Alzheimer’s Diagnosis Expansion Lead to Controversy

Rules Seek to Expand Diagnosis of Alzheimer’s Disease“, a July 13 New York Times article by Gina Kolata, examined proposed changes to guidelines used to diagnose Alzheimer’s disease. New diagnostic tests and their use at earlier stages in the disease may lead to a 2-3 fold increase in the number of people diagnosed with Alzheimer’s disease. This has lead to considerable concern by neurologists and public health experts.

The new guidelines include criteria for three stages of the disease: 1) preclinical disease, 2) mild cognitive impairment due to Alzheimer’s disease and, 3) Alzheimer’s dementia. The guidelines should make diagnosing the final stage of the disease in people who have dementia more definitive. But, the earlier a diagnosis is made the less certain it is. And so the new effort to diagnose the disease earlier could, at least initially, lead to more mistaken diagnoses.

Dr. P. Murali Doraiswamy, a psychiatry professor and Alzheimer’s disease researcher at Duke University, stated that “people have to be prepared for unintended consequences, which always occur when the diagnosis of a disease is changed.” He added that “We ought to be cautious that we don’t stimulate all this testing before we can give people something to manage their disease. There is no point in giving them just a label.”

In response to the article, another neurologist stated, ” I view this change with trepidation. Changing the diagnostic critera to include “preclinical” Alzheimer’s (as alluded to in the article) raises a number of issues. Most medical tests do not have 100 percent specificity. And who will pay for all of these imaging studies, if there is no treatment (as yet) for preclinical alzheimers? Probably not the insurance companies. Are patients who test positive going to have trouble finding or switching insurance? And what about the risk to benefit ratio of invasive proceedurs to sample biomarkers? This type of definition may be very useful in research, but if it is prematurely applied to the general population, it may harm more patients than it helps.”

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Leading Neurologist Speaks to Future of Epilepsy Care

Andrew Wilner, M.D., Neurologist

Andrew Wilner, M.D., Neurologist

Neurologist and Medscape blogger, Andrew Wilner, M.D. FAAN, interviewed a leading epilepsy expert, Chrysostomos P. Panayiotopoulos, MD,
about the advances made in diagnosing and treating epilepsy.

Dr. Panayiotopoulos is the editor of A Clinical Guide to Epileptic Syndromes and Their Treatment, as well as the author of more than 180 articles published in prestigious medical journals.

In his latest blog, “Progress in Epilepsy“, Dr. Wilner asked Dr. Panayiotopoulos “What works needs to be done to improve the care of people with epilepsy?”

Dr. Panayiotopoulos answered that “heightening medical and social education about epilepsies is crucial. Inappropriate generalizations on epilepsies is the single more important factor of errors and failures in diagnosis and management. The practice parameter guidelines of the American Academy of Neurology are the best examples of how this can be achieved.”

Dr. Panayiotopoulos pointed out that “there are currently over 20 antiepileptic drugs and more are being developed, but there are still around 20% of patients with epilepsies that fail to achieve acceptable seizure control. The ultimate aim of drugs that prevent epileptogenesis and drugs that cure has not been satisfied. Until then, and this may be a long way off, we depend on prophylactic antiepileptic drugs, which to be ideal (or near ideal), should be highly efficacious with little if any direct or indirect, acute or chronic, adverse drug reactions.”

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“Less is More” for Rosacea says Dr. Guadalupe Sanchez

Less is more” for those suffering from rosacea, says Guadalupe Sanchez, M.D. , a dermatologist in private practice at the Family Dermatology Center in St. Peters, Missouri. By “less”, she means “less scrubbing, less sun, less product.

Dr. Sanchez provided additional details regarding her rosacea management tips. “A simplified regimen of a mild cleanser (Cetaphil, Cerave), prescribed topical medications, and a sunblock rather than a sunscreen (Neutragena for sensitive skin, Clinique city block, Vanicream), and a foundation with minimum of ingredients (Dermablend).

“I advise against toners, scrubs, “antiaging” products”, said Dr. Sanchez.  She added that, “I have found that many patients with rosacea have photodamage often accompanied by subclinical precancers (actinic keratosis).  Treating the precancers often, improves the rosacea.

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Diet and Acne Update by Dermatologist, Dr. Bari Cunningham.

The connection between acne and diet has been elusive and somewhat controversial, leading to conflicting views among physicians and patients.

Bari Cunningham, M.D., a dermatologist in private practice in Encinatas, California, has reviewed the latest medical studies regarding the acne and diet connection at the 2010 Winter Clinical Dermatology Conference. These were recently published in the July issue of the Journal of Practical Dermatology, Acne Controversies.

Dr. Cunningham’s review included the following highlights:

  • Acne prevalence increases as populations adopt a Western diet, whether through migration or cultural change“. A western diet consists of high proportions of food with a high glycemic index, as well as more processed foods, soda, beef, and dairy, according to these reviews, while non-Western diets emphasize fruits, vegetables (including root vegetables) and only a small proportion of flour, sugar, and meat.
  • “Milk consumption was associated with increased risk for acne as well as increased acne severity”. The fat content of milk (skim versus whole) has not been found to influence its association with acne, suggesting that hormones in milk may therefore play a role in mediating the skin disease.
  • Several studies have indicated that a low glycemic load diet may lead to reduction of acne lesions compared to controls. Consumption of high glycemic index foods elevates serum insulin concentrations; elevated serum insulin levels are thought to stimulate sebum production and raise androgen levels.
  • Importantly, “chocolate was not associated with exacerbation of acne.”

These reports should provide some datat to help ground the discussion with patients with acne who are seeking lifestyle changes that may help to keep their acne under control.

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Rosacea Risk Not Related to History of Sun Damage

Sun damage resulting for excessive UV exposure does not appear to increase the risk of developing papulopustular rosacea according to a study published in the July issue of the Journal of the American Academy of Dermatology (JAAD) reported that

The study, “Papulopustular rosacea: Prevalence and relationship to photodamage“, found the prevalence of papulopustular rosacea (PPR), also known as “rosacea subtype 2″ in Ireland to be 2.7%.

The study also investigated the prevalence of papulopustular rosacea (PPR) and its relationship to UV radiation exposure in 1000 randomly selected Irish individuals. 1,000 individuals (500 with low UV exposure and 500 with high UV exposure) were examined. Papulopustular rosacea was diagnosed using a standardized definition and photodamage was assessed using a photodamage scale.

The study results showed that the risk of developing rosacea was not significantly related to photodamage or UV exposure. This study only evaluates the risk of first getting rosacea following excessive sun exposure. It does not discredit the finding that sun exposure can worsen rosacea symptoms, as is reported by many people with rosacea.

Managing rosacea often require lifestyle changes such as sun avoidance, as well as long-term use of medication that help to reduce the number and severity of rosacea flares.

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Dr. Toni McCullough Points Out the Dangers of “Sun Abuse”

Dermatologist Toni McCullough, M.D. calls for attention to be paid to “sun abuse”, equating the dangers to drug abuse and alcohol abuse.

“When it comes to teenagers, risks that may be years down the road seem so far in the future that they are essentially meaningless”, says Dr. McCullough.

Dr. McCullough, a dermatologist in private practice in Savannah, Georgia pointed how awareness of the dangers of driving under the influence of alcohol  grew as a result of the efforts of Candy Lightner, the founder of MADD (Mothers Against Drunk Driving). “As a dermatologist and a mother, I would like to start a movement to make a difference in sun abuse. MELANOMA IS THE MOST COMMON CANCER AGES 25-29! It is the SECOND MOST COMMON CANCER ages 15-29. What does this mean? This means that the young are getting too much sun too early in life. And who should be the ones to protect our young this early in life? PARENTS!!”, pointed out Dr. McCullough.

“Until parents respond to sun abuse seriously, the skin cancer epidemic will continue to spiral out of control. Furthermore, photoaging / sun damage of the skin is going to become more and more important as we continue to live longer.  Changes in the ozone and environment may be causing us to get more damage per unit of time per area now than ever before. Why do we as parents allow our children to abuse the sun without accountability and without retribution?”

Dr. McCullough referred to studies to show that the incidence of sunburns is higher in people with higher education to show that “education is not working with regards to sun abuse (just like education was not enough with drunk drivers).” She added that “some form of accountability and discipline when young may be the only way to “teach” and decrease sun abuse.

“Parents discipline and even punish their kids for doing drugs, drinking alcohol, drinking and driving, smoking, having premarital unprotected sex, not doing homework, making poor grades in school, not wearing seatbelts etc. What if mom and dad said, “We’re sorry but we told you not to abuse the sun, to be careful, wear sunblock, wear a hat, cover up, etc. You were not careful enough and are sunburned so you’re not going to the party tonight.” If this happened, kids would be more responsible with sun exposure.  When I was young, I myself baked in the sun. I have already had precancerous lesions and cancerous lesions. I was not properly educated and was not held accountable by my otherwise strict parents for my behavior in the sun.”

“Oh it’s not as serious as drugs and sex and alcohol… or is it? Teens going to tanning beds are now developing melanomas which are deadly! Yes, sun abuse can damage and even kill you”, pointed out Dr. McCullough.

She made the following suggestions to help reduce exposure to the sun’s damaging UV rays.

  • Slip! Slop! Slap! – Slip on a shirt (dark color, tightly woven fabric). Slop on sunscreen (broad spectrum with high numbers are better). Slap on a hat (best to shade face, neck, ears).
  • Remember the best defense is to COVER UP with clothing (SPF clothing is best). Be aware that a white T-shirt only offers a SPF of 4. Sunscreen should be your LAST line of defense (clothing & hats are best).
  • Avoid midday sun (10AM to 4PM).
  • Shadow rule – If your shadow is shorter than you are, the sun’s ultraviolet rays are intense. Seek shade.
  • Wear sunglasses that block UV rays and protect surrounding tender skin.
  • Proper sunscreens should be chosen, applied, and cared for properly. Sunscreens degrade in heat and sun. Studies show our sunscreen application is too thin resulting in products only delivering about half of the SPF noted on the bottle.
  • Adequate SPF –Choose the high numbers to help make up for imperfect application.
  • Use a broad spectrum sunscreen with adequate UVA protection
  • Adequate application – one ounce for the entire body
  • Apply sunscreen 30 minutes before going outside & reapply often.
  • Avoid tanning beds.

Toni McCullough, M.D. also pointed out that the following groups and organizations play an important role in reducing sun abuse.

  • Parents – There must be education by setting a good example as well as accountability and punishment for sun abuse.
  • Schools – Shaded areas are needed regardless of the cost.
  • Teachers – Formal sun education is needed in schools. Teachers (often tanners themselves) need to set examples.
  • Recreational centers – Shaded areas need to be developed. Peak sun hours should be avoided for activities.
  • Coaches – Help kids protect themselves from the sun while playing sports.
  • Automobile manufacturers – We need total UVB and UVA protection in car windows.
  • Beauty magazines – We need to change the concept of beauty. Americans still think a tan makes you look healthier, thinner, and more beautiful. Sarah Brown , Beauty Editor at Vogue, has had a healthy influence on women’s beauty and her dedication to helping women understand the dangers of sun damage.
  • Legislators – We need help with enforcing shade and sun education in schools / recreational facilities. Tanning bed facilities need to stop advertising to the young and should in fact be closed.
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“Use Physical Sunscreens” Advises Leading Dermatologist Laura E. Skellchock, M.D.

Dr. Laura Skellchock, Dermatologist

Laura Skellchock, M.D., FAAD, Dermatologist

Dermatologist Laura E. Skellchock, MD, FAAD advises her patients to use only physical sunscreens when seeking protection from the sun’s damaging UV rays and as an important step to maintain skin health.

Anything with titanium dioxide, zinc oxide, silica and boron are inert, meaning they simply lay on the skin, producing a physical barrier from the sun and its harmful rays,” said Dr. Skellchock. “I have never been a proponent of chemical sunscreens.  These are chemicals which absorb UV rays, preventing them from getting to your skin and doing damage.  Only problem is that they are applied to the skin, so they absorb the UV rays right on your skin!”

Dr. Laura Skellchock of Integrative Dermatology in Boca Raton Florida provided additional details about the problems with chemical sunscreens. “Chemical filters include a range of ingredients including avobenzone (also known as Parsol 1789), oxybenzone, dioxybensone, PABA and PABA esters, cinnimates, salicylates, digalloyl trioleate, methyl anthranilate, avobenzone (Parsol 1789) Tinosorb M, Tinosorb S, Mexoryl SX and Mexoryl XL. These agents work by interacting with the skin’s top layer to absorb UV rays and convert them into energy (what type? heat? free radicals? do we really know?) before these UV rays can harm the skin. Chemical sunscreens tend to use a combination of ingredients to protect against the full spectrum of UV rays. Some of these chemicals can act as estrogen mimics, and some produce free radicals. It’s common knowledge that benzene is a carcinogen.  Avobenzone is chemically similar to benzene, and I think it would have the capacity to penetrate into the skin; I don’t think we know if this is safe long-term.  I know that Avobenzone has the capacity to penetrate through a plastic jar – and I don’t feel comfortable putting that on my skin.”

Dr. Skellchock further described the benefits of physical sunblocks. They “are not irritating to the eye, so they can be used on the thin skin of the eyelids.  I like the ease of using a powder physical block that has pigment in it – I use it as a sunblock and my make-up both.  It won’t leak out of its container and cause a mess, it won’t degrade in the heat if left in the car, and I know it’s not getting into my body. I have an intuition that we may learn that a lot of the active ingredients in chemical sunblocks may actually be harmful to the skin and our bodies, and may be taken off the market in the future.”

Dr. Laura Skellchock provided her clinical perspective on other sun safe measures that people can take, in addition to reguarly applying sunscreen. “The absolute best sunblock is clothing that is thick enough to prevent UV penetration“.  I routinely cover myself with a beach towel while driving, and basically act like a “vampire” in the sun.  When I go into the water at the beach I wear a full thin body suit which also helps protect me from critters who live in the sea.  When I ride my bike, I wear a Yelomod shirt, sunglasses, a visor under my helmet and a bandana on my face, and the tip of my nose is covered with a physical sunblock.  I may look bizarre and get strange stares from people, but I’d rather protect my skin instead of having to fix sun damage in the future.”

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Rosacea Management Reviewed by Leading Dermatologist, Dr. Nelson Novick

Nelson Novick, M.D., Dermatologist

Nelson Novick, M.D., New York City Dermatologist, Professor of Dermatology

Nelson Novick, M.D., FAAD, FAACS reviews rosacea treatment options that offer long-term control of rosacea symptoms.

Dr. Nelson Lee Novick, a New York dermatologist in private practice and Clinical Professor of Dermatology at Mount Sinai School of Medicine stated that “while we still do not have a cure for rosacea,  we do have a variety of effective therapies to treat the symptoms. The twice daily application  of oxymetazoline, a blood vessel constrictor,  has been found extremely helpful in suppressing the embarassing blush. Brimonidine applied twice a day has also been helpful for this and may even suppress to some extent the development of telangiectasis (“broken blood vessels”).”

Dr. Novick also reviewed rosacea medications that provide long-term control of the papules and pustules that appear with type 2 rosacea. “Oracea, a relative of the antibiotic tetracycline, is an antiflammatory oral agent has been used successfully for both bringing about a remission  active lesions and, as well as for maintenance (for preventing the development of new lesions). Both metronidazole and azelaic acid used topically have been found extremely useful for the same purposes. Ideally one of these agents, without the need for any oral medication, is all that is necessary to maintain control.

Dr. Nelson Novick described his approach to providing targeted treatment of specific skin lesions associated with rosacea. “I have found that broken blood vessels can be simply and economically eliminated by a series of treatments with radiowaves that penetrate the skin and serve to destroy the tiny netorks of blood vessels. Likewise, simply electrocautery has proven successful for smoothing bumpy areas of sebaceous hyperplasia.”

Dr. Novick concluded that “while there may not be a cure, these days there are quite satisfactory and gratifying ways to achieve long-term control of rosacea symptoms.”

Rosacea is a condition that is estimated to effect between 10 and 14 million Americans. Although its precise cause is still not fully  understood, it is currently believed to have a genetic basis and can be triggered by exposure to a variety of environmental factors, including sun, heat, alcohol, hot-temperature beverages, certain medications, and spicy foods. Common signs and symptoms of rosacea include easy flushing (blushing), the development of broken blood vessels, pimples, pustules, and the appearance of “overgrown oil glands” known as sebaceous hyperplasia. Further information about rosacea can be found at the National Rosacea Society.

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Sunscreen Advice from Leading Dermatologists. Natural OK, But Need SPF 30 and Apply Lots

Jeff Dover, M.D., Dermatologist

Jeff Dover, M.D., Dermatologist

Esteemed dermatologists share their clinical opinion regarding sunscreen selection and usage.

A June 27 Los Angeles Times investigated the use of natural ingredients in sunscreens and reported that “Some consumers are turning to niche manufacturers’ so-called natural sunscreens,” with a variety of organic or plant derived ingredients, such as nut or hemp seed oils, green tea extracts, and beeswax.” Jeffrey Dover, M.D., a dermatologist in private practice at Skin Care Physicians of Chestnut Hill and President of the American Society for Dermatologic Surgery stated that “the products are effective”, but when on to explain that those ingredients do not confer any benefit. The active ingredients in natural sunscreens that actually protect one from the sun’s damaging UV rays are titanium dioxide and zinc oxide, both of which “work by physically blocking the sun’s rays”, said Dr. Jeff Dover. A sunscreen product without these physical sun blocks would not be effective.

Dr. Dover added that consumers typically apply enough of the natural products to make them effective. (The American Academy of Dermatology (AAD) recommends that consumers use enough sunscreen to fill a shot glass.)

The same issue investigated the benefits, if any, of sunscreens with high SPF values. “Many dermatologists” do not think sunscreens with extremely high SPF numbers are worth the money”, said dermatologist James Spencer, M.D. “SPF refers to multiples of how much longer it takes the skin to burn,’ but it isn’t a linear progression.” Dr. Spencer recommends sunscreens with an SPF of 30 because we know you’re not going to put enough on.’ In fact, studies have shown that most people apply only one-half as much sunscreen as they should to get the level of protection offered by the sunscreen.

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Sunscreen Rating System: FDA Delays Leaves Consumers Vulnerable

The U.S. FDA has been considering a set of guidelines for sunscreen that would set up a four star system for ranking their ability to protect the skin from ultraviolet A (UVA) rays. The guidelines would also ban the use of misleading terms like “sunblock” and “all-day protection”.

The problem is…..these rules have been under evaluation by the Food and Drug Administration for at least three years ago and, in the meantime, American consumers remain unable to get clear information to help them evaluate the best possible choices.

Darrell Rigel, M.D.

Darrel Rigle, M.D. – Dermatologist

This issue was covered  in a June 23rd New York Times article, “UVA Protection: It’s Not PDQ” by Catharine Saint Louis. The article explored the delays in approving final sunscreen labeling guidelines and the role that industry has played.

“One of the reasons that there’s been such controversy about the sunscreen monograph is that certain companies stand to benefit significantly from whatever comes out of the monograph,” said Dr. Zoe D. Draelos, a dermatologist in High Point, N.C. In other words, sunscreen makers will lobby for whichever UVA test gives their formulations an advantage.

“Companies have different views, because their products will perform best on one of the tests,” said Dr. Darrell S. Rigel, a New York City dermatologist. For example, Johnson & Johnson (which makes Neutrogena) and Schering-Plough (which makes Coppertone and recently merged with Merck) are in one camp that has qualms about one of the two tests proposed by the F.D.A. They are also against the proposed four-star UVA-ranking system and would instead like to see simple descriptions of UVA effectiveness on labels.

Hopefully, the FDA will be able to push through this gridlock soon so that the public has the ability to make informed decisions about the sunscreens they buy for themselves and their family. Today, most remain woefully unaware that many sunscreens available in the store do not sufficiently block UVA rays, one of the major causes of skin cancer.

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