Infectious Disease: Maui Derm 2019 Highlights

Matthew Zirwas, MD

In this session, Matt J. Zirwas, MD discussed the challenges of managing a range of contact dermatitis dilemmas, including:

  • When to patch test and when to treat empirically
  • Non-allergenic topicals
  • Low allergenicity personal care products
  • Allergen updates
  • The explosion of contact dermatitis from essential oils
  • Fragrances
  • Change in which formaldehyde releasers are most common
  • New or up-and-coming allergens, including long lasting nail polish, glucosides, and ammonium persulfate
  • Effects of L-histidine supplementation in atopic dermatitis
  • Oral management of xerotic dermatitis

 

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Infectious Disease: Maui Derm 2019 Highlights

Ted Rosen, MD

Ted Rosen, MD

Session moderator Ted Rosen, MD provided a thorough overview of the latest in infectious disease. Dr. Rosen discussed the arbovirus threat in the United States, including chikungunya and zika. Dr. Rosen also mentioned ongoing research on the potential oncolytic effects of the zika virus for neuroblastoma and glioblastoma. Yellow fever outbreak in Brazil and West Nile Virus in the US was reviewed, as well as the rising incidence of syphilis gonorrhea in the US. Dr. Rosen discussed his own research on ozenoxacin cream for the treatment of adult and pediatric patients with impetigo. Other research on 15% and 10% potassium hydroxide for Molluscum contagiosum was also reviewed. Other topics discussed include the possibility of a two-drug regimen for stable HIV, evidence for oral antibiotic exposure and increased risk of kidney disease, E. coli resistance to antibiotics after exposure to fluoxetine, tecovirimat for smallpox, leptospirosis associated with contaminated water from floods and the use of chemoprophylaxis after floods to reduce outbreaks, antibiotic links to increased risk of death in heart disease patients and cancer relapse, and hypoglycemia in patients taking fluoroquinolone.

Dr. Sheila Fallon-Friedlander

Dr. Sheila Fallon-Friedlander

Sheila Fallon-Friedlander, MD discussed infectious disease in pediatric patients.
Dr. Fallon-Friedlander discussed many cases and topics, including:
  • Invasive mold disease in immunocompromised children
  • Eczema herpeticum
  • A study showing a lack of significant efficacy of cyclosporine in pediatric cases of Stevens–Johnson syndrome/toxic epidermal necrolysis.
  • The case of a three-day-old boy with diffuse superficial skin erosions and brown crusts on the back
  • Perianal pseudoverrucous papules and nodules
  • Ivermectin and permethrin for treating scabies
Dr. Aditya K Gupta

Dr. Aditya K Gupta

Aditya K. Gupta, MD, PhD, FAAD, FRCP (C) provided attendees with updates on onychomycosis and tinea. Regarding onychomycosis epidemiology, Dr. Gupta addressed the role of the immune system in conferring protection or susceptibility to dermatophyte infections, the increased risk of Candida or Aspergillus onychomycosis in elderly individuals or those with renal transplants, HIV, or diabetes, and the increasing prevalence of onychomycosis. Dr. Gupta also compared diagnostic strategies and reviewed strain typing for onychomycosis. In addition, Dr. Gupta reviewed optimal regimens for oral drugs such as terbinafine, itraconazole, and fluconazole. He also discussed research on posaconazole and albaconazole. Topical therapies including ciclopirox 8% HPCH nail lacquer, efinaconazole, and tavaborole were reviewed. In addition, Dr. Gupta discussed a critical review of laser studies. Dr. Gupta finished his presentation with strategies to prevent onychomycosis recurrence and learning objectives for the future.

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Cosmeceuticals: Maui Derm 2019 Highlights

In this session, three of the world’s leading authorities in the cosmeceutical arena, Drs. Carl Thornfeldt and Henry Lim discussed the latest innovations in technology and product development in the field of cosmeceuticals.
Carl Thornfeldt, MD FAAD, RSM, educated attendees on selecting the best cosmeceutical, with an emphasis on herbs. Dr. Thornfeldt’s presentation covered such topics as:
  • The many conditions associated with destructive chronic inflammation and disrupted skin barrier
  • In vitro data as an inadequate method for predicting human success
  • The requirements for “active ingredients” to remain effective at varying concentrations and formulations, and methods for determining whether these ingredients actually work
  • Dermatopharmacokinetics
  • Manufacturing and packaging specifics to protect ingredient efficacy
  • Precedents for ensuring cosmeceutical efficacy and safety
  • The benefits of using herbs in cosmeceuticals
  • The effects on climatic and seasonal conditions, time of harvest, storage site and duration, and extraction method on the active ingredients in herbal extracts
  • Results from studies comparing herbal blends with prescription products for the treatment photoaging and eczema
Henry W. Lim, MD

Henry W. Lim, MD

Henry W. Lim, MD used his presentation to discuss the latest in photoprotection. He began with the results of a survey on photoprotective habits including using sunscreen, seeking shade, and wearing hats and other protective clothing. Survey respondents who reported engaging in all four habits showed the lowest likelihood of sunburn. Dr. Lim discussed another study comparing users of sun protection factor (SPF) 16 sunscreen with a control group that observed decreased squamous cell carcinoma, basal cell carcinoma, photoaging, and melanoma among the users of sunscreen. Dr. Lim went on to review the public health and environmental detriments of organic filters such as oxybenzone and octinoxate as well as the merits of inorganic (mineral) filters such as zinc oxide and titanium oxide. Dr. Lim finished his presentations with the benefits of photolyases and stabilized, biologically active antioxidants in sunscreens.

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Atopic Dermatitis: Maui Derm 2019 Highlights

Dramatic advances in our understanding of the immunology and pathogenesis of atopic dermatitis (AD) has resulted in the development of new and novel topical and systemic therapies. MauiDerm’s experts discussed new findings regarding the pathogenesis and comorbidities of AD. The spectrum of old and new topical therapies, such as crisaborole, and systemic therapies, including emerging biologic therapies, were discussed.

Andrew Blauvelt, MD

Andrew Blauvelt, MD, MBA, presented attendees with an update on the AD pipeline. Dr. Blauvelt reviewed recent research on biologics such as tralokinumab, an anti-IL-13 monoclonal antibody (mAb), lebrikizumab, an anti-IL-13 mAb, and nemolizumab, an anti-IL-31 receptor A mAb. Dr. Blauvelt discussed other studies on monoclonal antibodies for AD targeting IL-5, IL-22, TSLP, IL-17C, IL-1alpha, IL-33, and OX40.  In addition, Dr. Blauvelt discussed research on the JAK1 Blockers Baricitinib, upadactinib, and PF-04965842. Additional potential therapies discussed include ASN002, ZPL-389, and apremilast. Dr. Blauvelt also covered new topical drugs for AD, including JAK inhibitors, PDE4 inhibitors, and tapinarof.

Eric Simpson, MD, MCR

Eric Simpson, MD, MCR

Eric Simpson, MD, MCR, provided an update on dupilumab. Topics discussed by Dr. Simpson include:

  • When to use systemic therapy
  • What to tell patients to expect with systemic therapy
  • Are there patients who should not be put on dupilumab?
  • Should we check labs?
  • How to treat dupilumab conjunctivitis
  • How to treat facial resistance or flares
  • How long will patients stay on dupilumab?
  • Tapering
  • Other uses for dupilumab
  • Combination treatment
  • Vaccination

Lawrence Eichenfield, MD

Lawrence F. Eichenfield, MD, provided attendees with an update on pediatric AD.

Dr. Eichenfield began by reviewing the typical timeline for AD development and different disease trajectories for the distinct AD phenotypes, noting there is still much work to be done on phenotyping. He went on to review practical recommendations for the evolving therapeutic landscape and the algorithm for incorporating new therapies. Dr. Eichenfield also discussed recent research on topicals for pediatric AD and counseled attendees on an effective approach to infected AD. In addition, topical microbiome transplants and topical bacterial probiotics were discussed. Dr. Eichenfield finished his presentation with other ways to improve care and additional interesting articles from the literature.
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Red, Scaly Rashes: Clinical Pearls

Matthew Zirwas, MD

What should we do with patients who present with red, scaly rashes? Dr Zirwas provides some of his clinical pearls from Maui Derm NP+PA Summer 2015…

  • Look behind the earlobes, under the jaw, and at the upper eyelids to distinguish between airborne contact dermatitis and photodermatitis;
  • Look for islands of sparing and ask if it started on the scalp when you’re considering pityriasis rubra pilaris;
  • With a widespread facial dermatitis, look for sharply demarcated red, scaly patches to diagnose seborrheic dermatitis, even if it isn’t in the normal distribution of seborrhea;
  • In cases of rosacea that don’t respond to treatment the way you expect, look for tiny, pinpoint pustules as a clue that demodex is the driving factor;
  • Dermatitis under a ring is essentially always irritant dermatitis from irritants trapped in the band. Fill in concavities on the inside of the band and only wear one ring per finger;
  • When the fingertips are the main place that is affected with a hand eczema, suspect friction with paper and keyboards as the most likely cause;
  • A rash under a bra-strap is most likely caused by symptomatic dermographism. Push-up bras with thin straps are most likely to cause problems.

Skin of Color: Clinical Pearls

Seemal Desai, MD

Here are some important takeaway messages from Dr Desai’s presentation on skin of color at Maui Derm Summer NP+PA:

  1. Erythema can be difficult to distinguish in patients with skin of color. Don’t be fooled by areas of violaceous hue, brownish discoloration, and bluish brown discoloration that can actually represent erythema and thus active inflammation. For example, in patients with psoriasis
  2. Progressive Macular Hypomelanosis is a condition commonly on the trunk, and can be seen in the distribution of tinea versicolor
  3. Treat acne vulgaris in patients with skin of color aggressively. These patients are more prone to post-inflammatory hyperpigmentation, which can be difficult to treat
  4. Inflammatory disorders such as sarcoidosis, cutaneous lupus, and infectious pathologies can mimic psoriasis in skin of color and vice-versa. Biopsy when in doubt
  5. First line therapy in the treatment of melasma consists of triple combination topical therapy, but second line therapy, including chemical peels should be considered for recalcitrant cases

Clinical Pearls: Nevus

Ashfaq Marghoob, MD

Here are some important takeaway points from Dr Marghoob’s presentation during the Pigmented Lesion session at Maui Derm NP+PA Summer 2015…

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

Infectious Diseases: Clinical Pearls

Sheila Fallon-Friedlander, MD

What do we need to know about infectious diseases in our pediatric patients?

  • Remember that not all “infections” in atopic dermatitis are bacterial. HSV can infect AD lesions and the hint is “monomorphous, punched-out”
  • Rashes in neonates instill fear in family & staff alike – always first determine if the child appears ill, then set your “DefCon level”   Concern for molluscum is Defcon 5,   HSV is Defcon 1
  • Diaper dermatitis is a frustrating disease that can be infectious. Remember these possibilities:
    • Candida
    • Staph
    • Strep
    • Molluscum
  • Diaper dermatitis is frequently NOT infectious
    • MCI (baby wipes) irritant derm
    • Dyes from “colorful” diapers
    • Zinc /metabolic deficiencies
    • LCH
  • Measles is still an infectious disease concern world-wide. The risks of the vaccine are far outweighed by risk from the disease
  • Recent studies have shown that the measles vaccine can actually stimulate immune responsiveness

Psoriatic Arthritis: Key Developments and Future Directions

Arthur Kavanaugh, MD

Dr Kavanaugh provides us with his clinical pearls on psoriatic arthritis (PsA)…

  • There is increasing evidence that early diagnosis and treatment of PsA results in improved outcomes
  • There exists a large gap and unmet need in PsA, with many patients not being evaluated by doctors or receiving appropriate therapy
  • Because skin manifestations usually precede joint involvement, often by years, Dermatologists play a key role in PsA diagnosis. However, this can present challenges.
  • New guidelines for PsA treatment are under development, and may provide some assistance to clinicians.
  • TNF inhibitors have allowed improved outcomes in PsA, and there continues to be great interest in optimizing therapy with these agents.
  • There is great interest in new targets and agents for the treatment of PsA. Recently revealed data with IL-17 inhibition show promise for treatment of all the various domains of PsA, including peripheral arthritis, skin and nail disease, enthesitis and dactylitis, and axial/spinal arthritis.
  • The IL-12/23 inhibitor ustekinumab was approved last year in PsA and has been shown to be effective across domains of disease.
  • The PDE4 inhibitor apremilast received FDA approval for PsA 3/21/14 and for psoriasis 9/23/14. Its use is increasing in the clinic, for diverse PsA patients. Safety is a particularly attractive feature of this drug.
  • Additional agents are in development for PsA.
  • Optimal management of PsA depends on the levels of activity and severity across the various domains of disease.

10 Pearls from Dermatopathology

Whitney A. High, MD, JD, MEng

  1. 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.
  1. 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.
  1. 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

  1. 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.
  1. 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.
  1. 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.
  1. 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.
  1. 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)
  1. 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

  1. 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.