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SESSION HIGHLIGHTS
Infectious Disease Update 2022
by Ted Rosen, MD, Sheila Fallon-Friedlander, MD, and Aditya Gupta, MD, PhD, FAAD, FRCP
Maui Derm’s infectious disease experts shared what you need to know about developments in viral, bacterial, fungal, parasitic and arthropod infections for 2022. Dr. Rosen provided a broad update on infectious disease for 2022, starting with cutaneous manifestations of COVID-19 before moving on to discussing wild animals with COVD-19. He reviewed intralesional antigen immunotherapy for the treatment of periungal warts, then discussed research on cantharidin for molluscum contagiosum. Dr. Rosen also discussed herpetic neuralgia, as well as recurrent herpes zoster in older adults. Moving on to bacteria, Dr. Rosen reviewed antibiotic prophylaxis for the prevention of Lyme disease following a tick bite. With regard to fungus, Dr. Rosen discussed tinea facei from Trichophyton benhamiae in patients with pet guinea pigs. He moved on to discuss treatment for cutaneous sporotrichosis, then explained factors affecting medication adherence in patients prescribed efinaconazole 10% solution for onychomycosis. Dr. Rosen also discussed Mohs micrographic surgery for the treatment of deep cutaneous fungal infections. Moving on to parasites, Dr. Rosen discussed increasing resistance of scabies to permethrin, but noted that spinosad for scabies is still effective. With regard to sexually transmitted diseases, Dr. Rosen discussed newly approved treatments for HIV and racial inequities in PrEP use and taking prescribed HIV medications. Dr. Rosen moved on to discuss changes in shingles vaccine approval and the small risk of Guillain-Barre syndrome following recombinant zoster vaccines.
Dr. Fallon-Friedlander provided attendees with a pediatric infectious disease update. She began by explaining warts related to inherited T cell CD28 deficiency, then moved on to discuss inborn errors of type I interferon immunity in patients with life-threatening COVID-19. Dr. Fallon-Friedlander discussed COVID-19 infection rates and severity in children and multisystem inflammatory syndrome in children and adolescents in the United States. She also discussed instances of COVID toes in children. Regarding vaccinations, Dr. Fallon-Friedlander discussed myocarditis and pericarditis in children following COVID vaccinations and discussed the current state of research on COVID vaccines in children under five years of age.
Dr. Gupta delivered a presentation on new developments in onychomycosis. He reviewed new diagnosis methods, including PCR versus culture species identification, diagnosis using ultraviolet fluorescence, and diagnosis aided by artificial intelligence. Dr. Gupta discussed emerging oral therapies for onychomycosis, including posaconazole, fosravuconazole, voriconazole, and oteseconazole. Regarding developments in topical drugs, Dr. Gupta discussed long-term research on efinaconazole 10%, Phase III trial results on tavaborole, and topical nanotechnology. Dr. Gupta moved on to discuss devices for onychomycosis, including lasers and nonthermal plasma devices. Dr. Gupta also discussed how biofilms contribute to the persistence of fungal diseases and combination therapies for biofilms, as well as the use of prophylactic antifungals to prevent disease recurrence.
Challenging Cases
by Seemal Desai, MD, Ted Rosen, MD, Ali Alikhan, MD, and Jim Treat, MD
Maui Derm’s faculty presented an array of challenging and complex adult and pediatric cases that pushed their diagnostic and therapeutic skills to the limit. Each presenter shared great cases and explained the thought processes that led to a diagnosis in each patient.
Dr. Rosen presented the case of a 60-year-old man in good health except for a 30-year history of Crohn’s disease who received infliximab 5mg/kg via IV infusion every eight weeks. He presented with what appeared to be split papules on the muco-cutaneous labial commissure. Histology revealed plasma cells, leading to a diagnosis of secondary syphilis and condyloma lata, interestingly located at the oral commissure as opposed to in the anogenital area. Dr. Rosen reviewed atypical presentations of condyloma lata in between the toes, in and around the mouth, and on the belly button. He encouraged attendees to always perform biopsies in difficult cases and to always keep syphilis in their differential.
Dr. Alikhan presented a challenging case of hidradenitis suppurativa. This 39-year-old man presented with a three-year history of HS, dissecting cellulitis, and severe acne. This was the patient’s first time seeing a specialist and had been treating with warm compresses, ibuprofen, short courses of antibiotics, and trips to urgent care centers. The patient’s comorbidities included obesity, depression, and anxiety. The patient had disease activity in the groin and buttocks, which showed cysts, nodules, and a few sinus tracts (Hurley Stage II). He also had severe acne on his face and back. For general management, Dr. Gupta referred the patient to a weight loss clinic and to psychiatry for his mental health, along with zinc gluconate. After several months of various treatment approaches, Dr. Gupta finally found success with infliximab 10mg/kg every four weeks, as well as clindamycin 300mg BID plus rifampin 300mg BID for persistent scalp and thigh cysts.
Contact Dermatitis Update 2022
by Matthew Zirwas, MD
Dr. Zirwas used his presentation to review the Allergic Contact Dermatitis Society’s “Allergen of the Year” from 2000 to 2020. He began with disperse blue dyes, the 2000 Allergen of the Year. These numerous types of over 1,200 specific dyes are used in the textile industry, mainly to dye polyester, acetate, and nylon. Dr. Zirwas pointed to cases of contact dermatitis to disperse blue dyes found in a sport coat, a sleep mask, and black yoga pants, with the dermatitis usually occurring where the fabric is pressed against the skin. Dr. Zirwas recommends patients with this allergy purchase mainly natural fabrics of any color (e.g., cotton, wool, linen) and synthetic fabrics that are white or lightly colored. The 2001 Allergen of the year was gold, which most typically causes facial dermatitis in women and has been known to cause oral lichenoid reactions in individuals with gold crowns.
The 2002 Allergen of the Year was thimerosal. Dr. Zirwas noted that thimerosal is essentially not in anything, and the North American Contact Dermatitis Group no longer tests for thimerosal allergies. He noted that it is present in some flu vaccines and one tetanus vaccine and can cause localized reactions, but very rarely causes a generalized maculopapular eruption. The 2003 Allergen of the Year was bacitracin, a very common but easily avoidable allergen that can be replaced with a povidone-iodine cream. The 2004 Allergen of the Year was cocamidopropyl betaine, a surfactant that can be found in anything that foams (i.e., shampoo, soap, toothpaste, contact lens solution, makeup remover).
Glucocorticoids were crowned the 2005 Allergen of the Year, and Dr. Zirwas noted that this can be hard to recognize clinically, but to suspect this allergen if a patient’s dermatitis doesn’t improve as expected or spreads, improves when using the glucocorticoid but flares when taking a break, or if there are morphology changes to the rash. The 2006 Allergen of the Year was p-Phenylenediamine (PPD), found in hair dyes and considered one of the most potent allergens in any personal care product. Dr. Zirwas recommends patients who react to this allergen use Wella Koleston Perfect with Me+ as a replacement for any hair dyes containing PPD.
The 2007 allergen of the year was fragrance, which Dr. Zirwas noted is a difficult allergen to deal with because of the broad and ever-changing array of fragrances added to many personal care products. The 2008 Allergen of the Year was nickel, and Dr. Zirwas reviewed resources for educating patients on a low-nickel diet. The 2009 Allergen of the Year was mixed dialkyl thioureas, a chemical generally only found in neoprene rubber. The 2010 Allergen of the Year was neomycin, an allergy that Dr. Zirwas says seems to be trending downward with no clear reason why. The 2011 Allergen of the Year was dimethyl fumarate, a fungicide that was put in shipping containers to prevent mold growth and which caused an epidemic of contact dermatitis in Europe.
The 2012 Allergen of the Year was acrylates, which primarily cause a problem in those who use artificial fingernails. The 2013 Allergen of the Year was methylisothiazolinone, a commonly used preservative which became a problem in patients using personal care wipes; it has since not been used in wipes or other leave-on products for a number of years. However, Dr. Zirwas noted that this allergen is still used in almost all water-based paints and can become an issue in small rooms that aren’t well ventilated. The 2014 Allergen of the Year was benzophenones, a very common ingredient in sunscreens and personal care products that can also kill coral. The 2015 Allergen of the Year was formaldehyde; Dr. Zirwas recommends patients add one-fourth of a cup of non-fat powdered milk to laundry loads to remove accumulated formaldehyde. The 2016 Allergen of the Year was cobalt, and Dr. Zirwas recommends approaching this in the same was as you would approach a nickel allergy.
The 2017 Allergen of the Year was alkyl glucosides, a plant-derived, biodegradable surfactant used in cleansers and some lotions and sunscreens. The 2018 Allergen of the Year was propylene glycol, an extremely common ingredient in topical prescription products. The 2019 (non) Allergen of the Year, parabens, was chosen to emphasize their safety and infrequency as a cause of contact dermatitis, due to the new wave of products marketed as “paraben free.” Finally, the 2020 Allergen of the Year was isobornyl acrylate, which has caused cases of contact dermatitis in patients using wearable glucose monitoring systems and insulin pumps.
SESSION HIGHLIGHTS
Atopic Dermatitis and Pruritus: Current Concepts and Therapeutics for 2022
by Jonathan Silverberg, MD, PhD, MPH, Lawrence Eichenfield, MD, Eric Simpson, MD, Gil Yosipovitch, MD, PhD, Andrew Blauvelt, MD, MBA
Dramatic advances in our understanding of the immunology and pathogenesis of AD and pruritus has resulted in the development of new and novel topical and systemic therapies. In this session, Maui Derm’s experts discussed where these therapies will fit into our therapeutic armamentarium.
Dr. Yosipovitch began with an update on what’s new in itch and its management. He began with a review of the mechanism of chronic itch, including topics such as the neuroanatomy of itch, molecular anatomy of itch, the pathophysiology of itch and key players—describing this as a cross talk between keratinocytes, cytokines, and nerves with a predominant Type 2 immune response. He also reviewed the role of Th2 related cytokines in pruritic disease and research on periostin, an ECM protein which induces itch and inflammation via the Th2 pathway and integrins. Additionally, Dr. Yosipovitch reviewed the mechanistic differences between histaminergic itch and non-histaminergic itch. He moved on to review neural sensitization and itchy sensitive skin, a clinical phenomenon in chronic itch provoked by stimulus (i.e., itching after being touched). Dr. Yosipovitch also reviewed exciting emerging treatments for prurigo nodularis, including dupilumab, nemolizumab, vixarelimab, CDX-0159, and nalbuphine. Topical treatments for pruritus discussed included ruxolitinib cream and roflumilast. Dr. Yosipovitch concluded his review with emerging treatments for cholestatic and chronic kidney disease-associated pruritus, including maralixibat, odevixibat, difelikefalin.
Dr. Eichenfield dedicated his presentation to new topicals in atopic dermatitis, reviewing data and best clinical practices on topical ruxolitinib, tapinarof, roflumilast, and a Roseomonas-based medication for AD, which had promising preclinical and clinical success, but was ultimately abandoned after basic science studies were unable to predict human clinical results. Dr. Eichenfield also touched on topical cannabinoids in AD treatment, noting that these still reside in the alternative/complimentary realm, and finished his presentation with resources to improve topical care, including guidance on volumetric prescription of topicals and tips for providing resources to educate patients on how to use their topical treatments most effectively.
Dr. Silverberg delivered a concise presentation on navigating the wave of new therapies for AD, including biologics (dupilumab, tralokinumab, and lebrikizumab) and oral JAK inhibitors (baricitinib, abrocitinib, and upadacitinib). Dr. Silverberg reviewed a recent systematic review and meta-analysis comparing the treatment effectiveness of these therapies (lebrikizumab not included) at Week 12–16 with regard to EASI-75 and EASI-90. According to this analysis, the leaders in effectiveness were upadacitinib 30mg, abrocitinib 200mg, upadacitinib 15mg, and abrocitinib 100mg. Additionally, Dr. Silverberg discussed research investigating the effectiveness of these therapies when combined with topical corticosteroids, which showed a superior efficacy to monotherapy in trials for all agents except upadacitinib, which Dr. Silverberg attributes to its already high efficacy when administered as monotherapy. With regard to long-term efficacy, Dr. Silverberg noted that patients who responded to the aforementioned oral JAK inhibitors and tralokinumab showed good long-term maintenance of response with continuous dosing; further, patients who responded to the oral JAKs showed good long-term maintenance of response with lowered dosing. He finished his presentation with safety data and dosing regimens for these agents.
On behalf of Dr. Blauvelt, Dr. Simpson delivered a presentation on long-term safety data, and the limitations of this data, on baricitinib and upadacitinib in patients with rheumatoid arthritis (RA) and short-term JAK inhibitor safety data in patients with AD, with the goal of countering excess fear brought about by the FDA regarding JAK inhibitors and AD. To begin, Dr. Simpson reviewed the boxed warnings currently accompanying baricitinib and upadacitinib for RA, including serious infection, heart attack/stroke/death, thrombosis, and malignancy. Dr. Blauvelt warned that the boxed warnings for all JAK inhibitors, including those approved for AD, are derived from long-term data in tofacitinib, a JAK 1/3 blocker, in studies of patients with RA over the age of 50 with at least one cardiac risk factor, and most of those patients were also on prednisone and/or methotrexate. Dr. Simpson concluded the presentation by noting that the most common side effects associated with oral JAKs in AD are nausea, headache, and acne, which are usually mild to moderate in severity, easily management, and do not lead to drug discontinuation, and that the new JAKs approved for AD are safer than tofacitinib for RA, with a caveat that more long-term safety data in patients with AD are needed. However, he does recommend using these drugs with caution in patients with AD who are over 60 years of age and in those with classic risk factors for infection, MACE, DVT, and cancer.
Dr. Simpson also delivered his own presentation on offering the right AD treatments for your patient. He provided guidance on measuring disease burden in patients, noting the multidimensional burden of AD not limited to the symptoms of itch and pain, but low self-esteem, worsened sleep, decreased work productivity, comorbidities such as asthma and infection, and mental health impacts. Dr. Simpson also included additional burdens to consider, including dyspigmentation in patients with darker skin tones, guilt, embarrassment, and stigma. Dr. Simpson moved on to discuss the power of shared decision making when navigating AD treatment and recommended that dermatologists empower their patients by letting them choose their treatment based on what their goals are and tailoring their options using medical expertise. He moved on to discuss criteria to consider when deciding to use or not use a variety of treatments for AD, including phototherapy, cyclosporine, methotrexate, dupilumab, tralokinumab, and systemic JAK inhibitors.
Nail Disorders 2022: Diagnostic and Therapeutic Challenges
by Phoebe Rich, MD
Dr. Phoebe Rich, one of the world’s leading nail experts, presented a series of cases that challenged attendees’ diagnostic and therapeutic acumen. Dr. Rich began her presentation by emphasizing that it is incumbent on dermatologists to recognize, diagnose, and treat nail disease. She provided clues for the diagnosis and treatment of a wide range of nail disorders, starting with glomus tumors of the nail, the most common nail tumor. She provided guidance for determining which area to biopsy in these cases and showed attendees a helpful video of a nail tumor biopsy. Other nail disorders in her expansive talk included Quinke pulse of the nail, pincer nails, cases of painless paronychia, tuberculosis of the nail, pyogenic granuloma, squamous cell carcinoma, nail dystrophy secondary to carpal tunnel syndrome, and retronychia.
SESSION HIGHLIGHTS
Update 2022: Acne and Rosacea
by Guy Webster, MD, PhD, Hilary Baldwin, MD, Lawrence Eichenfield, MD, Julie Harper, MD, and James Leyden, MD
New drugs, new data, and new insights into acne and rosacea. Maui Derm’s esteemed faculty shared their insights into the management of acne and rosacea.
Dr. Webster began the session with a general overview of what’s new in acne. He began by discussing metformin as an effective off-label treatment for PCOS-related acne. He also discussed new research on spironolactone for acne in adult women and said it will probably remain an off-label treatment for the foreseeable future. He also mentioned spironolactone and the low risk of breast cancer associated with this drug. Dr. Webster moved on to isotretinoin safety, with a discussion on axial spondyloarthropathy and instances of isotretinoin lawsuits in cases of patient pregnancies, psychological damage, and irritable bowel disease. Regarding isotretinoin and psychiatric disease, Dr. Webster discussed the weak support for a connection between the two. He moved on to discuss research on antibiotics for the treatment of hidradenitis suppurativa. He then discussed new research on a variety of drugs for acne, including topical minocycline foam, topical clascoterone, encapsulated benzoyl peroxide and tretinoin, and topical trifarotene. He finished his presentation with a critical examination of “maskne.”
Dr. Baldwin provided attendees an update on isotretinoin. She began by discussing COVID-19 and isotretinoin, pointing to research demonstrating isotretinoin as the #1 drug out of 672 tested drugs that downregulated ACE2, suggesting it might inhibit viral entry, making it a possible protective agent against COVID-19; however, other research discussed showed no difference in SARS-CoV-2 infection in patients on isotretinoin versus patients not on the drug. Dr. Baldwin moved on to provide a critical review of the iPLEDGE system, noting how the burden of the system creates inequities due to limited patient understanding, trouble with access, and a language barrier. The system recently resolved a problem with gender binary categorization issues, changing gender categories to “person who can become pregnant” and “person who cannot become pregnant.” Dr. Baldwin called for substantiative changes to iPLEDGE, but believes that these changes will not happen. Dr. Baldwin recommends using videos over brochures and in-office enrollments and consultations to remedy issues with iPLEDGE. She then moved on to discuss monitoring isotretinoin patients for abnormal CK values, which appears to be most common in athletic male patients taking isotretinoin. Moving on to isotretinoin and pregnancy rates, Dr. Baldwin cited research showing that patients are not likely to adhere to abstinence and oral contraceptives aren’t satisfactorily effective for preventing pregnancy in these patients. She pointed to evidence suggesting that long-acting and infallible contraceptive methods, such as contraceptive implants, are more appropriate for patients taking isotretinoin.
Dr. Eichenfield shared an update on pediatric perspectives in acne, sharing papers from the past year that raised interesting questions and important insights. He began with a study on the effects of swimming on facial sebum in adolescents. He then discussed a paper examining non-first line topical acne medications in pediatric patients with acne. He reviewed a paper on spironolactone for acne and hidradenitis suppurativa in adolescents, which showed an increase in spironolactone use across all age groups from 13 years to 19 years over four years from 2014 to 2019; he also discussed the uncertainty and lack of data of anti-androgen effects on endocrine development in early adolescents. He moved on to discuss a meta-analysis of topical preparations for the treatment of mild to moderate acne; the analysis evaluated 81 papers, 40 trials, and over 18,000 participants and showed that benzoyl peroxide was effective, but benzoyl peroxide and adapalene and benzoyl peroxide and clindamycin were more effective than benzoyl peroxide alone. He moved on to a paper regarding the safe use of adapalene 0.1% gel in a non-prescription environment, concluding that, based on the available evidence, adapalene does not cause birth defects under normal-use conditions in humans.
Dr. Harper reviewed hormonal treatments for acne. She began by emphasizing that all acne is hormonal, as all acne is influenced by hormones, not just acne in adult women. She moved on to discuss clascoterone, a topical anti-androgen, reviewing the mechanism of this drug and noting some important information to remember as we start using this newly approved topical treatment in our practice. She then moved on to discuss new research on spironolactone and discussed using spironolactone in combination with other acne treatments and birth control. She revisited the issue of spironolactone and potassium levels and said she does not check for potassium in healthy women taking spironolactone for acne. Regarding spironolactone and the risk for breast cancer and other gynecologic cancers, Dr. Harper stated that studies suggest there is no association between spironolactone and breast cancer, nor is there evidence for a recurrence of breast cancer in people on spironolactone. She ended her presentation with a discussion of using birth control pills to treat acne and risks and protective benefits associated with birth control pills.
In the final presentation of this session, Dr. Leyden discussed research and his own experiences with regard to a variety of topics in acne, including C. Acnes antibiotic sensitivity and resistance, the lack of evidence for the anti-inflammatory effect of topical clindamycin in acne, scalp acne, the possible role of diet in acne, especially in patients with PCOS, and sebum reductions in patients taking minocycline for acne.
Innovation in Dermatology 2022
by R. Rox Anderson, MD, PhD, and Lilit Garibyan, MD, PhD
The explosion of science research in dermatology over the last decade has led to the development of several innovative therapies. Drs. Lilit Garibyan and Rox Anderson discussed how these therapies will impact aesthetic and medical dermatology in the future.
Dr. Garibyan spoke about novel injectable cooling technology called “ice slurry” for aesthetic fat removal, developed by Dr. Garibyan. According to Dr. Garibyan, the process began when she learned about cryolipolysis (i.e., CoolSculpting) and how this procedure yielded the side effect of long lasting but reversible hypoesthesia, leading her to question whether this could be used for long lasting blocking of itch and pain. She began investigating this in 2012, studying how topical cooling was affecting nerves and how this could be used to treat pain in dermatology in the future. Ultimately, she developed a novel injectable cooling technology that appeared to be more effective than topical cooling for fat reduction. While this technology is not yet approved by the FDA, the first in-human study was published in 2021. Dr. Garibyan noted that this technology can be used beyond aesthetic applications; she discussed research using the technology for obstructive sleep apnea and targeting disease associated with visceral fat, such as fat around the heart. Additionally, the technology has been investigated in mouse models for pain and itch relief without additional drugs or opioids, showing decreased pain sensations for up to 60 days after a single injection.
Dr. Anderson discussed innovations in technology for skin grafting, sharing newly developed coring needle devices that harvest skin “micro-columns” and will allow wounds to be grafted without donor site morbidity or bizarre appearance. According to research in mice performed in Dr. Anderson’s lab, skin structures are transferred with this method, enabling the remodeling of wounds to create new skin; large, full-thickness wounds were shown to heal quickly and effectively after scattering skin micro-columns in porcine models. Dr. Anderson also explained the benefits of properly orienting the collected skin columns versus scattering the columns, which resulted in full re-epithelization in one week in porcine models, and described the clever method his lab developed to easily orient the micro-columns using magnetic paint.
Neuromodulators and Dermal Fillers
by Joel L. Cohen, MD, Dee Anna Glaser, MD, and Michael Gold, MD
Maui Derm’s expert injectors discussed what’s new and trending in 2022 and what’s coming in the near future.
Dr. Gold dedicated most of his presentation to a discussion of higher-dose neurotoxin and research illustrating the benefits of this dosing approach. A pharmacodynamic, dose-response study discussed by Dr. Gold showed an increased duration of treatment response accompanied by increased patient-reported satisfaction with escalating doses of onabotulinumtoxinA (40, 60, and 80 U) compared to 20 U for the treatment of moderate to severe glabellar lines (GL), without a corresponding dose-response effect for safety. Another study on escalating doses of abobotulinumtoxinA showed that this neuromodulator was effective for moderate to severe GL across all doses from 50 U to 125 U, with a rapid onset of effect; additionally, the duration of effect was up to 36 weeks and appeared to increase with escalating doses. The final study discussed by Dr. Gold investigated the safety and duration effect of different incobotulinumtoxinA dose groups for the treatment of moderate to severe GL; the study found a clear dose effect with incobotulinumtoxinA of at least six months’ duration for the majority of included subjects.
Dr. Cohen presented next and discussed a variety of therapies he’s been using in his practice and investigating for efficacy, including a bipolar radiofrequency helmet for thermal skin remodeling and NanoPulse stimulation for a variety of dermatologic conditions, including sebaceous hyperplasia, non-genital warts, seborrheic keratosis, junctional nevi, syringoma, and basal cell carcinoma. Dr. Cohen also discussed “in-motion” pulsed light techniques and multi-wavelength laser hair removal for darker skin, a 1726nm acne laser, adrenergic drops for lid ptosis, and high-intensity focused electromagnetic field muscle stimulation.
Dr. Glaser provided an update on fillers. She discussed new hyaluronic acid fillers and non-hyaluronic acid products. She also reviewed new research that compared the water absorption of currently approved HA fillers and how this research can be used to improve outcomes. She also discussed research on flexible HA fillers for lip and perioral enhancement. Dr. Glaser reviewed filler injection techniques for hand rejuvenation, and filler techniques for the neck and chest, including combining fillers with other procedures for best outcomes in the chest area.
SESSION HIGHLIGHTS
Pediatric Dermatology 2022
by Lawrence Eichenfield, MD, Ilona Frieden, MD, Sheila Friedlander, MD, and Jim Treat, MD
Maui Derm’s panel of leading authorities in pediatric dermatology provided their 2022 update to attendees while also discussing a few of their “oldies but goldies,” articles that they revisit to inform their practice year after year.
Dr. Frieden began her oldies but goldies presentation with an article that she said she uses almost every day in her practice—a commentary on signature nevi that reviewed the types of signature nevi, including solid brown, solid pink, eclipse, cockade nevi, nevi with perifollicular hypopigmentation, multiple halo nevi, nonpigmented melanocytic nevi, and the “cheetah phenotype.” The second article she picked discussed the most common forms of scalp nevi—eclipse nevi and the cockade nevi—and how these nevi can be further interrogated using dermoscopy as opposed to biopsy. In Dr. Frieden’s pediatric update section, she discussed new perspectives of mosaicism in skin disease.
In Dr. Eichenfield’s oldies but goldies review, he began with a case report as a means to discuss the importance of tinea capitis culturing and the changing patterns of tinea, with increased awareness around immigration and travel. Dr. Eichenfield also mentioned growing terbinafine resistance in Africa, and while this isn’t yet an issue in the United States, he noted that this is something to watch out for. Dr. Eichenfield’s second oldie but goldie was an article discussing the association between diaper dermatitis and antibiotics, published before research on the microbiome in relation to skin diseases became more widespread. He used this article to provide recommendations for the management of candidal diaper dermatitis. The entire panel discussed whether they recommend probiotics for diaper dermatitis, and concluded that, due to the dearth of efficacy data, it’s difficult to recommend probiotics, but probiotics that have been evaluated for safety might be a viable option to explore. Dr. Eichenfield began his pediatric update with a case report of a two-year-old patient with a history of AD who presented with an oozing rash, severe itching, pain, and fever, which turned out to be AD infected with Staph and Strep. He used this case report to discuss infections in pediatric AD as well as increasing rates of clindamycin-resistant Staph. Dr. Eichenfiled moved on to discuss updates in rare pediatric diseases, including new consensus recommendations for using retinoids in ichthyosis in children and breakthroughs in the genomic diagnosis of epidermolysis bullosa.
Dr. Friedlander’s oldies but goldies presentation began with an article from 2012 which codified recognizing and managing eczematous id reactions to the molluscum contagiosum virus in children. She discussed another article that found that children with eczema struggled with persistent molluscum contagiosum that were more numerous and took longer to clear. She also reviewed an article from 2009 on the safety and efficacy data fluocinolone acetonide 0.01% in peanut oil in infants as young as three months of age. Dr. Friedlander began her pediatric update presentation with a discussion of distinguishing simple vascular stains and complex vascular lesions through the identification of genetic mutations and fast-flow using MRI. She also discussed the importance of dermatologists physically touching red stains on pediatric patients to identify possible lesional warmth. Dr. Friedlander moved on to discuss research on a future method of differentiating infantile hemangiomas and port wine stains using a colorimeter, which she says she looks forward to using in the future. She moved on to address frequently asked questions and dispel myths about melanocytic nevi in children. She concluded her presentation with a discussion of non-melanoma skin cancer in otherwise healthy children.
Dr. Treat focused on cranial dysraphism in his oldies but goldies presentation. He began with a discussion of hair collars and hair tufts as a marker for cranial dysraphism. He also discussed hemangiomas in the lumbosacral area as a marker for cranial dysraphism. Dr. Treat’s pediatric update presentation began with a discussion of pediatric psoriasis presentation, including facial involvement, perineum, scalp, and guttate, then moved on to emphasize important variations in pediatric psoriasis in skin of color. He discussed the risk for behavioral health issues in children with psoriasis. Dr. Treat then reviewed pediatric psoriasis comorbidity screening guidelines. He included an interesting discussion of tonsillectomy as a viable treatment option for patients with a clear correlation between Strep infections/tonsilitis and their psoriasis. He discussed being mindful about administering live vaccines to children before starting systemic drugs for psoriasis and the importance of boosting children before starting them on systemic psoriasis therapies. Dr. Treat also reviewed research on several drugs for children with psoriasis, including etanercept, ustekinumab, and secukinumab.
Update 2022: Disorders of Pigmentation
by John Harris, MD, PhD, and Pearl Grimes, MD
In this session, John Harris, MD, PhD, and Pearl Grimes, MD, discussed the latest approaches to treating vitiligo, melasma, and other disorders of pigmentation.
Dr. Harris provided an update on vitiligo, an autoimmune disease that he emphasized is fully reversable. Dr. Harris began by noting that pigmented hairs are a requirement for successful treatment of vitiligo. According to Dr. Harris, in cases where the patient presents with a lot of white hair in a depigmented patch, it’s important to set realistic expectations and inform this patient that continued treatment will likely be unsuccessful. Dr. Harris moved on to discuss narrowband UVB therapy for vitiligo and shared several case reports of successful narrowband UVB treatment. He also reviewed signs of disease activity in vitiligo, including trichrome vitiligo, inflammatory vitiligo, confetti vitiligo, and evidence of the Koebner phenomenon (i.e., vitiligo appearing on damaged skin). Dr. Harris then reviewed his treatment algorithm for vitiligo. He then discussed melanocyte keratinocyte transplant for stable vitiligo, a surgical intervention for stable vitiligo. According to Dr. Harris, there are currently only two or three centers in the country that perform this procedure, but researchers are investigating ways to make this procedure easier and more accessible; clinical trials recounting these investigations are currently underway and should produce data towards the end of 2022. Dr. Harris reviewed research on a variety of other therapies for vitiligo in the second half of his session, including monobenzyl ether of hydroquinone for vitiligo, systemic immunosuppression plus narrowband UVB, oral ruxolitinib, ruxolitinib cream, and ritlecitinib.
Dr. Grimes shared updates in hyperpigmentation. She began by discussing the psychological effects of pigmentary disorders and the imperative to improve patient quality of life by treating these conditions. Dr. Grimes moved on to review the pathogenesis of melasma and the potential mechanisms of post-inflammatory hyperpigmentation. She discussed therapeutic interventions for hyperpigmentation, including photoprotection, lighteners, antioxidants, exfoliants, moisturizers, anti-angiogenesis agents, resurfacing procedures, and emerging therapies. She moved on to discuss the impact of visible light photoprotection for melasma, then shared research on the impact of iron-oxide containing cosmetic formulations against visible light-induced pigmentation. Dr. Grimes discussed research on oral Polypodium leucotomos extract and its impact on visible light-induced pigmentation in human subjects and reviewed other antioxidants for the treatment of melasma, including liposomal glutathione, oral and topical vitamin E, oral and topical niacinamide, oral grape seed extract, and topical silymarin. Dr. Grimes then moved on to review the role of mast cells in melasma. She also reviewed topical lightening agents, including hydroquinone, but then discussed a push for non-hydroquinone lightening agents currently in development for melasma, including research on cysteamine, tranexamic acid, and malassezin. Dr. Grimes ended her presentation with a review of resurfacing procedures for the treatment of hyperpigmentation, including chemical peels, microdermabrasion, microneedling, platelet-rich plasma, ablative and nonablative lasers, and intense pulsed light.
Psoriasis Update 2022
by Bruce Strober, MD, PhD, Linda Stein Gold, MD, Arthur Kavanaugh, MD, Andrew Blauvelt, MD, MBA, and Joel Gelfand, MD, MSCE
Maui Derm’s panel of leading psoriasis authorities discussed the rapidly changing landscape of psoriasis and psoriatic arthritis. Their discussion included new topical and systemic drugs in 2022, new findings, management strategy updates, psoriatic arthritis, and the immunology and genetics of psoriasis.
Dr. Strober began with a review of recent research on IL-17 inhibitors, including a multicenter, randomized, double-blind study of the efficacy and safety of secukinumab every two weeks for patients with psoriasis who weigh 90kg or more, a study that measured PASI and sPGA responses with ixekizumab among pediatric patients with moderate to severe psoriasis, and a Phase III trial of secukinumab for pediatric patients with severe psoriasis. Dr. Strober’s key takeaways with regard to IL-17 inhibitors were that these agents show rapid response and strong efficacy but require more frequent dosing than IL-23 inhibitors. They show comparable efficacy to adalimumab for psoriatic arthritis and inhibit radiographic progression in PsA. Based on the first study discussed, a double dose of secukinumab (300mg every 2 weeks) appears most effective for heavier patients. IL-17s have shown a low signal for malignancy and serious infections and strong efficacy for nail psoriasis. Finally, they’ve demonstrated strong efficacy for pediatric psoriasis.
Dr. Strober moved on to discuss research on IL-23 (p19) inhibitors, including reSURFACE 2, which measured PASI and PGA responses with tildrakizumab in chronic plaque psoriasis, VOYAGE 1, which compared guselkumab to adalimumab for PASI response in patients with moderate to severe psoriasis, and ultIMMa-1 and ultIMMa-2, which measured PASI 90 responses with risankizumab through 52 weeks. According to Dr. Strober, conclusions from these studies show that IL-23 inhibitors yield robust and long-lasting skin efficacy, demonstrating high PASI 90 and 100 levels after 16 weeks of treatment, with risankizumab achieving PASI 100 in 58 percent of patients at Week 52. Dosing of these agents are infrequent and variable (e.g., every 2 or 3 months) and show the best long-term efficacy of approved drugs.
Dr. Strober then provided an update on apremilast, a PDE4 inhibitor, and discussed a 16-week, double-blind phase of the ADVANCE trial, which evaluated the efficacy and safety of apremilast in patients with mild to moderate psoriasis. Dr. Strober also discussed research on the TYK2 allosteric inhibitor deucravacitinib, including the POETYK PSO-1 and PSO-2 trials, which evaluated PASI 75 at Weeks 16 and 24. Upadacitinib, a JAK1 inhibitor, was also discussed, with a review of key outcomes after treatment with upadacitinib versus placebo and adalimumab among adults with psoriatic arthritis.
On behalf of Dr. Blauvelt, Dr. Strober also presented on new literature in psoriasis. This past year appeared to be the year of bimekizumab, with four papers published in 2021. Phase II results for sonelokimab, an IL-17A nanobody, were also shared. Dr. Strober also discussed research on spesolimab, an IL-36R antibody, for the improvement of generalized pustular psoriasis. Additionally, Dr. Strober discussed research concerning whether SARS-CoV-2 can enter the body through psoriasis lesions. Dr. Strober also discussed treatments on the horizon that could prevent psoriasis from returning once it was cleared by treatment.
Dr. Stein Gold reviewed the five biggest misconceptions regarding mild to moderate psoriasis. These misconceptions were: localized psoriasis doesn’t matter; localized psoriasis is easier to treat; nonsteroidal options don’t work, which included a discussion of the efficacy of tapinarof 1% cream and roflumilast; nonsteroidal options burn; and pharmaceutical companies gouge prices, with a brief review on how the research and development process leads to increases in drug prices.
Dr. Kavanaugh began his psoriatic arthritis update with a review of clinical features and domains of psoriatic arthritis and discussed defining PsA subsets by disease domains. Dr. Kavanaugh also reviewed treatment options for PsA, including adjunctive therapies, DMARDs, biologic, JAK inhibitors, PDE4 inhibitors, and a few experimental options and those in development. Dr. Kavanaugh also discussed new therapeutic agents for systemic inflammatory autoimmune diseases and autoimmune consequences for biologics. Dr. Kavanaugh finished his presentation with some future developments in PsA on the horizon, such as predicting and preventing psoriatic arthritis in patients with psoriasis, early treatment of PsA, altering the disease course through early intervention, and new treatment options using targeted therapy based on cellular and clinical phenotypes.
Dr. Gelfand presented on comorbidities and COVID-19 in the management of psoriasis. Here, Dr. Gelfand reviewed the risk factors for psoriatic arthritis and discussed whether biologic treatment of psoriasis reduces the risk of developing PsA. Dr. Gelfand also discussed the long-standing hypothesis that patients with psoriasis are more prone to liver disease, but noted that a lack of large scale outcomes-based data to test this hypothesis. He went on to discuss research on the risk of liver disease associated with methotrexate use in patients with psoriasis, psoriatic arthritis, and rheumatoid arthritis in Denmark. Dr. Gelfand moved on to discuss whether psoriasis should be aggressive treated to lower the risk of cardiovascular disease
(CVD) and reviewed the use of statins to prevent CVD in patients with psoriasis. Dr. Gelfand summarized current knowledge on psoriasis treatment and COVID-19 risks. In short, recommendations state that patients who are not infected with COVID-19 should continue their psoriasis treatments and that newly diagnosed patients should consider the risks of untreated psoriatic disease. Dr. Gelfand noted the need for large scale, longer term, population-based studies with appropriate comparator groups, adjustment for confounding variables, and complete ascertainment of clinically important COVID-19 outcomes. Additionally, Dr. Gelfand discussed research finding that psoriatic exacerbations have not been reported disproportionately following administration of COVID-19 vaccines compared to other types of vaccines, and discussed instances of COVID-19 infections leading to severe psoriasis flares. Dr. Gelfand finished his presentation with recommendations for COVID-19 vaccines in patients with psoriasis.
Dermatology in Review
by Hensin Tsao, MD, and Sheila Friedlander, MD
During Dermatology in Review, Dr. Hensin Tsao discussed the most important advances in dermatology from 2021. Dr. Sheila Friedlander-Fallon shared the podium and discussed the latest advances in pediatric dermatology.
Dr. Tsao began his presentation with a discussion of recent head-to-head research comparing upadacitinib, a Janus-kinase (JAK) inhibitor, and dupilumab, an interleukin (IL) 13 and 4 blocker, in adults with moderate-to-severe atopic dermatitis (AD). Dr. Tsao noted the superior efficacy of upadacitinib initially in achieving the primary endpoint of EASI 75, but also noted that these results converged at Week 16 of the study, with 60 to 70 percent of patients in both groups achieving EASI 75 at Week 16. However, upacitinib maintained superiority over dupilumab with regard to secondary endpoints of EASI 90, EASI 100, and greater reductions in NRS itch scores.
Dr. Tsao moved on to discuss research on the relative efficacy on bimekizumab, an anti-IL17A, anti-IL-17F, and anti-IL17AF agent for psoriasis. He discussed three head-to-head studies that compared bimekizumab to ustekinumab, adalimumab, and secukinumab, with bimekizumab showing superior efficacy with regard to the primary endpoints in all three studies. Dr. Tsao noted that in these studies, most of the recruited patients were White, and emphasized the need for future studies to include a more diverse sample of patients.
Dr. Tsao moved on to discuss research on fecal microbiota transplantation (FMT) in patients with melanoma, which, according to the studies discussed, appears to promote treatment response among immunotherapy-refractory melanoma patients.
Dr. Tsao moved on to discuss topical bacterial therapy for the treatment of AD, citing recent research that showed autologous bacteriotherapy in patients with AD led to a significant drop in Staph aureus content by Day 4 of therapy, and a significant reduction in EASI scores 11 days after receiving this topical bacterial therapy.
Dr. Tsao also discussed a recent mutational survey of acral nevi, which found that among patients with acral nevi, 86 percent had BRAF mutations, 10 percent had NRAS mutation, and two percent had EGFR mutations. According to Dr. Tsao, this small but unequivocal case series demonstrated that nearly all acral nevi arise from mutations in BRAF or NRAS despite the lack of sun exposure.
Dr. Tsao also touched on recent research illuminating gene mutations responsible for tree man syndrome; a National Cancer Database study that showed female patients have better survival rates of Merkel cell carcinoma than male patients; and a whole population case control study performed of Iceland that showed metformin is associated with a decreased risk in basal cell carcinoma.
Dr. Friedlander provided a brief update of the latest advances in pediatric dermatology. She began with a review of new consensus statements for the management of port wine stains, emphasizing that, contrary to prior practice, infants with port wine stains should be evaluated and treated as early as possible. She also discussed a new consensus recommendation for the use of retinoids in ichthyosis and other disorders of cornification in children and adolescents, noting that topical and systemic retinoids can be very effective in treating these difficult diseases. Dr. Friedlander also reviewed research on comorbidities in children with AD, which found that these children showed higher risks of anxiety, MRSA, autoimmune disorders, lymph heme malignancy, metabolic syndrome, and obesity. Dr. Friedlander discussed research that found that children with AD have a higher risk of learning disabilities independent of socioeconomic status or age of onset. Further, she touched on recent research exploring the trajectory of pediatric atopic dermatitis, bringing us one step closer to being able to accurately predict if a child will grow out of their AD. Dr. Friedlander rounded out her presentation with positive news, citing research showing decreasing rates of melanoma among adolescents.
Cutaneous Oncology: Part 1
by George Martin, MD, Theodore Rosen, MD
In this session, Ted Rosen, MD, and George Martin, MD, discussed the management and therapeutic options for actinic keratosis (AK) and non-melanoma skin cancer. Dr. Rosen and Dr. Martin began with articles of interest published in 2021, including a review of AK, skin field cancerization and the efficacy of topical therapies and a ten-year follow up of persons with sun-damaged skin associated with subsequent development of cutaneous squamous cell carcinoma.
Dr. Rosen and Dr. Martin also discussed the 2021 American Academy of Dermatology (AAD) actinic keratosis guidelines. A few concerns were discussed; they noted that to create these guidelines, databases were searched from inception through January 2019, making these guidelines outdated by two years by the time the draft was introduced to the dermatology community. Additionally, Dr. Martin noted that actinic cheilitis was left out of these guidelines, and guidance on immunocompromised individuals was also missing.
Dr. Rosen and Dr. Martin also discussed optimizing efficacy and minimizing pain when treating actinic keratoses with photodynamic therapy (PDT). In short, Dr. Martin recommended applying aminolevulinic acid to the treatment area, immediately treating the area with blue light, and illuminating for 30 minutes.
Other topics discussed by Drs. Rosen and Martin included PDT for cutaneous squamous cell carcinoma in situ and superficial basal cell carcinoma, case studies in actinic keratosis and superficial nonmelanoma skin cancer therapy, and new therapies for disseminated superficial actinic porokeratosis.
New Drugs and Therapies in 2022
by Neal Bhatia, MD, and Theodore Rosen, MD
Hana hou! The “Ted and Neal Show” with Ted Rosen, MD, and Neal Bhatia, MD, once again entertained and educated attendees about new drugs and therapies in dermatology and how we will be using them in 2022. The presentation began with a discussion of new therapies for acne and rosacea, including microencapsulated benzoyl peroxide 5% for rosacea and combination benzoyl peroxide 3%/tretinoin 0.1% for acne. Dr. Rosen and Dr. Bhatia moved on to discuss widespread pyrethroid resistance, noting that the gene for resistance to pyrethroid, which used to treat head lice, is now widespread across the United States. A new drug called abametapir is the answer to this problem, but unfortunately is not yet available for prescription.
Moving on, the duo discussed scabies, which is becoming less sensitive to conventional therapies such as permethrin and ivermectin. However, an effective new therapy called spinosad was approved for the treatment of scabies in April 2021. Dr. Rosen and Dr. Bhatia then discussed a new therapy called ibrexafungerp, which was approved in June 2021 for acute vulvovaginal candida (VVC) in adult and post-menarchal pediatric female patients with VVC. For chronic VVC, Dr. Rosen and Dr. Bhatia discussed oteseconazole, and noted that this therapy is in Phase III trials for onychomycosis.
The duo moved on to discuss strontium for the topical management of localized itch and the proposed mechanisms of this agent’s efficacy against itching. Dr. Rosen and Dr. Bhatia also discussed ruxolitinib cream 1.5%, approved in September 2021 for short-term, noncontinuous treatment for mild to moderate AD in non-immunocompromised patients 12 years of age and older; they also discussed the black box warning that comes with ruxolitinib cream and advised getting ahead of patient questions by proactively explaining these warnings. Other therapies discussed by Dr. Rosen and Dr. Bhatia included anifrolumab, which was approved in August 2021 for the treatment of lupus and is currently being studied for discoid lupus, tralokinumab for adults with moderate to severe atopic dermatitis (expected to be available by February 2022), vaccines for the Zika and Chikungunya entering Phase III trials, berdazimer 10.3% in Phase III development for molluscum contagiosum, and a new kappa-opioid receptor called difelikefalin being investigated for itch in atopic dermatitis.