Perspectives

In December 2014, the US Food and Drug Administration approved ivermectin cream 1% (Soolantra) for the treatment of inflammatory lesions of rosacea. This approval follows several safety and efficacy trials, particularly a phase 3 investigator-blinded, parallel-group study, published online in the British Journal of Dermatology on September 16, 2014, comparing once-daily application of ivermectin cream 1% and twice-daily metronidazole cream 0.75% in 962 patients with papulopustular rosacea over 16 weeks. Ivermectin showed more favorable local tolerability and significant reduction in lesion count versus metronidazole (83% vs 73.7%; P<.001) starting at week 3 and persisting throughout the study.

What’s the issue?

How many patients do you encounter each week who apply metronidazole topical treatments for years with little objective evidence of rosacea improvement? These data suggest that topical ivermectin may be a slightly more effective and tolerable alternative for papulopustular rosacea than the long-standing but modestly efficacious gold standard. With the recent approval of brimonidine gel for the erythematous component of rosacea, it is groundbreaking to introduce novel topical mechanisms into our rosacea prescription armamentarium as we attempt to elucidate the disease’s complex pathophysiology. What is your experience with this topical, and how do you think it will fit into your prescribing routines for rosacea?

We want to know your views! Tell us what you think.

In December 2014, the US Food and Drug Administration approved ivermectin cream 1% (Soolantra) for the treatment of inflammatory lesions of rosacea. This approval follows several safety and efficacy trials, particularly a phase 3 investigator-blinded, parallel-group study, published online in the British Journal of Dermatology on September 16, 2014, comparing once-daily application of ivermectin cream 1% and twice-daily metronidazole cream 0.75% in 962 patients with papulopustular rosacea over 16 weeks. Ivermectin showed more favorable local tolerability and significant reduction in lesion count versus metronidazole (83% vs 73.7%; P<.001) starting at week 3 and persisting throughout the study.

What’s the issue?

How many patients do you encounter each week who apply metronidazole topical treatments for years with little objective evidence of rosacea improvement? These data suggest that topical ivermectin may be a slightly more effective and tolerable alternative for papulopustular rosacea than the long-standing but modestly efficacious gold standard. With the recent approval of brimonidine gel for the erythematous component of rosacea, it is groundbreaking to introduce novel topical mechanisms into our rosacea prescription armamentarium as we attempt to elucidate the disease’s complex pathophysiology. What is your experience with this topical, and how do you think it will fit into your prescribing routines for rosacea?

We want to know your views! Tell us what you think.

In December 2014, the US Food and Drug Administration approved ivermectin cream 1% (Soolantra) for the treatment of inflammatory lesions of rosacea. This approval follows several safety and efficacy trials, particularly a phase 3 investigator-blinded, parallel-group study, published online in the British Journal of Dermatology on September 16, 2014, comparing once-daily application of ivermectin cream 1% and twice-daily metronidazole cream 0.75% in 962 patients with papulopustular rosacea over 16 weeks. Ivermectin showed more favorable local tolerability and significant reduction in lesion count versus metronidazole (83% vs 73.7%; P<.001) starting at week 3 and persisting throughout the study.

What’s the issue?

How many patients do you encounter each week who apply metronidazole topical treatments for years with little objective evidence of rosacea improvement? These data suggest that topical ivermectin may be a slightly more effective and tolerable alternative for papulopustular rosacea than the long-standing but modestly efficacious gold standard. With the recent approval of brimonidine gel for the erythematous component of rosacea, it is groundbreaking to introduce novel topical mechanisms into our rosacea prescription armamentarium as we attempt to elucidate the disease’s complex pathophysiology. What is your experience with this topical, and how do you think it will fit into your prescribing routines for rosacea?

We want to know your views! Tell us what you think.

The perioral region is second to the periorbital area in making a person appear tired, sad, happy, or healthy. Although a lot of emphasis has been given to improving the periorbital area, the perioral region has received less attention. The mainstay of addressing the perioral region is using fillers, mainly synthetic ones, to smooth rhytides and restore lost volume. Skin resurfacing is a second-line approach, in part due to the required 5 to 7 days of recovery time to heal. However, as we have learned through many other procedures, it is wrong to make one modality your hammer and every patient your nail.

In an article published online on November 20, 2014, in Aesthetic Plastic Surgery, Penna et al conducted a morphometric review of 462 perioral photographs to come up with a 2-dimensional classification system to evaluate the perioral region. The classification was based on 2 qualities: lip shape and surface changes. Lip shape was classified as (1) short concave upper lip with 2 to 3 mm of upper incisors visible and prominent everted vermilion; (2) moderately elongated and straight upper lip with upper incisors at the lower border of the upper lip and mild degree of vermilion inversion; and (3) strongly elongated upper lip that forms a convex curve around the frontal teeth row with upper incisors that are not visible and vermilion is inverted. Lip surface was classified as (1) distinct philtral columns, Cupid’s bow and white roll without static radial wrinkles, and minor dynamic radial wrinkles; (2) flattened philtral columns and Cupid’s bow, indistinct white roll, beginning static radial wrinkles, and strong dynamic radial wrinkles; and (3) invisible philtral columns, Cupid’s bow and white roll, and considerable static radial wrinkles.

This scale was validated for objectivity, interevaluator reliability, intraevaluator reliability, and reproducibility by having 3 plastic surgeons evaluate perioral photographs of 42 female patients. The scale proved to be valid to a significant degree using Cohen’s κ coefficient. Based on this evaluation scale, one can evaluate the anatomic structure of the lip to decide if no treatment is needed, if synthetic or autologous fillers would suffice, or if a surgical lip-lift is required. Furthermore, surface changes can help determine if no treatment is needed, if skin resurfacing is indicated, or if both skin resurfacing and volumizing is required. The authors studied female subjects because they constitute the majority of patients seeking perioral rejuvenation.

What’s the issue?

Certainly the field of noninvasive cosmetic procedures continues to grow yearly; however, one must temper the enthusiasm of the patient at times so that he/she does not undergo excessive procedures and end up with unnatural results. Furthermore, one must not neglect the importance of artistry and proper patient evaluation in order to achieve a natural rejuvenated appearance. For example, relying solely on fillers to address perioral aging has resulted in an astonishing number of celebrities and patients walking around with an unnatural and distorted appearance. In many instances, this look may age a patient rather than rejuvenate him/her. Cosmetic dermatology is a balance between knowing when to treat, how much to treat, and when to effectively combine modalities to ensure the best outcome. This classification system will be useful for training residents and newly graduated dermatologists.

We want to know your views! Tell us what you think.

The perioral region is second to the periorbital area in making a person appear tired, sad, happy, or healthy. Although a lot of emphasis has been given to improving the periorbital area, the perioral region has received less attention. The mainstay of addressing the perioral region is using fillers, mainly synthetic ones, to smooth rhytides and restore lost volume. Skin resurfacing is a second-line approach, in part due to the required 5 to 7 days of recovery time to heal. However, as we have learned through many other procedures, it is wrong to make one modality your hammer and every patient your nail.

In an article published online on November 20, 2014, in Aesthetic Plastic Surgery, Penna et al conducted a morphometric review of 462 perioral photographs to come up with a 2-dimensional classification system to evaluate the perioral region. The classification was based on 2 qualities: lip shape and surface changes. Lip shape was classified as (1) short concave upper lip with 2 to 3 mm of upper incisors visible and prominent everted vermilion; (2) moderately elongated and straight upper lip with upper incisors at the lower border of the upper lip and mild degree of vermilion inversion; and (3) strongly elongated upper lip that forms a convex curve around the frontal teeth row with upper incisors that are not visible and vermilion is inverted. Lip surface was classified as (1) distinct philtral columns, Cupid’s bow and white roll without static radial wrinkles, and minor dynamic radial wrinkles; (2) flattened philtral columns and Cupid’s bow, indistinct white roll, beginning static radial wrinkles, and strong dynamic radial wrinkles; and (3) invisible philtral columns, Cupid’s bow and white roll, and considerable static radial wrinkles.

This scale was validated for objectivity, interevaluator reliability, intraevaluator reliability, and reproducibility by having 3 plastic surgeons evaluate perioral photographs of 42 female patients. The scale proved to be valid to a significant degree using Cohen’s κ coefficient. Based on this evaluation scale, one can evaluate the anatomic structure of the lip to decide if no treatment is needed, if synthetic or autologous fillers would suffice, or if a surgical lip-lift is required. Furthermore, surface changes can help determine if no treatment is needed, if skin resurfacing is indicated, or if both skin resurfacing and volumizing is required. The authors studied female subjects because they constitute the majority of patients seeking perioral rejuvenation.

What’s the issue?

Certainly the field of noninvasive cosmetic procedures continues to grow yearly; however, one must temper the enthusiasm of the patient at times so that he/she does not undergo excessive procedures and end up with unnatural results. Furthermore, one must not neglect the importance of artistry and proper patient evaluation in order to achieve a natural rejuvenated appearance. For example, relying solely on fillers to address perioral aging has resulted in an astonishing number of celebrities and patients walking around with an unnatural and distorted appearance. In many instances, this look may age a patient rather than rejuvenate him/her. Cosmetic dermatology is a balance between knowing when to treat, how much to treat, and when to effectively combine modalities to ensure the best outcome. This classification system will be useful for training residents and newly graduated dermatologists.

We want to know your views! Tell us what you think.

The perioral region is second to the periorbital area in making a person appear tired, sad, happy, or healthy. Although a lot of emphasis has been given to improving the periorbital area, the perioral region has received less attention. The mainstay of addressing the perioral region is using fillers, mainly synthetic ones, to smooth rhytides and restore lost volume. Skin resurfacing is a second-line approach, in part due to the required 5 to 7 days of recovery time to heal. However, as we have learned through many other procedures, it is wrong to make one modality your hammer and every patient your nail.

In an article published online on November 20, 2014, in Aesthetic Plastic Surgery, Penna et al conducted a morphometric review of 462 perioral photographs to come up with a 2-dimensional classification system to evaluate the perioral region. The classification was based on 2 qualities: lip shape and surface changes. Lip shape was classified as (1) short concave upper lip with 2 to 3 mm of upper incisors visible and prominent everted vermilion; (2) moderately elongated and straight upper lip with upper incisors at the lower border of the upper lip and mild degree of vermilion inversion; and (3) strongly elongated upper lip that forms a convex curve around the frontal teeth row with upper incisors that are not visible and vermilion is inverted. Lip surface was classified as (1) distinct philtral columns, Cupid’s bow and white roll without static radial wrinkles, and minor dynamic radial wrinkles; (2) flattened philtral columns and Cupid’s bow, indistinct white roll, beginning static radial wrinkles, and strong dynamic radial wrinkles; and (3) invisible philtral columns, Cupid’s bow and white roll, and considerable static radial wrinkles.

This scale was validated for objectivity, interevaluator reliability, intraevaluator reliability, and reproducibility by having 3 plastic surgeons evaluate perioral photographs of 42 female patients. The scale proved to be valid to a significant degree using Cohen’s κ coefficient. Based on this evaluation scale, one can evaluate the anatomic structure of the lip to decide if no treatment is needed, if synthetic or autologous fillers would suffice, or if a surgical lip-lift is required. Furthermore, surface changes can help determine if no treatment is needed, if skin resurfacing is indicated, or if both skin resurfacing and volumizing is required. The authors studied female subjects because they constitute the majority of patients seeking perioral rejuvenation.

What’s the issue?

Certainly the field of noninvasive cosmetic procedures continues to grow yearly; however, one must temper the enthusiasm of the patient at times so that he/she does not undergo excessive procedures and end up with unnatural results. Furthermore, one must not neglect the importance of artistry and proper patient evaluation in order to achieve a natural rejuvenated appearance. For example, relying solely on fillers to address perioral aging has resulted in an astonishing number of celebrities and patients walking around with an unnatural and distorted appearance. In many instances, this look may age a patient rather than rejuvenate him/her. Cosmetic dermatology is a balance between knowing when to treat, how much to treat, and when to effectively combine modalities to ensure the best outcome. This classification system will be useful for training residents and newly graduated dermatologists.

We want to know your views! Tell us what you think.

We are all aware of the rising costs of medical care, especially for complex diseases such as psoriasis. The total cost of psoriasis in the United States is unknown. Brezinski et al (JAMA Dermatol. doi:10.1001/jamadermatol.2014.3593) sought to define the economic burden of psoriasis in the United States. They argued that this information is needed to provide the foundation for research, advocacy, and educational efforts within the disease.

The authors searched PubMed and MEDLINE databases for economic investigations on the costs of adult psoriasis in the United States. The primary objective of the analysis was to provide a comprehensive analysis of the literature on the economic burden of psoriasis in the United States. The direct, indirect, intangible, and comorbidity costs of psoriasis were reported based on this systematic literature review and adjusted to 2013 US dollars.

The direct costs included medical costs associated with (1) specialist medical evaluations, (2) hospitalization, (3) prescription medications, (4) phototherapy, (5) medication administration costs, (6) laboratory tests and monitoring studies, and (7) over-the-counter medications and self-care products. The indirect costs were determined by absenteeism and impaired work productivity. Intangible costs were calculated as a measure of the negative effect of psoriasis on quality of life. Finally, comorbidity costs measured the medical evaluations, treatment, and lab monitoring that were directly attributed to comorbid conditions associated with psoriasis.

An initial review of the literature generated 100 articles; 22 studies were included in the systematic review. The direct psoriasis costs ranged from $51.7 billion to $63.2 billion, the indirect costs ranged from $23.9 billion to $35.4 billion, and medical comorbidities were estimated to contribute $36.4 billion annually in 2013 US dollars. The annual cost of psoriasis in the United States amounted to approximately $112 billion in 2013.

The authors concluded that the economic burden of psoriasis was substantial and significant in the United States.

What’s the issue?

In the United States, the economic burden of psoriasis is substantial because this disease is associated with negative physical, psychiatric, and social consequences. In addition, treatment costs continue to rise. How will this analysis of cost influence your future management of psoriasis?

We want to know your views! Tell us what you think.

We are all aware of the rising costs of medical care, especially for complex diseases such as psoriasis. The total cost of psoriasis in the United States is unknown. Brezinski et al (JAMA Dermatol. doi:10.1001/jamadermatol.2014.3593) sought to define the economic burden of psoriasis in the United States. They argued that this information is needed to provide the foundation for research, advocacy, and educational efforts within the disease.

The authors searched PubMed and MEDLINE databases for economic investigations on the costs of adult psoriasis in the United States. The primary objective of the analysis was to provide a comprehensive analysis of the literature on the economic burden of psoriasis in the United States. The direct, indirect, intangible, and comorbidity costs of psoriasis were reported based on this systematic literature review and adjusted to 2013 US dollars.

The direct costs included medical costs associated with (1) specialist medical evaluations, (2) hospitalization, (3) prescription medications, (4) phototherapy, (5) medication administration costs, (6) laboratory tests and monitoring studies, and (7) over-the-counter medications and self-care products. The indirect costs were determined by absenteeism and impaired work productivity. Intangible costs were calculated as a measure of the negative effect of psoriasis on quality of life. Finally, comorbidity costs measured the medical evaluations, treatment, and lab monitoring that were directly attributed to comorbid conditions associated with psoriasis.

An initial review of the literature generated 100 articles; 22 studies were included in the systematic review. The direct psoriasis costs ranged from $51.7 billion to $63.2 billion, the indirect costs ranged from $23.9 billion to $35.4 billion, and medical comorbidities were estimated to contribute $36.4 billion annually in 2013 US dollars. The annual cost of psoriasis in the United States amounted to approximately $112 billion in 2013.

The authors concluded that the economic burden of psoriasis was substantial and significant in the United States.

What’s the issue?

In the United States, the economic burden of psoriasis is substantial because this disease is associated with negative physical, psychiatric, and social consequences. In addition, treatment costs continue to rise. How will this analysis of cost influence your future management of psoriasis?

We want to know your views! Tell us what you think.

We are all aware of the rising costs of medical care, especially for complex diseases such as psoriasis. The total cost of psoriasis in the United States is unknown. Brezinski et al (JAMA Dermatol. doi:10.1001/jamadermatol.2014.3593) sought to define the economic burden of psoriasis in the United States. They argued that this information is needed to provide the foundation for research, advocacy, and educational efforts within the disease.

The authors searched PubMed and MEDLINE databases for economic investigations on the costs of adult psoriasis in the United States. The primary objective of the analysis was to provide a comprehensive analysis of the literature on the economic burden of psoriasis in the United States. The direct, indirect, intangible, and comorbidity costs of psoriasis were reported based on this systematic literature review and adjusted to 2013 US dollars.

The direct costs included medical costs associated with (1) specialist medical evaluations, (2) hospitalization, (3) prescription medications, (4) phototherapy, (5) medication administration costs, (6) laboratory tests and monitoring studies, and (7) over-the-counter medications and self-care products. The indirect costs were determined by absenteeism and impaired work productivity. Intangible costs were calculated as a measure of the negative effect of psoriasis on quality of life. Finally, comorbidity costs measured the medical evaluations, treatment, and lab monitoring that were directly attributed to comorbid conditions associated with psoriasis.

An initial review of the literature generated 100 articles; 22 studies were included in the systematic review. The direct psoriasis costs ranged from $51.7 billion to $63.2 billion, the indirect costs ranged from $23.9 billion to $35.4 billion, and medical comorbidities were estimated to contribute $36.4 billion annually in 2013 US dollars. The annual cost of psoriasis in the United States amounted to approximately $112 billion in 2013.

The authors concluded that the economic burden of psoriasis was substantial and significant in the United States.

What’s the issue?

In the United States, the economic burden of psoriasis is substantial because this disease is associated with negative physical, psychiatric, and social consequences. In addition, treatment costs continue to rise. How will this analysis of cost influence your future management of psoriasis?

We want to know your views! Tell us what you think.

The role of diet in acne, both as a causative agent and therapeutic intervention, has been the topic of discussion in both the dermatology community as well as the laypress for decades. There is ample evidence highlighting the association of acne and high glycemic loads, certain dairy products, and refined sugar product ingestion. In the most recent edition to the repository, Grossi et al (J Eur Acad Dermatol Venereol. doi:10.1111/jdv.12878) reanalyzed data from their case-control study among young patients (age range, 10–24 years; N=563) with a diagnosis of moderate to severe acne versus control (participants with no or mild acne) between March 2009 and February 2010 that was originally published in 2012 (J Am Acad Dermatol. 2012;67:1129-1135). The unique element was how they evaluated the data. The investigators utilized a semantic connectivity map approach derived from artificial neural network computational models, which allowed for a better understanding of the complex connections between all of the studied variables. (The assumption of a given relation between any variables would not influence the results.) The data were presented on an Auto Semantic Connectivity Map that resembled a 4-leaf clover, representing “explanatory” information pertaining to the cases and controls and “residual” information of less importance. It is worth seeing in the manuscript to better appreciate the data.

What did they find? There is a close association between moderate to severe acne and a high intake of milk, other dairy products, sweets, and chocolate. Obesity and the low consumption of fish were linked to the presence of moderate to severe acne, while high consumption of fish (1 d/wk or more), high intake of fruits and vegetables, and body mass index lower than 18.5 were all associated with limited or no acne.

What’s the issue?

By adopting a different analytic approach, it was shown once again that diet plays a substantial role in acne, indicating that some food items may stimulate selected acne-promoting pathways. But what now? Here is the evidence yet again, but where is the medicine of “evidence-based medicine”? It is time to recommend guidelines for screening and counseling. In a recent article, Bronsnick et al (J Am Acad Dermatol. 2014;71:1039.e1-1039.e12) found that the level of evidence supporting the benefit of a low-glycemic, low-carbohydrate diet was sufficient to recommend to acne patients. How many dermatologists feel comfortable providing dietary guidance to their acne patients? A consensus statement from relevant organizations such as the American Academy of Dermatology, the Society for Investigative Dermatology, and the American Acne & Rosacea Society that provides tangible and realistic screening tools to identify those who would benefit from dietary intervention and implementation and practice guidelines for Dr. Derm seeing 40 to 50 patients a day in Springfield, USA (homage to The Simpsons) based on the level of evidence available would be useful. What are your thoughts?

We want to know your views! Tell us what you think.

Suggested Readings

• Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol. 2010;63:124-141.
• Ferdowsian HR, Levin S. Does diet really affect acne? Skin Therapy Lett. 2010;15:1-2, 5.
• Melnik B. Dietary intervention in acne: attenuation of increased mTORC1 signaling promoted by Western diet. Dermatoendocrinol. 2012;4:20-32.
• Veith WB, Silverberg NB. The association of acne vulgaris with diet. Cutis. 2011;88:84-91.

The role of diet in acne, both as a causative agent and therapeutic intervention, has been the topic of discussion in both the dermatology community as well as the laypress for decades. There is ample evidence highlighting the association of acne and high glycemic loads, certain dairy products, and refined sugar product ingestion. In the most recent edition to the repository, Grossi et al (J Eur Acad Dermatol Venereol. doi:10.1111/jdv.12878) reanalyzed data from their case-control study among young patients (age range, 10–24 years; N=563) with a diagnosis of moderate to severe acne versus control (participants with no or mild acne) between March 2009 and February 2010 that was originally published in 2012 (J Am Acad Dermatol. 2012;67:1129-1135). The unique element was how they evaluated the data. The investigators utilized a semantic connectivity map approach derived from artificial neural network computational models, which allowed for a better understanding of the complex connections between all of the studied variables. (The assumption of a given relation between any variables would not influence the results.) The data were presented on an Auto Semantic Connectivity Map that resembled a 4-leaf clover, representing “explanatory” information pertaining to the cases and controls and “residual” information of less importance. It is worth seeing in the manuscript to better appreciate the data.

What did they find? There is a close association between moderate to severe acne and a high intake of milk, other dairy products, sweets, and chocolate. Obesity and the low consumption of fish were linked to the presence of moderate to severe acne, while high consumption of fish (1 d/wk or more), high intake of fruits and vegetables, and body mass index lower than 18.5 were all associated with limited or no acne.

What’s the issue?

By adopting a different analytic approach, it was shown once again that diet plays a substantial role in acne, indicating that some food items may stimulate selected acne-promoting pathways. But what now? Here is the evidence yet again, but where is the medicine of “evidence-based medicine”? It is time to recommend guidelines for screening and counseling. In a recent article, Bronsnick et al (J Am Acad Dermatol. 2014;71:1039.e1-1039.e12) found that the level of evidence supporting the benefit of a low-glycemic, low-carbohydrate diet was sufficient to recommend to acne patients. How many dermatologists feel comfortable providing dietary guidance to their acne patients? A consensus statement from relevant organizations such as the American Academy of Dermatology, the Society for Investigative Dermatology, and the American Acne & Rosacea Society that provides tangible and realistic screening tools to identify those who would benefit from dietary intervention and implementation and practice guidelines for Dr. Derm seeing 40 to 50 patients a day in Springfield, USA (homage to The Simpsons) based on the level of evidence available would be useful. What are your thoughts?

We want to know your views! Tell us what you think.

Suggested Readings

• Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol. 2010;63:124-141.
• Ferdowsian HR, Levin S. Does diet really affect acne? Skin Therapy Lett. 2010;15:1-2, 5.
• Melnik B. Dietary intervention in acne: attenuation of increased mTORC1 signaling promoted by Western diet. Dermatoendocrinol. 2012;4:20-32.
• Veith WB, Silverberg NB. The association of acne vulgaris with diet. Cutis. 2011;88:84-91.

The role of diet in acne, both as a causative agent and therapeutic intervention, has been the topic of discussion in both the dermatology community as well as the laypress for decades. There is ample evidence highlighting the association of acne and high glycemic loads, certain dairy products, and refined sugar product ingestion. In the most recent edition to the repository, Grossi et al (J Eur Acad Dermatol Venereol. doi:10.1111/jdv.12878) reanalyzed data from their case-control study among young patients (age range, 10–24 years; N=563) with a diagnosis of moderate to severe acne versus control (participants with no or mild acne) between March 2009 and February 2010 that was originally published in 2012 (J Am Acad Dermatol. 2012;67:1129-1135). The unique element was how they evaluated the data. The investigators utilized a semantic connectivity map approach derived from artificial neural network computational models, which allowed for a better understanding of the complex connections between all of the studied variables. (The assumption of a given relation between any variables would not influence the results.) The data were presented on an Auto Semantic Connectivity Map that resembled a 4-leaf clover, representing “explanatory” information pertaining to the cases and controls and “residual” information of less importance. It is worth seeing in the manuscript to better appreciate the data.

What did they find? There is a close association between moderate to severe acne and a high intake of milk, other dairy products, sweets, and chocolate. Obesity and the low consumption of fish were linked to the presence of moderate to severe acne, while high consumption of fish (1 d/wk or more), high intake of fruits and vegetables, and body mass index lower than 18.5 were all associated with limited or no acne.

What’s the issue?

By adopting a different analytic approach, it was shown once again that diet plays a substantial role in acne, indicating that some food items may stimulate selected acne-promoting pathways. But what now? Here is the evidence yet again, but where is the medicine of “evidence-based medicine”? It is time to recommend guidelines for screening and counseling. In a recent article, Bronsnick et al (J Am Acad Dermatol. 2014;71:1039.e1-1039.e12) found that the level of evidence supporting the benefit of a low-glycemic, low-carbohydrate diet was sufficient to recommend to acne patients. How many dermatologists feel comfortable providing dietary guidance to their acne patients? A consensus statement from relevant organizations such as the American Academy of Dermatology, the Society for Investigative Dermatology, and the American Acne & Rosacea Society that provides tangible and realistic screening tools to identify those who would benefit from dietary intervention and implementation and practice guidelines for Dr. Derm seeing 40 to 50 patients a day in Springfield, USA (homage to The Simpsons) based on the level of evidence available would be useful. What are your thoughts?

We want to know your views! Tell us what you think.

Suggested Readings

• Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol. 2010;63:124-141.
• Ferdowsian HR, Levin S. Does diet really affect acne? Skin Therapy Lett. 2010;15:1-2, 5.
• Melnik B. Dietary intervention in acne: attenuation of increased mTORC1 signaling promoted by Western diet. Dermatoendocrinol. 2012;4:20-32.
• Veith WB, Silverberg NB. The association of acne vulgaris with diet. Cutis. 2011;88:84-91.

Tanghetti et al (J Drugs Dermatol. 2015;14:33-40) discuss the use of topical brimonidine for the redness associated with rosacea. Brimonidine is the newest therapeutic to combat the erythema associated with rosacea of all subtypes. It is a topical α₂-adrenergic agonist that causes peripheral vasoconstriction via a direct effect on smooth muscle receptors. The authors describe 2 large studies that studied the safety and efficacy of topical brimonidine and also give consensus recommendations regarding optimal utilization while minimizing adverse effects, such as the “rebound” phenomena described. It is important to note that it is not a traditional rebound effect, as it does not occur once the medication has stopped; however, it is a worsening of the erythema during active treatment with brimonidine. The authors discuss the various cases reported to the manufacturer after the medication was released. The most frequently associated side effects reported were erythema in almost all cases, flushing, feeling of heat or burning sensation, and rarely pain. Other issues such as dermatitis, pruritus, facial swelling, and pallor were seen in less than 10% of reports each.

These rebound effects were most likely to occur in the first 15 days after initiation of therapy, mainly in the first week. They also were noticed at 2 other time points—3 to 6 hours and 10 to 12 hours after application—which allowed the identification of 2 types of reactions based on the time to onset postapplication: appearing within 3 to 6 hours and observed after 10 to 12 hours. These events have been given new names. “Paradoxical erythema” is the redness appearing within 3 to 6 hours after application, which can be worse than baseline. “Exaggerated recurrence of erythema” is the redness that is greater than baseline and occurs as therapy wears off, approximately 10 to 12 hours after application. Allergic contact dermatitis also has been associated with the medication and can therefore be a source of redness 3 to 4 months after initiation.

What’s the issue?

The erythema associated with rosacea can be a distressing symptom for both the patient and the dermatologist. It can be difficult to treat and quite often recalcitrant to multiple treatments. Although pulsed dye laser is an effective therapy for treating telangiectases and dilated blood vessels, it can be expensive for many patients. Topical brimonidine represents a novel therapeutic to combat one of the most remarkable symptoms of rosacea. However, because of the possibility of this increased redness after use, Tanghetti et al suggest the following treatment algorithm:

• “Assess” the patient and rule out other causes of redness or associated conditions, such as seborrheic dermatitis or lupus.
• “Educate” the patient regarding the known triggers of rosacea flair and how they can be best avoided. Also educate that brimonidine only treats redness and not the papules, pustules, or other symptoms of rosacea.
• “Inhibit” inflammation that is currently present using gentle skin care practices, mild cleansers, and barrier-restoring emollients.
• “Optimize” the application of brimonidine. Instruct how to apply a pea-sized amount in the morning or how patients can best time the application to coincide with daily events or social events.
• “Understand” that worsening redness may occur, which can be key to patient satisfaction. Patients should be made aware that there is a risk for worsening redness in 10% to 20% of patients. It usually occurs within the first 2 weeks of starting the medication and it may be seen soon after application (3–6 hours) or after treatment has subsided (10–12 hours). Generally this worsening will subside within 12 to 24 hours after discontinuation. Also symptoms can be treated throughout with the use of nonsteroidal anti-inflammatory medications, antihistamines, topical calcineurin inhibitors, and topical steroids, if necessary.

What has been your experience with brimonidine gel and how do you manage these patients?

We want to know your views! Tell us what you think.

Tanghetti et al (J Drugs Dermatol. 2015;14:33-40) discuss the use of topical brimonidine for the redness associated with rosacea. Brimonidine is the newest therapeutic to combat the erythema associated with rosacea of all subtypes. It is a topical α₂-adrenergic agonist that causes peripheral vasoconstriction via a direct effect on smooth muscle receptors. The authors describe 2 large studies that studied the safety and efficacy of topical brimonidine and also give consensus recommendations regarding optimal utilization while minimizing adverse effects, such as the “rebound” phenomena described. It is important to note that it is not a traditional rebound effect, as it does not occur once the medication has stopped; however, it is a worsening of the erythema during active treatment with brimonidine. The authors discuss the various cases reported to the manufacturer after the medication was released. The most frequently associated side effects reported were erythema in almost all cases, flushing, feeling of heat or burning sensation, and rarely pain. Other issues such as dermatitis, pruritus, facial swelling, and pallor were seen in less than 10% of reports each.

These rebound effects were most likely to occur in the first 15 days after initiation of therapy, mainly in the first week. They also were noticed at 2 other time points—3 to 6 hours and 10 to 12 hours after application—which allowed the identification of 2 types of reactions based on the time to onset postapplication: appearing within 3 to 6 hours and observed after 10 to 12 hours. These events have been given new names. “Paradoxical erythema” is the redness appearing within 3 to 6 hours after application, which can be worse than baseline. “Exaggerated recurrence of erythema” is the redness that is greater than baseline and occurs as therapy wears off, approximately 10 to 12 hours after application. Allergic contact dermatitis also has been associated with the medication and can therefore be a source of redness 3 to 4 months after initiation.

What’s the issue?

The erythema associated with rosacea can be a distressing symptom for both the patient and the dermatologist. It can be difficult to treat and quite often recalcitrant to multiple treatments. Although pulsed dye laser is an effective therapy for treating telangiectases and dilated blood vessels, it can be expensive for many patients. Topical brimonidine represents a novel therapeutic to combat one of the most remarkable symptoms of rosacea. However, because of the possibility of this increased redness after use, Tanghetti et al suggest the following treatment algorithm:

• “Assess” the patient and rule out other causes of redness or associated conditions, such as seborrheic dermatitis or lupus.
• “Educate” the patient regarding the known triggers of rosacea flair and how they can be best avoided. Also educate that brimonidine only treats redness and not the papules, pustules, or other symptoms of rosacea.
• “Inhibit” inflammation that is currently present using gentle skin care practices, mild cleansers, and barrier-restoring emollients.
• “Optimize” the application of brimonidine. Instruct how to apply a pea-sized amount in the morning or how patients can best time the application to coincide with daily events or social events.
• “Understand” that worsening redness may occur, which can be key to patient satisfaction. Patients should be made aware that there is a risk for worsening redness in 10% to 20% of patients. It usually occurs within the first 2 weeks of starting the medication and it may be seen soon after application (3–6 hours) or after treatment has subsided (10–12 hours). Generally this worsening will subside within 12 to 24 hours after discontinuation. Also symptoms can be treated throughout with the use of nonsteroidal anti-inflammatory medications, antihistamines, topical calcineurin inhibitors, and topical steroids, if necessary.

What has been your experience with brimonidine gel and how do you manage these patients?

We want to know your views! Tell us what you think.

Tanghetti et al (J Drugs Dermatol. 2015;14:33-40) discuss the use of topical brimonidine for the redness associated with rosacea. Brimonidine is the newest therapeutic to combat the erythema associated with rosacea of all subtypes. It is a topical α₂-adrenergic agonist that causes peripheral vasoconstriction via a direct effect on smooth muscle receptors. The authors describe 2 large studies that studied the safety and efficacy of topical brimonidine and also give consensus recommendations regarding optimal utilization while minimizing adverse effects, such as the “rebound” phenomena described. It is important to note that it is not a traditional rebound effect, as it does not occur once the medication has stopped; however, it is a worsening of the erythema during active treatment with brimonidine. The authors discuss the various cases reported to the manufacturer after the medication was released. The most frequently associated side effects reported were erythema in almost all cases, flushing, feeling of heat or burning sensation, and rarely pain. Other issues such as dermatitis, pruritus, facial swelling, and pallor were seen in less than 10% of reports each.

These rebound effects were most likely to occur in the first 15 days after initiation of therapy, mainly in the first week. They also were noticed at 2 other time points—3 to 6 hours and 10 to 12 hours after application—which allowed the identification of 2 types of reactions based on the time to onset postapplication: appearing within 3 to 6 hours and observed after 10 to 12 hours. These events have been given new names. “Paradoxical erythema” is the redness appearing within 3 to 6 hours after application, which can be worse than baseline. “Exaggerated recurrence of erythema” is the redness that is greater than baseline and occurs as therapy wears off, approximately 10 to 12 hours after application. Allergic contact dermatitis also has been associated with the medication and can therefore be a source of redness 3 to 4 months after initiation.

What’s the issue?

The erythema associated with rosacea can be a distressing symptom for both the patient and the dermatologist. It can be difficult to treat and quite often recalcitrant to multiple treatments. Although pulsed dye laser is an effective therapy for treating telangiectases and dilated blood vessels, it can be expensive for many patients. Topical brimonidine represents a novel therapeutic to combat one of the most remarkable symptoms of rosacea. However, because of the possibility of this increased redness after use, Tanghetti et al suggest the following treatment algorithm:

• “Assess” the patient and rule out other causes of redness or associated conditions, such as seborrheic dermatitis or lupus.
• “Educate” the patient regarding the known triggers of rosacea flair and how they can be best avoided. Also educate that brimonidine only treats redness and not the papules, pustules, or other symptoms of rosacea.
• “Inhibit” inflammation that is currently present using gentle skin care practices, mild cleansers, and barrier-restoring emollients.
• “Optimize” the application of brimonidine. Instruct how to apply a pea-sized amount in the morning or how patients can best time the application to coincide with daily events or social events.
• “Understand” that worsening redness may occur, which can be key to patient satisfaction. Patients should be made aware that there is a risk for worsening redness in 10% to 20% of patients. It usually occurs within the first 2 weeks of starting the medication and it may be seen soon after application (3–6 hours) or after treatment has subsided (10–12 hours). Generally this worsening will subside within 12 to 24 hours after discontinuation. Also symptoms can be treated throughout with the use of nonsteroidal anti-inflammatory medications, antihistamines, topical calcineurin inhibitors, and topical steroids, if necessary.

What has been your experience with brimonidine gel and how do you manage these patients?

We want to know your views! Tell us what you think.

We are all aware that infections, particularly streptococcal infection, can be associated with psoriasis, especially the guttate variety. A logical question emanating from this fact is: Would tonsillectomy and adenoidectomy have any impact on psoriasis and its symptoms?

In a November 2014 article published online in the Journal of the American Academy of Dermatology, Rachakonda et al (doi:10.1016/j.jaad.2014.10.013) performed an extensive literature review to evaluate if tonsillectomy reduces psoriasis severity. The authors searched the following sources: MEDLINE, CINAHL, Cochrane, Embase, Web of Science, and Ovid databases (August 1, 1960, to September 12, 2013). In addition, they executed a manual search of selected references. Through this process, they identified observational studies and clinical trials examining psoriasis after tonsillectomy.

In the analysis, the authors included data from 20 articles from the 53 years they examined. From this literature, they included 545 patients with psoriasis who were either evaluated for or underwent tonsillectomy. Of 410 patients with psoriasis who actually underwent tonsillectomy, 290 experienced improvement in their psoriasis. Although some individuals who underwent tonsillectomy experienced sustained improvement in their disease, others experienced relapse following the procedure. The authors noted that their study was limited. Fifteen of 20 analyzed publications were case reports or series that lacked control groups. In addition, they noted that a publication bias that favored the reporting of improved cases needs to be considered.

Based on this comprehensive systematic review on the effect of tonsillectomy on psoriasis, the authors concluded that although tonsillectomy is effective in ameliorating psoriasis in a subpopulation of patients, there are insufficient data to describe the differences in clinical characteristics between responders versus nonresponders. Tonsillectomy may be a potential option for patients with recalcitrant psoriasis that is associated with occurrences of tonsillitis. Studies with long-term follow-up are needed to elucidate more clearly the extent and persistence of benefit of tonsillectomy in psoriasis.

What’s the issue?

Tonsillectomy represents an intriguing option not commonly considered for those with resistant disease. Based on the current data, will you discuss tonsillectomy with your patients?

We want to know your views! Tell us what you think.

Reader Comment
This concept so intrigued me when I heard Dr. Susan Katz discuss it at the NYU Advances in Medicine conference last June that I had the discussion with one of my patients, and she opted to have tonsillectomy this past fall. So far, she seems to improving, but I have not yet discontinued her long-term biologic therapy. At the same conference, Dr. Katz presented the idea that delaying antibiotic treatment of streptococcal pharyngitis by a few days might actually improve strep clearance rates by allowing the immune system to mount a greater response to the infection. Waiting for culture results before initiating antibiotic therapy might be prudent not only because it might reduce the unnecessary use of antibiotics in non-streptococcal pharyngitis, but because it might actually improve the long-term prognosis of patients (with or without psoriasis) who do have strep by reducing the odds of a chronic carrier state. Thanks for highlighting this area of study. Fascinating to consider that there might be a surgical cure for some psoriatic patients.

—Jennifer Goldwasser, MD (Scarsdale, New York)

We are all aware that infections, particularly streptococcal infection, can be associated with psoriasis, especially the guttate variety. A logical question emanating from this fact is: Would tonsillectomy and adenoidectomy have any impact on psoriasis and its symptoms?

In a November 2014 article published online in the Journal of the American Academy of Dermatology, Rachakonda et al (doi:10.1016/j.jaad.2014.10.013) performed an extensive literature review to evaluate if tonsillectomy reduces psoriasis severity. The authors searched the following sources: MEDLINE, CINAHL, Cochrane, Embase, Web of Science, and Ovid databases (August 1, 1960, to September 12, 2013). In addition, they executed a manual search of selected references. Through this process, they identified observational studies and clinical trials examining psoriasis after tonsillectomy.

In the analysis, the authors included data from 20 articles from the 53 years they examined. From this literature, they included 545 patients with psoriasis who were either evaluated for or underwent tonsillectomy. Of 410 patients with psoriasis who actually underwent tonsillectomy, 290 experienced improvement in their psoriasis. Although some individuals who underwent tonsillectomy experienced sustained improvement in their disease, others experienced relapse following the procedure. The authors noted that their study was limited. Fifteen of 20 analyzed publications were case reports or series that lacked control groups. In addition, they noted that a publication bias that favored the reporting of improved cases needs to be considered.

Based on this comprehensive systematic review on the effect of tonsillectomy on psoriasis, the authors concluded that although tonsillectomy is effective in ameliorating psoriasis in a subpopulation of patients, there are insufficient data to describe the differences in clinical characteristics between responders versus nonresponders. Tonsillectomy may be a potential option for patients with recalcitrant psoriasis that is associated with occurrences of tonsillitis. Studies with long-term follow-up are needed to elucidate more clearly the extent and persistence of benefit of tonsillectomy in psoriasis.

What’s the issue?

Tonsillectomy represents an intriguing option not commonly considered for those with resistant disease. Based on the current data, will you discuss tonsillectomy with your patients?

We want to know your views! Tell us what you think.

Reader Comment
This concept so intrigued me when I heard Dr. Susan Katz discuss it at the NYU Advances in Medicine conference last June that I had the discussion with one of my patients, and she opted to have tonsillectomy this past fall. So far, she seems to improving, but I have not yet discontinued her long-term biologic therapy. At the same conference, Dr. Katz presented the idea that delaying antibiotic treatment of streptococcal pharyngitis by a few days might actually improve strep clearance rates by allowing the immune system to mount a greater response to the infection. Waiting for culture results before initiating antibiotic therapy might be prudent not only because it might reduce the unnecessary use of antibiotics in non-streptococcal pharyngitis, but because it might actually improve the long-term prognosis of patients (with or without psoriasis) who do have strep by reducing the odds of a chronic carrier state. Thanks for highlighting this area of study. Fascinating to consider that there might be a surgical cure for some psoriatic patients.

—Jennifer Goldwasser, MD (Scarsdale, New York)

We are all aware that infections, particularly streptococcal infection, can be associated with psoriasis, especially the guttate variety. A logical question emanating from this fact is: Would tonsillectomy and adenoidectomy have any impact on psoriasis and its symptoms?

In a November 2014 article published online in the Journal of the American Academy of Dermatology, Rachakonda et al (doi:10.1016/j.jaad.2014.10.013) performed an extensive literature review to evaluate if tonsillectomy reduces psoriasis severity. The authors searched the following sources: MEDLINE, CINAHL, Cochrane, Embase, Web of Science, and Ovid databases (August 1, 1960, to September 12, 2013). In addition, they executed a manual search of selected references. Through this process, they identified observational studies and clinical trials examining psoriasis after tonsillectomy.

In the analysis, the authors included data from 20 articles from the 53 years they examined. From this literature, they included 545 patients with psoriasis who were either evaluated for or underwent tonsillectomy. Of 410 patients with psoriasis who actually underwent tonsillectomy, 290 experienced improvement in their psoriasis. Although some individuals who underwent tonsillectomy experienced sustained improvement in their disease, others experienced relapse following the procedure. The authors noted that their study was limited. Fifteen of 20 analyzed publications were case reports or series that lacked control groups. In addition, they noted that a publication bias that favored the reporting of improved cases needs to be considered.

Based on this comprehensive systematic review on the effect of tonsillectomy on psoriasis, the authors concluded that although tonsillectomy is effective in ameliorating psoriasis in a subpopulation of patients, there are insufficient data to describe the differences in clinical characteristics between responders versus nonresponders. Tonsillectomy may be a potential option for patients with recalcitrant psoriasis that is associated with occurrences of tonsillitis. Studies with long-term follow-up are needed to elucidate more clearly the extent and persistence of benefit of tonsillectomy in psoriasis.

What’s the issue?

Tonsillectomy represents an intriguing option not commonly considered for those with resistant disease. Based on the current data, will you discuss tonsillectomy with your patients?

We want to know your views! Tell us what you think.

Reader Comment
This concept so intrigued me when I heard Dr. Susan Katz discuss it at the NYU Advances in Medicine conference last June that I had the discussion with one of my patients, and she opted to have tonsillectomy this past fall. So far, she seems to improving, but I have not yet discontinued her long-term biologic therapy. At the same conference, Dr. Katz presented the idea that delaying antibiotic treatment of streptococcal pharyngitis by a few days might actually improve strep clearance rates by allowing the immune system to mount a greater response to the infection. Waiting for culture results before initiating antibiotic therapy might be prudent not only because it might reduce the unnecessary use of antibiotics in non-streptococcal pharyngitis, but because it might actually improve the long-term prognosis of patients (with or without psoriasis) who do have strep by reducing the odds of a chronic carrier state. Thanks for highlighting this area of study. Fascinating to consider that there might be a surgical cure for some psoriatic patients.

—Jennifer Goldwasser, MD (Scarsdale, New York)

There are anecdotal reports of dogs detecting melanoma and studies of canines being able to not only detect but also distinguish cancer from noncancer. Analysis of volatile compounds or metabolites from exhaled human breath and excreted urine also has been shown to differentiate between patients with certain cancers and healthy individuals. In addition, investigators have demonstrated that melanoma tissue has a volatile profile that is distinct from healthy nonneoplastic skin and nevi.

Abaffy et al (Metabolomics. 2013;9:998-1008) conducted a study that gives further support to the potential for analyzing volatile organic compounds as biomarkers of melanoma. They used the headspace solid phase microextraction method followed by gas chromatography and mass spectrometry to compare the volatile metabolic profiles of melanoma and nonneoplastic healthy-appearing adjacent skin from the same patient. They discovered increased levels of lauric acid (C12:0) and palmitic acid (C16:0) in melanoma and they postulated that the increased levels of these fatty acids were due to cancer-associated upregulation of de novo lipid synthesis.

What’s the issue?

In the 1980s, nail fold capillary microscopy using an ophthalmoscope was occasionally performed to evaluate for disease-associated vascular changes in patients who were being evaluated for connective tissue disorders. Within 2 decades, a dermoscope to assist in the evaluation of not only nail folds but also pigmented and other lesions replaced the ophthalmoscope. The US Food and Drug Administration recently approved a software-driven optical imaging and data analysis device that can be used to obtain additional information to assist the clinician in making a decision whether to biopsy a pigmented lesion.

As our ability to develop more sensitive and specific methods to diagnose melanoma and differentiate it from benign lesions advances, our approach to the evaluation of patients with pigmented lesions shall continue to be modified. Based on the detection of melanoma-associated volatile organic compounds coupled with their potential use as readily accessible tumor-related biomarkers, it is reasonable to speculate: (1) that a handheld office-based device, a dermatoscenter, that can identify melanoma-induced volatile tumor markers shall be developed to evaluate whether pigmented lesions are malignant or benign, and (2) that this device will eventually become an integral component of the dermatologist’s diagnostic armamentarium. Does your dermatology center need a dermatoscenter?

We want to know your views! Tell us what you think.

There are anecdotal reports of dogs detecting melanoma and studies of canines being able to not only detect but also distinguish cancer from noncancer. Analysis of volatile compounds or metabolites from exhaled human breath and excreted urine also has been shown to differentiate between patients with certain cancers and healthy individuals. In addition, investigators have demonstrated that melanoma tissue has a volatile profile that is distinct from healthy nonneoplastic skin and nevi.

Abaffy et al (Metabolomics. 2013;9:998-1008) conducted a study that gives further support to the potential for analyzing volatile organic compounds as biomarkers of melanoma. They used the headspace solid phase microextraction method followed by gas chromatography and mass spectrometry to compare the volatile metabolic profiles of melanoma and nonneoplastic healthy-appearing adjacent skin from the same patient. They discovered increased levels of lauric acid (C12:0) and palmitic acid (C16:0) in melanoma and they postulated that the increased levels of these fatty acids were due to cancer-associated upregulation of de novo lipid synthesis.

What’s the issue?

In the 1980s, nail fold capillary microscopy using an ophthalmoscope was occasionally performed to evaluate for disease-associated vascular changes in patients who were being evaluated for connective tissue disorders. Within 2 decades, a dermoscope to assist in the evaluation of not only nail folds but also pigmented and other lesions replaced the ophthalmoscope. The US Food and Drug Administration recently approved a software-driven optical imaging and data analysis device that can be used to obtain additional information to assist the clinician in making a decision whether to biopsy a pigmented lesion.

As our ability to develop more sensitive and specific methods to diagnose melanoma and differentiate it from benign lesions advances, our approach to the evaluation of patients with pigmented lesions shall continue to be modified. Based on the detection of melanoma-associated volatile organic compounds coupled with their potential use as readily accessible tumor-related biomarkers, it is reasonable to speculate: (1) that a handheld office-based device, a dermatoscenter, that can identify melanoma-induced volatile tumor markers shall be developed to evaluate whether pigmented lesions are malignant or benign, and (2) that this device will eventually become an integral component of the dermatologist’s diagnostic armamentarium. Does your dermatology center need a dermatoscenter?

We want to know your views! Tell us what you think.

There are anecdotal reports of dogs detecting melanoma and studies of canines being able to not only detect but also distinguish cancer from noncancer. Analysis of volatile compounds or metabolites from exhaled human breath and excreted urine also has been shown to differentiate between patients with certain cancers and healthy individuals. In addition, investigators have demonstrated that melanoma tissue has a volatile profile that is distinct from healthy nonneoplastic skin and nevi.

Abaffy et al (Metabolomics. 2013;9:998-1008) conducted a study that gives further support to the potential for analyzing volatile organic compounds as biomarkers of melanoma. They used the headspace solid phase microextraction method followed by gas chromatography and mass spectrometry to compare the volatile metabolic profiles of melanoma and nonneoplastic healthy-appearing adjacent skin from the same patient. They discovered increased levels of lauric acid (C12:0) and palmitic acid (C16:0) in melanoma and they postulated that the increased levels of these fatty acids were due to cancer-associated upregulation of de novo lipid synthesis.

What’s the issue?

In the 1980s, nail fold capillary microscopy using an ophthalmoscope was occasionally performed to evaluate for disease-associated vascular changes in patients who were being evaluated for connective tissue disorders. Within 2 decades, a dermoscope to assist in the evaluation of not only nail folds but also pigmented and other lesions replaced the ophthalmoscope. The US Food and Drug Administration recently approved a software-driven optical imaging and data analysis device that can be used to obtain additional information to assist the clinician in making a decision whether to biopsy a pigmented lesion.

As our ability to develop more sensitive and specific methods to diagnose melanoma and differentiate it from benign lesions advances, our approach to the evaluation of patients with pigmented lesions shall continue to be modified. Based on the detection of melanoma-associated volatile organic compounds coupled with their potential use as readily accessible tumor-related biomarkers, it is reasonable to speculate: (1) that a handheld office-based device, a dermatoscenter, that can identify melanoma-induced volatile tumor markers shall be developed to evaluate whether pigmented lesions are malignant or benign, and (2) that this device will eventually become an integral component of the dermatologist’s diagnostic armamentarium. Does your dermatology center need a dermatoscenter?

We want to know your views! Tell us what you think.

In summer 2014, the US Food and Drug Administration (FDA) approved 2 new topical medications for onychomycosis. In recent months, the Journal of Clinical and Aesthetic Dermatology (2014;7:10-18) and Medscape provided review materials to assist in sifting through this topic. In summary, efinaconazole, a triazole antifungal in a 10% solution recommended for daily application for 48 weeks, exhibited 17.8% complete and 55.2% mycological cure rates compared to vehicle (5.5% and 16.9%, respectively). Tavaborole, an oxaborole antifungal in a 5% solution recommended for daily application for 48 weeks, displayed 9.1% complete and 35.9% mycological cure rates versus vehicle (1.5% and 12.2%, respectively). To complete the discussion, ciclopirox nail lacquer, FDA approved in 1999 for onychomycosis for daily application for 48 weeks, heralded 8.5% complete and 36% mycological cure rates compared to vehicle (0% and 9%, respectively). Ciclopirox requires nail debridement periodically, and the newer agents do not.

What’s the issue?

Do you agree that nary a day goes by without an e-mailed article or continuing medical education opportunity tasked at “getting to know” new topical onychomycosis therapies? That being said, how often have you summarily deleted them, assuming that topicals just don’t work? I know I have, though I paused this week after thinking to myself, “How often have I written a prescription for ciclopirox nail lacquer to appease a patient who would prefer nonsystemic therapy?” And then I read on. Based on the data above, perhaps these medications, particularly efinaconazole, at least deserve perusal compared to our current meager topical and systemic options. What has your experience been with these novel topicals, their insurance coverage, and their tolerability and efficacy in your practice?

We want to know your views! Tell us what you think.

In summer 2014, the US Food and Drug Administration (FDA) approved 2 new topical medications for onychomycosis. In recent months, the Journal of Clinical and Aesthetic Dermatology (2014;7:10-18) and Medscape provided review materials to assist in sifting through this topic. In summary, efinaconazole, a triazole antifungal in a 10% solution recommended for daily application for 48 weeks, exhibited 17.8% complete and 55.2% mycological cure rates compared to vehicle (5.5% and 16.9%, respectively). Tavaborole, an oxaborole antifungal in a 5% solution recommended for daily application for 48 weeks, displayed 9.1% complete and 35.9% mycological cure rates versus vehicle (1.5% and 12.2%, respectively). To complete the discussion, ciclopirox nail lacquer, FDA approved in 1999 for onychomycosis for daily application for 48 weeks, heralded 8.5% complete and 36% mycological cure rates compared to vehicle (0% and 9%, respectively). Ciclopirox requires nail debridement periodically, and the newer agents do not.

What’s the issue?

Do you agree that nary a day goes by without an e-mailed article or continuing medical education opportunity tasked at “getting to know” new topical onychomycosis therapies? That being said, how often have you summarily deleted them, assuming that topicals just don’t work? I know I have, though I paused this week after thinking to myself, “How often have I written a prescription for ciclopirox nail lacquer to appease a patient who would prefer nonsystemic therapy?” And then I read on. Based on the data above, perhaps these medications, particularly efinaconazole, at least deserve perusal compared to our current meager topical and systemic options. What has your experience been with these novel topicals, their insurance coverage, and their tolerability and efficacy in your practice?

We want to know your views! Tell us what you think.

In summer 2014, the US Food and Drug Administration (FDA) approved 2 new topical medications for onychomycosis. In recent months, the Journal of Clinical and Aesthetic Dermatology (2014;7:10-18) and Medscape provided review materials to assist in sifting through this topic. In summary, efinaconazole, a triazole antifungal in a 10% solution recommended for daily application for 48 weeks, exhibited 17.8% complete and 55.2% mycological cure rates compared to vehicle (5.5% and 16.9%, respectively). Tavaborole, an oxaborole antifungal in a 5% solution recommended for daily application for 48 weeks, displayed 9.1% complete and 35.9% mycological cure rates versus vehicle (1.5% and 12.2%, respectively). To complete the discussion, ciclopirox nail lacquer, FDA approved in 1999 for onychomycosis for daily application for 48 weeks, heralded 8.5% complete and 36% mycological cure rates compared to vehicle (0% and 9%, respectively). Ciclopirox requires nail debridement periodically, and the newer agents do not.

What’s the issue?

Do you agree that nary a day goes by without an e-mailed article or continuing medical education opportunity tasked at “getting to know” new topical onychomycosis therapies? That being said, how often have you summarily deleted them, assuming that topicals just don’t work? I know I have, though I paused this week after thinking to myself, “How often have I written a prescription for ciclopirox nail lacquer to appease a patient who would prefer nonsystemic therapy?” And then I read on. Based on the data above, perhaps these medications, particularly efinaconazole, at least deserve perusal compared to our current meager topical and systemic options. What has your experience been with these novel topicals, their insurance coverage, and their tolerability and efficacy in your practice?

We want to know your views! Tell us what you think.

Over the last several years, we have come to understand that patients with inflammatory diseases may be at higher risk for major adverse cardiovascular events (MACEs) and cardiovascular death. In an article published online on October 28 in the Annals of the Rheumatic Diseases, Ogdie et al reported on a study of the risk for MACEs among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), and psoriasis without known PsA compared with the general population after adjusting for traditional cardiovascular risk factors.

The authors performed a population-based longitudinal cohort study (1994-2010) in The Health Improvement Network (THIN), a primary care medical record database in the United Kingdom. Patients aged 18 to 89 years with the applicable diagnoses were included. Up to 10 unexposed controls were selected for each patient with PsA, matched on practice and index date.

The study outcomes included the following: cardiovascular death, myocardial infarction, cerebrovascular accidents, and the composite outcome (MACE). Cox proportional hazards models were utilized to calculate the hazard ratios (HRs) for each of the outcomes after adjusting for traditional risk factors. The authors’ preliminary hypothesis was that there was an interaction between disease status and disease-modifying antirheumatic drug (DMARD) use.

In the analysis, the authors identified individuals with PsA (N=8706), RA (N=41,752), psoriasis (N=138,424), and unexposed controls (N=81,573). After adjusting for traditional risk factors, the risk for MACE was higher in the following populations: patients with PsA not prescribed a DMARD (HR, 1.24; 95% confidence interval [CI], 1.03-1.49), patients with RA (no DMARD: HR, 1.39; 95% CI, 1.28-1.50; DMARD: HR, 1.58; 95% CI, 1.46-1.70), patients with psoriasis not prescribed a DMARD (HR, 1.08; 95% CI, 1.02-1.15), and patients with severe psoriasis (DMARD: HR, 1.42; 95% CI, 1.17-1.73).

The authors concluded that cardiovascular risk should be addressed with all patients affected by psoriasis, PsA, or RA. These results suggest the need for improved screening and management of traditional cardiovascular risk factors in patients with inflammatory diseases.

What’s the issue?

Although there has been literature on MACE in these diseases, existing studies have not examined the risk for incident MACE including myocardial infarction, cerebrovascular accidents, and cardiovascular death in PsA compared with matched internal controls from a population-based perspective after accounting for the presence of traditional cardiovascular risk factors. This study is an additional piece of evidence that supports the need for comprehensive management of these patients. How do you currently address the concern for MACE?

We want to know your views! Tell us what you think.

Over the last several years, we have come to understand that patients with inflammatory diseases may be at higher risk for major adverse cardiovascular events (MACEs) and cardiovascular death. In an article published online on October 28 in the Annals of the Rheumatic Diseases, Ogdie et al reported on a study of the risk for MACEs among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), and psoriasis without known PsA compared with the general population after adjusting for traditional cardiovascular risk factors.

The authors performed a population-based longitudinal cohort study (1994-2010) in The Health Improvement Network (THIN), a primary care medical record database in the United Kingdom. Patients aged 18 to 89 years with the applicable diagnoses were included. Up to 10 unexposed controls were selected for each patient with PsA, matched on practice and index date.

The study outcomes included the following: cardiovascular death, myocardial infarction, cerebrovascular accidents, and the composite outcome (MACE). Cox proportional hazards models were utilized to calculate the hazard ratios (HRs) for each of the outcomes after adjusting for traditional risk factors. The authors’ preliminary hypothesis was that there was an interaction between disease status and disease-modifying antirheumatic drug (DMARD) use.

In the analysis, the authors identified individuals with PsA (N=8706), RA (N=41,752), psoriasis (N=138,424), and unexposed controls (N=81,573). After adjusting for traditional risk factors, the risk for MACE was higher in the following populations: patients with PsA not prescribed a DMARD (HR, 1.24; 95% confidence interval [CI], 1.03-1.49), patients with RA (no DMARD: HR, 1.39; 95% CI, 1.28-1.50; DMARD: HR, 1.58; 95% CI, 1.46-1.70), patients with psoriasis not prescribed a DMARD (HR, 1.08; 95% CI, 1.02-1.15), and patients with severe psoriasis (DMARD: HR, 1.42; 95% CI, 1.17-1.73).

The authors concluded that cardiovascular risk should be addressed with all patients affected by psoriasis, PsA, or RA. These results suggest the need for improved screening and management of traditional cardiovascular risk factors in patients with inflammatory diseases.

What’s the issue?

Although there has been literature on MACE in these diseases, existing studies have not examined the risk for incident MACE including myocardial infarction, cerebrovascular accidents, and cardiovascular death in PsA compared with matched internal controls from a population-based perspective after accounting for the presence of traditional cardiovascular risk factors. This study is an additional piece of evidence that supports the need for comprehensive management of these patients. How do you currently address the concern for MACE?

We want to know your views! Tell us what you think.

Over the last several years, we have come to understand that patients with inflammatory diseases may be at higher risk for major adverse cardiovascular events (MACEs) and cardiovascular death. In an article published online on October 28 in the Annals of the Rheumatic Diseases, Ogdie et al reported on a study of the risk for MACEs among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), and psoriasis without known PsA compared with the general population after adjusting for traditional cardiovascular risk factors.

The authors performed a population-based longitudinal cohort study (1994-2010) in The Health Improvement Network (THIN), a primary care medical record database in the United Kingdom. Patients aged 18 to 89 years with the applicable diagnoses were included. Up to 10 unexposed controls were selected for each patient with PsA, matched on practice and index date.

The study outcomes included the following: cardiovascular death, myocardial infarction, cerebrovascular accidents, and the composite outcome (MACE). Cox proportional hazards models were utilized to calculate the hazard ratios (HRs) for each of the outcomes after adjusting for traditional risk factors. The authors’ preliminary hypothesis was that there was an interaction between disease status and disease-modifying antirheumatic drug (DMARD) use.

In the analysis, the authors identified individuals with PsA (N=8706), RA (N=41,752), psoriasis (N=138,424), and unexposed controls (N=81,573). After adjusting for traditional risk factors, the risk for MACE was higher in the following populations: patients with PsA not prescribed a DMARD (HR, 1.24; 95% confidence interval [CI], 1.03-1.49), patients with RA (no DMARD: HR, 1.39; 95% CI, 1.28-1.50; DMARD: HR, 1.58; 95% CI, 1.46-1.70), patients with psoriasis not prescribed a DMARD (HR, 1.08; 95% CI, 1.02-1.15), and patients with severe psoriasis (DMARD: HR, 1.42; 95% CI, 1.17-1.73).

The authors concluded that cardiovascular risk should be addressed with all patients affected by psoriasis, PsA, or RA. These results suggest the need for improved screening and management of traditional cardiovascular risk factors in patients with inflammatory diseases.

What’s the issue?

Although there has been literature on MACE in these diseases, existing studies have not examined the risk for incident MACE including myocardial infarction, cerebrovascular accidents, and cardiovascular death in PsA compared with matched internal controls from a population-based perspective after accounting for the presence of traditional cardiovascular risk factors. This study is an additional piece of evidence that supports the need for comprehensive management of these patients. How do you currently address the concern for MACE?

We want to know your views! Tell us what you think.