Maui Derm NP+PA Fall 2021: October 2, 2021

SESSION HIGHLIGHTS

Neonates to Adolescents Pediatric Dermatology Update 2021

by Vikash S. Oza, MD, and Sheila Fallon-Friedlander, MD 

In Neonatal and Adolescent Dermatology, Vikash S. Oza, MD, explored the prevalence and morphology of various forms of diaper dermatitis. Then, Dr. Oza covered the case of a patient with infantile hemangioma, providing “red flags” to consider when testing and diagnosing, such as changes in appearance or the development of hot spots. After this, Dr. Oza highlighted the evaluation process of monitoring light brown birthmarks and associated mutations. Cases of nevus anemicus, legius syndrome, Noonan syndrome, constitutional mismatch repair deficiency syndrome were described, using patient photos throughout the presentation, as well. To end, Dr. Oza presented the available data that analyzed the potential relationship between isotretinoin and depression/mental illness in adolescent populations, emphasizing the importance of screening for adolescent depression.

In the following segment, Sheila Fallon-Friedlander, MD, focused on monitoring children with hemangiomas. The molecular classification of red birthmarks and overgrowth was then reviewed. Using current data, Dr. Fallon-Friedlander revaluated monthly blood testing needs for patients treated with isotretinoin and offered new recommendations for lab monitoring. The mechanism and treatment of morphea in pediatric patients was also highlighted; JAK-inhibitors, such as ruxolitinib and tofacitinib, were the most effective therapies in these cases. Tips for avoiding insect repellent on children 2 years or younger and opting for other bug-bite prevention methods, such as using mosquito netting, all the associated conditions linked to tick bites, and assessment of the Shear Diagnostic Triangle for drug reactions concluded this segment.

The Pigmented Lesion Clinic 2021

by Raegan Hunt, MD; Ashfaq Marghoob, MD; Whitney High, MD; and Hensin Tsao, MD

Using patient cases, Raegan Hunt, MD, presented information on managing different categories of congenital melanocytic nevi, starting with the clinical features of certain mutations and evolution of various proliferations. Congenital melanocytic nevus, congenital divided nevus, giant congenital melanocytic nevus, and neurocutaneous melanocytosis were the featured types highlighted. Next, Dr. hunt shared melanoma risk with congenital melanocytic nevi, providing photos of many at-risk lesions. For the remainder of this portion, Dr. Hunt presented challenging acquired melanocytic lesions in children and adolescents, mainly pertaining to scalp nevi, juvenile spitz nevi, and atypical spitz tumors.

After Dr. Hunt, Ashfaq Marghoob, MD, provided novel insights on neogenesis and melanomagenesis, which were obtained from dermoscopy data, exploring the inception, evolution, growth, and involution stages of each. Next, Dr. Marghoob assessed two studies involving cross-sectional data on nevus patterns and biological subsets, establishing type of nevi is dependent on driving mutation. Dr. Marghoob then covered the stem-cell origin of melanomas and melanoma cells, based on initial presentation and progression models.

In the next segment, Whitney High, MD, the morphological element of analyzing lesions. According to Dr. High, architecture, host response, pagetoid extent, cytology of the cell, immunostaining results, and grading are considered when evaluating atypical nevus and differentiating from melanoma. Following this, Dr. high discussed reasoning behind the rapid rate of cutaneous melanoma diagnoses and how genetic testing will overtake morphologic analysis.

To end this panel, Hensin Tsao, MD, presented cases from their pigmented lesions clinic to describe the impact of historical factors, such as family history of melanoma, sun exposure, previous skin cancers, sunbed use, immunosuppression, and, most recently, Parkinson’s disease, in conjunction with physical findings (i.e., atypical moles, when assessing patients for melanoma risk. Additionally, Dr. Tsao offered tips for setting appropriate surgical margins and estimating prognosis for new patients with melanoma lesions and the components for sentinel lymph node biopsy discussions with the patients. Featured systemic adjuvant treatments included nivolumab, pembrolizumab, or ipilimumab for BRAF wild-type mutation in Stage 3a, 3b, or 3c disease, and x nivolumab, pembrolizumab, or dabrafenib in conjunction with trametinib for BRAF-mutation (V600F) Stage 3a, 3b, 3c disease.

Update on Infectious Diseases 2021

by Ted Rosen, MD, and Sheila Fallon-Friedlander, MD 

Ted Rosen, MD, reviewed updated literature on various infectious diseases, beginning with nail and cutaneous manifestations of COVID-19. Next, Dr. Rosen discussed zoonotic diseases, mainly the Seoul virus that is contracted from rats. Therapeutic candidates for Zika virus were also highlighted; further, tetracycline was the most effective Zika virus treatment, per Dr. Rosen and the referenced studies. After, Dr. Rosen explored data on the “best” intralesional wart therapies and recent publications on various vaccine concerns, which mainly pertained to human papillomavirus (HPV) vaccines and changes in shingles vaccine approval. Dr. Rosen also reported the case of a festering bacterial infection on a patient’s leg, which was accompanied by fever and widespread pain, to present the novel scoring system for necrotizing fasciitis. Moving onto fungal infections, Dr. Rosen explored cases and therapeutic experiences pertaining to cutaneous sporotrichosis prevalence, topical 1% encapsulated terbinafine gel for tinea capitis, and efinaconazole 10% solution for onychomycosis. To end, Dr. Rosen briefly touched on the future of human immunodeficiency virus infection (HIV) vaccine development.

Following Dr. Rosen, Sheila Fallon-Friedlander, MD, began this segment with the case of a child with a T cell CD28 deficiency and who presented with severe warts. Next, Dr. Fallon-Friedlander reviewed updated data on the prevalence and subset manifestations of/relating to COVID-19 in pediatric populations and the current development of antivirals/protease inhibitors for the treatment of COVID-19. This portion also included children current COVID-19 hospitalizations based on patient characteristics, school protocols, and a variety of rash presentations. Dr. Falllon-Friedlander also highlighted literature on the link between myocarditis and the COVID-19 vaccine in younger populations. Concluding this segment, Dr. Fallon-Friedlander reviewed current studies on COVID-19 vaccines for younger children, particularly those aged 11 years and younger, and thoroughly explained why adults still need to wear masks and get vaccinated, given the possibility of a vaccine-resistant variant of COVID-19.

Maui Derm NP+PA Fall 2021: October 1, 2021

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Acne and Rosacea Update 2021

by Raegan Hunt, MD; Hilary Baldwin, MD; and Julie Harper, MD

In this acne segment, Raegan Hunt, MD, described pediatric cases involving the etiology and clinical findings for neonatal “acne,” infantile “acne,” and mid-childhood “acne.” Additionally, Dr. hunt listed available acne therapies for this population, such as benzoyl peroxide, topical retinoids, erythromycin, and azelaic acid, as well as the many ways isotretinoin can be given to infants and babies (for more difficult cases). Following, Dr. Hunt reviewed the cases of a 2- and 4-year-old with mid-childhood “acne” to depict how this skin presentation tends to be indicative of other underlying disorders, typically of the endocrine variety. Pre-adolescent acne was the next skin condition covered by Dr. Hunt. To end, Dr. Hunt explored acne in transgender youth, specifically the risk of acne development and/or exacerbation of acne with gender-affirming treatments.

Using the case of a patient with moderate-to-severe acne that affected different parts of the body and became more severe as they aged, Hilary Baldwin, MD, described methods and factors (i.e., age, sex, adherence, and child-bearing and menopausal years) to consider when making treatment and management decisions for this skin condition. Per Dr. Baldwin, the treatment was modified when the patient became pregnant, suffered from post-partum depression, and endured perimenopausal years. Through this case, Dr. Baldwin discussed increasing C. acnes resistance rates and the decrease of oral antibiotic development, as well as the importance of developing an “exit” strategy for patients with moderate-to-severe acne being treated with an oral antibiotic to avoid C. acnes resistance. Tazarotene 1.5% lotion at 11 years, combination benzoyl peroxide 2.5% and adapalene at 13 years, trifarotene at 17 years, isotretinoin at age 18 years, spironolactone at age 27 years, and trimethoprim/sulfamethoxazole at 31 years were some of the patient’s treatments mentioned by Dr. Baldwin.

Switching from acne to rosacea, Julie Harper, MD, highlighted why patient-reported signs and symptoms, triggers, and treatment goals should be kept in mind when forming treatment strategies for patients with this skin condition. Using clinical data and patient outcomes, Dr. Harper reported select therapies for elements of rosacea, such as beta-blockers (carvedilol, nadolol, and propranolol) for flushing, botulinum toxin for facial erythema, brimonidine 0.33% gel (and/or in conjunction with ivermectin) for persistent facial erythema, and oxymetazoline 1% cream for inflamed papules and pustules and facial erythema.

Eczema and Contact Dermatitis: Pearls and Pitfalls

by Matthew Zirwas, MD

To begin, Matthew Zirwas, MD, offered tips for interpreting patch tests and managing positive results. For such instances, Dr. Zirwas suggested allergen avoidance and keeping open communication with the patient. Throughout the presentation, Dr. Zirwas reported challenging cases that included diagnosing and treating a 12-year-old patient who presented with vesicular dermatitis, an 83-year-old female patient with an infra-nasal rash, an optometrist with pruritic rash on first three fingers, a 26-year-old female patient with ongoing cheilitis on the lips, a 42-year-old male who presented with recurrent periorbital swelling and itch, a 51-year old male patient with a rash on the inside of arms and shins, and a 64-year-old male patient with an eruption of itchy bumps on extensor elbows. Concluding this segment, Dr. Zirwas highlighted clinical data on dupilumab -induced psoriasis and psoriatic arthritis, risk of systemic infection in patients with atopic dermatitis decreasing with dupilumab use, and the future of atopic dermatitis treatments.

Cutaneous Oncology Update 2021

by George Martin, MD

This presentation began with George Martin, MD, listing flaws found within current American Academy of Dermatology actinic keratosis (AK) guidelines, including ultraviolet light (UV) protection methods, insufficient combination treatments, and recommendations for skin cryotherapy and red and blue light photodynamic therapy (PDT). Next, Dr. Martin shared information on the mechanism of tirbanibulin ointment, an antitumor and antiproliferative agent, as well as its outcome, long-term clearance rate, and approval data. Study designs and tolerability and stratified recurrence data for tirbanibulin treatment of AK lesions were highlighted as well. By using efficacy data from clinical trials, Dr. Martin described clearance rates following ALA PDT treatments and optimization of pain management for such therapies, which included use of daylight mediated PDT, in-office “painless PDT” with a blue light, and the “split face” method prior to PDT. Shared patient cases regarding cases AKs on various parts of the body (mainly scalp, arms, chest, face, and hands) and how to treat patients who are high-risk were next. Then, Dr. Martin explored the history of and treatment regimen of imiquimod for patients with AKs and other treatment options for patients with AKs who are either immunocompromised or who underwent transplantation. To conclude this segment, Dr. Martin reported treatment and management guideline updates for squamous cell carcinoma, such as treating lesions in accordance with their location, size, recurrence rate, eruptions, and pathology, and encouraged the appropriate use of systemic retinoids for skin cancer.

Maui Derm NP+PA Fall 2021: September 30, 2021

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New Drugs and New Therapies for 2021

by Ted Rosen, MD

Ted Rosen, MD, discussed various novel drugs and therapies being developed and/or released throughout 2021 and 2022, using their efficacy, mechanism of action, dosing, and safety data from referenced clinical trials. Dr. Rosen began by reviewing how the mechanism of encapsulated drugs can be used to enhance patient tolerability. Current encapsulated therapies awaiting FDA approval, including combination benzoyl peroxide (BPO) and tretinoin for the treatment of acne and microencapsulated BPO for rosacea, were then presented. After, Dr. Rosen discussed pyrethroid and permethrin resistance in patients with head lice and scabies, respectively, which led to release of abametapir, a novel treatment for head lice treatment resistance in adults, and the approval of spinosad for the treatment of scabies. Next, Phase 3 data for oteseconazole: tetrazole, an anti-fungal therapy, and Phase 2b data for oteseconazole as an onychomycosis treatment were shared. The recent approval of another anti-fungal agent, ibrexafungerp, was covered by Dr. Rosen as well. Other novel therapies that were featured included lonafarnib for progeria, a disease that causes premature aging, berotralstat for the prevention of hereditary angioedema, ruxolitinib cream 1.5% for the short-term, noncontinuous treatment of mild-to-moderate atopic dermatitis, tirbanibulin, an antitumor and antiproliferative agent, and patidegib gel for basal cell nevus syndrome facial lesions. Recent arbovirus vaccine and anifrolumab (as a systemic lupus treatment) Phase 3 data concluded Dr. Rosen’s presentation.

Psoriasis and Psoriatic Arthritis 2021

by Bruce Strober, MD, PhD; Martin Bergman, MD; and Melodie Young, MSN, A/GNP-c

Bruce Strober, MD, PhD, explored new psoriasis therapies and data, starting with head-to-head studies on various interleukin (IL)-17 and IL-23 inhibitors. To explain the tailoring of secukinumab dosing, Dr. Strober evaluated available clinical studies on its efficacy and safety. Psoriasis Area and Severity Index (PASI) and Static Physician’s Global Assessment (sPGA) scores and overall responses for pediatric patients with psoriasis treated with ixekizumab or secukinumab were then highlighted. Using patient data, Dr. Strober discussed and compared the use of ixekizumab for the treatment of nail psoriasis. Following this, Dr. Strober focused on IL-23 inhibitors in patients chronic plaque psoriasis, mainly using data from RESURFACE 2 trial, wherein patients were given tildrakizumab, VOYAGE 1 trial, wherein researchers compared guselkumab and adalimumab use, and ultlMMa 1 and 2 trials, which tested the efficacy of risankizumab. Next, Dr. Strober further analyzed the efficacy, safety, and PASI score data of apremilast from the ESTEEM and ADVANCE trials. Dr. Strober then provided updates for the tyrosine kinase 2 (TYK2)-inhibitor, deucravacitinib, comparing it with apremilast clinical outcomes. To end this segment, Dr. Strober shared efficacy and safety data on bimekizumab and roflumilast.

Following Dr. Strober, Martin Bergman, MD, used patient photos and cases to demonstrate the various presentations of psoriatic arthritis and how symptoms and related conditions affects different parts of the body. Additionally, Dr. Berman provided other physicians with screening tools for detecting psoriatic arthritis. Using the American College of Rheumatology (ACR) vaccination guidelines, Dr. Bergman discussed how patients treated with conventional synthetic DMARDs or biologics and Janus kinase (JAK)-inhibitors are considered immunocompromised and should opt for the COVID-19 vaccine; treatment management for these populations were also covered. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendation updates ended this portion of the presentation.

After, Melodie Young, MSN, A/GNP-c, reported tough-to-treat, complex patient cases, mainly pertaining to scalp, nail, genital, guttate, and palmar/plantar psoriasis.

Atopic Dermatitis Update 2021

by Vikash S. Oza, MD, and Matthew Zirwas, MD

For the last segment of Day 1, Vikash Oza, MD, provided pediatric atopic dermatitis updates, beginning with key concepts within this population and comparisons with adult atopic dermatitis. According to Dr. Oza, factors such as incident rates, symptom prevalence, and immunophenotype vary between pediatric and adult patients with atopic dermatitis. Using data from clinical studies, Dr. Oza then explored skin barrier differences between young and adult patients, and the use of emollients in the prevention of eczema and atopic dermatitis. However, many food allergies have been linked to early emollient use, according to Dr. Oza, which were likely due to the transmission of allergens from parent’s hands. It was established that bathing frequency and quality of water could play a role in eczema development during the early years of life as well. Next, Dr. Oza examined the influence of breast feeding in the prevention of atopic dermatitis, but ultimately, this relationship requires more research. Ending this portion of the presentation, Dr. Oza reviewed patient cases that prompted the questioning of initial diagnoses; these cases included Netherton syndrome, hyper IgE syndrome, and poor response to strong topical steroids.

Next, Matthew Zirwas, MD, presented atopic dermatitis updates in adult populations. Delays in the FDA-approval of certain JAK inhibitors for the treatment of atopic dermatitis, Phase 2 and 3 data on upadacitinib, baricitinib, abrocitinib, and tralokinumab, and studies comparing the efficacy and safety of these treatments with dupilumab in patients with atopic dermatitis were covered here. Following this, Dr. Zirwas shared a summary of recommendations for dupilumab and the above therapies.