Pacific Dermatologic Association (PDA): Annual Meeting

NEWPORT BEACH, CALIF. – For decades, hidradenitis suppurativa (HS) has been characterized as a rare disorder, but recent evidence from the medical dermatology literature suggests that between 0.4% and 4% of the population is affected, with a predominance in female and black individuals.

At the annual meeting of the Pacific Dermatologic Association, Haley Naik, MD, characterized those estimates as “astounding.” There is also diagnostic delay that ranges from 5 to 14 years in Western populations, said Dr. Naik, of the department of dermatology at the University of California, San Francisco (Br J Dermatol. 2015 Dec;173[6]:1546-9). “These patients are repeatedly interacting with the health care system and they’re not getting the correct diagnosis and therefore they’re not getting effective therapy for the management of their disease,” she said. “We can begin to tackle this problem by educating ourselves and our colleagues about the best ways to diagnose these patients.”

In 2015, a group of European researchers published proposed diagnostic criteria for hidradenitis suppurativa (Dermatology. 2015;231[2]:184-90). The criteria comprise three components: typical lesions (double-ended comedones, active inflammatory cysts and nodules, abscesses, follicularly-based papules and pustules, fistula and sinus formation, and scarring); typical distribution (in intertriginous areas such as the axilla and the buttocks), and chronicity (they suggest that patients must have at least two episodes of the disease over a 6-month period). “In addition to satisfying these three criteria, they also suggest that there are some secondary criteria that can be used to help make this diagnosis: a family history of [hidradenitis suppurativa] and absence of pathogens at lesional sites,” Dr. Naik said. “These criteria are a practical framework in which we can begin to educate our colleagues about this diagnosis, but they should not lead us to believe that hidradenitis suppurativa is a phenotypically homogenous disease.”

There are multiple phenotypes of HS, including comedonal, nodular/cystic, and ulcerative. Typical sites that are involved are the axilla, groin, and buttocks. “There is also a subset of patients who are typically thin and male who have a gluteal predominant, or exclusive presentation of their disease,” Dr. Naik said. “In my experience, these patients tend to have severe and progressive disease.” Atypical sites include the postauricular skin, the trunk, and the extremities.

In a cross-sectional study, researchers in France found that HS patients fall into one of three categories. Those in category 1 had involvement of breasts, axilla, and hypertrophic scars; those in category 2 had involvement of the breasts, axilla, ears, chest, back, follicular lesions, and acne, and tended to have a family history of HS; those in category 3 had gluteal involvement with prominent papules and folliculitis (J Invest Dermatol. 2013 Jun;133[6]:1506-11). “Ideally, we hope this type of phenotyping will facilitate phenotype-genotype correlation, and eventually help in understanding disease course of these patients leading to optimized therapeutic options,” Dr. Naik said. “We’re just at the tip of the iceberg here in learning about these various disease subtypes.”

In 2015, the tumor necrosis factor blocker adalimumab (Humira) became the first treatment approved by the Food and Drug Administration for HS, for moderate to severe disease in adults. “The problem is, the dosing and the dose frequency of adalimumab is fixed, so if your patient is only partially responding to the therapy, you don’t have much wiggle room in terms of trying to titrate this medication,” Dr. Naik said. “In that situation the agent of choice to switch to is infliximab.”

Another biologic agent, the interleukin-1 receptor antagonist anakinra (Kineret), also shows promise. Results from a small randomized study of 20 patients found that 7 of 10 patients in the treatment group reported 80% improvement in their disease, compared with 3 out of 10 in the placebo group (JAMA Dermatol. 2016;152[1]:52-9). “Further work needs to be done in this area to understand the efficacy of anakinra for HS,” she said. “I certainly wouldn’t consider anakinra a first- or second-line therapy for the management of HS, but it’s an option for patients who have refractory disease.”

In addition to experiencing fistula and sinus formation, scarring, and wound contractures, HS patients are at risk for developing a host of complications, including lymphedema, peripheral neuropathy, squamous cell carcinoma, chronic pain, anemia, hypoproteinemia, amyloidosis, nephrotic syndrome, and uveitis. According to Dr. Naik, surgical management of HS can be considered in patients who have localized severe disease in which the risks of long-term immunosuppressive therapy outweigh the benefits. “In patients who have chronic refractory disease, surgical management can be particularly helpful,” she said. “In those who have fistula or sinus formation, significant scarring, or range of motion limitation from wound contractures, medical management can only go so far, because the medication can’t really get to those areas.”

Dr. Naik concluded her presentation by emphasizing the role dermatologists can play in helping patients address comorbidities that can accompany HS, from obesity and lipid abnormalities, to depression and arthritis. “We as dermatologists may not be in a position to manage these patients’ comorbidities over the long term, but we are in a position to encourage them to seek additional medical attention and to communicate with our colleagues when appropriate to help facilitate multidisciplinary management of this disease,” she said. “I routinely pull on the sleeves of my surgical and medical colleagues to get help with my most complicated HS patients.”

Dr. Naik reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – For decades, hidradenitis suppurativa (HS) has been characterized as a rare disorder, but recent evidence from the medical dermatology literature suggests that between 0.4% and 4% of the population is affected, with a predominance in female and black individuals.

At the annual meeting of the Pacific Dermatologic Association, Haley Naik, MD, characterized those estimates as “astounding.” There is also diagnostic delay that ranges from 5 to 14 years in Western populations, said Dr. Naik, of the department of dermatology at the University of California, San Francisco (Br J Dermatol. 2015 Dec;173[6]:1546-9). “These patients are repeatedly interacting with the health care system and they’re not getting the correct diagnosis and therefore they’re not getting effective therapy for the management of their disease,” she said. “We can begin to tackle this problem by educating ourselves and our colleagues about the best ways to diagnose these patients.”

In 2015, a group of European researchers published proposed diagnostic criteria for hidradenitis suppurativa (Dermatology. 2015;231[2]:184-90). The criteria comprise three components: typical lesions (double-ended comedones, active inflammatory cysts and nodules, abscesses, follicularly-based papules and pustules, fistula and sinus formation, and scarring); typical distribution (in intertriginous areas such as the axilla and the buttocks), and chronicity (they suggest that patients must have at least two episodes of the disease over a 6-month period). “In addition to satisfying these three criteria, they also suggest that there are some secondary criteria that can be used to help make this diagnosis: a family history of [hidradenitis suppurativa] and absence of pathogens at lesional sites,” Dr. Naik said. “These criteria are a practical framework in which we can begin to educate our colleagues about this diagnosis, but they should not lead us to believe that hidradenitis suppurativa is a phenotypically homogenous disease.”

There are multiple phenotypes of HS, including comedonal, nodular/cystic, and ulcerative. Typical sites that are involved are the axilla, groin, and buttocks. “There is also a subset of patients who are typically thin and male who have a gluteal predominant, or exclusive presentation of their disease,” Dr. Naik said. “In my experience, these patients tend to have severe and progressive disease.” Atypical sites include the postauricular skin, the trunk, and the extremities.

In a cross-sectional study, researchers in France found that HS patients fall into one of three categories. Those in category 1 had involvement of breasts, axilla, and hypertrophic scars; those in category 2 had involvement of the breasts, axilla, ears, chest, back, follicular lesions, and acne, and tended to have a family history of HS; those in category 3 had gluteal involvement with prominent papules and folliculitis (J Invest Dermatol. 2013 Jun;133[6]:1506-11). “Ideally, we hope this type of phenotyping will facilitate phenotype-genotype correlation, and eventually help in understanding disease course of these patients leading to optimized therapeutic options,” Dr. Naik said. “We’re just at the tip of the iceberg here in learning about these various disease subtypes.”

In 2015, the tumor necrosis factor blocker adalimumab (Humira) became the first treatment approved by the Food and Drug Administration for HS, for moderate to severe disease in adults. “The problem is, the dosing and the dose frequency of adalimumab is fixed, so if your patient is only partially responding to the therapy, you don’t have much wiggle room in terms of trying to titrate this medication,” Dr. Naik said. “In that situation the agent of choice to switch to is infliximab.”

Another biologic agent, the interleukin-1 receptor antagonist anakinra (Kineret), also shows promise. Results from a small randomized study of 20 patients found that 7 of 10 patients in the treatment group reported 80% improvement in their disease, compared with 3 out of 10 in the placebo group (JAMA Dermatol. 2016;152[1]:52-9). “Further work needs to be done in this area to understand the efficacy of anakinra for HS,” she said. “I certainly wouldn’t consider anakinra a first- or second-line therapy for the management of HS, but it’s an option for patients who have refractory disease.”

In addition to experiencing fistula and sinus formation, scarring, and wound contractures, HS patients are at risk for developing a host of complications, including lymphedema, peripheral neuropathy, squamous cell carcinoma, chronic pain, anemia, hypoproteinemia, amyloidosis, nephrotic syndrome, and uveitis. According to Dr. Naik, surgical management of HS can be considered in patients who have localized severe disease in which the risks of long-term immunosuppressive therapy outweigh the benefits. “In patients who have chronic refractory disease, surgical management can be particularly helpful,” she said. “In those who have fistula or sinus formation, significant scarring, or range of motion limitation from wound contractures, medical management can only go so far, because the medication can’t really get to those areas.”

Dr. Naik concluded her presentation by emphasizing the role dermatologists can play in helping patients address comorbidities that can accompany HS, from obesity and lipid abnormalities, to depression and arthritis. “We as dermatologists may not be in a position to manage these patients’ comorbidities over the long term, but we are in a position to encourage them to seek additional medical attention and to communicate with our colleagues when appropriate to help facilitate multidisciplinary management of this disease,” she said. “I routinely pull on the sleeves of my surgical and medical colleagues to get help with my most complicated HS patients.”

Dr. Naik reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – For decades, hidradenitis suppurativa (HS) has been characterized as a rare disorder, but recent evidence from the medical dermatology literature suggests that between 0.4% and 4% of the population is affected, with a predominance in female and black individuals.

At the annual meeting of the Pacific Dermatologic Association, Haley Naik, MD, characterized those estimates as “astounding.” There is also diagnostic delay that ranges from 5 to 14 years in Western populations, said Dr. Naik, of the department of dermatology at the University of California, San Francisco (Br J Dermatol. 2015 Dec;173[6]:1546-9). “These patients are repeatedly interacting with the health care system and they’re not getting the correct diagnosis and therefore they’re not getting effective therapy for the management of their disease,” she said. “We can begin to tackle this problem by educating ourselves and our colleagues about the best ways to diagnose these patients.”

In 2015, a group of European researchers published proposed diagnostic criteria for hidradenitis suppurativa (Dermatology. 2015;231[2]:184-90). The criteria comprise three components: typical lesions (double-ended comedones, active inflammatory cysts and nodules, abscesses, follicularly-based papules and pustules, fistula and sinus formation, and scarring); typical distribution (in intertriginous areas such as the axilla and the buttocks), and chronicity (they suggest that patients must have at least two episodes of the disease over a 6-month period). “In addition to satisfying these three criteria, they also suggest that there are some secondary criteria that can be used to help make this diagnosis: a family history of [hidradenitis suppurativa] and absence of pathogens at lesional sites,” Dr. Naik said. “These criteria are a practical framework in which we can begin to educate our colleagues about this diagnosis, but they should not lead us to believe that hidradenitis suppurativa is a phenotypically homogenous disease.”

There are multiple phenotypes of HS, including comedonal, nodular/cystic, and ulcerative. Typical sites that are involved are the axilla, groin, and buttocks. “There is also a subset of patients who are typically thin and male who have a gluteal predominant, or exclusive presentation of their disease,” Dr. Naik said. “In my experience, these patients tend to have severe and progressive disease.” Atypical sites include the postauricular skin, the trunk, and the extremities.

In a cross-sectional study, researchers in France found that HS patients fall into one of three categories. Those in category 1 had involvement of breasts, axilla, and hypertrophic scars; those in category 2 had involvement of the breasts, axilla, ears, chest, back, follicular lesions, and acne, and tended to have a family history of HS; those in category 3 had gluteal involvement with prominent papules and folliculitis (J Invest Dermatol. 2013 Jun;133[6]:1506-11). “Ideally, we hope this type of phenotyping will facilitate phenotype-genotype correlation, and eventually help in understanding disease course of these patients leading to optimized therapeutic options,” Dr. Naik said. “We’re just at the tip of the iceberg here in learning about these various disease subtypes.”

In 2015, the tumor necrosis factor blocker adalimumab (Humira) became the first treatment approved by the Food and Drug Administration for HS, for moderate to severe disease in adults. “The problem is, the dosing and the dose frequency of adalimumab is fixed, so if your patient is only partially responding to the therapy, you don’t have much wiggle room in terms of trying to titrate this medication,” Dr. Naik said. “In that situation the agent of choice to switch to is infliximab.”

Another biologic agent, the interleukin-1 receptor antagonist anakinra (Kineret), also shows promise. Results from a small randomized study of 20 patients found that 7 of 10 patients in the treatment group reported 80% improvement in their disease, compared with 3 out of 10 in the placebo group (JAMA Dermatol. 2016;152[1]:52-9). “Further work needs to be done in this area to understand the efficacy of anakinra for HS,” she said. “I certainly wouldn’t consider anakinra a first- or second-line therapy for the management of HS, but it’s an option for patients who have refractory disease.”

In addition to experiencing fistula and sinus formation, scarring, and wound contractures, HS patients are at risk for developing a host of complications, including lymphedema, peripheral neuropathy, squamous cell carcinoma, chronic pain, anemia, hypoproteinemia, amyloidosis, nephrotic syndrome, and uveitis. According to Dr. Naik, surgical management of HS can be considered in patients who have localized severe disease in which the risks of long-term immunosuppressive therapy outweigh the benefits. “In patients who have chronic refractory disease, surgical management can be particularly helpful,” she said. “In those who have fistula or sinus formation, significant scarring, or range of motion limitation from wound contractures, medical management can only go so far, because the medication can’t really get to those areas.”

Dr. Naik concluded her presentation by emphasizing the role dermatologists can play in helping patients address comorbidities that can accompany HS, from obesity and lipid abnormalities, to depression and arthritis. “We as dermatologists may not be in a position to manage these patients’ comorbidities over the long term, but we are in a position to encourage them to seek additional medical attention and to communicate with our colleagues when appropriate to help facilitate multidisciplinary management of this disease,” she said. “I routinely pull on the sleeves of my surgical and medical colleagues to get help with my most complicated HS patients.”

Dr. Naik reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – Over the past 20 years, the number of medical malpractice claims against dermatologists has remained steady, in the ballpark of 86-123 per year, according to Abel Torres, MD, JD.

In fact, a study that used claims data from the Physician Insurers Association of America between 1985 and 2008 revealed that dermatology ranked 19th among 28 medical specialties evaluated. “The bad news is we’re not ranked 28th, so we’re still getting sued,” said Dr. Torres, professor and chairman of dermatology at Loma Linda (Calif.) University and professor of dermatology at Case Western Reserve University, Cleveland. In the study, 2,704 of 239,756 (1.1%) closed claims in this time period involved dermatologists; only 29% of the claims that involved dermatologists resulted in a payment for the plaintiff, with a median and average indemnity of $35,000 and $137,538, respectively (J Am Acad Dermatol. 2012 Jan;66[1]:78-85).

Speaking at the annual meeting of the Pacific Dermatologic Association, Dr. Torres, who is also current president of the American Academy of Dermatology, said that communication breakdowns between health care providers and patients account for more than 80% of medical errors and adverse events. In addition, ineffective communication can lead to below-average scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), and other surveys, impacting public scrutiny, reputation, referrals, patient retention, and loyalty, and pay for performance. “Physicians who are on the lower third of communication on surveys tend to have 110% more lawsuits than everybody else,” he said.

Dr. Torres underscored the importance of obtaining verbal or written consent with patients prior to performing dermatologic procedures. “You want to discuss material risk, that is, What’s the likely significant risk? What’s a viable alternative? Do you think it’s viable? And if not, be prepared with data to support that. And what’s your rationale of benefit?” he said.

In a study that evaluated informed consent in dermatologic surgery, 85 patients undergoing Mohs surgery were given verbal and written instructions, including information about the potential for 10 possible complications (Dermatol Surg. 2003;29[9]:952-5). The researchers asked the patients to recall the 10 complications at 20 minutes and at 1 week after the informed consent process. The overall group retention rates for both time periods were 27% and 24%, respectively.

“The reality is, people are nervous,” said Dr. Torres, who was not involved with the study. “They’re not focusing well and may not be listening very carefully to you. So when you give them informed consent you need to help them focus on the important issues. Be cautious about diluting the discussion with so much information that they’re not getting the message.”

Lawsuits involving the use of lasers in dermatology are on the rise, according to one study that examined trends in legal cases secondary to cutaneous laser surgery over a 28-year period that peaked in 2010 (JAMA Dermatol. 2013;149[2]:188-93). It found that laser hair removal was the most commonly litigated procedure (63%), followed by lack of informed consent (53%). Nearly half of the cases favored the defendant and the mean indemnity payment was $380,719.

This is in contrast with commonly reported litigation trends where a majority of the cases favor the defendant. The study also found that nearly 40% of cases involved a nonphysician operator. “So you need to be extra careful when you’re dealing with laser procedures, or you’re dealing with nonphysician operators or extenders,” Dr. Torres noted. “In that regard, know the rules in your state; make sure that you’re clear on them. Make sure that the people who are going to [perform the procedures] are appropriately trained. Provide an adequate degree of supervision to make sure that the proper procedure is being followed, especially as it relates to informed consent.”

Another liability risk for clinicians is failing to follow up with patients. “As a doctor, you may have the responsibility to make sure the patient actually saw the specialist and that their reports were acted upon,” Dr. Torres said. “The law requires that you interact with the specialist in the patients’ best interest. Also, if you refer a patient to another doctor and you have a reason to think that [doctor is] incompetent, you may be held accountable. Referring to the wrong specialist can be a pitfall.”

Dermatologists may at times also be liable for providing interpreter services for patients, no matter the size of their office or the number of employees on their payroll. He recommended that physicians explore whether the Canopy Medical Translator APP, a technology that enables clinicians to communicate with patients in 15 languages, can prove useful to them. Funded by the National Institutes of Health, the technology can be run on any device that runs on iOS or Android. “It can take phrases you have and translate them, or translate phrases that patients have to you,” Dr. Torres said.

In his clinical experience, dermatologists can protect themselves from a legal standpoint by maintaining honesty with the patient; showing kindness and concern at each encounter; validating the patient’s complaints about complications without conveying blame; avoiding isolating the patient after a complication; having a remedy planned for the complication, and seeing and communicating with the patient frequently.

When things go wrong, he offered the “AAA” mnemonic: Always acknowledge a complaint and express empathy; make sure someone you designate is easily accessible to the patient making a complaint, and avoid premature conclusions or comments. “Why? Because you want to maintain honesty with your patients, you want to show kindness and concern and validate patients’ emotions,” Dr. Torres said. “In other words, treat them as you would like to be treated.”

He reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – Over the past 20 years, the number of medical malpractice claims against dermatologists has remained steady, in the ballpark of 86-123 per year, according to Abel Torres, MD, JD.

In fact, a study that used claims data from the Physician Insurers Association of America between 1985 and 2008 revealed that dermatology ranked 19th among 28 medical specialties evaluated. “The bad news is we’re not ranked 28th, so we’re still getting sued,” said Dr. Torres, professor and chairman of dermatology at Loma Linda (Calif.) University and professor of dermatology at Case Western Reserve University, Cleveland. In the study, 2,704 of 239,756 (1.1%) closed claims in this time period involved dermatologists; only 29% of the claims that involved dermatologists resulted in a payment for the plaintiff, with a median and average indemnity of $35,000 and $137,538, respectively (J Am Acad Dermatol. 2012 Jan;66[1]:78-85).

Speaking at the annual meeting of the Pacific Dermatologic Association, Dr. Torres, who is also current president of the American Academy of Dermatology, said that communication breakdowns between health care providers and patients account for more than 80% of medical errors and adverse events. In addition, ineffective communication can lead to below-average scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), and other surveys, impacting public scrutiny, reputation, referrals, patient retention, and loyalty, and pay for performance. “Physicians who are on the lower third of communication on surveys tend to have 110% more lawsuits than everybody else,” he said.

Dr. Torres underscored the importance of obtaining verbal or written consent with patients prior to performing dermatologic procedures. “You want to discuss material risk, that is, What’s the likely significant risk? What’s a viable alternative? Do you think it’s viable? And if not, be prepared with data to support that. And what’s your rationale of benefit?” he said.

In a study that evaluated informed consent in dermatologic surgery, 85 patients undergoing Mohs surgery were given verbal and written instructions, including information about the potential for 10 possible complications (Dermatol Surg. 2003;29[9]:952-5). The researchers asked the patients to recall the 10 complications at 20 minutes and at 1 week after the informed consent process. The overall group retention rates for both time periods were 27% and 24%, respectively.

“The reality is, people are nervous,” said Dr. Torres, who was not involved with the study. “They’re not focusing well and may not be listening very carefully to you. So when you give them informed consent you need to help them focus on the important issues. Be cautious about diluting the discussion with so much information that they’re not getting the message.”

Lawsuits involving the use of lasers in dermatology are on the rise, according to one study that examined trends in legal cases secondary to cutaneous laser surgery over a 28-year period that peaked in 2010 (JAMA Dermatol. 2013;149[2]:188-93). It found that laser hair removal was the most commonly litigated procedure (63%), followed by lack of informed consent (53%). Nearly half of the cases favored the defendant and the mean indemnity payment was $380,719.

This is in contrast with commonly reported litigation trends where a majority of the cases favor the defendant. The study also found that nearly 40% of cases involved a nonphysician operator. “So you need to be extra careful when you’re dealing with laser procedures, or you’re dealing with nonphysician operators or extenders,” Dr. Torres noted. “In that regard, know the rules in your state; make sure that you’re clear on them. Make sure that the people who are going to [perform the procedures] are appropriately trained. Provide an adequate degree of supervision to make sure that the proper procedure is being followed, especially as it relates to informed consent.”

Another liability risk for clinicians is failing to follow up with patients. “As a doctor, you may have the responsibility to make sure the patient actually saw the specialist and that their reports were acted upon,” Dr. Torres said. “The law requires that you interact with the specialist in the patients’ best interest. Also, if you refer a patient to another doctor and you have a reason to think that [doctor is] incompetent, you may be held accountable. Referring to the wrong specialist can be a pitfall.”

Dermatologists may at times also be liable for providing interpreter services for patients, no matter the size of their office or the number of employees on their payroll. He recommended that physicians explore whether the Canopy Medical Translator APP, a technology that enables clinicians to communicate with patients in 15 languages, can prove useful to them. Funded by the National Institutes of Health, the technology can be run on any device that runs on iOS or Android. “It can take phrases you have and translate them, or translate phrases that patients have to you,” Dr. Torres said.

In his clinical experience, dermatologists can protect themselves from a legal standpoint by maintaining honesty with the patient; showing kindness and concern at each encounter; validating the patient’s complaints about complications without conveying blame; avoiding isolating the patient after a complication; having a remedy planned for the complication, and seeing and communicating with the patient frequently.

When things go wrong, he offered the “AAA” mnemonic: Always acknowledge a complaint and express empathy; make sure someone you designate is easily accessible to the patient making a complaint, and avoid premature conclusions or comments. “Why? Because you want to maintain honesty with your patients, you want to show kindness and concern and validate patients’ emotions,” Dr. Torres said. “In other words, treat them as you would like to be treated.”

He reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – Over the past 20 years, the number of medical malpractice claims against dermatologists has remained steady, in the ballpark of 86-123 per year, according to Abel Torres, MD, JD.

In fact, a study that used claims data from the Physician Insurers Association of America between 1985 and 2008 revealed that dermatology ranked 19th among 28 medical specialties evaluated. “The bad news is we’re not ranked 28th, so we’re still getting sued,” said Dr. Torres, professor and chairman of dermatology at Loma Linda (Calif.) University and professor of dermatology at Case Western Reserve University, Cleveland. In the study, 2,704 of 239,756 (1.1%) closed claims in this time period involved dermatologists; only 29% of the claims that involved dermatologists resulted in a payment for the plaintiff, with a median and average indemnity of $35,000 and $137,538, respectively (J Am Acad Dermatol. 2012 Jan;66[1]:78-85).

Speaking at the annual meeting of the Pacific Dermatologic Association, Dr. Torres, who is also current president of the American Academy of Dermatology, said that communication breakdowns between health care providers and patients account for more than 80% of medical errors and adverse events. In addition, ineffective communication can lead to below-average scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), and other surveys, impacting public scrutiny, reputation, referrals, patient retention, and loyalty, and pay for performance. “Physicians who are on the lower third of communication on surveys tend to have 110% more lawsuits than everybody else,” he said.

Dr. Torres underscored the importance of obtaining verbal or written consent with patients prior to performing dermatologic procedures. “You want to discuss material risk, that is, What’s the likely significant risk? What’s a viable alternative? Do you think it’s viable? And if not, be prepared with data to support that. And what’s your rationale of benefit?” he said.

In a study that evaluated informed consent in dermatologic surgery, 85 patients undergoing Mohs surgery were given verbal and written instructions, including information about the potential for 10 possible complications (Dermatol Surg. 2003;29[9]:952-5). The researchers asked the patients to recall the 10 complications at 20 minutes and at 1 week after the informed consent process. The overall group retention rates for both time periods were 27% and 24%, respectively.

“The reality is, people are nervous,” said Dr. Torres, who was not involved with the study. “They’re not focusing well and may not be listening very carefully to you. So when you give them informed consent you need to help them focus on the important issues. Be cautious about diluting the discussion with so much information that they’re not getting the message.”

Lawsuits involving the use of lasers in dermatology are on the rise, according to one study that examined trends in legal cases secondary to cutaneous laser surgery over a 28-year period that peaked in 2010 (JAMA Dermatol. 2013;149[2]:188-93). It found that laser hair removal was the most commonly litigated procedure (63%), followed by lack of informed consent (53%). Nearly half of the cases favored the defendant and the mean indemnity payment was $380,719.

This is in contrast with commonly reported litigation trends where a majority of the cases favor the defendant. The study also found that nearly 40% of cases involved a nonphysician operator. “So you need to be extra careful when you’re dealing with laser procedures, or you’re dealing with nonphysician operators or extenders,” Dr. Torres noted. “In that regard, know the rules in your state; make sure that you’re clear on them. Make sure that the people who are going to [perform the procedures] are appropriately trained. Provide an adequate degree of supervision to make sure that the proper procedure is being followed, especially as it relates to informed consent.”

Another liability risk for clinicians is failing to follow up with patients. “As a doctor, you may have the responsibility to make sure the patient actually saw the specialist and that their reports were acted upon,” Dr. Torres said. “The law requires that you interact with the specialist in the patients’ best interest. Also, if you refer a patient to another doctor and you have a reason to think that [doctor is] incompetent, you may be held accountable. Referring to the wrong specialist can be a pitfall.”

Dermatologists may at times also be liable for providing interpreter services for patients, no matter the size of their office or the number of employees on their payroll. He recommended that physicians explore whether the Canopy Medical Translator APP, a technology that enables clinicians to communicate with patients in 15 languages, can prove useful to them. Funded by the National Institutes of Health, the technology can be run on any device that runs on iOS or Android. “It can take phrases you have and translate them, or translate phrases that patients have to you,” Dr. Torres said.

In his clinical experience, dermatologists can protect themselves from a legal standpoint by maintaining honesty with the patient; showing kindness and concern at each encounter; validating the patient’s complaints about complications without conveying blame; avoiding isolating the patient after a complication; having a remedy planned for the complication, and seeing and communicating with the patient frequently.

When things go wrong, he offered the “AAA” mnemonic: Always acknowledge a complaint and express empathy; make sure someone you designate is easily accessible to the patient making a complaint, and avoid premature conclusions or comments. “Why? Because you want to maintain honesty with your patients, you want to show kindness and concern and validate patients’ emotions,” Dr. Torres said. “In other words, treat them as you would like to be treated.”

He reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – The way Seemal R. Desai, MD, sees it, becoming a leader in dermatology doesn’t have to involve a huge time commitment.

The effort “can take as little as 5 minutes a week or as much as a few hours a week, depending on your level of interest,” he said at the annual meeting of the Pacific Dermatologic Association. “But I think that we all need to contribute in some way to give back to our specialty, which is constantly under threat from lots of other specialties and other influences.”

He discussed several practical ways to assume a leadership role in the field, such as lecturing to high school, medical school, or even nurse practitioner students; volunteering in the local academic dermatology department or indigent clinic; lobbying local legislative officials; organizing health policy campaigns, or attending events such as the Capitol Hill Skin Cancer Screening and Prevention Health Fair, One Voice Against Cancer (OVAC) Lobby Day, and the American Academy of Dermatology Annual Legislative Conference (held this year in Washington, D.C., Sept. 11-13).

“Your leadership does not have to be in the traditional sense of getting involved in a committee, getting involved on a board, or in your medical society. There are lots of different things we can do to be leaders,” said Dr. Desai, founder and medical director of Plano, Tex.–based Innovative Dermatology.

Resources he highlighted include the AAD’s Leadership Learning Center, which includes videos on topics such as how to talk to legislators, how to review an article for the Journal of the American Academy of Dermatology, and the nuts and bolts of how to run an efficient staff meeting. The site also contains short podcasts on topics such as time management and conflict resolution, and an extensive list of recommended books about leadership, including the New York Times best seller “Quiet: The Power of Introverts in a World That Can’t Stop Talking”(Crown Publishers, 2012), by Susan Cain. “This book highlights some helpful tips on what you can do to make your practice life a lot better in your day-to-day setting,” Dr. Desai said. “That’s really important when we talk about physician burnout.”

He also encouraged dermatologists to become mentors to clinicians entering the field or those in the early stages of their careers. “None of us became leaders without mentors,” said Dr. Desai, who also holds a faculty position in the department of dermatology at the University of Texas Southwestern Medical Center, Dallas. “Being a mentor is a way to advocate for dermatology, because you’re helping someone become a leader, to take our specialty to the next level.” Information about AAD’s mentoring program is available at: www.aad.org/members/leadership-institute/mentoring.

For those inclined to become politically involved, opportunities abound in local, regional, and national dermatology societies, as well as with SkinPAC, the only federal political action committee representing dermatology’s interests, he said. “Advocacy is important to our specialty to make sure that our voices are heard by policymakers at the state and federal level,” Dr. Desai added. “We as dermatologists work hard; we deal with very difficult patients. In fact, studies have shown that we as outpatient physicians are some of the busiest in the entire organized medicine sea. However, people don’t really understand what we as dermatologists do.”

Dr. Desai reported having no relevant financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – The way Seemal R. Desai, MD, sees it, becoming a leader in dermatology doesn’t have to involve a huge time commitment.

The effort “can take as little as 5 minutes a week or as much as a few hours a week, depending on your level of interest,” he said at the annual meeting of the Pacific Dermatologic Association. “But I think that we all need to contribute in some way to give back to our specialty, which is constantly under threat from lots of other specialties and other influences.”

He discussed several practical ways to assume a leadership role in the field, such as lecturing to high school, medical school, or even nurse practitioner students; volunteering in the local academic dermatology department or indigent clinic; lobbying local legislative officials; organizing health policy campaigns, or attending events such as the Capitol Hill Skin Cancer Screening and Prevention Health Fair, One Voice Against Cancer (OVAC) Lobby Day, and the American Academy of Dermatology Annual Legislative Conference (held this year in Washington, D.C., Sept. 11-13).

“Your leadership does not have to be in the traditional sense of getting involved in a committee, getting involved on a board, or in your medical society. There are lots of different things we can do to be leaders,” said Dr. Desai, founder and medical director of Plano, Tex.–based Innovative Dermatology.

Resources he highlighted include the AAD’s Leadership Learning Center, which includes videos on topics such as how to talk to legislators, how to review an article for the Journal of the American Academy of Dermatology, and the nuts and bolts of how to run an efficient staff meeting. The site also contains short podcasts on topics such as time management and conflict resolution, and an extensive list of recommended books about leadership, including the New York Times best seller “Quiet: The Power of Introverts in a World That Can’t Stop Talking”(Crown Publishers, 2012), by Susan Cain. “This book highlights some helpful tips on what you can do to make your practice life a lot better in your day-to-day setting,” Dr. Desai said. “That’s really important when we talk about physician burnout.”

He also encouraged dermatologists to become mentors to clinicians entering the field or those in the early stages of their careers. “None of us became leaders without mentors,” said Dr. Desai, who also holds a faculty position in the department of dermatology at the University of Texas Southwestern Medical Center, Dallas. “Being a mentor is a way to advocate for dermatology, because you’re helping someone become a leader, to take our specialty to the next level.” Information about AAD’s mentoring program is available at: www.aad.org/members/leadership-institute/mentoring.

For those inclined to become politically involved, opportunities abound in local, regional, and national dermatology societies, as well as with SkinPAC, the only federal political action committee representing dermatology’s interests, he said. “Advocacy is important to our specialty to make sure that our voices are heard by policymakers at the state and federal level,” Dr. Desai added. “We as dermatologists work hard; we deal with very difficult patients. In fact, studies have shown that we as outpatient physicians are some of the busiest in the entire organized medicine sea. However, people don’t really understand what we as dermatologists do.”

Dr. Desai reported having no relevant financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – The way Seemal R. Desai, MD, sees it, becoming a leader in dermatology doesn’t have to involve a huge time commitment.

The effort “can take as little as 5 minutes a week or as much as a few hours a week, depending on your level of interest,” he said at the annual meeting of the Pacific Dermatologic Association. “But I think that we all need to contribute in some way to give back to our specialty, which is constantly under threat from lots of other specialties and other influences.”

He discussed several practical ways to assume a leadership role in the field, such as lecturing to high school, medical school, or even nurse practitioner students; volunteering in the local academic dermatology department or indigent clinic; lobbying local legislative officials; organizing health policy campaigns, or attending events such as the Capitol Hill Skin Cancer Screening and Prevention Health Fair, One Voice Against Cancer (OVAC) Lobby Day, and the American Academy of Dermatology Annual Legislative Conference (held this year in Washington, D.C., Sept. 11-13).

“Your leadership does not have to be in the traditional sense of getting involved in a committee, getting involved on a board, or in your medical society. There are lots of different things we can do to be leaders,” said Dr. Desai, founder and medical director of Plano, Tex.–based Innovative Dermatology.

Resources he highlighted include the AAD’s Leadership Learning Center, which includes videos on topics such as how to talk to legislators, how to review an article for the Journal of the American Academy of Dermatology, and the nuts and bolts of how to run an efficient staff meeting. The site also contains short podcasts on topics such as time management and conflict resolution, and an extensive list of recommended books about leadership, including the New York Times best seller “Quiet: The Power of Introverts in a World That Can’t Stop Talking”(Crown Publishers, 2012), by Susan Cain. “This book highlights some helpful tips on what you can do to make your practice life a lot better in your day-to-day setting,” Dr. Desai said. “That’s really important when we talk about physician burnout.”

He also encouraged dermatologists to become mentors to clinicians entering the field or those in the early stages of their careers. “None of us became leaders without mentors,” said Dr. Desai, who also holds a faculty position in the department of dermatology at the University of Texas Southwestern Medical Center, Dallas. “Being a mentor is a way to advocate for dermatology, because you’re helping someone become a leader, to take our specialty to the next level.” Information about AAD’s mentoring program is available at: www.aad.org/members/leadership-institute/mentoring.

For those inclined to become politically involved, opportunities abound in local, regional, and national dermatology societies, as well as with SkinPAC, the only federal political action committee representing dermatology’s interests, he said. “Advocacy is important to our specialty to make sure that our voices are heard by policymakers at the state and federal level,” Dr. Desai added. “We as dermatologists work hard; we deal with very difficult patients. In fact, studies have shown that we as outpatient physicians are some of the busiest in the entire organized medicine sea. However, people don’t really understand what we as dermatologists do.”

Dr. Desai reported having no relevant financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – Cutaneous lupus erythematosus and dermatomyositis look identical on histology, so the diagnosis boils down to your clinical exam.

At the annual meeting of the Pacific Dermatologic Association, Nicole Fett, MD, provided clinical pearls on how to differentiate between the two conditions. She began by discussing the case of a 28-year-old female who presents with fatigue, arthralgias, myalgias, photosensitivity, and erythematous scaling papules coalescing into plaques on the face (sparing the nasolabial folds), neck, chest, and bilateral arms and hands (sparing the dorsal hand joints). Earlier in the week, she saw her primary care physician, who ordered an antinuclear antibody test, which was positive at 1:640.

This patient, who was previously healthy, has no known allergies, is on a prenatal vitamin, does not use any drugs or alcohol, is a nonsmoker, and has a family history of autoimmunity, said Dr. Fett, of the department of dermatology at Oregon Health and Science University, Portland. The woman’s clinical findings were most consistent with acute cutaneous lupus erythematosus (CLE).

“Acute CLE spares the nasolabial folds, whereas patients who have dermatomyositis have involvement of the nasolabial folds,” she noted. Examining the hands can also provide clues, as patients with CLE have involvement of the interjoint spaces and sparing of the joints, while patients with dermatomyositis have involvement of the joints and sparing of the interjoint spaces. In addition, patients with dermatomyositis are more likely to have lower extremity involvement, compared with patients who have CLE. “Patients with dermatomyositis will tend to have diffuse scalp involvement that is itchy,” Dr. Fett added. “That is not something you commonly see in cutaneous lupus.”

Other common features of CLE include concomitant discoid lupus erythematosus or another lupus subtype, and mucosal ulcerations, while other common features of dermatomyositis include the Shawl sign and poikiloderma.

The recommended review of systems and exams to assess for systemic lupus erythematosus in CLE patients include asking about photosensitivity, looking for mucosal ulcers, assessing for arthritis, asking about a history of pericarditis or pleuritis, as well as asking about a history of low blood counts, kidney disease, seizures, and malar rash. On cutaneous exam, look for signs of concomitant CLE subtypes, assess for nonspecific cutaneous lupus findings, and evaluate the mucosa. Recommended labs include a complete blood count and an additional workup for anemia, complete metabolic panel, urinalysis, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, complement C3 and C4, and antiphospholipid and anticardiolipin antibodies.

The recommended review of systems and exams in patients with dermatomyositis, she said, include assessing for dysphonia/dysphagia, weakness with overhead tasks, weakness when climbing stairs or standing from a seated position, cough, shortness of breath, or dyspnea on exertion, fever, weight loss, night sweats, and pruritus. “When I think about the dermatomyositis patient I think not only about their skin, but about their muscles, lungs and risk of malignancy,” Dr. Fett said. “They have a high risk for developing interstitial lung disease, and about 25% of adult patients are going to have an underlying malignancy.”

She reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – Cutaneous lupus erythematosus and dermatomyositis look identical on histology, so the diagnosis boils down to your clinical exam.

At the annual meeting of the Pacific Dermatologic Association, Nicole Fett, MD, provided clinical pearls on how to differentiate between the two conditions. She began by discussing the case of a 28-year-old female who presents with fatigue, arthralgias, myalgias, photosensitivity, and erythematous scaling papules coalescing into plaques on the face (sparing the nasolabial folds), neck, chest, and bilateral arms and hands (sparing the dorsal hand joints). Earlier in the week, she saw her primary care physician, who ordered an antinuclear antibody test, which was positive at 1:640.

This patient, who was previously healthy, has no known allergies, is on a prenatal vitamin, does not use any drugs or alcohol, is a nonsmoker, and has a family history of autoimmunity, said Dr. Fett, of the department of dermatology at Oregon Health and Science University, Portland. The woman’s clinical findings were most consistent with acute cutaneous lupus erythematosus (CLE).

“Acute CLE spares the nasolabial folds, whereas patients who have dermatomyositis have involvement of the nasolabial folds,” she noted. Examining the hands can also provide clues, as patients with CLE have involvement of the interjoint spaces and sparing of the joints, while patients with dermatomyositis have involvement of the joints and sparing of the interjoint spaces. In addition, patients with dermatomyositis are more likely to have lower extremity involvement, compared with patients who have CLE. “Patients with dermatomyositis will tend to have diffuse scalp involvement that is itchy,” Dr. Fett added. “That is not something you commonly see in cutaneous lupus.”

Other common features of CLE include concomitant discoid lupus erythematosus or another lupus subtype, and mucosal ulcerations, while other common features of dermatomyositis include the Shawl sign and poikiloderma.

The recommended review of systems and exams to assess for systemic lupus erythematosus in CLE patients include asking about photosensitivity, looking for mucosal ulcers, assessing for arthritis, asking about a history of pericarditis or pleuritis, as well as asking about a history of low blood counts, kidney disease, seizures, and malar rash. On cutaneous exam, look for signs of concomitant CLE subtypes, assess for nonspecific cutaneous lupus findings, and evaluate the mucosa. Recommended labs include a complete blood count and an additional workup for anemia, complete metabolic panel, urinalysis, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, complement C3 and C4, and antiphospholipid and anticardiolipin antibodies.

The recommended review of systems and exams in patients with dermatomyositis, she said, include assessing for dysphonia/dysphagia, weakness with overhead tasks, weakness when climbing stairs or standing from a seated position, cough, shortness of breath, or dyspnea on exertion, fever, weight loss, night sweats, and pruritus. “When I think about the dermatomyositis patient I think not only about their skin, but about their muscles, lungs and risk of malignancy,” Dr. Fett said. “They have a high risk for developing interstitial lung disease, and about 25% of adult patients are going to have an underlying malignancy.”

She reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – Cutaneous lupus erythematosus and dermatomyositis look identical on histology, so the diagnosis boils down to your clinical exam.

At the annual meeting of the Pacific Dermatologic Association, Nicole Fett, MD, provided clinical pearls on how to differentiate between the two conditions. She began by discussing the case of a 28-year-old female who presents with fatigue, arthralgias, myalgias, photosensitivity, and erythematous scaling papules coalescing into plaques on the face (sparing the nasolabial folds), neck, chest, and bilateral arms and hands (sparing the dorsal hand joints). Earlier in the week, she saw her primary care physician, who ordered an antinuclear antibody test, which was positive at 1:640.

This patient, who was previously healthy, has no known allergies, is on a prenatal vitamin, does not use any drugs or alcohol, is a nonsmoker, and has a family history of autoimmunity, said Dr. Fett, of the department of dermatology at Oregon Health and Science University, Portland. The woman’s clinical findings were most consistent with acute cutaneous lupus erythematosus (CLE).

“Acute CLE spares the nasolabial folds, whereas patients who have dermatomyositis have involvement of the nasolabial folds,” she noted. Examining the hands can also provide clues, as patients with CLE have involvement of the interjoint spaces and sparing of the joints, while patients with dermatomyositis have involvement of the joints and sparing of the interjoint spaces. In addition, patients with dermatomyositis are more likely to have lower extremity involvement, compared with patients who have CLE. “Patients with dermatomyositis will tend to have diffuse scalp involvement that is itchy,” Dr. Fett added. “That is not something you commonly see in cutaneous lupus.”

Other common features of CLE include concomitant discoid lupus erythematosus or another lupus subtype, and mucosal ulcerations, while other common features of dermatomyositis include the Shawl sign and poikiloderma.

The recommended review of systems and exams to assess for systemic lupus erythematosus in CLE patients include asking about photosensitivity, looking for mucosal ulcers, assessing for arthritis, asking about a history of pericarditis or pleuritis, as well as asking about a history of low blood counts, kidney disease, seizures, and malar rash. On cutaneous exam, look for signs of concomitant CLE subtypes, assess for nonspecific cutaneous lupus findings, and evaluate the mucosa. Recommended labs include a complete blood count and an additional workup for anemia, complete metabolic panel, urinalysis, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, complement C3 and C4, and antiphospholipid and anticardiolipin antibodies.

The recommended review of systems and exams in patients with dermatomyositis, she said, include assessing for dysphonia/dysphagia, weakness with overhead tasks, weakness when climbing stairs or standing from a seated position, cough, shortness of breath, or dyspnea on exertion, fever, weight loss, night sweats, and pruritus. “When I think about the dermatomyositis patient I think not only about their skin, but about their muscles, lungs and risk of malignancy,” Dr. Fett said. “They have a high risk for developing interstitial lung disease, and about 25% of adult patients are going to have an underlying malignancy.”

She reported having no financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – Current treatment of autoimmune blistering diseases is not backed by evidence-based medicine and solid randomized, controlled trials, according to David T. Woodley, MD.

“These are rare diseases; there’s no consensus on the treatment of choice,” Dr. Woodley said at the annual meeting of the Pacific Dermatologic Association.

Dr. Woodley, professor of dermatology at the University of Southern California, Los Angeles, limited his discussion to pemphigus vulgaris (PV), pemphigus foliaceus (PF), and bullous pemphigoid (BP). The histologic hallmark of PV and PF is acantholysis. “Because these are intraepidermal blistering diseases, you don’t see the blister very often; maybe you’ll have a few intact loose sacklike blisters, but you mostly see erosions and crusting,” he said. “PV often only begins with mouth lesions.”

Work-up for a suspected autoimmune blistering disease includes a physical exam, histology, direct and indirect immunofluorescence, and serologic tests. The diagnosis should be based on the target autoantigen in the skin. PV and PF can appear identical on direct immunofluorescence, even though the blister cleavage plane is very high in PF and usually just above the basal keratinocytes in PV. “PF can have an intercellular keratinocyte cell surface staining pattern throughout the full epidermis or sometimes only the upper epidermal layers,” Dr. Woodley said.

At an international meeting on pemphigus in 2015, Dr. Woodley and his associates presented results from an ongoing study that is following 44 pemphigus patients at Keck Hospital of USC (a private university health care system) and 40 patients at Los Angeles County and USC Medical Center (a public safety net health care system). “The question we asked was, When the same doctors treat patients with a serious complicated disease requiring lots of details and follow-up at two very different health care systems, were there any differences in the outcomes of these patients?”

They found that the rates of clinical and immunologic remission were identical at both hospitals. However, at the county hospital, there was a higher incidence of relapses (59% vs. 30%). In addition, complications between the county and private hospitals differed in terms of hyperglycemia (38% vs. 11%, respectively), infections (79% vs. 37%), deaths (1 vs. none), medication dosage nonadherence (68% vs. 22%), and inappropriate discontinuation of one or more medications (68% vs. 15%). “Current research goals are to determine what factors cause medication compliance and noncompliance,” he said.

Dr. Woodley noted that one autoimmune blistering disease can evolve into another because of the phenomenon of epitope spreading. “The concept is that inflammation from one autoimmune blistering disease creates skin injury and reveals new neoautoantigens that get recognized by the patient’s immune system,” he said.

For example, a patient who had PF and high-titer autoantibodies to desmoglein 1 after a couple of years began to have blisters and erosions in her mouth, which is not supposed to happen in PF. Immunologic testing of this patient showed that in addition to antibodies against desmoglein 1, she began making high-titer autoantibodies against desmoglein 3 and had transformed into PV.

Bullous pemphigoid is another well-characterized autoimmune bullous disease that usually occurs in elderly patients. The blister is beneath the epidermis at the dermal-epidermal junction. These patients may have oral involvement. BP is characterized by tense subepidermal bullae on inflammatory bases. Histology reveals epidermal-dermal separation, many eosinophils and mast cells, and sometimes many polymorphonuclear leukocytes. “Many of these patients have very high IgE antibodies as well as IgG,” he said.

Features of BP include IgG and C3 deposits at the dermal-epidermal junction by direct immunofluorescence and by indirect immunofluorescence. “On salt-split human skin substrate, these antibodies bind to the epidermal roof of the separation and not to the dermal floor,” Dr. Woodley said. “You can send off the patient’s serum for ELISA [enzyme-linked immunosorbent assay] testing to detect autoantibodies against the BP230 antigen and the BP180 antigen to confirm the diagnosis. Autoantibodies to the BP180 antigen often correlate with the patient’s disease activity. The sensitivity of indirect immunofluorescence and ELISA are both above 95%.”

BP can present with urticarial plaques and pruritus and without blisters. Also, recent research has demonstrated that BP can present with just pruritus and no skin lesions. “So that’s something to keep in mind in refractory pruritus patients,” he said.

The incidence of BP seems to be increasing, from an estimated 7 cases per million in 1995 to 43 cases per million in 2008, Dr. Woodley said. “It may be that it is associated with some drugs like loop diuretics and spironolactone, but the precise reason is not known,” he said. “If your patient has dementia or Parkinson’s disease, he or she has a fourfold increased chance that they will have BP, because the BP180 and BP230 antigens are also in neuronal cells. Parkinson’s patients are known to make antibodies to the BP180 antigen, but not to the NC16A domain of the BP180 antigen. The development of BP in a Parkinson’s patient occurs when he or she begins to also make autoantibodies against the NC16A domain.”

The standard of treatment for autoimmune blistering diseases is prednisone 0.7-2 mg/kg. Nonsteroidal immunosuppressive agents are also helpful, including methotrexate, azathioprine, cyclophosphamide, and mycophenolate mofetil. Emerging evidence suggests that rituximab is the drug of choice for PV and PF, and should be the first-line therapy. Rituximab is a chimeric monoclonal antibody that targets CD20–positive B lymphocytes. “It removes cells that are ready to transform into autoantibody-producing short-lived plasma cells,” Dr. Woodley said. “The depletion lasts 6-12 months.”

Another new development in BP is the use of omalizumab, a monoclonal antibody to IgE. “Omalizumab inhibits the IgE antibody binding to the BP180,” Dr. Woodley said.

“It’s thought that the BP180 antigen is released from basal keratinocytes into the high papillary dermis. In BP patients, there are numerous mast cells at that location. IgE binds to the mast cells, which have IgE receptors on their surface, and in the presence of the BP180 antigen, forms dimers on the mast cells, and causes them to release inflammatory cytokines, some of which recruit eosinophils. This is likely why BP is such an inflammatory disorder. You cannot follow the IgE levels; you have to follow the eosinophils. The IgE is still high, but it’s nullified and inactive.”

Other biologics that have been successfully used in PV, PF, and BP include tumor necrosis factor–alpha inhibitors and rituximab (Rituxan). Common dosing for rituximab is 325 mg/m² per week for 4 weeks. Infusion reactions are the most common side effect, he said, but other reported adverse reactions include infections, transient hypogammaglobulinemia, neutropenia, deep vein thrombosis, and pulmonary embolism. “The incidence of side effects seems to be going down, because we are now premedicating patients with antihistamines and IV hydrocortisone before giving them rituximab,” Dr. Woodley noted.

The development of progressive multifocal leukoencephalopathy has also been reported with the use of rituximab. “This is exceedingly rare with rituximab but has been described, and this is what keeps doctors who use this drug awake at night,” he said.

Elderly patients with mild BP sometimes can get by without using immunosuppressive agents to manage their disease. One option is potent topical steroids plus niacinamide 0.5-2 g after each meal as an anti-inflammatory B vitamin. “Doxycycline 100 mg b.i.d. also works to inhibit neutrophils,” he said. “Antihistamines can also be helpful, and some French dermatologists have found total body clobetasol to be useful.”

Dr. Woodley disclosed that he holds patents on human recombinant type VII collagen. He is also a consultant for Shire Pharmaceuticals and a speaker for Biofusion.

[email protected]

NEWPORT BEACH, CALIF. – Current treatment of autoimmune blistering diseases is not backed by evidence-based medicine and solid randomized, controlled trials, according to David T. Woodley, MD.

“These are rare diseases; there’s no consensus on the treatment of choice,” Dr. Woodley said at the annual meeting of the Pacific Dermatologic Association.

Dr. Woodley, professor of dermatology at the University of Southern California, Los Angeles, limited his discussion to pemphigus vulgaris (PV), pemphigus foliaceus (PF), and bullous pemphigoid (BP). The histologic hallmark of PV and PF is acantholysis. “Because these are intraepidermal blistering diseases, you don’t see the blister very often; maybe you’ll have a few intact loose sacklike blisters, but you mostly see erosions and crusting,” he said. “PV often only begins with mouth lesions.”

Work-up for a suspected autoimmune blistering disease includes a physical exam, histology, direct and indirect immunofluorescence, and serologic tests. The diagnosis should be based on the target autoantigen in the skin. PV and PF can appear identical on direct immunofluorescence, even though the blister cleavage plane is very high in PF and usually just above the basal keratinocytes in PV. “PF can have an intercellular keratinocyte cell surface staining pattern throughout the full epidermis or sometimes only the upper epidermal layers,” Dr. Woodley said.

At an international meeting on pemphigus in 2015, Dr. Woodley and his associates presented results from an ongoing study that is following 44 pemphigus patients at Keck Hospital of USC (a private university health care system) and 40 patients at Los Angeles County and USC Medical Center (a public safety net health care system). “The question we asked was, When the same doctors treat patients with a serious complicated disease requiring lots of details and follow-up at two very different health care systems, were there any differences in the outcomes of these patients?”

They found that the rates of clinical and immunologic remission were identical at both hospitals. However, at the county hospital, there was a higher incidence of relapses (59% vs. 30%). In addition, complications between the county and private hospitals differed in terms of hyperglycemia (38% vs. 11%, respectively), infections (79% vs. 37%), deaths (1 vs. none), medication dosage nonadherence (68% vs. 22%), and inappropriate discontinuation of one or more medications (68% vs. 15%). “Current research goals are to determine what factors cause medication compliance and noncompliance,” he said.

Dr. Woodley noted that one autoimmune blistering disease can evolve into another because of the phenomenon of epitope spreading. “The concept is that inflammation from one autoimmune blistering disease creates skin injury and reveals new neoautoantigens that get recognized by the patient’s immune system,” he said.

For example, a patient who had PF and high-titer autoantibodies to desmoglein 1 after a couple of years began to have blisters and erosions in her mouth, which is not supposed to happen in PF. Immunologic testing of this patient showed that in addition to antibodies against desmoglein 1, she began making high-titer autoantibodies against desmoglein 3 and had transformed into PV.

Bullous pemphigoid is another well-characterized autoimmune bullous disease that usually occurs in elderly patients. The blister is beneath the epidermis at the dermal-epidermal junction. These patients may have oral involvement. BP is characterized by tense subepidermal bullae on inflammatory bases. Histology reveals epidermal-dermal separation, many eosinophils and mast cells, and sometimes many polymorphonuclear leukocytes. “Many of these patients have very high IgE antibodies as well as IgG,” he said.

Features of BP include IgG and C3 deposits at the dermal-epidermal junction by direct immunofluorescence and by indirect immunofluorescence. “On salt-split human skin substrate, these antibodies bind to the epidermal roof of the separation and not to the dermal floor,” Dr. Woodley said. “You can send off the patient’s serum for ELISA [enzyme-linked immunosorbent assay] testing to detect autoantibodies against the BP230 antigen and the BP180 antigen to confirm the diagnosis. Autoantibodies to the BP180 antigen often correlate with the patient’s disease activity. The sensitivity of indirect immunofluorescence and ELISA are both above 95%.”

BP can present with urticarial plaques and pruritus and without blisters. Also, recent research has demonstrated that BP can present with just pruritus and no skin lesions. “So that’s something to keep in mind in refractory pruritus patients,” he said.

The incidence of BP seems to be increasing, from an estimated 7 cases per million in 1995 to 43 cases per million in 2008, Dr. Woodley said. “It may be that it is associated with some drugs like loop diuretics and spironolactone, but the precise reason is not known,” he said. “If your patient has dementia or Parkinson’s disease, he or she has a fourfold increased chance that they will have BP, because the BP180 and BP230 antigens are also in neuronal cells. Parkinson’s patients are known to make antibodies to the BP180 antigen, but not to the NC16A domain of the BP180 antigen. The development of BP in a Parkinson’s patient occurs when he or she begins to also make autoantibodies against the NC16A domain.”

The standard of treatment for autoimmune blistering diseases is prednisone 0.7-2 mg/kg. Nonsteroidal immunosuppressive agents are also helpful, including methotrexate, azathioprine, cyclophosphamide, and mycophenolate mofetil. Emerging evidence suggests that rituximab is the drug of choice for PV and PF, and should be the first-line therapy. Rituximab is a chimeric monoclonal antibody that targets CD20–positive B lymphocytes. “It removes cells that are ready to transform into autoantibody-producing short-lived plasma cells,” Dr. Woodley said. “The depletion lasts 6-12 months.”

Another new development in BP is the use of omalizumab, a monoclonal antibody to IgE. “Omalizumab inhibits the IgE antibody binding to the BP180,” Dr. Woodley said.

“It’s thought that the BP180 antigen is released from basal keratinocytes into the high papillary dermis. In BP patients, there are numerous mast cells at that location. IgE binds to the mast cells, which have IgE receptors on their surface, and in the presence of the BP180 antigen, forms dimers on the mast cells, and causes them to release inflammatory cytokines, some of which recruit eosinophils. This is likely why BP is such an inflammatory disorder. You cannot follow the IgE levels; you have to follow the eosinophils. The IgE is still high, but it’s nullified and inactive.”

Other biologics that have been successfully used in PV, PF, and BP include tumor necrosis factor–alpha inhibitors and rituximab (Rituxan). Common dosing for rituximab is 325 mg/m² per week for 4 weeks. Infusion reactions are the most common side effect, he said, but other reported adverse reactions include infections, transient hypogammaglobulinemia, neutropenia, deep vein thrombosis, and pulmonary embolism. “The incidence of side effects seems to be going down, because we are now premedicating patients with antihistamines and IV hydrocortisone before giving them rituximab,” Dr. Woodley noted.

The development of progressive multifocal leukoencephalopathy has also been reported with the use of rituximab. “This is exceedingly rare with rituximab but has been described, and this is what keeps doctors who use this drug awake at night,” he said.

Elderly patients with mild BP sometimes can get by without using immunosuppressive agents to manage their disease. One option is potent topical steroids plus niacinamide 0.5-2 g after each meal as an anti-inflammatory B vitamin. “Doxycycline 100 mg b.i.d. also works to inhibit neutrophils,” he said. “Antihistamines can also be helpful, and some French dermatologists have found total body clobetasol to be useful.”

Dr. Woodley disclosed that he holds patents on human recombinant type VII collagen. He is also a consultant for Shire Pharmaceuticals and a speaker for Biofusion.

[email protected]

NEWPORT BEACH, CALIF. – Current treatment of autoimmune blistering diseases is not backed by evidence-based medicine and solid randomized, controlled trials, according to David T. Woodley, MD.

“These are rare diseases; there’s no consensus on the treatment of choice,” Dr. Woodley said at the annual meeting of the Pacific Dermatologic Association.

Dr. Woodley, professor of dermatology at the University of Southern California, Los Angeles, limited his discussion to pemphigus vulgaris (PV), pemphigus foliaceus (PF), and bullous pemphigoid (BP). The histologic hallmark of PV and PF is acantholysis. “Because these are intraepidermal blistering diseases, you don’t see the blister very often; maybe you’ll have a few intact loose sacklike blisters, but you mostly see erosions and crusting,” he said. “PV often only begins with mouth lesions.”

Work-up for a suspected autoimmune blistering disease includes a physical exam, histology, direct and indirect immunofluorescence, and serologic tests. The diagnosis should be based on the target autoantigen in the skin. PV and PF can appear identical on direct immunofluorescence, even though the blister cleavage plane is very high in PF and usually just above the basal keratinocytes in PV. “PF can have an intercellular keratinocyte cell surface staining pattern throughout the full epidermis or sometimes only the upper epidermal layers,” Dr. Woodley said.

At an international meeting on pemphigus in 2015, Dr. Woodley and his associates presented results from an ongoing study that is following 44 pemphigus patients at Keck Hospital of USC (a private university health care system) and 40 patients at Los Angeles County and USC Medical Center (a public safety net health care system). “The question we asked was, When the same doctors treat patients with a serious complicated disease requiring lots of details and follow-up at two very different health care systems, were there any differences in the outcomes of these patients?”

They found that the rates of clinical and immunologic remission were identical at both hospitals. However, at the county hospital, there was a higher incidence of relapses (59% vs. 30%). In addition, complications between the county and private hospitals differed in terms of hyperglycemia (38% vs. 11%, respectively), infections (79% vs. 37%), deaths (1 vs. none), medication dosage nonadherence (68% vs. 22%), and inappropriate discontinuation of one or more medications (68% vs. 15%). “Current research goals are to determine what factors cause medication compliance and noncompliance,” he said.

Dr. Woodley noted that one autoimmune blistering disease can evolve into another because of the phenomenon of epitope spreading. “The concept is that inflammation from one autoimmune blistering disease creates skin injury and reveals new neoautoantigens that get recognized by the patient’s immune system,” he said.

For example, a patient who had PF and high-titer autoantibodies to desmoglein 1 after a couple of years began to have blisters and erosions in her mouth, which is not supposed to happen in PF. Immunologic testing of this patient showed that in addition to antibodies against desmoglein 1, she began making high-titer autoantibodies against desmoglein 3 and had transformed into PV.

Bullous pemphigoid is another well-characterized autoimmune bullous disease that usually occurs in elderly patients. The blister is beneath the epidermis at the dermal-epidermal junction. These patients may have oral involvement. BP is characterized by tense subepidermal bullae on inflammatory bases. Histology reveals epidermal-dermal separation, many eosinophils and mast cells, and sometimes many polymorphonuclear leukocytes. “Many of these patients have very high IgE antibodies as well as IgG,” he said.

Features of BP include IgG and C3 deposits at the dermal-epidermal junction by direct immunofluorescence and by indirect immunofluorescence. “On salt-split human skin substrate, these antibodies bind to the epidermal roof of the separation and not to the dermal floor,” Dr. Woodley said. “You can send off the patient’s serum for ELISA [enzyme-linked immunosorbent assay] testing to detect autoantibodies against the BP230 antigen and the BP180 antigen to confirm the diagnosis. Autoantibodies to the BP180 antigen often correlate with the patient’s disease activity. The sensitivity of indirect immunofluorescence and ELISA are both above 95%.”

BP can present with urticarial plaques and pruritus and without blisters. Also, recent research has demonstrated that BP can present with just pruritus and no skin lesions. “So that’s something to keep in mind in refractory pruritus patients,” he said.

The incidence of BP seems to be increasing, from an estimated 7 cases per million in 1995 to 43 cases per million in 2008, Dr. Woodley said. “It may be that it is associated with some drugs like loop diuretics and spironolactone, but the precise reason is not known,” he said. “If your patient has dementia or Parkinson’s disease, he or she has a fourfold increased chance that they will have BP, because the BP180 and BP230 antigens are also in neuronal cells. Parkinson’s patients are known to make antibodies to the BP180 antigen, but not to the NC16A domain of the BP180 antigen. The development of BP in a Parkinson’s patient occurs when he or she begins to also make autoantibodies against the NC16A domain.”

The standard of treatment for autoimmune blistering diseases is prednisone 0.7-2 mg/kg. Nonsteroidal immunosuppressive agents are also helpful, including methotrexate, azathioprine, cyclophosphamide, and mycophenolate mofetil. Emerging evidence suggests that rituximab is the drug of choice for PV and PF, and should be the first-line therapy. Rituximab is a chimeric monoclonal antibody that targets CD20–positive B lymphocytes. “It removes cells that are ready to transform into autoantibody-producing short-lived plasma cells,” Dr. Woodley said. “The depletion lasts 6-12 months.”

Another new development in BP is the use of omalizumab, a monoclonal antibody to IgE. “Omalizumab inhibits the IgE antibody binding to the BP180,” Dr. Woodley said.

“It’s thought that the BP180 antigen is released from basal keratinocytes into the high papillary dermis. In BP patients, there are numerous mast cells at that location. IgE binds to the mast cells, which have IgE receptors on their surface, and in the presence of the BP180 antigen, forms dimers on the mast cells, and causes them to release inflammatory cytokines, some of which recruit eosinophils. This is likely why BP is such an inflammatory disorder. You cannot follow the IgE levels; you have to follow the eosinophils. The IgE is still high, but it’s nullified and inactive.”

Other biologics that have been successfully used in PV, PF, and BP include tumor necrosis factor–alpha inhibitors and rituximab (Rituxan). Common dosing for rituximab is 325 mg/m² per week for 4 weeks. Infusion reactions are the most common side effect, he said, but other reported adverse reactions include infections, transient hypogammaglobulinemia, neutropenia, deep vein thrombosis, and pulmonary embolism. “The incidence of side effects seems to be going down, because we are now premedicating patients with antihistamines and IV hydrocortisone before giving them rituximab,” Dr. Woodley noted.

The development of progressive multifocal leukoencephalopathy has also been reported with the use of rituximab. “This is exceedingly rare with rituximab but has been described, and this is what keeps doctors who use this drug awake at night,” he said.

Elderly patients with mild BP sometimes can get by without using immunosuppressive agents to manage their disease. One option is potent topical steroids plus niacinamide 0.5-2 g after each meal as an anti-inflammatory B vitamin. “Doxycycline 100 mg b.i.d. also works to inhibit neutrophils,” he said. “Antihistamines can also be helpful, and some French dermatologists have found total body clobetasol to be useful.”

Dr. Woodley disclosed that he holds patents on human recombinant type VII collagen. He is also a consultant for Shire Pharmaceuticals and a speaker for Biofusion.

[email protected]

NEWPORT BEACH, CALIF. – As the health care delivery landscape continues to evolve, expect the use of telemedicine to expand in dermatology.

“We have a robust evidence base that this is a valid way to deliver health care that can significantly improve patient access and offer comparable diagnostic and therapeutic outcomes, compared with in-person dermatology,” Ivy A. Lee, MD, said at the annual meeting of the Pacific Dermatologic Association. “This is an efficient way to improve access to our small and mighty workforce.”

Many factors are driving teledermatology’s rise in popularity, including patient access issues. “These are getting more prominent and more prevalent, not only in the uninsured and the underinsured, but also in our insured population,” said Dr. Lee, a Pasadena, Calif.–based dermatologist who also chairs the American Academy of Dermatology’s Telemedicine Task Force. “In my private practice, it’s about a 6- to 8-week wait for a new patient appointment, and this is in an affluent part of Los Angeles.”

Then there’s the increasing expectations of today’s health care consumers, who “want a better medical experience,” she said. “They don’t want to spend all their day in our waiting room, and they want to be able to get in touch with their physicians and not play phone tag with the front office staff. There’s also omnipresent technology. We have devices in our office, in our home, and in our hand – in every aspect of our lives. That’s also affecting our experience and expectations of medicine and health.”

Current forms of telemedicine range from “store and forward” (which refers to the submission of clinical images and history to a remote provider who reviews the material and sends a recommendation at a different time), “live interactive” (which uses synchronous video technology similar to FaceTime or Skype where you’re interacting with the patient or with the patient’s provider at the same time, even though you are separated by space), and “hybrid” (a combination of the two forms).

Dr. Lee said that store and forward currently is the predominant form of teledermatology “because of the convenience and ease of use. We’re a lot more efficient with that modality. We’ve used it predominantly for care delivery in a consultative practice model (provider interacts with another provider for consultation or triage of a patient). But, we also see an increasing interest and practice of direct-to-patient or direct-to-consumer care where providers interact with patients. This trend is predominantly led by telemedicine companies as a response to increasing patient demand for convenience, but also we see this practice model being adopted by larger health care systems and private practices.”

In the past, she continued, most telemedicine technology has consisted of stand-alone software platforms. The new focus is integration, asking software platforms to be more interoperable with EHRs. “Also, some EHRs are offering telemedicine capabilities,” she said. Recent interest in value-based medicine, especially since the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), also plays a role in the growing adoption of telemedicine. “The focus on value and data collection is increasingly imposed upon us by multiple sources,” Dr. Lee said.

Reimbursement remains a barrier for wide adoption of teledermatology. Current models include volume-based (fee-for-service) and value-based models such as capitation, bundled payments, and pay for performance. Advances in the volume-based realm include increasing adoption of parity laws for private insurers (29 states hold such laws, which call for telemedicine services to be covered to the same extent and in a similar manner as in-person services).

In this era of higher-deductible insurance plans and narrowing networks, patients are also paying for their own care out of pocket or by using flexible savings accounts, to the tune of $30-$200 per teledermatology encounter. “We also have seen some progress with government payers in the fee-for-service models: Medicare, and less so with Medicaid,” she said. Telemedicine payments from Medicare have increased, from about $5 million in 2011 to about $18 million in 2015, but it currently reimburses live video with geographic restrictions and reimburses for store-and-forward technologies only in Alaska and Hawaii.

Medicaid “lags behind other payers,” Dr. Lee said. “Few states reimburse for store and forward, and reimbursement depends on distance requirements, eligible patient populations and health care providers, authorized technologies, and patient consent. Currently, reimbursement varies significantly across the country; it varies by state and, within each state, by payer. With the passage of MACRA, we have to start thinking about how we will practice and measure the value-based care we deliver and whether we as dermatologists will implement an alternative payment model or a merit-based incentive system. There are a lot of legislative changes in terms of getting properly paid for these services.”

On the legislative front, the Federation of State Medical Boards Interstate Medical Licensure Compact should help promote the adoption of teledermatology. This is proposed legislation to provide expedited and streamlined processes for physicians to obtain a multistate license to provide care. It’s been enacted by 17 states and proposed by 9 states and will go into effect in 2017.

“For teledermatology, this is an exciting time full of changes in practice, utilization, reimbursement, regulation, and research,” Dr. Lee concluded. “We see telemedicine increasingly integrated into mainstream medicine and health maintenance, and the outlook for dermatology is very positive.”

She reported having no relevant financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – As the health care delivery landscape continues to evolve, expect the use of telemedicine to expand in dermatology.

“We have a robust evidence base that this is a valid way to deliver health care that can significantly improve patient access and offer comparable diagnostic and therapeutic outcomes, compared with in-person dermatology,” Ivy A. Lee, MD, said at the annual meeting of the Pacific Dermatologic Association. “This is an efficient way to improve access to our small and mighty workforce.”

Many factors are driving teledermatology’s rise in popularity, including patient access issues. “These are getting more prominent and more prevalent, not only in the uninsured and the underinsured, but also in our insured population,” said Dr. Lee, a Pasadena, Calif.–based dermatologist who also chairs the American Academy of Dermatology’s Telemedicine Task Force. “In my private practice, it’s about a 6- to 8-week wait for a new patient appointment, and this is in an affluent part of Los Angeles.”

Then there’s the increasing expectations of today’s health care consumers, who “want a better medical experience,” she said. “They don’t want to spend all their day in our waiting room, and they want to be able to get in touch with their physicians and not play phone tag with the front office staff. There’s also omnipresent technology. We have devices in our office, in our home, and in our hand – in every aspect of our lives. That’s also affecting our experience and expectations of medicine and health.”

Current forms of telemedicine range from “store and forward” (which refers to the submission of clinical images and history to a remote provider who reviews the material and sends a recommendation at a different time), “live interactive” (which uses synchronous video technology similar to FaceTime or Skype where you’re interacting with the patient or with the patient’s provider at the same time, even though you are separated by space), and “hybrid” (a combination of the two forms).

Dr. Lee said that store and forward currently is the predominant form of teledermatology “because of the convenience and ease of use. We’re a lot more efficient with that modality. We’ve used it predominantly for care delivery in a consultative practice model (provider interacts with another provider for consultation or triage of a patient). But, we also see an increasing interest and practice of direct-to-patient or direct-to-consumer care where providers interact with patients. This trend is predominantly led by telemedicine companies as a response to increasing patient demand for convenience, but also we see this practice model being adopted by larger health care systems and private practices.”

In the past, she continued, most telemedicine technology has consisted of stand-alone software platforms. The new focus is integration, asking software platforms to be more interoperable with EHRs. “Also, some EHRs are offering telemedicine capabilities,” she said. Recent interest in value-based medicine, especially since the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), also plays a role in the growing adoption of telemedicine. “The focus on value and data collection is increasingly imposed upon us by multiple sources,” Dr. Lee said.

Reimbursement remains a barrier for wide adoption of teledermatology. Current models include volume-based (fee-for-service) and value-based models such as capitation, bundled payments, and pay for performance. Advances in the volume-based realm include increasing adoption of parity laws for private insurers (29 states hold such laws, which call for telemedicine services to be covered to the same extent and in a similar manner as in-person services).

In this era of higher-deductible insurance plans and narrowing networks, patients are also paying for their own care out of pocket or by using flexible savings accounts, to the tune of $30-$200 per teledermatology encounter. “We also have seen some progress with government payers in the fee-for-service models: Medicare, and less so with Medicaid,” she said. Telemedicine payments from Medicare have increased, from about $5 million in 2011 to about $18 million in 2015, but it currently reimburses live video with geographic restrictions and reimburses for store-and-forward technologies only in Alaska and Hawaii.

Medicaid “lags behind other payers,” Dr. Lee said. “Few states reimburse for store and forward, and reimbursement depends on distance requirements, eligible patient populations and health care providers, authorized technologies, and patient consent. Currently, reimbursement varies significantly across the country; it varies by state and, within each state, by payer. With the passage of MACRA, we have to start thinking about how we will practice and measure the value-based care we deliver and whether we as dermatologists will implement an alternative payment model or a merit-based incentive system. There are a lot of legislative changes in terms of getting properly paid for these services.”

On the legislative front, the Federation of State Medical Boards Interstate Medical Licensure Compact should help promote the adoption of teledermatology. This is proposed legislation to provide expedited and streamlined processes for physicians to obtain a multistate license to provide care. It’s been enacted by 17 states and proposed by 9 states and will go into effect in 2017.

“For teledermatology, this is an exciting time full of changes in practice, utilization, reimbursement, regulation, and research,” Dr. Lee concluded. “We see telemedicine increasingly integrated into mainstream medicine and health maintenance, and the outlook for dermatology is very positive.”

She reported having no relevant financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – As the health care delivery landscape continues to evolve, expect the use of telemedicine to expand in dermatology.

“We have a robust evidence base that this is a valid way to deliver health care that can significantly improve patient access and offer comparable diagnostic and therapeutic outcomes, compared with in-person dermatology,” Ivy A. Lee, MD, said at the annual meeting of the Pacific Dermatologic Association. “This is an efficient way to improve access to our small and mighty workforce.”

Many factors are driving teledermatology’s rise in popularity, including patient access issues. “These are getting more prominent and more prevalent, not only in the uninsured and the underinsured, but also in our insured population,” said Dr. Lee, a Pasadena, Calif.–based dermatologist who also chairs the American Academy of Dermatology’s Telemedicine Task Force. “In my private practice, it’s about a 6- to 8-week wait for a new patient appointment, and this is in an affluent part of Los Angeles.”

Then there’s the increasing expectations of today’s health care consumers, who “want a better medical experience,” she said. “They don’t want to spend all their day in our waiting room, and they want to be able to get in touch with their physicians and not play phone tag with the front office staff. There’s also omnipresent technology. We have devices in our office, in our home, and in our hand – in every aspect of our lives. That’s also affecting our experience and expectations of medicine and health.”

Current forms of telemedicine range from “store and forward” (which refers to the submission of clinical images and history to a remote provider who reviews the material and sends a recommendation at a different time), “live interactive” (which uses synchronous video technology similar to FaceTime or Skype where you’re interacting with the patient or with the patient’s provider at the same time, even though you are separated by space), and “hybrid” (a combination of the two forms).

Dr. Lee said that store and forward currently is the predominant form of teledermatology “because of the convenience and ease of use. We’re a lot more efficient with that modality. We’ve used it predominantly for care delivery in a consultative practice model (provider interacts with another provider for consultation or triage of a patient). But, we also see an increasing interest and practice of direct-to-patient or direct-to-consumer care where providers interact with patients. This trend is predominantly led by telemedicine companies as a response to increasing patient demand for convenience, but also we see this practice model being adopted by larger health care systems and private practices.”

In the past, she continued, most telemedicine technology has consisted of stand-alone software platforms. The new focus is integration, asking software platforms to be more interoperable with EHRs. “Also, some EHRs are offering telemedicine capabilities,” she said. Recent interest in value-based medicine, especially since the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), also plays a role in the growing adoption of telemedicine. “The focus on value and data collection is increasingly imposed upon us by multiple sources,” Dr. Lee said.

Reimbursement remains a barrier for wide adoption of teledermatology. Current models include volume-based (fee-for-service) and value-based models such as capitation, bundled payments, and pay for performance. Advances in the volume-based realm include increasing adoption of parity laws for private insurers (29 states hold such laws, which call for telemedicine services to be covered to the same extent and in a similar manner as in-person services).

In this era of higher-deductible insurance plans and narrowing networks, patients are also paying for their own care out of pocket or by using flexible savings accounts, to the tune of $30-$200 per teledermatology encounter. “We also have seen some progress with government payers in the fee-for-service models: Medicare, and less so with Medicaid,” she said. Telemedicine payments from Medicare have increased, from about $5 million in 2011 to about $18 million in 2015, but it currently reimburses live video with geographic restrictions and reimburses for store-and-forward technologies only in Alaska and Hawaii.

Medicaid “lags behind other payers,” Dr. Lee said. “Few states reimburse for store and forward, and reimbursement depends on distance requirements, eligible patient populations and health care providers, authorized technologies, and patient consent. Currently, reimbursement varies significantly across the country; it varies by state and, within each state, by payer. With the passage of MACRA, we have to start thinking about how we will practice and measure the value-based care we deliver and whether we as dermatologists will implement an alternative payment model or a merit-based incentive system. There are a lot of legislative changes in terms of getting properly paid for these services.”

On the legislative front, the Federation of State Medical Boards Interstate Medical Licensure Compact should help promote the adoption of teledermatology. This is proposed legislation to provide expedited and streamlined processes for physicians to obtain a multistate license to provide care. It’s been enacted by 17 states and proposed by 9 states and will go into effect in 2017.

“For teledermatology, this is an exciting time full of changes in practice, utilization, reimbursement, regulation, and research,” Dr. Lee concluded. “We see telemedicine increasingly integrated into mainstream medicine and health maintenance, and the outlook for dermatology is very positive.”

She reported having no relevant financial disclosures.

[email protected]

NEWPORT BEACH, CALIF. – In the clinical opinion of Kelly M. Cordoro, MD, anyone who cares for patients with severe atopic dermatitis understands the sense of misery that can ensue.

“Atopic dermatitis patients don’t sleep well; they have poor school and work performance,” she said at the annual meeting of the Pacific Dermatologic Association. “They have absences. They’re unable to play; they can’t exercise. This leads to social disability; isolation from peers, and it goes on and on. The patients are miserable, the whole family is miserable, and we as physicians trying to sort out how to optimally treat them are miserable trying to figure out what the next best step is.”

The good news is, several drugs in the pipeline hold promise for atopic dermatitis patients, thanks largely to emerging data on its pathophysiology. In addition, mechanisms of itch, which are not yet fully understood, are also being unraveled. “It’s exciting to read the literature about the interaction of the skin, the immune system, and the nervous system,” said Dr. Cordoro, a pediatric dermatologist at the University of California, San Francisco. “Many of the mediators of itch are being identified. That has allowed for the development of targeted therapies against many of them.”

One of the promising treatments on the horizon for atopic dermatitis patients is phosphodiesterase-4 (PDE4) inhibitors. PDE-4 is a predominant cAMP-degrading enzyme in keratinocytes and inflammatory cells. “It’s really a candidate for not only atopic dermatitis but for psoriasis,” she said.

Oral PDE-4 inhibitors are already approved for psoriasis. Apremilast (Otezla) was approved by the Food and Drug Administration in 2014 for psoriasis and psoriatic arthritis, and a phase II trial of topical apremilast in adults with AD has been completed and the results are pending. “I look forward to seeing if this can help our patients,” Dr. Cordoro said.

Another promising agent for atopic dermatitis is 2% crisaborole topical ointment, a boron-based PDE-4 inhibitor developed by Anacor Pharmaceuticals. Dr. Cordoro described this compound as an anti-inflammatory agent that modifies inflammation by inhibiting the degradation of cAMP by PDE4, resulting in downstream modification of nuclear factor-kB and T-cell signaling pathways.

“Crisaborole has shown promising results from four clinical studies in patients 2 years of age and older, with notable improvements in all atopic dermatitis parameters,” she said (J Am Acad Dermatol. 2016 Sept;75[3]:494-503.e). The FDA review of crisaborole for the treatment of mild to moderate atopic dermatitis in children and adults is currently underway, and is expected to be completed by early January 2017.

An especially favorable drug in development for atopic dermatitis is dupilumab, a fully human monoclonal antibody that targets the interleukin (IL)–4 receptor, and inhibits IL-4 and IL-13 signaling. A published trial of its use in adults with moderate to severe atopic dermatitis showed rapid improvements in all atopic dermatitis clinical indices (N Engl J Med. 2014;371[2]:130-9). The most common side effects were headache and pharyngitis, and skin infections and flares were more common in the placebo group, compared with the treatment group.

Dupilumab “has the potential to shift the treatment landscape of atopic dermatitis, because it can actually change the molecular signature of dermatitic skin, reducing inflammatory and proliferative markers,” Dr. Cordoro said. There are ongoing trials in adult and pediatric populations and FDA approval is anticipated in early 2017.

Published reports also suggest a role for the IL-12/23 pathway inhibitor ustekinumab in severe refractory adult atopic dermatitis (Int J Dermatol. 2012;51[1]:115-6 and JAAD Case Reports 2015;1:25-6). Additional studies are ongoing.

Therapies for itch that have completed phase II trials include the anti-IL31R monoclonal antibody nemolizumab (CIM331); the neurokinin-1R antagonist VLY-686; and the neurokinin-1R antagonist aprepitant gel.

Dr. Cordoro disclosed that she is a consultant for Celgene Corporation, Valeant, and Anacor Pharmaceuticals.

[email protected]

NEWPORT BEACH, CALIF. – In the clinical opinion of Kelly M. Cordoro, MD, anyone who cares for patients with severe atopic dermatitis understands the sense of misery that can ensue.

“Atopic dermatitis patients don’t sleep well; they have poor school and work performance,” she said at the annual meeting of the Pacific Dermatologic Association. “They have absences. They’re unable to play; they can’t exercise. This leads to social disability; isolation from peers, and it goes on and on. The patients are miserable, the whole family is miserable, and we as physicians trying to sort out how to optimally treat them are miserable trying to figure out what the next best step is.”

The good news is, several drugs in the pipeline hold promise for atopic dermatitis patients, thanks largely to emerging data on its pathophysiology. In addition, mechanisms of itch, which are not yet fully understood, are also being unraveled. “It’s exciting to read the literature about the interaction of the skin, the immune system, and the nervous system,” said Dr. Cordoro, a pediatric dermatologist at the University of California, San Francisco. “Many of the mediators of itch are being identified. That has allowed for the development of targeted therapies against many of them.”

One of the promising treatments on the horizon for atopic dermatitis patients is phosphodiesterase-4 (PDE4) inhibitors. PDE-4 is a predominant cAMP-degrading enzyme in keratinocytes and inflammatory cells. “It’s really a candidate for not only atopic dermatitis but for psoriasis,” she said.

Oral PDE-4 inhibitors are already approved for psoriasis. Apremilast (Otezla) was approved by the Food and Drug Administration in 2014 for psoriasis and psoriatic arthritis, and a phase II trial of topical apremilast in adults with AD has been completed and the results are pending. “I look forward to seeing if this can help our patients,” Dr. Cordoro said.

Another promising agent for atopic dermatitis is 2% crisaborole topical ointment, a boron-based PDE-4 inhibitor developed by Anacor Pharmaceuticals. Dr. Cordoro described this compound as an anti-inflammatory agent that modifies inflammation by inhibiting the degradation of cAMP by PDE4, resulting in downstream modification of nuclear factor-kB and T-cell signaling pathways.

“Crisaborole has shown promising results from four clinical studies in patients 2 years of age and older, with notable improvements in all atopic dermatitis parameters,” she said (J Am Acad Dermatol. 2016 Sept;75[3]:494-503.e). The FDA review of crisaborole for the treatment of mild to moderate atopic dermatitis in children and adults is currently underway, and is expected to be completed by early January 2017.

An especially favorable drug in development for atopic dermatitis is dupilumab, a fully human monoclonal antibody that targets the interleukin (IL)–4 receptor, and inhibits IL-4 and IL-13 signaling. A published trial of its use in adults with moderate to severe atopic dermatitis showed rapid improvements in all atopic dermatitis clinical indices (N Engl J Med. 2014;371[2]:130-9). The most common side effects were headache and pharyngitis, and skin infections and flares were more common in the placebo group, compared with the treatment group.

Dupilumab “has the potential to shift the treatment landscape of atopic dermatitis, because it can actually change the molecular signature of dermatitic skin, reducing inflammatory and proliferative markers,” Dr. Cordoro said. There are ongoing trials in adult and pediatric populations and FDA approval is anticipated in early 2017.

Published reports also suggest a role for the IL-12/23 pathway inhibitor ustekinumab in severe refractory adult atopic dermatitis (Int J Dermatol. 2012;51[1]:115-6 and JAAD Case Reports 2015;1:25-6). Additional studies are ongoing.

Therapies for itch that have completed phase II trials include the anti-IL31R monoclonal antibody nemolizumab (CIM331); the neurokinin-1R antagonist VLY-686; and the neurokinin-1R antagonist aprepitant gel.

Dr. Cordoro disclosed that she is a consultant for Celgene Corporation, Valeant, and Anacor Pharmaceuticals.

[email protected]

NEWPORT BEACH, CALIF. – In the clinical opinion of Kelly M. Cordoro, MD, anyone who cares for patients with severe atopic dermatitis understands the sense of misery that can ensue.

“Atopic dermatitis patients don’t sleep well; they have poor school and work performance,” she said at the annual meeting of the Pacific Dermatologic Association. “They have absences. They’re unable to play; they can’t exercise. This leads to social disability; isolation from peers, and it goes on and on. The patients are miserable, the whole family is miserable, and we as physicians trying to sort out how to optimally treat them are miserable trying to figure out what the next best step is.”

The good news is, several drugs in the pipeline hold promise for atopic dermatitis patients, thanks largely to emerging data on its pathophysiology. In addition, mechanisms of itch, which are not yet fully understood, are also being unraveled. “It’s exciting to read the literature about the interaction of the skin, the immune system, and the nervous system,” said Dr. Cordoro, a pediatric dermatologist at the University of California, San Francisco. “Many of the mediators of itch are being identified. That has allowed for the development of targeted therapies against many of them.”

One of the promising treatments on the horizon for atopic dermatitis patients is phosphodiesterase-4 (PDE4) inhibitors. PDE-4 is a predominant cAMP-degrading enzyme in keratinocytes and inflammatory cells. “It’s really a candidate for not only atopic dermatitis but for psoriasis,” she said.

Oral PDE-4 inhibitors are already approved for psoriasis. Apremilast (Otezla) was approved by the Food and Drug Administration in 2014 for psoriasis and psoriatic arthritis, and a phase II trial of topical apremilast in adults with AD has been completed and the results are pending. “I look forward to seeing if this can help our patients,” Dr. Cordoro said.

Another promising agent for atopic dermatitis is 2% crisaborole topical ointment, a boron-based PDE-4 inhibitor developed by Anacor Pharmaceuticals. Dr. Cordoro described this compound as an anti-inflammatory agent that modifies inflammation by inhibiting the degradation of cAMP by PDE4, resulting in downstream modification of nuclear factor-kB and T-cell signaling pathways.

“Crisaborole has shown promising results from four clinical studies in patients 2 years of age and older, with notable improvements in all atopic dermatitis parameters,” she said (J Am Acad Dermatol. 2016 Sept;75[3]:494-503.e). The FDA review of crisaborole for the treatment of mild to moderate atopic dermatitis in children and adults is currently underway, and is expected to be completed by early January 2017.

An especially favorable drug in development for atopic dermatitis is dupilumab, a fully human monoclonal antibody that targets the interleukin (IL)–4 receptor, and inhibits IL-4 and IL-13 signaling. A published trial of its use in adults with moderate to severe atopic dermatitis showed rapid improvements in all atopic dermatitis clinical indices (N Engl J Med. 2014;371[2]:130-9). The most common side effects were headache and pharyngitis, and skin infections and flares were more common in the placebo group, compared with the treatment group.

Dupilumab “has the potential to shift the treatment landscape of atopic dermatitis, because it can actually change the molecular signature of dermatitic skin, reducing inflammatory and proliferative markers,” Dr. Cordoro said. There are ongoing trials in adult and pediatric populations and FDA approval is anticipated in early 2017.

Published reports also suggest a role for the IL-12/23 pathway inhibitor ustekinumab in severe refractory adult atopic dermatitis (Int J Dermatol. 2012;51[1]:115-6 and JAAD Case Reports 2015;1:25-6). Additional studies are ongoing.

Therapies for itch that have completed phase II trials include the anti-IL31R monoclonal antibody nemolizumab (CIM331); the neurokinin-1R antagonist VLY-686; and the neurokinin-1R antagonist aprepitant gel.

Dr. Cordoro disclosed that she is a consultant for Celgene Corporation, Valeant, and Anacor Pharmaceuticals.

[email protected]

NEWPORT BEACH, CALIF. – In medical school you may have been taught that herpes zoster infection primarily impacts elderly patients, but the burden of disease is shifting – along with the understanding of herpes zoster itself.

“Herpes zoster is a disease that can lull us into a false sense of security because we see it all the time,” Iris Ahronowitz, MD, said at the annual meeting of the Pacific Dermatologic Association. “But our understanding of how to manage this disease is still very much a work in progress.”

She noted that while 50% of people will acquire herpes zoster by the time they reach 85 years of age due to diminishing cell-mediated immunity, the major burden of disease impacts immunocompromised patients of all ages. HIV patients and solid-organ transplant recipients are well known to face an increased risk of acquiring herpes zoster, but the most overwhelming risk is seen in leukemia patients, who have rates as high as 100-fold that of the general population.

“More recent data on stem cell transplant patients show that about 50% of them will get zoster,” added Dr. Ahronowitz, a dermatologist at the University of Southern California, Los Angeles. “Most of that’s happening within the first year and a half after their transplant.”

Several recent epidemiologic studies in the medical literature have reported herpes zoster in patients who are not traditionally believed to be immunosuppressed, such as those with lupus, dermatomyositis, rheumatoid arthritis, asthma, and atopic dermatitis. “It begs the question: is it the disease or is it the treatment?” Dr. Ahronowitz said. “We don’t know the answer to that yet. In dermatomyositis and lupus, use of antimalarials has been found to be most associated with the risk of herpes zoster. Other studies looking at one disease are so heterogeneous, some saying that it’s one medication, some saying that it’s another. There’s no cohesive message yet about which medications cause the highest risk of zoster.”

Herpes zoster was originally believed to be far less transmissible than varicella. “Later it was thought that the only way that you can get VZV [varicella zoster virus] from a zoster patient was by direct contact with vesicle fluid,” Dr. Ahronowitz said. “That turns out to be wrong as well.” One study of pediatric patients found similar rates of secondary varicella cases from varicella and herpes zoster cases (15% vs. 9%, respectively), regardless of anatomic location of zoster (J Infect Dis. 2012; 205[9]:1336-41).

Another report that called into question prevailing beliefs about the disease involved an immunocompetent patient in a long-term care facility who developed localized herpes zoster (J Infect Dis. 2008;197[5]:646-53). That individual turned out to be “patient zero” in a varicella outbreak in the facility, even though the person’s lesions had been covered by gauze and clothing at all times. “The next patient who got infected was one of the health care workers who had never been in the room at the same time as the patient but who had changed the patient’s bed linens,” said Dr. Ahronowitz, who was not involved with the study. “Environmental samples were collected from the patient’s room and were contaminated with VZV DNA.”

She went on to note that VZV DNA has been found in vesicle fluid, serum, peripheral blood mononuclear cells, and saliva. One randomized, controlled trial found that hydrocolloid dressings are superior to traditional gauze and paper dressings in preventing the excretion of aerosolized VZV DNA from skin lesions of patients with localized herpes zoster (J Infect Dis. 2004;189[6]:1009-12). Using hydrocolloid dressings to cover lesions “does seem to make a difference,” she said. “Because of all this new data coming out, I think it’s time to reconsider isolation precautions in all hospitalized patients with herpes zoster, because the consequences of VZV transmission within a hospital where there are other patients nearby who have low immune systems could be absolutely devastating.”

The impact of herpes zoster infection on the central nervous system can be significant, including cranial nerve palsy, encephalitis, encephalopathy, and aseptic meningitis. “Patients can have long-lasting residual neurologic deficits from this at 6 months or longer despite appropriate treatment,” she said. “No correlation between CSF viral load and neurologic sequelae has been found at 3 months.”

More recent research has found an association between herpes zoster infection and an increased risk of stroke – up to threefold in some cases. “That risk doesn’t normalize until 6 months after the infection,” Dr. Ahronowitz said. “We’re even seeing it in kids, who have two times the risk of stroke in the first 6 months after VZV infection.” MI risk also seems to be elevated as a secondary outcome (a 1.7-fold increase in the first week of infection).

“There have also been recent reports of VZV antigen/DNA found in the vessel wall of patients with giant cell arteritis and granulomatous arteritis of the aorta,” she said. “This is an evolving story about zoster that we never knew about.”

Drug-induced hypersensitivity syndrome (DIHS) is also associated with CNS manifestations, but they resolve much faster, unlike those of CNS zoster. “As long as you take away the offending medication and put them on steroids they will recover very quickly,” she said. At least one case in the medical literature to date has reported DIHS in association with VZV (Acta Derm Venereol. 2015;95[4]:503-4).

The zoster vaccine (Zostavax, Merck & Co.) is currently indicated in patients aged 60 years and older, but since it is a live attenuated vaccine, it is contraindicated in many patients who could most benefit from it, including those with primary immunodeficiency disorders, those with a hematologic malignancy, those who have had a hematopoietic stem cell transplant within the last 2 years, pregnant patients, and patients taking high-dose steroids or anti–tumor necrosis factor biologics.

“There is an inactivated vaccine in the works being tested, and that is showing good efficacy,” Dr. Ahronowitz said. “Hopefully we’ll be able to prevaccinate patients, even young patients, prior to immune suppression.”

She reported having no relevant disclosures.

[email protected]

NEWPORT BEACH, CALIF. – In medical school you may have been taught that herpes zoster infection primarily impacts elderly patients, but the burden of disease is shifting – along with the understanding of herpes zoster itself.

“Herpes zoster is a disease that can lull us into a false sense of security because we see it all the time,” Iris Ahronowitz, MD, said at the annual meeting of the Pacific Dermatologic Association. “But our understanding of how to manage this disease is still very much a work in progress.”

She noted that while 50% of people will acquire herpes zoster by the time they reach 85 years of age due to diminishing cell-mediated immunity, the major burden of disease impacts immunocompromised patients of all ages. HIV patients and solid-organ transplant recipients are well known to face an increased risk of acquiring herpes zoster, but the most overwhelming risk is seen in leukemia patients, who have rates as high as 100-fold that of the general population.

“More recent data on stem cell transplant patients show that about 50% of them will get zoster,” added Dr. Ahronowitz, a dermatologist at the University of Southern California, Los Angeles. “Most of that’s happening within the first year and a half after their transplant.”

Several recent epidemiologic studies in the medical literature have reported herpes zoster in patients who are not traditionally believed to be immunosuppressed, such as those with lupus, dermatomyositis, rheumatoid arthritis, asthma, and atopic dermatitis. “It begs the question: is it the disease or is it the treatment?” Dr. Ahronowitz said. “We don’t know the answer to that yet. In dermatomyositis and lupus, use of antimalarials has been found to be most associated with the risk of herpes zoster. Other studies looking at one disease are so heterogeneous, some saying that it’s one medication, some saying that it’s another. There’s no cohesive message yet about which medications cause the highest risk of zoster.”

Herpes zoster was originally believed to be far less transmissible than varicella. “Later it was thought that the only way that you can get VZV [varicella zoster virus] from a zoster patient was by direct contact with vesicle fluid,” Dr. Ahronowitz said. “That turns out to be wrong as well.” One study of pediatric patients found similar rates of secondary varicella cases from varicella and herpes zoster cases (15% vs. 9%, respectively), regardless of anatomic location of zoster (J Infect Dis. 2012; 205[9]:1336-41).

Another report that called into question prevailing beliefs about the disease involved an immunocompetent patient in a long-term care facility who developed localized herpes zoster (J Infect Dis. 2008;197[5]:646-53). That individual turned out to be “patient zero” in a varicella outbreak in the facility, even though the person’s lesions had been covered by gauze and clothing at all times. “The next patient who got infected was one of the health care workers who had never been in the room at the same time as the patient but who had changed the patient’s bed linens,” said Dr. Ahronowitz, who was not involved with the study. “Environmental samples were collected from the patient’s room and were contaminated with VZV DNA.”

She went on to note that VZV DNA has been found in vesicle fluid, serum, peripheral blood mononuclear cells, and saliva. One randomized, controlled trial found that hydrocolloid dressings are superior to traditional gauze and paper dressings in preventing the excretion of aerosolized VZV DNA from skin lesions of patients with localized herpes zoster (J Infect Dis. 2004;189[6]:1009-12). Using hydrocolloid dressings to cover lesions “does seem to make a difference,” she said. “Because of all this new data coming out, I think it’s time to reconsider isolation precautions in all hospitalized patients with herpes zoster, because the consequences of VZV transmission within a hospital where there are other patients nearby who have low immune systems could be absolutely devastating.”

The impact of herpes zoster infection on the central nervous system can be significant, including cranial nerve palsy, encephalitis, encephalopathy, and aseptic meningitis. “Patients can have long-lasting residual neurologic deficits from this at 6 months or longer despite appropriate treatment,” she said. “No correlation between CSF viral load and neurologic sequelae has been found at 3 months.”

More recent research has found an association between herpes zoster infection and an increased risk of stroke – up to threefold in some cases. “That risk doesn’t normalize until 6 months after the infection,” Dr. Ahronowitz said. “We’re even seeing it in kids, who have two times the risk of stroke in the first 6 months after VZV infection.” MI risk also seems to be elevated as a secondary outcome (a 1.7-fold increase in the first week of infection).

“There have also been recent reports of VZV antigen/DNA found in the vessel wall of patients with giant cell arteritis and granulomatous arteritis of the aorta,” she said. “This is an evolving story about zoster that we never knew about.”

Drug-induced hypersensitivity syndrome (DIHS) is also associated with CNS manifestations, but they resolve much faster, unlike those of CNS zoster. “As long as you take away the offending medication and put them on steroids they will recover very quickly,” she said. At least one case in the medical literature to date has reported DIHS in association with VZV (Acta Derm Venereol. 2015;95[4]:503-4).

The zoster vaccine (Zostavax, Merck & Co.) is currently indicated in patients aged 60 years and older, but since it is a live attenuated vaccine, it is contraindicated in many patients who could most benefit from it, including those with primary immunodeficiency disorders, those with a hematologic malignancy, those who have had a hematopoietic stem cell transplant within the last 2 years, pregnant patients, and patients taking high-dose steroids or anti–tumor necrosis factor biologics.

“There is an inactivated vaccine in the works being tested, and that is showing good efficacy,” Dr. Ahronowitz said. “Hopefully we’ll be able to prevaccinate patients, even young patients, prior to immune suppression.”

She reported having no relevant disclosures.

[email protected]

NEWPORT BEACH, CALIF. – In medical school you may have been taught that herpes zoster infection primarily impacts elderly patients, but the burden of disease is shifting – along with the understanding of herpes zoster itself.

“Herpes zoster is a disease that can lull us into a false sense of security because we see it all the time,” Iris Ahronowitz, MD, said at the annual meeting of the Pacific Dermatologic Association. “But our understanding of how to manage this disease is still very much a work in progress.”

She noted that while 50% of people will acquire herpes zoster by the time they reach 85 years of age due to diminishing cell-mediated immunity, the major burden of disease impacts immunocompromised patients of all ages. HIV patients and solid-organ transplant recipients are well known to face an increased risk of acquiring herpes zoster, but the most overwhelming risk is seen in leukemia patients, who have rates as high as 100-fold that of the general population.

“More recent data on stem cell transplant patients show that about 50% of them will get zoster,” added Dr. Ahronowitz, a dermatologist at the University of Southern California, Los Angeles. “Most of that’s happening within the first year and a half after their transplant.”

Several recent epidemiologic studies in the medical literature have reported herpes zoster in patients who are not traditionally believed to be immunosuppressed, such as those with lupus, dermatomyositis, rheumatoid arthritis, asthma, and atopic dermatitis. “It begs the question: is it the disease or is it the treatment?” Dr. Ahronowitz said. “We don’t know the answer to that yet. In dermatomyositis and lupus, use of antimalarials has been found to be most associated with the risk of herpes zoster. Other studies looking at one disease are so heterogeneous, some saying that it’s one medication, some saying that it’s another. There’s no cohesive message yet about which medications cause the highest risk of zoster.”

Herpes zoster was originally believed to be far less transmissible than varicella. “Later it was thought that the only way that you can get VZV [varicella zoster virus] from a zoster patient was by direct contact with vesicle fluid,” Dr. Ahronowitz said. “That turns out to be wrong as well.” One study of pediatric patients found similar rates of secondary varicella cases from varicella and herpes zoster cases (15% vs. 9%, respectively), regardless of anatomic location of zoster (J Infect Dis. 2012; 205[9]:1336-41).

Another report that called into question prevailing beliefs about the disease involved an immunocompetent patient in a long-term care facility who developed localized herpes zoster (J Infect Dis. 2008;197[5]:646-53). That individual turned out to be “patient zero” in a varicella outbreak in the facility, even though the person’s lesions had been covered by gauze and clothing at all times. “The next patient who got infected was one of the health care workers who had never been in the room at the same time as the patient but who had changed the patient’s bed linens,” said Dr. Ahronowitz, who was not involved with the study. “Environmental samples were collected from the patient’s room and were contaminated with VZV DNA.”

She went on to note that VZV DNA has been found in vesicle fluid, serum, peripheral blood mononuclear cells, and saliva. One randomized, controlled trial found that hydrocolloid dressings are superior to traditional gauze and paper dressings in preventing the excretion of aerosolized VZV DNA from skin lesions of patients with localized herpes zoster (J Infect Dis. 2004;189[6]:1009-12). Using hydrocolloid dressings to cover lesions “does seem to make a difference,” she said. “Because of all this new data coming out, I think it’s time to reconsider isolation precautions in all hospitalized patients with herpes zoster, because the consequences of VZV transmission within a hospital where there are other patients nearby who have low immune systems could be absolutely devastating.”

The impact of herpes zoster infection on the central nervous system can be significant, including cranial nerve palsy, encephalitis, encephalopathy, and aseptic meningitis. “Patients can have long-lasting residual neurologic deficits from this at 6 months or longer despite appropriate treatment,” she said. “No correlation between CSF viral load and neurologic sequelae has been found at 3 months.”

More recent research has found an association between herpes zoster infection and an increased risk of stroke – up to threefold in some cases. “That risk doesn’t normalize until 6 months after the infection,” Dr. Ahronowitz said. “We’re even seeing it in kids, who have two times the risk of stroke in the first 6 months after VZV infection.” MI risk also seems to be elevated as a secondary outcome (a 1.7-fold increase in the first week of infection).

“There have also been recent reports of VZV antigen/DNA found in the vessel wall of patients with giant cell arteritis and granulomatous arteritis of the aorta,” she said. “This is an evolving story about zoster that we never knew about.”

Drug-induced hypersensitivity syndrome (DIHS) is also associated with CNS manifestations, but they resolve much faster, unlike those of CNS zoster. “As long as you take away the offending medication and put them on steroids they will recover very quickly,” she said. At least one case in the medical literature to date has reported DIHS in association with VZV (Acta Derm Venereol. 2015;95[4]:503-4).

The zoster vaccine (Zostavax, Merck & Co.) is currently indicated in patients aged 60 years and older, but since it is a live attenuated vaccine, it is contraindicated in many patients who could most benefit from it, including those with primary immunodeficiency disorders, those with a hematologic malignancy, those who have had a hematopoietic stem cell transplant within the last 2 years, pregnant patients, and patients taking high-dose steroids or anti–tumor necrosis factor biologics.

“There is an inactivated vaccine in the works being tested, and that is showing good efficacy,” Dr. Ahronowitz said. “Hopefully we’ll be able to prevaccinate patients, even young patients, prior to immune suppression.”

She reported having no relevant disclosures.

[email protected]

NEWPORT BEACH, CALIF. – Offering photodynamic therapy is a smart move for any dermatology practice, but also it requires common sense. That starts with making sure you treat only appropriate candidates.

“They can’t be intimidated by the thought of light or looking red, and you have to go into depth ahead of time as far as managing reactions, as well as long-term expectations,” Neal Bhatia, MD, said at the annual meeting of the Pacific Dermatologic Association. That includes reviewing any oral medications they’re taking, as well as topical products they may be using on their face or scalp.

“I like to do this treatment on Fridays so it gives patients the weekend to stay indoors for the next 48 hours, which is really what they need to optimize the response rate,” said Dr. Bhatia, director of clinical dermatology at Therapeutics Clinical Research in San Diego. “The other part of this is managing your staff. Make sure they have enough time to check in on the patients while they’re incubating away from light, as well as to review the post-treatment plan. And make sure they have a comfortable chair. Some patients might feel claustrophobic if you lay them down and put the light above them. Others might like to lay down for the procedure versus sitting down.”

His checklist for treatment day includes a reminder for patients to bring a wide-brimmed hat to shield the treated lesions from ambient light, as well as a book, computer, or paperwork to pass the time. He also advises putting together a take-home bag for patients that includes topical anesthetics, moisturizers, and sunscreen. In his clinical experience, prior to photodynamic therapy (PDT), there is no reason for patients to discontinue medications that are sensitizing in the UV spectrum such as antibiotics, diuretics, anti-hypertensives, since PDT works in the 410-417 nm range. “If you are concerned, you can hold the drugs the day before [the procedure], the day of, and maybe the day after, but that’s really all you need,” he said.

Dr. Bhatia discussed combinations with 5-fluorouracil (5-FU) before and after PDT, imiquimod plus aminolevulinic acid–PDT (ALA-PDT), and ingenol mebutate plus ALA-PDT. Antihistamines may play a role in helping to reduce the anticipated ALA-PDT response (J Invest Dermatol. 2006;126[10]:2296-301). Dr. Bhatia explained that the edema component is generated by mast cell release and can be uncoupled using selected H1-antihistamines, which can provide symptom relief without compromising efficacy. “Some studies talk about reducing erythema and edema based on the presence of mast cells and the surge of mast cells within first 48 to 72 hours,” he said. “Symptomatic relief is going to mean a lot to that patient who’s getting red, feeling itchy, and feeling swollen, but we don’t want to stop the reaction pattern and the efficacy by undoing what we’ve created as a response.”

It may seem counterintuitive, but direct tissue cooling after PDT appears to have a negative impact on perforin conversion, “to the point where it actually reduces the efficacy and treatment when you do direct tissue cooling,” Dr. Bhatia said. One study showed found significantly less resolution of actinic keratosis (AK) lesions treated with direct tissue cooling, compared with those who did not receive tissue cooling (J Photochem Photobiol B. 2011;103:1-7). In addition, there was a failure of conversion and optimization of the accumulated protoporphyrin IX when direct tissue cooling was used.

“That’s not to say a handheld fan or a fan in the room or aerating, making sure they have enough oxygen around the treatment area [isn’t useful],” Dr. Bhatia said. “I’m talking about the direct tissue cooling that we use with the pulsed laser device, or the Zimmer cooler. You get better conversion when you have a warming device, compared with contact cooling.”

Dr. Bhatia predicted that in the future, microneedle pre-treatment of human skin is going to gain popularity as a PDT adjunct. On early study of microneedling found that it improved 5-ALA and 5-MAL–induced protoporphyrin IX production for topical photodynamic therapy without increasing pain or erythema (Pharm Res. 2010;27[10]:2213-20). “I think that’s very important,” he said.

Dr. Bhatia disclosed having affiliations with Biofrontera and Dusa, the two main manufacturers of PDT in the United States.

[email protected]

NEWPORT BEACH, CALIF. – Offering photodynamic therapy is a smart move for any dermatology practice, but also it requires common sense. That starts with making sure you treat only appropriate candidates.

“They can’t be intimidated by the thought of light or looking red, and you have to go into depth ahead of time as far as managing reactions, as well as long-term expectations,” Neal Bhatia, MD, said at the annual meeting of the Pacific Dermatologic Association. That includes reviewing any oral medications they’re taking, as well as topical products they may be using on their face or scalp.

“I like to do this treatment on Fridays so it gives patients the weekend to stay indoors for the next 48 hours, which is really what they need to optimize the response rate,” said Dr. Bhatia, director of clinical dermatology at Therapeutics Clinical Research in San Diego. “The other part of this is managing your staff. Make sure they have enough time to check in on the patients while they’re incubating away from light, as well as to review the post-treatment plan. And make sure they have a comfortable chair. Some patients might feel claustrophobic if you lay them down and put the light above them. Others might like to lay down for the procedure versus sitting down.”

His checklist for treatment day includes a reminder for patients to bring a wide-brimmed hat to shield the treated lesions from ambient light, as well as a book, computer, or paperwork to pass the time. He also advises putting together a take-home bag for patients that includes topical anesthetics, moisturizers, and sunscreen. In his clinical experience, prior to photodynamic therapy (PDT), there is no reason for patients to discontinue medications that are sensitizing in the UV spectrum such as antibiotics, diuretics, anti-hypertensives, since PDT works in the 410-417 nm range. “If you are concerned, you can hold the drugs the day before [the procedure], the day of, and maybe the day after, but that’s really all you need,” he said.

Dr. Bhatia discussed combinations with 5-fluorouracil (5-FU) before and after PDT, imiquimod plus aminolevulinic acid–PDT (ALA-PDT), and ingenol mebutate plus ALA-PDT. Antihistamines may play a role in helping to reduce the anticipated ALA-PDT response (J Invest Dermatol. 2006;126[10]:2296-301). Dr. Bhatia explained that the edema component is generated by mast cell release and can be uncoupled using selected H1-antihistamines, which can provide symptom relief without compromising efficacy. “Some studies talk about reducing erythema and edema based on the presence of mast cells and the surge of mast cells within first 48 to 72 hours,” he said. “Symptomatic relief is going to mean a lot to that patient who’s getting red, feeling itchy, and feeling swollen, but we don’t want to stop the reaction pattern and the efficacy by undoing what we’ve created as a response.”

It may seem counterintuitive, but direct tissue cooling after PDT appears to have a negative impact on perforin conversion, “to the point where it actually reduces the efficacy and treatment when you do direct tissue cooling,” Dr. Bhatia said. One study showed found significantly less resolution of actinic keratosis (AK) lesions treated with direct tissue cooling, compared with those who did not receive tissue cooling (J Photochem Photobiol B. 2011;103:1-7). In addition, there was a failure of conversion and optimization of the accumulated protoporphyrin IX when direct tissue cooling was used.

“That’s not to say a handheld fan or a fan in the room or aerating, making sure they have enough oxygen around the treatment area [isn’t useful],” Dr. Bhatia said. “I’m talking about the direct tissue cooling that we use with the pulsed laser device, or the Zimmer cooler. You get better conversion when you have a warming device, compared with contact cooling.”

Dr. Bhatia predicted that in the future, microneedle pre-treatment of human skin is going to gain popularity as a PDT adjunct. On early study of microneedling found that it improved 5-ALA and 5-MAL–induced protoporphyrin IX production for topical photodynamic therapy without increasing pain or erythema (Pharm Res. 2010;27[10]:2213-20). “I think that’s very important,” he said.

Dr. Bhatia disclosed having affiliations with Biofrontera and Dusa, the two main manufacturers of PDT in the United States.

[email protected]

NEWPORT BEACH, CALIF. – Offering photodynamic therapy is a smart move for any dermatology practice, but also it requires common sense. That starts with making sure you treat only appropriate candidates.

“They can’t be intimidated by the thought of light or looking red, and you have to go into depth ahead of time as far as managing reactions, as well as long-term expectations,” Neal Bhatia, MD, said at the annual meeting of the Pacific Dermatologic Association. That includes reviewing any oral medications they’re taking, as well as topical products they may be using on their face or scalp.

“I like to do this treatment on Fridays so it gives patients the weekend to stay indoors for the next 48 hours, which is really what they need to optimize the response rate,” said Dr. Bhatia, director of clinical dermatology at Therapeutics Clinical Research in San Diego. “The other part of this is managing your staff. Make sure they have enough time to check in on the patients while they’re incubating away from light, as well as to review the post-treatment plan. And make sure they have a comfortable chair. Some patients might feel claustrophobic if you lay them down and put the light above them. Others might like to lay down for the procedure versus sitting down.”

His checklist for treatment day includes a reminder for patients to bring a wide-brimmed hat to shield the treated lesions from ambient light, as well as a book, computer, or paperwork to pass the time. He also advises putting together a take-home bag for patients that includes topical anesthetics, moisturizers, and sunscreen. In his clinical experience, prior to photodynamic therapy (PDT), there is no reason for patients to discontinue medications that are sensitizing in the UV spectrum such as antibiotics, diuretics, anti-hypertensives, since PDT works in the 410-417 nm range. “If you are concerned, you can hold the drugs the day before [the procedure], the day of, and maybe the day after, but that’s really all you need,” he said.

Dr. Bhatia discussed combinations with 5-fluorouracil (5-FU) before and after PDT, imiquimod plus aminolevulinic acid–PDT (ALA-PDT), and ingenol mebutate plus ALA-PDT. Antihistamines may play a role in helping to reduce the anticipated ALA-PDT response (J Invest Dermatol. 2006;126[10]:2296-301). Dr. Bhatia explained that the edema component is generated by mast cell release and can be uncoupled using selected H1-antihistamines, which can provide symptom relief without compromising efficacy. “Some studies talk about reducing erythema and edema based on the presence of mast cells and the surge of mast cells within first 48 to 72 hours,” he said. “Symptomatic relief is going to mean a lot to that patient who’s getting red, feeling itchy, and feeling swollen, but we don’t want to stop the reaction pattern and the efficacy by undoing what we’ve created as a response.”

It may seem counterintuitive, but direct tissue cooling after PDT appears to have a negative impact on perforin conversion, “to the point where it actually reduces the efficacy and treatment when you do direct tissue cooling,” Dr. Bhatia said. One study showed found significantly less resolution of actinic keratosis (AK) lesions treated with direct tissue cooling, compared with those who did not receive tissue cooling (J Photochem Photobiol B. 2011;103:1-7). In addition, there was a failure of conversion and optimization of the accumulated protoporphyrin IX when direct tissue cooling was used.

“That’s not to say a handheld fan or a fan in the room or aerating, making sure they have enough oxygen around the treatment area [isn’t useful],” Dr. Bhatia said. “I’m talking about the direct tissue cooling that we use with the pulsed laser device, or the Zimmer cooler. You get better conversion when you have a warming device, compared with contact cooling.”

Dr. Bhatia predicted that in the future, microneedle pre-treatment of human skin is going to gain popularity as a PDT adjunct. On early study of microneedling found that it improved 5-ALA and 5-MAL–induced protoporphyrin IX production for topical photodynamic therapy without increasing pain or erythema (Pharm Res. 2010;27[10]:2213-20). “I think that’s very important,” he said.

Dr. Bhatia disclosed having affiliations with Biofrontera and Dusa, the two main manufacturers of PDT in the United States.

[email protected]

NEWPORT BEACH, CALIF. – In the clinical opinion of Richard L. Gallo, MD, PhD, current nomenclature for the diagnosis of rosacea could use a makeover.

“Currently, we’re still operating with an almost 20-year-old set of diagnostic subtypes of rosacea,” Dr. Gallo said at the annual meeting of the Pacific Dermatologic Association. He plans to participate in consensus meeting of experts who will convene this fall in an effort to update and modify these diagnostic criteria.

According to current nomenclature, subtype 1 is erythematotelangiectatic rosacea characterized by facial redness; subtype 2 is papulopustular, marked by bumps and pimples; subtype 3 is phymatous, characterized by enlargement of the nose, and subtype 4 is ocular, marked by eye irritation. Dr. Gallo pointed out that it’s rare to see just one of these subtypes in rosacea patients, with the exception of the erythematotelangiectatic rosacea (ETR). “There is a large population with ETR alone,” he said.” Most patients with the papulopustular subtype have aspects of ETR. There is a mix of subtypes of rosacea and we clearly need to modify our diagnostic criteria.”

Secondary rosacea features may include burning or stinging, plaque, dry appearance and scale, edema, ocular manifestations, peripheral location, and phymatous changes. Work by several researchers in recent years has shed light on the pathophysiology of rosacea. “We’re learning that there are many aspects to this disease that both trigger it and result in progression of the disease,” said Dr. Gallo, professor and chair of the department of dermatology at the University of California, San Diego. “It seems to have biological triggers that exist both in the environment and initiate from internal sources. We’re understanding more about the nature of those, at least specific molecules externally from microbes and so forth. Internally we understand more about the unique inflammatory signals.”

For example, he and other researchers began to look at the innate immune system patients with rosacea and identified LL37, a multifunction peptide that plays a role in a number of skin diseases, as something that can promote inflammation (Nat Med. 2007;13[8]:975-80). “It also promotes the vascular changes [that occur with the disease],” Dr. Gallo said. “We’re now learning how a dysregulation of enzymes in the skin contributes to making too much of these types of peptides. Therefore, treatment approaches that might modify enzymatic activity become useful.” Researchers have also discovered that some of the innate recognition molecules like toll-like receptor 2 (TLR2) are overexpressed in rosacea patients. “Similarly, in terms of the vascular signals, a number of labs are identifying some of the newer vascular transmitters that seem to be uniquely elevated in rosacea, so there’s great reason to be optimistic that given the increased specificity and understanding of what uniquely makes this disease happen, we’ll be able to target it in a safe way.”

A number of published studies have supported these notions, including an analysis of 275 twin pairs (JAMA Dermatol. 2015;151[11]:1213-9). The researchers found that compared with fraternal twins, identical twins had a higher association of National Rosacea Society scores (P = .04), “supporting the concept that there are fundamental genetic factors that are influencing disease,” Dr. Gallo said. Environmental factors found to be associated with rosacea include lifetime UV exposure, smoking, obesity, and alcohol use.

In an assessment of the genetic basis of rosacea by genome-wide association study, researchers identified one confirmed single-nucleotide polymorphism that could be associated with rosacea (J Invest Dermatol. 2015;135[6]:1548-55). It was located in an intergenic region between HLA-DRA and BTNL2, “which is consistent with the overall concept that there is perhaps a genetic abnormality that is leading to increased amino modulation of difficulties,” Dr. Gallo said. For another recent study, researchers analyzed 14 randomized or case control trials involving rosacea patients (Int J Med Sci. 2015;12[5]:387-96). They concluded that vasculature, chronic inflammatory responses, environmental triggers, food and chemicals ingested, and microorganisms either alone or in combination are responsible for rosacea.

Dr. Gallo went on to highlight findings from several studies that link rosacea to an increased risk for certain comorbidities. One, a nationwide case-control study from Taiwan that comprised 35,553 rosacea patients, found that the disease was significantly associated with a risk of certain cardiovascular comorbidities (J Acad Dermatol. 2015;73:249-54). These included dyslipidemia (OR 1.41), coronary artery disease (OR 1.35), and hypertension (OR 1.17). A separate analysis, based 93,314 participants in the Nurse’s Health Study, found that rosacea was significantly associated with a risk of coronary artery disease (OR 2.2). The researchers also observed that comorbidities seemed to increase with duration of the disease (Clin Gastroenterol Hepatol. 2016;14[2]:220-5). Another smaller case-control study of 65 patients and 65 controls found an increased risk with rosacea for coronary artery disease, hyperlipidemia, hypertension, and gastroesophageal reflux disease (J Am Acad Dermatol. 2015;73[4]:604-8).

A recent analysis of 75,088 participants in the Nurses’ Health Study found that women with rosacea faced an increased risk of thyroid cancer (HR 1.59) and basal cell carcinoma (HR 1.50; Br J Cancer 2015;113[3]:520-3). Rosacea may also impact one’s risk for developing certain neurological conditions. One study found an increased risk for dementia (HR 1.42) and Alzheimer’s disease (HR 1.92; Ann Neurol. 2016;79:921-8), while another found an increased risk for Parkinson’s disease (an adjusted incident ratio of 1.71 in patients with rosacea, compared with the referent population; JAMA Neurol. 2016;73[5]:529-34).

As for therapy, a recent Cochrane systematic review found strong evidence supporting benefits of several therapies over placebo, including metronidazole, azelaic acid, brimonidine, tetracycline, doxycycline 40 mg, ivermectin, and isotretinoin (Br J Dermatol. 2015;173[3]:651-2). A separate, 7-year retrospective study of 275 adults with rosacea published online in The Journal of Dermatology on Oct. 28, 2015, found that patients with the PPR subtype had a better overall prognosis, compared with their counterparts with the other subtypes. Overall, the median time to complete remission was 56 months. Complete remission was achieved in 46% of those with PPR subtype, compared with 19% of those with mixed subtype and 11% of those with ETR subtype.

Dr. Gallo disclosed that he has received research grants from the National Institutes of Health, Allergan, L’Oreal, Colgate-Palmolive, Regeneron, GSK, Galderma, and Bayer. He is a consultant for Allergan, Colgate-Palmolive, Sente, Matrisys, Dermata, Alnylam, Abbvie, Roche, and Promius.

[email protected]

NEWPORT BEACH, CALIF. – In the clinical opinion of Richard L. Gallo, MD, PhD, current nomenclature for the diagnosis of rosacea could use a makeover.

“Currently, we’re still operating with an almost 20-year-old set of diagnostic subtypes of rosacea,” Dr. Gallo said at the annual meeting of the Pacific Dermatologic Association. He plans to participate in consensus meeting of experts who will convene this fall in an effort to update and modify these diagnostic criteria.

According to current nomenclature, subtype 1 is erythematotelangiectatic rosacea characterized by facial redness; subtype 2 is papulopustular, marked by bumps and pimples; subtype 3 is phymatous, characterized by enlargement of the nose, and subtype 4 is ocular, marked by eye irritation. Dr. Gallo pointed out that it’s rare to see just one of these subtypes in rosacea patients, with the exception of the erythematotelangiectatic rosacea (ETR). “There is a large population with ETR alone,” he said.” Most patients with the papulopustular subtype have aspects of ETR. There is a mix of subtypes of rosacea and we clearly need to modify our diagnostic criteria.”

Secondary rosacea features may include burning or stinging, plaque, dry appearance and scale, edema, ocular manifestations, peripheral location, and phymatous changes. Work by several researchers in recent years has shed light on the pathophysiology of rosacea. “We’re learning that there are many aspects to this disease that both trigger it and result in progression of the disease,” said Dr. Gallo, professor and chair of the department of dermatology at the University of California, San Diego. “It seems to have biological triggers that exist both in the environment and initiate from internal sources. We’re understanding more about the nature of those, at least specific molecules externally from microbes and so forth. Internally we understand more about the unique inflammatory signals.”

For example, he and other researchers began to look at the innate immune system patients with rosacea and identified LL37, a multifunction peptide that plays a role in a number of skin diseases, as something that can promote inflammation (Nat Med. 2007;13[8]:975-80). “It also promotes the vascular changes [that occur with the disease],” Dr. Gallo said. “We’re now learning how a dysregulation of enzymes in the skin contributes to making too much of these types of peptides. Therefore, treatment approaches that might modify enzymatic activity become useful.” Researchers have also discovered that some of the innate recognition molecules like toll-like receptor 2 (TLR2) are overexpressed in rosacea patients. “Similarly, in terms of the vascular signals, a number of labs are identifying some of the newer vascular transmitters that seem to be uniquely elevated in rosacea, so there’s great reason to be optimistic that given the increased specificity and understanding of what uniquely makes this disease happen, we’ll be able to target it in a safe way.”

A number of published studies have supported these notions, including an analysis of 275 twin pairs (JAMA Dermatol. 2015;151[11]:1213-9). The researchers found that compared with fraternal twins, identical twins had a higher association of National Rosacea Society scores (P = .04), “supporting the concept that there are fundamental genetic factors that are influencing disease,” Dr. Gallo said. Environmental factors found to be associated with rosacea include lifetime UV exposure, smoking, obesity, and alcohol use.

In an assessment of the genetic basis of rosacea by genome-wide association study, researchers identified one confirmed single-nucleotide polymorphism that could be associated with rosacea (J Invest Dermatol. 2015;135[6]:1548-55). It was located in an intergenic region between HLA-DRA and BTNL2, “which is consistent with the overall concept that there is perhaps a genetic abnormality that is leading to increased amino modulation of difficulties,” Dr. Gallo said. For another recent study, researchers analyzed 14 randomized or case control trials involving rosacea patients (Int J Med Sci. 2015;12[5]:387-96). They concluded that vasculature, chronic inflammatory responses, environmental triggers, food and chemicals ingested, and microorganisms either alone or in combination are responsible for rosacea.

Dr. Gallo went on to highlight findings from several studies that link rosacea to an increased risk for certain comorbidities. One, a nationwide case-control study from Taiwan that comprised 35,553 rosacea patients, found that the disease was significantly associated with a risk of certain cardiovascular comorbidities (J Acad Dermatol. 2015;73:249-54). These included dyslipidemia (OR 1.41), coronary artery disease (OR 1.35), and hypertension (OR 1.17). A separate analysis, based 93,314 participants in the Nurse’s Health Study, found that rosacea was significantly associated with a risk of coronary artery disease (OR 2.2). The researchers also observed that comorbidities seemed to increase with duration of the disease (Clin Gastroenterol Hepatol. 2016;14[2]:220-5). Another smaller case-control study of 65 patients and 65 controls found an increased risk with rosacea for coronary artery disease, hyperlipidemia, hypertension, and gastroesophageal reflux disease (J Am Acad Dermatol. 2015;73[4]:604-8).

A recent analysis of 75,088 participants in the Nurses’ Health Study found that women with rosacea faced an increased risk of thyroid cancer (HR 1.59) and basal cell carcinoma (HR 1.50; Br J Cancer 2015;113[3]:520-3). Rosacea may also impact one’s risk for developing certain neurological conditions. One study found an increased risk for dementia (HR 1.42) and Alzheimer’s disease (HR 1.92; Ann Neurol. 2016;79:921-8), while another found an increased risk for Parkinson’s disease (an adjusted incident ratio of 1.71 in patients with rosacea, compared with the referent population; JAMA Neurol. 2016;73[5]:529-34).

As for therapy, a recent Cochrane systematic review found strong evidence supporting benefits of several therapies over placebo, including metronidazole, azelaic acid, brimonidine, tetracycline, doxycycline 40 mg, ivermectin, and isotretinoin (Br J Dermatol. 2015;173[3]:651-2). A separate, 7-year retrospective study of 275 adults with rosacea published online in The Journal of Dermatology on Oct. 28, 2015, found that patients with the PPR subtype had a better overall prognosis, compared with their counterparts with the other subtypes. Overall, the median time to complete remission was 56 months. Complete remission was achieved in 46% of those with PPR subtype, compared with 19% of those with mixed subtype and 11% of those with ETR subtype.

Dr. Gallo disclosed that he has received research grants from the National Institutes of Health, Allergan, L’Oreal, Colgate-Palmolive, Regeneron, GSK, Galderma, and Bayer. He is a consultant for Allergan, Colgate-Palmolive, Sente, Matrisys, Dermata, Alnylam, Abbvie, Roche, and Promius.

[email protected]

NEWPORT BEACH, CALIF. – In the clinical opinion of Richard L. Gallo, MD, PhD, current nomenclature for the diagnosis of rosacea could use a makeover.

“Currently, we’re still operating with an almost 20-year-old set of diagnostic subtypes of rosacea,” Dr. Gallo said at the annual meeting of the Pacific Dermatologic Association. He plans to participate in consensus meeting of experts who will convene this fall in an effort to update and modify these diagnostic criteria.

According to current nomenclature, subtype 1 is erythematotelangiectatic rosacea characterized by facial redness; subtype 2 is papulopustular, marked by bumps and pimples; subtype 3 is phymatous, characterized by enlargement of the nose, and subtype 4 is ocular, marked by eye irritation. Dr. Gallo pointed out that it’s rare to see just one of these subtypes in rosacea patients, with the exception of the erythematotelangiectatic rosacea (ETR). “There is a large population with ETR alone,” he said.” Most patients with the papulopustular subtype have aspects of ETR. There is a mix of subtypes of rosacea and we clearly need to modify our diagnostic criteria.”

Secondary rosacea features may include burning or stinging, plaque, dry appearance and scale, edema, ocular manifestations, peripheral location, and phymatous changes. Work by several researchers in recent years has shed light on the pathophysiology of rosacea. “We’re learning that there are many aspects to this disease that both trigger it and result in progression of the disease,” said Dr. Gallo, professor and chair of the department of dermatology at the University of California, San Diego. “It seems to have biological triggers that exist both in the environment and initiate from internal sources. We’re understanding more about the nature of those, at least specific molecules externally from microbes and so forth. Internally we understand more about the unique inflammatory signals.”

For example, he and other researchers began to look at the innate immune system patients with rosacea and identified LL37, a multifunction peptide that plays a role in a number of skin diseases, as something that can promote inflammation (Nat Med. 2007;13[8]:975-80). “It also promotes the vascular changes [that occur with the disease],” Dr. Gallo said. “We’re now learning how a dysregulation of enzymes in the skin contributes to making too much of these types of peptides. Therefore, treatment approaches that might modify enzymatic activity become useful.” Researchers have also discovered that some of the innate recognition molecules like toll-like receptor 2 (TLR2) are overexpressed in rosacea patients. “Similarly, in terms of the vascular signals, a number of labs are identifying some of the newer vascular transmitters that seem to be uniquely elevated in rosacea, so there’s great reason to be optimistic that given the increased specificity and understanding of what uniquely makes this disease happen, we’ll be able to target it in a safe way.”

A number of published studies have supported these notions, including an analysis of 275 twin pairs (JAMA Dermatol. 2015;151[11]:1213-9). The researchers found that compared with fraternal twins, identical twins had a higher association of National Rosacea Society scores (P = .04), “supporting the concept that there are fundamental genetic factors that are influencing disease,” Dr. Gallo said. Environmental factors found to be associated with rosacea include lifetime UV exposure, smoking, obesity, and alcohol use.

In an assessment of the genetic basis of rosacea by genome-wide association study, researchers identified one confirmed single-nucleotide polymorphism that could be associated with rosacea (J Invest Dermatol. 2015;135[6]:1548-55). It was located in an intergenic region between HLA-DRA and BTNL2, “which is consistent with the overall concept that there is perhaps a genetic abnormality that is leading to increased amino modulation of difficulties,” Dr. Gallo said. For another recent study, researchers analyzed 14 randomized or case control trials involving rosacea patients (Int J Med Sci. 2015;12[5]:387-96). They concluded that vasculature, chronic inflammatory responses, environmental triggers, food and chemicals ingested, and microorganisms either alone or in combination are responsible for rosacea.

Dr. Gallo went on to highlight findings from several studies that link rosacea to an increased risk for certain comorbidities. One, a nationwide case-control study from Taiwan that comprised 35,553 rosacea patients, found that the disease was significantly associated with a risk of certain cardiovascular comorbidities (J Acad Dermatol. 2015;73:249-54). These included dyslipidemia (OR 1.41), coronary artery disease (OR 1.35), and hypertension (OR 1.17). A separate analysis, based 93,314 participants in the Nurse’s Health Study, found that rosacea was significantly associated with a risk of coronary artery disease (OR 2.2). The researchers also observed that comorbidities seemed to increase with duration of the disease (Clin Gastroenterol Hepatol. 2016;14[2]:220-5). Another smaller case-control study of 65 patients and 65 controls found an increased risk with rosacea for coronary artery disease, hyperlipidemia, hypertension, and gastroesophageal reflux disease (J Am Acad Dermatol. 2015;73[4]:604-8).

A recent analysis of 75,088 participants in the Nurses’ Health Study found that women with rosacea faced an increased risk of thyroid cancer (HR 1.59) and basal cell carcinoma (HR 1.50; Br J Cancer 2015;113[3]:520-3). Rosacea may also impact one’s risk for developing certain neurological conditions. One study found an increased risk for dementia (HR 1.42) and Alzheimer’s disease (HR 1.92; Ann Neurol. 2016;79:921-8), while another found an increased risk for Parkinson’s disease (an adjusted incident ratio of 1.71 in patients with rosacea, compared with the referent population; JAMA Neurol. 2016;73[5]:529-34).

As for therapy, a recent Cochrane systematic review found strong evidence supporting benefits of several therapies over placebo, including metronidazole, azelaic acid, brimonidine, tetracycline, doxycycline 40 mg, ivermectin, and isotretinoin (Br J Dermatol. 2015;173[3]:651-2). A separate, 7-year retrospective study of 275 adults with rosacea published online in The Journal of Dermatology on Oct. 28, 2015, found that patients with the PPR subtype had a better overall prognosis, compared with their counterparts with the other subtypes. Overall, the median time to complete remission was 56 months. Complete remission was achieved in 46% of those with PPR subtype, compared with 19% of those with mixed subtype and 11% of those with ETR subtype.

Dr. Gallo disclosed that he has received research grants from the National Institutes of Health, Allergan, L’Oreal, Colgate-Palmolive, Regeneron, GSK, Galderma, and Bayer. He is a consultant for Allergan, Colgate-Palmolive, Sente, Matrisys, Dermata, Alnylam, Abbvie, Roche, and Promius.

[email protected]