Remissions of psoriasis with excimer laser treatment.
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Humans↗
Biomedical subjects
Steven R Feldman
Publications and source records attributed to Steven R Feldman.
Terbinafine is more effective than itraconazole in treating toenail onychomycosis: results from a meta-analysis of randomized controlled trials.
BACKGROUND: Toenail onychomycosis is a challenge for clinicians to treat, and this challenge is compounded by conflicting information in the medical literature concerning the efficacy of the two principal agents used in its treatment: terbinafine and itraconazole. OBJECTIVE: The purpose of this meta-analysis is to compare the efficacy of terbinafinewith that of itraconazole in the treatment of toenail onychomycosis caused by dermatophytes. METHODS: A Medline search was performed for all English language publications from 1966 to June 1999 on the use of terbinafine and itraconazole in the treatment of toenail onychomycosis. Included were randomized studies in which subjects received no less than 3 months (or cycles) and no more than 4 months (or cycles) of either terbinafine or itraconazole. Data were abstracted and statistical analyses (random effects model, fixed effects model, and Peto's method) were applied. RESULTS: Thirteen studies were included from the original literature review of 1636 total referenced reports; four studies did not fulfill our inclusion or exclusion criteria. The primary analysis of six studies directly comparing terbinafine to itraconazole resulted in an odds ratio ranging from 1.8 (95% CI = 1.8, 2.8) to 2.9 (1.9, 4.1). The secondary analysis of three studies comparing either itraconazole or terbinafine to placebo estimated an odds ratio of 1.1-1.7. The former shows that terbinafine is 80%-190% more likely to result in mycologic cure than is itraconazole; the latter demonstrates a 10%-70% greater likelihood. The difference between the relative efficacies of terbinafine and itraconazole was highly statistically significant (p < 0.0001). CONCLUSION: Meta-analysis of the published worldwide literature finds that terbinafine is significantly more effective than itraconazole at achieving mycologic cure of toenail onychomycosis.
Antifungal Agents↗
The frequent use of oral retinoids in combination with other treatments for psoriasis: a retrospective analysis.
BACKGROUND: Combination treatment in psoriasis may be common, logical, and appropriate, even if not well tested or well documented by clinical trials. While oral retinoids such as acitretin can be used as monotherapy, efficacy can be further augmented by combination use with other agents. Similarly, because of its safety profile, acitretin can be added in low doses to help patients who have not achieved adequate control with other psoriasis treatments. OBJECTIVE: The purpose of this study was to assess how oral retinoids are used in combination with other drugs to treat psoriasis. METHODS: We assessed the use of acitretin and other oral retinoids for the treatment of psoriasis using two sources of information: nationally representative survey data from the National Ambulatory Medical Care Survey (NAMCS) and local data obtained by chart review of 518 patients seen in a university dermatology clinic. RESULTS: In the NAMCS, oral retinoids were prescribed with other psoriasis medications at 71% of visits. In the chart review, combination use was even more frequent (96% of subjects were on combination treatment) and included combinations of acitretin with topicals, phototherapy, and other systemic treatments. Adverse events were reported in 53% of patients treated with acitretin, although none were severe. CONCLUSION: Use of acitretin in combination with many other psoriasis treatments is a common practice. Mucocutaneous side effects of oral retinoids are common but with appropriate dosing are generally mild.
Acitretin↗
Tachyphylaxis to topical corticosteroids: the more you use them, the less they work?
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Administration, Topical↗
Surgery for basal-cell carcinoma of the face.
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Basal Cell Carcinoma↗
The family impact of atopic dermatitis in children: the role of the parent caregiver.
Although some preliminary work exists examining the impact of atopic dermatitis (AD) in children on their families, there is no empirical work examining specific parent caregiver factors that could contribute to the family impact of this condition. We conducted a cross-sectional, exploratory analysis of how parent caregivers are affected by their child's AD, and how certain parent caregiver characteristics and perceptions affect the family impact of this condition. Parent caregivers of children with AD (n = 49) were administered a survey to collect detailed data on socioeconomic status, health perceptions, and caregiving issues. Family impact of the child's AD was measured using a modified AD Family Impact Scale. Multiple regression analyses revealed that three major factors associated with the parent caregiver were correlated with large increases in the family impact scores: 1) perception that the child's condition is severe (13%, p < 0.01), 2) high use of nonmedical services for child's condition (21%, p < 0.01), and 3) financial concern about the child's condition (18%, p < 0.01). These preliminary data indicate distinct characteristics of the parent caregiver that are associated with higher family impact of AD in children. These parent caregiver factors may be important in identifying suitable audiences and areas for education for optimal management of children's AD.
Adult↗
Treatment of psoriasis in children: is there a role for antibiotic therapy and tonsillectomy?
Numerous studies implicate subclinical or recurrent streptococcal infection as a trigger or maintenance factor in the pathogenesis of psoriasis in children. The purpose of this article is to review the efficacy of antibiotic therapy and tonsillectomy as treatments for childhood psoriasis. Clinical trials assessing the efficacy of antibiotics or tonsillectomy as treatments for childhood psoriasis were identified with a search of the medical literature and the results were compared. Only one controlled clinical trial was identified and it did not find a significant effect of antibiotic treatment on psoriasis. In other studies, the percentage of psoriasis patients who experienced disease clearance with antibiotic therapy ranged from 0% to 55%, with no patients experiencing disease worsening during treatment. No controlled trials of tonsillectomy for psoriasis were identified. The percentage of patients who experienced disease clearance after tonsillectomy in uncontrolled trials ranged from 32% to 53% and a similar percentage reported significant improvement in their psoriasis, with a maximum of 7% noting worsening of the disease after the operation. The available evidence does not demonstrate the efficacy of either antibiotic therapy or tonsillectomy in the treatment of childhood psoriasis. Because these treatments are relatively benign compared to other treatments for severe psoriasis, the use of antibiotic therapy or tonsillectomy may still be worth considering, especially for those patients with recurrent streptococcal infections that seem to trigger or maintain their skin disease.
Adolescent↗
Patient demographics and utilization of health care services for molluscum contagiosum.
Our objective was to describe the demographics of molluscum contagiosum patients and physician utilization patterns in the United States. We obtained weighted data for office visits throughout the United States for molluscum contagiosum and common warts from the National Ambulatory Medical Care Survey (NAMCS) from 1990 to 1999. Outpatient visit data for patients diagnosed with molluscum contagiosum were analyzed using statistical software and compared to those for patients diagnosed with common warts. The main outcome measures studied were physician office visits by patients with molluscum contagiosum and patient demographic parameters including age, gender, and race. We found that health care utilization for molluscum contagiosum was the greatest for patients <or=9 years of age (51%). Ninety-three percent of patients diagnosed with molluscum contagiosum were white. The number of visits for molluscum contagiosum was evenly divided between males and females. Visits to dermatologists comprised the majority of health care utilization units for molluscum contagiosum (71%). In conclusion, visits for molluscum contagiosum are frequent and are most often handled by dermatologists. When compared to those for common warts, molluscum contagiosum visits are less common and have an age distribution more limited to children.
Adolescent↗
Tanning and skin cancer.
Skin cancer is a large and growing problem in the United States. Sun and other ultraviolet (UV) light exposures play a key role in the development of skin cancer. Pediatricians can play an important role in counseling patients and are in a position to help educate children and their families about skin cancer. The purpose of this review is to familiarize pediatricians with the magnitude of the skin cancer problem and the evidence that ultraviolet light exposure, particularly indoor tanning, contributes to this problem. We reviewed the literature on ultraviolet light and skin cancer (based on a MEDLINE search of articles using the headings "ultraviolet light" and "skin cancer") and found that skin cancer is the most rapidly growing cause of cancer deaths in the United State. There is strong epidemiologic evidence for the relationship between UV exposure and nonmelanoma skin cancer and growing evidence for the relationship between indoor tanning and melanoma. We recommend that pediatricians counsel children and their parents about UV protection. Measures such as use of sunscreen and hats for outdoor play, both at home and in school, should be encouraged.
Adolescent↗
The burden of atopic dermatitis: impact on the patient, family, and society.
Atopic dermatitis is a common disease of increasing prevalence. Affected individuals must cope with a significant psychosocial burden, in addition to dealing with the medical aspects of the disease. Furthermore, because this is primarily a disease of childhood, family members, especially parents, are also affected by the condition. Individuals and family members are burdened with time-consuming treatment regimens for the disease, as well as dietary and household changes. The financial impact of atopic dermatitis on families can also be great. Moreover, the cost to society is significant, with estimates ranging from less than 100 dollars to more than 2000 dollars per patient per year. It is estimated that the direct cost of atopic dermatitis in the United States alone is almost 1 billion dollars per year. Reducing the onus of this disease must take into account the full breadth of its burden. Targeting parents and caregivers with education and psychosocial support can decrease family and personal burden, which in turn may decrease the cost of treating the condition because of better medical, psychosocial, and family outcomes.
Cost of Illness↗
Healthcare utilization for acute and chronic diseases of young, school-age children in the rural and non-rural setting.
To determine the most frequently diagnosed conditions among rural and non-rural children age 5 to 9 and assess for environmental influences, data from the National Ambulatory Medical Care Survey (1996-2001) were used to examine frequencies of diagnoses in children age 5 to 9. Separately, we examined rural and non-rural outpatient physician visits in weighted multivariate logistic regression models. Overall, the most frequent diagnosis was routine health check, followed by several acute conditions. When analyzed separately, non-rural children were significantly more likely to visit a physician for routine health check (P = 0.002), asthma (P = 0.005), and acute upper respiratory infection (P = 0.037). Rural counterparts were significantly more likely to be seen for attention deficit disorder (P = 0.000), otitis media (P = 0.017), chronic rhinitis (P = 0.017) and influenza (P = 0.037). Children age 5 to 9 are healthy overall. When illness occurs, it is usually acute. Rural and non-rural, young, school-aged children exhibit many similarities in healthcare utilization, but differences occur. Most surprising is the difference in the diagnosis frequency of attention deficit disorder.
Acute Disease↗
Dermatological illnesses of immigrant poultry-processing workers in North Carolina.
The authors designed this study to assess skin ailments among male Latino poultry-processing workers in one plant in North Carolina. Because conditions in poultry plants expose workers to multiple agents affecting the skin, the number of skin ailments was expected to be high. A visual skin examination was conducted by a single board-certified dermatologist for 25 male workers. Dermatological Life Quality Index scores and self-reported skin treatment data were obtained through interviews. Each worker had at least one dermatological diagnosis. Infections were most common (onychomycosis, 76%; tinea pedis, 72%), followed by inflammatory diagnoses (acne, 64%). No workers had sought medical treatment. Dermatological Life Quality Index scores indicated impaired quality of life. Worker self-reports were not strongly associated with dermatologist diagnoses. Skin diseases are common among poultry workers and impact workers' quality of life; reasons for lack of medical care should be investigated.
Adult↗
Medication and health care service utilization related to depressive symptoms in older adults with psoriasis.
OBJECTIVE: This study examined the relationship between depressive symptoms and related medication adherence and health care costs in older adults (age > or = 65 years) with psoriasis. DESIGN: Prospective longitudinal cohort study over a 2-year post enrollment period in a population of older adults with psoriasis enrolled in managed care. SETTING: A Medicare Health Maintenance Organization (HMO) in southeastern United States with prescription benefits. PARTICIPANTS: Sixty-three older adults with psoriasis using topical corticosteroids therapy and enrolled in a Medicare HMO for a 2-year continuous period. MEASUREMENT: Upon enrollment, each enrollee was mailed a comprehensive health status assessment battery, which included the Center for Epidemiologic Studies Depression (CES-D) scale. Information on medication adherence (using medication possession ratio) and total health care utilization/costs following enrollment were retrieved from the Medicare HMO database. RESULTS: Nearly one-fifth of the patient population had depressive symptoms. Patients with psoriasis who had depressive symptoms at the time of enrollment were less likely to be adherent to topical corticosteroid medication (r= -0.29, p<0.01) and less likely to utilize health care resources as evidenced by lower health care costs (r= -0.27, p<0.05), after confounder adjustment. CONCLUSIONS: The prevalence of depressive symptoms in older adults with psoriasis is commonplace, with strong, yet unexplained correlations between presence of depressive symptoms and lower rates of medication and health care service use among these patients.
Aged↗
Hyperpigmentation: a review of common treatment options.
Hyperpigmentation disorders are common and include a multitude of forms. They are typically divided into three large categories: dermal, epidermal, or mixed, depending on the site of abnormality. The location of the increased melanin affects treatment options, but therapy within a group is often similar. This paper discusses the treatment modalities, including topical and surgical approaches, available for the different types of hyperpigmentation.
Administration, Cutaneous↗
Prescribing patterns for topical retinoids within NAMCS data.
OBJECTIVE: Fears of potentially costly use of topical retinoids for cosmetic treatment of photodamaged skin have resulted in many managed care organizations placing prior authorization requirements on this class of medications. The purpose of this investigation was to examine whether prescribing patterns of a nationally representative sample of US physicians shed light on the incidence of use of topical retinoids for indications other than acne. METHODS: A retrospective, cross-sectional study of data from the National Ambulatory Medical Care Survey (1996--2000) was used to examine the impact of physician specialty as well as patient diagnosis of acne on the probability of retinoid prescription in weighted multivariate logistic regression models. RESULTS: Topical retinoids were prescribed in 0.4% (14.7 million out of 3.67 billion) physician visits for any diagnosis in the 5-year period from 1996 to 2000, and in nearly 31% (12.0 million out of 38.7 million) of physician visits for a diagnosis of acne. Topical retinoids were prescribed for acne in 77.1% of the cases. This finding held when individual retinoids (tretinoin and adapalene) were examined separately. Clear age-related prescription trends are observed, with a significant decrease in prescriptions beyond the teen years. In older patients, tretinoin prescribing did not decrease as much as adapalene prescribing. CONCLUSIONS: These data suggest that managed care organizations may want to examine their own data to determine the optimum criteria for operation of prior authorization (PA) programs for retinoids. PA requirements for these medications appear unnecessary in young patients, given the very small probability of non-acne related use. PA in older patients might be targeted to those patients on topical retinoids (such as tretinoin) for which there is evidence of efficacy in treatment of cosmetic photoaging.
Acne Vulgaris↗
Tazarotene cream (0.1%) in combination with betamethasone valerate foam (0.12%) for plaque-type psoriasis.
A combination of multiple agents is often required to achieve treatment success for plaque-type psoriasis. We report a case series of 10 patients that were treated with betamethasone valerate foam (0.12%) in the morning and topical tazarotene cream (0.1%) in the evening for a total of 12 weeks or until plaques cleared. Erythema, scale, and thickness along with an aggregate severity score were determined at weeks 4, 8, and 12. One patient was lost to follow-up. Eight of the other 9 patients experienced improvement in their disease by week 12. Two patients were clear of their psoriasis at week 4 and 4 were clear at week 8. No adverse events, including irritation were reported; the use of the corticosteroid foam may protect against potential local irritation reported with tazarotene. The combination of tazarotene cream and betamethasone valerate foam is an effective combination approach to treating localized plaque-type psoriasis.
Betamethasone Valerate↗
Inpatient management of severe psoriasis.
Historically, severe psoriasis frequently required inpatient hospitalization for several weeks to reduce symptoms and prevent morbidity and mortality, Despite declining hospitalization rates there remain patients who undergo severe, acute psoriasis exacerbations requiring inpatient care. The majority of the literature describes the treatment of psoriasis in the outpatient setting. We review the inherent differences between the inpatient and outpatient management of psoriasis along several dimensions and discuss an approach to the inpatient treatment of severe psoriasis based upon therapeutic rate of onset, efficacy, and safety. The inpatient setting benefits from and lends itself to use of rapid acting, highly effective agents. Given the acute nature of psoriasis inpatient episodes, the risks associated with long-term use of a treatment are far less important in inpatient setting treatment planning than they are in the outpatient setting.
Biological Therapy↗
Factors affecting prescription of ultra-high potency topical corticosteroids in skin disease: an analysis of US national practice data.
Of the topical preparations available, the ultra-high potency corticosteroids have an important role in treating psoriasis. However, the use of these agents in many other conditions and patient populations may not be appropriate. This study examines the prescribing patterns of Class I topical corticosteroids in patients with skin disease by analyzing data from the National Ambulatory Medical Care Survey (1990-2000). Of the nearly 718 million visits for skin disease, Class I topical corticosteroids were prescribed in nearly 3% of all skin disease-related visits, with prescription rates being highest in psoriasis (22%). The study found greater prescription rates of Class I topical steroids by dermatologists compared to non-dermatologists [Odds Ratio (OR) = 4.39 (95% CI: 2.15, 8.99)]. However, there were also a large number of questionable prescriptions for other conditions, which could be construed as misuse of these medications. Despite limitations and the potential dubious use seen here, Class I topical corticosteroid use is relatively commonplace. Education efforts and novel preparations of Class I agents will help to ensure the best possible care for patients suffering from significant skin diseases like psoriasis.
Administration, Cutaneous↗