Joseph Merola: Managing Recalcitrant Psoriasis and Psoriatic Arthritis

JUNE 27, 2020

Dr. Merola discusses the treatment of a 41-year-old male patient with psoriasis and a family history of psoriatic arthritis.

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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