Maui Derm for Dermatologists 2022: January 25, 2022

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.

Maui Derm for Dermatologists 2022: January 24, 2022

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.