By Louis Kuritzky, MD

The Heavy Emotional Costs of Rosacea

Source: Moustafa F, et al J Am Acad Dermatol 2014;71:973-980.

Quality-of-life (QOL) assessments of persons with health maladies document that even for asymptomatic disorders like hypertension, scores on validated instruments such as the SF-36 worsen. Is it any surprise, then, that for a symptomatic disorder such as rosacea, the emotional burden is significant?

There are a variety of reasons why, of the non-malignant dermatoses, rosacea is particularly burdensome. The facial cutaneous erythema of rosacea may be mistaken for the flush associated with excessive alcohol use, prompting queries about potential alcohol problems. Additionally, as opposed to most cases of inflammatory facial dermatitis, such as acne, which either spontaneously disappear in the post-adolescent interval or are markedly improved by anti-inflammatory and antibacterial treatments, treatments for rosacea are often not fully successful, and patients must learn to cope with residual visible skin changes.

Moustafa et al published their review of studies (n = 17) that specifically looked at QOL issues in patients with rosacea. Depression, embarrassment, social phobia, and stress were increased in patients with rosacea. The good news is that some treatments that improve rosacea (e.g., azelaic acid gel, doxycycline, ivermectin) also demonstrate improved QOL scores. The authors suggest that clinician acknowledgement of the psychosocial burdens of rosacea may enhance opportunities for better outcomes.

Treatment Choices Among the PDE5 Inhibitors

Source: Hatzimouratidis K, et al Int J Impotence Research 2014;26:223-229

The currently available PDE5 inhibitors — avanafil (Stendra), sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) — all function by the same basic mechanism and have similar efficacy. Hence the choice of which agent to USE depends more on specific patient-related factors and preferences.

The primary focus of this study by Hatzimouratidis et al was to evaluate the psychosocial outcomes of patients with erectile dysfunction when treated with an on-demand PDE5 inhibitor (sildenafil 50 mg or tadalafil 10 mg) vs daily tadalafil 5 mg. After the first 8 weeks of treatment, patients (n = 770) were informed about the option to try the other two treatments and decide which one they preferred, and were told to use their preferred PDE5 inhibitor for the next 16 weeks.

At the conclusion of the trial, there were no statistically significant differences among the three treatment options for most of the study metrics. There was a greater improvement in sexual self-confidence and spontaneity in patients who took tadalafil (daily or on-demand) than sildenafil, perhaps related to the longer half-life of tadalafil, which allows a substantially greater window of efficacy than sildenafil.

Patients may benefit from an opportunity to try more than one PDE5 inhibitor, but the differences between them are generally quite modest.

Screening Asymptomatic Diabetics with CT angiography

Source: Muhlestein JB, et al. JAMA 2014;312:2234-2243

Persons with diabetes are recognized to be at increased risk for coronary artery disease (CAD). Their high-risk status has prompted employment of tools for cardiovascular (CV) endpoint prevention, such as aspirin, despite the fact that none of the clinical trials of aspirin done solely among diabetics has shown a reduction in mortality.

Some experts, recognizing the high-risk CV status of diabetics, have condoned screening with tools such as exercise treadmill testing to identify otherwise-silent CAD. The United States Preventive Services Task Force in 2012 recommended against screening for CAD in asymptomatic individuals in general. Why? Well if we were to perform treadmill testing on a room full of 70-year-old men,, a good number would indeed be found to have “meaningful” CAD, some of whom would be recommended to undergo interventions. The reason we don’t do that is that no one has been able to demonstrate that intervening with such screening in asymptomatic men improves outcomes. Might a more sophisticated indicator of CAD — as obtained through computed tomography angiography (CT) — better identify diabetics who would benefit from intervention?

Muhlestein et al report on the FACTOR-64 study, which was a randomized trial of asymptomatic diabetics (n = 900) who underwent CT angiography screening, or “routine care,” and were followed for a mean of 4 years.

In concordance with the previous U.S. Preventative Services Task Force advice not to screen asymptomatic patients with exercise testing, this trial also found that computed tomography angiography did not reduce all-cause mortality or non-fatal MI. CT angiography is expensive and exposes patients to significant radiation. In the absence of any evidence of benefit, it would be difficult to justify screening asymptomatic diabetic individuals.