Maui Derm 2016 Highlights: Dermatology in Review

Hensin Tsao, MD, PhD

How in this day and age is the message of UV protective sunscreen still not clear? Why are we seeing so many BCC’s and SCC’s? All sun-exposed skin contains a large number of driver mutations for skin cancer. The number of persons with at least 1 procedure for NMSC increased by 14% (from 1,177,618 to 1,336,800) from 2006 through 2012 and this may be due in large part to failure to use sunscreen by >80% of men and >50% of women. Our strategies for patient education with regard to the importance of sunscreens and sun avoidance need a continued and renewed voice. Consider educating general practitioners in your area on skin cancer screening and prevention measures. It can save lives.

When sun damage and other factors yield the worst results, combination therapy with new agents targeting immune function have increased survival in patients with melanoma. The result of that is a rise to a growing population of cancer survivors that will require close monitoring. Recent studies, though small in design suggest vitamin B3 supplementation may aid in chemoprevention in high-risk patients. You might consider adding B3 (a more benign option) to a regimen of potentially chemo-preventive agents such as nicotinamide, oral retinoids, topical DNA repair enzymes, and oral NSAIDs.

Finally, it appears that the microbiome is the key to tumor immunity. Studies indicate that gut flora/tumor interaction may extend to therapeutic response. You may want to consider a broader treatment regimen which includes the ingestion of probiotics along with checkpoint inhibitors.

Pediatric Dermatology Update: Clinical Pearls from Albert Yan, MD

  • Treatment of molluscum can result in stereotypical ID reactions resembling Gianotti-Crosti syndrome
  • Papular-purpuric gloves and socks eruption resembles RMSF, but is painful and caused by a virus
  • Candidal diaper dermatitis can be treated with mupirocin
  • Kerions may become less symptomatic with oral corticosteroid
  • Atypical mongolian spots may indicate mucopolysaccharidosis
  • Multiple satellites are associated with neurocutaneous melanosis
  • Segmental pigmentation can occasionally be associated with underlying syndromes
  • Forehead port wine stains indicate a risk for Sturge-Weber syndrome
  • The site of the hemangioma dictates its associated risks

Models of Collaborative Practice: Pearls from Abby Jacobson

  • Understand that an employment contract is different than the supervisory or collaborative agreement required by many state practice regulations.  The employment contract covers important items such as compensation, duties, and benefits whereas most supervisory or collaborative agreements required by the state outline how you and the physician will interact to provide patient care.
  • Make sure your contract includes a provision to have access to patient records even if no longer employed there in the event a malpractice case is brought against you.  Although eventually a judge will court order it, avoid the expense and delay and have it in your contract.
  • Look at what aspects of your employment contract would be impacted if the practice is sold or closes, and develop language to address those potential changes.
  • Although you may be the eternal optimist, employment contracts need to be reviewed with a pessimistic eye – always asking “what if…” and imaging the worse case ever scenario.
  • A good PA/NP employment contract develops a crucial framework for your working relationship.  It needs to cover important aspects such as hours, duties, location, support staff, and benefits.  Paying attention to just the compensation aspect of your contract can be a critical error that can negatively impact your future.

Nail Disease: Clinical Pearls from Phoebe Rich

  1. In a patient with chronic onycholysis with oozing that is unresponsive to therapy, consider Bowen’s disease of the nail bed.
  2. A thickened nail with white longitudinal and channels with splinter hemorrhages are likely to be an onychomatricoma.
  3. Brittle nails can be caused by or exacerbated by anemia and hypothyroidism.
  4. New onset pincer nails can be drug induced, the most common of which is beta blockers.
  5. A strong association of subungual glomus tumors and type 1 Neurofibromatosis has been identified.
  6. Longitudinal erythronychia (red band in the nail) is most commonly due to an onychopapilloma but other rare causes include SCC and amelanotic melanoma.

Psoriasis 2015: More Pearls from Bruce Strober, MD, PhD

  • Hepatitis B serologies should be obtained prior to starting TNF inhibitors. Understanding the meaning of the various tests is important.
  • Continuous therapy with biologics more reliably guarantees persistent response.
  • Palmoplantar psoriasis is usually more difficult to treat, yet most effective psoriasis medications can be successful in at least 1/3 of patients.
  • Subcutaneous methotrexate demonstrates better bioavailability, tolerability, and efficacy when compared to oral methotrexate.
  • Ustekinumab is approved for the signs and symptoms of psoriatic arthritis, yet displays lesser efficacy for this disease than that of the TNF inhibitors.
  • All biologics have demonstrated efficacy for the treatment of nail psoriasis.
  • It is safe to use TNF-inhibitors in the context of hepatitis C infection.
  • Immunogenicity is one reason biologic therapies lose efficacy over time.
  • Biologic therapies have not been demonstrated to cause solid tumor malignancies at a rate greater than the baseline rate of patients with psoriasis.
  • Patients with a prior history of malignancy often can safely receive biologic therapies.
  • Live vaccines should only be administered to patients who are not currently receiving biologic therapies.
  • TNF inhibitors are thought to be safe to use during pregnancy and breastfeeding.

Psoriasis 2015: Pearls from Bruce Strober, MD, PhD

  • Apremilast achieves PASI 75 in approximately 30% of patients after 16 weeks of therapy.
  • Apremilast has FDA-approval for the treatment of both psoriasis and psoriatic arthritis.
  • Apremilast is associated with a >5% weight loss in between 10-20% of treated patients.
  • Secukinumab is the FDA-approved biologic medication with currently the highest level of clinical efficacy of all the self-injectable medications.
  • A side effect of secukinumab is oral candidiasis, which is usually mild and occurs in up to 5% of patients.
  • Secukinimab therapy should be used with caution in patients with inflammatory bowel disease.
  • IL-23 inhibition is a future mechanism of action for psoriasis therapy that shows very high efficacy in early clinical trials.
  • Ixekizumab is an IL-17 inhibitor that promises the highest level of efficacy of its class.
  • Tofacitinib inhibits JAK kinases and likely will be an oral drug approved for psoriasis. The only question is which dose, 5 or 10 mg, will be approved.
  • Secukinumab, ustekinumab and apremilast, like TNF inhibitors, are able to treat psoriatic arthritis to varying levels of efficacy. The TNF inhibitors remain the gold-standard therapies for psoriatic arthritis, though.

Blistering Disease: Clinical Pearls from Neil Korman, MD

  1. Blisters can be caused by infections, inflammation (including several autoimmune conditions) as well as physical and mechanical injury.
  2. Diagnostic testing to make a diagnosis of an autoimmune blistering disease includes biopsies for histology and direct immunofluorescence as well as serum studies for indirect immunofluorescence and/or ELISA studies.
  3. The pemphigus family of diseases are uncommon but can be quite severe and typically require treatment with aggressive systemic immunosuppressive agents.
  4. These agents include oral corticosteroids often in combination with mycophenolate mofetil, azathioprine and rituximab.
  5. There are several subepidermal blistering diseases including Bullous Pemphigoid,

Mucous Membrane Pemphigoid, Epidermolysis Bullosa Acquisita, Dermatitis Herpetiformis, Linear IgA Disease and Pemphigoid Gestationis.

  1. Bullous pemphigoid is typically a disease of the elderly and is the most common of the subepidermal autoimmune blistering diseases.
  2. Indirect immunofluorescence studies utilizing salt split skin are extremely helpful in distinguishing between bullous pemphigoid and epidermolysis bullosa acquisita.
  3. Patients with mucous membrane pemphigoid more commonly have IgA antibody responses than do patients with bullous pemphigoid.
  4. Rituximuab is becoming a more commonly used and very successful therapy in the treatment of most of the autoimmune blistering diseases except for those with an IgA antibody response.

Dermatopathology: 10 Pearls from Whitney High, MD

  • Dermatopathology is one of two ABMS-recognized subspecialties in dermatology, and one may become fellowship-trained after first being a board-certified dermatogist or general pathologist.
  • Biopsy use is increasing. In nine geographic areas of the USA, over the time period 1986-2001, the biopsy rate among those >65 years of age rose 5-fold and the melanoma rate rose 2.4-fold.
  • There are mulitple steps involved in taking a specimen from a piece of “wet” tissue, in formalin, to an interpretable slide and to a typewritten report. These steps include:
    • biopsy performed & fixed in formalin
    • accessioned
    • grossed
    • processed
    • embedded
    • cut
    • stained and coverslipped
    • analyzed
    • transcribed/typed/signed
    • transmitted back to the provider
  • The dermatopathologist is examining but a small portion of your original sampling, and this must always be considered when one assesses the “representative nature” of the results.
  • There is an old mantra in pathology: crap in = crap out. No dermatopathologist, regardless of skill or expertise, can weave a poor sample into an outstanding result.
  • It is the clinician responsibility to secure a “representative biopsy,” and if this is not done, eventually this inadequacy will be discovered. Over the period of 1998-2005, the number of shaves increased, but the volume of a typical shaves decreased.
  • The technique employed (shave, punch, excision) must be adapted to the clinical situation – there are no fixed rules that may be applied to every situation. This is why the clinician is being paid an “evaluation/management” code; to select a biopsy that is appropriate for the circumstances.
  • A recent study of pigmented lesions showed the odds of misdiagnosis (overall and that associated with adverse outcome) were higher with a punch biopsy than with an excisional biopsy, whereas a shave biopsy was only weakly associated with misdiagnosis. (Ng et al. 2010)
  • Situations where the biopsy technique should be carefully considered include suspected:
    • verrucous carcinoma
    • mycosis fungoides
    • bullous pemphigoid
    • immunofluorescence studies
    • panniculitis
    • alopecia
    • lymphoid proliferations
    • pigmented lesions
  • The pathology report itself should be carefully read and scrutinized to understand precisely what the dermatopathologist is trying to convey. Demographic data should be confirmed. The technique and specimen size should be verified. Data used by the dermatopathologist to formulate the diagnosis should be noted (i.e. step levels, immunostains, special stains, etc.). If questions still exist, a phone call should be placed to the dermatopathologist for expanded dialog.

Nevus: Clinical Pearls from Ashfaq Marghoob, MD

  1. Globular nevi, reticular nevi, starburst nevi, homogeneous blue nevi are all biologically distinct subsets of nevi
  2. Peripheral globular and starburst pattern correlate with the radial growth phase of dysplastic nevi and Spitz/Reeds nevi respectively
  3. DN and Spitz nevi are markers for increased risk for developing melanoma
  4. DN and markers for increase risk for melanoma and potential precursors to melanoma
  5. Congenital nevi have a 1-5% risk for developing an associated melanoma
  6. Screening for melanoma requires looking for lesions that are different, uneven in distribution of texture/color (ABCD), and/or changing
  7. Dermoscopy improves the clinical sensitivity and specificity for cutaneous malignancy

Clinical Pearls from Melinda Jen, MD

  • Propranolol is now FDA approved for the treatment of hemangiomas in infants over 5 weeks of age and can be administered twice a day;
  • The greatest risk for Sturge-Weber syndrome may be involvement of the forehead and nose;
  • Early introduction of peanuts may decrease the likelihood of peanut allergy in high risk infants;
  • Washing dishes by hands may decrease the risk for children to develop eczema and allergies;
  • MRSA can be found on household surface, especially the TV remote, bathroom hand towels, sheets, bathroom light switch, and bathroom sink;
  • Most genital nevi can be observed;
  • A large, long term, prospective study showed that there is no increased risk of malignancy with pimecrolimus.