Elevate-Derm West Conference 2024 Clinical Insights Day 2
- In:
Clinical Practice,
Professional Development
Day 2: Friday, November 8, 2024
What’s in Our Cosmetic Toolbox for the Medical Derm Provider: Suneel Chilukuri, MD
The four main causes of acne vulgaris are decreased epithelial cell turnover, increased keratinization within the follicle, increased sebum production, and proliferation of Cutibacterium acnes.
Scarring in the top reason dermatology providers are sued.
Azelaic acid and licorice extract inhibit 5 Alpha-Reductase.
Collagen induction therapy can be used to improve scars through injury/inflammation, tissue proliferation, and tissue remodeling.
In adults inflammation plays a role in the creation of scars following wound healing.
Updates in Hyperpigmentation: Suneel Chilukuri, MD
The goals for treating hyperpigmentation are to inhibit melanogenesis, protect from UV exposure and other inflammatory stimulants, and increase cell turnover of pigmented keratinocytes.
When recommending sunscreens to patients with hyperpigmentation the sunscreen needs a physical block and a tint.
Cysteamine was shown to be significantly more effective than hydroquinone in vivo, but its intense odor has historically prohibited topical use.
Herparan Sulfate is a natural repairing molecule essential for renewing damaged, inflamed skin and helps preserve structural integrity of collagen and elastin fibers.
Maqui Berry is the most antioxidant fruit on Earth, with 5-7 times more antioxidant power. It inhibits glycosylation of tyrosinase enzyme and decreases erythema,
Do not use a beta or alpha hydroxy acid washes alongside a retinol, because it will deactivate the retinol.
Corticosteroids” The Good, The Bad, The Ugly: Douglas DiRuggiero, PA-C
Glucocorticoids work through vasoconstriction, antiproliferative effects, immunosuppression, and anti-inflammatory effects.
Clobetasol is 600 times more potent than over-the-counter Hydrocortisone.
Topical, periocular steroid creams/ointments used for eczema may lead to a significant rise in intraocular eye pressure in eyes with baseline elevated intraocular pressure.Combination steroid and vitamin D analogue treatment minimizes skin atrophy and decreases other steroid monotherapy-related risks.Topical corticosteroids and cumulative corticosteroid usage need to be evaluated for risk of total exposure when considering treatment options since topical options with new mechanisms of action are available.
Predictive factors for adrenal insufficiency in patients who used topical corticosteroids for at least 12 months are higher body surface area greater than 10 percent involved for dermatologic condition, age less than 60 years old, and basal serum cortisol of less than 7ug/dL.
Discussions in CSU: Jason Hawkes, MD, and Jennifer Hsiao, MD
Urticaria is a heterogeneous, inflammatory, pruritic skin condition with a 2:1 female predominance.
Chronic urticaria is defined by hives continuing longer than six weeks and acute urticaria is less than six weeks.
Chronic urticaria can have a significant quality of life impact, including work impairments, sleep disorders, anxiety, mood disorders, anticipatory fear, social withdrawal, and substance abuse. Quality of life impact is similar to coronary artery disease.
Mast cell activation and degranulation drive all types of urticaria.
Four times antihistamines can be tried for chronic spontaneous urticaria, but approximately 50% of patients will not have an adequate response, so other treatments are necessary.
Dupilumab and Omalizumab are FDA-approved for the treatment of chronic spontaneous urticaria. Omalizumab has a black box warning for anaphylaxis risk.
Urticaria Activity Score 7(UAS7) is a score that measures the severity of itch and wheals daily for a seven-day period. This score is being used in clinical trials.
Remibrutinib is a bruton tyrosine kinase inhibitor that is being studied for the treatment of chronic spontaneous urticaria.
Checking Your Knowledge: Cutaneous Manifestations of Immune Checkpoint Inhibitors: Jason Hawkes, MD and James Song, MD
In a patient with immune checkpoint inhibitor-related toxicities with severe pruritus, consider treating them with gabapentinoids, and if there is no response after one month, consider dupilumab, omalizumab, or narrow-band UVB phototherapy.
Treatment-related adverse reactions are common in patients being treated with immunotherapy for cancer. Rashes and pruritus are especially common skin manifestations. It is important to treat these adverse reactions to prevent discontinuation of the cancer medication.
Pain in the skin, blisters or erosions, especially in the mucous membranes, or morbilliform eruption on the face are very concerning rashes in cancer patients being treated with immunotherapy. They usually need to be hospitalized.
Cancer patients can be in clinical trials. When treating a cancer patient, ask if they are in a clinical trial because your treatment could make them ineligible to continue in the clinical trial.
There are distinct reactions with specific agents/cancers; for example, vitiligo is often seen in melanoma trials or patients on Ipilimumab can develop Ipilimumab-induced Grover’s disease.
Update on AD Therapeutics: James Song, MD
Interleukin-13 is the predominant driver of atopic dermatitis, whereas interleukin-4 has been shown to be less predominant.
The use of topical Ruxolitinib 1.5% cream is not recommended in combination with therapeutic biologics, other Janus Kinase inhibitors, or potent immunosuppressants like azathioprine or cyclosporine.
Delgocitinib is an investigational topical, PAN-JAKi, that targets key mediators of chronic hand eczema pathogenesis. There are currently no FDA-approved treatments for chronic hand eczema.
If a patient with atopic dermatitis on dupilumab has low disease activity and has been on dupilumab for at least one year, can consider tapering it to once every three weeks or once every four weeks dosing if the patient is interested in decreased dosing.
Topical roflumilast is formulated without fragrances or irritating ingredients, such as propylene glycol, which is associated with tolerability issues.
OX40 (ROCA)/OX40L (AMLIT) inhibition has the potential for disease modifications with extended periods of disease control, even off therapy.
Methotrexate, Dapsone, Acitretin, Cyclosporin: Revisiting Old Friends: James Song, MD
Methotrexate with a low-dose prednisone showed significant efficacy in treating alopecia areata versus methotrexate alone.
In atopic dermatitis patients, methotrexate showed the lowest 6-month risk of significant infection compared to azathioprine, prednisone, and mycophenolate.
Caffeine/cocoa antagonizes adenosine receptors, thereby making methotrexate gastrointestinal side effects more tolerable. Coffee (approximately two strong cups) should be consumed the morning of the methotrexate dose, 1-3 hours before the methotrexate dose, and again the morning after the methotrexate dose.
Liver biopsies are not necessary for patients on methotrexate. Noninvasive blood serology tests(FibroTest/FibroSure) or imaging (Fibroscan) are available to monitor liver health instead.
Patients taking methotrexate should limit their alcohol intake to no more than 1-2 drinks daily for liver protection.
Glucosamine can improve the therapeutic effect of low-dose cyclosporin.
Alcohol will promote the re-esterification of acitretin to etretinate, which is fifty times more lipophilic than acitretin, which can then be stored in fat for years. Even using mouthwash with alcohol can cause this so use caution in women of childbearing age.
You can reduce the risk of dapsone-induced methemoglobinemia by giving patients vitamin D 800 IU daily, and cimetidine 400 mg TID.