Physical assaults by patients are an occupational hazard of practicing medicine. Assaults can happen in any clinical setting, occur unexpectedly, and have a lasting impact on all involved. In an anonymous survey of 11,000 hospital workers, 18.8% reported being physically assaulted.¹ Psychiatric clinicians may be at greater risk for violence than those who work in other specialties. In a survey of 380 health care employees who worked in a psychiatric setting, 40% of physicians reported being victims of a physical assault.^2,3 Although there are no guidelines on how to manage the aftermath of being assaulted by a patient, we offer the following advice based on our experiences.

Remain calm. Although it may be difficult to do so immediately after being assaulted, remaining calm is essential. You may experience a myriad of emotions, such as anger, fear, vulnerability, shock, or guilt. Although these responses are normal, they can hinder your ability to accomplish subsequent tasks.

Recall the assault. Despite the unpleasantness of replaying the incident, recall as many details as you can and immediately write them down. Because of the copious amount of paperwork you may be required to file (eg, incident reports, employee health forms) and statements that you will likely repeat, having an accurate version of what happened is paramount to determining a course of action. You also may be required to give a statement to law enforcement officials.

Report the assault to your supervisor(s). Informing supervisors and colleagues of what happened could begin the implementation of corrective measures to decrease the risk of future assaults.

Talk about the incident with coworkers, supervisors, and friends to help process what happened, normalize what you are experiencing, and allow others to learn from you. Being assaulted can be traumatic and can result in experiencing post-assault symptoms, such as disruptions in sleep patterns, changes in appetite, and nightmares of the incident. These can be normal reactions to what is an abnormal situation. If necessary, seek medical assistance.

Evaluate the circumstances. Although you may not be at fault, consider if there may have been contributing factors:

• Were there signs of escalating aggressiveness in the patient’s behavior that you may have missed?
• Would the presence of a chaperone during interactions with the patient have reduced the risk of an assault?
• Did you maintain a safe distance from the patient?
• Were existing safety policies followed?

Examine your surroundings. Could the surroundings where the assault occurred have hindered your ability to escape? If so, can they be altered to increase your chance of escaping? Are there items that could be used as potential weapons and should be removed?Expect changes to processes and procedures as part of the reverberations after an assault. Your firsthand account of the assault can limit staff overreactions by analyzing whether existing policies were appropriately implemented, before deeming them ineffective and enacting new policies.

Physical assaults by patients are an occupational hazard of practicing medicine. Assaults can happen in any clinical setting, occur unexpectedly, and have a lasting impact on all involved. In an anonymous survey of 11,000 hospital workers, 18.8% reported being physically assaulted.¹ Psychiatric clinicians may be at greater risk for violence than those who work in other specialties. In a survey of 380 health care employees who worked in a psychiatric setting, 40% of physicians reported being victims of a physical assault.^2,3 Although there are no guidelines on how to manage the aftermath of being assaulted by a patient, we offer the following advice based on our experiences.

Remain calm. Although it may be difficult to do so immediately after being assaulted, remaining calm is essential. You may experience a myriad of emotions, such as anger, fear, vulnerability, shock, or guilt. Although these responses are normal, they can hinder your ability to accomplish subsequent tasks.

Recall the assault. Despite the unpleasantness of replaying the incident, recall as many details as you can and immediately write them down. Because of the copious amount of paperwork you may be required to file (eg, incident reports, employee health forms) and statements that you will likely repeat, having an accurate version of what happened is paramount to determining a course of action. You also may be required to give a statement to law enforcement officials.

Report the assault to your supervisor(s). Informing supervisors and colleagues of what happened could begin the implementation of corrective measures to decrease the risk of future assaults.

Talk about the incident with coworkers, supervisors, and friends to help process what happened, normalize what you are experiencing, and allow others to learn from you. Being assaulted can be traumatic and can result in experiencing post-assault symptoms, such as disruptions in sleep patterns, changes in appetite, and nightmares of the incident. These can be normal reactions to what is an abnormal situation. If necessary, seek medical assistance.

Evaluate the circumstances. Although you may not be at fault, consider if there may have been contributing factors:

• Were there signs of escalating aggressiveness in the patient’s behavior that you may have missed?
• Would the presence of a chaperone during interactions with the patient have reduced the risk of an assault?
• Did you maintain a safe distance from the patient?
• Were existing safety policies followed?

Examine your surroundings. Could the surroundings where the assault occurred have hindered your ability to escape? If so, can they be altered to increase your chance of escaping? Are there items that could be used as potential weapons and should be removed?Expect changes to processes and procedures as part of the reverberations after an assault. Your firsthand account of the assault can limit staff overreactions by analyzing whether existing policies were appropriately implemented, before deeming them ineffective and enacting new policies.

Physical assaults by patients are an occupational hazard of practicing medicine. Assaults can happen in any clinical setting, occur unexpectedly, and have a lasting impact on all involved. In an anonymous survey of 11,000 hospital workers, 18.8% reported being physically assaulted.¹ Psychiatric clinicians may be at greater risk for violence than those who work in other specialties. In a survey of 380 health care employees who worked in a psychiatric setting, 40% of physicians reported being victims of a physical assault.^2,3 Although there are no guidelines on how to manage the aftermath of being assaulted by a patient, we offer the following advice based on our experiences.

Remain calm. Although it may be difficult to do so immediately after being assaulted, remaining calm is essential. You may experience a myriad of emotions, such as anger, fear, vulnerability, shock, or guilt. Although these responses are normal, they can hinder your ability to accomplish subsequent tasks.

Recall the assault. Despite the unpleasantness of replaying the incident, recall as many details as you can and immediately write them down. Because of the copious amount of paperwork you may be required to file (eg, incident reports, employee health forms) and statements that you will likely repeat, having an accurate version of what happened is paramount to determining a course of action. You also may be required to give a statement to law enforcement officials.

Report the assault to your supervisor(s). Informing supervisors and colleagues of what happened could begin the implementation of corrective measures to decrease the risk of future assaults.

Talk about the incident with coworkers, supervisors, and friends to help process what happened, normalize what you are experiencing, and allow others to learn from you. Being assaulted can be traumatic and can result in experiencing post-assault symptoms, such as disruptions in sleep patterns, changes in appetite, and nightmares of the incident. These can be normal reactions to what is an abnormal situation. If necessary, seek medical assistance.

Evaluate the circumstances. Although you may not be at fault, consider if there may have been contributing factors:

• Were there signs of escalating aggressiveness in the patient’s behavior that you may have missed?
• Would the presence of a chaperone during interactions with the patient have reduced the risk of an assault?
• Did you maintain a safe distance from the patient?
• Were existing safety policies followed?

Examine your surroundings. Could the surroundings where the assault occurred have hindered your ability to escape? If so, can they be altered to increase your chance of escaping? Are there items that could be used as potential weapons and should be removed?Expect changes to processes and procedures as part of the reverberations after an assault. Your firsthand account of the assault can limit staff overreactions by analyzing whether existing policies were appropriately implemented, before deeming them ineffective and enacting new policies.

Photo courtesy of ASTRO

SAN DIEGO—New research suggests a need for mental health screening among cancer patients.

The study revealed a 40% rate of depression among patients treated at an urban cancer center over a 3-year period.

Three-quarters of the depressed patients were previously undiagnosed.

Female patients and those who were unable to work due to disability were more likely to be depressed.

Jason Domogauer, PhD, of Rutgers New Jersey Medical School in Newark, New Jersey, presented these findings at ASTRO’s 59th Annual Meeting.

“Depression is widely recognized as an underdiagnosed disorder, particularly among older adults and cancer patients,” Dr Domogauer said. “Our findings point to a clear need for action, including depression screening during initial and continuing patient visits, initiation of mental health treatments for identified patients, and increased collaboration with mental health providers in cancer treatment centers. These efforts are particularly important for patients in urban centers, those who are female, and those who are unable to work because of their disease.”

Dr Domogauer and his colleagues studied 400 cancer patients who received treatment at Rutgers New Jersey Medical School/University Hospital Cancer Center between 2013 and 2016.

The average patient age was 55 (range, 20-86), and 53% of patients were female. Forty-eight percent of patients were African-American, 29% were non-Hispanic white, and 16% were Hispanic.

Nearly equal numbers of patients reported being able to work (49%) or unable to work due to disability (51%). Most patients (85%) received radiation as part of their cancer treatment.

The researchers assessed depression in the patients using a minimum score of 16 on the Center for Epidemiologic Studies Depression Scale.

In this way, 40% of the patients were diagnosed with depression. In 75% of these patients, depression was previously undiagnosed. This means roughly 30% of the overall patient population suffered from undiagnosed and untreated depression.

Depression was more common among females than males—47% and 32%, respectively (odds ratio [OR]=1.9, P=0.007).

Depression was also more likely among patients who were unable to work due to disability—48%, compared to 33% of those able to work (OR=1.9, P=0.005).

Depression prevalence did not differ significantly among racial/ethnic groups.

When the researchers looked specifically at patients who were previously not diagnosed with depression, the effects of being female or unable to work persisted.

In this subgroup, depression was more common among women than men—43% and 29%, respectively (OR=1.9, P=0.02)—and patients with disability compared to able patients—43% and 31%, respectively (OR=1.7, P=0.03).

Photo courtesy of ASTRO

SAN DIEGO—New research suggests a need for mental health screening among cancer patients.

The study revealed a 40% rate of depression among patients treated at an urban cancer center over a 3-year period.

Three-quarters of the depressed patients were previously undiagnosed.

Female patients and those who were unable to work due to disability were more likely to be depressed.

Jason Domogauer, PhD, of Rutgers New Jersey Medical School in Newark, New Jersey, presented these findings at ASTRO’s 59th Annual Meeting.

“Depression is widely recognized as an underdiagnosed disorder, particularly among older adults and cancer patients,” Dr Domogauer said. “Our findings point to a clear need for action, including depression screening during initial and continuing patient visits, initiation of mental health treatments for identified patients, and increased collaboration with mental health providers in cancer treatment centers. These efforts are particularly important for patients in urban centers, those who are female, and those who are unable to work because of their disease.”

Dr Domogauer and his colleagues studied 400 cancer patients who received treatment at Rutgers New Jersey Medical School/University Hospital Cancer Center between 2013 and 2016.

The average patient age was 55 (range, 20-86), and 53% of patients were female. Forty-eight percent of patients were African-American, 29% were non-Hispanic white, and 16% were Hispanic.

Nearly equal numbers of patients reported being able to work (49%) or unable to work due to disability (51%). Most patients (85%) received radiation as part of their cancer treatment.

The researchers assessed depression in the patients using a minimum score of 16 on the Center for Epidemiologic Studies Depression Scale.

In this way, 40% of the patients were diagnosed with depression. In 75% of these patients, depression was previously undiagnosed. This means roughly 30% of the overall patient population suffered from undiagnosed and untreated depression.

Depression was more common among females than males—47% and 32%, respectively (odds ratio [OR]=1.9, P=0.007).

Depression was also more likely among patients who were unable to work due to disability—48%, compared to 33% of those able to work (OR=1.9, P=0.005).

Depression prevalence did not differ significantly among racial/ethnic groups.

When the researchers looked specifically at patients who were previously not diagnosed with depression, the effects of being female or unable to work persisted.

In this subgroup, depression was more common among women than men—43% and 29%, respectively (OR=1.9, P=0.02)—and patients with disability compared to able patients—43% and 31%, respectively (OR=1.7, P=0.03).

Photo courtesy of ASTRO

SAN DIEGO—New research suggests a need for mental health screening among cancer patients.

The study revealed a 40% rate of depression among patients treated at an urban cancer center over a 3-year period.

Three-quarters of the depressed patients were previously undiagnosed.

Female patients and those who were unable to work due to disability were more likely to be depressed.

Jason Domogauer, PhD, of Rutgers New Jersey Medical School in Newark, New Jersey, presented these findings at ASTRO’s 59th Annual Meeting.

“Depression is widely recognized as an underdiagnosed disorder, particularly among older adults and cancer patients,” Dr Domogauer said. “Our findings point to a clear need for action, including depression screening during initial and continuing patient visits, initiation of mental health treatments for identified patients, and increased collaboration with mental health providers in cancer treatment centers. These efforts are particularly important for patients in urban centers, those who are female, and those who are unable to work because of their disease.”

Dr Domogauer and his colleagues studied 400 cancer patients who received treatment at Rutgers New Jersey Medical School/University Hospital Cancer Center between 2013 and 2016.

The average patient age was 55 (range, 20-86), and 53% of patients were female. Forty-eight percent of patients were African-American, 29% were non-Hispanic white, and 16% were Hispanic.

Nearly equal numbers of patients reported being able to work (49%) or unable to work due to disability (51%). Most patients (85%) received radiation as part of their cancer treatment.

The researchers assessed depression in the patients using a minimum score of 16 on the Center for Epidemiologic Studies Depression Scale.

In this way, 40% of the patients were diagnosed with depression. In 75% of these patients, depression was previously undiagnosed. This means roughly 30% of the overall patient population suffered from undiagnosed and untreated depression.

Depression was more common among females than males—47% and 32%, respectively (odds ratio [OR]=1.9, P=0.007).

Depression was also more likely among patients who were unable to work due to disability—48%, compared to 33% of those able to work (OR=1.9, P=0.005).

Depression prevalence did not differ significantly among racial/ethnic groups.

When the researchers looked specifically at patients who were previously not diagnosed with depression, the effects of being female or unable to work persisted.

In this subgroup, depression was more common among women than men—43% and 29%, respectively (OR=1.9, P=0.02)—and patients with disability compared to able patients—43% and 31%, respectively (OR=1.7, P=0.03).

It seemed appropriate this month for me to step aside for the Editor’s commentary and provide a forum for one of our associate editors to talk about his experience during Hurricane Harvey.

John I. Allen, MD, MBA, AGAF
Editor in Chief

We knew that a powerful storm was coming, but very few anticipated the widespread destruction Hurricane Harvey would bring. Houston is no stranger to floods, but the amount of water that Harvey unleashed was record-breaking. Areas that had never flooded were underwater, evacuations were commonplace; the devastation was heart-breaking. In the midst of significant personal tragedy, Houston came together. Neighbors took in flooded colleagues, personal boats were used for rescues, and many braved impassable roads to donate clothes, food, labor and medical aid. Shelters across the city were assisted by volunteers; community groups collected and coordinated distribution of supplies. Medical teams were mobilized to treat chronically ill patients who evacuated without their medications or those injured while escaping the floods.

At one of the largest medical centers in the world, floodgates constructed after Tropical Storm Allison kept the waters at bay. And physicians, nurses, janitors, and other employees slept in hospitals for days to provide care to our patients during the worst of the floods. Those who relieved them worked long hours to see the many patients rescheduled in the aftermath of the storm. After-work crews of neighbors continue to go from house to house removing flooded floor boards and ripping out drywall. Houston came together.

Dr. Ketwaroo is an assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an advanced endoscopist at the Michael E. Debakey VA Medical Center in Houston. He is an associate editor for GI & Hepatology News.

It seemed appropriate this month for me to step aside for the Editor’s commentary and provide a forum for one of our associate editors to talk about his experience during Hurricane Harvey.

John I. Allen, MD, MBA, AGAF
Editor in Chief

We knew that a powerful storm was coming, but very few anticipated the widespread destruction Hurricane Harvey would bring. Houston is no stranger to floods, but the amount of water that Harvey unleashed was record-breaking. Areas that had never flooded were underwater, evacuations were commonplace; the devastation was heart-breaking. In the midst of significant personal tragedy, Houston came together. Neighbors took in flooded colleagues, personal boats were used for rescues, and many braved impassable roads to donate clothes, food, labor and medical aid. Shelters across the city were assisted by volunteers; community groups collected and coordinated distribution of supplies. Medical teams were mobilized to treat chronically ill patients who evacuated without their medications or those injured while escaping the floods.

At one of the largest medical centers in the world, floodgates constructed after Tropical Storm Allison kept the waters at bay. And physicians, nurses, janitors, and other employees slept in hospitals for days to provide care to our patients during the worst of the floods. Those who relieved them worked long hours to see the many patients rescheduled in the aftermath of the storm. After-work crews of neighbors continue to go from house to house removing flooded floor boards and ripping out drywall. Houston came together.

Dr. Ketwaroo is an assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an advanced endoscopist at the Michael E. Debakey VA Medical Center in Houston. He is an associate editor for GI & Hepatology News.

It seemed appropriate this month for me to step aside for the Editor’s commentary and provide a forum for one of our associate editors to talk about his experience during Hurricane Harvey.

John I. Allen, MD, MBA, AGAF
Editor in Chief

We knew that a powerful storm was coming, but very few anticipated the widespread destruction Hurricane Harvey would bring. Houston is no stranger to floods, but the amount of water that Harvey unleashed was record-breaking. Areas that had never flooded were underwater, evacuations were commonplace; the devastation was heart-breaking. In the midst of significant personal tragedy, Houston came together. Neighbors took in flooded colleagues, personal boats were used for rescues, and many braved impassable roads to donate clothes, food, labor and medical aid. Shelters across the city were assisted by volunteers; community groups collected and coordinated distribution of supplies. Medical teams were mobilized to treat chronically ill patients who evacuated without their medications or those injured while escaping the floods.

At one of the largest medical centers in the world, floodgates constructed after Tropical Storm Allison kept the waters at bay. And physicians, nurses, janitors, and other employees slept in hospitals for days to provide care to our patients during the worst of the floods. Those who relieved them worked long hours to see the many patients rescheduled in the aftermath of the storm. After-work crews of neighbors continue to go from house to house removing flooded floor boards and ripping out drywall. Houston came together.

Dr. Ketwaroo is an assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an advanced endoscopist at the Michael E. Debakey VA Medical Center in Houston. He is an associate editor for GI & Hepatology News.

CE/CME No: CR-1710

PROGRAM OVERVIEW
Earn credit by reading this article and successfully completing the posttest and evaluation. Successful completion is defined as a cumulative score of at least 70% correct.

EDUCATIONAL OBJECTIVES
• Describe the main factors involved in the pathogenesis of acne.
• Assess acne severity and classify acne as mild, moderate, or severe.
• Describe available acne therapies, including their mechanisms of action, indications, and potential adverse effects.
• Identify strategies patients can employ to mitigate the adverse effects of acne treatments.

FACULTY
Janet Purath is an Associate Professor at Washington State University in Spokane, Washington. Theresa Coyner practices at Randall Dermatology, West Lafayette, Indiana.

The authors have no financial relationships to disclose.

ACCREDITATION STATEMENT

This program has been reviewed and is approved for a maximum of 1.0 hour of American Academy of Physician Assistants (AAPA) Category 1 CME credit by the Physician Assistant Review Panel. [NPs: Both ANCC and the AANP Certification Program recognize AAPA as an approved provider of Category 1 credit.] Approval is valid through September 30, 2018.

Article begins on next page >>

Many of the 50 million persons affected by acne in the United States present to primary care. Acne severity guides treatment choices, which include topical antibiotics and retinoids, hormonal agents, and systemic antibiotics and retinoids. Formulating a treatment plan requires a thorough understanding of the dosing, mechanism of action, and potential adverse effects of available medications.

Acne vulgaris (acne) is a common skin condition that is frequently encountered in primary care. Acne affects up to 50 million people in the United States, and about 85% of teenagers experience it at some point.¹ Costs for treatment exceed $3 billion per year.² Although commonly considered a condition of adolescence and young adults (85% prevalence), acne may persist in both men and women well into their 30s and 40s (43% prevalence). In fact, 5% of women ages 40 and older may experience acne.³

Acne is associated with considerable, long-lasting psychological sequelae, even in those with mild conditions, as many affected patients experience self-esteem issues and may avoid social interactions.⁴ Recognition of patients’ concerns about acne will help to promote a trusting patient-provider relationship. This article describes the pathophysiology and classifications of acne and reviews therapeutic options, enabling the practitioner to initiate treatment.

PRESENTATION AND ASSESSMENT

Acne lesions may occur on the face, neck, trunk, and extremities. The severity of acne is assessed based on lesion type, number, and size, and this grading is used to inform decisions about treatment options. Mild acne is characterized by plugging of the sebaceous gland (comedones), with small numbers of inflammatory papules and pustules. Moderate acne involves a larger number of inflammatory papules/pustules as well as the presence of small cystic nodules. Severe acne is marked by the presence of large numbers of noninflammatory and inflammatory lesions and cystic nodules or widespread involvement of these lesions.⁵ Examples of mild, moderate, and severe acne are shown in Figure 1. Assessment should include questions about the patient’s experiences with prior therapies.

PATHOGENESIS

The pathogenesis of acne is a complex process involving multiple factors (see Figure 2). Knowledge about acne pathogenesis continues to evolve, but the current view is that a combination of simultaneous noninflammatory and inflammatory events involving pilosebaceous units (which consist of sebaceous glands and hair follicles) contribute to its development.⁶ Activation of the sebaceous glands is influenced by androgens, which increase sebum production and shedding of the keratinocytes lining the gland. Plugging of the pilosebaceous canal ensues, leading to the development of a microcomedone. Increased proliferation of Propionibacterium acnes occurs within the obstructed gland. The inflammatory response to this process includes a cascade of numerous cytokines, most notably toll-like receptor 2 (TLR-2).⁷ The plug at the opening of the sebaceous gland creates either an open comedone (blackhead) or a closed comedone (whitehead). Eventually, the follicular wall ruptures, leading to the formation of erythematous papules and pustules on the skin surface or deep-seated cystic structures under the skin surface. Current pharmacologic agents target one or more of these identified factors underlying acne pathogenesis.

THERAPEUTIC OPTIONS

Pharmacologic treatment options for acne include topical, systemic, and hormonal agents. Topical and systemic therapies reduce inflammation and follicular plugging. Topical treatments include antibiotics, anti-inflammatories, and retinoids. Oral treatments include antibiotics, hormones, and retinoids. The clinician must have a thorough understanding of the actions, potential adverse reactions, and drug interactions of each proposed therapy prior to formulating a treatment plan.

Topical retinoids

Topical retinoids are the most effective comedolytic agents available.¹ Since comedones are thought to be the precursor of all other acne lesions, retinoids are appropriate for cases in which comedones are seen.¹ Retinoids belong to a class of compounds structurally related to vitamin A. Topical retinoids act by promoting normal follicular keratinocyte desquamation, which prevents obstruction of the pilosebaceous canal and thereby inhibits the formation of microcomedones.⁸

They also exhibit anti-inflammatory action via inhibition of TLR-2.⁹ The comedolytic and anti-inflammatory actions of topical retinoids make them a mainstay of acne treatment, although some patients are unable to tolerate their adverse effects, which include erythema and dryness related to increases in transepidermal water loss. Application of noncomedogenic emollients can improve these common effects.¹⁰ The newer micronized and time-release retinoid formulations may have less potential for irritation.⁸ Vehicle formulation and concentration also play a role in skin irritation, with gels and liquids and formulations with higher concentrations of retinoids generally causing more drying than creams and lower potency formulations.⁸ Table 1 summarizes the mechanisms of action, available formulations, and potential adverse effects of the topical retinoids and other topical agents.^1,6,9-16

It is important to note that retinoids can adversely affect the developing fetus when absorbed in large quantities. Notably, tazarotene is assigned to pregnancy category X because when it is used to treat psoriasis, one of its approved indications, large surface areas may be treated, increasing absorption. Absorption amounts are extremely low when tazarotene is used to treat acne. Nevertheless, verification of a negative pregnancy test is recommended prior to initiating tazarotene therapy. Effective birth control measures should be utilized throughout therapy. Even though other commonly used retinoids (tretinoin and adapalene) are assigned to pregnancy category C, all topical retinoids should be avoided during pregnancy.⁹

As noted, patient education is key for increasing patient adherence to therapy. Patients should be instructed to use a small (pea-sized) amount of medication for the entire face. Providers should also inform patients that transient erythema and dryness can be expected, and that application of a noncomedolytic moisturizer may reduce irritation. Tretinoin is best used at night,¹ and it is useful to advise that erythema and irritation associated with retinoid use can be reduced by initially using the medication every other night to every third night, gradually building up to nightly use.¹

Topical antibiotic and anti-inflammatory agents

Topical agents used to treat inflammatory lesions include benzoyl peroxide, erythromycin, clindamycin, dapsone, azelaic acid, and sulfacetamide (Table 1).^1,6,9-16 These topical agents are generally well tolerated, with most adverse reactions limited to facial irritation and erythema. They come in an array of vehicle formulations, including washes, creams, gels, solutions, foams, and lotions. Vehicle selection should be based upon patient preference and skin type. Gels and solutions have a drying effect, making them more appropriate for individuals with oily skin, whereas creams are moisturizing and appropriate for individuals with dry skin. Lotions are appropriate for all skin types.¹¹

Benzoyl peroxide (BPO) has both keratolytic and comedolytic activity and is available in concentrations ranging from 2.5% to 10%. It is available OTC, as well as by prescription, and is thus readily accessed by the patient. Because BPO is bactericidal for P acnes, resistance to BPO among P acnes has not occurred.¹ All concentrations are equally effective, but the higher concentrations are more likely to cause skin dryness and other adverse effects.¹² Combination therapy with topical antibiotics, tretinoin, and BPO is more clinically effective than monotherapy.¹⁷ Combination products reduce the complexity of acne treatment and likely increase therapy adherence.¹¹ Currently available combination products in various percentages are erythromycin with BPO, clindamycin with BPO, adapalene with BPO, and clindamycin with tretinoin.¹

Oral antibiotics

Oral antibiotics should be reserved for use in situations where topical therapy is ineffective. All antibiotics are effective in treating acne due to their antimicrobial activity against P acnes.¹ These agents play a key role in managing moderate to severe acne that is likely to scar, as well as in cases of widespread acne involving the face, arms, and trunk. Note that the use of oral antibiotics in acne treatment is controversial, as chronic use contributes to rising rates of bacterial resistance.¹⁸ For this reason, antibiotic therapy for acne should be limited to a duration of three months or less, and these agents should not be used as monotherapy.⁶ In particular, recent recommendations restrict the use of erythromycin for acne treatment due to an increase of P acnes resistance.¹ Cephalosporins, macrolides, and penicillin class antibiotics are not routinely recommended due to lack of data regarding their clinical effectiveness in treating acne.¹

Tetracycline class antibiotics are the most commonly used oral antibiotics for acne therapy, particularly doxycycline and minocycline.⁵ Common adverse effects include gastrointestinal upset, photosensitivity, and some pigmentation issues.¹⁹ Trimethoprim-sulfamethoxazole (TMP-SMX) is a folate synthesis inhibitor class antibiotic also used to treat acne. Its use should be reserved for individuals who are allergic to tetracyclines or in cases of acne resistant to other antimicrobials.¹ Potential adverse reactions include photosensitivity and severe hypersensitivity conditions ranging from a mild rash to toxic epidermal necrolysis.¹⁹ Table 2 summarizes the dosage ranges, pregnancy category risk, and potential adverse effects of oral antibiotics used to treat acne.^1,19,20

The firstline choice for treating moderate acne with papules and pustules is oral antibiotics with topical retinoids and BPO.⁵ Patients should be educated about potential adverse effects of these agents, including the development of antibiotic resistance.

Hormonal agents

Hormonal therapies should be reserved for females with acne lesions influenced by fluctuations in hormone levels.²¹ Pubertal changes initiate the production of adrenal dehydroepiandrosterone, which leads to increased testosterone production. Testosterone is converted to dihydrotestosterone (DHT), which binds to androgen receptors in the sebaceous glands, stimulating the glands and potentially increasing production of sebum. Hormonal agents act by reducing androgen activity in the sebaceous gland. Combined oral hormones, those containing both estrogen and progesterone, reduce the amount of free testosterone and ovarian androgens by suppressing ovulation.¹ Hormonal therapy can be quite effective for females of childbearing age. Females who report acne flares with their menstrual cycles may be good candidates for hormonal therapy.¹

The estrogen agent most frequently used in oral contraceptives is ethinyl estradiol. Numerous progesterone agents can also be used, but those with low androgenicity or antiandrogenic properties are more effective for acne therapy.²¹ It is prudent to screen patients for thromboembolic risks, as this is a major adverse effect of combined hormonal agents. Risks of thromboembolic episodes are increased in obese persons, those who smoke, and those older than age 35.¹⁵ Other contraindications for combined hormonal therapy are pregnancy, liver disease, current breast cancer, heart disease, hypertension, and migraines with neurologic symptoms. Minor adverse effects include nausea, breast tenderness, cyclic weight gain, and headaches.¹⁵ Although many combined oral contraceptives improve acne, only four have FDA indications for the treatment of acne: ethinyl estradiol/norgestimate, norethindrone acetate/ethinyl estradiol, drospirenone/ethinyl estradiol, and drospirenone/ethinyl estradiol/folate.⁵

Spironolactone, a potassium-sparing diur­etic, may also be appropriate for treating acne in women due to its antiandrogenic properties. The drug binds androgen receptors in the skin, which then blocks testosterone and DHT. Spironolactone can be an effective firstline agent in treating hormonal-pattern acne, which presents as inflammatory lesions located on the lower face and neck. In particular, it can be an appropriate choice for women with adult-onset acne.¹⁵ Spironolactone is not approved by the FDA for acne treatment, but it has been used successfully for many years.⁵ Spironolactone was found in rodent studies to cause feminization of the male rat fetus, so patients taking this drug should use reliable birth control methods. It can be used concomitantly with oral contraceptives.⁵ Common side effects include breast tenderness, diuretic effects, headaches, and menstrual irregularities. Although the risk for hypokalemia is low in healthy young women, it may be prudent to periodically assess potassium, sodium, and renal function in patients.¹ Spironolactone should be avoided in patients with renal disease and those on other diuretics.¹⁵

Isotretinoin

Isotretinoin is an oral systemic retinoid that modulates nuclear receptors and regulates gene transcription in the epidermis.¹⁶ Isotretinoin’s mechanisms of action target the main pathogenic factors underlying acne, including reduction of follicular hyperkeratosis, comedogenesis, sebum production, and inflammation and suppression of P acnes.²² These combined actions make isotretinoin a highly effective treatment option for acne.

The drug is approved by the FDA for treatment of nodular acne refractory to traditional acne therapies.²³ Isotretinoin is available in 10, 20, 25, 30, and 40 mg capsules, and the recommended dosing is 0.5 to 2.0 mg/kg/d. The usual course of therapy is 15 to 20 weeks or until an accumulative dosage of 120 to 150 mg/kg is attained.²³ Patients should be instructed to take isotretinoin with meals, as oral availability is increased with high-fat foods.²³

Isotretinoin has major adverse effects. It is a teratogenic medication that can cause congenital anomalies in exposed fetuses, including craniofacial, cardiac, and neurologic issues.¹⁶ Due to the seriousness of the congenital anomalies, all prescribers must be registered in the iPledge program, a computer-based risk management program instituted in 2006 by the FDA and the companies that manufacture isotretinoin to eliminate congenital risks associated with isotretinoin. All patients, both male and female, must sign an informed consent form when they register in the program.

Although the iPledge program does not mandate consistent condom use for male patients, they should be informed that minute amounts of isotretinoin can be found in semen. The risk for fathering a fetus with congenital anomalies when taking isotretinoin appears to be extremely low.¹⁶ Women of childbearing potential must commit to the use of two highly reliable forms of birth control when taking the medication, including one month before starting therapy and one month after completing therapy.¹⁶ Monthly pregnancy testing is mandatory throughout the course of treatment.²⁴ Further information regarding the risk management program can be found at iPledgeprogram.com.

Isotretinoin is metabolized by the liver and may cause lipid abnormalities and hepatic enzyme elevations. Baseline and monthly laboratory monitoring of liver enzymes and cholesterol and triglyceride levels are recommended.²⁴ The process of initiating and monitoring isotretinoin therapy is quite complex, and unless the practitioner plans to routinely prescribe this medi­cation, patients needing isotretinoin therapy should be referred to a dermatology practice.

PATIENT EDUCATION

Patients are more likely to adhere to treatment when simplified regimens are used and when they have realistic expectations for therapy outcomes. Providers need to educate patients that all treatments may require at least two to three months of use before visible results occur. Initial and subsequent visits should include discussions about clear expectations and strategies to reduce potential adverse effects.

PUTTING IT ALL TOGETHER

Acne therapy starts with the use of a topical retinoid in mild acne cases, unless the patient is unable to tolerate the associated skin irritability. Addition of a topical antibiotic or anti-inflammatory agent, preferably BPO, either alone or with a combination product, is also recommended for mild to moderate acne. Patients with moderate to severe acne may benefit from a short course (three months or less) of antibiotics.

Oral hormones may be an excellent therapy choice when acne treatment is needed for women of childbearing age. Isotretinoin is indicated in select cases of severe acne resistant to other treatments.

CE/CME No: CR-1710

PROGRAM OVERVIEW
Earn credit by reading this article and successfully completing the posttest and evaluation. Successful completion is defined as a cumulative score of at least 70% correct.

EDUCATIONAL OBJECTIVES
• Describe the main factors involved in the pathogenesis of acne.
• Assess acne severity and classify acne as mild, moderate, or severe.
• Describe available acne therapies, including their mechanisms of action, indications, and potential adverse effects.
• Identify strategies patients can employ to mitigate the adverse effects of acne treatments.

FACULTY
Janet Purath is an Associate Professor at Washington State University in Spokane, Washington. Theresa Coyner practices at Randall Dermatology, West Lafayette, Indiana.

The authors have no financial relationships to disclose.

ACCREDITATION STATEMENT

This program has been reviewed and is approved for a maximum of 1.0 hour of American Academy of Physician Assistants (AAPA) Category 1 CME credit by the Physician Assistant Review Panel. [NPs: Both ANCC and the AANP Certification Program recognize AAPA as an approved provider of Category 1 credit.] Approval is valid through September 30, 2018.

Article begins on next page >>

Many of the 50 million persons affected by acne in the United States present to primary care. Acne severity guides treatment choices, which include topical antibiotics and retinoids, hormonal agents, and systemic antibiotics and retinoids. Formulating a treatment plan requires a thorough understanding of the dosing, mechanism of action, and potential adverse effects of available medications.

Acne vulgaris (acne) is a common skin condition that is frequently encountered in primary care. Acne affects up to 50 million people in the United States, and about 85% of teenagers experience it at some point.¹ Costs for treatment exceed $3 billion per year.² Although commonly considered a condition of adolescence and young adults (85% prevalence), acne may persist in both men and women well into their 30s and 40s (43% prevalence). In fact, 5% of women ages 40 and older may experience acne.³

Acne is associated with considerable, long-lasting psychological sequelae, even in those with mild conditions, as many affected patients experience self-esteem issues and may avoid social interactions.⁴ Recognition of patients’ concerns about acne will help to promote a trusting patient-provider relationship. This article describes the pathophysiology and classifications of acne and reviews therapeutic options, enabling the practitioner to initiate treatment.

PRESENTATION AND ASSESSMENT

Acne lesions may occur on the face, neck, trunk, and extremities. The severity of acne is assessed based on lesion type, number, and size, and this grading is used to inform decisions about treatment options. Mild acne is characterized by plugging of the sebaceous gland (comedones), with small numbers of inflammatory papules and pustules. Moderate acne involves a larger number of inflammatory papules/pustules as well as the presence of small cystic nodules. Severe acne is marked by the presence of large numbers of noninflammatory and inflammatory lesions and cystic nodules or widespread involvement of these lesions.⁵ Examples of mild, moderate, and severe acne are shown in Figure 1. Assessment should include questions about the patient’s experiences with prior therapies.

PATHOGENESIS

The pathogenesis of acne is a complex process involving multiple factors (see Figure 2). Knowledge about acne pathogenesis continues to evolve, but the current view is that a combination of simultaneous noninflammatory and inflammatory events involving pilosebaceous units (which consist of sebaceous glands and hair follicles) contribute to its development.⁶ Activation of the sebaceous glands is influenced by androgens, which increase sebum production and shedding of the keratinocytes lining the gland. Plugging of the pilosebaceous canal ensues, leading to the development of a microcomedone. Increased proliferation of Propionibacterium acnes occurs within the obstructed gland. The inflammatory response to this process includes a cascade of numerous cytokines, most notably toll-like receptor 2 (TLR-2).⁷ The plug at the opening of the sebaceous gland creates either an open comedone (blackhead) or a closed comedone (whitehead). Eventually, the follicular wall ruptures, leading to the formation of erythematous papules and pustules on the skin surface or deep-seated cystic structures under the skin surface. Current pharmacologic agents target one or more of these identified factors underlying acne pathogenesis.

THERAPEUTIC OPTIONS

Pharmacologic treatment options for acne include topical, systemic, and hormonal agents. Topical and systemic therapies reduce inflammation and follicular plugging. Topical treatments include antibiotics, anti-inflammatories, and retinoids. Oral treatments include antibiotics, hormones, and retinoids. The clinician must have a thorough understanding of the actions, potential adverse reactions, and drug interactions of each proposed therapy prior to formulating a treatment plan.

Topical retinoids

Topical retinoids are the most effective comedolytic agents available.¹ Since comedones are thought to be the precursor of all other acne lesions, retinoids are appropriate for cases in which comedones are seen.¹ Retinoids belong to a class of compounds structurally related to vitamin A. Topical retinoids act by promoting normal follicular keratinocyte desquamation, which prevents obstruction of the pilosebaceous canal and thereby inhibits the formation of microcomedones.⁸

They also exhibit anti-inflammatory action via inhibition of TLR-2.⁹ The comedolytic and anti-inflammatory actions of topical retinoids make them a mainstay of acne treatment, although some patients are unable to tolerate their adverse effects, which include erythema and dryness related to increases in transepidermal water loss. Application of noncomedogenic emollients can improve these common effects.¹⁰ The newer micronized and time-release retinoid formulations may have less potential for irritation.⁸ Vehicle formulation and concentration also play a role in skin irritation, with gels and liquids and formulations with higher concentrations of retinoids generally causing more drying than creams and lower potency formulations.⁸ Table 1 summarizes the mechanisms of action, available formulations, and potential adverse effects of the topical retinoids and other topical agents.^1,6,9-16

It is important to note that retinoids can adversely affect the developing fetus when absorbed in large quantities. Notably, tazarotene is assigned to pregnancy category X because when it is used to treat psoriasis, one of its approved indications, large surface areas may be treated, increasing absorption. Absorption amounts are extremely low when tazarotene is used to treat acne. Nevertheless, verification of a negative pregnancy test is recommended prior to initiating tazarotene therapy. Effective birth control measures should be utilized throughout therapy. Even though other commonly used retinoids (tretinoin and adapalene) are assigned to pregnancy category C, all topical retinoids should be avoided during pregnancy.⁹

As noted, patient education is key for increasing patient adherence to therapy. Patients should be instructed to use a small (pea-sized) amount of medication for the entire face. Providers should also inform patients that transient erythema and dryness can be expected, and that application of a noncomedolytic moisturizer may reduce irritation. Tretinoin is best used at night,¹ and it is useful to advise that erythema and irritation associated with retinoid use can be reduced by initially using the medication every other night to every third night, gradually building up to nightly use.¹

Topical antibiotic and anti-inflammatory agents

Topical agents used to treat inflammatory lesions include benzoyl peroxide, erythromycin, clindamycin, dapsone, azelaic acid, and sulfacetamide (Table 1).^1,6,9-16 These topical agents are generally well tolerated, with most adverse reactions limited to facial irritation and erythema. They come in an array of vehicle formulations, including washes, creams, gels, solutions, foams, and lotions. Vehicle selection should be based upon patient preference and skin type. Gels and solutions have a drying effect, making them more appropriate for individuals with oily skin, whereas creams are moisturizing and appropriate for individuals with dry skin. Lotions are appropriate for all skin types.¹¹

Benzoyl peroxide (BPO) has both keratolytic and comedolytic activity and is available in concentrations ranging from 2.5% to 10%. It is available OTC, as well as by prescription, and is thus readily accessed by the patient. Because BPO is bactericidal for P acnes, resistance to BPO among P acnes has not occurred.¹ All concentrations are equally effective, but the higher concentrations are more likely to cause skin dryness and other adverse effects.¹² Combination therapy with topical antibiotics, tretinoin, and BPO is more clinically effective than monotherapy.¹⁷ Combination products reduce the complexity of acne treatment and likely increase therapy adherence.¹¹ Currently available combination products in various percentages are erythromycin with BPO, clindamycin with BPO, adapalene with BPO, and clindamycin with tretinoin.¹

Oral antibiotics

Oral antibiotics should be reserved for use in situations where topical therapy is ineffective. All antibiotics are effective in treating acne due to their antimicrobial activity against P acnes.¹ These agents play a key role in managing moderate to severe acne that is likely to scar, as well as in cases of widespread acne involving the face, arms, and trunk. Note that the use of oral antibiotics in acne treatment is controversial, as chronic use contributes to rising rates of bacterial resistance.¹⁸ For this reason, antibiotic therapy for acne should be limited to a duration of three months or less, and these agents should not be used as monotherapy.⁶ In particular, recent recommendations restrict the use of erythromycin for acne treatment due to an increase of P acnes resistance.¹ Cephalosporins, macrolides, and penicillin class antibiotics are not routinely recommended due to lack of data regarding their clinical effectiveness in treating acne.¹

Tetracycline class antibiotics are the most commonly used oral antibiotics for acne therapy, particularly doxycycline and minocycline.⁵ Common adverse effects include gastrointestinal upset, photosensitivity, and some pigmentation issues.¹⁹ Trimethoprim-sulfamethoxazole (TMP-SMX) is a folate synthesis inhibitor class antibiotic also used to treat acne. Its use should be reserved for individuals who are allergic to tetracyclines or in cases of acne resistant to other antimicrobials.¹ Potential adverse reactions include photosensitivity and severe hypersensitivity conditions ranging from a mild rash to toxic epidermal necrolysis.¹⁹ Table 2 summarizes the dosage ranges, pregnancy category risk, and potential adverse effects of oral antibiotics used to treat acne.^1,19,20

The firstline choice for treating moderate acne with papules and pustules is oral antibiotics with topical retinoids and BPO.⁵ Patients should be educated about potential adverse effects of these agents, including the development of antibiotic resistance.

Hormonal agents

Hormonal therapies should be reserved for females with acne lesions influenced by fluctuations in hormone levels.²¹ Pubertal changes initiate the production of adrenal dehydroepiandrosterone, which leads to increased testosterone production. Testosterone is converted to dihydrotestosterone (DHT), which binds to androgen receptors in the sebaceous glands, stimulating the glands and potentially increasing production of sebum. Hormonal agents act by reducing androgen activity in the sebaceous gland. Combined oral hormones, those containing both estrogen and progesterone, reduce the amount of free testosterone and ovarian androgens by suppressing ovulation.¹ Hormonal therapy can be quite effective for females of childbearing age. Females who report acne flares with their menstrual cycles may be good candidates for hormonal therapy.¹

The estrogen agent most frequently used in oral contraceptives is ethinyl estradiol. Numerous progesterone agents can also be used, but those with low androgenicity or antiandrogenic properties are more effective for acne therapy.²¹ It is prudent to screen patients for thromboembolic risks, as this is a major adverse effect of combined hormonal agents. Risks of thromboembolic episodes are increased in obese persons, those who smoke, and those older than age 35.¹⁵ Other contraindications for combined hormonal therapy are pregnancy, liver disease, current breast cancer, heart disease, hypertension, and migraines with neurologic symptoms. Minor adverse effects include nausea, breast tenderness, cyclic weight gain, and headaches.¹⁵ Although many combined oral contraceptives improve acne, only four have FDA indications for the treatment of acne: ethinyl estradiol/norgestimate, norethindrone acetate/ethinyl estradiol, drospirenone/ethinyl estradiol, and drospirenone/ethinyl estradiol/folate.⁵

Spironolactone, a potassium-sparing diur­etic, may also be appropriate for treating acne in women due to its antiandrogenic properties. The drug binds androgen receptors in the skin, which then blocks testosterone and DHT. Spironolactone can be an effective firstline agent in treating hormonal-pattern acne, which presents as inflammatory lesions located on the lower face and neck. In particular, it can be an appropriate choice for women with adult-onset acne.¹⁵ Spironolactone is not approved by the FDA for acne treatment, but it has been used successfully for many years.⁵ Spironolactone was found in rodent studies to cause feminization of the male rat fetus, so patients taking this drug should use reliable birth control methods. It can be used concomitantly with oral contraceptives.⁵ Common side effects include breast tenderness, diuretic effects, headaches, and menstrual irregularities. Although the risk for hypokalemia is low in healthy young women, it may be prudent to periodically assess potassium, sodium, and renal function in patients.¹ Spironolactone should be avoided in patients with renal disease and those on other diuretics.¹⁵

Isotretinoin

Isotretinoin is an oral systemic retinoid that modulates nuclear receptors and regulates gene transcription in the epidermis.¹⁶ Isotretinoin’s mechanisms of action target the main pathogenic factors underlying acne, including reduction of follicular hyperkeratosis, comedogenesis, sebum production, and inflammation and suppression of P acnes.²² These combined actions make isotretinoin a highly effective treatment option for acne.

The drug is approved by the FDA for treatment of nodular acne refractory to traditional acne therapies.²³ Isotretinoin is available in 10, 20, 25, 30, and 40 mg capsules, and the recommended dosing is 0.5 to 2.0 mg/kg/d. The usual course of therapy is 15 to 20 weeks or until an accumulative dosage of 120 to 150 mg/kg is attained.²³ Patients should be instructed to take isotretinoin with meals, as oral availability is increased with high-fat foods.²³

Isotretinoin has major adverse effects. It is a teratogenic medication that can cause congenital anomalies in exposed fetuses, including craniofacial, cardiac, and neurologic issues.¹⁶ Due to the seriousness of the congenital anomalies, all prescribers must be registered in the iPledge program, a computer-based risk management program instituted in 2006 by the FDA and the companies that manufacture isotretinoin to eliminate congenital risks associated with isotretinoin. All patients, both male and female, must sign an informed consent form when they register in the program.

Although the iPledge program does not mandate consistent condom use for male patients, they should be informed that minute amounts of isotretinoin can be found in semen. The risk for fathering a fetus with congenital anomalies when taking isotretinoin appears to be extremely low.¹⁶ Women of childbearing potential must commit to the use of two highly reliable forms of birth control when taking the medication, including one month before starting therapy and one month after completing therapy.¹⁶ Monthly pregnancy testing is mandatory throughout the course of treatment.²⁴ Further information regarding the risk management program can be found at iPledgeprogram.com.

Isotretinoin is metabolized by the liver and may cause lipid abnormalities and hepatic enzyme elevations. Baseline and monthly laboratory monitoring of liver enzymes and cholesterol and triglyceride levels are recommended.²⁴ The process of initiating and monitoring isotretinoin therapy is quite complex, and unless the practitioner plans to routinely prescribe this medi­cation, patients needing isotretinoin therapy should be referred to a dermatology practice.

PATIENT EDUCATION

Patients are more likely to adhere to treatment when simplified regimens are used and when they have realistic expectations for therapy outcomes. Providers need to educate patients that all treatments may require at least two to three months of use before visible results occur. Initial and subsequent visits should include discussions about clear expectations and strategies to reduce potential adverse effects.

PUTTING IT ALL TOGETHER

Acne therapy starts with the use of a topical retinoid in mild acne cases, unless the patient is unable to tolerate the associated skin irritability. Addition of a topical antibiotic or anti-inflammatory agent, preferably BPO, either alone or with a combination product, is also recommended for mild to moderate acne. Patients with moderate to severe acne may benefit from a short course (three months or less) of antibiotics.

Oral hormones may be an excellent therapy choice when acne treatment is needed for women of childbearing age. Isotretinoin is indicated in select cases of severe acne resistant to other treatments.

CE/CME No: CR-1710

PROGRAM OVERVIEW
Earn credit by reading this article and successfully completing the posttest and evaluation. Successful completion is defined as a cumulative score of at least 70% correct.

EDUCATIONAL OBJECTIVES
• Describe the main factors involved in the pathogenesis of acne.
• Assess acne severity and classify acne as mild, moderate, or severe.
• Describe available acne therapies, including their mechanisms of action, indications, and potential adverse effects.
• Identify strategies patients can employ to mitigate the adverse effects of acne treatments.

FACULTY
Janet Purath is an Associate Professor at Washington State University in Spokane, Washington. Theresa Coyner practices at Randall Dermatology, West Lafayette, Indiana.

The authors have no financial relationships to disclose.

ACCREDITATION STATEMENT

This program has been reviewed and is approved for a maximum of 1.0 hour of American Academy of Physician Assistants (AAPA) Category 1 CME credit by the Physician Assistant Review Panel. [NPs: Both ANCC and the AANP Certification Program recognize AAPA as an approved provider of Category 1 credit.] Approval is valid through September 30, 2018.

Article begins on next page >>

Many of the 50 million persons affected by acne in the United States present to primary care. Acne severity guides treatment choices, which include topical antibiotics and retinoids, hormonal agents, and systemic antibiotics and retinoids. Formulating a treatment plan requires a thorough understanding of the dosing, mechanism of action, and potential adverse effects of available medications.

Acne vulgaris (acne) is a common skin condition that is frequently encountered in primary care. Acne affects up to 50 million people in the United States, and about 85% of teenagers experience it at some point.¹ Costs for treatment exceed $3 billion per year.² Although commonly considered a condition of adolescence and young adults (85% prevalence), acne may persist in both men and women well into their 30s and 40s (43% prevalence). In fact, 5% of women ages 40 and older may experience acne.³

Acne is associated with considerable, long-lasting psychological sequelae, even in those with mild conditions, as many affected patients experience self-esteem issues and may avoid social interactions.⁴ Recognition of patients’ concerns about acne will help to promote a trusting patient-provider relationship. This article describes the pathophysiology and classifications of acne and reviews therapeutic options, enabling the practitioner to initiate treatment.

PRESENTATION AND ASSESSMENT

Acne lesions may occur on the face, neck, trunk, and extremities. The severity of acne is assessed based on lesion type, number, and size, and this grading is used to inform decisions about treatment options. Mild acne is characterized by plugging of the sebaceous gland (comedones), with small numbers of inflammatory papules and pustules. Moderate acne involves a larger number of inflammatory papules/pustules as well as the presence of small cystic nodules. Severe acne is marked by the presence of large numbers of noninflammatory and inflammatory lesions and cystic nodules or widespread involvement of these lesions.⁵ Examples of mild, moderate, and severe acne are shown in Figure 1. Assessment should include questions about the patient’s experiences with prior therapies.

PATHOGENESIS

The pathogenesis of acne is a complex process involving multiple factors (see Figure 2). Knowledge about acne pathogenesis continues to evolve, but the current view is that a combination of simultaneous noninflammatory and inflammatory events involving pilosebaceous units (which consist of sebaceous glands and hair follicles) contribute to its development.⁶ Activation of the sebaceous glands is influenced by androgens, which increase sebum production and shedding of the keratinocytes lining the gland. Plugging of the pilosebaceous canal ensues, leading to the development of a microcomedone. Increased proliferation of Propionibacterium acnes occurs within the obstructed gland. The inflammatory response to this process includes a cascade of numerous cytokines, most notably toll-like receptor 2 (TLR-2).⁷ The plug at the opening of the sebaceous gland creates either an open comedone (blackhead) or a closed comedone (whitehead). Eventually, the follicular wall ruptures, leading to the formation of erythematous papules and pustules on the skin surface or deep-seated cystic structures under the skin surface. Current pharmacologic agents target one or more of these identified factors underlying acne pathogenesis.

THERAPEUTIC OPTIONS

Pharmacologic treatment options for acne include topical, systemic, and hormonal agents. Topical and systemic therapies reduce inflammation and follicular plugging. Topical treatments include antibiotics, anti-inflammatories, and retinoids. Oral treatments include antibiotics, hormones, and retinoids. The clinician must have a thorough understanding of the actions, potential adverse reactions, and drug interactions of each proposed therapy prior to formulating a treatment plan.

Topical retinoids

Topical retinoids are the most effective comedolytic agents available.¹ Since comedones are thought to be the precursor of all other acne lesions, retinoids are appropriate for cases in which comedones are seen.¹ Retinoids belong to a class of compounds structurally related to vitamin A. Topical retinoids act by promoting normal follicular keratinocyte desquamation, which prevents obstruction of the pilosebaceous canal and thereby inhibits the formation of microcomedones.⁸

They also exhibit anti-inflammatory action via inhibition of TLR-2.⁹ The comedolytic and anti-inflammatory actions of topical retinoids make them a mainstay of acne treatment, although some patients are unable to tolerate their adverse effects, which include erythema and dryness related to increases in transepidermal water loss. Application of noncomedogenic emollients can improve these common effects.¹⁰ The newer micronized and time-release retinoid formulations may have less potential for irritation.⁸ Vehicle formulation and concentration also play a role in skin irritation, with gels and liquids and formulations with higher concentrations of retinoids generally causing more drying than creams and lower potency formulations.⁸ Table 1 summarizes the mechanisms of action, available formulations, and potential adverse effects of the topical retinoids and other topical agents.^1,6,9-16

It is important to note that retinoids can adversely affect the developing fetus when absorbed in large quantities. Notably, tazarotene is assigned to pregnancy category X because when it is used to treat psoriasis, one of its approved indications, large surface areas may be treated, increasing absorption. Absorption amounts are extremely low when tazarotene is used to treat acne. Nevertheless, verification of a negative pregnancy test is recommended prior to initiating tazarotene therapy. Effective birth control measures should be utilized throughout therapy. Even though other commonly used retinoids (tretinoin and adapalene) are assigned to pregnancy category C, all topical retinoids should be avoided during pregnancy.⁹

As noted, patient education is key for increasing patient adherence to therapy. Patients should be instructed to use a small (pea-sized) amount of medication for the entire face. Providers should also inform patients that transient erythema and dryness can be expected, and that application of a noncomedolytic moisturizer may reduce irritation. Tretinoin is best used at night,¹ and it is useful to advise that erythema and irritation associated with retinoid use can be reduced by initially using the medication every other night to every third night, gradually building up to nightly use.¹

Topical antibiotic and anti-inflammatory agents

Topical agents used to treat inflammatory lesions include benzoyl peroxide, erythromycin, clindamycin, dapsone, azelaic acid, and sulfacetamide (Table 1).^1,6,9-16 These topical agents are generally well tolerated, with most adverse reactions limited to facial irritation and erythema. They come in an array of vehicle formulations, including washes, creams, gels, solutions, foams, and lotions. Vehicle selection should be based upon patient preference and skin type. Gels and solutions have a drying effect, making them more appropriate for individuals with oily skin, whereas creams are moisturizing and appropriate for individuals with dry skin. Lotions are appropriate for all skin types.¹¹

Benzoyl peroxide (BPO) has both keratolytic and comedolytic activity and is available in concentrations ranging from 2.5% to 10%. It is available OTC, as well as by prescription, and is thus readily accessed by the patient. Because BPO is bactericidal for P acnes, resistance to BPO among P acnes has not occurred.¹ All concentrations are equally effective, but the higher concentrations are more likely to cause skin dryness and other adverse effects.¹² Combination therapy with topical antibiotics, tretinoin, and BPO is more clinically effective than monotherapy.¹⁷ Combination products reduce the complexity of acne treatment and likely increase therapy adherence.¹¹ Currently available combination products in various percentages are erythromycin with BPO, clindamycin with BPO, adapalene with BPO, and clindamycin with tretinoin.¹

Oral antibiotics

Oral antibiotics should be reserved for use in situations where topical therapy is ineffective. All antibiotics are effective in treating acne due to their antimicrobial activity against P acnes.¹ These agents play a key role in managing moderate to severe acne that is likely to scar, as well as in cases of widespread acne involving the face, arms, and trunk. Note that the use of oral antibiotics in acne treatment is controversial, as chronic use contributes to rising rates of bacterial resistance.¹⁸ For this reason, antibiotic therapy for acne should be limited to a duration of three months or less, and these agents should not be used as monotherapy.⁶ In particular, recent recommendations restrict the use of erythromycin for acne treatment due to an increase of P acnes resistance.¹ Cephalosporins, macrolides, and penicillin class antibiotics are not routinely recommended due to lack of data regarding their clinical effectiveness in treating acne.¹

Tetracycline class antibiotics are the most commonly used oral antibiotics for acne therapy, particularly doxycycline and minocycline.⁵ Common adverse effects include gastrointestinal upset, photosensitivity, and some pigmentation issues.¹⁹ Trimethoprim-sulfamethoxazole (TMP-SMX) is a folate synthesis inhibitor class antibiotic also used to treat acne. Its use should be reserved for individuals who are allergic to tetracyclines or in cases of acne resistant to other antimicrobials.¹ Potential adverse reactions include photosensitivity and severe hypersensitivity conditions ranging from a mild rash to toxic epidermal necrolysis.¹⁹ Table 2 summarizes the dosage ranges, pregnancy category risk, and potential adverse effects of oral antibiotics used to treat acne.^1,19,20

The firstline choice for treating moderate acne with papules and pustules is oral antibiotics with topical retinoids and BPO.⁵ Patients should be educated about potential adverse effects of these agents, including the development of antibiotic resistance.

Hormonal agents

Hormonal therapies should be reserved for females with acne lesions influenced by fluctuations in hormone levels.²¹ Pubertal changes initiate the production of adrenal dehydroepiandrosterone, which leads to increased testosterone production. Testosterone is converted to dihydrotestosterone (DHT), which binds to androgen receptors in the sebaceous glands, stimulating the glands and potentially increasing production of sebum. Hormonal agents act by reducing androgen activity in the sebaceous gland. Combined oral hormones, those containing both estrogen and progesterone, reduce the amount of free testosterone and ovarian androgens by suppressing ovulation.¹ Hormonal therapy can be quite effective for females of childbearing age. Females who report acne flares with their menstrual cycles may be good candidates for hormonal therapy.¹

The estrogen agent most frequently used in oral contraceptives is ethinyl estradiol. Numerous progesterone agents can also be used, but those with low androgenicity or antiandrogenic properties are more effective for acne therapy.²¹ It is prudent to screen patients for thromboembolic risks, as this is a major adverse effect of combined hormonal agents. Risks of thromboembolic episodes are increased in obese persons, those who smoke, and those older than age 35.¹⁵ Other contraindications for combined hormonal therapy are pregnancy, liver disease, current breast cancer, heart disease, hypertension, and migraines with neurologic symptoms. Minor adverse effects include nausea, breast tenderness, cyclic weight gain, and headaches.¹⁵ Although many combined oral contraceptives improve acne, only four have FDA indications for the treatment of acne: ethinyl estradiol/norgestimate, norethindrone acetate/ethinyl estradiol, drospirenone/ethinyl estradiol, and drospirenone/ethinyl estradiol/folate.⁵

Spironolactone, a potassium-sparing diur­etic, may also be appropriate for treating acne in women due to its antiandrogenic properties. The drug binds androgen receptors in the skin, which then blocks testosterone and DHT. Spironolactone can be an effective firstline agent in treating hormonal-pattern acne, which presents as inflammatory lesions located on the lower face and neck. In particular, it can be an appropriate choice for women with adult-onset acne.¹⁵ Spironolactone is not approved by the FDA for acne treatment, but it has been used successfully for many years.⁵ Spironolactone was found in rodent studies to cause feminization of the male rat fetus, so patients taking this drug should use reliable birth control methods. It can be used concomitantly with oral contraceptives.⁵ Common side effects include breast tenderness, diuretic effects, headaches, and menstrual irregularities. Although the risk for hypokalemia is low in healthy young women, it may be prudent to periodically assess potassium, sodium, and renal function in patients.¹ Spironolactone should be avoided in patients with renal disease and those on other diuretics.¹⁵

Isotretinoin

Isotretinoin is an oral systemic retinoid that modulates nuclear receptors and regulates gene transcription in the epidermis.¹⁶ Isotretinoin’s mechanisms of action target the main pathogenic factors underlying acne, including reduction of follicular hyperkeratosis, comedogenesis, sebum production, and inflammation and suppression of P acnes.²² These combined actions make isotretinoin a highly effective treatment option for acne.

The drug is approved by the FDA for treatment of nodular acne refractory to traditional acne therapies.²³ Isotretinoin is available in 10, 20, 25, 30, and 40 mg capsules, and the recommended dosing is 0.5 to 2.0 mg/kg/d. The usual course of therapy is 15 to 20 weeks or until an accumulative dosage of 120 to 150 mg/kg is attained.²³ Patients should be instructed to take isotretinoin with meals, as oral availability is increased with high-fat foods.²³

Isotretinoin has major adverse effects. It is a teratogenic medication that can cause congenital anomalies in exposed fetuses, including craniofacial, cardiac, and neurologic issues.¹⁶ Due to the seriousness of the congenital anomalies, all prescribers must be registered in the iPledge program, a computer-based risk management program instituted in 2006 by the FDA and the companies that manufacture isotretinoin to eliminate congenital risks associated with isotretinoin. All patients, both male and female, must sign an informed consent form when they register in the program.

Although the iPledge program does not mandate consistent condom use for male patients, they should be informed that minute amounts of isotretinoin can be found in semen. The risk for fathering a fetus with congenital anomalies when taking isotretinoin appears to be extremely low.¹⁶ Women of childbearing potential must commit to the use of two highly reliable forms of birth control when taking the medication, including one month before starting therapy and one month after completing therapy.¹⁶ Monthly pregnancy testing is mandatory throughout the course of treatment.²⁴ Further information regarding the risk management program can be found at iPledgeprogram.com.

Isotretinoin is metabolized by the liver and may cause lipid abnormalities and hepatic enzyme elevations. Baseline and monthly laboratory monitoring of liver enzymes and cholesterol and triglyceride levels are recommended.²⁴ The process of initiating and monitoring isotretinoin therapy is quite complex, and unless the practitioner plans to routinely prescribe this medi­cation, patients needing isotretinoin therapy should be referred to a dermatology practice.

PATIENT EDUCATION

Patients are more likely to adhere to treatment when simplified regimens are used and when they have realistic expectations for therapy outcomes. Providers need to educate patients that all treatments may require at least two to three months of use before visible results occur. Initial and subsequent visits should include discussions about clear expectations and strategies to reduce potential adverse effects.

PUTTING IT ALL TOGETHER

Acne therapy starts with the use of a topical retinoid in mild acne cases, unless the patient is unable to tolerate the associated skin irritability. Addition of a topical antibiotic or anti-inflammatory agent, preferably BPO, either alone or with a combination product, is also recommended for mild to moderate acne. Patients with moderate to severe acne may benefit from a short course (three months or less) of antibiotics.

Oral hormones may be an excellent therapy choice when acne treatment is needed for women of childbearing age. Isotretinoin is indicated in select cases of severe acne resistant to other treatments.

SAN FRANCISCO – Pediatric ambulatory blood pressure monitoring (ABPM) is not stable over time and should be repeated before hypertension is diagnosed, according to an investigation of 102 children at Seattle Children’s Hospital.

Most of the children in the study had two 24-hour ABPM sessions at least 6 months apart (median, 1.5 years apart); a few children had three or four sessions. The children were aged 14.6 years, on average, at the first session, and had lifestyle counseling during the study period, but were not on blood pressure medications. Children were considered hypertensive if their average 24-hour readings were above the 95th percentile for sex and height until age 17 years, when they were considered hypertensive with readings of 140/85 mm Hg awake and 120/70 mm Hg asleep. Children with secondary causes of hypertension were excluded from the study.

Half of the children had a change in their ABPM classification from their first to their last session. Among 19 children with an initially normal reading, five progressed to prehypertension, and five to overt hypertension. Among 37 children initially classified as prehypertensive, 10 reverted to normal, and 9 progressed to hypertension. Among 46 children who were hypertensive on the first ABPM, 4 reverted to normal, and 17 improved to prehypertension. Among the 20 children with initially blunted nocturnal dipping, 9 normalized and 1 progressed to reverse dipping.

“These findings support greater use of repeat ABPM. It is possible that children with initially normal ABP may progress to hypertension or prehypertension, or that those with initial prehypertension or hypertension may be normal on repeat,” lead investigator Coral Hanevold, MD, said at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.

ABPM “is a great tool, but I think we have to realize it has some limitations,” she added. One limitation is that the patterns may not be that stable, and “before we go in and label people, it’s a good idea not to rely on just one session of monitoring,” added Dr. Hanevold, a clinical professor of pediatrics and director of the hypertension program at Seattle Children’s Hospital.

“Kids could be having a bad day the first time and get labeled hypertensive when maybe they’re not. Maybe they will improve,” she said.

The investigators plan to combine their data with a similar dataset from the Children’s Hospital of Pittsburgh. The goal is to be able to predict when white coat and prehypertension will progress to hypertension. Part of the work will involve putting a finer tooth on the broad ABPM categories of normal, prehypertensive, and hypertensive. It’s possible, for instance, that prehypertensive children who are initially closer to the threshold of hypertension will be more likely than other prehypertensive children to actually develop it.

“Our question is what’s going to happen long term. The telling thing is what’s the kid going to be like in 5 years, 10 years,” data that are not available, Dr. Hanevold said.

There was no external funding for the work, and the investigators had no disclosures.

[email protected]

SAN FRANCISCO – Pediatric ambulatory blood pressure monitoring (ABPM) is not stable over time and should be repeated before hypertension is diagnosed, according to an investigation of 102 children at Seattle Children’s Hospital.

Most of the children in the study had two 24-hour ABPM sessions at least 6 months apart (median, 1.5 years apart); a few children had three or four sessions. The children were aged 14.6 years, on average, at the first session, and had lifestyle counseling during the study period, but were not on blood pressure medications. Children were considered hypertensive if their average 24-hour readings were above the 95th percentile for sex and height until age 17 years, when they were considered hypertensive with readings of 140/85 mm Hg awake and 120/70 mm Hg asleep. Children with secondary causes of hypertension were excluded from the study.

Half of the children had a change in their ABPM classification from their first to their last session. Among 19 children with an initially normal reading, five progressed to prehypertension, and five to overt hypertension. Among 37 children initially classified as prehypertensive, 10 reverted to normal, and 9 progressed to hypertension. Among 46 children who were hypertensive on the first ABPM, 4 reverted to normal, and 17 improved to prehypertension. Among the 20 children with initially blunted nocturnal dipping, 9 normalized and 1 progressed to reverse dipping.

“These findings support greater use of repeat ABPM. It is possible that children with initially normal ABP may progress to hypertension or prehypertension, or that those with initial prehypertension or hypertension may be normal on repeat,” lead investigator Coral Hanevold, MD, said at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.

ABPM “is a great tool, but I think we have to realize it has some limitations,” she added. One limitation is that the patterns may not be that stable, and “before we go in and label people, it’s a good idea not to rely on just one session of monitoring,” added Dr. Hanevold, a clinical professor of pediatrics and director of the hypertension program at Seattle Children’s Hospital.

“Kids could be having a bad day the first time and get labeled hypertensive when maybe they’re not. Maybe they will improve,” she said.

The investigators plan to combine their data with a similar dataset from the Children’s Hospital of Pittsburgh. The goal is to be able to predict when white coat and prehypertension will progress to hypertension. Part of the work will involve putting a finer tooth on the broad ABPM categories of normal, prehypertensive, and hypertensive. It’s possible, for instance, that prehypertensive children who are initially closer to the threshold of hypertension will be more likely than other prehypertensive children to actually develop it.

“Our question is what’s going to happen long term. The telling thing is what’s the kid going to be like in 5 years, 10 years,” data that are not available, Dr. Hanevold said.

There was no external funding for the work, and the investigators had no disclosures.

[email protected]

SAN FRANCISCO – Pediatric ambulatory blood pressure monitoring (ABPM) is not stable over time and should be repeated before hypertension is diagnosed, according to an investigation of 102 children at Seattle Children’s Hospital.

Most of the children in the study had two 24-hour ABPM sessions at least 6 months apart (median, 1.5 years apart); a few children had three or four sessions. The children were aged 14.6 years, on average, at the first session, and had lifestyle counseling during the study period, but were not on blood pressure medications. Children were considered hypertensive if their average 24-hour readings were above the 95th percentile for sex and height until age 17 years, when they were considered hypertensive with readings of 140/85 mm Hg awake and 120/70 mm Hg asleep. Children with secondary causes of hypertension were excluded from the study.

Half of the children had a change in their ABPM classification from their first to their last session. Among 19 children with an initially normal reading, five progressed to prehypertension, and five to overt hypertension. Among 37 children initially classified as prehypertensive, 10 reverted to normal, and 9 progressed to hypertension. Among 46 children who were hypertensive on the first ABPM, 4 reverted to normal, and 17 improved to prehypertension. Among the 20 children with initially blunted nocturnal dipping, 9 normalized and 1 progressed to reverse dipping.

“These findings support greater use of repeat ABPM. It is possible that children with initially normal ABP may progress to hypertension or prehypertension, or that those with initial prehypertension or hypertension may be normal on repeat,” lead investigator Coral Hanevold, MD, said at the joint scientific sessions of the AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.

ABPM “is a great tool, but I think we have to realize it has some limitations,” she added. One limitation is that the patterns may not be that stable, and “before we go in and label people, it’s a good idea not to rely on just one session of monitoring,” added Dr. Hanevold, a clinical professor of pediatrics and director of the hypertension program at Seattle Children’s Hospital.

“Kids could be having a bad day the first time and get labeled hypertensive when maybe they’re not. Maybe they will improve,” she said.

The investigators plan to combine their data with a similar dataset from the Children’s Hospital of Pittsburgh. The goal is to be able to predict when white coat and prehypertension will progress to hypertension. Part of the work will involve putting a finer tooth on the broad ABPM categories of normal, prehypertensive, and hypertensive. It’s possible, for instance, that prehypertensive children who are initially closer to the threshold of hypertension will be more likely than other prehypertensive children to actually develop it.

“Our question is what’s going to happen long term. The telling thing is what’s the kid going to be like in 5 years, 10 years,” data that are not available, Dr. Hanevold said.

There was no external funding for the work, and the investigators had no disclosures.

[email protected]

Officials at the Centers for Disease Control and Prevention are deactivating their emergency operations related to the Zika virus, the agency announced Sept. 29.

The Zika Coordination and Operations Transition Team will instead shift the CDC’s efforts toward long-term activities, including continued support for physicians counseling pregnant women and advice on follow-up care for infants.

Data from the agency show that while there was a steady stream of possible Zika cases reported among pregnant women in the summer of 2017 – about 100 cases every 2 weeks – the numbers were lower than in 2016, when the infection hit its peak. Overall, during 2015-2017, there have been a total of 2,197 cases of possible Zika infection among pregnant women reported in U.S. states and 4,504 in U.S. territories. During that same time period, there have been 98 liveborn infants with birth defects in the U.S. states and 138 in the U.S. territories.

CDC activated the Emergency Operations Center in January 2016 in response to reports on the impact of Zika virus infection in pregnancy, including cases of microcephaly.

“Deactivation does not mean that the threat of Zika has lessened in importance or that people are no longer at risk of infection,” CDC officials said in a statement. “Zika continues to be a public health threat in the United States and internationally. Zika is still a risk for pregnant women, and the continental United States and Hawaii will continue to see some travel-related cases as travelers visit countries and territories with risk of Zika transmission.”

[email protected]

On Twitter @maryellenny

Officials at the Centers for Disease Control and Prevention are deactivating their emergency operations related to the Zika virus, the agency announced Sept. 29.

The Zika Coordination and Operations Transition Team will instead shift the CDC’s efforts toward long-term activities, including continued support for physicians counseling pregnant women and advice on follow-up care for infants.

Data from the agency show that while there was a steady stream of possible Zika cases reported among pregnant women in the summer of 2017 – about 100 cases every 2 weeks – the numbers were lower than in 2016, when the infection hit its peak. Overall, during 2015-2017, there have been a total of 2,197 cases of possible Zika infection among pregnant women reported in U.S. states and 4,504 in U.S. territories. During that same time period, there have been 98 liveborn infants with birth defects in the U.S. states and 138 in the U.S. territories.

CDC activated the Emergency Operations Center in January 2016 in response to reports on the impact of Zika virus infection in pregnancy, including cases of microcephaly.

“Deactivation does not mean that the threat of Zika has lessened in importance or that people are no longer at risk of infection,” CDC officials said in a statement. “Zika continues to be a public health threat in the United States and internationally. Zika is still a risk for pregnant women, and the continental United States and Hawaii will continue to see some travel-related cases as travelers visit countries and territories with risk of Zika transmission.”

[email protected]

On Twitter @maryellenny

Officials at the Centers for Disease Control and Prevention are deactivating their emergency operations related to the Zika virus, the agency announced Sept. 29.

The Zika Coordination and Operations Transition Team will instead shift the CDC’s efforts toward long-term activities, including continued support for physicians counseling pregnant women and advice on follow-up care for infants.

Data from the agency show that while there was a steady stream of possible Zika cases reported among pregnant women in the summer of 2017 – about 100 cases every 2 weeks – the numbers were lower than in 2016, when the infection hit its peak. Overall, during 2015-2017, there have been a total of 2,197 cases of possible Zika infection among pregnant women reported in U.S. states and 4,504 in U.S. territories. During that same time period, there have been 98 liveborn infants with birth defects in the U.S. states and 138 in the U.S. territories.

CDC activated the Emergency Operations Center in January 2016 in response to reports on the impact of Zika virus infection in pregnancy, including cases of microcephaly.

“Deactivation does not mean that the threat of Zika has lessened in importance or that people are no longer at risk of infection,” CDC officials said in a statement. “Zika continues to be a public health threat in the United States and internationally. Zika is still a risk for pregnant women, and the continental United States and Hawaii will continue to see some travel-related cases as travelers visit countries and territories with risk of Zika transmission.”

[email protected]

On Twitter @maryellenny

The risk of contracting HIV was almost three to five times higher among people infected with herpes simplex virus type 2 (HSV-2), in a systematic review and meta-analysis.

The analysis of 57 longitudinal studies found that the adjusted relative risk (RR) of HIV incidence after exposure to HSV-2 infection at baseline (“prevalent infection”) was 2.7 and was 4.7 after exposure to HSV-2 infection during follow-up (“incident infection”). The studies, mostly conducted in Africa, were found in PubMed, MEDLINE, and Embase publications from Jan. 1, 2003, to May 25, 2017; the analysis was published online on Aug. 23 (Lancet Infect Dis. 2017. pii: S1473-3099[17]30405-X. doi: 10.1016/S1473-3099[17]30405-X).

“The greater cofactor effect for incident HSV-2 infection than for prevalent HSV-2 infection might be because newly acquired HSV-2 infection is associated with an increased frequency and severity of genital ulceration, viral shedding, and inflammation in the genital tract, symptoms and manifestations that decrease with time after infection,” according to Katharine J. Looker, PhD, of the University of Bristol (England), and Jocelyn A.R. Elmes, PhD, of Imperial College London (England) and their coauthors.

Associations still were significant but lower in higher-risk populations, such as female sex workers and their clients, men who have sex with men, and serodiscordant couples, the researchers said. For those with prevalent HSV-2, the adjusted RR of contracting HIV was 1.7 (95% confidence interval, 1.4-2.1), compared with 2.9 for those with incident HSV-2 infection (95% CI, 1.7-5.0).

“Quantifying the effect of HSV-2 infection on HIV acquisition has important public health implications, particularly in high-prevalence settings where coinfection is common, because prevention of HSV-2 infection ... might indirectly prevent HIV infection,” the authors wrote. “Knowledge of this association informs the advice and information given to individuals diagnosed with genital herpes, who might be at increased risk of acquiring HIV.”

The study was funded by the World Health Organization. Dr. Looker reported personal fees from the WHO. Dr. Elmes reported grants from the National Institutes of Health and the Wellcome Trust outside of this study. Two authors reported financial support from Aquarius Population Health and other support from WHO and NIH; the three remaining authors had no disclosures.
 

The risk of contracting HIV was almost three to five times higher among people infected with herpes simplex virus type 2 (HSV-2), in a systematic review and meta-analysis.

The analysis of 57 longitudinal studies found that the adjusted relative risk (RR) of HIV incidence after exposure to HSV-2 infection at baseline (“prevalent infection”) was 2.7 and was 4.7 after exposure to HSV-2 infection during follow-up (“incident infection”). The studies, mostly conducted in Africa, were found in PubMed, MEDLINE, and Embase publications from Jan. 1, 2003, to May 25, 2017; the analysis was published online on Aug. 23 (Lancet Infect Dis. 2017. pii: S1473-3099[17]30405-X. doi: 10.1016/S1473-3099[17]30405-X).

“The greater cofactor effect for incident HSV-2 infection than for prevalent HSV-2 infection might be because newly acquired HSV-2 infection is associated with an increased frequency and severity of genital ulceration, viral shedding, and inflammation in the genital tract, symptoms and manifestations that decrease with time after infection,” according to Katharine J. Looker, PhD, of the University of Bristol (England), and Jocelyn A.R. Elmes, PhD, of Imperial College London (England) and their coauthors.

Associations still were significant but lower in higher-risk populations, such as female sex workers and their clients, men who have sex with men, and serodiscordant couples, the researchers said. For those with prevalent HSV-2, the adjusted RR of contracting HIV was 1.7 (95% confidence interval, 1.4-2.1), compared with 2.9 for those with incident HSV-2 infection (95% CI, 1.7-5.0).

“Quantifying the effect of HSV-2 infection on HIV acquisition has important public health implications, particularly in high-prevalence settings where coinfection is common, because prevention of HSV-2 infection ... might indirectly prevent HIV infection,” the authors wrote. “Knowledge of this association informs the advice and information given to individuals diagnosed with genital herpes, who might be at increased risk of acquiring HIV.”

The study was funded by the World Health Organization. Dr. Looker reported personal fees from the WHO. Dr. Elmes reported grants from the National Institutes of Health and the Wellcome Trust outside of this study. Two authors reported financial support from Aquarius Population Health and other support from WHO and NIH; the three remaining authors had no disclosures.
 

The risk of contracting HIV was almost three to five times higher among people infected with herpes simplex virus type 2 (HSV-2), in a systematic review and meta-analysis.

The analysis of 57 longitudinal studies found that the adjusted relative risk (RR) of HIV incidence after exposure to HSV-2 infection at baseline (“prevalent infection”) was 2.7 and was 4.7 after exposure to HSV-2 infection during follow-up (“incident infection”). The studies, mostly conducted in Africa, were found in PubMed, MEDLINE, and Embase publications from Jan. 1, 2003, to May 25, 2017; the analysis was published online on Aug. 23 (Lancet Infect Dis. 2017. pii: S1473-3099[17]30405-X. doi: 10.1016/S1473-3099[17]30405-X).

“The greater cofactor effect for incident HSV-2 infection than for prevalent HSV-2 infection might be because newly acquired HSV-2 infection is associated with an increased frequency and severity of genital ulceration, viral shedding, and inflammation in the genital tract, symptoms and manifestations that decrease with time after infection,” according to Katharine J. Looker, PhD, of the University of Bristol (England), and Jocelyn A.R. Elmes, PhD, of Imperial College London (England) and their coauthors.

Associations still were significant but lower in higher-risk populations, such as female sex workers and their clients, men who have sex with men, and serodiscordant couples, the researchers said. For those with prevalent HSV-2, the adjusted RR of contracting HIV was 1.7 (95% confidence interval, 1.4-2.1), compared with 2.9 for those with incident HSV-2 infection (95% CI, 1.7-5.0).

“Quantifying the effect of HSV-2 infection on HIV acquisition has important public health implications, particularly in high-prevalence settings where coinfection is common, because prevention of HSV-2 infection ... might indirectly prevent HIV infection,” the authors wrote. “Knowledge of this association informs the advice and information given to individuals diagnosed with genital herpes, who might be at increased risk of acquiring HIV.”

The study was funded by the World Health Organization. Dr. Looker reported personal fees from the WHO. Dr. Elmes reported grants from the National Institutes of Health and the Wellcome Trust outside of this study. Two authors reported financial support from Aquarius Population Health and other support from WHO and NIH; the three remaining authors had no disclosures.
 

Treatment with tumor necrosis factor (TNF) inhibitors was associated with fewer adverse events (AEs) than with methotrexate, in an international, retrospective study of children with psoriasis.

“Patients with pediatric psoriasis treated with methotrexate had a greater risk of having one or more AEs than those treated with TNF-I [tumor necrosis factor inhibitors], although fewer AEs occurred with methotrexate or TNF-I than with other drug classes,” Inge M.G.J. Bronckers, MD, of the department of dermatology at Radboud University, Nijmegen, the Netherlands, and his coauthors reported.

eenevski/Thinkstock

Among those treated with methotrexate, administration of folic acid six to seven times a week was more protective against methotrexate-associated gastrointestinal AEs, than when administered only once a week. The study was published on Sept. 13 in JAMA Dermatology (2017. doi: 10.1001/jamadermatol.2017.3029).

The study evaluated 390 children with moderate to severe psoriasis, treated with at least one systemic medication at 20 centers in Canada, Europe, and the United States, during December 1990-September 2014. They were diagnosed at a mean age of about 8 years, and started systemic therapy a mean of 3 years later. Of the 390 children treated for psoriasis, 270 were treated with methotrexate and 106 were treated with biologics, most often the TNF inhibitor etanercept. The remaining treatments were acitretin, cyclosporine, and fumaric acid esters; almost 19% were treated with more than one medication.

Of those treated with methotrexate, 130 (48.1%) experienced one or more treatment-related AEs, compared with 41 (38.7%) of those treated with a biologic agent (odds ratio, 1.76; P = .03). Almost 25% of those on methotrexate had GI-related AEs, the most common AE; other AEs included elevated transaminase levels and fatigue. Among those on biologics, injection site reactions were the most common (in 18.9%); 12 patients (11.3%) of those on biologics had infections, primarily airway infections.

Compared with those on a TNF inhibitor, patients on methotrexate were more likely to experience GI-related AEs (OR, 11.49; P less than .001) or to discontinue treatment (OR, 5.69; P = .02), the investigators said. But associated infections were more common with TNF inhibitors (OR, 0.36; P = .03), compared with methotrexate. There were no cases of malignancies or tuberculosis.

Folic acid was prescribed to 239 patients receiving methotrexate in one of three regimens: once weekly; six times weekly, avoiding the methotrexate day; and seven times weekly, according to the investigators. Compared with once-weekly treatment, administration six or seven times weekly was associated with a lower probability of developing a GI-related AE (OR, 0.16; P less than .001; OR, 0.21; P = .003, respectively).

“Data are sparse on the relative use of systemic agents and their toxic effects in the pediatric population,” Dr. Bronckers and his coauthors wrote, adding that standardized guidelines and more data concerning children are needed. “Our data suggest that a weekly administration of folic acid could be replaced with a daily or six times weekly administration to reduce GI AEs, although the potential efficacy of six vs. seven times weekly dosing deserves further investigation,” they concluded.

The study was supported by a grant from the International Psoriasis Council. Of the 23 authors, 11 had financial disclosures with various pharmaceutical manufacturers.

Treatment with tumor necrosis factor (TNF) inhibitors was associated with fewer adverse events (AEs) than with methotrexate, in an international, retrospective study of children with psoriasis.

“Patients with pediatric psoriasis treated with methotrexate had a greater risk of having one or more AEs than those treated with TNF-I [tumor necrosis factor inhibitors], although fewer AEs occurred with methotrexate or TNF-I than with other drug classes,” Inge M.G.J. Bronckers, MD, of the department of dermatology at Radboud University, Nijmegen, the Netherlands, and his coauthors reported.

eenevski/Thinkstock

Among those treated with methotrexate, administration of folic acid six to seven times a week was more protective against methotrexate-associated gastrointestinal AEs, than when administered only once a week. The study was published on Sept. 13 in JAMA Dermatology (2017. doi: 10.1001/jamadermatol.2017.3029).

The study evaluated 390 children with moderate to severe psoriasis, treated with at least one systemic medication at 20 centers in Canada, Europe, and the United States, during December 1990-September 2014. They were diagnosed at a mean age of about 8 years, and started systemic therapy a mean of 3 years later. Of the 390 children treated for psoriasis, 270 were treated with methotrexate and 106 were treated with biologics, most often the TNF inhibitor etanercept. The remaining treatments were acitretin, cyclosporine, and fumaric acid esters; almost 19% were treated with more than one medication.

Of those treated with methotrexate, 130 (48.1%) experienced one or more treatment-related AEs, compared with 41 (38.7%) of those treated with a biologic agent (odds ratio, 1.76; P = .03). Almost 25% of those on methotrexate had GI-related AEs, the most common AE; other AEs included elevated transaminase levels and fatigue. Among those on biologics, injection site reactions were the most common (in 18.9%); 12 patients (11.3%) of those on biologics had infections, primarily airway infections.

Compared with those on a TNF inhibitor, patients on methotrexate were more likely to experience GI-related AEs (OR, 11.49; P less than .001) or to discontinue treatment (OR, 5.69; P = .02), the investigators said. But associated infections were more common with TNF inhibitors (OR, 0.36; P = .03), compared with methotrexate. There were no cases of malignancies or tuberculosis.

Folic acid was prescribed to 239 patients receiving methotrexate in one of three regimens: once weekly; six times weekly, avoiding the methotrexate day; and seven times weekly, according to the investigators. Compared with once-weekly treatment, administration six or seven times weekly was associated with a lower probability of developing a GI-related AE (OR, 0.16; P less than .001; OR, 0.21; P = .003, respectively).

“Data are sparse on the relative use of systemic agents and their toxic effects in the pediatric population,” Dr. Bronckers and his coauthors wrote, adding that standardized guidelines and more data concerning children are needed. “Our data suggest that a weekly administration of folic acid could be replaced with a daily or six times weekly administration to reduce GI AEs, although the potential efficacy of six vs. seven times weekly dosing deserves further investigation,” they concluded.

The study was supported by a grant from the International Psoriasis Council. Of the 23 authors, 11 had financial disclosures with various pharmaceutical manufacturers.

Treatment with tumor necrosis factor (TNF) inhibitors was associated with fewer adverse events (AEs) than with methotrexate, in an international, retrospective study of children with psoriasis.

“Patients with pediatric psoriasis treated with methotrexate had a greater risk of having one or more AEs than those treated with TNF-I [tumor necrosis factor inhibitors], although fewer AEs occurred with methotrexate or TNF-I than with other drug classes,” Inge M.G.J. Bronckers, MD, of the department of dermatology at Radboud University, Nijmegen, the Netherlands, and his coauthors reported.

eenevski/Thinkstock

Among those treated with methotrexate, administration of folic acid six to seven times a week was more protective against methotrexate-associated gastrointestinal AEs, than when administered only once a week. The study was published on Sept. 13 in JAMA Dermatology (2017. doi: 10.1001/jamadermatol.2017.3029).

The study evaluated 390 children with moderate to severe psoriasis, treated with at least one systemic medication at 20 centers in Canada, Europe, and the United States, during December 1990-September 2014. They were diagnosed at a mean age of about 8 years, and started systemic therapy a mean of 3 years later. Of the 390 children treated for psoriasis, 270 were treated with methotrexate and 106 were treated with biologics, most often the TNF inhibitor etanercept. The remaining treatments were acitretin, cyclosporine, and fumaric acid esters; almost 19% were treated with more than one medication.

Of those treated with methotrexate, 130 (48.1%) experienced one or more treatment-related AEs, compared with 41 (38.7%) of those treated with a biologic agent (odds ratio, 1.76; P = .03). Almost 25% of those on methotrexate had GI-related AEs, the most common AE; other AEs included elevated transaminase levels and fatigue. Among those on biologics, injection site reactions were the most common (in 18.9%); 12 patients (11.3%) of those on biologics had infections, primarily airway infections.

Compared with those on a TNF inhibitor, patients on methotrexate were more likely to experience GI-related AEs (OR, 11.49; P less than .001) or to discontinue treatment (OR, 5.69; P = .02), the investigators said. But associated infections were more common with TNF inhibitors (OR, 0.36; P = .03), compared with methotrexate. There were no cases of malignancies or tuberculosis.

Folic acid was prescribed to 239 patients receiving methotrexate in one of three regimens: once weekly; six times weekly, avoiding the methotrexate day; and seven times weekly, according to the investigators. Compared with once-weekly treatment, administration six or seven times weekly was associated with a lower probability of developing a GI-related AE (OR, 0.16; P less than .001; OR, 0.21; P = .003, respectively).

“Data are sparse on the relative use of systemic agents and their toxic effects in the pediatric population,” Dr. Bronckers and his coauthors wrote, adding that standardized guidelines and more data concerning children are needed. “Our data suggest that a weekly administration of folic acid could be replaced with a daily or six times weekly administration to reduce GI AEs, although the potential efficacy of six vs. seven times weekly dosing deserves further investigation,” they concluded.

The study was supported by a grant from the International Psoriasis Council. Of the 23 authors, 11 had financial disclosures with various pharmaceutical manufacturers.

This is the second in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Family physicians increasingly recognize the importance of shared decision making, where the patient and provider work together to make a health care decision. Shared decision making means the decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences. More and more patients and providers want to participate in shared decision making, but the “how” often is neglected in standard medical and graduate medical education. AHRQ provides two resources to assist in your practice’s use of shared decision making.

The SHARE Approach is a five-step process for shared decision making:

• Seek your patient’s participation.
• Help your patient explore & compare treatment options.
• Assess your patient’s values and preferences.
• Reach a decision with your patient.
• Evaluate your patient’s decision.

AHRQ’s SHARE Approach curriculum provides both a quick overview (for the busy clinician) and an extensive course (complete with slides and a trainer’s module). The website provides the clinician the opportunity to learn the key elements of the SHARE Approach, while providing the educator a full curriculum with slides, handouts, and a video in order to demonstrate the approach. Complementing the SHARE curriculum, AHRQ’s Effective Health Care Program offers excellent, easy-to-read summaries of evidence reports to help clinicians and consumers make informed health care decisions. AHRQ recently released Lung Cancer Screening Tools, including a decision aid, for patients and clinicians to facilitate discussions about lung cancer screening with low-dose computed tomography.

The SHARE Approach and other tools can be found at the NCEPCR website.

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

This is the second in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Family physicians increasingly recognize the importance of shared decision making, where the patient and provider work together to make a health care decision. Shared decision making means the decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences. More and more patients and providers want to participate in shared decision making, but the “how” often is neglected in standard medical and graduate medical education. AHRQ provides two resources to assist in your practice’s use of shared decision making.

The SHARE Approach is a five-step process for shared decision making:

• Seek your patient’s participation.
• Help your patient explore & compare treatment options.
• Assess your patient’s values and preferences.
• Reach a decision with your patient.
• Evaluate your patient’s decision.

AHRQ’s SHARE Approach curriculum provides both a quick overview (for the busy clinician) and an extensive course (complete with slides and a trainer’s module). The website provides the clinician the opportunity to learn the key elements of the SHARE Approach, while providing the educator a full curriculum with slides, handouts, and a video in order to demonstrate the approach. Complementing the SHARE curriculum, AHRQ’s Effective Health Care Program offers excellent, easy-to-read summaries of evidence reports to help clinicians and consumers make informed health care decisions. AHRQ recently released Lung Cancer Screening Tools, including a decision aid, for patients and clinicians to facilitate discussions about lung cancer screening with low-dose computed tomography.

The SHARE Approach and other tools can be found at the NCEPCR website.

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

This is the second in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Family physicians increasingly recognize the importance of shared decision making, where the patient and provider work together to make a health care decision. Shared decision making means the decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences. More and more patients and providers want to participate in shared decision making, but the “how” often is neglected in standard medical and graduate medical education. AHRQ provides two resources to assist in your practice’s use of shared decision making.

The SHARE Approach is a five-step process for shared decision making:

• Seek your patient’s participation.
• Help your patient explore & compare treatment options.
• Assess your patient’s values and preferences.
• Reach a decision with your patient.
• Evaluate your patient’s decision.

AHRQ’s SHARE Approach curriculum provides both a quick overview (for the busy clinician) and an extensive course (complete with slides and a trainer’s module). The website provides the clinician the opportunity to learn the key elements of the SHARE Approach, while providing the educator a full curriculum with slides, handouts, and a video in order to demonstrate the approach. Complementing the SHARE curriculum, AHRQ’s Effective Health Care Program offers excellent, easy-to-read summaries of evidence reports to help clinicians and consumers make informed health care decisions. AHRQ recently released Lung Cancer Screening Tools, including a decision aid, for patients and clinicians to facilitate discussions about lung cancer screening with low-dose computed tomography.

The SHARE Approach and other tools can be found at the NCEPCR website.

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

The Ohio Supreme Court has ruled that apologies by physicians that include an admission of fault cannot be used against them in court, upholding a lower court decision that spared a doctor’s comments from being heard at trial.

In a Sept. 12 decision, state Supreme Court justices concluded that Ohio’s apology statute protects both expressions of regret for an unanticipated outcome and acknowledgments that the patient’s treatment fell below the standard of care. The decision resolves a split among Ohio appeals courts over whether expressions of fault are admissible.

AndreyPopov/ThinkStock

The decision declaring Ohio’s apology statute “unambiguous” is an important and clarifying ruling for physicians and settles the differing opinions of some lower courts, said Reginald Fields, director of external and professional relations for the Ohio State Medical Association.

“We applaud the high court’s decision,” Mr. Fields said in an interview. “Even the two dissenting justices agreed that the apology law is clear; they just questioned whether it applied in this particular case. This ruling likely means pending legislation thought to be needed to clarify the law is now unnecessary. The OSMA will now focus on other aspects of tort reform, such as ‘loss of chance’ claims and further elimination of frivolous lawsuits.”

The Ohio Association for Justice, the state’s plaintiffs’ bar did not respond to a request for comment.

The case of Stewart v. Vivian resulted from a lawsuit filed by Dennis Stewart against Cincinnati psychiatrist Rodney Vivian, MD, after the death of Mr. Stewart’s wife by suicide. Michelle Stewart was admitted to the emergency department of Mt. Orab MediCenter in February 2010 after attempting suicide and was later transferred to the psychiatric unit at Mercy Hospital Clermont in Batavia, Ohio. After consulting with nurses, Dr. Vivian ordered that a staff member of the psychiatric unit visually observe Ms. Stewart every 15 minutes, according to court documents. The next evening, Mr. Stewart arrived at the psychiatric unit to visit his wife and found her unconscious as a result of hanging.

Two days later, Dr. Vivian went to Ms. Stewart’s room in the intensive care unit to speak with family members. The content of the conversation between Dr. Vivian and family members is disputed. Family members allege that Dr. Vivian expressed that it was a “terrible situation” and that the patient had told Dr. Vivian that she “wanted to be dead” would “keep trying” to kill herself. Dr. Vivian testified that he told the family he was “sorry this has happened.” Ms. Stewart was later taken off life support and died.

In 2011, Mr. Stewart sued Dr. Vivian and Mercy Hospital Clermont for medical malpractice, loss of spousal consortium, and wrongful death. Dr. Vivian argued that his statements to family members in the ICU room were inadmissible under the state’s apology law because they were “intended to express commiseration, condolence, or sympathy.” Mr. Stewart countered that Dr. Vivian’s statements were admissible because they were not “pure expressions of apology, sympathy, commiseration, condolence, compassion, or a general sense of benevolence.” The trial court sided with Dr. Vivian and his statements were kept from trial testimony. The jury returned a verdict in favor of Dr. Vivian, concluding that he was not negligent in his assessment, care, or treatment.

The 12th District Court of Appeals ruled that Dr. Vivian’s statements were properly excluded, finding that the Ohio’s apology law is ambiguous because according to the term’s dictionary definition, “apology” may or may not include an admission of fault. But the decision conflicted with the case of Davis v. Wooster Orthopaedics & Sports Medicine, Inc. in which the Court of Appeals for the 9th District in Ohio determined Ohio’s apology statute protects from admission “pure expressions of apology, sympathy, commiseration, condolence, compassion, or a general sense of benevolence,” but not “admission of fault.”

Resolving the split, the Ohio Supreme Court concluded that the state law is unambiguous and that its legislative intent is to shield expressions of regret for unexpected outcomes that may include acknowledgments that the patient’s medical care fell below the standard of care.

Ohio Supreme Court Chief Justice Maureen O’Connor and Justice William M. O’Neill partially dissented. While they agreed with the majority’s holding regarding the intent of Ohio’s apology law, Justice O’Connor wrote that the Dr. Vivian’s statements fell outside the law’s protection.

“Dr. Vivian’s statements were not an apology nor did they express regret or a type of shared sadness associated with sympathy or commiseration,” she wrote in her dissent.

At least 36 states have apology laws that shield against certain statements, expressions, or other evidence related to disclosures being used against physicians in court.
 

[email protected]

On Twitter @legal_med

The Ohio Supreme Court has ruled that apologies by physicians that include an admission of fault cannot be used against them in court, upholding a lower court decision that spared a doctor’s comments from being heard at trial.

In a Sept. 12 decision, state Supreme Court justices concluded that Ohio’s apology statute protects both expressions of regret for an unanticipated outcome and acknowledgments that the patient’s treatment fell below the standard of care. The decision resolves a split among Ohio appeals courts over whether expressions of fault are admissible.

AndreyPopov/ThinkStock

The decision declaring Ohio’s apology statute “unambiguous” is an important and clarifying ruling for physicians and settles the differing opinions of some lower courts, said Reginald Fields, director of external and professional relations for the Ohio State Medical Association.

“We applaud the high court’s decision,” Mr. Fields said in an interview. “Even the two dissenting justices agreed that the apology law is clear; they just questioned whether it applied in this particular case. This ruling likely means pending legislation thought to be needed to clarify the law is now unnecessary. The OSMA will now focus on other aspects of tort reform, such as ‘loss of chance’ claims and further elimination of frivolous lawsuits.”

The Ohio Association for Justice, the state’s plaintiffs’ bar did not respond to a request for comment.

The case of Stewart v. Vivian resulted from a lawsuit filed by Dennis Stewart against Cincinnati psychiatrist Rodney Vivian, MD, after the death of Mr. Stewart’s wife by suicide. Michelle Stewart was admitted to the emergency department of Mt. Orab MediCenter in February 2010 after attempting suicide and was later transferred to the psychiatric unit at Mercy Hospital Clermont in Batavia, Ohio. After consulting with nurses, Dr. Vivian ordered that a staff member of the psychiatric unit visually observe Ms. Stewart every 15 minutes, according to court documents. The next evening, Mr. Stewart arrived at the psychiatric unit to visit his wife and found her unconscious as a result of hanging.

Two days later, Dr. Vivian went to Ms. Stewart’s room in the intensive care unit to speak with family members. The content of the conversation between Dr. Vivian and family members is disputed. Family members allege that Dr. Vivian expressed that it was a “terrible situation” and that the patient had told Dr. Vivian that she “wanted to be dead” would “keep trying” to kill herself. Dr. Vivian testified that he told the family he was “sorry this has happened.” Ms. Stewart was later taken off life support and died.

In 2011, Mr. Stewart sued Dr. Vivian and Mercy Hospital Clermont for medical malpractice, loss of spousal consortium, and wrongful death. Dr. Vivian argued that his statements to family members in the ICU room were inadmissible under the state’s apology law because they were “intended to express commiseration, condolence, or sympathy.” Mr. Stewart countered that Dr. Vivian’s statements were admissible because they were not “pure expressions of apology, sympathy, commiseration, condolence, compassion, or a general sense of benevolence.” The trial court sided with Dr. Vivian and his statements were kept from trial testimony. The jury returned a verdict in favor of Dr. Vivian, concluding that he was not negligent in his assessment, care, or treatment.

The 12th District Court of Appeals ruled that Dr. Vivian’s statements were properly excluded, finding that the Ohio’s apology law is ambiguous because according to the term’s dictionary definition, “apology” may or may not include an admission of fault. But the decision conflicted with the case of Davis v. Wooster Orthopaedics & Sports Medicine, Inc. in which the Court of Appeals for the 9th District in Ohio determined Ohio’s apology statute protects from admission “pure expressions of apology, sympathy, commiseration, condolence, compassion, or a general sense of benevolence,” but not “admission of fault.”

Resolving the split, the Ohio Supreme Court concluded that the state law is unambiguous and that its legislative intent is to shield expressions of regret for unexpected outcomes that may include acknowledgments that the patient’s medical care fell below the standard of care.

Ohio Supreme Court Chief Justice Maureen O’Connor and Justice William M. O’Neill partially dissented. While they agreed with the majority’s holding regarding the intent of Ohio’s apology law, Justice O’Connor wrote that the Dr. Vivian’s statements fell outside the law’s protection.

“Dr. Vivian’s statements were not an apology nor did they express regret or a type of shared sadness associated with sympathy or commiseration,” she wrote in her dissent.

At least 36 states have apology laws that shield against certain statements, expressions, or other evidence related to disclosures being used against physicians in court.
 

[email protected]

On Twitter @legal_med

The Ohio Supreme Court has ruled that apologies by physicians that include an admission of fault cannot be used against them in court, upholding a lower court decision that spared a doctor’s comments from being heard at trial.

In a Sept. 12 decision, state Supreme Court justices concluded that Ohio’s apology statute protects both expressions of regret for an unanticipated outcome and acknowledgments that the patient’s treatment fell below the standard of care. The decision resolves a split among Ohio appeals courts over whether expressions of fault are admissible.

AndreyPopov/ThinkStock

The decision declaring Ohio’s apology statute “unambiguous” is an important and clarifying ruling for physicians and settles the differing opinions of some lower courts, said Reginald Fields, director of external and professional relations for the Ohio State Medical Association.

“We applaud the high court’s decision,” Mr. Fields said in an interview. “Even the two dissenting justices agreed that the apology law is clear; they just questioned whether it applied in this particular case. This ruling likely means pending legislation thought to be needed to clarify the law is now unnecessary. The OSMA will now focus on other aspects of tort reform, such as ‘loss of chance’ claims and further elimination of frivolous lawsuits.”

The Ohio Association for Justice, the state’s plaintiffs’ bar did not respond to a request for comment.

The case of Stewart v. Vivian resulted from a lawsuit filed by Dennis Stewart against Cincinnati psychiatrist Rodney Vivian, MD, after the death of Mr. Stewart’s wife by suicide. Michelle Stewart was admitted to the emergency department of Mt. Orab MediCenter in February 2010 after attempting suicide and was later transferred to the psychiatric unit at Mercy Hospital Clermont in Batavia, Ohio. After consulting with nurses, Dr. Vivian ordered that a staff member of the psychiatric unit visually observe Ms. Stewart every 15 minutes, according to court documents. The next evening, Mr. Stewart arrived at the psychiatric unit to visit his wife and found her unconscious as a result of hanging.

Two days later, Dr. Vivian went to Ms. Stewart’s room in the intensive care unit to speak with family members. The content of the conversation between Dr. Vivian and family members is disputed. Family members allege that Dr. Vivian expressed that it was a “terrible situation” and that the patient had told Dr. Vivian that she “wanted to be dead” would “keep trying” to kill herself. Dr. Vivian testified that he told the family he was “sorry this has happened.” Ms. Stewart was later taken off life support and died.

In 2011, Mr. Stewart sued Dr. Vivian and Mercy Hospital Clermont for medical malpractice, loss of spousal consortium, and wrongful death. Dr. Vivian argued that his statements to family members in the ICU room were inadmissible under the state’s apology law because they were “intended to express commiseration, condolence, or sympathy.” Mr. Stewart countered that Dr. Vivian’s statements were admissible because they were not “pure expressions of apology, sympathy, commiseration, condolence, compassion, or a general sense of benevolence.” The trial court sided with Dr. Vivian and his statements were kept from trial testimony. The jury returned a verdict in favor of Dr. Vivian, concluding that he was not negligent in his assessment, care, or treatment.

The 12th District Court of Appeals ruled that Dr. Vivian’s statements were properly excluded, finding that the Ohio’s apology law is ambiguous because according to the term’s dictionary definition, “apology” may or may not include an admission of fault. But the decision conflicted with the case of Davis v. Wooster Orthopaedics & Sports Medicine, Inc. in which the Court of Appeals for the 9th District in Ohio determined Ohio’s apology statute protects from admission “pure expressions of apology, sympathy, commiseration, condolence, compassion, or a general sense of benevolence,” but not “admission of fault.”

Resolving the split, the Ohio Supreme Court concluded that the state law is unambiguous and that its legislative intent is to shield expressions of regret for unexpected outcomes that may include acknowledgments that the patient’s medical care fell below the standard of care.

Ohio Supreme Court Chief Justice Maureen O’Connor and Justice William M. O’Neill partially dissented. While they agreed with the majority’s holding regarding the intent of Ohio’s apology law, Justice O’Connor wrote that the Dr. Vivian’s statements fell outside the law’s protection.

“Dr. Vivian’s statements were not an apology nor did they express regret or a type of shared sadness associated with sympathy or commiseration,” she wrote in her dissent.

At least 36 states have apology laws that shield against certain statements, expressions, or other evidence related to disclosures being used against physicians in court.
 

[email protected]

On Twitter @legal_med