, but similar symptoms may co-occur or overlap with depression, highlighting the importance of concomitant assessment of mood when evaluating potential PBA. Furthermore, PBA may be associated with cognitive impairment in people with MS. North American Research Committee on MS (NARCOMS) registry participants completed the Center for Neurologic Study-Lability Scale (CNS-LS), a validated 7-question self-report measure of PBA. Researchers categorized individuals as PBA-positive (PBA[+]) if they had a composite score ≥17 without current depression. Participants also reported their demographic characteristics and their clinical characteristics using Patient-Determined Disease Steps and Performance Scales. They found:

• Of the 8,136 responders, 574 (7%) had scores ≥17 on the CNS-LS; however, only 200 (2.5%) individuals had scores ≥17 without comorbid depression, of whom only 22 (11%) reported a diagnosis of PBA.
• PBA(+) individuals tended to be younger (mean [SD] 53.4 [11.0] vs 57.2 [10.3] years), non-white (13% vs 9%), and have lower socioeconomic status (≤$30,000 annual income: 28% vs 22%).
• In multivariable models, PBA(+) was associated with increased odds of more severe cognitive impairment.

Fitzgerald KC, Salter A, Tyry T, Fox RJ, Cutter G, Marrie RA. Pseudobulbar affect.

Prevalence and association with symptoms in multiple sclerosis. Neurol Clin Pract. 2018;8(6):472-481. doi:10.1212/CPJ.0000000000000523.

LAS VEGAS – Northern California’s Michael S. Baggish, MD, wants more gynecologists to feel comfortable treating disorders of the vulva.

In a presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium, Dr. Baggish ran through some tips about diagnosing and treating vulvar conditions. He discussed routine disorders (such as pubic lice), potentially dangerous disorders (such as lichen sclerosis, an inflammatory skin condition that can develop into squamous cell carcinoma), and rare disorders (such as Behçet’s syndrome, an inflammation of the blood vessels that can cause genital sores, and Fox-Fordyce disease of the vulva, which produces intense itching).

Dr. Baggish, a professor at the University of California, San Francisco, who treats patients in the Wine Country town of Saint Helena, elaborated on the treatment of vulvar disease in an interview at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company. The following are a few of his tips for gynecologists who want to expand their expertise and treat more patients with vulvar disorders.

• Get training in pathology. “That has made a big difference in my ability to intercept different kinds of vulvar and skin diseases,” he said. “You also need to see a lot of abnormalities so you can recognize the kinds of changes that you’re seeing.”
• Take a closer look with a microscope. “I have an operating microscope like an ophthalmologist would use, and it’s on a stand, not a table,” he said. “It always provides magnification with good light. This is a big advantage because misdiagnoses can be made when you can’t see the lesion well.” He added that he projects what he sees in the microscope onto a monitor so the patient can take a look herself. “I’ve found that very valuable,” he said.
• Be alert for chemical burns. “I’ve seen chemical burns when patients have had fungal infections and treated it with certain topical treatments like gentian violet. Somebody may also get a chemical burn from putting some kind of deodorant on their vulva,” Dr. Baggish said. “If you have a chemical burn, you’ll want to treat it with a cream to cover the lesion until it heals on its own. Silvadene is soothing, and patients find it very comfortable.”
• Get the right kind of biopsy. If you can’t identify a lesion, he said, “it’s better to do a biopsy.” He recommends asking pathologists for a reticulum stain. “It shows the support structure of the underlying tissue in the dermis of the layers of the skin, like the structure of a building before you put the covering on the girders,” he said. “The support structure is broken up in lichen planus [a common inflammatory condition that affects the skin and mucous membranes and can cause pain and itch]. You see that if you do a reticulum stain.” If a patient has an inflammatory condition, ask for relevant stains, he said. “For example, if there’s a question that this could be a viral disease like herpes simplex, I’m going to ask them to do a stain for viral inclusions,” he said. “Likewise, I will always ask for a stain for fungal particles, for yeast particles. Sometimes I’ll pick up something like an infection I otherwise would have missed.”
• Contact a specialist when needed. If a biopsy doesn’t help you identify a lesion, he said, “seek out an expert in this area who could be helpful.”

A number of gynecologists like Dr. Baggish specialize in vulvar disease, and several medical centers in the United States operate specialized vulvar clinics including Oregon Health & Science University, Portland; the University of Michigan, Ann Arbor; and Saint Louis University.

Dr. Baggish said he had no disclosures.

LAS VEGAS – Northern California’s Michael S. Baggish, MD, wants more gynecologists to feel comfortable treating disorders of the vulva.

In a presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium, Dr. Baggish ran through some tips about diagnosing and treating vulvar conditions. He discussed routine disorders (such as pubic lice), potentially dangerous disorders (such as lichen sclerosis, an inflammatory skin condition that can develop into squamous cell carcinoma), and rare disorders (such as Behçet’s syndrome, an inflammation of the blood vessels that can cause genital sores, and Fox-Fordyce disease of the vulva, which produces intense itching).

Dr. Baggish, a professor at the University of California, San Francisco, who treats patients in the Wine Country town of Saint Helena, elaborated on the treatment of vulvar disease in an interview at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company. The following are a few of his tips for gynecologists who want to expand their expertise and treat more patients with vulvar disorders.

• Get training in pathology. “That has made a big difference in my ability to intercept different kinds of vulvar and skin diseases,” he said. “You also need to see a lot of abnormalities so you can recognize the kinds of changes that you’re seeing.”
• Take a closer look with a microscope. “I have an operating microscope like an ophthalmologist would use, and it’s on a stand, not a table,” he said. “It always provides magnification with good light. This is a big advantage because misdiagnoses can be made when you can’t see the lesion well.” He added that he projects what he sees in the microscope onto a monitor so the patient can take a look herself. “I’ve found that very valuable,” he said.
• Be alert for chemical burns. “I’ve seen chemical burns when patients have had fungal infections and treated it with certain topical treatments like gentian violet. Somebody may also get a chemical burn from putting some kind of deodorant on their vulva,” Dr. Baggish said. “If you have a chemical burn, you’ll want to treat it with a cream to cover the lesion until it heals on its own. Silvadene is soothing, and patients find it very comfortable.”
• Get the right kind of biopsy. If you can’t identify a lesion, he said, “it’s better to do a biopsy.” He recommends asking pathologists for a reticulum stain. “It shows the support structure of the underlying tissue in the dermis of the layers of the skin, like the structure of a building before you put the covering on the girders,” he said. “The support structure is broken up in lichen planus [a common inflammatory condition that affects the skin and mucous membranes and can cause pain and itch]. You see that if you do a reticulum stain.” If a patient has an inflammatory condition, ask for relevant stains, he said. “For example, if there’s a question that this could be a viral disease like herpes simplex, I’m going to ask them to do a stain for viral inclusions,” he said. “Likewise, I will always ask for a stain for fungal particles, for yeast particles. Sometimes I’ll pick up something like an infection I otherwise would have missed.”
• Contact a specialist when needed. If a biopsy doesn’t help you identify a lesion, he said, “seek out an expert in this area who could be helpful.”

A number of gynecologists like Dr. Baggish specialize in vulvar disease, and several medical centers in the United States operate specialized vulvar clinics including Oregon Health & Science University, Portland; the University of Michigan, Ann Arbor; and Saint Louis University.

Dr. Baggish said he had no disclosures.

LAS VEGAS – Northern California’s Michael S. Baggish, MD, wants more gynecologists to feel comfortable treating disorders of the vulva.

In a presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium, Dr. Baggish ran through some tips about diagnosing and treating vulvar conditions. He discussed routine disorders (such as pubic lice), potentially dangerous disorders (such as lichen sclerosis, an inflammatory skin condition that can develop into squamous cell carcinoma), and rare disorders (such as Behçet’s syndrome, an inflammation of the blood vessels that can cause genital sores, and Fox-Fordyce disease of the vulva, which produces intense itching).

Dr. Baggish, a professor at the University of California, San Francisco, who treats patients in the Wine Country town of Saint Helena, elaborated on the treatment of vulvar disease in an interview at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company. The following are a few of his tips for gynecologists who want to expand their expertise and treat more patients with vulvar disorders.

• Get training in pathology. “That has made a big difference in my ability to intercept different kinds of vulvar and skin diseases,” he said. “You also need to see a lot of abnormalities so you can recognize the kinds of changes that you’re seeing.”
• Take a closer look with a microscope. “I have an operating microscope like an ophthalmologist would use, and it’s on a stand, not a table,” he said. “It always provides magnification with good light. This is a big advantage because misdiagnoses can be made when you can’t see the lesion well.” He added that he projects what he sees in the microscope onto a monitor so the patient can take a look herself. “I’ve found that very valuable,” he said.
• Be alert for chemical burns. “I’ve seen chemical burns when patients have had fungal infections and treated it with certain topical treatments like gentian violet. Somebody may also get a chemical burn from putting some kind of deodorant on their vulva,” Dr. Baggish said. “If you have a chemical burn, you’ll want to treat it with a cream to cover the lesion until it heals on its own. Silvadene is soothing, and patients find it very comfortable.”
• Get the right kind of biopsy. If you can’t identify a lesion, he said, “it’s better to do a biopsy.” He recommends asking pathologists for a reticulum stain. “It shows the support structure of the underlying tissue in the dermis of the layers of the skin, like the structure of a building before you put the covering on the girders,” he said. “The support structure is broken up in lichen planus [a common inflammatory condition that affects the skin and mucous membranes and can cause pain and itch]. You see that if you do a reticulum stain.” If a patient has an inflammatory condition, ask for relevant stains, he said. “For example, if there’s a question that this could be a viral disease like herpes simplex, I’m going to ask them to do a stain for viral inclusions,” he said. “Likewise, I will always ask for a stain for fungal particles, for yeast particles. Sometimes I’ll pick up something like an infection I otherwise would have missed.”
• Contact a specialist when needed. If a biopsy doesn’t help you identify a lesion, he said, “seek out an expert in this area who could be helpful.”

A number of gynecologists like Dr. Baggish specialize in vulvar disease, and several medical centers in the United States operate specialized vulvar clinics including Oregon Health & Science University, Portland; the University of Michigan, Ann Arbor; and Saint Louis University.

Dr. Baggish said he had no disclosures.

LAS VEGAS – Gynecologist Michael S. Baggish, MD, offered tips about diagnosis and treatment of vulvar conditions at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Pubic lice

Treat with malathion 0.5% lotion (Ovide), permethrin 1%-5% (Nix), or lindane 1% (Kwell). Be aware that the U.S. Library of Medicine cautions that lindane can cause serious side effects, and patients should use it only “if there is some reason you cannot use the other medications or if you have tried the other medications and they have not worked.”

Pruritus (itchy skin)

Eliminate possible contact allergens such as soaps, detergents, and undergarments. Swabs with 2% acetic acid solution can assist with general hygiene. It’s important to address secondary infections, and control of diet and stress may be helpful.

Folliculitis (inflammation of hair follicles)

A salt water bath can be helpful. Try 2 cups of “Instant Ocean” – a sea salt product for aquariums – in a shallow bath twice daily.

It can be treated with silver sulfadiazine (Silvadene) cream (three times daily and at bedtime) or clindamycin (Cleocin) cream (three times daily and at bedtime).

Consider a systemic drug after culture results come back if needed.
 

Lichen sclerosus (a skin inflammation also known as white spot disease)

“I see a lot of lichen sclerosus,” Dr. Baggish said. “Every single practice day, I’m seeing two or three [cases].”

Topical treatments include testosterone cream (which has low efficacy) and topical corticosteroid creams and ointments (the standard treatment).

Other treatments provide better and more consistent results: Etretinate (Tegison), a retinoid that is expensive and can produce serious side effects, and injectable dexamethasone (Decadron), which can stop progression.

Be aware that 10% of patients with this condition may develop squamous cell carcinoma. Monitor for any changes in appearance and biopsy if needed.

Behçet’s disease (a blood vessel inflammation disorder also known as silk road disease)

This rare condition can cause mouth and genital ulcers and uveitis (eye inflammation). For treatment, start 40 mg prednisone for 2-3 days, then 20 mg for 2 days, then 10 mg for 4 days, then stop. Start treatment immediately if there are signs of an oral lesion.

Fox-Fordyce disease (an inflammatory response that blocks sweat ducts and causes intense itching)

Treatment includes estrogen (2.5 mg per day) and tretinoin (Retin-A, apply once daily), usually given together. Suggest that patients try the Instant Ocean salt water treatment in the bath once daily (see details above under folliculitis entry).

Genital warts

Vaporize the warts via laser. “If they look like they’re recurring, I put them on interferon for 3 months because otherwise they just keep recurring,” Dr. Baggish said. “You could put topical treatments on them, but they’ll recur.”

Dr. Baggish, of the University of California, San Francisco, had no relevant financial disclosures. The meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Gynecologist Michael S. Baggish, MD, offered tips about diagnosis and treatment of vulvar conditions at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Pubic lice

Treat with malathion 0.5% lotion (Ovide), permethrin 1%-5% (Nix), or lindane 1% (Kwell). Be aware that the U.S. Library of Medicine cautions that lindane can cause serious side effects, and patients should use it only “if there is some reason you cannot use the other medications or if you have tried the other medications and they have not worked.”

Pruritus (itchy skin)

Eliminate possible contact allergens such as soaps, detergents, and undergarments. Swabs with 2% acetic acid solution can assist with general hygiene. It’s important to address secondary infections, and control of diet and stress may be helpful.

Folliculitis (inflammation of hair follicles)

A salt water bath can be helpful. Try 2 cups of “Instant Ocean” – a sea salt product for aquariums – in a shallow bath twice daily.

It can be treated with silver sulfadiazine (Silvadene) cream (three times daily and at bedtime) or clindamycin (Cleocin) cream (three times daily and at bedtime).

Consider a systemic drug after culture results come back if needed.
 

Lichen sclerosus (a skin inflammation also known as white spot disease)

“I see a lot of lichen sclerosus,” Dr. Baggish said. “Every single practice day, I’m seeing two or three [cases].”

Topical treatments include testosterone cream (which has low efficacy) and topical corticosteroid creams and ointments (the standard treatment).

Other treatments provide better and more consistent results: Etretinate (Tegison), a retinoid that is expensive and can produce serious side effects, and injectable dexamethasone (Decadron), which can stop progression.

Be aware that 10% of patients with this condition may develop squamous cell carcinoma. Monitor for any changes in appearance and biopsy if needed.

Behçet’s disease (a blood vessel inflammation disorder also known as silk road disease)

This rare condition can cause mouth and genital ulcers and uveitis (eye inflammation). For treatment, start 40 mg prednisone for 2-3 days, then 20 mg for 2 days, then 10 mg for 4 days, then stop. Start treatment immediately if there are signs of an oral lesion.

Fox-Fordyce disease (an inflammatory response that blocks sweat ducts and causes intense itching)

Treatment includes estrogen (2.5 mg per day) and tretinoin (Retin-A, apply once daily), usually given together. Suggest that patients try the Instant Ocean salt water treatment in the bath once daily (see details above under folliculitis entry).

Genital warts

Vaporize the warts via laser. “If they look like they’re recurring, I put them on interferon for 3 months because otherwise they just keep recurring,” Dr. Baggish said. “You could put topical treatments on them, but they’ll recur.”

Dr. Baggish, of the University of California, San Francisco, had no relevant financial disclosures. The meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Gynecologist Michael S. Baggish, MD, offered tips about diagnosis and treatment of vulvar conditions at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Pubic lice

Treat with malathion 0.5% lotion (Ovide), permethrin 1%-5% (Nix), or lindane 1% (Kwell). Be aware that the U.S. Library of Medicine cautions that lindane can cause serious side effects, and patients should use it only “if there is some reason you cannot use the other medications or if you have tried the other medications and they have not worked.”

Pruritus (itchy skin)

Eliminate possible contact allergens such as soaps, detergents, and undergarments. Swabs with 2% acetic acid solution can assist with general hygiene. It’s important to address secondary infections, and control of diet and stress may be helpful.

Folliculitis (inflammation of hair follicles)

A salt water bath can be helpful. Try 2 cups of “Instant Ocean” – a sea salt product for aquariums – in a shallow bath twice daily.

It can be treated with silver sulfadiazine (Silvadene) cream (three times daily and at bedtime) or clindamycin (Cleocin) cream (three times daily and at bedtime).

Consider a systemic drug after culture results come back if needed.
 

Lichen sclerosus (a skin inflammation also known as white spot disease)

“I see a lot of lichen sclerosus,” Dr. Baggish said. “Every single practice day, I’m seeing two or three [cases].”

Topical treatments include testosterone cream (which has low efficacy) and topical corticosteroid creams and ointments (the standard treatment).

Other treatments provide better and more consistent results: Etretinate (Tegison), a retinoid that is expensive and can produce serious side effects, and injectable dexamethasone (Decadron), which can stop progression.

Be aware that 10% of patients with this condition may develop squamous cell carcinoma. Monitor for any changes in appearance and biopsy if needed.

Behçet’s disease (a blood vessel inflammation disorder also known as silk road disease)

This rare condition can cause mouth and genital ulcers and uveitis (eye inflammation). For treatment, start 40 mg prednisone for 2-3 days, then 20 mg for 2 days, then 10 mg for 4 days, then stop. Start treatment immediately if there are signs of an oral lesion.

Fox-Fordyce disease (an inflammatory response that blocks sweat ducts and causes intense itching)

Treatment includes estrogen (2.5 mg per day) and tretinoin (Retin-A, apply once daily), usually given together. Suggest that patients try the Instant Ocean salt water treatment in the bath once daily (see details above under folliculitis entry).

Genital warts

Vaporize the warts via laser. “If they look like they’re recurring, I put them on interferon for 3 months because otherwise they just keep recurring,” Dr. Baggish said. “You could put topical treatments on them, but they’ll recur.”

Dr. Baggish, of the University of California, San Francisco, had no relevant financial disclosures. The meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

Sagar Lonial, MD, an expert in the biology and treatment of multiple myeloma, was recently named as the Anne and Bernard Gray Family Chair in Cancer at Winship Cancer Institute of Emory University, Atlanta.

The endowment was created in honor of Mrs. Gray’s sister, Karen Ammons Howell, who died of breast cancer. Dr. Lonial, who joined Emory more than 20 years ago, is also the chief medical officer for Winship Cancer Institute and the chairman of the department of hematology and medical oncology. He is currently leading a global genome sequencing study for patients with newly diagnosed myeloma.

The Moffitt Cancer Center, Tampa, is taking a step toward precision medicine. They recently created the position of artificial intelligence officer. J. Ross Mitchell, PhD, is taking on the new role and is tasked with using computer science – and, specifically, artificial intelligence applications – to improve efficiency and quality of care at the center. Dr. Mitchell previously worked at the Mayo Clinic in Scottsdale, Ariz., leading medical imaging information projects, including the application of machine learning in brain tumor imaging.

Oren Cahlon, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center, New York, has been tapped as associate deputy physician in chief for the institution’s Regional Care Network. This puts Dr. Cahlon, an expert in proton therapy, in a new role overseeing outpatient clinical programs across seven locations in New York and New Jersey. Dr. Cahlon will continue in his position as vice chair of the department of radiation oncology, in which he has served since 2016.

John Barrett, MD, is the new editor in chief of the British Journal of Haematology. He begins his term in January 2019. Dr. Barrett, who is a clinical professor of medicine at George Washington University Cancer Center in Washington takes over from Finbarr E. Cotter, MBBS, PhD, who had served in the role since 2006.

The cancer community is mourning the passage of Bertrand Coiffier, MD, PhD, who died in January 2019 at the age of 71. The well-known lymphoma researcher led the team that first described the use of the R-CHOP chemotherapy regimen for the treatment of diffuse large B-cell lymphoma in 2002. Dr. Coiffier also was a founding member of the Groupe d’Etude des Lymphomes de l’Adulte (GELA), which began in Europe in 1984 to advance basic and clinical research on lymphoma in adults, and later became LYSA (Lymphoma Study Association).

[email protected]

Sagar Lonial, MD, an expert in the biology and treatment of multiple myeloma, was recently named as the Anne and Bernard Gray Family Chair in Cancer at Winship Cancer Institute of Emory University, Atlanta.

The endowment was created in honor of Mrs. Gray’s sister, Karen Ammons Howell, who died of breast cancer. Dr. Lonial, who joined Emory more than 20 years ago, is also the chief medical officer for Winship Cancer Institute and the chairman of the department of hematology and medical oncology. He is currently leading a global genome sequencing study for patients with newly diagnosed myeloma.

The Moffitt Cancer Center, Tampa, is taking a step toward precision medicine. They recently created the position of artificial intelligence officer. J. Ross Mitchell, PhD, is taking on the new role and is tasked with using computer science – and, specifically, artificial intelligence applications – to improve efficiency and quality of care at the center. Dr. Mitchell previously worked at the Mayo Clinic in Scottsdale, Ariz., leading medical imaging information projects, including the application of machine learning in brain tumor imaging.

Oren Cahlon, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center, New York, has been tapped as associate deputy physician in chief for the institution’s Regional Care Network. This puts Dr. Cahlon, an expert in proton therapy, in a new role overseeing outpatient clinical programs across seven locations in New York and New Jersey. Dr. Cahlon will continue in his position as vice chair of the department of radiation oncology, in which he has served since 2016.

John Barrett, MD, is the new editor in chief of the British Journal of Haematology. He begins his term in January 2019. Dr. Barrett, who is a clinical professor of medicine at George Washington University Cancer Center in Washington takes over from Finbarr E. Cotter, MBBS, PhD, who had served in the role since 2006.

The cancer community is mourning the passage of Bertrand Coiffier, MD, PhD, who died in January 2019 at the age of 71. The well-known lymphoma researcher led the team that first described the use of the R-CHOP chemotherapy regimen for the treatment of diffuse large B-cell lymphoma in 2002. Dr. Coiffier also was a founding member of the Groupe d’Etude des Lymphomes de l’Adulte (GELA), which began in Europe in 1984 to advance basic and clinical research on lymphoma in adults, and later became LYSA (Lymphoma Study Association).

[email protected]

Sagar Lonial, MD, an expert in the biology and treatment of multiple myeloma, was recently named as the Anne and Bernard Gray Family Chair in Cancer at Winship Cancer Institute of Emory University, Atlanta.

The endowment was created in honor of Mrs. Gray’s sister, Karen Ammons Howell, who died of breast cancer. Dr. Lonial, who joined Emory more than 20 years ago, is also the chief medical officer for Winship Cancer Institute and the chairman of the department of hematology and medical oncology. He is currently leading a global genome sequencing study for patients with newly diagnosed myeloma.

The Moffitt Cancer Center, Tampa, is taking a step toward precision medicine. They recently created the position of artificial intelligence officer. J. Ross Mitchell, PhD, is taking on the new role and is tasked with using computer science – and, specifically, artificial intelligence applications – to improve efficiency and quality of care at the center. Dr. Mitchell previously worked at the Mayo Clinic in Scottsdale, Ariz., leading medical imaging information projects, including the application of machine learning in brain tumor imaging.

Oren Cahlon, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center, New York, has been tapped as associate deputy physician in chief for the institution’s Regional Care Network. This puts Dr. Cahlon, an expert in proton therapy, in a new role overseeing outpatient clinical programs across seven locations in New York and New Jersey. Dr. Cahlon will continue in his position as vice chair of the department of radiation oncology, in which he has served since 2016.

John Barrett, MD, is the new editor in chief of the British Journal of Haematology. He begins his term in January 2019. Dr. Barrett, who is a clinical professor of medicine at George Washington University Cancer Center in Washington takes over from Finbarr E. Cotter, MBBS, PhD, who had served in the role since 2006.

The cancer community is mourning the passage of Bertrand Coiffier, MD, PhD, who died in January 2019 at the age of 71. The well-known lymphoma researcher led the team that first described the use of the R-CHOP chemotherapy regimen for the treatment of diffuse large B-cell lymphoma in 2002. Dr. Coiffier also was a founding member of the Groupe d’Etude des Lymphomes de l’Adulte (GELA), which began in Europe in 1984 to advance basic and clinical research on lymphoma in adults, and later became LYSA (Lymphoma Study Association).

[email protected]