From Medscape Medical News
January 1, 2010 — Adolescents whose parents mandate bedtimes of midnight or later are 24% more likely to be depressed and 20% more likely to express suicidal ideation than adolescents whose parents set bedtimes of 10 pm or earlier, according to a study in the January 1 issue of Sleep.
These findings suggest that earlier parentally set bedtimes may help protect adolescents from depression by ensuring they get enough sleep. James Gangwisch, PhD, Columbia University Medical Center, New York City, and multicenter colleagues found that the average amount of sleep reported by 15,659 adolescents involved in the National Longitudinal Study of Adolescent Health (Add Health) was 7 hours and 53 minutes — considerably less than the 9 or more hours recommended for adolescents by the American Academy of Sleep Medicine.
However, adolescents whose parents had set a bedtime of 10 pm or earlier slept 33 minutes more, on average, than those with a bedtime of 11 pm, and 40 minutes more on average than adolescents with a parental bedtime of midnight or later. Adolescents who reported getting on average 5 or fewer hours of sleep per night were also 71% more likely to be depressed and 48% more likely to think about committing suicide than adolescents who reported getting 8 hours of sleep a night.
"Short sleep duration could be either a symptom of depression or it could be causative of depression, so we tried to get at this question by looking at parentally mandated bedtimes because if you leave it up to a child as to when they go to bed, an argument could be made that [lack of] sleep is simply a symptom of depression," Dr. Gangwisch told Medscape Neurology. "And our study lends support to the idea that lack of sleep could be causative for depression."
Add Health
Add Health involved a nationally representative sample of adolescents in the United States who were in grades 7 to 12 between 1994 and 1996. An 18-item version of the Centers for Epidemiologic Study–Depression Scale was administered to assess individuals for the presence of depressive symptoms, and the presence of suicidal ideation was determined by responses to the question: "During the past 12 months, did you ever seriously think about committing suicide?"
As investigators note, more than two thirds of Add Health participants reported going to bed at a time that complied with their parents' reported set bedtime. In unadjusted analyses, adolescents with late parentally mandated bedtimes of midnight and later were 42% more likely to be depressed, and those with set bedtimes of 11 pm were 15% more like to be depressed, than adolescents with set bedtimes of 10 pm.
Again in unadjusted analyses, adolescents with parentally set bedtimes of midnight or later and 11 pm were 30% and 15% more likely to suffer from suicidal ideation, respectively, in comparison with adolescents with parental set bedtimes of 10 pm. Risks were attenuated depending on the model used.
"Adolescents want to go to bed later now because there are so many different distractions, plus they have to get up really early for school, so it's easy for them not to get enough sleep," Dr. Gangwisch noted.
"But what we are saying is that getting adequate sleep is very important for mental health, and compromising on the amount of sleep by doing other activities can have negative consequences, including a increased risk of depression."Substantiated Empirical Belief
Commenting on the study, William Kohler, MD, from the Florida Sleep Institute, Springhill, told Medscape Neurology that the study "substantiated the empirical belief that lack of sleep leads to difficulties with cognition." Even though inherent inaccuracies do occur with a questionnaire-based study such as this one, "the sample size was large, and it was a very good study." There was, as he indicated, no information on the quality of sleep reported by the adolescents, so that participants might have been in bed 8 hours but had gotten little sleep.
Still, Dr. Kohler feels that the study underscored how important it is for physicians to ask adolescent patients about their sleep habits — what time they go to bed, how much sleep they have or perceive they get — to make sure poor sleeping habits are not contributing to underlying depression.
He also feels that schools need to look at start times for students because "no matter how much money we throw at public education, if children are getting up at 5 in the morning to get to school, they are not going to learn properly because they are sleep-deprived."
Financial support for this study was provided by a grant from the Robert Wood Johnson Health and Society Scholars Program at Columbia University, but it was not an industry-supported study. Dr. Gangwisch and Dr. Kohler have disclosed no relevant financial relationships.
Sleep. 2010;33(1):97-106.
Thursday, January 14, 2010
Wednesday, January 13, 2010
New Data Support Long-Term Health Benefits of Male Circumcision
From Medscape Medical News
Fran Lowry
Review data January 4, 2010 — The American Academy of Pediatrics (AAP) policy on newborn male circumcision, initiated in 1999 and reaffirmed in 2005, states that data are insufficient to recommend routine neonatal circumcision. However, recent results from 3 randomized trials showing that it prevents sexually transmitted infections suggest that it is time to revise this policy to fully reflect these benefits, according to a review published in the January 2010 issue of the Archives of Pediatric and Adolescent Medicine.
“During the past 4 years, substantial new data have been published on the health benefits of circumcision,” write Aaron A. R. Tobian, MD, from Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues. “While the historical evidence strongly suggests that male circumcision reduces urinary tract infections and penile inflammatory disorders in infants, we reviewed the more recent evidence with regard to effects on sexually transmitted infections (STIs) in adulthood.”
To evaluate the effect of circumcision on HIV prevention, the researchers analyzed 3 randomized controlled trials of more than 10,000 men from South Africa, Kenya, and Uganda.
The trials enrolled HIV-negative men to circumcision on enrollment or after 21 to 24 months, and all 3 trials demonstrated that male circumcision significantly decreased male heterosexual HIV acquisition by 53% to 60%, despite differences in age eligibility criteria, urban or rural settings, and surgical procedure.
Results Prompted New WHO/UNAIDS Recommendations
Because of this new evidence, the World Health Organization (WHO), together with the Joint United Nations Program on HIV/AIDS (UNAIDS), recommended that male circumcision be provided as an important intervention to reduce heterosexually acquired HIV in men, the study authors report.
The trials also found that male circumcision decreased herpes simplex virus type 2 (HSV-2) acquisition by 28% to 34% and the prevalence of human papillomavirus (HPV) by 32% to 35% in men.
Among female partners of circumcised men, bacterial vaginosis was reduced by 40% and Trichomonas vaginalis infection was reduced by 48%, the study authors write.
The study authors note that the rates of neonatal circumcision complications are between 0.2% and 0.6% of operations performed. The most common complications are bleeding and local infection, which are controlled with pressure and wound care or antibiotics. Other complications, such as phimosis and concealed penis, adhesions, fistula, meatitis, meatal stenosis, and injury to the glans, are extremely rare.
They add that there was no evidence of change in sexual behavior after circumcision in the African randomized controlled trials. “Thus, there are risks to neonatal circumcision, but serious long-term complications are extremely rare,” the study authors write.
“The rare short-term risks of neonatal circumcision need to be weighed against the potential benefits accrued in infancy and childhood (eg, reduction of urinary tract infections), the longer-term benefits that may accrue in adolescence and adulthood (eg, reduced risks of HIV, HSV-2, and HPV), as well as possible benefits to female sexual partners of circumcised men (eg, reduced bacterial vaginosis and trichomonas),” Dr. Tobian and colleagues write.
Medicaid does not cover the cost of male circumcision in 16 states, and the lack of coverage particularly affects disadvantaged minorities, who have the highest risk for HIV and sexually transmitted diseases. “These socioeconomically disadvantaged groups could benefit most if Medicaid covered the costs of neonatal circumcision. Thus, the AAP’s policy has important implications for the health of disadvantaged minorities,” they write.
They conclude that it is time for the AAP policy to fully reflect current data.
Coverage for Circumcision
In an accompanying editorial, Michael T. Brady, MD, from Nationwide Children’s Hospital in Columbus, Ohio, writes that the study authors have provided a very objective review of the available data. Although the 3 randomized trials were performed in Africa, “it is clear that circumcision does offer health benefits, even in the United States,” he notes.
The current evidence on the health benefits of circumcision is adequate enough to include circumcision in medical coverage provided by Medicaid or commercial insurance providers, Dr. Brady points out. “This is particularly relevant since over the past decade many state Medicaid programs have discontinued payment for circumcision.”
He concludes that recommendations for routine newborn circumcision will need to wait for well-designed studies that verify its cost-effectiveness for the individual and/or society. “With available data, we are not there yet, but we may be getting closer.”
Dr. Tobian and Dr. Brady have disclosed no relevant financial relationships.
Arch Pediatr Adolesc Med. 2010;164:78-84, 94-96.
Fran Lowry
Review data January 4, 2010 — The American Academy of Pediatrics (AAP) policy on newborn male circumcision, initiated in 1999 and reaffirmed in 2005, states that data are insufficient to recommend routine neonatal circumcision. However, recent results from 3 randomized trials showing that it prevents sexually transmitted infections suggest that it is time to revise this policy to fully reflect these benefits, according to a review published in the January 2010 issue of the Archives of Pediatric and Adolescent Medicine.
“During the past 4 years, substantial new data have been published on the health benefits of circumcision,” write Aaron A. R. Tobian, MD, from Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues. “While the historical evidence strongly suggests that male circumcision reduces urinary tract infections and penile inflammatory disorders in infants, we reviewed the more recent evidence with regard to effects on sexually transmitted infections (STIs) in adulthood.”
To evaluate the effect of circumcision on HIV prevention, the researchers analyzed 3 randomized controlled trials of more than 10,000 men from South Africa, Kenya, and Uganda.
The trials enrolled HIV-negative men to circumcision on enrollment or after 21 to 24 months, and all 3 trials demonstrated that male circumcision significantly decreased male heterosexual HIV acquisition by 53% to 60%, despite differences in age eligibility criteria, urban or rural settings, and surgical procedure.
Results Prompted New WHO/UNAIDS Recommendations
Because of this new evidence, the World Health Organization (WHO), together with the Joint United Nations Program on HIV/AIDS (UNAIDS), recommended that male circumcision be provided as an important intervention to reduce heterosexually acquired HIV in men, the study authors report.
The trials also found that male circumcision decreased herpes simplex virus type 2 (HSV-2) acquisition by 28% to 34% and the prevalence of human papillomavirus (HPV) by 32% to 35% in men.
Among female partners of circumcised men, bacterial vaginosis was reduced by 40% and Trichomonas vaginalis infection was reduced by 48%, the study authors write.
The study authors note that the rates of neonatal circumcision complications are between 0.2% and 0.6% of operations performed. The most common complications are bleeding and local infection, which are controlled with pressure and wound care or antibiotics. Other complications, such as phimosis and concealed penis, adhesions, fistula, meatitis, meatal stenosis, and injury to the glans, are extremely rare.
They add that there was no evidence of change in sexual behavior after circumcision in the African randomized controlled trials. “Thus, there are risks to neonatal circumcision, but serious long-term complications are extremely rare,” the study authors write.
“The rare short-term risks of neonatal circumcision need to be weighed against the potential benefits accrued in infancy and childhood (eg, reduction of urinary tract infections), the longer-term benefits that may accrue in adolescence and adulthood (eg, reduced risks of HIV, HSV-2, and HPV), as well as possible benefits to female sexual partners of circumcised men (eg, reduced bacterial vaginosis and trichomonas),” Dr. Tobian and colleagues write.
Medicaid does not cover the cost of male circumcision in 16 states, and the lack of coverage particularly affects disadvantaged minorities, who have the highest risk for HIV and sexually transmitted diseases. “These socioeconomically disadvantaged groups could benefit most if Medicaid covered the costs of neonatal circumcision. Thus, the AAP’s policy has important implications for the health of disadvantaged minorities,” they write.
They conclude that it is time for the AAP policy to fully reflect current data.
Coverage for Circumcision
In an accompanying editorial, Michael T. Brady, MD, from Nationwide Children’s Hospital in Columbus, Ohio, writes that the study authors have provided a very objective review of the available data. Although the 3 randomized trials were performed in Africa, “it is clear that circumcision does offer health benefits, even in the United States,” he notes.
The current evidence on the health benefits of circumcision is adequate enough to include circumcision in medical coverage provided by Medicaid or commercial insurance providers, Dr. Brady points out. “This is particularly relevant since over the past decade many state Medicaid programs have discontinued payment for circumcision.”
He concludes that recommendations for routine newborn circumcision will need to wait for well-designed studies that verify its cost-effectiveness for the individual and/or society. “With available data, we are not there yet, but we may be getting closer.”
Dr. Tobian and Dr. Brady have disclosed no relevant financial relationships.
Arch Pediatr Adolesc Med. 2010;164:78-84, 94-96.
Tuesday, January 12, 2010
Childhood and Adolescent Immunization Schedules Approved for 2010
From Medscape Medical News
Laurie Barclay, MD
January 4, 2010 — The 2010 recommended childhood and adolescent immunization schedules have been approved by the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention, and the American Academy of Family Physicians, according to a report posted online January 4 and to be published in the January 2010 issue of Pediatrics.
There are 3 revised schedules describing current guidelines for use of US Food and Drug Administration (FDA)–licensed vaccines: one for children from birth through age 6 years, one for children and adolescents aged 7 through 18 years, and a catch-up immunization schedule for children and adolescents who start late or fall behind with scheduled vaccinations.
Noteworthy changes in the 2010 schedule are a new recommendation for influenza A (H1N1) 2009 monovalent vaccine, a recommendation to revaccinate children who remain at increased risk for meningococcal disease with meningococcal conjugate vaccine (MCV4), recommendations on combination vaccines, and recommendations for the recently licensed bivalent human papillomavirus (HPV) vaccine in girls and the quadrivalent HPV vaccine in boys.
Specific changes from last year's recommendations for vaccination with FDA-approved vaccines include the following:
A footnote refers to ACIP recommendations regarding use of influenza A (H1N1) 2009 monovalent vaccine.
Only children 6 months or older should receive trivalent inactivated influenza vaccine (TIV), and only those 2 years or older should receive the live attenuated influenza vaccine (LAIV).
Healthy children aged 2 to 6 years may receive either TIV or LAIV.
However, children aged 2 to 4 years who have a history of wheezing in the preceding 12 months should not receive LAIV.
The dose of TIV is 0.25 mL for children aged 6 to 35 months and 0.5 mL for those at least 3 years old. For children younger than 9 years given the influenza vaccine for the first time, 2 doses should be given 4 weeks apart. Children who received a single dose of influenza vaccine the previous season should be given 2 doses, separated by 4 weeks or more.
Children who remain at increased risk for meningococcal disease because of persistent complement deficiency, asplenia, or other conditions should be revaccinated with MCV4.
Children who received the initial MCV4 dose at ages 2 through 6 years should receive a dose of MCV4 after 3 years.
If the first dose was given at age 7 years or older, children should be revaccinated after 5 years. These children should then be revaccinated with MCV4 every 5 years.
Children not previously vaccinated with MCV4 should be given this vaccine at age 11 or 12 years or between ages 13 and 18 years.
College freshmen living in a dormitory who have not previously received MCV4 should be given this vaccine.
Combination vaccines are usually preferred to separate injections of the equivalent component vaccines. Updated recommendations regarding the inactivated poliovirus vaccine series are that the final dose should be given on or after the fourth birthday and at least 6 months after the previous dose.
Children receiving 4 doses before age 4 years should receive an additional (fifth) dose at ages 4 through 6 years.
Updated recommendations describe use of the recently licensed bivalent HPV vaccine in girls and the quadrivalent HPV vaccine in boys. Girls not previously vaccinated against HPV should receive the bivalent HPV series at ages 13 through 18 years.
For catch-up, the second and third HPV dose should be given at 1 to 2 months and at 6 months after the first dose. The minimal interval for vaccination is 4 weeks between the first and second doses, 12 weeks between the second and third doses, and 24 weeks or more between the first dose and third dose.
Revisions to most of the footnotes for the individual vaccines offer additional information and explain recommendations provided in the schedules.
The guidelines note that clinically significant adverse events after vaccination should be reported to the Vaccine Adverse Event Reporting System or at 1-800-822-7967. Details of ACIP recommendations for individual vaccines, including recommendations for children with high-risk conditions, are available on the Centers for Disease Control and Prevention Web site.
All of the guidelines authors filed conflict-of-interest statements with the AAP, and any conflicts were resolved through a process approved by the Board of Directors. The AAP neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Pediatrics. Published online January 4, 2010.
Laurie Barclay, MD
January 4, 2010 — The 2010 recommended childhood and adolescent immunization schedules have been approved by the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention, and the American Academy of Family Physicians, according to a report posted online January 4 and to be published in the January 2010 issue of Pediatrics.
There are 3 revised schedules describing current guidelines for use of US Food and Drug Administration (FDA)–licensed vaccines: one for children from birth through age 6 years, one for children and adolescents aged 7 through 18 years, and a catch-up immunization schedule for children and adolescents who start late or fall behind with scheduled vaccinations.
Noteworthy changes in the 2010 schedule are a new recommendation for influenza A (H1N1) 2009 monovalent vaccine, a recommendation to revaccinate children who remain at increased risk for meningococcal disease with meningococcal conjugate vaccine (MCV4), recommendations on combination vaccines, and recommendations for the recently licensed bivalent human papillomavirus (HPV) vaccine in girls and the quadrivalent HPV vaccine in boys.
Specific changes from last year's recommendations for vaccination with FDA-approved vaccines include the following:
A footnote refers to ACIP recommendations regarding use of influenza A (H1N1) 2009 monovalent vaccine.
Only children 6 months or older should receive trivalent inactivated influenza vaccine (TIV), and only those 2 years or older should receive the live attenuated influenza vaccine (LAIV).
Healthy children aged 2 to 6 years may receive either TIV or LAIV.
However, children aged 2 to 4 years who have a history of wheezing in the preceding 12 months should not receive LAIV.
The dose of TIV is 0.25 mL for children aged 6 to 35 months and 0.5 mL for those at least 3 years old. For children younger than 9 years given the influenza vaccine for the first time, 2 doses should be given 4 weeks apart. Children who received a single dose of influenza vaccine the previous season should be given 2 doses, separated by 4 weeks or more.
Children who remain at increased risk for meningococcal disease because of persistent complement deficiency, asplenia, or other conditions should be revaccinated with MCV4.
Children who received the initial MCV4 dose at ages 2 through 6 years should receive a dose of MCV4 after 3 years.
If the first dose was given at age 7 years or older, children should be revaccinated after 5 years. These children should then be revaccinated with MCV4 every 5 years.
Children not previously vaccinated with MCV4 should be given this vaccine at age 11 or 12 years or between ages 13 and 18 years.
College freshmen living in a dormitory who have not previously received MCV4 should be given this vaccine.
Combination vaccines are usually preferred to separate injections of the equivalent component vaccines. Updated recommendations regarding the inactivated poliovirus vaccine series are that the final dose should be given on or after the fourth birthday and at least 6 months after the previous dose.
Children receiving 4 doses before age 4 years should receive an additional (fifth) dose at ages 4 through 6 years.
Updated recommendations describe use of the recently licensed bivalent HPV vaccine in girls and the quadrivalent HPV vaccine in boys. Girls not previously vaccinated against HPV should receive the bivalent HPV series at ages 13 through 18 years.
For catch-up, the second and third HPV dose should be given at 1 to 2 months and at 6 months after the first dose. The minimal interval for vaccination is 4 weeks between the first and second doses, 12 weeks between the second and third doses, and 24 weeks or more between the first dose and third dose.
Revisions to most of the footnotes for the individual vaccines offer additional information and explain recommendations provided in the schedules.
The guidelines note that clinically significant adverse events after vaccination should be reported to the Vaccine Adverse Event Reporting System or at 1-800-822-7967. Details of ACIP recommendations for individual vaccines, including recommendations for children with high-risk conditions, are available on the Centers for Disease Control and Prevention Web site.
All of the guidelines authors filed conflict-of-interest statements with the AAP, and any conflicts were resolved through a process approved by the Board of Directors. The AAP neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Pediatrics. Published online January 4, 2010.
Bifocals Slow Myopic Progression in Children
From Medscape Medical News
Fran Lowry
January 11, 2010 — Bifocal lenses can moderately slow myopic progression in children with high rates of myopic progression after 24 months, according to new research published in the January issue of the Archives of Ophthalmology.
"Myopia is a common refractive problem, particularly in East Asia, where reported prevalence values in children can be as high as 50% to 60% by the age of 12 years. Prevalence of myopia is also high among Asian children living in Western countries," write Desmond Cheng, OD, MSc, PhD, formerly from Queensland University of Technology, Brisbane, Australia, and currently from Hong Kong Polytechnic University, Hong Kong, and colleagues.
"A number of well-designed prospective studies have investigated the effect of positive lenses, in bifocal or multifocal form, on myopic progression in children. However, bifocals and multifocals have proven to be relatively ineffective myopia-control treatments in children," the authors write.
Myopic progression rate appears to be an important factor in determining the effectiveness of multifocal lens treatment, the authors point out.
The aim of this study was to determine whether bifocal and prismatic bifocal spectacles could control myopia in children with high rates of myopic progression, defined as 0.5 diopters or more in the preceding year.
The study randomly assigned 135 Chinese Canadian children (73 girls and 62 boys) with myopia of at least 1.00 diopter to receive single-vision lenses (n = 41), +1.50-diopter executive bifocals (n = 48), or +1.50-diopter executive bifocals with a 3-prism diopter base-in prism in the near segment of each lens (n = 46).
The authors explain that their randomization was done by putting subjects' file numbers on slips of paper and drawing them from a container at random. In addition, subjects and the investigator were aware of the treatment assignments, as blinding was difficult to achieve because the lens treatments were visually very different.
The mean age of the children was 10.3 years (standard error [SE], 0.15 years), and their mean visual acuity was −3.08 diopter (SE, 0.10 diopter).
Myopic progression was measured by an automated refractor under cycloplegia, and increase in axial length was measured by A-scan ultrasonography at 6-month intervals for 24 months.
Of the original 135 children, 131 (97%) completed the trial at 24 months.
The results showed that myopic progression averaged −1.55 diopter (SE, 0.12 diopter) for children who wore single-vision lenses, −0.96 diopter (SE, 0.09 diopter) for those who wore bifocals, and −0.70 diopter (SE, 0.10 diopter) for those who wore prismatic bifocals.
Significant Effect of Lens Design
There was a significant effect of lens design on the degree of myopic progression (P < .001), the authors report. Compared with the single-vision lens group, the magnitude of mean myopic progression was −0.59 diopter (P < .001) in the bifocal lens group and −0.85 diopter (P < .001) less in the prismatic bifocal lens group.
The study also found that axial length increased an average of 0.62 mm (SE, 0.04 mm), 0.41 mm (SE, 0.04 mm), and 0.41 mm (SE, 0.05 mm) in the single-vision lens, bifocal lens, and prismatic bifocal lens groups, respectively.
The treatment effect of bifocals (0.59 diopter) and prismatic bifocals (0.85 diopter) was significant, with a P value less than .001, and both bifocal groups had less axial elongation than the single-vision lens group (0.21 mm; P < .001), the authors report.
The findings of this study could be generalized to children with rapidly progressing myopia, irrespective of ethnicity, although this clearly needs to be tested, the authors state.
Limitations of the study include the use of an atypical randomization scheme to assign subjects to treatment groups and potential bias because the investigator was not masked.
The authors concede that the treatment effect of bifocal and prismatic bifocal lenses of 38% and 55%, respectively, that they found in their study — although greater than those in other studies — is still modest.
"Whether or not the effect tapers off will decide clinical significance," they write. "If the treatment effects continued over time, then the treatment could have a significant role in preventing the development of very high pathologic myopia."
For now, they conclude, bifocals should be offered to myopic children "with caution" in clinical practice.
Dr. Cheng has reported no relevant financial relationships.
Arch Ophthalmol. 2010;128:12-19.
[
Fran Lowry
January 11, 2010 — Bifocal lenses can moderately slow myopic progression in children with high rates of myopic progression after 24 months, according to new research published in the January issue of the Archives of Ophthalmology.
"Myopia is a common refractive problem, particularly in East Asia, where reported prevalence values in children can be as high as 50% to 60% by the age of 12 years. Prevalence of myopia is also high among Asian children living in Western countries," write Desmond Cheng, OD, MSc, PhD, formerly from Queensland University of Technology, Brisbane, Australia, and currently from Hong Kong Polytechnic University, Hong Kong, and colleagues.
"A number of well-designed prospective studies have investigated the effect of positive lenses, in bifocal or multifocal form, on myopic progression in children. However, bifocals and multifocals have proven to be relatively ineffective myopia-control treatments in children," the authors write.
Myopic progression rate appears to be an important factor in determining the effectiveness of multifocal lens treatment, the authors point out.
The aim of this study was to determine whether bifocal and prismatic bifocal spectacles could control myopia in children with high rates of myopic progression, defined as 0.5 diopters or more in the preceding year.
The study randomly assigned 135 Chinese Canadian children (73 girls and 62 boys) with myopia of at least 1.00 diopter to receive single-vision lenses (n = 41), +1.50-diopter executive bifocals (n = 48), or +1.50-diopter executive bifocals with a 3-prism diopter base-in prism in the near segment of each lens (n = 46).
The authors explain that their randomization was done by putting subjects' file numbers on slips of paper and drawing them from a container at random. In addition, subjects and the investigator were aware of the treatment assignments, as blinding was difficult to achieve because the lens treatments were visually very different.
The mean age of the children was 10.3 years (standard error [SE], 0.15 years), and their mean visual acuity was −3.08 diopter (SE, 0.10 diopter).
Myopic progression was measured by an automated refractor under cycloplegia, and increase in axial length was measured by A-scan ultrasonography at 6-month intervals for 24 months.
Of the original 135 children, 131 (97%) completed the trial at 24 months.
The results showed that myopic progression averaged −1.55 diopter (SE, 0.12 diopter) for children who wore single-vision lenses, −0.96 diopter (SE, 0.09 diopter) for those who wore bifocals, and −0.70 diopter (SE, 0.10 diopter) for those who wore prismatic bifocals.
Significant Effect of Lens Design
There was a significant effect of lens design on the degree of myopic progression (P < .001), the authors report. Compared with the single-vision lens group, the magnitude of mean myopic progression was −0.59 diopter (P < .001) in the bifocal lens group and −0.85 diopter (P < .001) less in the prismatic bifocal lens group.
The study also found that axial length increased an average of 0.62 mm (SE, 0.04 mm), 0.41 mm (SE, 0.04 mm), and 0.41 mm (SE, 0.05 mm) in the single-vision lens, bifocal lens, and prismatic bifocal lens groups, respectively.
The treatment effect of bifocals (0.59 diopter) and prismatic bifocals (0.85 diopter) was significant, with a P value less than .001, and both bifocal groups had less axial elongation than the single-vision lens group (0.21 mm; P < .001), the authors report.
The findings of this study could be generalized to children with rapidly progressing myopia, irrespective of ethnicity, although this clearly needs to be tested, the authors state.
Limitations of the study include the use of an atypical randomization scheme to assign subjects to treatment groups and potential bias because the investigator was not masked.
The authors concede that the treatment effect of bifocal and prismatic bifocal lenses of 38% and 55%, respectively, that they found in their study — although greater than those in other studies — is still modest.
"Whether or not the effect tapers off will decide clinical significance," they write. "If the treatment effects continued over time, then the treatment could have a significant role in preventing the development of very high pathologic myopia."
For now, they conclude, bifocals should be offered to myopic children "with caution" in clinical practice.
Dr. Cheng has reported no relevant financial relationships.
Arch Ophthalmol. 2010;128:12-19.
[
Anitbiotics in H1N1 pneumonia
When to Consider the Use of Antibiotics in the Treatment of 2009 H1N1 Influenza-Associated Pneumonia
A difficulty arises when a patient has influenza or influenza with a bacterial superinfection that requires antibiotics.[3]
A recent report showed that bacterial pathogens, including Staphylococcus aureus, were present in 17/53 (32%) of fatal cases of novel H1N1 infection, including 8 in children.[4]
Table 3 summarizes the clinical features of influenza vs influenza with a bacterial superinfection.
Table 3. Detection of Agents of Pneumonia: Influenza vs Influenza + Bacterial Pathogen
Indicator Influenza Influenza + Bacterial Pathogen
Influenza identified Usually found Often found less because later in disease course
Fever Usually found Usually found after a period of defervescence
Respiratory specimen culture Normal flora Pathogen: usually S pneumoniae, S aureus or Group A strep
X-ray Diffuse Lobar consolidation
Onset of respiratory compromise Early: 1-2 days Later: 4-7 days
In regard to antimicrobial selection, these experts recommend coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Streptococcus pneumoniae using a second- or third-generation cephalosporin with the addition of MRSA coverage if there is evidence of necrotizing pneumonia or if a Gram stain or culture of respiratory secretions suggests this pathogen. For outpatients, they suggest amoxicillin-clavulanate or a second- or third-generation cephalosporin.
Commentary. The clinical features suggesting bacterial superinfection are reminders of the well-known report of the 1957-1958 pandemic from NY Hospital-Cornell,[5] when the classic biphasic pattern with typical flu symptoms -- improvement and then rapid deterioration with lobar pneumonia -- was described. The main pathogens then and now are S pneumoniae, S aureus, and group A streptococci. The antibiotics preferred for hospitalized patients with suspected S pneumoniae would be cefotaxime or ceftriaxone. For S aureus (either MRSA or untested), the preference would be for vancomycin dosed to trough levels of 15-20 µg/mL or linezolid (which appears to have better lung penetration).
A difficulty arises when a patient has influenza or influenza with a bacterial superinfection that requires antibiotics.[3]
A recent report showed that bacterial pathogens, including Staphylococcus aureus, were present in 17/53 (32%) of fatal cases of novel H1N1 infection, including 8 in children.[4]
Table 3 summarizes the clinical features of influenza vs influenza with a bacterial superinfection.
Table 3. Detection of Agents of Pneumonia: Influenza vs Influenza + Bacterial Pathogen
Indicator Influenza Influenza + Bacterial Pathogen
Influenza identified Usually found Often found less because later in disease course
Fever Usually found Usually found after a period of defervescence
Respiratory specimen culture Normal flora Pathogen: usually S pneumoniae, S aureus or Group A strep
X-ray Diffuse Lobar consolidation
Onset of respiratory compromise Early: 1-2 days Later: 4-7 days
In regard to antimicrobial selection, these experts recommend coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Streptococcus pneumoniae using a second- or third-generation cephalosporin with the addition of MRSA coverage if there is evidence of necrotizing pneumonia or if a Gram stain or culture of respiratory secretions suggests this pathogen. For outpatients, they suggest amoxicillin-clavulanate or a second- or third-generation cephalosporin.
Commentary. The clinical features suggesting bacterial superinfection are reminders of the well-known report of the 1957-1958 pandemic from NY Hospital-Cornell,[5] when the classic biphasic pattern with typical flu symptoms -- improvement and then rapid deterioration with lobar pneumonia -- was described. The main pathogens then and now are S pneumoniae, S aureus, and group A streptococci. The antibiotics preferred for hospitalized patients with suspected S pneumoniae would be cefotaxime or ceftriaxone. For S aureus (either MRSA or untested), the preference would be for vancomycin dosed to trough levels of 15-20 µg/mL or linezolid (which appears to have better lung penetration).
Firecracker Injury to Eye
From Medscape Ophthalmology > Interactive Case Series
A 5-Year-Old With Firecracker Injury to the Eye
Caroline L. Belanger, MD; Kimberly G. Yen, MD; Evelyn A. Paysse, MD
Posted: 12/17/2009
Firecracker damage to the eye can result in mechanical, thermal, and chemical injury. Most firecrackers are made of flash-powder, a mixture of oxidizer and metallic fuel that burns quickly and, if confined, produces a loud noise.[1] Metallic particles, such as aluminum, may be found in firecrackers, and they can appear radio-opaque on CT scans.
The treatment for chemical injury to the eye from a firecracker includes copious irrigation of the eye as soon as the injury is detected.
Any remaining particles in the fornices should be removed because they can cause tissue necrosis.
A shield is recommended to protect the eye and a regimen of cycloplegics and steroid drops or ointments should be started as soon as possible to decrease inflammation. Amniotic membranes are thought to deliver anti-inflammatory factors to the ocular surface, thus reducing scarring and providing a protective structure where the epithelial cells could replicate.
Steroids must be decreased after 1 week of treatment because they can inhibit wound healing and promote infection.
Treatment for the 4 grades of corneal burns must be adjusted according to the severity of injury.
In a grade 1 corneal burn, only corneal epithelial loss is present and no conjunctival ischemia is found. The prognosis is very good.
Grade 2 is associated with some corneal edema and corneal haze; conjunctival ischemia affects less than one third of the limbus and some permanent scarring may occur.
Grade 3 is associated with significant haziness of the cornea, and limbal ischemia is less than one half of the limbus. Prognosis is variable and vision is usually impaired. Finally, a corneal burn is grade 4. The cornea is opaque, and limbal ischemia affects greater than one half of the limbus.
Grade 4 burns may be associated with globe perforation, and the prognosis is poor.
Fireworks-related Injuries
Fireworks are thought to have originated in China[5] and are commonly used throughout the world to celebrate the New Year, Independence Day (United States), Halloween, and many smaller festivals.
In 2006, 9200 people were treated in emergency departments for fireworks-related injuries in the United States.[1] One of every 3 people injured were children younger than 15 years, with boys being affected 3 times more frequently than girls.[1] Some reports state that people actively participating in fireworks-related activities are more frequently and severely injured than bystanders.[1] The body parts most often injured were hands, eyes, and the head, face, and ear.[6] Common injures that occur are blindness, third-degree burns, and permanent scarring.[1]
Burns were the most common injury to all body parts, except the eyes and head, where contusions, lacerations, and foreign bodies in the eye occurred more frequently.[1] Although fewer injuries were associated with items such as sparklers and rockets,[1] one third of the injuries to children younger than 5 years were due to sparklers.[1] Injuries resulting from public fireworks displays are extremely rare. Risk factors for injuries include proximity to the device; lack of physical coordination necessary to safely handle fireworks, such as in the case of younger children; and curiosity, a common factor in children.[1] Alcohol consumption is also admitted in a high percentage of patients with fireworks injuries.[6]
Preventive safety measures when working with firecrackers, such as wearing safety glasses, have been shown to be effective in reducing the number of injuries.[6]
The World Health Organization (1984) has recommended a worldwide ban on the manufacture of all fireworks.
My note: Wear Eye protection when playing with firecrackers - they can blind u!!
A 5-Year-Old With Firecracker Injury to the Eye
Caroline L. Belanger, MD; Kimberly G. Yen, MD; Evelyn A. Paysse, MD
Posted: 12/17/2009
Firecracker damage to the eye can result in mechanical, thermal, and chemical injury. Most firecrackers are made of flash-powder, a mixture of oxidizer and metallic fuel that burns quickly and, if confined, produces a loud noise.[1] Metallic particles, such as aluminum, may be found in firecrackers, and they can appear radio-opaque on CT scans.
The treatment for chemical injury to the eye from a firecracker includes copious irrigation of the eye as soon as the injury is detected.
Any remaining particles in the fornices should be removed because they can cause tissue necrosis.
A shield is recommended to protect the eye and a regimen of cycloplegics and steroid drops or ointments should be started as soon as possible to decrease inflammation. Amniotic membranes are thought to deliver anti-inflammatory factors to the ocular surface, thus reducing scarring and providing a protective structure where the epithelial cells could replicate.
Steroids must be decreased after 1 week of treatment because they can inhibit wound healing and promote infection.
Treatment for the 4 grades of corneal burns must be adjusted according to the severity of injury.
In a grade 1 corneal burn, only corneal epithelial loss is present and no conjunctival ischemia is found. The prognosis is very good.
Grade 2 is associated with some corneal edema and corneal haze; conjunctival ischemia affects less than one third of the limbus and some permanent scarring may occur.
Grade 3 is associated with significant haziness of the cornea, and limbal ischemia is less than one half of the limbus. Prognosis is variable and vision is usually impaired. Finally, a corneal burn is grade 4. The cornea is opaque, and limbal ischemia affects greater than one half of the limbus.
Grade 4 burns may be associated with globe perforation, and the prognosis is poor.
Fireworks-related Injuries
Fireworks are thought to have originated in China[5] and are commonly used throughout the world to celebrate the New Year, Independence Day (United States), Halloween, and many smaller festivals.
In 2006, 9200 people were treated in emergency departments for fireworks-related injuries in the United States.[1] One of every 3 people injured were children younger than 15 years, with boys being affected 3 times more frequently than girls.[1] Some reports state that people actively participating in fireworks-related activities are more frequently and severely injured than bystanders.[1] The body parts most often injured were hands, eyes, and the head, face, and ear.[6] Common injures that occur are blindness, third-degree burns, and permanent scarring.[1]
Burns were the most common injury to all body parts, except the eyes and head, where contusions, lacerations, and foreign bodies in the eye occurred more frequently.[1] Although fewer injuries were associated with items such as sparklers and rockets,[1] one third of the injuries to children younger than 5 years were due to sparklers.[1] Injuries resulting from public fireworks displays are extremely rare. Risk factors for injuries include proximity to the device; lack of physical coordination necessary to safely handle fireworks, such as in the case of younger children; and curiosity, a common factor in children.[1] Alcohol consumption is also admitted in a high percentage of patients with fireworks injuries.[6]
Preventive safety measures when working with firecrackers, such as wearing safety glasses, have been shown to be effective in reducing the number of injuries.[6]
The World Health Organization (1984) has recommended a worldwide ban on the manufacture of all fireworks.
My note: Wear Eye protection when playing with firecrackers - they can blind u!!
Psoriasis
Treatment of Severe Scalp Psoriasis: From the Medical Board of the National Psoriasis Foundation
Chan CS, Van Voorhees AS, Lebwohl MG, et al
J Am Acad Dermatol. 2009;60:962-971
A task force of the National Psoriasis Foundation Medical Board has written a consensus statement on therapy for scalp psoriasis. A MEDLINE search for "scalp psoriasis" was performed and the results were graded on the basis of levels of evidence developed by Shekelle and colleagues.[1] Treatment recommendations within the consensus statement are divided into first- and second-line options, and first-line treatment options are further divided into those that are appropriate for short-term vs long-term use.
The recommended first-line, short-term therapy for scalp psoriasis is topical corticosteroids, which have been the mainstay in the treatment of scalp psoriasis for years. The lowest-strength agent that is efficacious is preferred, although in general high-potency agents can be used safely. A limited number of head-to-head studies have demonstrated the superior efficacy of topical corticosteroids in scalp psoriasis compared with other topical agents. However, the major limitation of these agents is that superpotent topical corticosteroids are approved by the US Food and Drug Administration (FDA) for a maximum of 4 weeks of consecutive use due to the risk for skin atrophy, striae, and telangiectasias. No studies exist supporting the safety of these agents for use on the scalp beyond this time period. Because steroid-sparing medications are associated with fewer long-term risks, agents such as calcipotriene/calcipotriol, salicylic acid, dithranol/anthralin, coal tar, and topical retinoids (ie, tazarotene) are recommended as first-line, long-term therapy for scalp psoriasis. Combination therapy with the aforementioned topical agents has advantages over monotherapy because of enhanced efficacy with minimized toxicity and side effects.
All other treatment options for scalp psoriasis were based on anecdotal evidence. Alternative first-line treatment options include intralesional corticosteroids, which should be used only for localized scalp disease due to the increased risk for side effects associated with this method of administration. Alternative second-line treatment options include phototherapy and systemic medications. Although phototherapy is an effective treatment for nonscalp psoriasis, this modality is difficult to use on the scalp due to the presence of hair, which blocks the adequate penetration of ultraviolet light. To date, no studies exist that have specifically evaluated systemic treatments for scalp psoriasis. However, on the basis of the known efficacy of systemic agents in plaque psoriasis, a therapeutic trial of these agents can be considered when scalp psoriasis has not responded adequately to the aforementioned topical therapies.
Viewpoint
The scalp is the most common area of psoriasis involvement and one of the most difficult to treat. Scalp involvement occurs in approximately 79% of psoriasis patients[2] and historically has been treated with low-potency topical steroids. FDA safety labeling limits the consecutive use of superpotent topical corticosteroids to 4 weeks. However, despite the lack of clinical trial data supporting the use of these agents for more than 4weeks, most -- if not all -- clinicians use long-term dosing of topical corticosteroids in the treatment of scalp psoriasis, especially corticosteroids of less than super potency. Underused options are coal tar, anthralin, and salicylic acid. Coal tar and anthralin are safe and effective for long-term use but often stain hair and may have a distinct, pungent smell. Salicylic acid is effective for the removal of thick scale, which allows for better penetration of other topical agents, rendering them more efficacious. Combination treatment regimens using topical steroids and topical nonsteroidal treatments can minimize or avoid the risk for steroid side effects. Because scalp skin is quite thick, some of the common side effects of topical steroids, such as atrophy, striae, and telangiectasias, are virtually never seen on the scalp. Consequently, the main safety concern with the use of topical steroids on the scalp is adrenal suppression, especially during long-term use of superpotent topical steroids. To minimize such risk, we recommend intermittent use of regimens with potent agents, such as the one we use with clobetasol propionate spray: 2-4 weeks on, followed by 2-4 weeks off, then back to 2-4 weeks on, if necessary, and so on. Used in this way, it is unlikely that the adrenal suppression encountered will be anything more than transient physiologic adrenal suppression rather than pathologic adrenal suppression leading to clinically relevant adrenal insufficiency.
References
Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999;318:593-596.
Van de Kerkhof PC, Steegers-Theunissen RP, Kuipers MV. Evaluation of topical drug treatment in psoriasis. Dermatology. 1998;197:31-36. Abstract
Guidelines of Care for the Management of Psoriasis and Psoriatic Arthritis. Section 3. Guidelines of Care for the Management and Treatment of Psoriasis With Topical Therapies
Menter A, Korman NJ, Elmets CA, et al
J Am Acad Dermatol. 2009;60:643-659
A work group of experts in psoriasis is formulating consensus guidelines for the management of psoriasis and psoriatic arthritis. The individual sections of these guidelines focus on different aspects of psoriasis management. Section 3 pertains to the management of psoriasis with topical therapies. It discusses the efficacy and safety of corticosteroids, vitamin D analogs, tazarotene, tacrolimus, pimecrolimus, emollients, salicylic acid, anthralin, and coal tar. Combination therapies are also evaluated.
Data were obtained using an evidence-based model via search of the MEDLINE database from 1960 to 2008. The evaluation of evidence was based on the 3-point numeric grading scale of the Strength of Recommendation Taxonomy used in primary care journals: I = good-quality patient-oriented evidence; II = limited-quality patient-oriented evidence; and III = other evidence, including consensus guidelines, opinion, or case studies.[1] Clinical recommendations were then formulated using the following scale: A = recommendation based on consistent and good-quality evidence; B = recommendation based on inconsistent or limited-quality patient-oriented evidence; C = recommendation based on consensus, opinion, or case studies.
Ultimately, the work group formulated recommendations for the practical clinical use of each of the topical agents and commented on the following aspects: indications, dosing, efficacy, contraindications/adverse reactions, pregnancy/nursing use, and pediatric use. The document is too complex to summarize in this review, but the reader is referred to the especially helpful tables in the article that summarize treatments, strength of recommendation, level of evidence, and supporting references.
Viewpoint
Psoriasis affects approximately 2% of the population, and clinicians need to become familiar with the treatment of this cutaneous disease. The expanding arsenal of agents used to treat this often complex condition is growing constantly. This set of guidelines, presented in an evidence-based approach by top psoriasis experts, is crucial to the care of people with psoriasis. In our opinion, every clinician who treats psoriasis should use this document. Although not every patient presents a straightforward case, these guidelines should be used as a starting point for the creation of treatment regimens based on each patient's unique disease parameters. In our clinical practice, these guidelines are not only an extremely useful reference for patient care but also an essential "textbook" for the education of medical students, residents, and fellows who are attempting to become familiar with the management of psoriasis patients.
Reference
Ebell MH, Siwek J, Weiss BD, et al. Simplifying the language of evidence to improve patient care: strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in medical literature. J Fam Pract. 2004;53:111-120. Abstract
Cochrane Review: Topical Treatments for Chronic Plaque Psoriasis
Mason AR, Mason J, Cork M, Dooley G, Edwards G
Cochrane Database Syst Rev. 2009;(2):CD005028. DOI: 10.1002/14651858.CD005028.pub2.
The Cochrane Collaboration is an independent organization that produces quarterly systematic reviews of healthcare interventions called Cochrane Reviews. These reviews seek to address the effectiveness and appropriateness of disease-related treatment regimens in a comprehensive, unbiased, and scientifically validated manner. The purpose is to facilitate the choices made by healthcare providers and policy makers regarding the care of patients. This recent Cochrane Review focuses on topical treatments for plaque psoriasis with 2 goals in mind: (1) to compare the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis with placebo; and (2) to compare vitamin D analogs with other topical treatments.
Results of 13 randomized controlled trials with a total of 21,448 study participants revealed the following regarding the topical treatments for plaque psoriasis:
Vitamin D agents, corticosteroids, anthralin, and tazarotene were each more effective than placebo;
Head-to-head comparisons of vitamin D agents vs potent/very potent corticosteroids showed no statistically significant efficacy differences;
The combination of a vitamin D agent and a steroid was more efficacious than either agent alone;
Vitamin D agents were superior to coal tar;
Vitamin D agents were more effective with occlusion and/or twice-daily application;
Potent corticosteroids were less likely than vitamin D agents to cause local adverse events such as skin irritation; and
There was no difference in frequency of systemic adverse events between placebo and all other topical agents (although the Cochrane authors pointed out that this may be due to absence of evidence rather than evidence of absence).
Viewpoint
The authors recommend that practicing dermatologists become acquainted with the Cochrane Library as a source of sound scientific information for treatment decisions. The discerning reader has the opportunity to appraise the actual data used by the authors to draw conclusions on treatment regimens by reviewing the full document version, while the more time-constrained reader can quickly peruse the summary section for a brief overview.
A quick search for Cochrane Reviews on psoriasis revealed 6 related articles. With the advent of biologic agents, it is impressive that the Cochrane reviewers chose to focus on the use of topical agents in the treatment of psoriasis. Because the majority of psoriasis patients have localized involvement, topical agents are and should remain the first-line agents of choice in most psoriasis cases and will continue to be a mainstay of treatment, except for those with generalized disease.
The obvious limitation of this document is that the information cannot be generalized to long-term maintenance therapy because the studies of these topical agents were, on average, only 6 weeks in duration. One-year safety and efficacy data are available only for vitamin D analogs (calcipotriene cream, calcipotriene plus betamethasone dipropionate ointment, and calcitriol ointment). The results showed that these agents are safe and effective for up to 1 year, and clinical practice suggests that they are safe and effective for even longer use. More long-term studies are needed, especially for agents that are not vitamin D analogs.
Abstract
This activity is supported by an independent educational grant from Galderma.
Chan CS, Van Voorhees AS, Lebwohl MG, et al
J Am Acad Dermatol. 2009;60:962-971
A task force of the National Psoriasis Foundation Medical Board has written a consensus statement on therapy for scalp psoriasis. A MEDLINE search for "scalp psoriasis" was performed and the results were graded on the basis of levels of evidence developed by Shekelle and colleagues.[1] Treatment recommendations within the consensus statement are divided into first- and second-line options, and first-line treatment options are further divided into those that are appropriate for short-term vs long-term use.
The recommended first-line, short-term therapy for scalp psoriasis is topical corticosteroids, which have been the mainstay in the treatment of scalp psoriasis for years. The lowest-strength agent that is efficacious is preferred, although in general high-potency agents can be used safely. A limited number of head-to-head studies have demonstrated the superior efficacy of topical corticosteroids in scalp psoriasis compared with other topical agents. However, the major limitation of these agents is that superpotent topical corticosteroids are approved by the US Food and Drug Administration (FDA) for a maximum of 4 weeks of consecutive use due to the risk for skin atrophy, striae, and telangiectasias. No studies exist supporting the safety of these agents for use on the scalp beyond this time period. Because steroid-sparing medications are associated with fewer long-term risks, agents such as calcipotriene/calcipotriol, salicylic acid, dithranol/anthralin, coal tar, and topical retinoids (ie, tazarotene) are recommended as first-line, long-term therapy for scalp psoriasis. Combination therapy with the aforementioned topical agents has advantages over monotherapy because of enhanced efficacy with minimized toxicity and side effects.
All other treatment options for scalp psoriasis were based on anecdotal evidence. Alternative first-line treatment options include intralesional corticosteroids, which should be used only for localized scalp disease due to the increased risk for side effects associated with this method of administration. Alternative second-line treatment options include phototherapy and systemic medications. Although phototherapy is an effective treatment for nonscalp psoriasis, this modality is difficult to use on the scalp due to the presence of hair, which blocks the adequate penetration of ultraviolet light. To date, no studies exist that have specifically evaluated systemic treatments for scalp psoriasis. However, on the basis of the known efficacy of systemic agents in plaque psoriasis, a therapeutic trial of these agents can be considered when scalp psoriasis has not responded adequately to the aforementioned topical therapies.
Viewpoint
The scalp is the most common area of psoriasis involvement and one of the most difficult to treat. Scalp involvement occurs in approximately 79% of psoriasis patients[2] and historically has been treated with low-potency topical steroids. FDA safety labeling limits the consecutive use of superpotent topical corticosteroids to 4 weeks. However, despite the lack of clinical trial data supporting the use of these agents for more than 4weeks, most -- if not all -- clinicians use long-term dosing of topical corticosteroids in the treatment of scalp psoriasis, especially corticosteroids of less than super potency. Underused options are coal tar, anthralin, and salicylic acid. Coal tar and anthralin are safe and effective for long-term use but often stain hair and may have a distinct, pungent smell. Salicylic acid is effective for the removal of thick scale, which allows for better penetration of other topical agents, rendering them more efficacious. Combination treatment regimens using topical steroids and topical nonsteroidal treatments can minimize or avoid the risk for steroid side effects. Because scalp skin is quite thick, some of the common side effects of topical steroids, such as atrophy, striae, and telangiectasias, are virtually never seen on the scalp. Consequently, the main safety concern with the use of topical steroids on the scalp is adrenal suppression, especially during long-term use of superpotent topical steroids. To minimize such risk, we recommend intermittent use of regimens with potent agents, such as the one we use with clobetasol propionate spray: 2-4 weeks on, followed by 2-4 weeks off, then back to 2-4 weeks on, if necessary, and so on. Used in this way, it is unlikely that the adrenal suppression encountered will be anything more than transient physiologic adrenal suppression rather than pathologic adrenal suppression leading to clinically relevant adrenal insufficiency.
References
Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999;318:593-596.
Van de Kerkhof PC, Steegers-Theunissen RP, Kuipers MV. Evaluation of topical drug treatment in psoriasis. Dermatology. 1998;197:31-36. Abstract
Guidelines of Care for the Management of Psoriasis and Psoriatic Arthritis. Section 3. Guidelines of Care for the Management and Treatment of Psoriasis With Topical Therapies
Menter A, Korman NJ, Elmets CA, et al
J Am Acad Dermatol. 2009;60:643-659
A work group of experts in psoriasis is formulating consensus guidelines for the management of psoriasis and psoriatic arthritis. The individual sections of these guidelines focus on different aspects of psoriasis management. Section 3 pertains to the management of psoriasis with topical therapies. It discusses the efficacy and safety of corticosteroids, vitamin D analogs, tazarotene, tacrolimus, pimecrolimus, emollients, salicylic acid, anthralin, and coal tar. Combination therapies are also evaluated.
Data were obtained using an evidence-based model via search of the MEDLINE database from 1960 to 2008. The evaluation of evidence was based on the 3-point numeric grading scale of the Strength of Recommendation Taxonomy used in primary care journals: I = good-quality patient-oriented evidence; II = limited-quality patient-oriented evidence; and III = other evidence, including consensus guidelines, opinion, or case studies.[1] Clinical recommendations were then formulated using the following scale: A = recommendation based on consistent and good-quality evidence; B = recommendation based on inconsistent or limited-quality patient-oriented evidence; C = recommendation based on consensus, opinion, or case studies.
Ultimately, the work group formulated recommendations for the practical clinical use of each of the topical agents and commented on the following aspects: indications, dosing, efficacy, contraindications/adverse reactions, pregnancy/nursing use, and pediatric use. The document is too complex to summarize in this review, but the reader is referred to the especially helpful tables in the article that summarize treatments, strength of recommendation, level of evidence, and supporting references.
Viewpoint
Psoriasis affects approximately 2% of the population, and clinicians need to become familiar with the treatment of this cutaneous disease. The expanding arsenal of agents used to treat this often complex condition is growing constantly. This set of guidelines, presented in an evidence-based approach by top psoriasis experts, is crucial to the care of people with psoriasis. In our opinion, every clinician who treats psoriasis should use this document. Although not every patient presents a straightforward case, these guidelines should be used as a starting point for the creation of treatment regimens based on each patient's unique disease parameters. In our clinical practice, these guidelines are not only an extremely useful reference for patient care but also an essential "textbook" for the education of medical students, residents, and fellows who are attempting to become familiar with the management of psoriasis patients.
Reference
Ebell MH, Siwek J, Weiss BD, et al. Simplifying the language of evidence to improve patient care: strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in medical literature. J Fam Pract. 2004;53:111-120. Abstract
Cochrane Review: Topical Treatments for Chronic Plaque Psoriasis
Mason AR, Mason J, Cork M, Dooley G, Edwards G
Cochrane Database Syst Rev. 2009;(2):CD005028. DOI: 10.1002/14651858.CD005028.pub2.
The Cochrane Collaboration is an independent organization that produces quarterly systematic reviews of healthcare interventions called Cochrane Reviews. These reviews seek to address the effectiveness and appropriateness of disease-related treatment regimens in a comprehensive, unbiased, and scientifically validated manner. The purpose is to facilitate the choices made by healthcare providers and policy makers regarding the care of patients. This recent Cochrane Review focuses on topical treatments for plaque psoriasis with 2 goals in mind: (1) to compare the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis with placebo; and (2) to compare vitamin D analogs with other topical treatments.
Results of 13 randomized controlled trials with a total of 21,448 study participants revealed the following regarding the topical treatments for plaque psoriasis:
Vitamin D agents, corticosteroids, anthralin, and tazarotene were each more effective than placebo;
Head-to-head comparisons of vitamin D agents vs potent/very potent corticosteroids showed no statistically significant efficacy differences;
The combination of a vitamin D agent and a steroid was more efficacious than either agent alone;
Vitamin D agents were superior to coal tar;
Vitamin D agents were more effective with occlusion and/or twice-daily application;
Potent corticosteroids were less likely than vitamin D agents to cause local adverse events such as skin irritation; and
There was no difference in frequency of systemic adverse events between placebo and all other topical agents (although the Cochrane authors pointed out that this may be due to absence of evidence rather than evidence of absence).
Viewpoint
The authors recommend that practicing dermatologists become acquainted with the Cochrane Library as a source of sound scientific information for treatment decisions. The discerning reader has the opportunity to appraise the actual data used by the authors to draw conclusions on treatment regimens by reviewing the full document version, while the more time-constrained reader can quickly peruse the summary section for a brief overview.
A quick search for Cochrane Reviews on psoriasis revealed 6 related articles. With the advent of biologic agents, it is impressive that the Cochrane reviewers chose to focus on the use of topical agents in the treatment of psoriasis. Because the majority of psoriasis patients have localized involvement, topical agents are and should remain the first-line agents of choice in most psoriasis cases and will continue to be a mainstay of treatment, except for those with generalized disease.
The obvious limitation of this document is that the information cannot be generalized to long-term maintenance therapy because the studies of these topical agents were, on average, only 6 weeks in duration. One-year safety and efficacy data are available only for vitamin D analogs (calcipotriene cream, calcipotriene plus betamethasone dipropionate ointment, and calcitriol ointment). The results showed that these agents are safe and effective for up to 1 year, and clinical practice suggests that they are safe and effective for even longer use. More long-term studies are needed, especially for agents that are not vitamin D analogs.
Abstract
This activity is supported by an independent educational grant from Galderma.
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