Maui Derm 2023 Session Summaries

Top Stories of 2022–2023

presented by Hensin Tsao, MD, PhD

Dr. Tsao guided attendees through main takeaways from the top research in dermatology from the past year. He began with a discussion of Phase III results from two recent clinical trials investigating topical ruxolitinib cream for the treatment of vitiligo (TruE-V1 and TruE-V2). Ruxolitinib cream appeared to be more effective for vitiligo on the face versus non-facial locations, with half of the patients seeing a 75-percent improvement in facial vitiligo.

Dr. Tsao also discussed an international multicenter study on clinical outcomes and risk stratification of early-stage melanoma micrometastases, which found that the five-year disease-specific survival difference between N-low risk (<0.3mm nodal tumor deposit) and N-high risk (≥0.3mm nodal tumor deposit) was 14.3% (94.7% vs. 14.3%). Next up, Dr. Tsao discussed a randomized, controlled trial that investigated the effect of prior diagnoses on dermatopathologists’ interpretations of melanocytic lesions, then reviewed a paper on the risk of invasive cutaneous squamous cell carcinoma following different treatments for actinic keratosis. He moved on to discuss Phase III results on pembrolizumab as an adjuvant therapy in completely resected Stage IIB and IIC melanoma, then discussed combination dabrafenib and trametinib versus combination nivolumab and ipilimumab for patients with advanced BRAF-mutant melanoma.

Additionally, Dr. Tsao discussed the possible role of cemiplimab as a neoadjuvant treatment for advanced squamous cell carcinomas. He also discussed advancements in treating epidermolysis bullosa, citing promising results from a Phase I and II trial investigating in-vivo topical gene therapy for the condition. Research on new and emerging therapies in psoriasis were discussed, including results from the POETYK PSO-1 and POETYK PSO-2 clinical trials investigating deucravacitinib, in which the tyrosine kinase 2 inhibitor demonstrated benefit relative to placebo and phosphodiesterase 4 (PDE4) inhibitors, with 50 percent of patients achieving PASI-75 and 25 percent achieving PASI-25 within 16 weeks.

New Drugs and Therapies in 2023

presented by Ted Rosen, MD, and Neal Bhatia, MD

The Ted and Neal Show never fails to entertain each year at Maui Derm, and this year was no different. Drs. Rosen and Bhatia presented a zombie-themed talk that covered an expansive range of new and emerging therapies to look out for in 2023. The duo began the session with a discussion of two new devices. The first was Ellacor®, a new aesthetic micro-coring device that removes cores of skin 5mm deep with a width of a 22-gauge needle. This treatment has been shown to reduce fine lines and wrinkling and is particularly useful for the lower cheek and jawline. The second was AviClear™, an energy advice now approved for the treatment of mild to severe acne.

With regard to new antifungals, Drs. Rosen and Bhatia discussed ibrexafungerp for the treatment of acute vulvovaginal candidiasis (VVC) and osteconazole for chronic VVC. Spinosad 0.9% suspension, which is approved for the treatment of scabies in patients aged 4 and older, in addition to patients six months and older with head lice, was also discussed. The drug contains potent insecticides that cause hyperexcitation in the neurological system of insects, but exerts no activity on mammals or avian or aquatic animals. The duo moved on to discuss results from a Phase II multicenter trial investigating sirolimus gel for the treatment of angiofibromas in adults and children older than six years with tuberous sclerosis; after twice-daily application for 12 weeks, lesion size and color were both decreased.

Drs. Rosen and Bhatia also spent part of their session discussing new therapies for atopic dermatitis, including oral difelikefalin, a selective kappa-opioid receptor agonist for itch in AD, which also recently demonstrated efficacy for notalgia paresthetica, a sensory neuropathy that can include symptoms of pruritus, tenderness, burning pain, and hyperalgesia. The duo also discussed the new Janus kinase (JAK) inhibitors for AD, including oral upadacitinib and abrocitinib, as well as topical ruxolitinib cream. They discussed research comparing the oral JAK inhibitors against dupilumab; in these studies, abrocitinib demonstrated a faster onset, superior EASI 75 rates, and better itch relief. Upadacitinib performed similarly, demonstrating a faster onset, superior EASI 75/90/100 rates, and better itch relief compared to dupilumab. New and emerging treatments for alopecia, including baricitinib and ritlecitinib, were also discussed.

The duo also reviewed intriguing research on optimizing treatment selection for patients with psoriasis using a dermal biomarker patch called Mind.Px, which demonstrated efficacy in predicting biologic drug response prior to initiating treatment. Drs. Rosen and Bhatia finished their session with a discussion of emerging treatments for hidradenitis suppurativa, including secukinumab, bimekizumab, sonelokimab, orismilast, RIST4721, metformin combined with doxycycline, and BDB-001.

Pediatric Dermatology 2023

Lawrence Eichenfield, MD: Favorite Articles and Pearls

Dr. Eichenfield began his presentation with a discussion of advances in epidermolysis bullosa (EB). Excitingly, dystrophic EB might be the first EB type to have a specifically approved targeted therapy in the form of beremagene geperpavec (B-VEC). Dr. Eichenfield discussed a trial of B-VEC published in December of last year. This topical herpes simplex virus type-1-based gene therapy delivers COL7A1 to the skin, which restores type VII collagen. 

He moved on to discuss inflammatory linear verrucous epidermal nevi, a rare skin disease characterized by pruritic erythematous scaly plaques distributed along the lines of Blaschko, and reviewed a study aimed at investigating the genetic cause of the condition.

Described as the most significant paper for regular practice, Dr. Eichenfield discussed results of a randomized, double-blind, placebo-controlled study published in September 2022 investigating dupilumab for the treatment of uncontrolled atopic dermatitis in children aged six months to younger than six years. Here, dupilumab significantly improved AD signs and symptoms versus placebo after 16 weeks.

Dr. Eichenfield ended his presentation with two pearls: he shared some of his own research on a technique for wrapping infants and toddlers to immobilize them before dermatology procedures, then Dr. Eichenfield reviewed helpful and easy methods for recording BSA in pediatric patients with inflammatory skin diseases.

Ilona J. Frieden, MD: Two Pearls and New Uses for an “Old Medication”

Dr. Frieden began her presentation with two pearls. The first was curettage for onychomycosis. This method is better for pediatric patients because a curette is less scary than a blade and decreases the chance for an accidental cut. It also allows for more sites for nail specimen collection of distal, lateral, and proximal onychomycosis, and collecting from more than one location increases positive KOH exam and culture results.

In her second pearl, Dr. Frieden shared tips and tricks for minimizing pain during local anesthesia, including distraction techniques, buffering or warming lidocaine, using smaller diameter needles, and decreasing the speed of the injection. Additional techniques include the ShotBlocker—a small plastic device held against the injection site to reduce pain—high-frequency vibration, and ice.

Dr. Frieden rounded out her presentation with a discussion of timolol maleate, a non-selective topical beta blocker currently indicated for glaucoma. Dr. Frieden discussed research on the off-label use of timolol for infantile hemangiomas. Beyond IH, Dr. Frieden discussed the use of timolol for pyogenic granuloma, granulation tissue, tufted angioma, Kaposi sarcoma, chronic recalcitrant wound healing, post-surgical wounds, post-acne erythema and erythematotelangiectatic rosacea, “red scrotum” syndrome, and leg ulcers.

Update 2023: Disorders of Pigmentation

John E. Harris, MD, PhD: Vitiligo Updates

Dr. Harris reviewed a variety of new and emerging therapies that have shown efficacy and promise for treating vitiligo, including melanocyte keratinocyte transplant procedure, the RECELL® system, which is currently approved in the United States for acute thermal burns and is being investigated for stable vitiligo, and complete depigmentation with monobenzyl ether of hydroquinone. More recent developments in emerging treatments for the condition include ruxolitinib cream.

Dr. Harris discussed results from a Phase III clinical trial for ruxolitinib cream published in October 2022, in which the application of ruxolitinib cream resulted in greater regimentation of vitiligo lesions than vehicle though 52 weeks despite the occurrence of application-site acne and pruritus. Excitingly, ruxolitinib cream was approved for patients with vitiligo aged 12 years and older in July 2022.

Dr. Harris discussed treatments still under investigation for vitiligo, including ritlecitinib, a JAK3/TEC inhibitor which demonstrated efficacy and tolerability over 48 weeks in patients with stable vitiligo in phase IIb trials, warranting further investigation in phase III studies.

Psoriasis Update 2023

Bruce E. Strober, MD, PhD: Systemics

Dr. Strober began by discussing deucravacitinib, an oral selective tyrosine kinase 2 (TYK2) inhibitor. Dr. Strober deemed this drug the best oral drug currently available for psoriasis due to its once-daily dosing, lack of drug interactions, lack of requirements for monitoring, with a mechanism of action more tolerant to dosing “laziness” given its inhibition of interleukin (IL)-12/23.

Dr. Strober moved on to discuss new data for IL-23 inhibitors for psoriasis. These drugs have demonstrated robust and long-lasting skin efficacy, with high PASI 90 and 100 levels at 16 weeks and onward; Dr. Strober cited risankizumab and guselkumab yielding a PASI 100 response in over 50 percent of participants at Week 52 of their respective trials. He also noted the IL-23 inhibitors have demonstrated the best long-term efficacy of approved systemic drugs for psoriasis. Additionally, the IL-23s have demonstrated no candidiasis signal and raise no concerns for patients with irritable bowl syndrome (IBD).

Moving on to IL-17 inhibitors, Dr. Strober noted that these drugs are good for patients with a history of prior malignancy, as they’ve exhibited a low signal for malignancy and serious infections. Additionally, he deemed IL-17s as the best systemic drugs for nail psoriasis and highlighted their strong efficacy for pediatric psoriasis. However, these are contraindicated for patients with IBD.

More Maui Derm 2023 Video Coverage

Dr. Zirwas reviews new advancements in systemics for atopic dermatitis...