Maui Derm Connect Coverage: September 26, 2020

SESSION HIGHLIGHTS

Neonates to Adolescents Pediatric Dermatology Update 2020

Maui Derm’s pediatric dermatology faculty, including Alan Yan, MD, and Marissa Perman, MD, presented a range of cases for discussion that presented a diagnostic and therapeutic challenge. Neonatal rashes, viral exanthems, lumps and bumps, hot topics in peds derm, creative solutions for hard to treat common problems, and more!

To begin the Neonates to Adolescents Pediatric Dermatology Update, Dr. Perman evaluated how bathing practices affect the improvement or exacerbation of atopic dermatitis, as well as studies that observed whether early emollient use could be used to prevent atopic dermatitis in infants. Using cases and clinical data, Dr. Perman then reviewed the adverse effects children experienced when being treated with propranolol and triamcinolone. After sharing photos and relative case information, Dr. Perman discussed the difference between bier spots and anemic spots. The segment concluded with an analysis involving the “bumpy” adolescent nose, a type of acne scarring that mimic papule acneiform lesions.

In the second half of the session, Dr. Perman thoroughly reviewed common and new pediatric dermatology conditions to provide physicians with diagnostic clues and therapeutic pearls. The five cases used included photos and descriptions of the patient’s history, symptoms, diagnosis, and management and treatment choices from the physicians.

 

Cutaneous Oncology Update 2020

The spectrum of cutaneous oncology, ranging from AKs to advanced NMSC, were discussed. New concepts, new drugs, and new applications for existing therapies were discussed in a case-based approach.

The presentation began with an overview of the history, epidemiology, and etiology of dermatofibromasarcoma protuberans. Next, clinical exam features and the differential diagnosis of dermatofibrosarcoma protuberans were discussed, which included the early and late stages of the disease. Dr. Gladstone then explored the histopathology of the disease, highlighting the histologic variants. Using photographs and follow-up data from different cases, the immunohistochemistry and available treatments for dermatofibrosarcoma protuberans were explored, as well as the role of some therapies, such as Mohs micrographic surgery, radiation, and molecular targeting. The presentation ended with information regarding means for prognosis of dermatofibrosarcoma protuberans, and criteria to determine duration between and frequency of follow-up visits.

 

Atopic Dermatitis Update 2020

The explosion of new topical and systemic therapies for atopic dermatitis has challenged clinicians in dermatology to stay abreast of the latest treatment algorithms for treating AD. In this session, Eric Simpson, MD, and Lawrence Eichenfield, MD, discussed a variety of cases, ranging from severe AD in infancy through adulthood.

Dr. Simpson began the session the systemic treatment options for atopic dermatitis, providing information on the factors involved in choosing a specific systemic therapy, when to apply systemic therapy, and determining the reasons for previously poor outcomes. The phenotypes endotyping and predictive biomarkers of atopic dermatitis were also explored. Dr. Simpson wrapped up the segment with instructions on preparing for future options for the skin condition.

Topicals and counseling updates for atopic dermatitis were covered by Dr. Eichenfield. In-depth studies featuring topical treatment data, such as crisaborole use in infants and children with the skin condition, and ruxolitinib, delgocitinib, tapinarof, and roflumilast treatments, were analyzed. Next, Dr. Eichenfield compared the effects of frequent and infrequent bathing in children with atopic dermatitis using previously published data, and later discussed why physicians should include body surface area estimates when assessing the skin condition in children. Dr. Eichenfield ended his presentation by discussing ways to counsel patients on systemic therapy and enhance care in pediatric dermatology, with the aim to improve patient outcomes.

Maui Derm Connect Coverage: September 25, 2020

SESSION HIGHLIGHTS

Update on Infectious Diseases 2020

In this session, Ted Rosen, MD, and Alan Yan, MD, discussed diagnostic and therapeutic challenges in children and adults, covering a range of viral, bacterial, fungal, parasitic, and arthropod diseases. An overview of molluscum contagiosum (MC) commenced the Pediatric Disease Update presentation from Dr. Yan, beginning with a discussion of whether MC is correlated with infection or inflammation using data from previously published studies. Next, Dr. Yan discussed cases of children with jaw abscesses from nontuberculous mycobacteria, and how associated sinus tract infections might not be strictly due to actinomyces.

Following were examples of cutaneous red nodules in immunocompromised patients, with an emphasis on the importance of biopsies, as they provide the opportunity to clarify diagnosis and management, regardless of their ability to determine infection. The presentation then shifted to evidence of “COVID toes” and chilblains observed in children who have tested negative for SARS-CoV2 during the pandemic. Plausible explanations were thoroughly analyzed before discussing differentiating between multisystem inflammatory syndrome and Kawasaki disease in children. The presentation ended with ample evidence that suggested the two conditions share similarities and that multisystem inflammatory syndrome is correlated to COVID-19.

 

Acne and Rosacea Update 2020

Maui Derm’s faculty of acne and rosacea experts, including Julie Harper, MD, Hilary Baldwin, MD, and Marissa Perman, MD, covered the complete spectrum of acne and rosacea disorders while also presenting therapeutic conundrums and how they optimized therapy even in their most challenging patients.

To start, Dr. Harper built a case for combination rosacea therapy by evaluating patient symptoms and impacts of available treatments. Then, Dr. Harper reviewed rosacea subtypes, triggers, avoidances, and the indications for current therapies.

Dr. Baldwin presented on acne tips and tidbits and discussed whether acne relapse is due to failure of isotretinoin, insufficient isotretinoin dosing, or recurrence, while also highlighting common risk factors for acne relapse. Diet and isotretinoin were examined next, specifically how isotretinoin is affected by fasting and a high-fat diet. Using cases of various types of inflammation, Dr. Baldwin then evaluated prevention and treatment measures for isotretinoin-related flares. To wrap up the segment, Dr. Baldwin offered methods to prevent acne scarring and care for adult female patients with acne.

Dr. Perman provided an update in pediatric acne. Through case studies, the mechanisms of neonatal, infantile, mid-childhood, preadolescent, and adolescent acne were intensively explored. Dr. Perman also provided the clinical features and signs to determine if acne occurring in teenage female patients is actually hyperandrogenism. To conclude this segment, Dr. Perman addressed whether diet impacts the development and persistence of acne.

 

Zebras in Dermatology

There are those skin disorders that we encounter only once every few years, or in some cases, once in a career, referred to in medicine as “zebras”. In this session, the Maui Derm faculty presented a series of clinical “zebras” that challenged their clinical skills in making the diagnosis. Each case presented required an extensive differential diagnosis and, in some cases, a diagnostic workup and full armamentarium of therapeutic agents.

Alan Yan, MD, began his segment of the lecture with a case of a 17-year-old patient with a history of acne who later developed inflamed neck papules and nodules that seemed resistant to acne treatment. This led to the discussion of atypical neck hidradenitis suppurativa and a genetics workshop regarding autoinflammatory syndromes associated with hidradenitis suppurativa acne.

The second case presented involved an 18-year-old patient who had undergone draining of nodules in the axillae, inframammary, and inguinal areas of the body. Despite draining, the nodules became more severe over time, so the treating physicians employed the anti-inflammatory potency of a biologic that targets the cytokine believed to influence the condition. According to Dr. Yan, the patient still exhibited deeper wounds and poor healing, as well as a substantial weight loss, and had to be admitted for wound care and debridement. Factors to consider in the approach to treat hidradenitis suppurativa were listed and evaluated, with an emphasis on involving the pathology and psychopathology of the condition. A review of the efficacy and safety of adjunctive hyperbaric oxygen therapy and combining it with ustekinumab for the treatment of severe hidradenitis suppurativa concluded the presentation.

Maui Derm Connect Coverage: September 24, 2020

SESSION HIGHLIGHTS

Dermatology Update 2020

In this session, featuring Ted Rosen, MD, Matthew Zirwas, MD, Lucia Diaz, MD, and Seemal Desai, MD, top articles from the literature in 2019 and 2020 that affect the way we practice dermatology were discussed. Dr. Rosen began the lecture with an update from the literature on patient care, surgery, and cutaneous oncology. Additional topics discussed throughout the presentation were the use of vibrational anesthesia to prevent the pain of local injections, the importance of hedgehog inhibitors for the improved quality of life of patients with prominent lesions related to end-stage cancer, and the increased prevalence of thyroid dysfunction in people with psoriasis. The segment ended with studies that evaluated the link between atopic dermatitis and cancer.

Next, Dr. Zirwas presented articles that covered topics such as dietary modifications for patients with psoriasis to improve their symptoms and optimizing the way physicians speak to patients to promote better adherence and agreement. Dr. Zirwas also explored the use of statins and the occurrence of atopic dermatosis and reported on the effectiveness of the hypnosis method when treating atopic dermatitis and the safety and efficacy of various atopic dermatitis treatments.

Following this, Dr. Diaz provided updates in pediatric dermatology practices, including new practice and treatment guidelines from pediatric dermatology specialists. Next, Dr. Diaz shared data on the use of dupilumab for children and the methods for use depending on age. Lastly, Dr. Desai examined what’s new in publications for dermatology in general, beginning with a study of global epidemiology and clinical spectrum of rosacea in skin of color. The differential diagnosis for various skin conditions in patients with skin of color were also analyzed.

 

New Drugs and New Therapies for 2020 and 2021

New drugs and therapies that will change the way in which we practice dermatology are coming our way! Will you be ready to use them? The Maui Derm faculty, including Ted Rosen, MD, and Linda Stein Gold, MD, provided key elements to the early adoption of these amazing therapies. They also gave us a glimpse into the pipeline of amazing drugs and devices headed our way.

Dr. Rosen and Dr. Stein Gold discussed new topical treatments for acne, including trifarotene 0.005%, tretinoin 0.05%, tazarotene 0.045%, clascoterone 1.0%, and minocycline 4.0%. They discussed drug class, formulation dosage, and clear/almost clear and two-grade improvement scores. The technological advancement of porous silica microencapsulation, which forms a shell around monomers to determine egress speed, and how this will be applied in dermatologic treatments, was also explored.

Dr. Rosen and Dr. Stein Gold also discussed the new topical therapy agents that are currently being studied for the treatment of psoriasis and atopic dermatitis, followed by the mechanism of action for oral tirbanibulin for the treatment of actinic keratosis. The physicians ended their presentations with updates in vaccines for zika, tuberculosis, and the 40 viable vaccines for COVID-19, as well as changes in indications for skin disease treatments.

 

Psoriasis and Psoriatic Arthritis in the COVID-19 Era

New drugs, new data, new approaches to psoriasis and psoriatic arthritis were discussed in this series of lectures from Joel Gelfand, MD, Bruce Strober, MD, PhD, and Arthur Kavanaugh, MD. The talks were followed by a discussion of a series of challenging case scenarios.

Dr. Gelfand provided a brief overview of the National Psoriasis Foundation and the COVID-19 taskforce, addressing COVID-19-related questions and concerns, especially within the psoriasis and psoriatic arthritis community. The methods of protection, continuation of treatment, and effects on psoriatic disease were covered. Dr. Gelfand concluded this part of the presentation by offering management instructions for those with psoriatic disease who have contracted COVID-19, as well as an in-depth look at the scientific progressive of COVID-19.

Next, Dr. Strober provided updates of modern psoriasis therapies and current data on the skin disease. To begin, Dr. Strober compared the cytokine-regulation abilities of tyrosine-protein kinase- and Janus kinase 1 inhibitors. Then, the efficacy, safety, and changes in PASI scores of the IL-17 and IL-17f inhibitor, bimekizumab, was examined through solid findings from Phase III studies. Following this, Dr. Strober switched focus to IL-23 inhibitors, specifically guselkumab, sharing current findings and tolerability and safety data. Dr. Strober later compared changes in PASI scores and above data between IL-17 inhibitors and IL-23 inhibitors. The segment ended with the exploration of current topical treatments and severity guidelines for the treatment of psoriasis.

Last to present was Dr. Kavanaugh, who described recent advancements in psoriatic arthritis. Dr. Kavanaugh highlighted the putative etiopathogenesis for psoriatic arthritis and newer therapeutic agents for systemic inflammatory autoimmune diseases, including data from clinical and head-to-head studies that exhibited and compared their success and safety. He concluded the presentation by discussing the future of psoriatic arthritis, combination therapies, and personalized medicine approaches.

Maui Derm Connect Coverage: September 23, 2020

SESSION HIGHLIGHTS

Contact Dermatitis and Eczema

In this presentation, Matthew Zirwas, MD, discussed contact dermatitis, patch testing, and the approach to a wide variety of eczematous eruptions. In the first part of his presentation, Dr. Zirwas discussed updates in the world of contact dermatitis through specific cases and published studies, beginning with contact dermatitis induced by nickel. Next, Dr. Zirwas explored allergic reactions caused by commonly used materials, such as rubber, acrylates, and isobornyl acrylates. Following these allergens, Dr. Zirwas examined how contact dermatitis was impacted by the preservative methylisothiazolinone, which can be found in typical household items, and the dangers of “paraben-free” labeled products and fragrance allergies. Dr. Zirwas ended this part of the presentation with the systemic treatments involved with the management of atopic contact dermatitis and an evaluation of the role of TRUE testing, patch testing procedures and issues, and preparing for allergens with and without immunosuppressants.

In the next part of his presentation, Dr. Zirwas explored the diagnostic approach for spongiotic dermatitis, the history and distribution of dermatitis, and various instances of dermatitis that is not otherwise specified. Skin conditions that mimic dermatitis not otherwise specified are reviewed, highlighting characteristics of dermal hypersensitivity, urticarial, facial, eyelid, and seborrheic dermatitis, and dermographism. To conclude the presentation, the focus shifted to various types of hand eczema, as Dr. Zirwas provided a general diagnostic algorithm, characteristics, and a list of low allergenicity products for the skin condition.

 

Psoriasis and Psoriatic Arthritis

This session, featuring Bruce Strober, MD, PhD, Arthur Kavanaugh, MD, and Melodie Young, MSN, ANP-c, was designed as a series of case-based studies covering a wide range of diseased states in psoriasis that challenged even the most experienced clinician. The featured physicians began by advocating for the safe continuation of biologic therapies during the era of COVID-19, using cases of patients with psoriasis who wanted to discontinue their treatment as a precautionary measure. After reviewing a few biologic options, each physician discussed the importance of monitoring patients who being treated with biologics, infection risks, the biologic response to vaccines, and how patients can effectively be vaccinated in conjunction with treatment.

Next, using published data, Dr. Strober compared the 24-week clinical trial responses and changes in joint structural damage effects of treatment options for psoriatic arthritis. Based on this data, Dr. Kavanaugh explored whether different inhibitors should be used interchangeably for psoriatic arthritics; moreover, questions regarding drug efficacy in axial spondyloarthritis were thoroughly examined.

Dr. Young then shifted the presentation to treatment plans for patients with guttate psoriasis or palmoplantar psoriasis, analyzing cases of patients with the above conditions that featured photos depicting clearance progression. This led to the exploration of biologic treatments for pediatric patients with psoriasis or psoriatic arthritis.

The presenters concluded their lecture by examining how weight affects and potentially dictates psoriasis and psoriatic arthritis treatment (and vice versa). Each physician adumbrated their treatment choice logic based on patients with psoriasis and obesity, then examined various weight quartiles for dosing and PASI scores from related studies.

 

Cutaneous Surgery and Non-melanoma Skin Cancer: Diagnosis and Management

Here, the participants were given the opportunity to assess non-melanoma skin cancers using a “case study” format. The lesions were evaluated to determine the degree of risk for recurrence and metastasis and appropriate management strategies were presented.

George Martin, MD, aimed to evaluate the epidemiology, clinical features, global guidelines, and histology of actinic keratosis (AK), basal cell carcinoma (BCC), squamous cell carcinoma (SCC). To start the presentation, Dr. Martin reviewed the pathology and terminology of AKs, focusing on its progression to SCC. The FDA-approved topical treatment options for AK and how they perform were then discussed. Following were the available data on BCC and SCC, including risk factors and characteristics of greater risk. The clinical features and histology of BCC were highlighted, along with the pathogens and etiologic factors of SCC. Case studies and photos were used to exhibit the low- and high-risk subtypes of SCC as well. Dr. Martin concluded his half of the presentation with diagnosis and treatment protocols for BCC and SCC.

Suneel Chilukuri, MD, delivered the second part of the presentation, which pertained to risk assessment and treatment recommendations and modalities for BCC and SCC. The parameters that indicate high- or low-risk tumors, as well as risk stratification, were reviewed using previously published data. Then, the typical treatment modalities and recommendations were analyzed, along with the margins and protocols for each. How to determine which surgical approach is appropriate and which is most effective for high- and low-risk tumors were also discussed. Dr. Chilukuri also addressed the rate of reoccurrence for each type of cancer cell before explaining the importance of long-term follow-ups and wrapped up the presentation by promoting self-skin exams and the use of sun protection to reduce the risk for future skin cancers.

Virtual Congress Coverage: June 28, 2020

SESSION HIGHLIGHTS

Atopic Dermatitis Update 2020

Albert Yan, MD, FAAP, FAAD used his presentation on pediatric atopic dermatitis (AD) to review case reports of pediatric patients who exhibited common symptoms of AD. Throughout the presentation, Dr. Yan provided guidance for how to answer frequently asked questions from parents regarding the skin condition, which primarily focused on food avoidances, prevention, and management.

Andrew Blauvelt, MD, MBA, presented on systemic therapies for AD, starting with dupilumab and its published history and data from clinical trials. Dr. Blauvelt also discussed key points for clinical practices when prescribing this kind of treatment. Dr. Blauvelt also highlighted the status of promising new biologics for atopic dermatitis, including tralokinumab, lebrikizumab, and nemolizumab, then moved on to discussing the safety of oral Janus kinase (JAK) inhibitors and their use in treating patients with AD. Dr. Blauvelt wrapped up his lecture by discussing the future of therapies for moderate-to-severe AD, including new biologics and JAK inhibitors.

Acne and Rosacea Update 2020

Jim Treat, MD, discussed the specific types of acne seen in babies and older children. Dr. Treat first presented a case of a three-year-old child with open and closed comedones on the cheeks, explaining the reasoning behind performing a hormonal workup on this patient. Then, Dr. Treat reviewed the definitions of acne according to age, from neonatal to adolescence, providing photo examples and causes of each throughout the lecture. The next case reviewed was that of a seven-month-old with a two-month history of acne. Dr. Treat also discussed management plans for treating young children with isotretinoin. He concluded his presentation by providing examples of conditions that aren’t acne-related, though similar in appearance, to make differentiating these skin conditions easier.

Julie Harper, MD, discussed the clinical relevance of acne, the aim of enhancing acne clearance, and provided an explanation of the CLEAR plan and why it can be used to achieve optimal results. Next, Dr. Harper reviewed acne pathogens and the corresponding therapies, such as oral contraceptives and antibiotics, offering data, adverse effects, and outcomes from clinical trials. To conclude her lecture, Dr. Harper reinforced that prescribing medications, using combination therapies, and clearing acne should always be done safely.

Hilary E. Baldwin, MD, began her lecture on rosacea by reviewing the epidemiology of rosacea, leading to clinical presentations and the complexity of its pathophysiology. Next, Dr. Baldwin discussed why patients with rosacea have too much pathogen recognition receptor activity and potential triggers for the skin condition and immune response. Next, Dr. Baldwin examined how differential diagnosis comes into play with rosacea by presenting two related cases. Following this, Dr. Baldwin covered skin care needs in rosacea, as well as cleansers and moisturizers to avoid. Dr. Baldwin also evaluated rosacea treatments based on phenotype and how to choose first-line products for papules and pustules. Regarding other manifestations of rosacea, Dr. Baldwin assessed therapies for the vascular symptoms, the mechanisms of alpha agonists for background erythema, vascular laser therapy for telangiectasias, and phymatous-type treatments. Dr. Baldwin concluded her presentation by summarizing key takeaways to create optimal treatment plans that address all symptoms, signs, goals, and concerns of the patient.

Virtual Congress Coverage: June 27, 2020

SESSION HIGHLIGHTS

Psoriasis and Psoriatic Arthritis

Arthur Kavanaugh, MD, began his presentation by reviewing basic information on psoriatic arthritis (PsA), including affected areas, the development of PsA, and related comorbidities. Dr. Kavanaugh then discussed how epigenetics serve as a biomarker for progression from psoriasis to psoriatic arthritis in some patients, as well as the cumulative incidence of joint surgery in patients aged 18 to 60 years and older. After, Dr. Kavanaugh reviewed defining subsets of psoriatic arthritis based on disease domains, then transitioned to current treatment options and their results from clinical trials. Next, Dr. Kavanaugh examined biologic studies regarding psoriasis that can assist in determining the best therapeutic options for each patient. Upon the presentation’s conclusion, Dr. Kavanaugh highlighted the potential direction for psoriatic arthritis in terms of treatment optimization, personalized medicine, prediction, and prevention.

Bruce Strober, MD, PhD, discussed what’s new in psoriasis, reviewing data from clinical trials of spesolimab, BMS-986165/TYK2-inhibtors, Ixekizumab/IL-17A-inhbitors, risankizumab/IL-23-inhibitor, apremilast/PDE-4-inhibitor, and tapinarof/AhR modulating agents. Dr. Strober ended his presentation by discussing methods to better determine severity of psoriasis, reviewing new severity guidelines and the current treatment paradigm based on these guidelines.

Melodie S. Young, MSN A/GNP-C, summarized 30 years of psoriasis-specialized practice and essential suggestions to effectively treat patients with psoriasis. Ms. Young began with techniques for being more thorough when examining patients and how to integrate medical, family, and therapy history during the examination. Ms. Young continued her presentation by reviewing questions to ask patients in regard to treatment preferences, what can be offered, reviewing goals and treatment courses, modifying methods of speaking and presenting information to better communicate with patients, and setting expectations. Next, Ms. Young shared her knowledge of existing medications, types of infections, and other methods to apply if skin conditions aren’t clearing.

Grand Rounds in Dermatology

Seemal Desai, MD, FAAD, presented a “potpourri” of different cases, beginning with a patient with pink, papular nodule lesions and a history of multiple surgeries. Because it was difficult to develop a differential, Dr. Desai reviewed the necessary factors to reach an effective diagnosing. Regarding the next case, a patient presented with an asymptomatic eruption/hyperpigmented patches without itching or scaling. Dr. Desai highlighted the probable causes and rationale for performing a biopsy. After sharing the results of the biopsy, Dr. Desai introduced the next case, which involved an 18-year-old male with dense, scaly plaques on the central part of the back, and discussed the chosen treatment. The next patient evaluated had symptoms akin to vitiligo but with a “dusky” hyperpigmentation. This perplexing case taught Dr. Desai that vitiligo cases might involve other pigmentary anomalies. To conclude the lecture, Dr. Desai explained why it’s integral to focus on aesthetic safety of patients with skin of color using the case of an 18-year-old female patient. The patient presented with oozing, crusting pain on her face, and a low-grade fever. Dr. Desai highlighted the necessary cosmetic procedure protocols for the wellbeing of future patients.

Matthew Zirwas, MD, shared the case of a woman with a recurrent rash under her ring to explain an odd instance of irritant ring dermatitis. Dr. Zirwas reviewed a typical course of action, which involved evaluating common symptoms, differential diagnosis, and deciding on appropriate workups. The presented first case ended with a description of management and treatment. The next case pertained to resistant rosacea and demodex driven rosacea. Similar to the first case, Dr. Zirwas discussed potential course of action, management, and treatment for these skin conditions. For his final case, Dr. Zirwas presented the case of a patient experiencing symptoms akin to non-pruritic poison ivy that was ultimately diagnosed as insect-driven dermatitis caused by an indigenous blister beetle.

Jim Treat, MD, presented two cases for Grand Rounds in Dermatology. The first case involved a 14-year old with salmonella-related diarrhea and a seven-day fever who had been canoeing in fresh water for a week while camping and later presented with clusters of lesions on their legs. Dr. Treat reviewed the differential diagnosis, results from workups, and explained the formal diagnosis. Additionally, Dr. Treat discussed the case of a four-hour-old infant with a red patch on their back. Dr. Treat concluded the evaluation of the case with his chosen course of management and treatment.

Ted Rosen, MD, evaluated two challenging cases and prefaced the lecture by reviewing key patterns in a medical emergency. The first case involved a 31-year-old woman with systemic lupus, presenting with fever, chills, nausea, vomiting, and a small, painless lesion on her thigh. Dr. Rosen shared the differential diagnosis, why it qualified as a medical emergency, and the urgent treatment performed. In the second case, a 75-year-old man with diabetes and end-stage renal disease on hemodialysis presented with lesions on his feet and toes, along with chills, nausea, low temperature, anorexia, and evaluated white blood cell count. Dr. Rosen discussed the reasons why this patient was hospitalized and referred to dermatologists when new lesions appeared during treatment with antibiotics. Because the distribution of lesions was so odd, Dr. Rosen highlighted the potential differential diagnosis and results from the biopsies, using the decided diagnosis to conclude the presentation and reaffirm the importance of examining other factors besides bacteria and considering the patient more carefully when dealing with infection.

Virtual Congress Coverage: June 26, 2020

SESSION HIGHLIGHTS

Infectious Disease Update 2020

Ted Rosen, MD began his infectious disease update by reviewing published data from all over the world on immunity for the novel coronavirus, COVID-19, that involved key target proteins for the virus’s vaccine development. Dr. Rosen then discussed the skin manifestations and findings related to COVID-19, such as petechiae, purpura, transient livedo pattern, urticaria, vesicles, chilblains-like lesions on the hands and feet, and non-specific viral exanthema.

Next, Dr. Rosen highlighted the impact of cosmetic product contamination and the typical bacterial load in eyeliner, lipstick, mascara, lip-gloss, and sponge applicators. Following strategies to reduce bacterial growth on common cosmetics products, Dr. Rosen assessed genital ulcers and their causes, specifically lymphogranuloma venereum that presents as a proctitis.

An antibiotic discovery, halicin, that works against bacteria like E. coli and M. tuberculosis was the next topic reviewed, followed by the issue of prescribing antibiotics without documentation indication in ambulatory care clinics. Dr. Rosen explained which antibiotics are being prescribed inappropriately. The therapeutic function of the human papillomavirus vaccine in regard to the treatment of refectory warts was also discussed.

Next, Dr. Rosen looked at data that evaluated the risk of using oral and topical terbinafine during pregnancy. Shortly after, Dr. Rosen shifted his focus to the correlation between exposure to common pyrethroid insecticides (i.e., mosquito repellants, lice treatments, pet sprays, and fruits and vegetable sprays) and the risk of all-cause and cause-specific mortality by reviewing a previously published study. Spinosad for treatment of scabies also discussed, reaffirming its safety and efficacy. Dr. Rosen also reviewed how to eliminate scabies parasites from fomites, discussing a study that exposed fomites to various environmental conditions to determine the most efficient way to treat them. To conclude his lecture, Dr. Rosen compared microbacterial cultures versus histology/biopsies, or both, for accurately diagnosing cutaneous infections.

Sheila Fallon-Friedlander, MD, provided an update on pediatric infectious disease, in which she reviewed 18 studies that assessed SARS-CoV- 2 in a total of 1,065 children and adolescents, including the commonly experienced symptoms and recovery duration. To follow, Dr. Fallon-Friedlander determined a potential reason for why children account for less than two percent of SARS-Cov-2 cases. Though they aren’t greatly affected by COVID-19, Dr. Fallon-Friedlander noted that children were still being diagnosed with a severe COVID-related illness known as Kawasaki disease. She discussed how the disease affected children, and the many cases that surfaced. Dr. Fallon-Friedlander continued her lecture by evaluating the correlation between Kawasaki disease and COVID-19, and then moved on to discussing rashes related to COVID-19, another symptom that typically appears in children. The rash is often mistaken for dengue, and Dr. Fallon-Friedlander explained why assessing skin rashes tends to be complicated, as they present for a myriad of reasons. COVID-toes was another skin manifestation of the virus covered by Dr. Fallon-Friedlander, as well other rash forms like urticaria, acral Ischemia, morbilliform, livedo reticularis, vesicular, and petechial.

Dr. Fallon-Friedlander then explained the biopsy process for determining the correlation between the virus and rashes before moving on to another pediatric infectious disease, measles. Transplacental antibody levels in children, as well as vaccination recommendations, were highlighted throughout the presentation. To follow, Dr. Fallon-Friedlander assessed the countries where measles are circulating less and the level of transplacental antibodies in children in those areas. By comparing the various antibody levels, Dr. Fallon Friedlander determined the best age for vaccination, which ultimately remains the same, but mentioned the associated risks and factors that need to be considered when vaccinating early.
After measles, Dr. Fallon-Friedlander covered some international infectious disease news involving hand, foot, and mouth disease, the virus that causes the disease, and its incidence rate. Next, Dr. Fallon-Friedlander reviewed the risks of tetracycline-type antibiotics, specifically the relationship between pseudotumor cerebri syndrome and tetracycline antibiotics.

Contact Dermatitis and Eczema

Matthew Zirwas, MD, began his Contact Dermatitis Workshop by introducing the seventh edition of Fisher’s Contact Dermatitis and its new chapters on using web-based tools to optimize allergen-avoidance plans and patch testing. Next, Dr. Zirwas evaluated atopic contact dermatitis and reactions to personal care products versus objects such as glasses, belt buckles, and cell phones, leading the evaluation to nickel allergy factors and testing, as well as allergic reactions or metal hypersensitivity to orthopedic implants, intracardiac devices, and rubber gloves. Dr. Zirwas then reviewed the allergic effect that acrylates, typically found in long-term nail polishes and products made for home use, have on atopic individuals. Dr. Zirwas also included isobornyl acrylate, commonly found in adhesives, and colophony or cyanoacrylate-containing devices.

Following this, Dr. Zirwas discussed late-type reactions to injected local anesthetics, news regarding poison ivy, oak, and sumac dermatitis, and the progress of a potential poison ivy vaccine. Moving onto the personal care product portion of the lecture, Dr. Zirwas discussed methylisothiazolinone in shampoo, conditioner, body wash, liquid hand soaps, glues, paints, cleaning products, and laundry detergents. Parabens and the dangers of “paraben-free” labeled products were also discussed. Instances of fragrance allergies, the use of essential oils, ingredients like beeswax and propolis, and flavored toothpastes were highlighted next in the lecture, as Dr. Zirwas recommended how to avoid reactions these regents and products. In the next part of his lecture, Dr. Zirwas focused on managing atopic contact dermatitis, beginning with systemic treatments and more information on patch testing and prognostic effects that impact patient outcomes. Next, Dr. Zirwas reviewed the role of TRUE testing, patch testing procedures and issues, and preparing for allergens with and without immunosuppressants. Dr. Zirwas ended the workshop by reviewing patch test results and providing guidance on educating patients on allergen management and avoidance.

Virtual Congress Coverage: June 25, 2020

SESSION HIGHLIGHTS

What Lies Beneath: Understanding the Structure and Function of Skin

This session was provided by Maui Derm as part of its Core Competency in Medical Dermatology Boot Camp, designed to provide essential information to clinicians new to dermatology or those wanting to increase their knowledge of basic science and therapies used in dermatology.

Whitney High, MD, JD, MEng, used this presentation to review the structure and function of the skin; he began with an overview of the  three main functions of the organ, including protection, homeostasis, and aesthetics. After describing each layer of the skin, Dr. High addressed the histopathology of epidermolysis bullosa simplex, following the description of each layer of the epidermis and common conditions that affect them, such as basal cell carcinoma, epidermal maturation, pemphigus, mutation/loss of filaggrin, ichthyosis vulgaris, atopic dermatitis, melanoma, and carcinoma.

Dr. High then shifted his focus to the dermoepidermal junction and overall structure of the dermis layer, including its three building blocks: collagen, elastic fibers, and ground substance. Scurvy and other disorders of each building block was highlighted and followed by essential structures of the dermis. Dr. High then examined pruritus in dermatology and the specialized skin receptors that signal different sensations to the body. Following this, Dr. High reviewed additional adnexal structures of the dermis and the basics of hair and the scalp, covering related factors like androgenic hair loss and sebaceous glands. Dr. High moved on to the anatomy and function of holocrine secretion, eccrine, and apocrine glands, and their associated conditions, such as hyperhidrosis. Dr. High concluded his lecture with the functional changes of the skin that tend to occur with age.

Pediatric Dermatology

This session was provided as part of Maui Derm’s Master Classes, designed as interactive sessions in which Maui Derm’s expert faculty discussed management strategies for challenging cases.

Jim Treat, MD, began his Pediatric Dermatology Master Session with a case study involving a nine-year-old girl who developed a painful rash after being kicked in the abdomen, leading to a diagnosis of Henoch-Schonlein syndrome. Next, Dr. Treat discussed a two-week-old with a band of scarring and crusting skin from one temple to the other, which he revealed to be halo scalp ring. The next case transitioned to the causes, mechanisms, symptoms, and risk factors of ascorbic acid deficiency. Next, dietary allergies and related skin manifestations, specifically swashiorkor and atopic dermatitis, were reviewed. Nodules as a result of subcutaneous fat necrosis, pyogenic granuloma, and pediatric amelanotic melanoma were evaluated to express the importance of testing vascular anomalies. The differences between congenial hemangiomas and non-involving congenial hemangioma, as well as their risks, were also discussed. Another next case involving a four-year-old with red patches and gastrointestinal bleeding was assessed, along with treatment; Dr. Treat used this case to propose better management and diagnosis for children with vascular stains and highlight other capillary malformations and their associated syndromes. Dr. Treat finished his presentation by reviewing the importance of clinically diagnosing differentiating lesions of the skin and reaffirming that discovery of vascular tumors can impact future therapies.

Albert Yan, MD, FAAP, FAAD presented cases that exhibited vital diagnoses in the pediatric dermatology field to highlight unique diagnostic features of skin conditions and embolden preexisting diagnoses for rare pediatric disorders in his Master Class. The presentation commenced with the case of a four-year-old that was experiencing a neck and shoulder rash following the placement of a pacemaker. Dr. Yan outlined testing and treatment options, and eventually assessed data from the lab results, which confirmed the diagnosis of neonatal lupus erythematosus (NLE). Other symptoms, such as raccoon- or owl-eye appearance, impetigo-like NLE, tinea-like NLE, and erythema-like NLE should prompt testing and evaluating for risk factors related to NLE in children, according to Dr. Yan. A three-month-old with stubborn eczema and spreading rash despite treatment was the next case covered. After receiving results from infectious, non-infectious, and interim treatment workups, a treatment plan to control the chronic mucocutaneous candidiasis, with an emphasis on monitoring the baby’s zinc levels, was performed. Dr. Yan explained the importance of zinc values and an immune deficiency workup, as the skin condition could be related to the immune system, suggesting physicians should consider data from both tests for children presenting with stubborn eczema and recurring rash.

Next, Dr. Yan reviewed the case of an 11-year-old who presented with fever, malaise, lip swelling, erosions of the mouth, and painful rashes and blisters. The patient had shown symptoms of mycoplasma-included rash and mucositis. Two other cases that presented with similar symptoms had chlamydia pneumoniae and influenza viruses, which, along with mycoplasma, can cause reactive infectious mucocutaneous eruptions in children, and should be screened via PCR for treatment course. Next, umbilical remnants and congenial umbilical epidermal inclusion cysts were evaluated using the case of a five-year-old with a persistent lump on their bellybutton as an example. Dr. Yan expressed the importance of ultrasound imaging to determine a proper course of action for excision. To conclude his lecture, Dr. Yan reviewed the effectiveness of skin biopsies, imaging studies, and critical thinking when many diagnoses are plausible by using the case of a three-day-old infant with a rash.

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