Meeting Highlights 2019

Infectious Disease: Maui Derm 2019 Highlights

January 31, 2019

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

Infectious Disease: Maui Derm 2019 Highlights

January 31, 2019

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

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

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.

Cosmeceuticals: Maui Derm 2019 Highlights

January 30, 2019

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 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.

Atopic Dermatitis: Maui Derm 2019 Highlights

January 30, 2019

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, 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.

Evaluating and Treating Pruritus: Maui Derm 2019 Highlights

January 29, 2019

Sonja Ständer, MD

In this session, Sonja Ständer, MD and Gil Yosipovitch, MD, two of the world’s leading authorities on pruritus, discussed the pathophysiology and management of a wide variety of itch disorders.

Topics discussed during the session presentations include:

Gil Yosipovitch, MD

Important questions to ask an itchy patient
Simple tools for assessing itch for the dermatologist and allergist
Cases of chronic itch without rash
Treatment regimen for pruritus of undetermined origin
Ending the antihistamine era for atopic dermatitis
Addressing the neural system in connection with itch treatment
Central nervous system targets for itch treatment by reducing neural sensitization
Mature aging itch immunosenescence in the elderly

Acne and Rosacea Update: Maui Derm 2019 Highlights

January 29, 2019

In this session, presenters discussed new drugs, new data, and new insights into acne and rosacea.

Guy Webster, MD

Guy Webster, MD, PhD began his presentation by reviewing the case of a 17-year-old patient who experienced myalgia while taking isotretinoin, then elaborated on isotretinoin and muscle damage and how he handles these cases. He also reviewed the very uncommon problem of resistance to isotretinoin and how to address this issue, then discussed the case of one isotretinoin-resistant nodule in a 20-year-old patient. Dr. Webster also discussed adalimumab for the treatment of hidradenitis suppurativa. Additional treatments for acne were reviewed, including topical minocycline, topical androgen inhibitors, sarecycline, and a new tetracycline.

Richard Gallo, MD

Richard L. Gallo, MD, PhD, used his presentation to provide an update of the pathophysiology of acne. Dr. Gallo covered such topics as:

The age of the microbiome and acne
Name change of Propionibacterium acnes to Cutibacterium acnes (C. acnes)
How to detect C. acnes
The specific types of C. acnes that are associated with acne
C. acnes global epigenetic inflammatory response
Model of epigenetic control of acne pathogenesis
Therapy by targeting acne metabolites
Updates to the diagnosis, classification, and assessment of rosacea
The complex pathology of rosacea and how this differs greatly from acne

James Leyden, MD

James Leyden, MD presented on treating acne without antibiotics. He began with a review of the history of antibiotic therapy for acne, starting in 1950 with the discovery of the anti-acne effects of tetracycline and erythromycin, to today with antibiotic effects on P. acnes being greatly compromised. Dr. Leyden went on to discuss non-antibiotic options for treating acne, including methods for sebum suppression such as spironolactone, oral contraceptives, isotretinoin, and topical clascoterone, anti-microbials such as benzoyl peroxide, addressing comedogenesis with topical retinoids, and anti-inflammatory treatments such as dapsone.

Psoriasis Update: Maui Derm 2019 Highlights

January 28, 2019

Maui Derm’s panel of leading authorities discussed a number of topics related to psoriasis, including the “metabolic” impact of psoriasis, new topical and systemic drugs in 2019, psoriatic arthritis, and the immunology and genetics of psoriasis.

Andrew Blauvelt, MD

Andrew Blauvelt, MD, MBA, focused his presentation on new translational psoriasis research. Dr. Blauvelt discussed important clinical questions in psoriasis, including:

Why does skin disease recur at the same anatomic sites when relapsing?
Can we cure patients with currently available biologic therapies?
Do biologic therapies decrease the risk of cardiovascular disease?

Arthur Kavanaugh, MD

Arthur Kavanaugh, MD presented attendees with a psoriatic arthritis (PsA) update. PsA treatment options discussed by Dr. Kavanaugh include adjunctive treatments, DMARDs, biologics, JAK inhibitors, PDE4 inhibitors, and experimental treatments.

LInda Stein-Gold, MD

Linda Stein-Gold, MD, educated attendees on how to optimize treatment approaches with topical therapies. Dr. Stein-Gold discussed the importance of vehicles and how they affect the potency, and as a result, the efficacy of topical treatments. She pointed to different vehicles used with betamethasone dipropionate 0.05% to illustrate the concept. Dr. Stein-Gold discussed other ways to enhance topical treatment penetration, including hydration and heat as well as topical vitamin D3. She also discussed the prevention of steroid-induced atrophy using combination therapies. Also discussed was a phase 3 clinical study to assess the safety and efficacy of halobetasol propionate and tazarotene lotion in plaque psoriasis. Dr. Stein-Gold also reviewed new topical molecules including PDE4 inhibitors, JAK inhibitors, and aryl hydrocarbon receptor agonists.

Bruce Strober, MD, PhD

Bruce E. Strober, MD, PhD presented interesting psoriasis data from 2018. He discussed apremilast, specifically changes in weight and A1c after 16 weeks of apremilast in patients with psoriasis and PsA. Dr. Strober also discussed cardiovascular risk in psoriasis, reviewing research on the effect of systemic and biologic drug treatment on carotid intima-media thickness in patients with moderate-to-severe psoriasis as well as vascular and systemic inflammation following treatment with ustekinumab in patients with psoriasis. Finally, Dr. Strober discussed pediatric psoriasis and reviewed research on the efficacy and safety of apremilast for pediatric patients with moderate-to-severe plaque psoriasis. Another treatment discussed included ixekizumab and ustekinumab for the treatment of nail lesions in patients with plaque psoriasis.

Pediatric Dermatology: Maui Derm 2019 Highlights

January 28, 2019

In this session, Maui Derm’s expert panel of dermatologists covered a wide range of topics in pediatric dermatology. Among those experts were Sheila Fallon-Friedlander, MD, and Ilona Frieden, MD.

Sheila Fallon-Friedlander, MD

Dr. Fallon-Friedlander began her presentation with a discussion of rare cases of Spitz nevi in children and strategies when encountering Spitz nevi in pediatric patients under the age of 12. In addition, Dr. Fallon-Friedlander discussed the incidence of melanoma in pediatric patients with congenital melanocytic nevus (CMN), including how to identify which patients with CMN are most at risk for melanoma. In addition, the role of genetic mutations in CMN was discussed, as well as a case of aggressive melanoma in an infant with congenital nevus syndrome and multiple NRAS and BRAF mutation-negative nodules. Dr. Fallon-Friedlander also reviewed screening guidelines for thyroid function in children with alopecia areata. In addition, Dr. Fallon-Friedlander discussed terbinafine therapy for pediatric onychomycosis and culture methods for the diagnosis of the condition. Dr. Fallon-Friedlander concluded her presentation with a discussion of molluscum contagiosum.

Ilona Frieden, MD

Dr. Frieden’s presentation covered such topics as infantile hemangiomas (IH) and vascular malformation updates. Dr. Frieden reviewed the clinical practice guidelines for the management of IH from the American Academy of Pediatrics, including guidelines on risk stratification, timing of referrals for IH, and the management of IH across multiple medical and surgical specialties. In addition, Dr. Frieden discussed risk factors for the degree and type of sequelae after the involution of untreated IH as well as studies on propranolol for the treatment of high-risk IH and timolol for superficial IH. Moving on to vascular malformations, Dr. Frieden discussed somatic mosaicism, new research on the cause of birthmarks, and a case of Klippel-Trenaunay syndrome treated with sirolimus. Dr. Frieden also discussed sirolimus for the treatment of lymphatic malformation.

Pigmented Lesion Clinic: Maui Derm 2019 Highlights

January 27, 2019

Hensin Tsao, MD, PhD

In this session, several challenging clinical cases involving pigmented lesions that challenged our experts were presented. Critical issues vital to the practicing dermatologist were discussed, including congenital and Spitz nevi, management of dysplastic/atypical nevi, genetic testing and surgical management of melanoma, and therapies for metastatic melanoma.

Session moderator Hensin Tsao, MD, PhD discussed the clinical questions used to structure the evidence review that informed the new American Academy of Dermatology (AAD) Melanoma Guidelines.

Ashfaq Marghoob, MD

Ashfaq A. Marghoob, MD, discussed biopsies, covering such topics as new CPT biopsy codes for 2019, achieving primary and secondary aims of biopsies, the trend toward smaller specimens, affirming the safety of melanoma biopsies, partial and complete biopsies, differences between tangential biopsies and saucerization, and the importance of step-sectioning nevi.

Whitney High, Whitney A. High, MD, JD, MEng

Whitney A. High, MD, JD, MEng discussed genetic tests for the diagnosis and prognosis of melanoma. Genetic tests that were covered included comparative genomic hybridization (aCGH), fluorescent in situ hybridization (FISH), and gene expression profiling (GEP). Specifically, Dr. High presented on gain/loss in genetic information in aCGH and

FISH, gene expression via mRNA in GEP, and two “new” tests based on GEP technology—diagnostic 23-GEP and prognostic 31-GEP.

Cutaneous Oncology: Maui Derm 2019 Highlights

January 27, 2019

George Martin, MD

In the first cutaneous oncology session of the meeting, George Martin, MD, Brian Berman, MD, PhD, Ted Rosen, MD, and Neal Bhatia, MD provided attendees with their presentation, Actinic Keratosis Update and Pearls 2019.

To start the presentation, the importance of treating every AK due to the inability to predict which AKs will eventuate into invasive squamous cell carcinoma (SCC) was emphasized. Language used to communicate treatment urgency to patients, as well as adherence, persistence, and therapy preferences among patients with AKs was discussed. New diagnostic approaches for AKs, including optical coherence tomography and thermal imaging were presented. Treatment guidelines for AKs were compared.

Ted Rosen, MD

Dr. Berman elaborated on topical treatment of actinic keratosis, including 5-Fluorouracil; imiquimod 5%, 3.75%, and 2.5%; diclofenac 3% gel; and ingenol mebutate. Future treatments on the horizon for AKs were also discussed, including KX2-391 ointment, VDA-1102 ointment, SR-T100 gel, and Actikerall (LAS41005). Dr. Rosen also highlighted two “wild suggestions” for the future of AK treatment: a green tea extract and honey.

Neal Bhatia, MD

Drs. Martin and Bhatia provided attendees with an update on photodynamic therapy for the treatment of actinic keratoses, including a PDT clinical consensus guide, approved light sources, and commercially available products such as 20% aminolevulinic acid (ALA) solution and a new 10% ALA gel. PDT topics also covered included daylight mediated PDT, methods for painless in-office PDT, and increasing the cost-effectiveness of PDT.