Bruce Jancin

SNOWMASS, COLO. – It’s now confirmed: obesity in psoriasis patients is a major independent risk factor for psoriatic arthritis.

This finding is actually good news. It opens the door to the potential prevention of psoriatic arthritis (PsA) through weight loss. Many psoriasis patients are obese and have the metabolic syndrome. And since a decade goes by on average between onset of psoriasis and development of joint disease, the prospect of a lowered risk of PsA could be a powerful motivator for heavy psoriasis patients to shed pounds, according to Dr. Christopher T. Ritchlin, professor of medicine and director of the Translational Immunology Research Center at the University of Rochester (N.Y.).

That being said, it must be noted that there is as yet no solid evidence that weight loss actually lowers a psoriasis patient’s risk of developing PsA. A few studies are looking into whether weight loss makes a difference, but these investigations have been hampered – no surprise – by difficulty in getting patients to achieve and maintain significant weight loss, the rheumatologist noted.

Obesity is an established risk factor for psoriasis. The possibility that obesity among psoriasis patients is also a risk factor for PsA was raised in a study by investigators with the Utah Psoriasis Initiative, who found that self-reported increased body mass index (BMI) at age 18 years was associated with greater risk of PsA (Arch. Dermatol. 2010;146:721-6).

The Utah finding that greater obesity contributes to an increased risk of PsA has since been confirmed in an impressively large cohort study using data from The Health Improvement Network (THIN), a general practice electronic medical records database that includes more than 7.5 million U.K. patients. THIN is a newer database that is separate from the renowned U.K. General Practice Research Database, which has generated key findings on psoriasis as an independent cardiovascular risk factor.

At last year’s annual meeting of the American College of Rheumatology, THIN investigators reported that among 75,395 THIN enrollees with psoriasis followed for a mean of 5 years, 976 developed PsA.

The incidence of PsA was 23.09 cases/10,000 person-years in subjects whose first BMI measurement after diagnosis of psoriasis showed a BMI of less than 25 kg/m². The incidence climbed stepwise with increasing BMI. Among subjects with a BMI of 25-29.9 kg/m², the incidence was 25.37 cases/10,000 person-years. For those with a BMI of 30-34.9 kg/m², it was 29.33 cases/10,000, while in those with a BMI of 35 kg/m² or more the incidence of PsA was 38.04 cases/10,000.

In a multivariate analysis adjusted for potential confounders, the risk of developing PsA was 12% higher in subjects with a BMI of 25-29.9 than in those with a BMI below 25 kg/m², 46% greater in those with a BMI of 30-34.9 kg/m², and 75% higher in subjects with a BMI of 35 kg/m² or more.

Dr. Ritchlin noted that a separate THIN analysis recently demonstrated that the prevalence of PsA climbs dramatically with more extensive psoriasis independent of other risk factors. This analysis included 4,539 middle-aged psoriasis patients. The overall prevalence of PsA was 8.4%. The lifetime prevalence of PsA was 4.5% among patients whose psoriasis involved 2% or less of their body surface area (BSA), 9.3% among those with 3%-10% BSA involvement, and 22.1% in subjects whose psoriasis affected more than 10% of their BSA.

"I know you’re all going to say, ‘Wait a minute, I have patients who have almost no psoriasis and yet have psoriatic arthritis.’ That’s very true. I have the same experience. But if you look at population-based data, the more severe your psoriasis, the more likely you are to get psoriatic arthritis," the rheumatologist declared.

He reported serving as a consultant to Abbott, Amgen, Centocor, Genentech, Targacept, UCB, and Wyeth and receiving research funding from multiple sources.

SNOWMASS, COLO. – It’s now confirmed: obesity in psoriasis patients is a major independent risk factor for psoriatic arthritis.

This finding is actually good news. It opens the door to the potential prevention of psoriatic arthritis (PsA) through weight loss. Many psoriasis patients are obese and have the metabolic syndrome. And since a decade goes by on average between onset of psoriasis and development of joint disease, the prospect of a lowered risk of PsA could be a powerful motivator for heavy psoriasis patients to shed pounds, according to Dr. Christopher T. Ritchlin, professor of medicine and director of the Translational Immunology Research Center at the University of Rochester (N.Y.).

That being said, it must be noted that there is as yet no solid evidence that weight loss actually lowers a psoriasis patient’s risk of developing PsA. A few studies are looking into whether weight loss makes a difference, but these investigations have been hampered – no surprise – by difficulty in getting patients to achieve and maintain significant weight loss, the rheumatologist noted.

Obesity is an established risk factor for psoriasis. The possibility that obesity among psoriasis patients is also a risk factor for PsA was raised in a study by investigators with the Utah Psoriasis Initiative, who found that self-reported increased body mass index (BMI) at age 18 years was associated with greater risk of PsA (Arch. Dermatol. 2010;146:721-6).

The Utah finding that greater obesity contributes to an increased risk of PsA has since been confirmed in an impressively large cohort study using data from The Health Improvement Network (THIN), a general practice electronic medical records database that includes more than 7.5 million U.K. patients. THIN is a newer database that is separate from the renowned U.K. General Practice Research Database, which has generated key findings on psoriasis as an independent cardiovascular risk factor.

At last year’s annual meeting of the American College of Rheumatology, THIN investigators reported that among 75,395 THIN enrollees with psoriasis followed for a mean of 5 years, 976 developed PsA.

The incidence of PsA was 23.09 cases/10,000 person-years in subjects whose first BMI measurement after diagnosis of psoriasis showed a BMI of less than 25 kg/m². The incidence climbed stepwise with increasing BMI. Among subjects with a BMI of 25-29.9 kg/m², the incidence was 25.37 cases/10,000 person-years. For those with a BMI of 30-34.9 kg/m², it was 29.33 cases/10,000, while in those with a BMI of 35 kg/m² or more the incidence of PsA was 38.04 cases/10,000.

In a multivariate analysis adjusted for potential confounders, the risk of developing PsA was 12% higher in subjects with a BMI of 25-29.9 than in those with a BMI below 25 kg/m², 46% greater in those with a BMI of 30-34.9 kg/m², and 75% higher in subjects with a BMI of 35 kg/m² or more.

Dr. Ritchlin noted that a separate THIN analysis recently demonstrated that the prevalence of PsA climbs dramatically with more extensive psoriasis independent of other risk factors. This analysis included 4,539 middle-aged psoriasis patients. The overall prevalence of PsA was 8.4%. The lifetime prevalence of PsA was 4.5% among patients whose psoriasis involved 2% or less of their body surface area (BSA), 9.3% among those with 3%-10% BSA involvement, and 22.1% in subjects whose psoriasis affected more than 10% of their BSA.

"I know you’re all going to say, ‘Wait a minute, I have patients who have almost no psoriasis and yet have psoriatic arthritis.’ That’s very true. I have the same experience. But if you look at population-based data, the more severe your psoriasis, the more likely you are to get psoriatic arthritis," the rheumatologist declared.

He reported serving as a consultant to Abbott, Amgen, Centocor, Genentech, Targacept, UCB, and Wyeth and receiving research funding from multiple sources.

SNOWMASS, COLO. – It’s now confirmed: obesity in psoriasis patients is a major independent risk factor for psoriatic arthritis.

This finding is actually good news. It opens the door to the potential prevention of psoriatic arthritis (PsA) through weight loss. Many psoriasis patients are obese and have the metabolic syndrome. And since a decade goes by on average between onset of psoriasis and development of joint disease, the prospect of a lowered risk of PsA could be a powerful motivator for heavy psoriasis patients to shed pounds, according to Dr. Christopher T. Ritchlin, professor of medicine and director of the Translational Immunology Research Center at the University of Rochester (N.Y.).

That being said, it must be noted that there is as yet no solid evidence that weight loss actually lowers a psoriasis patient’s risk of developing PsA. A few studies are looking into whether weight loss makes a difference, but these investigations have been hampered – no surprise – by difficulty in getting patients to achieve and maintain significant weight loss, the rheumatologist noted.

Obesity is an established risk factor for psoriasis. The possibility that obesity among psoriasis patients is also a risk factor for PsA was raised in a study by investigators with the Utah Psoriasis Initiative, who found that self-reported increased body mass index (BMI) at age 18 years was associated with greater risk of PsA (Arch. Dermatol. 2010;146:721-6).

The Utah finding that greater obesity contributes to an increased risk of PsA has since been confirmed in an impressively large cohort study using data from The Health Improvement Network (THIN), a general practice electronic medical records database that includes more than 7.5 million U.K. patients. THIN is a newer database that is separate from the renowned U.K. General Practice Research Database, which has generated key findings on psoriasis as an independent cardiovascular risk factor.

At last year’s annual meeting of the American College of Rheumatology, THIN investigators reported that among 75,395 THIN enrollees with psoriasis followed for a mean of 5 years, 976 developed PsA.

The incidence of PsA was 23.09 cases/10,000 person-years in subjects whose first BMI measurement after diagnosis of psoriasis showed a BMI of less than 25 kg/m². The incidence climbed stepwise with increasing BMI. Among subjects with a BMI of 25-29.9 kg/m², the incidence was 25.37 cases/10,000 person-years. For those with a BMI of 30-34.9 kg/m², it was 29.33 cases/10,000, while in those with a BMI of 35 kg/m² or more the incidence of PsA was 38.04 cases/10,000.

In a multivariate analysis adjusted for potential confounders, the risk of developing PsA was 12% higher in subjects with a BMI of 25-29.9 than in those with a BMI below 25 kg/m², 46% greater in those with a BMI of 30-34.9 kg/m², and 75% higher in subjects with a BMI of 35 kg/m² or more.

Dr. Ritchlin noted that a separate THIN analysis recently demonstrated that the prevalence of PsA climbs dramatically with more extensive psoriasis independent of other risk factors. This analysis included 4,539 middle-aged psoriasis patients. The overall prevalence of PsA was 8.4%. The lifetime prevalence of PsA was 4.5% among patients whose psoriasis involved 2% or less of their body surface area (BSA), 9.3% among those with 3%-10% BSA involvement, and 22.1% in subjects whose psoriasis affected more than 10% of their BSA.

"I know you’re all going to say, ‘Wait a minute, I have patients who have almost no psoriasis and yet have psoriatic arthritis.’ That’s very true. I have the same experience. But if you look at population-based data, the more severe your psoriasis, the more likely you are to get psoriatic arthritis," the rheumatologist declared.

He reported serving as a consultant to Abbott, Amgen, Centocor, Genentech, Targacept, UCB, and Wyeth and receiving research funding from multiple sources.

WAIKOLOA, HAWAII – Using EMLA or lidocaine cream in conjunction with topical 5-aminolevulinic acid photodynamic therapy may boost uptake of the photosensitizer, but the clinical outcomes can be unpredictable, according to Dr. E. Victor Ross.

"Our worst scenarios have been when we’ve used EMLA on the skin. We’ve stopped using EMLA or lidocaine cream on the skin in ALA-PDT because of the very pronounced, enhanced photodynamic effects. You get great long-term results, but such a bad short-term result that lots of people didn’t want to go through it," said Dr. Ross of Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, Calif.

Bruce Jancin/Elsevier Global Medical News

Using a topical numbing agent seemed to be an attractive option because patients often complain that photodynamic therapy (PDT) is painful. Plus, there seemed to be an added benefit: The anesthetic cream increased aminolevulanic acid (ALA) uptake by the skin, such that ALA incubation times before application of the light source could be greatly compressed. But clinical outcomes were too unpredictable, he said at the seminar sponsored by Skin Disease Education Foundation (SDEF). After several patients had unintended florid full photopeels involving 1½ weeks of downtime, it was time to abandon the practice.

When ALA-PDT first appeared about 10 years ago, the indication was for the treatment of actinic keratoses (AKs). Today this approved indication remains the No. 1 reason Dr. Ross utilizes the therapy, he said. But PDT’s role has expanded off label to include cosmetic procedures and the treatment of warts, nonmelanoma skin cancer, nevus sebaceous, as well as acne, which he considers "one of the great opportunities for PDT." In addition, in Asia, dermatologists are now refining the use of PDT with hematoporphyrin derivatives for the treatment of port wine stains and other vascular lesions.

Many U.S. dermatologists have incorporated PDT into their practices, with ALA being more widely used as a photosensitizer than methyl aminolevulinate (MAL). Yet PDT is a therapy that hasn’t been fully optimized; it is still fraught with side effects and suboptimal results, he said. Moreover, some fundamental issues regarding PDT remain unanswered: For example, the optimal duration of photosensitizer incubation time for various indications is still controversial.

Dr. Ross said he opts for what he considers a middle-of-the-road approach, with ALA application times of about 90-120 minutes, which he views as having an optimal balance between side effects and effectiveness. Even so, he noted that among the 8-10 patients per week he treats with ALA-PDT on average, 1 or 2 experience mild side effects.

"I don’t think we’re quite ‘there’ yet with PDT, although we’re getting closer. There are still so many tricks involved in making it work without side effects. We’ve still got some work to do," he said.

In addition to advising his colleagues to stay away from topical anesthetic creams, he offered additional tips for the use of ALA-PDT. Among them:

• Sending acne into long-term remission via PDT remains the Holy Grail, he said. The objective is to enhance the fluorescence of protoporphyrin 9 at the sebaceous gland while sparing the epidermis.

Some investigators are using low-intensity blue light at the skin surface while the photosensitizer is incubating in order to bleach it out of the epidermis, or, alternatively, warming and cooling the skin.

The best results Dr. Ross said he has seen have come through an arduous regimen involving three 3-hour-long ALA applications scheduled a month apart. There’s a delayed effect, with significant improvement coming at 3-6 months.

"It’s a tough, tough therapy to get through. There are lots of pustules and papules, and the acne invariably gets worse before it gets better. This doesn’t play into the hands of the typical teenager, who wants to get better right away," Dr. Ross said.

• A creamy solution of ALA will create more protoporphyrin 9 than an aqueous solution will.

• A red light source should be considered for deeper structures, such as basal cell carcinomas or sebaceous glands, and blue light for treating more superficial skin lesions. Although continuous blue light is 40 times more potent per photon than red light in exciting protoporphyrin 9, it doesn’t penetrate as deeply.

• Performing low-density fractional CO₂ ablative laser therapy prior to application of the photosensitizing agent is "an exciting advance" in PDT, he said.

The innovation was developed by an international team led by investigators at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, who published a split-face randomized study involving 15 patients with a total of 212 facial AKs. At the 3-month follow-up, the complete response rate of grade II-III lesions treated with MAL-PDT preceded by fractional ablative laser therapy was 87.5%, vs. 58.8% with conventional MAL-PDT. The complete response rate of grade I AKs was 100% with fractional laser/MAL-PDT, vs. 79% for MAL-PDT alone.

The fractional laser–pretreated areas also displayed significantly greater improvement in photoaging and fewer new AKs at follow-up: 3, compared with 11. But these superior outcomes came at a price: higher pain scores during illumination and significantly worse erythema and crusting post treatment (Br. J. Dermatol. 2012 Feb. 20 [doi:10.1111/j.1365-2133.2012.10893.x]).

Fractional CO₂ laser pretreatment enhances conversion of the photosensitizing agent to protoporphyrin 9, Dr. Ross explained. He compared the tiny holes in the skin created by the fractional laser to the process of aerating a lawn. The holes create conduits for the photosensitizer to bypass the stratum corneum, which is the major obstacle to uptake of ALA or MAL. Once the photosensitizer skips past the stratum corneum, it quickly spreads laterally throughout the epidermis.

However, Dr. Ross offered a note of caution regarding this novel approach. He said that he performed the therapy recently and found that 30 minutes of ALA incubation was too much.

"If you do these procedures, I would say go very light and just leave the ALA for less than 30 minutes to start, because the response you’re going to get when using a fractional laser beforehand is profound. It’s a huge difference," he said.

Dr. Ross reported that he serves as a consultant to and receives research support from Palomar. He also disclosed receiving research support from Candela, Cutera, Lumenis, Sciton, and Ulthera.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Using EMLA or lidocaine cream in conjunction with topical 5-aminolevulinic acid photodynamic therapy may boost uptake of the photosensitizer, but the clinical outcomes can be unpredictable, according to Dr. E. Victor Ross.

"Our worst scenarios have been when we’ve used EMLA on the skin. We’ve stopped using EMLA or lidocaine cream on the skin in ALA-PDT because of the very pronounced, enhanced photodynamic effects. You get great long-term results, but such a bad short-term result that lots of people didn’t want to go through it," said Dr. Ross of Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, Calif.

Bruce Jancin/Elsevier Global Medical News

Using a topical numbing agent seemed to be an attractive option because patients often complain that photodynamic therapy (PDT) is painful. Plus, there seemed to be an added benefit: The anesthetic cream increased aminolevulanic acid (ALA) uptake by the skin, such that ALA incubation times before application of the light source could be greatly compressed. But clinical outcomes were too unpredictable, he said at the seminar sponsored by Skin Disease Education Foundation (SDEF). After several patients had unintended florid full photopeels involving 1½ weeks of downtime, it was time to abandon the practice.

When ALA-PDT first appeared about 10 years ago, the indication was for the treatment of actinic keratoses (AKs). Today this approved indication remains the No. 1 reason Dr. Ross utilizes the therapy, he said. But PDT’s role has expanded off label to include cosmetic procedures and the treatment of warts, nonmelanoma skin cancer, nevus sebaceous, as well as acne, which he considers "one of the great opportunities for PDT." In addition, in Asia, dermatologists are now refining the use of PDT with hematoporphyrin derivatives for the treatment of port wine stains and other vascular lesions.

Many U.S. dermatologists have incorporated PDT into their practices, with ALA being more widely used as a photosensitizer than methyl aminolevulinate (MAL). Yet PDT is a therapy that hasn’t been fully optimized; it is still fraught with side effects and suboptimal results, he said. Moreover, some fundamental issues regarding PDT remain unanswered: For example, the optimal duration of photosensitizer incubation time for various indications is still controversial.

Dr. Ross said he opts for what he considers a middle-of-the-road approach, with ALA application times of about 90-120 minutes, which he views as having an optimal balance between side effects and effectiveness. Even so, he noted that among the 8-10 patients per week he treats with ALA-PDT on average, 1 or 2 experience mild side effects.

"I don’t think we’re quite ‘there’ yet with PDT, although we’re getting closer. There are still so many tricks involved in making it work without side effects. We’ve still got some work to do," he said.

In addition to advising his colleagues to stay away from topical anesthetic creams, he offered additional tips for the use of ALA-PDT. Among them:

• Sending acne into long-term remission via PDT remains the Holy Grail, he said. The objective is to enhance the fluorescence of protoporphyrin 9 at the sebaceous gland while sparing the epidermis.

Some investigators are using low-intensity blue light at the skin surface while the photosensitizer is incubating in order to bleach it out of the epidermis, or, alternatively, warming and cooling the skin.

The best results Dr. Ross said he has seen have come through an arduous regimen involving three 3-hour-long ALA applications scheduled a month apart. There’s a delayed effect, with significant improvement coming at 3-6 months.

"It’s a tough, tough therapy to get through. There are lots of pustules and papules, and the acne invariably gets worse before it gets better. This doesn’t play into the hands of the typical teenager, who wants to get better right away," Dr. Ross said.

• A creamy solution of ALA will create more protoporphyrin 9 than an aqueous solution will.

• A red light source should be considered for deeper structures, such as basal cell carcinomas or sebaceous glands, and blue light for treating more superficial skin lesions. Although continuous blue light is 40 times more potent per photon than red light in exciting protoporphyrin 9, it doesn’t penetrate as deeply.

• Performing low-density fractional CO₂ ablative laser therapy prior to application of the photosensitizing agent is "an exciting advance" in PDT, he said.

The innovation was developed by an international team led by investigators at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, who published a split-face randomized study involving 15 patients with a total of 212 facial AKs. At the 3-month follow-up, the complete response rate of grade II-III lesions treated with MAL-PDT preceded by fractional ablative laser therapy was 87.5%, vs. 58.8% with conventional MAL-PDT. The complete response rate of grade I AKs was 100% with fractional laser/MAL-PDT, vs. 79% for MAL-PDT alone.

The fractional laser–pretreated areas also displayed significantly greater improvement in photoaging and fewer new AKs at follow-up: 3, compared with 11. But these superior outcomes came at a price: higher pain scores during illumination and significantly worse erythema and crusting post treatment (Br. J. Dermatol. 2012 Feb. 20 [doi:10.1111/j.1365-2133.2012.10893.x]).

Fractional CO₂ laser pretreatment enhances conversion of the photosensitizing agent to protoporphyrin 9, Dr. Ross explained. He compared the tiny holes in the skin created by the fractional laser to the process of aerating a lawn. The holes create conduits for the photosensitizer to bypass the stratum corneum, which is the major obstacle to uptake of ALA or MAL. Once the photosensitizer skips past the stratum corneum, it quickly spreads laterally throughout the epidermis.

However, Dr. Ross offered a note of caution regarding this novel approach. He said that he performed the therapy recently and found that 30 minutes of ALA incubation was too much.

"If you do these procedures, I would say go very light and just leave the ALA for less than 30 minutes to start, because the response you’re going to get when using a fractional laser beforehand is profound. It’s a huge difference," he said.

Dr. Ross reported that he serves as a consultant to and receives research support from Palomar. He also disclosed receiving research support from Candela, Cutera, Lumenis, Sciton, and Ulthera.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Using EMLA or lidocaine cream in conjunction with topical 5-aminolevulinic acid photodynamic therapy may boost uptake of the photosensitizer, but the clinical outcomes can be unpredictable, according to Dr. E. Victor Ross.

"Our worst scenarios have been when we’ve used EMLA on the skin. We’ve stopped using EMLA or lidocaine cream on the skin in ALA-PDT because of the very pronounced, enhanced photodynamic effects. You get great long-term results, but such a bad short-term result that lots of people didn’t want to go through it," said Dr. Ross of Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, Calif.

Bruce Jancin/Elsevier Global Medical News

Using a topical numbing agent seemed to be an attractive option because patients often complain that photodynamic therapy (PDT) is painful. Plus, there seemed to be an added benefit: The anesthetic cream increased aminolevulanic acid (ALA) uptake by the skin, such that ALA incubation times before application of the light source could be greatly compressed. But clinical outcomes were too unpredictable, he said at the seminar sponsored by Skin Disease Education Foundation (SDEF). After several patients had unintended florid full photopeels involving 1½ weeks of downtime, it was time to abandon the practice.

When ALA-PDT first appeared about 10 years ago, the indication was for the treatment of actinic keratoses (AKs). Today this approved indication remains the No. 1 reason Dr. Ross utilizes the therapy, he said. But PDT’s role has expanded off label to include cosmetic procedures and the treatment of warts, nonmelanoma skin cancer, nevus sebaceous, as well as acne, which he considers "one of the great opportunities for PDT." In addition, in Asia, dermatologists are now refining the use of PDT with hematoporphyrin derivatives for the treatment of port wine stains and other vascular lesions.

Many U.S. dermatologists have incorporated PDT into their practices, with ALA being more widely used as a photosensitizer than methyl aminolevulinate (MAL). Yet PDT is a therapy that hasn’t been fully optimized; it is still fraught with side effects and suboptimal results, he said. Moreover, some fundamental issues regarding PDT remain unanswered: For example, the optimal duration of photosensitizer incubation time for various indications is still controversial.

Dr. Ross said he opts for what he considers a middle-of-the-road approach, with ALA application times of about 90-120 minutes, which he views as having an optimal balance between side effects and effectiveness. Even so, he noted that among the 8-10 patients per week he treats with ALA-PDT on average, 1 or 2 experience mild side effects.

"I don’t think we’re quite ‘there’ yet with PDT, although we’re getting closer. There are still so many tricks involved in making it work without side effects. We’ve still got some work to do," he said.

In addition to advising his colleagues to stay away from topical anesthetic creams, he offered additional tips for the use of ALA-PDT. Among them:

• Sending acne into long-term remission via PDT remains the Holy Grail, he said. The objective is to enhance the fluorescence of protoporphyrin 9 at the sebaceous gland while sparing the epidermis.

Some investigators are using low-intensity blue light at the skin surface while the photosensitizer is incubating in order to bleach it out of the epidermis, or, alternatively, warming and cooling the skin.

The best results Dr. Ross said he has seen have come through an arduous regimen involving three 3-hour-long ALA applications scheduled a month apart. There’s a delayed effect, with significant improvement coming at 3-6 months.

"It’s a tough, tough therapy to get through. There are lots of pustules and papules, and the acne invariably gets worse before it gets better. This doesn’t play into the hands of the typical teenager, who wants to get better right away," Dr. Ross said.

• A creamy solution of ALA will create more protoporphyrin 9 than an aqueous solution will.

• A red light source should be considered for deeper structures, such as basal cell carcinomas or sebaceous glands, and blue light for treating more superficial skin lesions. Although continuous blue light is 40 times more potent per photon than red light in exciting protoporphyrin 9, it doesn’t penetrate as deeply.

• Performing low-density fractional CO₂ ablative laser therapy prior to application of the photosensitizing agent is "an exciting advance" in PDT, he said.

The innovation was developed by an international team led by investigators at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, who published a split-face randomized study involving 15 patients with a total of 212 facial AKs. At the 3-month follow-up, the complete response rate of grade II-III lesions treated with MAL-PDT preceded by fractional ablative laser therapy was 87.5%, vs. 58.8% with conventional MAL-PDT. The complete response rate of grade I AKs was 100% with fractional laser/MAL-PDT, vs. 79% for MAL-PDT alone.

The fractional laser–pretreated areas also displayed significantly greater improvement in photoaging and fewer new AKs at follow-up: 3, compared with 11. But these superior outcomes came at a price: higher pain scores during illumination and significantly worse erythema and crusting post treatment (Br. J. Dermatol. 2012 Feb. 20 [doi:10.1111/j.1365-2133.2012.10893.x]).

Fractional CO₂ laser pretreatment enhances conversion of the photosensitizing agent to protoporphyrin 9, Dr. Ross explained. He compared the tiny holes in the skin created by the fractional laser to the process of aerating a lawn. The holes create conduits for the photosensitizer to bypass the stratum corneum, which is the major obstacle to uptake of ALA or MAL. Once the photosensitizer skips past the stratum corneum, it quickly spreads laterally throughout the epidermis.

However, Dr. Ross offered a note of caution regarding this novel approach. He said that he performed the therapy recently and found that 30 minutes of ALA incubation was too much.

"If you do these procedures, I would say go very light and just leave the ALA for less than 30 minutes to start, because the response you’re going to get when using a fractional laser beforehand is profound. It’s a huge difference," he said.

Dr. Ross reported that he serves as a consultant to and receives research support from Palomar. He also disclosed receiving research support from Candela, Cutera, Lumenis, Sciton, and Ulthera.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Mineral makeup has been game changing for everything from covering acne blemishes to masking postprocedure discoloration, noted Dr. Howard K. Steinman.

"Mineral makeup has done to medical makeup what fillers and Botox have done to the field of facial cosmetic surgery. You now have little excuse for not using makeup in your office," said Steinman, director of dermatologic and skin cancer surgery at Scott and White Medical Center, Temple, Texas.

Mineral makeup is easy for patients to learn how to apply effectively; anyone on the office staff can be trained to teach patients how, he said. The products take up a trivial amount of office space, cost very little, pose negligible risk, and generate considerable patient satisfaction.

Bruce Jancin/Elsevier Global Medical News

"Mineral makeup achieves really spectacular results," said Dr. Steinman at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Patients go to a dermatologist because they want cure or control of a medical condition, symptomatic relief, and an improved appearance. But while successful treatment of melasma, for example, may take months, the patient’s appearance can be improved immediately in the interim – on day 1 of therapy –through the use of mineral makeup.

Mineral makeup provides complete coverage for macular medical conditions including acne erythema, rosacea, vitiligo, sarcoidosis, port wine stains, and spider vessels. These products are also the answer to postprocedure discoloration following chemical peels, laser resurfacing, and fillers.

"It’s your fire extinguisher for procedural misadventures. The nice thing about having mineral makeups in your office is you don’t have to worry about these things as much because the problem is going to leave the office fixed," Dr. Steinman explained.

Green-tinted concealer is a popular but ineffective solution for red discoloration of skin. The results tend to be muddy looking and unconvincing. Mineral makeup, he said, is far superior.

Dr. Steinman singled out four companies as the major players in the mineral makeup market: Youngblood, Bare Minerals, Color Science, and Jane Iredale. All have been in business a long time, offer products of excellent quality, and provide reasonably good service to physicians, he said.

He prefers Youngblood in his own office because his wife, a paramedical camouflage therapist trained to cover burn scars and disfiguring surgical wounds, prefers the quality.

"My suggestion is to have your esthetician, or whoever will be doing your makeup, try them all and decide which one they prefer," said Dr. Steinman.

He also recommends Dermacolor (Kryolan), a specialized camouflage foundation system made in Germany that is formulated for postoperative skin and contains an opaque sunscreen. Unlike mineral makeup, Dermacolor is waterproof even with swimming. The company offers more than 70 premixed colors, although a selection of about 20 is sufficient to cover virtually any clinical situation, he said.

Dr. Steinman suggested that the makeup artist match the patient’s skin tones before surgery so Dermacolor is ready to be applied at the first postoperative visit.

Dr. Steinman said a relatively new comprehensive line of makeup products he recommends is Cover FX. The product texture and coverage are outstanding, it’s easy for patients to apply, and the company caters to physicians, he said.

Camouflage makeup does have limitations. It won’t effectively cover three-dimensional lesions, such as acne scars or keloids. And it can’t do much for burn scars with absent hair and skin pores, he noted.

That being said, Dr. Steinman considers makeup in the office an indispensable part of his practice. "Makeup is just essential, I think, if you’re going to do cosmetic surgery or you want to treat patients with medical macular problems," he said.

Dr. Steinman reported having no financial relationships with any of the companies he discussed.

SDEF and this news organization are owned by Elsevier.

^{*This post was updated on 3/7/12.}

WAIKOLOA, HAWAII – Mineral makeup has been game changing for everything from covering acne blemishes to masking postprocedure discoloration, noted Dr. Howard K. Steinman.

"Mineral makeup has done to medical makeup what fillers and Botox have done to the field of facial cosmetic surgery. You now have little excuse for not using makeup in your office," said Steinman, director of dermatologic and skin cancer surgery at Scott and White Medical Center, Temple, Texas.

Mineral makeup is easy for patients to learn how to apply effectively; anyone on the office staff can be trained to teach patients how, he said. The products take up a trivial amount of office space, cost very little, pose negligible risk, and generate considerable patient satisfaction.

Bruce Jancin/Elsevier Global Medical News

"Mineral makeup achieves really spectacular results," said Dr. Steinman at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Patients go to a dermatologist because they want cure or control of a medical condition, symptomatic relief, and an improved appearance. But while successful treatment of melasma, for example, may take months, the patient’s appearance can be improved immediately in the interim – on day 1 of therapy –through the use of mineral makeup.

Mineral makeup provides complete coverage for macular medical conditions including acne erythema, rosacea, vitiligo, sarcoidosis, port wine stains, and spider vessels. These products are also the answer to postprocedure discoloration following chemical peels, laser resurfacing, and fillers.

"It’s your fire extinguisher for procedural misadventures. The nice thing about having mineral makeups in your office is you don’t have to worry about these things as much because the problem is going to leave the office fixed," Dr. Steinman explained.

Green-tinted concealer is a popular but ineffective solution for red discoloration of skin. The results tend to be muddy looking and unconvincing. Mineral makeup, he said, is far superior.

Dr. Steinman singled out four companies as the major players in the mineral makeup market: Youngblood, Bare Minerals, Color Science, and Jane Iredale. All have been in business a long time, offer products of excellent quality, and provide reasonably good service to physicians, he said.

He prefers Youngblood in his own office because his wife, a paramedical camouflage therapist trained to cover burn scars and disfiguring surgical wounds, prefers the quality.

"My suggestion is to have your esthetician, or whoever will be doing your makeup, try them all and decide which one they prefer," said Dr. Steinman.

He also recommends Dermacolor (Kryolan), a specialized camouflage foundation system made in Germany that is formulated for postoperative skin and contains an opaque sunscreen. Unlike mineral makeup, Dermacolor is waterproof even with swimming. The company offers more than 70 premixed colors, although a selection of about 20 is sufficient to cover virtually any clinical situation, he said.

Dr. Steinman suggested that the makeup artist match the patient’s skin tones before surgery so Dermacolor is ready to be applied at the first postoperative visit.

Dr. Steinman said a relatively new comprehensive line of makeup products he recommends is Cover FX. The product texture and coverage are outstanding, it’s easy for patients to apply, and the company caters to physicians, he said.

Camouflage makeup does have limitations. It won’t effectively cover three-dimensional lesions, such as acne scars or keloids. And it can’t do much for burn scars with absent hair and skin pores, he noted.

That being said, Dr. Steinman considers makeup in the office an indispensable part of his practice. "Makeup is just essential, I think, if you’re going to do cosmetic surgery or you want to treat patients with medical macular problems," he said.

Dr. Steinman reported having no financial relationships with any of the companies he discussed.

SDEF and this news organization are owned by Elsevier.

^{*This post was updated on 3/7/12.}

WAIKOLOA, HAWAII – Mineral makeup has been game changing for everything from covering acne blemishes to masking postprocedure discoloration, noted Dr. Howard K. Steinman.

"Mineral makeup has done to medical makeup what fillers and Botox have done to the field of facial cosmetic surgery. You now have little excuse for not using makeup in your office," said Steinman, director of dermatologic and skin cancer surgery at Scott and White Medical Center, Temple, Texas.

Mineral makeup is easy for patients to learn how to apply effectively; anyone on the office staff can be trained to teach patients how, he said. The products take up a trivial amount of office space, cost very little, pose negligible risk, and generate considerable patient satisfaction.

Bruce Jancin/Elsevier Global Medical News

"Mineral makeup achieves really spectacular results," said Dr. Steinman at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Patients go to a dermatologist because they want cure or control of a medical condition, symptomatic relief, and an improved appearance. But while successful treatment of melasma, for example, may take months, the patient’s appearance can be improved immediately in the interim – on day 1 of therapy –through the use of mineral makeup.

Mineral makeup provides complete coverage for macular medical conditions including acne erythema, rosacea, vitiligo, sarcoidosis, port wine stains, and spider vessels. These products are also the answer to postprocedure discoloration following chemical peels, laser resurfacing, and fillers.

"It’s your fire extinguisher for procedural misadventures. The nice thing about having mineral makeups in your office is you don’t have to worry about these things as much because the problem is going to leave the office fixed," Dr. Steinman explained.

Green-tinted concealer is a popular but ineffective solution for red discoloration of skin. The results tend to be muddy looking and unconvincing. Mineral makeup, he said, is far superior.

Dr. Steinman singled out four companies as the major players in the mineral makeup market: Youngblood, Bare Minerals, Color Science, and Jane Iredale. All have been in business a long time, offer products of excellent quality, and provide reasonably good service to physicians, he said.

He prefers Youngblood in his own office because his wife, a paramedical camouflage therapist trained to cover burn scars and disfiguring surgical wounds, prefers the quality.

"My suggestion is to have your esthetician, or whoever will be doing your makeup, try them all and decide which one they prefer," said Dr. Steinman.

He also recommends Dermacolor (Kryolan), a specialized camouflage foundation system made in Germany that is formulated for postoperative skin and contains an opaque sunscreen. Unlike mineral makeup, Dermacolor is waterproof even with swimming. The company offers more than 70 premixed colors, although a selection of about 20 is sufficient to cover virtually any clinical situation, he said.

Dr. Steinman suggested that the makeup artist match the patient’s skin tones before surgery so Dermacolor is ready to be applied at the first postoperative visit.

Dr. Steinman said a relatively new comprehensive line of makeup products he recommends is Cover FX. The product texture and coverage are outstanding, it’s easy for patients to apply, and the company caters to physicians, he said.

Camouflage makeup does have limitations. It won’t effectively cover three-dimensional lesions, such as acne scars or keloids. And it can’t do much for burn scars with absent hair and skin pores, he noted.

That being said, Dr. Steinman considers makeup in the office an indispensable part of his practice. "Makeup is just essential, I think, if you’re going to do cosmetic surgery or you want to treat patients with medical macular problems," he said.

Dr. Steinman reported having no financial relationships with any of the companies he discussed.

SDEF and this news organization are owned by Elsevier.

^{*This post was updated on 3/7/12.}

WAIKOLOA, HAWAII – Oral aprepitant has shown considerable promise as a novel therapy in patients with refractory pruritus, including those with severe itching induced by biologic therapies for cancer.

"I think it’s a tool we should consider using in our patients with pruritus who do not respond to the usual measures," Dr. Mario E. Lacouture said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

BRUCE JANCIN/Elsevier Global Medical News

Aprepitant (Emend) is approved as an antiemetic agent for cancer patients undergoing chemotherapy. But a growing body of data, including two single-arm proof-of-concept studies, has shown a high response rate in patients with itching resistant to standard treatment, including corticosteroids, UV therapy, and antihistamines, noted Dr. Lacouture, a dermatologist at Memorial Sloan-Kettering Cancer Center, New York.

Severe itching is increasingly recognized as an important side effect of targeted biologic agents for cancer, including erlotinib (Tarceva) and cetuximab (Erbitux). At last year’s meeting of the American Society of Clinical Oncology, Dr. Daniele Santini and coworkers at the Università "Campus Bio-Medico" di Roma presented a study involving 22 patients with severe pruritus treated with aprepitant using a regimen of 125 mg on day 1 and 80 mg on days 3 and 5.

After the single 3-dose cycle of aprepitant, the patients’ median pruritus intensity plummeted from a baseline of 8 down to 1 on a 0-10 visual analog scale (VAS). Twenty of 22 patients experienced a greater than 50% reduction in pruritus. The median duration of benefit following a 3-dose cycle given over 5 days was 25 days.

In the second proof-of-concept study, dermatologists at the Westfälische Wilhelms-Universität Münster (Germany) reported on 20 patients with refractory chronic pruritus from nonmalignant underlying disorders placed on aprepitant at 80 mg/day for 1 week. Sixteen of the 20 patients experienced a marked reduction in itch intensity. From a baseline mean of 8.4 points on the VAS, the group as a whole averaged a 42% improvement to a post-treatment score of 4.3.

A significant reduction in itching was observed as early as 2 days after initiating aprepitant in the study population (PLoS One. 2010;5:e10968).

Patients with itching related to prurigo nodularis or atopic disease responded better than those without the conditions, and patients under age 60 obtained greater improvement than older patients. However, patients with chronic kidney disease as the underlying cause of their itching achieved only minimal benefit.

Side effects were confined to mild, non-treatment-limiting nausea, dizziness, and drowsiness in three patients.

Between the two proof-of-concept studies and smaller published case series, Dr. Lacouture said that he is aware of 63 reported patients with severe refractory pruritus, including 6 with Sézary syndrome and 2 with mycosis fungoides, who were treated with aprepitant on various dosing regimens. The result was an improvement from a mean baseline VAS of 8.4 to 2.3.

Aprepitant’s mechanism of benefit in cases of severe pruritus is believed to lie in the drug’s high affinity as an antagonist of neurokinin receptor 1, which is expressed in the skin and CNS, he explained. Substance P, an important mediator in the initiation and maintenance of pruritus, binds to this receptor.

Dry skin due to radiation therapy, chemotherapy, or cachexia is the most common cause of pruritus in oncology. But he added that pruritus is intrinsically often a prominent feature of a variety of paraneoplastic diseases and malignancies, and aprepitant is worthy of study in refractory cases.

Pruritic paraneoplastic dermatoses in which the skin findings are an indication of potential concurrent underlying malignancy include dermatomyositis, erythroderma, generalized granuloma annulare, and acrokeratosis paraneoplastica.

Hematologic malignancies where itch often figures prominently include Hodgkin’s disease, polycythemia vera, and Waldenström macroglobulinemia. The solid cancers most frequently accompanied by severe itching include malignancies of the brain, prostate, rectum, and vulva.

Dr. Lacouture reported serving as a consultant to more than a dozen pharmaceutical companies, although Merck, which markets aprepitant, is not among them.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Oral aprepitant has shown considerable promise as a novel therapy in patients with refractory pruritus, including those with severe itching induced by biologic therapies for cancer.

"I think it’s a tool we should consider using in our patients with pruritus who do not respond to the usual measures," Dr. Mario E. Lacouture said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

BRUCE JANCIN/Elsevier Global Medical News

Aprepitant (Emend) is approved as an antiemetic agent for cancer patients undergoing chemotherapy. But a growing body of data, including two single-arm proof-of-concept studies, has shown a high response rate in patients with itching resistant to standard treatment, including corticosteroids, UV therapy, and antihistamines, noted Dr. Lacouture, a dermatologist at Memorial Sloan-Kettering Cancer Center, New York.

Severe itching is increasingly recognized as an important side effect of targeted biologic agents for cancer, including erlotinib (Tarceva) and cetuximab (Erbitux). At last year’s meeting of the American Society of Clinical Oncology, Dr. Daniele Santini and coworkers at the Università "Campus Bio-Medico" di Roma presented a study involving 22 patients with severe pruritus treated with aprepitant using a regimen of 125 mg on day 1 and 80 mg on days 3 and 5.

After the single 3-dose cycle of aprepitant, the patients’ median pruritus intensity plummeted from a baseline of 8 down to 1 on a 0-10 visual analog scale (VAS). Twenty of 22 patients experienced a greater than 50% reduction in pruritus. The median duration of benefit following a 3-dose cycle given over 5 days was 25 days.

In the second proof-of-concept study, dermatologists at the Westfälische Wilhelms-Universität Münster (Germany) reported on 20 patients with refractory chronic pruritus from nonmalignant underlying disorders placed on aprepitant at 80 mg/day for 1 week. Sixteen of the 20 patients experienced a marked reduction in itch intensity. From a baseline mean of 8.4 points on the VAS, the group as a whole averaged a 42% improvement to a post-treatment score of 4.3.

A significant reduction in itching was observed as early as 2 days after initiating aprepitant in the study population (PLoS One. 2010;5:e10968).

Patients with itching related to prurigo nodularis or atopic disease responded better than those without the conditions, and patients under age 60 obtained greater improvement than older patients. However, patients with chronic kidney disease as the underlying cause of their itching achieved only minimal benefit.

Side effects were confined to mild, non-treatment-limiting nausea, dizziness, and drowsiness in three patients.

Between the two proof-of-concept studies and smaller published case series, Dr. Lacouture said that he is aware of 63 reported patients with severe refractory pruritus, including 6 with Sézary syndrome and 2 with mycosis fungoides, who were treated with aprepitant on various dosing regimens. The result was an improvement from a mean baseline VAS of 8.4 to 2.3.

Aprepitant’s mechanism of benefit in cases of severe pruritus is believed to lie in the drug’s high affinity as an antagonist of neurokinin receptor 1, which is expressed in the skin and CNS, he explained. Substance P, an important mediator in the initiation and maintenance of pruritus, binds to this receptor.

Dry skin due to radiation therapy, chemotherapy, or cachexia is the most common cause of pruritus in oncology. But he added that pruritus is intrinsically often a prominent feature of a variety of paraneoplastic diseases and malignancies, and aprepitant is worthy of study in refractory cases.

Pruritic paraneoplastic dermatoses in which the skin findings are an indication of potential concurrent underlying malignancy include dermatomyositis, erythroderma, generalized granuloma annulare, and acrokeratosis paraneoplastica.

Hematologic malignancies where itch often figures prominently include Hodgkin’s disease, polycythemia vera, and Waldenström macroglobulinemia. The solid cancers most frequently accompanied by severe itching include malignancies of the brain, prostate, rectum, and vulva.

Dr. Lacouture reported serving as a consultant to more than a dozen pharmaceutical companies, although Merck, which markets aprepitant, is not among them.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Oral aprepitant has shown considerable promise as a novel therapy in patients with refractory pruritus, including those with severe itching induced by biologic therapies for cancer.

"I think it’s a tool we should consider using in our patients with pruritus who do not respond to the usual measures," Dr. Mario E. Lacouture said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

BRUCE JANCIN/Elsevier Global Medical News

Aprepitant (Emend) is approved as an antiemetic agent for cancer patients undergoing chemotherapy. But a growing body of data, including two single-arm proof-of-concept studies, has shown a high response rate in patients with itching resistant to standard treatment, including corticosteroids, UV therapy, and antihistamines, noted Dr. Lacouture, a dermatologist at Memorial Sloan-Kettering Cancer Center, New York.

Severe itching is increasingly recognized as an important side effect of targeted biologic agents for cancer, including erlotinib (Tarceva) and cetuximab (Erbitux). At last year’s meeting of the American Society of Clinical Oncology, Dr. Daniele Santini and coworkers at the Università "Campus Bio-Medico" di Roma presented a study involving 22 patients with severe pruritus treated with aprepitant using a regimen of 125 mg on day 1 and 80 mg on days 3 and 5.

After the single 3-dose cycle of aprepitant, the patients’ median pruritus intensity plummeted from a baseline of 8 down to 1 on a 0-10 visual analog scale (VAS). Twenty of 22 patients experienced a greater than 50% reduction in pruritus. The median duration of benefit following a 3-dose cycle given over 5 days was 25 days.

In the second proof-of-concept study, dermatologists at the Westfälische Wilhelms-Universität Münster (Germany) reported on 20 patients with refractory chronic pruritus from nonmalignant underlying disorders placed on aprepitant at 80 mg/day for 1 week. Sixteen of the 20 patients experienced a marked reduction in itch intensity. From a baseline mean of 8.4 points on the VAS, the group as a whole averaged a 42% improvement to a post-treatment score of 4.3.

A significant reduction in itching was observed as early as 2 days after initiating aprepitant in the study population (PLoS One. 2010;5:e10968).

Patients with itching related to prurigo nodularis or atopic disease responded better than those without the conditions, and patients under age 60 obtained greater improvement than older patients. However, patients with chronic kidney disease as the underlying cause of their itching achieved only minimal benefit.

Side effects were confined to mild, non-treatment-limiting nausea, dizziness, and drowsiness in three patients.

Between the two proof-of-concept studies and smaller published case series, Dr. Lacouture said that he is aware of 63 reported patients with severe refractory pruritus, including 6 with Sézary syndrome and 2 with mycosis fungoides, who were treated with aprepitant on various dosing regimens. The result was an improvement from a mean baseline VAS of 8.4 to 2.3.

Aprepitant’s mechanism of benefit in cases of severe pruritus is believed to lie in the drug’s high affinity as an antagonist of neurokinin receptor 1, which is expressed in the skin and CNS, he explained. Substance P, an important mediator in the initiation and maintenance of pruritus, binds to this receptor.

Dry skin due to radiation therapy, chemotherapy, or cachexia is the most common cause of pruritus in oncology. But he added that pruritus is intrinsically often a prominent feature of a variety of paraneoplastic diseases and malignancies, and aprepitant is worthy of study in refractory cases.

Pruritic paraneoplastic dermatoses in which the skin findings are an indication of potential concurrent underlying malignancy include dermatomyositis, erythroderma, generalized granuloma annulare, and acrokeratosis paraneoplastica.

Hematologic malignancies where itch often figures prominently include Hodgkin’s disease, polycythemia vera, and Waldenström macroglobulinemia. The solid cancers most frequently accompanied by severe itching include malignancies of the brain, prostate, rectum, and vulva.

Dr. Lacouture reported serving as a consultant to more than a dozen pharmaceutical companies, although Merck, which markets aprepitant, is not among them.

SDEF and this news organization are owned by Elsevier.

STEAMBOAT SPRINGS, COLO. – The youth obesity crisis has a huge and underappreciated flip side: An epidemic of overuse injuries in heavy kids who've been told to start exercising without receiving any informed guidance.

“A lot of times we're turning to sports and exercise in the battle against obesity, and it's backfiring,” according to Dr. Paul R. Stricker, a pediatric sports medicine specialist at the Scripps Clinic in San Diego.

“We hear about overweight all the time in the media, but overuse injuries are also an epidemic in my world. They are rampant. We've got millions of kids every year with overuse injuries from doing too much, too fast after a lifetime of inactivity,” he said at the meeting.

“Obese youth are being told to 'just start jogging,' and a few weeks later they're ending up in my sports medicine clinic. And they're already defeated,” said Dr. Stricker, a past president of the American Medical Society for Sports Medicine who served as a U.S. team physician at the Olympics.

The approach to exercise among previously sedentary overweight and obese youth needs to be quite different from that taken with active kids experienced in sports. The start is more gradual and cautious. The initial emphasis is placed upon stretching, strengthening, and conditioning in order to allow the body time to adapt to new demands.

Dr. Stricker likes to start these kids off with non-impact exercises, such as swimming, water aerobics, bicycling, and low-impact dance or walking. Supervised strength training is a particularly good way for these heavy kids to get on board the life-long exercise train.

“They can see real progress very quickly. It really gets them motivated, and the increased muscle mass is helpful because it brings an increased metabolic rate, which promotes weight loss,” he explained.

If a heavy, sedentary kid wants to take up a team sport – be it wrestling, football, or a non-contact sport – the message from coaches and parents ought to be that the first season should be a learning experience in which the emphasis focuses on catching up in terms of sport skills. The new player might not see much game time this year, but next year could be different.

“The experience of camaraderie and accomplishment of being on a team can absolutely do wonders for these children,” according to the pediatrician.

Overweight and obese kids face multiple challenges in taking up exercise. Not only do they have a lengthy history as couch potatoes, but their diet is typically quite poor. And while heavy kids look like they're skeletally mature because of their size, in fact they're often late bloomers. Their open growth plates predispose to fractures.

Among the most common overuse injuries Dr. Stricker encounters in overweight kids who've taken up exercise are:

▸ Patellar maltracking. Heavy children often have knock knees, shortened and inflexible hamstrings and quadriceps, and weak patella muscles, all of which promote patellar maltracking laterally. The extra weight being carried around increases the patellar load, further predisposing to kneecap pain and maltracking. Affected kids find running, jumping, and going up and down stairs particularly problematic.

▸ Foot overpronation. Overweight youth typically have flattened arches. This results in biomechanical problems, including tibial rotation with resultant excess forces being transmitted through the medial side of the lower leg. The faulty biomechanics, coupled with excess weight and a rapid increase in physical activity, results in tissue overload. Shin splints, foot pain, and patellar maltracking are common.

“It's very important for us to evaluate below the knee, to look at the feet and say, 'Hey, you might benefit from an insert,'” Dr. Stricker said.

He almost never refers these heavy kids with flattened arches to a podiatrist for a $400 pair of custom orthotics. It's a waste of money.

Over-the-counter inserts costing $30-$35 work as well or better. Avoid the soft, floppy, spongy variety in favor of inserts comprised of a thin layer of cushioning over hard molded plastic; Superfeet and Spenco make good-quality products, he said.

▸ Heat sickness. Young people in general are more vulnerable to heat injury than their adult counterparts. They have a higher metabolic rate as well as a greater body surface to mass ratio. They have a poor thirst drive. Plus, sweat glands are typically immature and fewer in number in youth below ages 12-14 years. Their smaller blood volume makes it more difficult to dissipate heat.

All of these issues are accentuated in overweight kids. Moreover, since they are new to exercise and sports, their inefficiency of movement results in generation of extra heat, Dr. Stricker explained.

▸ Low back pain. This is very common when heavy kids take up exercise. Contributing factors include a lack of tone in the core abdominal and lower back muscles, coupled with hamstring and quadriceps inflexibility and excess weight being carried around the abdomen.

“These kids need to generate core strength through planks and other exercises that engage their core besides sit-ups, which for a lot of these kids are no fun and usually embarrassing,” he continued.

▸ Slipped capital femoral epiphysis. This is the most common hip disorder in overweight 10- to 18-year-olds. Black males are at increased risk. The injury occurs when the proximal hip epiphysis slides off the growth plate.

“If a kid comes in with knee or thigh pain or a limp, always think 'hip' as well. Check for hip range of motion. If it's not equal and symmetric or it brings on a lot of pain, you've got to get an x-ray and you'd better be thinking about [slipped capital femoral epiphysis]. It's usually a surgical situation,” according to Dr. Stricker.

He reported having no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – The youth obesity crisis has a huge and underappreciated flip side: An epidemic of overuse injuries in heavy kids who've been told to start exercising without receiving any informed guidance.

“A lot of times we're turning to sports and exercise in the battle against obesity, and it's backfiring,” according to Dr. Paul R. Stricker, a pediatric sports medicine specialist at the Scripps Clinic in San Diego.

“We hear about overweight all the time in the media, but overuse injuries are also an epidemic in my world. They are rampant. We've got millions of kids every year with overuse injuries from doing too much, too fast after a lifetime of inactivity,” he said at the meeting.

“Obese youth are being told to 'just start jogging,' and a few weeks later they're ending up in my sports medicine clinic. And they're already defeated,” said Dr. Stricker, a past president of the American Medical Society for Sports Medicine who served as a U.S. team physician at the Olympics.

The approach to exercise among previously sedentary overweight and obese youth needs to be quite different from that taken with active kids experienced in sports. The start is more gradual and cautious. The initial emphasis is placed upon stretching, strengthening, and conditioning in order to allow the body time to adapt to new demands.

Dr. Stricker likes to start these kids off with non-impact exercises, such as swimming, water aerobics, bicycling, and low-impact dance or walking. Supervised strength training is a particularly good way for these heavy kids to get on board the life-long exercise train.

“They can see real progress very quickly. It really gets them motivated, and the increased muscle mass is helpful because it brings an increased metabolic rate, which promotes weight loss,” he explained.

If a heavy, sedentary kid wants to take up a team sport – be it wrestling, football, or a non-contact sport – the message from coaches and parents ought to be that the first season should be a learning experience in which the emphasis focuses on catching up in terms of sport skills. The new player might not see much game time this year, but next year could be different.

“The experience of camaraderie and accomplishment of being on a team can absolutely do wonders for these children,” according to the pediatrician.

Overweight and obese kids face multiple challenges in taking up exercise. Not only do they have a lengthy history as couch potatoes, but their diet is typically quite poor. And while heavy kids look like they're skeletally mature because of their size, in fact they're often late bloomers. Their open growth plates predispose to fractures.

Among the most common overuse injuries Dr. Stricker encounters in overweight kids who've taken up exercise are:

▸ Patellar maltracking. Heavy children often have knock knees, shortened and inflexible hamstrings and quadriceps, and weak patella muscles, all of which promote patellar maltracking laterally. The extra weight being carried around increases the patellar load, further predisposing to kneecap pain and maltracking. Affected kids find running, jumping, and going up and down stairs particularly problematic.

▸ Foot overpronation. Overweight youth typically have flattened arches. This results in biomechanical problems, including tibial rotation with resultant excess forces being transmitted through the medial side of the lower leg. The faulty biomechanics, coupled with excess weight and a rapid increase in physical activity, results in tissue overload. Shin splints, foot pain, and patellar maltracking are common.

“It's very important for us to evaluate below the knee, to look at the feet and say, 'Hey, you might benefit from an insert,'” Dr. Stricker said.

He almost never refers these heavy kids with flattened arches to a podiatrist for a $400 pair of custom orthotics. It's a waste of money.

Over-the-counter inserts costing $30-$35 work as well or better. Avoid the soft, floppy, spongy variety in favor of inserts comprised of a thin layer of cushioning over hard molded plastic; Superfeet and Spenco make good-quality products, he said.

▸ Heat sickness. Young people in general are more vulnerable to heat injury than their adult counterparts. They have a higher metabolic rate as well as a greater body surface to mass ratio. They have a poor thirst drive. Plus, sweat glands are typically immature and fewer in number in youth below ages 12-14 years. Their smaller blood volume makes it more difficult to dissipate heat.

All of these issues are accentuated in overweight kids. Moreover, since they are new to exercise and sports, their inefficiency of movement results in generation of extra heat, Dr. Stricker explained.

▸ Low back pain. This is very common when heavy kids take up exercise. Contributing factors include a lack of tone in the core abdominal and lower back muscles, coupled with hamstring and quadriceps inflexibility and excess weight being carried around the abdomen.

“These kids need to generate core strength through planks and other exercises that engage their core besides sit-ups, which for a lot of these kids are no fun and usually embarrassing,” he continued.

▸ Slipped capital femoral epiphysis. This is the most common hip disorder in overweight 10- to 18-year-olds. Black males are at increased risk. The injury occurs when the proximal hip epiphysis slides off the growth plate.

“If a kid comes in with knee or thigh pain or a limp, always think 'hip' as well. Check for hip range of motion. If it's not equal and symmetric or it brings on a lot of pain, you've got to get an x-ray and you'd better be thinking about [slipped capital femoral epiphysis]. It's usually a surgical situation,” according to Dr. Stricker.

He reported having no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – The youth obesity crisis has a huge and underappreciated flip side: An epidemic of overuse injuries in heavy kids who've been told to start exercising without receiving any informed guidance.

“A lot of times we're turning to sports and exercise in the battle against obesity, and it's backfiring,” according to Dr. Paul R. Stricker, a pediatric sports medicine specialist at the Scripps Clinic in San Diego.

“We hear about overweight all the time in the media, but overuse injuries are also an epidemic in my world. They are rampant. We've got millions of kids every year with overuse injuries from doing too much, too fast after a lifetime of inactivity,” he said at the meeting.

“Obese youth are being told to 'just start jogging,' and a few weeks later they're ending up in my sports medicine clinic. And they're already defeated,” said Dr. Stricker, a past president of the American Medical Society for Sports Medicine who served as a U.S. team physician at the Olympics.

The approach to exercise among previously sedentary overweight and obese youth needs to be quite different from that taken with active kids experienced in sports. The start is more gradual and cautious. The initial emphasis is placed upon stretching, strengthening, and conditioning in order to allow the body time to adapt to new demands.

Dr. Stricker likes to start these kids off with non-impact exercises, such as swimming, water aerobics, bicycling, and low-impact dance or walking. Supervised strength training is a particularly good way for these heavy kids to get on board the life-long exercise train.

“They can see real progress very quickly. It really gets them motivated, and the increased muscle mass is helpful because it brings an increased metabolic rate, which promotes weight loss,” he explained.

If a heavy, sedentary kid wants to take up a team sport – be it wrestling, football, or a non-contact sport – the message from coaches and parents ought to be that the first season should be a learning experience in which the emphasis focuses on catching up in terms of sport skills. The new player might not see much game time this year, but next year could be different.

“The experience of camaraderie and accomplishment of being on a team can absolutely do wonders for these children,” according to the pediatrician.

Overweight and obese kids face multiple challenges in taking up exercise. Not only do they have a lengthy history as couch potatoes, but their diet is typically quite poor. And while heavy kids look like they're skeletally mature because of their size, in fact they're often late bloomers. Their open growth plates predispose to fractures.

Among the most common overuse injuries Dr. Stricker encounters in overweight kids who've taken up exercise are:

▸ Patellar maltracking. Heavy children often have knock knees, shortened and inflexible hamstrings and quadriceps, and weak patella muscles, all of which promote patellar maltracking laterally. The extra weight being carried around increases the patellar load, further predisposing to kneecap pain and maltracking. Affected kids find running, jumping, and going up and down stairs particularly problematic.

▸ Foot overpronation. Overweight youth typically have flattened arches. This results in biomechanical problems, including tibial rotation with resultant excess forces being transmitted through the medial side of the lower leg. The faulty biomechanics, coupled with excess weight and a rapid increase in physical activity, results in tissue overload. Shin splints, foot pain, and patellar maltracking are common.

“It's very important for us to evaluate below the knee, to look at the feet and say, 'Hey, you might benefit from an insert,'” Dr. Stricker said.

He almost never refers these heavy kids with flattened arches to a podiatrist for a $400 pair of custom orthotics. It's a waste of money.

Over-the-counter inserts costing $30-$35 work as well or better. Avoid the soft, floppy, spongy variety in favor of inserts comprised of a thin layer of cushioning over hard molded plastic; Superfeet and Spenco make good-quality products, he said.

▸ Heat sickness. Young people in general are more vulnerable to heat injury than their adult counterparts. They have a higher metabolic rate as well as a greater body surface to mass ratio. They have a poor thirst drive. Plus, sweat glands are typically immature and fewer in number in youth below ages 12-14 years. Their smaller blood volume makes it more difficult to dissipate heat.

All of these issues are accentuated in overweight kids. Moreover, since they are new to exercise and sports, their inefficiency of movement results in generation of extra heat, Dr. Stricker explained.

▸ Low back pain. This is very common when heavy kids take up exercise. Contributing factors include a lack of tone in the core abdominal and lower back muscles, coupled with hamstring and quadriceps inflexibility and excess weight being carried around the abdomen.

“These kids need to generate core strength through planks and other exercises that engage their core besides sit-ups, which for a lot of these kids are no fun and usually embarrassing,” he continued.

▸ Slipped capital femoral epiphysis. This is the most common hip disorder in overweight 10- to 18-year-olds. Black males are at increased risk. The injury occurs when the proximal hip epiphysis slides off the growth plate.

“If a kid comes in with knee or thigh pain or a limp, always think 'hip' as well. Check for hip range of motion. If it's not equal and symmetric or it brings on a lot of pain, you've got to get an x-ray and you'd better be thinking about [slipped capital femoral epiphysis]. It's usually a surgical situation,” according to Dr. Stricker.

He reported having no relevant financial disclosures.

SNOWMASS, COLO. – The guideline-endorsed demotion of nonsteroidal anti-inflammatory drugs in favor of narcotic analgesics for chronic pain has led to a marked increase in falls, fractures, and other bad outcomes among elderly arthritis patients.

“The real take-home message here is that current guidelines for the treatment of pain should be revisited,” Dr. Bruce N. Cronstein asserted at the conference.

Since the cyclo-oxygenase-2 (COX-2)-selective NSAID rofecoxib (Vioxx) was taken off the market in late 2004 because of a scandal related to cover-up of an increased risk of myocardial infarction, prescriptions for narcotic analgesics in elderly patients with arthritis have risen sharply. This trend accelerated following the 2007 publication of an American Heart Association scientific statement on the treatment of chronic pain in patients with or at increased risk for heart disease (Circulation 2007;115:1634-42). The AHA guidelines elevated short-term use of narcotic analgesics to first-tier status alongside aspirin, acetaminophen, and tramadol, while demoting both COX-2-selective and nonselective NSAIDs to second-tier status.

Data supporting the unintended consequences of such changes in treatment priorities come from a study by Dr. Cronstein, Dr. Paul R. Esserman professor of medicine at New York University, and his associates. They conducted a nested case-control study of 3,830 elderly patients with osteoarthritis (OA) in the Geisinger Health Plan in Danville, Pa., who had fractures and 11,490 others matched for age and Charlson Comorbidity Index without fractures. In a multivariate analysis, patients on narcotic analgesics had a threefold greater risk of falls or fractures than those on either COX-2-selective or nonselective NSAIDs.

Thus, the use of narcotic analgesics as the sole prescription medication for pain relief in elderly OA patients more than doubled after Vioxx was withdrawn from the market. The patients on narcotic analgesics with or without a COX-2-selective NSAID had a fourfold greater rate of falls or fractures than those on nonselective NSAIDs or COX-2-selective agents.

Dr. Cronstein noted that the AHA guidelines focus on the evidence of increased cardiovascular risk associated with nearly all NSAIDs without considering how the drugs stack up in terms of overall safety – noncardiovascular as well as cardiovascular – compared with the other major analgesic group: narcotic analgesics. And it turns out that the NSAIDs look pretty good in comparison, he added.

“You're trading off falls and fractures for MIs – and it turns out that in patients over age 65, the mortality from hip fracture is significantly greater than it is for MI,” said Dr. Cronstein, who is also director of the Clinical and Translational Science Institute.

He cited a large Medicare study conducted that examined the comparative safety of analgesics in elderly arthritis patients and concluded that narcotic analgesics come up short.

The investigators, at Brigham and Women's Hospital, Boston, sifted through the population of Medicare beneficiaries in Pennsylvania and New Jersey to identify elderly patients with rheumatoid arthritis or osteoarthritis (OA) who were started on a nonselective NSAID, a COX-2-selective NSAID, or a narcotic analgesic during 1999-2005. They came up with 4,280 propensity score–matched patients in each of the three groups.

The composite incidence of fractures of the hip, pelvis, humerus, or radius was 26 per 1,000 person-years in patients on nonselective NSAIDs, 19 with COX-2-selective NSAIDs, and 101 with opioids.

While it's not really surprising that opiate analgesics should be linked with increased risk of falls and fractures, another finding in this study proved unexpected: The composite cardiovascular event rate was 77 per 1,000 person-years with nonselective NSAIDs, 88 per 1,000 with COX-2-selective NSAIDs, and 122 with narcotic analgesics.

The patients taking opioids had a 77% greater risk of cardiovascular events and those taking COX-2-selective NSAIDs had a 28% greater risk than did patients on nonselective NSAIDs, according to findings from a multivariate Cox regression analysis. The fracture risk was 4.47-fold greater with narcotic analgesics than with NSAIDs. The GI bleeding risk was 40% lower in the COX-2-selective NSAID group than in the other groups. The all-cause mortality risk was 87% greater in the narcotic analgesic group than with nonselective NSAIDs, while COX-2-selective NSAIDs weren't tied to increased risk (Arch. Intern. Med. 2010;170:1968-78).

This work was funded by the National Institutes of Health, the Geisinger Clinic, and the Clinical and Translational Science Institute. Dr. Cronstein has served as a paid consultant to Allos, Bristol-Myers Squibb, Novartis, and several other pharmaceutical companies.

'You're trading off falls and fractures for MIs,' while hip fracture is significantly deadlier than MI after age 65.

Source DR. CRONSTEIN

SNOWMASS, COLO. – The guideline-endorsed demotion of nonsteroidal anti-inflammatory drugs in favor of narcotic analgesics for chronic pain has led to a marked increase in falls, fractures, and other bad outcomes among elderly arthritis patients.

“The real take-home message here is that current guidelines for the treatment of pain should be revisited,” Dr. Bruce N. Cronstein asserted at the conference.

Since the cyclo-oxygenase-2 (COX-2)-selective NSAID rofecoxib (Vioxx) was taken off the market in late 2004 because of a scandal related to cover-up of an increased risk of myocardial infarction, prescriptions for narcotic analgesics in elderly patients with arthritis have risen sharply. This trend accelerated following the 2007 publication of an American Heart Association scientific statement on the treatment of chronic pain in patients with or at increased risk for heart disease (Circulation 2007;115:1634-42). The AHA guidelines elevated short-term use of narcotic analgesics to first-tier status alongside aspirin, acetaminophen, and tramadol, while demoting both COX-2-selective and nonselective NSAIDs to second-tier status.

Data supporting the unintended consequences of such changes in treatment priorities come from a study by Dr. Cronstein, Dr. Paul R. Esserman professor of medicine at New York University, and his associates. They conducted a nested case-control study of 3,830 elderly patients with osteoarthritis (OA) in the Geisinger Health Plan in Danville, Pa., who had fractures and 11,490 others matched for age and Charlson Comorbidity Index without fractures. In a multivariate analysis, patients on narcotic analgesics had a threefold greater risk of falls or fractures than those on either COX-2-selective or nonselective NSAIDs.

Thus, the use of narcotic analgesics as the sole prescription medication for pain relief in elderly OA patients more than doubled after Vioxx was withdrawn from the market. The patients on narcotic analgesics with or without a COX-2-selective NSAID had a fourfold greater rate of falls or fractures than those on nonselective NSAIDs or COX-2-selective agents.

Dr. Cronstein noted that the AHA guidelines focus on the evidence of increased cardiovascular risk associated with nearly all NSAIDs without considering how the drugs stack up in terms of overall safety – noncardiovascular as well as cardiovascular – compared with the other major analgesic group: narcotic analgesics. And it turns out that the NSAIDs look pretty good in comparison, he added.

“You're trading off falls and fractures for MIs – and it turns out that in patients over age 65, the mortality from hip fracture is significantly greater than it is for MI,” said Dr. Cronstein, who is also director of the Clinical and Translational Science Institute.

He cited a large Medicare study conducted that examined the comparative safety of analgesics in elderly arthritis patients and concluded that narcotic analgesics come up short.

The investigators, at Brigham and Women's Hospital, Boston, sifted through the population of Medicare beneficiaries in Pennsylvania and New Jersey to identify elderly patients with rheumatoid arthritis or osteoarthritis (OA) who were started on a nonselective NSAID, a COX-2-selective NSAID, or a narcotic analgesic during 1999-2005. They came up with 4,280 propensity score–matched patients in each of the three groups.

The composite incidence of fractures of the hip, pelvis, humerus, or radius was 26 per 1,000 person-years in patients on nonselective NSAIDs, 19 with COX-2-selective NSAIDs, and 101 with opioids.

While it's not really surprising that opiate analgesics should be linked with increased risk of falls and fractures, another finding in this study proved unexpected: The composite cardiovascular event rate was 77 per 1,000 person-years with nonselective NSAIDs, 88 per 1,000 with COX-2-selective NSAIDs, and 122 with narcotic analgesics.

The patients taking opioids had a 77% greater risk of cardiovascular events and those taking COX-2-selective NSAIDs had a 28% greater risk than did patients on nonselective NSAIDs, according to findings from a multivariate Cox regression analysis. The fracture risk was 4.47-fold greater with narcotic analgesics than with NSAIDs. The GI bleeding risk was 40% lower in the COX-2-selective NSAID group than in the other groups. The all-cause mortality risk was 87% greater in the narcotic analgesic group than with nonselective NSAIDs, while COX-2-selective NSAIDs weren't tied to increased risk (Arch. Intern. Med. 2010;170:1968-78).

This work was funded by the National Institutes of Health, the Geisinger Clinic, and the Clinical and Translational Science Institute. Dr. Cronstein has served as a paid consultant to Allos, Bristol-Myers Squibb, Novartis, and several other pharmaceutical companies.

'You're trading off falls and fractures for MIs,' while hip fracture is significantly deadlier than MI after age 65.

Source DR. CRONSTEIN

SNOWMASS, COLO. – The guideline-endorsed demotion of nonsteroidal anti-inflammatory drugs in favor of narcotic analgesics for chronic pain has led to a marked increase in falls, fractures, and other bad outcomes among elderly arthritis patients.

“The real take-home message here is that current guidelines for the treatment of pain should be revisited,” Dr. Bruce N. Cronstein asserted at the conference.

Since the cyclo-oxygenase-2 (COX-2)-selective NSAID rofecoxib (Vioxx) was taken off the market in late 2004 because of a scandal related to cover-up of an increased risk of myocardial infarction, prescriptions for narcotic analgesics in elderly patients with arthritis have risen sharply. This trend accelerated following the 2007 publication of an American Heart Association scientific statement on the treatment of chronic pain in patients with or at increased risk for heart disease (Circulation 2007;115:1634-42). The AHA guidelines elevated short-term use of narcotic analgesics to first-tier status alongside aspirin, acetaminophen, and tramadol, while demoting both COX-2-selective and nonselective NSAIDs to second-tier status.

Data supporting the unintended consequences of such changes in treatment priorities come from a study by Dr. Cronstein, Dr. Paul R. Esserman professor of medicine at New York University, and his associates. They conducted a nested case-control study of 3,830 elderly patients with osteoarthritis (OA) in the Geisinger Health Plan in Danville, Pa., who had fractures and 11,490 others matched for age and Charlson Comorbidity Index without fractures. In a multivariate analysis, patients on narcotic analgesics had a threefold greater risk of falls or fractures than those on either COX-2-selective or nonselective NSAIDs.

Thus, the use of narcotic analgesics as the sole prescription medication for pain relief in elderly OA patients more than doubled after Vioxx was withdrawn from the market. The patients on narcotic analgesics with or without a COX-2-selective NSAID had a fourfold greater rate of falls or fractures than those on nonselective NSAIDs or COX-2-selective agents.

Dr. Cronstein noted that the AHA guidelines focus on the evidence of increased cardiovascular risk associated with nearly all NSAIDs without considering how the drugs stack up in terms of overall safety – noncardiovascular as well as cardiovascular – compared with the other major analgesic group: narcotic analgesics. And it turns out that the NSAIDs look pretty good in comparison, he added.

“You're trading off falls and fractures for MIs – and it turns out that in patients over age 65, the mortality from hip fracture is significantly greater than it is for MI,” said Dr. Cronstein, who is also director of the Clinical and Translational Science Institute.

He cited a large Medicare study conducted that examined the comparative safety of analgesics in elderly arthritis patients and concluded that narcotic analgesics come up short.

The investigators, at Brigham and Women's Hospital, Boston, sifted through the population of Medicare beneficiaries in Pennsylvania and New Jersey to identify elderly patients with rheumatoid arthritis or osteoarthritis (OA) who were started on a nonselective NSAID, a COX-2-selective NSAID, or a narcotic analgesic during 1999-2005. They came up with 4,280 propensity score–matched patients in each of the three groups.

The composite incidence of fractures of the hip, pelvis, humerus, or radius was 26 per 1,000 person-years in patients on nonselective NSAIDs, 19 with COX-2-selective NSAIDs, and 101 with opioids.

While it's not really surprising that opiate analgesics should be linked with increased risk of falls and fractures, another finding in this study proved unexpected: The composite cardiovascular event rate was 77 per 1,000 person-years with nonselective NSAIDs, 88 per 1,000 with COX-2-selective NSAIDs, and 122 with narcotic analgesics.

The patients taking opioids had a 77% greater risk of cardiovascular events and those taking COX-2-selective NSAIDs had a 28% greater risk than did patients on nonselective NSAIDs, according to findings from a multivariate Cox regression analysis. The fracture risk was 4.47-fold greater with narcotic analgesics than with NSAIDs. The GI bleeding risk was 40% lower in the COX-2-selective NSAID group than in the other groups. The all-cause mortality risk was 87% greater in the narcotic analgesic group than with nonselective NSAIDs, while COX-2-selective NSAIDs weren't tied to increased risk (Arch. Intern. Med. 2010;170:1968-78).

This work was funded by the National Institutes of Health, the Geisinger Clinic, and the Clinical and Translational Science Institute. Dr. Cronstein has served as a paid consultant to Allos, Bristol-Myers Squibb, Novartis, and several other pharmaceutical companies.

'You're trading off falls and fractures for MIs,' while hip fracture is significantly deadlier than MI after age 65.

Source DR. CRONSTEIN

STEAMBOAT SPRINGS, COLO. – Klinefelter syndrome, the most common cause of hypergonadotrophic hypogonadism in boys, affects 1 in 660 males and is greatly underdiagnosed, according to Dr. Charlotte M. Boney.

“Seventy-five percent of guys with Klinefelter syndrome aren't diagnosed until they are adults. We are missing the opportunity to diagnose Klinefelter when we could actually intervene in a timely way to promote normal pubertal development,” said Dr. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children's Hospital in Providence, R.I.

Neonates with Klinefelter syndrome look normal. But missed opportunities to make the diagnosis later in childhood abound. Among the most common red flags are cryptorchidism, in 25%–40% of affected boys; language delay, present in more than 40%; learning disabilities, in more than 75%; and mood and behavior problems, such as attention-deficit/hyperactivity disorder, in more than 25%. Problems fitting in socially with peers in preschool and kindergarten are also common in boys with Klinefelter syndrome.

“So if you see a boy with an undescended testis at 1 year of age, and that same boy later has language delay, and he's a wreck in kindergarten, and then in third or fourth grade there are learning disabilities, think about Klinefelter syndrome. I'd like all of us to connect the dots a little better,” Dr. Boney said at the meeting.

She added that since well under 10% of boys should have undescended testes at age 1 year, if at that age she still can't palpate testes, she'd obtain a karyotype study to rule out Klinefelter syndrome before sending the boy to the urologist to bring down the testes.

Klinefelter syndrome is marked by delayed puberty, and endocrinologically by high serum FSH and LH and low testosterone levels for the child's Tanner stage. Puberty in the majority of affected boys will turn sluggish and stall. Diagnosis is confirmed by karyotyping. Roughly 90% of individuals with Klinefelter syndrome are 47XXY, 10% are 47XXY/46XY, and less than 1% are 48XXY.

Treatment is straightforward: testosterone replacement to achieve normal pubertal development. The goals include a normal-trajectory pubertal growth spurt; normal male muscle mass, body fat distribution, and bone mineralization; induction of secondary sex characteristics; and a sense of psychosocial well-being.

If the boy didn't virilize normally during puberty, treatment begins with intramuscular injections of a low-dose, long-acting testosterone ester, starting at 50 mg once every 3-4 weeks and working up over the course of a year to 200-300 mg every 2-3 weeks, Dr. Boney said.

Once the patient is in the Tanner 4 range and his serum testosterone climbs above 300 ng/dL, he can transition to maintenance therapy with transdermal testosterone patches. The patches are self-administered and result in less-dramatic serum testosterone peaks and troughs than with intramuscular injections. Most patients prefer the Androderm patch, placed on the arm, thigh, or back, rather than the Testoderm patch, which has to be stuck on the scrotum, she said. Testosterone gels such as AndroGel or Testim, rubbed into the skin on a daily basis, are another option for replacement therapy. They result in smooth serum hormone levels, but “have the consistency of ultrasound gel, and a lot of teenagers don't like them,” said Dr. Boney.

Proper diagnosis and treatment will result in normal sexual functioning, but there is no way to forestall the death of the patient's sperm cells. To preserve the option of parenthood, many centers offer the option of testicular biopsy to harvest and bank healthy sperm. But the biopsy must be done at age 16-20 years, so the conversation must occur before many teens are emotionally mature, she said.

Dr. Boney had no disclosures.

STEAMBOAT SPRINGS, COLO. – Klinefelter syndrome, the most common cause of hypergonadotrophic hypogonadism in boys, affects 1 in 660 males and is greatly underdiagnosed, according to Dr. Charlotte M. Boney.

“Seventy-five percent of guys with Klinefelter syndrome aren't diagnosed until they are adults. We are missing the opportunity to diagnose Klinefelter when we could actually intervene in a timely way to promote normal pubertal development,” said Dr. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children's Hospital in Providence, R.I.

Neonates with Klinefelter syndrome look normal. But missed opportunities to make the diagnosis later in childhood abound. Among the most common red flags are cryptorchidism, in 25%–40% of affected boys; language delay, present in more than 40%; learning disabilities, in more than 75%; and mood and behavior problems, such as attention-deficit/hyperactivity disorder, in more than 25%. Problems fitting in socially with peers in preschool and kindergarten are also common in boys with Klinefelter syndrome.

“So if you see a boy with an undescended testis at 1 year of age, and that same boy later has language delay, and he's a wreck in kindergarten, and then in third or fourth grade there are learning disabilities, think about Klinefelter syndrome. I'd like all of us to connect the dots a little better,” Dr. Boney said at the meeting.

She added that since well under 10% of boys should have undescended testes at age 1 year, if at that age she still can't palpate testes, she'd obtain a karyotype study to rule out Klinefelter syndrome before sending the boy to the urologist to bring down the testes.

Klinefelter syndrome is marked by delayed puberty, and endocrinologically by high serum FSH and LH and low testosterone levels for the child's Tanner stage. Puberty in the majority of affected boys will turn sluggish and stall. Diagnosis is confirmed by karyotyping. Roughly 90% of individuals with Klinefelter syndrome are 47XXY, 10% are 47XXY/46XY, and less than 1% are 48XXY.

Treatment is straightforward: testosterone replacement to achieve normal pubertal development. The goals include a normal-trajectory pubertal growth spurt; normal male muscle mass, body fat distribution, and bone mineralization; induction of secondary sex characteristics; and a sense of psychosocial well-being.

If the boy didn't virilize normally during puberty, treatment begins with intramuscular injections of a low-dose, long-acting testosterone ester, starting at 50 mg once every 3-4 weeks and working up over the course of a year to 200-300 mg every 2-3 weeks, Dr. Boney said.

Once the patient is in the Tanner 4 range and his serum testosterone climbs above 300 ng/dL, he can transition to maintenance therapy with transdermal testosterone patches. The patches are self-administered and result in less-dramatic serum testosterone peaks and troughs than with intramuscular injections. Most patients prefer the Androderm patch, placed on the arm, thigh, or back, rather than the Testoderm patch, which has to be stuck on the scrotum, she said. Testosterone gels such as AndroGel or Testim, rubbed into the skin on a daily basis, are another option for replacement therapy. They result in smooth serum hormone levels, but “have the consistency of ultrasound gel, and a lot of teenagers don't like them,” said Dr. Boney.

Proper diagnosis and treatment will result in normal sexual functioning, but there is no way to forestall the death of the patient's sperm cells. To preserve the option of parenthood, many centers offer the option of testicular biopsy to harvest and bank healthy sperm. But the biopsy must be done at age 16-20 years, so the conversation must occur before many teens are emotionally mature, she said.

Dr. Boney had no disclosures.

STEAMBOAT SPRINGS, COLO. – Klinefelter syndrome, the most common cause of hypergonadotrophic hypogonadism in boys, affects 1 in 660 males and is greatly underdiagnosed, according to Dr. Charlotte M. Boney.

“Seventy-five percent of guys with Klinefelter syndrome aren't diagnosed until they are adults. We are missing the opportunity to diagnose Klinefelter when we could actually intervene in a timely way to promote normal pubertal development,” said Dr. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children's Hospital in Providence, R.I.

Neonates with Klinefelter syndrome look normal. But missed opportunities to make the diagnosis later in childhood abound. Among the most common red flags are cryptorchidism, in 25%–40% of affected boys; language delay, present in more than 40%; learning disabilities, in more than 75%; and mood and behavior problems, such as attention-deficit/hyperactivity disorder, in more than 25%. Problems fitting in socially with peers in preschool and kindergarten are also common in boys with Klinefelter syndrome.

“So if you see a boy with an undescended testis at 1 year of age, and that same boy later has language delay, and he's a wreck in kindergarten, and then in third or fourth grade there are learning disabilities, think about Klinefelter syndrome. I'd like all of us to connect the dots a little better,” Dr. Boney said at the meeting.

She added that since well under 10% of boys should have undescended testes at age 1 year, if at that age she still can't palpate testes, she'd obtain a karyotype study to rule out Klinefelter syndrome before sending the boy to the urologist to bring down the testes.

Klinefelter syndrome is marked by delayed puberty, and endocrinologically by high serum FSH and LH and low testosterone levels for the child's Tanner stage. Puberty in the majority of affected boys will turn sluggish and stall. Diagnosis is confirmed by karyotyping. Roughly 90% of individuals with Klinefelter syndrome are 47XXY, 10% are 47XXY/46XY, and less than 1% are 48XXY.

Treatment is straightforward: testosterone replacement to achieve normal pubertal development. The goals include a normal-trajectory pubertal growth spurt; normal male muscle mass, body fat distribution, and bone mineralization; induction of secondary sex characteristics; and a sense of psychosocial well-being.

If the boy didn't virilize normally during puberty, treatment begins with intramuscular injections of a low-dose, long-acting testosterone ester, starting at 50 mg once every 3-4 weeks and working up over the course of a year to 200-300 mg every 2-3 weeks, Dr. Boney said.

Once the patient is in the Tanner 4 range and his serum testosterone climbs above 300 ng/dL, he can transition to maintenance therapy with transdermal testosterone patches. The patches are self-administered and result in less-dramatic serum testosterone peaks and troughs than with intramuscular injections. Most patients prefer the Androderm patch, placed on the arm, thigh, or back, rather than the Testoderm patch, which has to be stuck on the scrotum, she said. Testosterone gels such as AndroGel or Testim, rubbed into the skin on a daily basis, are another option for replacement therapy. They result in smooth serum hormone levels, but “have the consistency of ultrasound gel, and a lot of teenagers don't like them,” said Dr. Boney.

Proper diagnosis and treatment will result in normal sexual functioning, but there is no way to forestall the death of the patient's sperm cells. To preserve the option of parenthood, many centers offer the option of testicular biopsy to harvest and bank healthy sperm. But the biopsy must be done at age 16-20 years, so the conversation must occur before many teens are emotionally mature, she said.

Dr. Boney had no disclosures.

STEAMBOAT SPRINGS, COLO. – New-onset type 1 diabetes in an obese youth cannot reliably be distinguished from pediatric type 2 diabetes on clinical grounds in this era of epidemic obesity.

“The only way to distinguish obese type 1 diabetes from type 2 diabetes is to measure diabetes autoantibodies. And those autoantibody panels are commercially available now. Signs and symptoms, diabetic ketoacidosis, family history – they don't really help you. We get an autoantibody panel routinely in obese kids above age 10 presenting with new-onset diabetes,” said Dr. Charlotte M. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children's Hospital in Providence, R.I.

Diabetic ketoacidosis is widely thought of as incompatible with type 2 diabetes. Not true. Close to 20% of youth with type 2 diabetes present with DKA. Similarly, while a history of recent weight loss is considered a classic presenting symptom of type 1 diabetes, it's also present in about one-quarter of young people presenting with type 2 diabetes, Dr. Boney noted.

The presence of pancreatic autoantibodies spells type 1 diabetes metabolically, even if the patient appears phenotypically to have type 2 disease.

“Some pediatric endocrinologists call this 'type one-and-a-half' diabetes. No, no, no. Let's not make things any weirder than they already are. They have autoimmune diabetes, which is clearly type 1 diabetes. It just happens to be a little more complicated in them because they also have the morbidity of obesity,” she explained at the meeting.

The obesity epidemic has muddied the diagnostic waters, because now 20%–30% of patients with new-onset type 1 diabetes are obese, as is a similar proportion of the general pediatric population. At the same time, the obesity epidemic has led to an increase in type 2 diabetes.

But it's important to bear in mind that most youths with new-onset diabetes still have type 1 disease, she said.

In the landmark, prospective The SEARCH for Diabetes in Youth study, nearly all children who presented under age 10 years had type 1 diabetes. Among 10- to 19-year-olds, the proportion with type 2 disease was 15% among whites, but considerably greater among racial minorities: 58% among African Americans, 46% in Hispanics, 70% in Asian/Pacific Islanders, and 86% among Native Americans (JAMA 2007;297:2716–24).

In the ongoing, multicenter, National Institutes of Health–sponsored Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, which enrolled 1,206 subjects with a presumptive diagnosis of type 2 diabetes, 9.8% proved to be positive for GAD-65 and/or insulinoma-associated protein 2 autoantibodies. They had to be excluded from participation in the treatment phase (Diabetes Care 2010;33:1970–5).

As a practical approach to the initial therapy of young patients with new-onset diabetes, Dr. Boney urged that those with DKA and ketosis should be started on intravenous fluids and insulin, regardless of their age and body habitus. If they are over age 10 and obese, however, pancreatic autoimmunity should be ruled out before transitioning to long-term therapy. For autoantibody-negative patients whose clinical picture is consistent with type 2 diabetes, the treatment is metformin, the only Food and Drug Administration–approved therapy for children. Extensive experience shows that it's a very safe drug, she said.

The TODAY trial is designed to determine whether the best treatment for type 2 diabetes in youth is metformin alone, metformin plus rosiglitazone, or metformin and an intensive lifestyle intervention aimed at achieving a 7%–10% weight loss.

The use of metformin to try to prevent diabetes in obese children with insulin resistance and the metabolic syndrome is the subject of large ongoing clinical trials. Until the results come in, Dr. Boney said she sees no role for off-label prescribing of metformin, given that weight loss and exercise are quite effective in improving insulin sensitivity.

Maturity Onset Diabetes of the Young, or MODY, is worth considering in white youth who are pancreatic autoantibody–negative and have a strong history of parental non–type 1 diabetes. MODY is a single-gene disorder that causes diabetes and is inherited from a parent.

“There are a lot of experts in the MODY field that think we're grossly underdiagnosing monogenic diabetes,” said Dr. Boney.

The treatment for MODY is not insulin or metformin, but rather oral sulfonylureas, although those agents are not FDA-approved for use in children, she observed.

Dr. Boney reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – New-onset type 1 diabetes in an obese youth cannot reliably be distinguished from pediatric type 2 diabetes on clinical grounds in this era of epidemic obesity.

“The only way to distinguish obese type 1 diabetes from type 2 diabetes is to measure diabetes autoantibodies. And those autoantibody panels are commercially available now. Signs and symptoms, diabetic ketoacidosis, family history – they don't really help you. We get an autoantibody panel routinely in obese kids above age 10 presenting with new-onset diabetes,” said Dr. Charlotte M. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children's Hospital in Providence, R.I.

Diabetic ketoacidosis is widely thought of as incompatible with type 2 diabetes. Not true. Close to 20% of youth with type 2 diabetes present with DKA. Similarly, while a history of recent weight loss is considered a classic presenting symptom of type 1 diabetes, it's also present in about one-quarter of young people presenting with type 2 diabetes, Dr. Boney noted.

The presence of pancreatic autoantibodies spells type 1 diabetes metabolically, even if the patient appears phenotypically to have type 2 disease.

“Some pediatric endocrinologists call this 'type one-and-a-half' diabetes. No, no, no. Let's not make things any weirder than they already are. They have autoimmune diabetes, which is clearly type 1 diabetes. It just happens to be a little more complicated in them because they also have the morbidity of obesity,” she explained at the meeting.

The obesity epidemic has muddied the diagnostic waters, because now 20%–30% of patients with new-onset type 1 diabetes are obese, as is a similar proportion of the general pediatric population. At the same time, the obesity epidemic has led to an increase in type 2 diabetes.

But it's important to bear in mind that most youths with new-onset diabetes still have type 1 disease, she said.

In the landmark, prospective The SEARCH for Diabetes in Youth study, nearly all children who presented under age 10 years had type 1 diabetes. Among 10- to 19-year-olds, the proportion with type 2 disease was 15% among whites, but considerably greater among racial minorities: 58% among African Americans, 46% in Hispanics, 70% in Asian/Pacific Islanders, and 86% among Native Americans (JAMA 2007;297:2716–24).

In the ongoing, multicenter, National Institutes of Health–sponsored Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, which enrolled 1,206 subjects with a presumptive diagnosis of type 2 diabetes, 9.8% proved to be positive for GAD-65 and/or insulinoma-associated protein 2 autoantibodies. They had to be excluded from participation in the treatment phase (Diabetes Care 2010;33:1970–5).

As a practical approach to the initial therapy of young patients with new-onset diabetes, Dr. Boney urged that those with DKA and ketosis should be started on intravenous fluids and insulin, regardless of their age and body habitus. If they are over age 10 and obese, however, pancreatic autoimmunity should be ruled out before transitioning to long-term therapy. For autoantibody-negative patients whose clinical picture is consistent with type 2 diabetes, the treatment is metformin, the only Food and Drug Administration–approved therapy for children. Extensive experience shows that it's a very safe drug, she said.

The TODAY trial is designed to determine whether the best treatment for type 2 diabetes in youth is metformin alone, metformin plus rosiglitazone, or metformin and an intensive lifestyle intervention aimed at achieving a 7%–10% weight loss.

The use of metformin to try to prevent diabetes in obese children with insulin resistance and the metabolic syndrome is the subject of large ongoing clinical trials. Until the results come in, Dr. Boney said she sees no role for off-label prescribing of metformin, given that weight loss and exercise are quite effective in improving insulin sensitivity.

Maturity Onset Diabetes of the Young, or MODY, is worth considering in white youth who are pancreatic autoantibody–negative and have a strong history of parental non–type 1 diabetes. MODY is a single-gene disorder that causes diabetes and is inherited from a parent.

“There are a lot of experts in the MODY field that think we're grossly underdiagnosing monogenic diabetes,” said Dr. Boney.

The treatment for MODY is not insulin or metformin, but rather oral sulfonylureas, although those agents are not FDA-approved for use in children, she observed.

Dr. Boney reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – New-onset type 1 diabetes in an obese youth cannot reliably be distinguished from pediatric type 2 diabetes on clinical grounds in this era of epidemic obesity.

“The only way to distinguish obese type 1 diabetes from type 2 diabetes is to measure diabetes autoantibodies. And those autoantibody panels are commercially available now. Signs and symptoms, diabetic ketoacidosis, family history – they don't really help you. We get an autoantibody panel routinely in obese kids above age 10 presenting with new-onset diabetes,” said Dr. Charlotte M. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children's Hospital in Providence, R.I.

Diabetic ketoacidosis is widely thought of as incompatible with type 2 diabetes. Not true. Close to 20% of youth with type 2 diabetes present with DKA. Similarly, while a history of recent weight loss is considered a classic presenting symptom of type 1 diabetes, it's also present in about one-quarter of young people presenting with type 2 diabetes, Dr. Boney noted.

The presence of pancreatic autoantibodies spells type 1 diabetes metabolically, even if the patient appears phenotypically to have type 2 disease.

“Some pediatric endocrinologists call this 'type one-and-a-half' diabetes. No, no, no. Let's not make things any weirder than they already are. They have autoimmune diabetes, which is clearly type 1 diabetes. It just happens to be a little more complicated in them because they also have the morbidity of obesity,” she explained at the meeting.

The obesity epidemic has muddied the diagnostic waters, because now 20%–30% of patients with new-onset type 1 diabetes are obese, as is a similar proportion of the general pediatric population. At the same time, the obesity epidemic has led to an increase in type 2 diabetes.

But it's important to bear in mind that most youths with new-onset diabetes still have type 1 disease, she said.

In the landmark, prospective The SEARCH for Diabetes in Youth study, nearly all children who presented under age 10 years had type 1 diabetes. Among 10- to 19-year-olds, the proportion with type 2 disease was 15% among whites, but considerably greater among racial minorities: 58% among African Americans, 46% in Hispanics, 70% in Asian/Pacific Islanders, and 86% among Native Americans (JAMA 2007;297:2716–24).

In the ongoing, multicenter, National Institutes of Health–sponsored Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, which enrolled 1,206 subjects with a presumptive diagnosis of type 2 diabetes, 9.8% proved to be positive for GAD-65 and/or insulinoma-associated protein 2 autoantibodies. They had to be excluded from participation in the treatment phase (Diabetes Care 2010;33:1970–5).

As a practical approach to the initial therapy of young patients with new-onset diabetes, Dr. Boney urged that those with DKA and ketosis should be started on intravenous fluids and insulin, regardless of their age and body habitus. If they are over age 10 and obese, however, pancreatic autoimmunity should be ruled out before transitioning to long-term therapy. For autoantibody-negative patients whose clinical picture is consistent with type 2 diabetes, the treatment is metformin, the only Food and Drug Administration–approved therapy for children. Extensive experience shows that it's a very safe drug, she said.

The TODAY trial is designed to determine whether the best treatment for type 2 diabetes in youth is metformin alone, metformin plus rosiglitazone, or metformin and an intensive lifestyle intervention aimed at achieving a 7%–10% weight loss.

The use of metformin to try to prevent diabetes in obese children with insulin resistance and the metabolic syndrome is the subject of large ongoing clinical trials. Until the results come in, Dr. Boney said she sees no role for off-label prescribing of metformin, given that weight loss and exercise are quite effective in improving insulin sensitivity.

Maturity Onset Diabetes of the Young, or MODY, is worth considering in white youth who are pancreatic autoantibody–negative and have a strong history of parental non–type 1 diabetes. MODY is a single-gene disorder that causes diabetes and is inherited from a parent.

“There are a lot of experts in the MODY field that think we're grossly underdiagnosing monogenic diabetes,” said Dr. Boney.

The treatment for MODY is not insulin or metformin, but rather oral sulfonylureas, although those agents are not FDA-approved for use in children, she observed.

Dr. Boney reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – Klinefelter syndrome, the most common cause of hypergonadotrophic hypogonadism in boys, affects 1 in 660 males and is greatly underdiagnosed, according to Dr. Charlotte M. Boney.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults. We are missing the opportunity to diagnose Klinefelter when we could actually intervene in a timely way to promote normal pubertal development," said Dr. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children’s Hospital in Providence, R.I.

Neonates with Klinefelter syndrome look completely normal. But missed opportunities to make the diagnosis later in childhood abound. Among the most common red flags are cryptorchidism, which occurs in 25%-40% of affected boys; language delay, present in more than 40%; learning disabilities, present in more than 75%; and mood and behavior problems, such as attention-deficit/hyperactivity disorder, in more than 25%.

Problems fitting in socially with peers in preschool and kindergarten are also common in boys with Klinefelter syndrome.

"So if you see a boy with an undescended testis at 1 year of age, and that same boy later has language delay, and he’s a wreck in kindergarten, and then in third or fourth grade there are learning disabilities, think about Klinefelter syndrome. I’d like all of us to connect the dots a little better," Dr. Boney said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

She added that since well under 10% of boys should have undescended testes at age 1 year, if at that age she still can’t palpate testes, she’d obtain a karyotype study to rule out Klinefelter syndrome before sending the boy to the urologist to bring down the testes.

Klinefelter syndrome is characterized by delayed puberty, and endocrinologically by high serum FSH and LH and low testosterone levels for the child’s Tanner stage. The majority of affected boys will begin puberty, but it will then turn sluggish and stall.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults."

The diagnosis of Klinefelter syndrome is confirmed by karyotyping. Roughly 90% of individuals with Klinefelter syndrome are 47XXY, 10% are 47XXY/46XY, and less than 1% is 48XXY.

The treatment of Klinefelter syndrome is straightforward: testosterone replacement aimed at achieving normal pubertal development. The goals include a normal-trajectory pubertal growth spurt; normal male muscle mass, body fat distribution, and bone mineralization; induction of secondary sex characteristics; and a sense of psychosocial well-being.

If the boy didn’t virilize normally during puberty, treatment begins with intramuscular injections of a low-dose, long-acting testosterone ester, starting at 50 mg once every 3-4 weeks and working up over the course of a year to 200-300 mg every 2-3 weeks, Dr. Boney said.

Once the patient is in the Tanner 4 range and his serum testosterone climbs above 300 ng/dL, he can transition to maintenance therapy with transdermal testosterone patches. For the patient this is a most welcome event because the patches are self-administered and result in less-dramatic serum testosterone peaks and troughs than with intramuscular injections. Most patients prefer the Androderm patch, which can be placed on the arm, thigh, or back, rather than the Testoderm patch, which has to be stuck on the scrotum, she said.

Testosterone gels that are rubbed into the skin on a daily basis, such as AndroGel or Testim, are another option for replacement therapy. The gels result in impressively smooth serum hormone levels, but they are messy products.

"They have the consistency of ultrasound gel, and a lot of teenagers don’t like them," according to Dr. Boney.

Although a properly diagnosed and treated patient with Klinefelter syndrome will have completely normal sexual functioning, there is at present no way to forestall the death of the patient’s germ cells. In order to preserve the option of parenthood, many large centers are now offering patients with Klinefelter syndrome the option of testicular biopsy to harvest healthy sperm, then banking the sperm for assisted reproduction later in life. But the window for finding healthy sperm in these patients is quite narrow; the biopsy needs to be done when they are roughly 16-20 years old, so the conversation with the patient regarding this option must occur before many teens are emotionally mature, she said.

Dr. Boney reported having no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – Klinefelter syndrome, the most common cause of hypergonadotrophic hypogonadism in boys, affects 1 in 660 males and is greatly underdiagnosed, according to Dr. Charlotte M. Boney.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults. We are missing the opportunity to diagnose Klinefelter when we could actually intervene in a timely way to promote normal pubertal development," said Dr. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children’s Hospital in Providence, R.I.

Neonates with Klinefelter syndrome look completely normal. But missed opportunities to make the diagnosis later in childhood abound. Among the most common red flags are cryptorchidism, which occurs in 25%-40% of affected boys; language delay, present in more than 40%; learning disabilities, present in more than 75%; and mood and behavior problems, such as attention-deficit/hyperactivity disorder, in more than 25%.

Problems fitting in socially with peers in preschool and kindergarten are also common in boys with Klinefelter syndrome.

"So if you see a boy with an undescended testis at 1 year of age, and that same boy later has language delay, and he’s a wreck in kindergarten, and then in third or fourth grade there are learning disabilities, think about Klinefelter syndrome. I’d like all of us to connect the dots a little better," Dr. Boney said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

She added that since well under 10% of boys should have undescended testes at age 1 year, if at that age she still can’t palpate testes, she’d obtain a karyotype study to rule out Klinefelter syndrome before sending the boy to the urologist to bring down the testes.

Klinefelter syndrome is characterized by delayed puberty, and endocrinologically by high serum FSH and LH and low testosterone levels for the child’s Tanner stage. The majority of affected boys will begin puberty, but it will then turn sluggish and stall.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults."

The diagnosis of Klinefelter syndrome is confirmed by karyotyping. Roughly 90% of individuals with Klinefelter syndrome are 47XXY, 10% are 47XXY/46XY, and less than 1% is 48XXY.

The treatment of Klinefelter syndrome is straightforward: testosterone replacement aimed at achieving normal pubertal development. The goals include a normal-trajectory pubertal growth spurt; normal male muscle mass, body fat distribution, and bone mineralization; induction of secondary sex characteristics; and a sense of psychosocial well-being.

If the boy didn’t virilize normally during puberty, treatment begins with intramuscular injections of a low-dose, long-acting testosterone ester, starting at 50 mg once every 3-4 weeks and working up over the course of a year to 200-300 mg every 2-3 weeks, Dr. Boney said.

Once the patient is in the Tanner 4 range and his serum testosterone climbs above 300 ng/dL, he can transition to maintenance therapy with transdermal testosterone patches. For the patient this is a most welcome event because the patches are self-administered and result in less-dramatic serum testosterone peaks and troughs than with intramuscular injections. Most patients prefer the Androderm patch, which can be placed on the arm, thigh, or back, rather than the Testoderm patch, which has to be stuck on the scrotum, she said.

Testosterone gels that are rubbed into the skin on a daily basis, such as AndroGel or Testim, are another option for replacement therapy. The gels result in impressively smooth serum hormone levels, but they are messy products.

"They have the consistency of ultrasound gel, and a lot of teenagers don’t like them," according to Dr. Boney.

Although a properly diagnosed and treated patient with Klinefelter syndrome will have completely normal sexual functioning, there is at present no way to forestall the death of the patient’s germ cells. In order to preserve the option of parenthood, many large centers are now offering patients with Klinefelter syndrome the option of testicular biopsy to harvest healthy sperm, then banking the sperm for assisted reproduction later in life. But the window for finding healthy sperm in these patients is quite narrow; the biopsy needs to be done when they are roughly 16-20 years old, so the conversation with the patient regarding this option must occur before many teens are emotionally mature, she said.

Dr. Boney reported having no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – Klinefelter syndrome, the most common cause of hypergonadotrophic hypogonadism in boys, affects 1 in 660 males and is greatly underdiagnosed, according to Dr. Charlotte M. Boney.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults. We are missing the opportunity to diagnose Klinefelter when we could actually intervene in a timely way to promote normal pubertal development," said Dr. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children’s Hospital in Providence, R.I.

Neonates with Klinefelter syndrome look completely normal. But missed opportunities to make the diagnosis later in childhood abound. Among the most common red flags are cryptorchidism, which occurs in 25%-40% of affected boys; language delay, present in more than 40%; learning disabilities, present in more than 75%; and mood and behavior problems, such as attention-deficit/hyperactivity disorder, in more than 25%.

Problems fitting in socially with peers in preschool and kindergarten are also common in boys with Klinefelter syndrome.

"So if you see a boy with an undescended testis at 1 year of age, and that same boy later has language delay, and he’s a wreck in kindergarten, and then in third or fourth grade there are learning disabilities, think about Klinefelter syndrome. I’d like all of us to connect the dots a little better," Dr. Boney said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

She added that since well under 10% of boys should have undescended testes at age 1 year, if at that age she still can’t palpate testes, she’d obtain a karyotype study to rule out Klinefelter syndrome before sending the boy to the urologist to bring down the testes.

Klinefelter syndrome is characterized by delayed puberty, and endocrinologically by high serum FSH and LH and low testosterone levels for the child’s Tanner stage. The majority of affected boys will begin puberty, but it will then turn sluggish and stall.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults."

The diagnosis of Klinefelter syndrome is confirmed by karyotyping. Roughly 90% of individuals with Klinefelter syndrome are 47XXY, 10% are 47XXY/46XY, and less than 1% is 48XXY.

The treatment of Klinefelter syndrome is straightforward: testosterone replacement aimed at achieving normal pubertal development. The goals include a normal-trajectory pubertal growth spurt; normal male muscle mass, body fat distribution, and bone mineralization; induction of secondary sex characteristics; and a sense of psychosocial well-being.

If the boy didn’t virilize normally during puberty, treatment begins with intramuscular injections of a low-dose, long-acting testosterone ester, starting at 50 mg once every 3-4 weeks and working up over the course of a year to 200-300 mg every 2-3 weeks, Dr. Boney said.

Once the patient is in the Tanner 4 range and his serum testosterone climbs above 300 ng/dL, he can transition to maintenance therapy with transdermal testosterone patches. For the patient this is a most welcome event because the patches are self-administered and result in less-dramatic serum testosterone peaks and troughs than with intramuscular injections. Most patients prefer the Androderm patch, which can be placed on the arm, thigh, or back, rather than the Testoderm patch, which has to be stuck on the scrotum, she said.

Testosterone gels that are rubbed into the skin on a daily basis, such as AndroGel or Testim, are another option for replacement therapy. The gels result in impressively smooth serum hormone levels, but they are messy products.

"They have the consistency of ultrasound gel, and a lot of teenagers don’t like them," according to Dr. Boney.

Although a properly diagnosed and treated patient with Klinefelter syndrome will have completely normal sexual functioning, there is at present no way to forestall the death of the patient’s germ cells. In order to preserve the option of parenthood, many large centers are now offering patients with Klinefelter syndrome the option of testicular biopsy to harvest healthy sperm, then banking the sperm for assisted reproduction later in life. But the window for finding healthy sperm in these patients is quite narrow; the biopsy needs to be done when they are roughly 16-20 years old, so the conversation with the patient regarding this option must occur before many teens are emotionally mature, she said.

Dr. Boney reported having no relevant financial disclosures.

WAIKOLOA, HAWAII – Ruling out herpes simplex virus infection is the first order of business in any neonate who displays interrupted skin integrity, whether in the form of erosions, vesicles, pustules, erythroderma, or purpura.

"Always think about [herpes simplex virus (HSV)] in neonates with interrupted skin integrity. HSV is first, second, third, fourth, and fifth on my differential diagnosis list," said Dr. Albert C. Yan, director of pediatric dermatology at Children’s Hospital of Philadelphia.

"This can be a devastating disease. The main issue is that a lot of people don’t recognize it until the later stages. Prompt recognition and initiation of empiric therapy when you’re even remotely thinking about neonatal HSV can significantly reduce morbidity and mortality. Once the work-up is negative, you can stop," he said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Yan highlighted findings from a recent large retrospective cohort study led by investigators at Cincinnati Children’s Hospital Medical Center that underscored the importance of early treatment. The study included 1,086 neonates with HSV at 41 tertiary-care children’s hospitals. The babies were a median of 10 days old when hospitalized.

Three-quarters of the neonates were started on intravenous acyclovir within 1 day after hospital admission. Their in-hospital mortality was 6.6%, as compared to 9.5% in the remaining one-quarter of children who received delayed acyclovir, defined as treatment initiated on day 2-7 after admission. Of neonates with delayed acyclovir, 86% started on the antiviral agent on day 2 or 3 of hospitalization.

In a multivariate logistic regression analysis adjusted for differences in illness severity between the two groups, delayed commencement of intravenous acyclovir was independently associated with a highly significant 2.6-fold increased risk of in-hospital mortality (Pediatrics 2011;128:1153-60).

Dr. Yan noted that common systemic signs of neonatal HSV in term babies include lethargy, temperature instability, hypotension, and transaminitis.

"HSV is first, second, third, fourth, and fifth on my differential diagnosis list."

In contrast, premature babies with neonatal HSV are much more likely to have respiratory distress as a presenting feature. Their onset is earlier – typically within 2 weeks in the NICU – and the infection’s mortality and neurologic sequelae are greater than in term infants.

Both term infants and preemies can develop neonatal HSV in the absence of maternal genital HSV lesions at delivery or even a maternal history of HSV.

Most cases of neonatal HSV infection involve HSV-1; however, HSV-2 disease is far more severe. "Those are kids you’re going to have to monitor more closely because they’re more likely to have dissemination and CNS disease and more likely to have a fatal outcome," the pediatric dermatologist cautioned at the seminar sponsored by the Skin Disease Education Foundation.

Skin vesicles are often absent in neonates with HSV. To maximize the diagnostic yield of testing by PCR or culture, it’s important to obtain swabs from multiple sites, including oral and nasopharyngeal secretions, blood, cerebrospinal fluid, and the trachea, as well as skin.

Dr. Yan reported having no financial conflicts.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Ruling out herpes simplex virus infection is the first order of business in any neonate who displays interrupted skin integrity, whether in the form of erosions, vesicles, pustules, erythroderma, or purpura.

"Always think about [herpes simplex virus (HSV)] in neonates with interrupted skin integrity. HSV is first, second, third, fourth, and fifth on my differential diagnosis list," said Dr. Albert C. Yan, director of pediatric dermatology at Children’s Hospital of Philadelphia.

"This can be a devastating disease. The main issue is that a lot of people don’t recognize it until the later stages. Prompt recognition and initiation of empiric therapy when you’re even remotely thinking about neonatal HSV can significantly reduce morbidity and mortality. Once the work-up is negative, you can stop," he said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Yan highlighted findings from a recent large retrospective cohort study led by investigators at Cincinnati Children’s Hospital Medical Center that underscored the importance of early treatment. The study included 1,086 neonates with HSV at 41 tertiary-care children’s hospitals. The babies were a median of 10 days old when hospitalized.

Three-quarters of the neonates were started on intravenous acyclovir within 1 day after hospital admission. Their in-hospital mortality was 6.6%, as compared to 9.5% in the remaining one-quarter of children who received delayed acyclovir, defined as treatment initiated on day 2-7 after admission. Of neonates with delayed acyclovir, 86% started on the antiviral agent on day 2 or 3 of hospitalization.

In a multivariate logistic regression analysis adjusted for differences in illness severity between the two groups, delayed commencement of intravenous acyclovir was independently associated with a highly significant 2.6-fold increased risk of in-hospital mortality (Pediatrics 2011;128:1153-60).

Dr. Yan noted that common systemic signs of neonatal HSV in term babies include lethargy, temperature instability, hypotension, and transaminitis.

"HSV is first, second, third, fourth, and fifth on my differential diagnosis list."

In contrast, premature babies with neonatal HSV are much more likely to have respiratory distress as a presenting feature. Their onset is earlier – typically within 2 weeks in the NICU – and the infection’s mortality and neurologic sequelae are greater than in term infants.

Both term infants and preemies can develop neonatal HSV in the absence of maternal genital HSV lesions at delivery or even a maternal history of HSV.

Most cases of neonatal HSV infection involve HSV-1; however, HSV-2 disease is far more severe. "Those are kids you’re going to have to monitor more closely because they’re more likely to have dissemination and CNS disease and more likely to have a fatal outcome," the pediatric dermatologist cautioned at the seminar sponsored by the Skin Disease Education Foundation.

Skin vesicles are often absent in neonates with HSV. To maximize the diagnostic yield of testing by PCR or culture, it’s important to obtain swabs from multiple sites, including oral and nasopharyngeal secretions, blood, cerebrospinal fluid, and the trachea, as well as skin.

Dr. Yan reported having no financial conflicts.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Ruling out herpes simplex virus infection is the first order of business in any neonate who displays interrupted skin integrity, whether in the form of erosions, vesicles, pustules, erythroderma, or purpura.

"Always think about [herpes simplex virus (HSV)] in neonates with interrupted skin integrity. HSV is first, second, third, fourth, and fifth on my differential diagnosis list," said Dr. Albert C. Yan, director of pediatric dermatology at Children’s Hospital of Philadelphia.

"This can be a devastating disease. The main issue is that a lot of people don’t recognize it until the later stages. Prompt recognition and initiation of empiric therapy when you’re even remotely thinking about neonatal HSV can significantly reduce morbidity and mortality. Once the work-up is negative, you can stop," he said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Dr. Yan highlighted findings from a recent large retrospective cohort study led by investigators at Cincinnati Children’s Hospital Medical Center that underscored the importance of early treatment. The study included 1,086 neonates with HSV at 41 tertiary-care children’s hospitals. The babies were a median of 10 days old when hospitalized.

Three-quarters of the neonates were started on intravenous acyclovir within 1 day after hospital admission. Their in-hospital mortality was 6.6%, as compared to 9.5% in the remaining one-quarter of children who received delayed acyclovir, defined as treatment initiated on day 2-7 after admission. Of neonates with delayed acyclovir, 86% started on the antiviral agent on day 2 or 3 of hospitalization.

In a multivariate logistic regression analysis adjusted for differences in illness severity between the two groups, delayed commencement of intravenous acyclovir was independently associated with a highly significant 2.6-fold increased risk of in-hospital mortality (Pediatrics 2011;128:1153-60).

Dr. Yan noted that common systemic signs of neonatal HSV in term babies include lethargy, temperature instability, hypotension, and transaminitis.

"HSV is first, second, third, fourth, and fifth on my differential diagnosis list."

In contrast, premature babies with neonatal HSV are much more likely to have respiratory distress as a presenting feature. Their onset is earlier – typically within 2 weeks in the NICU – and the infection’s mortality and neurologic sequelae are greater than in term infants.

Both term infants and preemies can develop neonatal HSV in the absence of maternal genital HSV lesions at delivery or even a maternal history of HSV.

Most cases of neonatal HSV infection involve HSV-1; however, HSV-2 disease is far more severe. "Those are kids you’re going to have to monitor more closely because they’re more likely to have dissemination and CNS disease and more likely to have a fatal outcome," the pediatric dermatologist cautioned at the seminar sponsored by the Skin Disease Education Foundation.

Skin vesicles are often absent in neonates with HSV. To maximize the diagnostic yield of testing by PCR or culture, it’s important to obtain swabs from multiple sites, including oral and nasopharyngeal secretions, blood, cerebrospinal fluid, and the trachea, as well as skin.

Dr. Yan reported having no financial conflicts.

SDEF and this news organization are owned by Elsevier.