Seemal Desai: What's New in Vitiligo

JUNE 14, 2020

Dr. Desai discusses what’s new in vitiligo, including outcome measures, stabilizing the skin disorder with multimodal treatment methods, and its psychological impact on patients and their families.

Annual Meeting Coverage: June 16, 2020

SESSION HIGHLIGHTS

Systemic Therapies for Dermatologists: Comprehensive Review and Update

Adam Friedman, MD, FAAD, presented on the topic of cannabinoids for treating inflammatory skin diseases, a fledgling area of dermatology gaining interest among dermatologists and consumers. Dr. Friedman started with a review of cannabinoids, the endocannabinoid system, and how these interact with inflammation. He then reviewed the therapeutic potential of cannabinoids in atopic dermatitis, allergic contact dermatitis, prurigo nodularis, lichen simplex chronicus, psoriasis, acne, scleroderma, dermatomyositis, and cutaneous lupus erythematosus. Dr. Friedman also reviewed safety implications and quality assurance measures to watch out for as the use of synthetic cannabinoids and over-the-counter cannabidiol products increase. Regarding the future of cannabinoids, Dr. Friedman identified opportunities for growth in optimizing the clinical effects of cannabinoids.  

Anne Chang, MD, provided a review and update of non-melanoma skin cancer (NMSC). Dr. Chang guided viewers through scenarios when surgery is not sufficient for controlling aggressive basal or squamous cell carcinoma, reviewed the current systemic treatment options for these cancers, and instructed viewers on how to manage the cutaneous side effects of systemic therapies. Additionally, Dr. Chang reviewed the risks and benefits of the available systemic therapies for NMSCs so viewers can provide better counsel to their patients before starting therapy. Finally, Dr. Chang provided strategies for effective collaboration with disciplines outside dermatology in order to manage aggressive basal and squamous cell carcinoma. 

Jennifer Choi, MD, FAAD, presented on adverse effects of newer systemic medications, including pembrolizumab, nivolumab, and cemiplimab. Dr. Choi reviewed the most common cutaneous side effects of immune checkpoint inhibitors (ICI), the most common organs affected as a side effect of ICI, and the spectrum of immune-related adverse events. 

Rajiv Nijhawan, MD, presented on perioperative pain management in dermatologic surgery. Dr. Nijhawan instructed viewers on how to identify pre-operative patients with a high risk of post-operative pain and reviewed interesting data on managing pre-operative pain anxiety as a means to reduce post-operative pain. He reviewed additional pre-operative pain management strategies, including pre-operative acetaminophen and carbohydrate loading, as well as tips for managing pain during the pre-operative anesthesia injection. Dr. Nijhawan also reviewed data on non-pharmacological options for managing intra-operative pain, including music, art activities while patients wait for results, and virtual reality headsets showing calming videos. Pharmacological approaches to intra-operative pain included long-acting anesthesia and nitrous oxide. Dr. Nijhawan then reviewed methods for managing post-operative pain, with a special focus on minimizing prescription opioid use. 

 

 

Skin of Color 

Amit G. Pandya, MD, FAAD, discussed facial hyperpigmentation. Dr. Pandya reviewed the differential diagnosis of facial hyperpigmentation, providing examples of cases that illustrated the variety of pigmentary disorders that can lead to hyperpigmentation. Dr. Pandya also discussed the superiority of using sunscreens containing iron oxides versus sunscreens with UV protection alone for blocking visible light and improving melasma and discussed research that refuted the idea that computers and smartphones cause melasma. Additionally, Dr. Pandya reviewed research behind effective therapies for melasma, including hydroquinone, topical steroids, tretinoin, peels, new lasers, and of course, sunscreen. 

John Harris, MD, PhD, presented on what’s new in vitiligo. Dr. Harris reviewed rapid progression of vitiligo and the four clinical signs of disease activity, including trichrome, inflammatory, and confetti vitiligo, as well as the Koebner phenomenon. Dr. Harris noted the importance of recognizing the reasons behind resistant patches of vitiligo, then shared treatment goals in vitiligo and the treatment algorithm that he uses in his practice. 

 

 

AWARD-WINNING POSTERS

Spironolactone use does not increase the risk of estrogen‐dependent cancer recurrence: A retrospective analysis

Authors: Chapman Wei, Patwut Bovonratwetc, Jonathan I. Silverbergb, Alex Gua, Gaby Moawadd, Adam J. Friedman

This retrospective analysis won first place at the annual meeting. The authors sought to determine if spironolactone was associated with an increased risk for estrogen-dependent cancer recurrence, given its estrogenic effects and lack of safety information. With the Humana insurance database and the International Classification of Diseases codes, Wei et al gathered and identified data from patients with a history of breast, ovarian, or endometrial cancer that was stratified by spironolactone usage. Researchers did not find a correlation between estrogen-dependent cancer recurrence and spironolactone.

Intranasal butorphanol as a rescue therapy for the treatment of intractable pruritus

Authors: Raveena Khanna, Christina D. Kwon, Sagar P. Patel Micah Belzberg, Kyle A. Williams, Emily Boozalis, and Shawn G. Kwatra

This poster won the second-place award at the annual meeting. In this case series, the authors examined the efficacy of intranasal butorphanol as a rescue therapy for chronic pruritus, though it’s commonly used to treat migraine headaches, musculoskeletal pain, and postoperative pain. Sixteen patients with a diagnosis of chronic pruritus and failure of at least four therapies were given butorphanol 10mg/mL inhaler, and changes in itching were recorded using the Numerical Rating Scale, Dermatology Life Quality Index, and Beck Depression Inventory scores. Results indicated improved itch symptoms and a positive impact on patients’ quality of life.

Annual Meeting Coverage: June 15, 2020

SESSION HIGHLIGHTS

Cosmetics

Susan Taylor, MD, FAAD, discussed photoprotection for patients with pigmentary disorders, with a focus on melasma, post-inflammatory hyperpigmentation (PIH), and chronic ultraviolet-induced hyperpigmentation. Dr. Taylor noted the past paradigm of photoprotection as a preventative method for the worsening of pigmentary disorders, but asserted that more current knowledge and research supports a therapeutic role of photoprotective measures in these disorders. Dr. Taylor discussed the beneficial role of iron oxides and antioxidants in sunscreen and foundation formulations for protecting the skin from visible light. She also reviewed research on oral agents, such as Polypodium leucotomos, for vitiligo, melasma, and post-inflammatory hyperpigmentation.

Diane Berson, MD, presented on the future of skincare in acne and rosacea, which she believes is increasingly becoming an adjunctive focus in treating patients with these conditions. According to Dr. Berson, skincare in patients with acne and rosacea can aid with barrier compromise and inflammation, camouflage redness and lesions, support the microbiome, and control oil. She reviewed beneficial formulations and ingredients in cleansers, moisturizers, sunscreens, and makeup. Dr. Berson also reviewed topical and cosmeceutical ingredients that target specific skin concerns, including PIH and erythema, as well as new vehicle innovations that improve the delivery and cosmetic acceptability of existing active agents such as retinoids and antimicrobials. Additionally, Dr. Berson also touched on the recent surge of popularity around “clean” skin care and the trends this has established in the formulation of cosmeceuticals. Other adjunctive interventions for acne and rosacea discussed by Dr. Berson included diet modifications, supplements, at-home devices, peels, and masks.

Neil Sadick, MD, FAAD, presented on the future of neuromodulators. Topics discussed included prabotulinumtoxin-A xvf and daxibotulinumtoxin A, two new neuromodulators that have emerged as competitors to onabotulinumtoxin A. Dr. Sadick also discussed the advantages and disadvantages of liquid toxins currently in clinical trials for glabellar and lateral canthal lines. He also reviewed new application techniques for neurotoxins, including botulinum toxin use in the brow, jawline, and calf regions, as well as botulinum toxin use for patients with rosacea and alopecia.

Making Teledermatology Work

The annual meeting provided a special focus on teledermatology, providing dermatologists looking to implement and optimize teledermatology in his or her practice with helpful strategies for doing so. 

Four presentations provided attendees with the information needed to implement and use teledermatology, code for teledermatology visits, and choose the right platform for teledermatology visits in their practice. The presenters provided an in-depth review of different types of teledermatology visits, including virtual visits, e-visits, check-ins, and telephone visits, and noted which type is best suited for different patients. The presenters also reviewed the technical requirements for different types of teledermatology visits. Also discussed were the various challenges of teledermatology, including technical hurdles, reimbursement concerns, liability concerns and malpractice coverage, and obstacles to documentation, prescribing, and follow up. 

 

 

NOTABLE POSTERS

CME on Acne Improves Dermatologists’ Knowledge and Competence on Patient Management
Authors: Shari Dermer, John Maeglin, and Linda Stein Gold, MD

The authors determined if continuing medical education (CME) increased knowledge of acne management among dermatologists using the results from three multiple-choice questions and one self-efficacy question administered after a 30-minute panel discussion and two 15-minute two-person video conversations. The authors concluded the multiple CME formats were effective, and the dermatologists were able to identify clinical practice gaps concerning acne management as well as enhance their knowledge of the psychological impact acne has on patients.

The efficacy and safety of pulse vs. continuous therapy for dermatophyte toenail onychomycosis
Authors: Aditya Gupta; Nadia Stec, MSc; Mary A. Bamimore, MSc; Kelly A. Foley, PhD; Neil H. Shear, MD; Vincent Piguet, MD, PhD, FRCP

This poster won the fourth-place award at the annual meeting. The authors compared pulse and continuous systemic therapies for toenail onychomycosis by reviewing 22 previously published studies on PubMed that included 4,205 randomized patients and reported mycological cure and adverse events results. The authors found that though it is plausible drug concentrations in the nail are maintained during the off period of pulse therapy, the studies did not present any differences between pulse and systemic therapies.

Annual Meeting Coverage: June 14, 2020

SESSION HIGHLIGHTS

Psoriasis

Bruce Strober, MD, PhD, presented on new drug developments related to psoriasis. Dr. Strober started with a discussion of spesolimab, an anti-interleukin (IL)-36 receptor antibody on the horizon for pustular psoriasis. He then reviewed Phase II data for BMS-986165, an oral tyrosine kinase 2 inhibitor, for moderate-to-severe psoriasis. Next, Dr. Strober reviewed new studies on ixekizumab, including a head-to-head trial of ixekizumab versus guselkumab for moderate-to-severe psoriasis and a Phase III trial that investigated ixekizumab for pediatric patients with moderate-to-severe psoriasis. He moved on to new studies on risankizumab, an IL-23 inhibitor, which demonstrated superiority over secukinumab in a head-to-head trial of the two drugs. A new Phase II open-label study on apremilast, a phosphodiesterase (PDE)-4 inhibitor, for pediatric patients with moderate-to-severe plaque psoriasis was briefly reviewed. Dr. Strober then reviewed the proposed mechanism of action and efficacy of tapinarof, an unapproved topical aryl hydrocarbon receptor modulating agent, for plaque psoriasis. He then discussed a newly developed guideline for evaluating psoriasis severity, which separates patients with psoriasis into two groups: topical therapy candidates and systemic therapy candidates. He completed his presentation with a review of the current treatment paradigm based on these new severity evaluation guidelines.

Joel Gelfand, MD, MSCE, presented on the effect of psoriasis treatment on cardiovascular risk, where he identified the impact of psoriasis treatment on cardiovascular events and surrogate markers of cardiovascular disease and reviewed the strengths and weaknesses of various methods applied to research on psoriasis and cardiovascular disease. Dr. Gelfand also reviewed the latest joint guidelines from the American Academy of Dermatology and the National Psoriasis Foundation for patients with psoriasis and cardiovascular disease.

Mark Lebwohl, MD, provided an in-depth discussion on individualizing biologic therapy for patients with psoriasis, outlining the best biologic therapy options for patients with psoriasis and concurrent psoriatic arthritis, obesity, cardiovascular disease, cardiac risk factors, squamous cell carcinoma, positive antinuclear antibody test results, lupus, multiple sclerosis, Crohn’s disease, hepatitis C, congestive heart failure, latent tuberculosis, and/or HIV. New factors discussed by Dr. Lebwohl included pregnancy, psoriasis in pediatric patients, and patients who require a therapy that yields a speedy response.

Kenneth Gordon, MD, rounded out the session with a review of the debate and rationale behind the use of biologic therapy for patients with limited or moderate psoriasis. Dr. Gordon made the case for not expanding the use of biologics to patients with limited disease and argued for the use of alternative therapies, such as topicals, phototherapy, and oral systemic therapies, as viable options for these patients.

What’s New in Dermatology

Terrence Cronin, MD, presented on new developments in dermatologic surgery and cosmetic dermatology. Topics related to dermatologic surgery included research on the use of human papillomavirus vaccines for skin cancer prevention, cemiplimab for advanced squamous cell carcinoma, transplant-associated cancers and checkpoint inhibitors, presurgical curettage for Mohs surgery and excisional surgery, and enhancing physical drug delivery using lasers and microneedling in patients with actinic keratoses or non-melanoma skin cancer. Topics related to cosmetic dermatology included multimodal treatments, platelet-rich plasma, and fillers as biostimulators. Additionally, Dr. Cronin discussed some ways in which he and his colleagues have changed how their practices operate in the wake of the COVID-19 outbreak. He discussed teledermatology, pre-operative COVID-19 testing, changes in the Mohs workflow, the use of personal protective equipment, N-95 masks, and smoke evacuators in dermatologic surgery, and decreasing patient exposure through the use of absorbable buried sutures to decrease postoperative care.

Kari Martin, MD presented on pediatric contact dermatitis. She discussed whether allergic contact dermatitis (ACD) happens in children and how this differs in children with atopy or atopic dermatitis. Dr. Martin also reviewed how ACD or contact dermatitis looks different in children versus adults, then completed her presentation with cases highlighting allergens and dermatitis patterns in children.

NOTABLE POSTERS

Reductions in Absolute PASI Over 144 Weeks of Treatment with Certolizumab Pegol in Patients with Plaque Psoriasis: Pooled Analysis from Two Phase III Trials (CIMPASI-1 and CIMPASI-2)
Authors: Andrew Blauvelt, Diamant Thaçi, Yves Poulin, Fiona Brock, Catherine Arendt, Marion Boehnlein, and Kristian Reich

The authors of this study assessed the long-term maintenance of absolute Psoriasis Area Severity Index (PASI) scores of 5, 3, and 2, over three years. The data was pooled from two identically designed Phase III trials of certolizumab pegol (CZP) for patients with psoriasis. Based on this analysis, the authors found that high proportions of patients dosed with both CZP 400mg every two weeks and CZP 200mg every two weeks achieved and maintained stringent absolute PASI thresholds.

Number needed to treat analysis of skin cancers among referrals for suspicious lesions
Authors: Nikolai Klebanov, Michael Shaughnessy, Nicole Gunasekera, Sally Tan, Hensin Tsao
This poster took the third-place award at the annual meeting this year. The authors conducted a retrospective review of patients referred to a tertiary medical center for suspicious lesions in order to calculate number needed to treat (NNT) metrics for melanoma and non-melanoma skin cancer using referral- and biopsy-level data. They calculated the number needed to biopsy for melanoma as 7.5, which they note is consistent with the literature. The authors noted a decrease in NNT from the referral to the biopsy stage, which, according to the authors, suggests that referral-level changes could be targeted for cost-savings in skin cancer management.

Annual Meeting Coverage: June 13, 2020

SESSION HIGHLIGHTS

Hair Disorders Made Easier

Great for practitioners who see patients with alopecia, this session covered the basics of the patient evaluation for hair loss, including diagnostic tips, treatment pearls, ethnic hairstyling, surgical procedures, and clinicopathologic correlation.

Jerry Shapiro, MD, FAAD, whose clinic is unique in that it exclusively serves patients with disorders of the hair and scalp, presented on treatment and follow up of nonscarring alopecia. He discussed how he manages telogen effluvium, androgenetic alopecia, and alopecia areata in his practice, and reviewed how he uses platelet-rich plasma in patients with alopecia.

 

Melissa Piliang, MD, FAAD, provided presentation viewers with tips on the evaluation of scarring alopecia and cases that present diagnostic challenges, including patients with subtle scarring and those who don’t fit the well-described clinical patterns or expected age, sex, or ethnic variations. She also discussed the importance of biopsy location for accurate diagnosis of patients with scarring alopecia and condition mimics to watch out for.

 

Maryanne Senna, MD, discussed pearls in the management of scarring alopecia. She reviewed overcoming obstacles to determining the best treatment option for patients with scarring alopecia, described the types of inflammation present in these patients and how these correspond to treatment, and touched on a few less conventional and new approaches for treating scarring alopecia.

 

Meena Singh, MD, FAAD, provided viewers with an in-depth review of hair transplantation. She provided tips for hair loss and scalp exams in patients seeking hair transplant surgery, focusing on signs of conditions that would render the patient an unsuitable candidate for surgery. Other topics discussed included patient consultations for hair transplants, donor harvesting technique options, and platelet-rich plasma and microneedling for patients with alopecia.

 

JAK Inhibitors: A New Frontier in Dermatology

This presentation reviewed the use of Janus kinase (JAK) inhibitors for the treatment of a wide range of conditions, including psoriatic disease, atopic dermatitis, and sarcoidosis and granuloma annulare.

 

Jeffrey M. Sobell, MD, FAAD, discussed JAK inhibitors for psoriatic disease, Dr. Sobell first discussed the pathophysiology of psoriasis and the rationale behind the use of JAK inhibitors for psoriatic diseases. He then examined the use of tofacitinib, a JAK inhibitor that is already approved for treating psoriatic arthritis. Dr. Sobell also reviewed currently available data on JAK inhibitors being investigated for use in chronic plaque psoriasis.

 

Eric Simpson, MD, MCR, presented on JAK inhibitors for atopic dermatitis (AD). He started his presentation with a review of AD pathogenesis, then identified and discussed gaps in topical and systemic therapies that need to be filled. He also reviewed Phase III data for topical two topical JAK inhibitors, ruxolitinib and delgocitinib, under investigation for AD, and finished his presentation with a discussion of Phase II data for oral JAK inhibitors for AD, including baricitinib, abrocitinib, upadacitinib, and gusacitinib.

 

William Damsky, MD, PhD, discussed JAK inhibitors in sarcoidosis and granuloma annulare (GA). Dr. Damsky reviewed the poorly understood pathogenesis and significant burden of these granulomatous disorders and the significant unmet need for effective therapies. He then reviewed emerging data from studies on JAK inhibitors for sarcoidosis and GA, which have also provided insight into disease pathomechanisms for these disorders.

 

NOTABLE POSTERS

Treatment of Moderate-to-Severe Acne with Once-daily Tazarotene 0.045% Lotion in Males: Pooled Analysis of Two Phase 3 Studies 

Authors: Neal Bhatia, MD; Linda Stein Gold, MD; Gina Martin, MOT; Radhakrishnan Pillai, PhD; and Eric Guenin, PharmD, PhD

This poster presented results of a post-hoc analysis of male participants of two pivotal Phase III trials that evaluated once-daily tazarotene 0.045% lotion in patients with moderate-to-severe acne. The authors conducted efficacy assessments in the change from baseline at Weeks 4, 8, and 12 in inflammatory and noninflammatory lesion counts and the percent of male patients achieving a two-grade or greater reduction from baseline at Week 12 in Evaluator’s Global Severity Score with a rating of “clear” or “almost clear,” indicating treatment success. According to the analysis, mean percent change from baseline in noninflammatory lesions were greater for tazarotene 0.045% lotion when compared to the vehicle at Week 4, and were greater for both inflammatory and noninflammatory lesion counts at Weeks 8 and 12. Additionally, the percent of male patients achieving treatment success at Week 12 was significantly greater for those using tazarotene 0.045% lotion versus vehicle (25.1% vs 12.8%; P<0.001).

 

Durable Efficacy of Certolizumab Pegol Dosed at 400mg Every Two Weeks Over 128 Weeks in Patients with Plaque Psoriasis Enrolled in Three Phase 3 Trials (CIMPASI-1, CIMPASI-2 and CIMPACT)

Authors: Richard Warren, Alice Gottlieb, Andrew Blauvelt, Diamant Thaçi, Yves Poulin, Marion Boehnlein, Fiona Brock, Catherine Arendt, and Kristian Reich

This study assessed the long-term efficacy of certolizumab pegol (CZP), an Fc-free, PEGylated anti-tumor necrosis factor, dosed at 400mg every two weeks and the durability of response in patients who achieved Psoriasis Area Severity Index (PASI) 75 after an initial 16 weeks of treatment. According to the authors, placebo-randomized patients who achieved PASI 50 or less at Week 16 demonstrated a rapid response during the first 16 weeks of treatment with CZP 400mg and sustained these response rates at Week 144. Additionally, of the patients who achieved PASI 75 at Week 16, 82.4 percent of these patients maintained PASI 75 after 128 additional weeks of treatment and 64.4 percent went on to achieve PASI 90 in this time.

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