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Focus on factors that can be controlled during surgery for a good cosmetic result
ORLANDO – Some is to focus on those within a surgeon’s control, Robert H. Gotkin, MD, said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
“Patients often judge the surgeon by the appearance of the scar. Not fair, but that’s what happens,” said Dr. Gotkin, director of plastic surgery at a private practice in Greenvale, N.Y.
What’s in a surgeon’s control? An accurate diagnosis, operating plan, knowledge of relevant anatomy, surgical technique, and tools for managing and modulating scars, he noted. Achieving a good cosmetic outcome starts before surgery with proper surgical planning, which includes a backup plan on “how to get out of trouble.” Visualize the ideal outcome of surgery in three dimensions, and know the relevant anatomy to help with surgical marking, as well as relevant muscular and vascular anatomy, and motor nerve danger zones, he advised. When performing facial reconstruction, reconstruct defects using the cosmetic units of the face, and place scars at the borders of cosmetic units, if possible, he said.
An order of priorities during surgery is also important. In the same way a vending machine that spits out ingredients to make a coffee in the wrong order will not result in a cup of coffee, he said, the surgical plan must be in an order that makes sense.
Tension is “one of the greatest enemies in surgery,” Dr. Gotkin said. Too much tension on a closure, for example, can cut off the blood supply and result in tissue ischemia, which could result in infection and dehiscence. It’s important to know one’s limitations during surgery and when in doubt, not to perform the surgery, he added. “Never do today what you can put off until tomorrow, because a lot of things heal and get better on their own,” he said.
Tools for good surgical outcome
A surgeon performing dermatologic procedures needs an operating room with good lighting, and a set of sharp surgical instruments. Use needle holders that do not lock, and handle needles with instruments instead of your fingers to hold the needles with just the right amount of tension, Dr. Gotkin said.
“There is no question” that palming a needle holder should not be done, he added. “Granted, this is a little dogmatic, but there is no use for palming a needle holder in surgery. It makes you much less accurate.”
Suture material is another important consideration. Surgeons have their pick of braided or monofilament sutures available in absorbable and nonabsorbable material. Absorbable sutures are made with synthetic materials such as polyglactin 910 (Vicryl), poliglecaprone 25 (Monocryl) and polydioxanone (PDS), while nonabsorbable sutures include those manufactured with polypropylene (Prolene). Nonabsorbable suture materials made of polyester and stainless steel exist, but are not commonly used in dermatologic surgery, he said.
The most common needles Dr. Gotkin uses in his practice are the Ethicon P-3, P-1, PS-2, and PS-6 types for precision point reverse cutting, and the PC-1 and PC-3 types for precision cosmetic procedures. Other needles that have similar shapes are marketed under different names, he noted. For local anesthesia, surgeons can use either lidocaine hydrochloride with epinephrine, 1% (1:100,000 u) for a rapid-onset, short-acting effect, or bupivacaine hydrochloride with epinephrine, 0.5% (1:200,000 u) for a slower-onset, long-acting effect. Dr. Gotkin recommends using a combination of both in a half-half mixture (1:150,000 epinephrine) with a buffer of sodium bicarbonate since both are acidic. Instead of stretching the skin before inserting the needle, he advised pinching or rubbing the skin to distract the patient from the injection instead of stretching the skin. Small gauge needles (such as 30-gauge or 27-gauge) are best for administering local anesthetic, he said.
Factor patient health into planning
When planning surgery, consider a patient’s comorbidities, previous surgeries, as well as current medications; those include anticoagulants or systemic steroids, which can affect the outcome of surgery. For patients who have had previous surgeries, determine whether they had any surgical complications, or experienced adverse outcomes such as keloids, hypertrophic scars, or soft tissue infections.
When planning your surgical “roadmap,” the general area of the surgery can factor into how a wound heals. Consider the vascularity of local tissues, and any tension in local tissues that can increase tension on the skin such as in the scalp, the foot, the ankle, or the back. Use the patient’s relaxed skin tension lines to minimize scarring. Since they were developed while experimenting on cadavers, the Langer lines of skin tension are not always ideal to use, and Kraissl’s lines, developed by a plastic surgeon, are a better guide for surgical planning, Dr. Gotkin said.
He also advised placing surgical markers on a patient in the way they’ll be lying during surgery. “I always tell people to crosshatch the fusiform design before surgery, because once you make the incision, they may open up and everything gets distorted, particularly when a patient’s lying down,” he said. “We have to put these markings on while the patient is sitting. Then, when you put your sutures in, you can use those lines to line everything up, so that you end up with a scar that fits in how you designed it when the patient was upright.” The rule is a 3:1 or 4:1 ratio for length/width when designing a fusiform incision for excision of a lesion.
Incisions are made perpendicular to the surface of the skin instead of beveled. “Repair in tension” rather than layers, Dr. Gotkin said. “It’s important when you put a needle in the skin, pronate so that the needle goes in at 90 degrees from the skin surface,” he explained. “Follow the curve of the needle through and supinate as you’re putting the needle through. That way, you get the right amount of tension and the right amount of tissue in the grasp of the needle.”
When tying sutures, Dr. Gotkin said he uses a hand tie in addition to an instrument tie, everting the skin edges as he closes subcuticular and cuticular sutures.
During surgery, gentle handling of tissues with forceps that have teeth, rather than a smooth surface, will help avoid crushing the skin. “That’s very important in plastic surgery, and it’s very important in any surgical procedure that you do,” he said.
These technical factors are “completely under the control of the surgeon,” but above all, a good surgical plan following an accurate diagnosis is most likely to yield the best result for patients, Dr. Gotkin said. “An architect wouldn’t build a house without blueprints, so you have to do the same thing when you’re doing surgery.”
Dr. Gotkin reported no relevant financial disclosures.
ORLANDO – Some is to focus on those within a surgeon’s control, Robert H. Gotkin, MD, said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
“Patients often judge the surgeon by the appearance of the scar. Not fair, but that’s what happens,” said Dr. Gotkin, director of plastic surgery at a private practice in Greenvale, N.Y.
What’s in a surgeon’s control? An accurate diagnosis, operating plan, knowledge of relevant anatomy, surgical technique, and tools for managing and modulating scars, he noted. Achieving a good cosmetic outcome starts before surgery with proper surgical planning, which includes a backup plan on “how to get out of trouble.” Visualize the ideal outcome of surgery in three dimensions, and know the relevant anatomy to help with surgical marking, as well as relevant muscular and vascular anatomy, and motor nerve danger zones, he advised. When performing facial reconstruction, reconstruct defects using the cosmetic units of the face, and place scars at the borders of cosmetic units, if possible, he said.
An order of priorities during surgery is also important. In the same way a vending machine that spits out ingredients to make a coffee in the wrong order will not result in a cup of coffee, he said, the surgical plan must be in an order that makes sense.
Tension is “one of the greatest enemies in surgery,” Dr. Gotkin said. Too much tension on a closure, for example, can cut off the blood supply and result in tissue ischemia, which could result in infection and dehiscence. It’s important to know one’s limitations during surgery and when in doubt, not to perform the surgery, he added. “Never do today what you can put off until tomorrow, because a lot of things heal and get better on their own,” he said.
Tools for good surgical outcome
A surgeon performing dermatologic procedures needs an operating room with good lighting, and a set of sharp surgical instruments. Use needle holders that do not lock, and handle needles with instruments instead of your fingers to hold the needles with just the right amount of tension, Dr. Gotkin said.
“There is no question” that palming a needle holder should not be done, he added. “Granted, this is a little dogmatic, but there is no use for palming a needle holder in surgery. It makes you much less accurate.”
Suture material is another important consideration. Surgeons have their pick of braided or monofilament sutures available in absorbable and nonabsorbable material. Absorbable sutures are made with synthetic materials such as polyglactin 910 (Vicryl), poliglecaprone 25 (Monocryl) and polydioxanone (PDS), while nonabsorbable sutures include those manufactured with polypropylene (Prolene). Nonabsorbable suture materials made of polyester and stainless steel exist, but are not commonly used in dermatologic surgery, he said.
The most common needles Dr. Gotkin uses in his practice are the Ethicon P-3, P-1, PS-2, and PS-6 types for precision point reverse cutting, and the PC-1 and PC-3 types for precision cosmetic procedures. Other needles that have similar shapes are marketed under different names, he noted. For local anesthesia, surgeons can use either lidocaine hydrochloride with epinephrine, 1% (1:100,000 u) for a rapid-onset, short-acting effect, or bupivacaine hydrochloride with epinephrine, 0.5% (1:200,000 u) for a slower-onset, long-acting effect. Dr. Gotkin recommends using a combination of both in a half-half mixture (1:150,000 epinephrine) with a buffer of sodium bicarbonate since both are acidic. Instead of stretching the skin before inserting the needle, he advised pinching or rubbing the skin to distract the patient from the injection instead of stretching the skin. Small gauge needles (such as 30-gauge or 27-gauge) are best for administering local anesthetic, he said.
Factor patient health into planning
When planning surgery, consider a patient’s comorbidities, previous surgeries, as well as current medications; those include anticoagulants or systemic steroids, which can affect the outcome of surgery. For patients who have had previous surgeries, determine whether they had any surgical complications, or experienced adverse outcomes such as keloids, hypertrophic scars, or soft tissue infections.
When planning your surgical “roadmap,” the general area of the surgery can factor into how a wound heals. Consider the vascularity of local tissues, and any tension in local tissues that can increase tension on the skin such as in the scalp, the foot, the ankle, or the back. Use the patient’s relaxed skin tension lines to minimize scarring. Since they were developed while experimenting on cadavers, the Langer lines of skin tension are not always ideal to use, and Kraissl’s lines, developed by a plastic surgeon, are a better guide for surgical planning, Dr. Gotkin said.
He also advised placing surgical markers on a patient in the way they’ll be lying during surgery. “I always tell people to crosshatch the fusiform design before surgery, because once you make the incision, they may open up and everything gets distorted, particularly when a patient’s lying down,” he said. “We have to put these markings on while the patient is sitting. Then, when you put your sutures in, you can use those lines to line everything up, so that you end up with a scar that fits in how you designed it when the patient was upright.” The rule is a 3:1 or 4:1 ratio for length/width when designing a fusiform incision for excision of a lesion.
Incisions are made perpendicular to the surface of the skin instead of beveled. “Repair in tension” rather than layers, Dr. Gotkin said. “It’s important when you put a needle in the skin, pronate so that the needle goes in at 90 degrees from the skin surface,” he explained. “Follow the curve of the needle through and supinate as you’re putting the needle through. That way, you get the right amount of tension and the right amount of tissue in the grasp of the needle.”
When tying sutures, Dr. Gotkin said he uses a hand tie in addition to an instrument tie, everting the skin edges as he closes subcuticular and cuticular sutures.
During surgery, gentle handling of tissues with forceps that have teeth, rather than a smooth surface, will help avoid crushing the skin. “That’s very important in plastic surgery, and it’s very important in any surgical procedure that you do,” he said.
These technical factors are “completely under the control of the surgeon,” but above all, a good surgical plan following an accurate diagnosis is most likely to yield the best result for patients, Dr. Gotkin said. “An architect wouldn’t build a house without blueprints, so you have to do the same thing when you’re doing surgery.”
Dr. Gotkin reported no relevant financial disclosures.
ORLANDO – Some is to focus on those within a surgeon’s control, Robert H. Gotkin, MD, said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
“Patients often judge the surgeon by the appearance of the scar. Not fair, but that’s what happens,” said Dr. Gotkin, director of plastic surgery at a private practice in Greenvale, N.Y.
What’s in a surgeon’s control? An accurate diagnosis, operating plan, knowledge of relevant anatomy, surgical technique, and tools for managing and modulating scars, he noted. Achieving a good cosmetic outcome starts before surgery with proper surgical planning, which includes a backup plan on “how to get out of trouble.” Visualize the ideal outcome of surgery in three dimensions, and know the relevant anatomy to help with surgical marking, as well as relevant muscular and vascular anatomy, and motor nerve danger zones, he advised. When performing facial reconstruction, reconstruct defects using the cosmetic units of the face, and place scars at the borders of cosmetic units, if possible, he said.
An order of priorities during surgery is also important. In the same way a vending machine that spits out ingredients to make a coffee in the wrong order will not result in a cup of coffee, he said, the surgical plan must be in an order that makes sense.
Tension is “one of the greatest enemies in surgery,” Dr. Gotkin said. Too much tension on a closure, for example, can cut off the blood supply and result in tissue ischemia, which could result in infection and dehiscence. It’s important to know one’s limitations during surgery and when in doubt, not to perform the surgery, he added. “Never do today what you can put off until tomorrow, because a lot of things heal and get better on their own,” he said.
Tools for good surgical outcome
A surgeon performing dermatologic procedures needs an operating room with good lighting, and a set of sharp surgical instruments. Use needle holders that do not lock, and handle needles with instruments instead of your fingers to hold the needles with just the right amount of tension, Dr. Gotkin said.
“There is no question” that palming a needle holder should not be done, he added. “Granted, this is a little dogmatic, but there is no use for palming a needle holder in surgery. It makes you much less accurate.”
Suture material is another important consideration. Surgeons have their pick of braided or monofilament sutures available in absorbable and nonabsorbable material. Absorbable sutures are made with synthetic materials such as polyglactin 910 (Vicryl), poliglecaprone 25 (Monocryl) and polydioxanone (PDS), while nonabsorbable sutures include those manufactured with polypropylene (Prolene). Nonabsorbable suture materials made of polyester and stainless steel exist, but are not commonly used in dermatologic surgery, he said.
The most common needles Dr. Gotkin uses in his practice are the Ethicon P-3, P-1, PS-2, and PS-6 types for precision point reverse cutting, and the PC-1 and PC-3 types for precision cosmetic procedures. Other needles that have similar shapes are marketed under different names, he noted. For local anesthesia, surgeons can use either lidocaine hydrochloride with epinephrine, 1% (1:100,000 u) for a rapid-onset, short-acting effect, or bupivacaine hydrochloride with epinephrine, 0.5% (1:200,000 u) for a slower-onset, long-acting effect. Dr. Gotkin recommends using a combination of both in a half-half mixture (1:150,000 epinephrine) with a buffer of sodium bicarbonate since both are acidic. Instead of stretching the skin before inserting the needle, he advised pinching or rubbing the skin to distract the patient from the injection instead of stretching the skin. Small gauge needles (such as 30-gauge or 27-gauge) are best for administering local anesthetic, he said.
Factor patient health into planning
When planning surgery, consider a patient’s comorbidities, previous surgeries, as well as current medications; those include anticoagulants or systemic steroids, which can affect the outcome of surgery. For patients who have had previous surgeries, determine whether they had any surgical complications, or experienced adverse outcomes such as keloids, hypertrophic scars, or soft tissue infections.
When planning your surgical “roadmap,” the general area of the surgery can factor into how a wound heals. Consider the vascularity of local tissues, and any tension in local tissues that can increase tension on the skin such as in the scalp, the foot, the ankle, or the back. Use the patient’s relaxed skin tension lines to minimize scarring. Since they were developed while experimenting on cadavers, the Langer lines of skin tension are not always ideal to use, and Kraissl’s lines, developed by a plastic surgeon, are a better guide for surgical planning, Dr. Gotkin said.
He also advised placing surgical markers on a patient in the way they’ll be lying during surgery. “I always tell people to crosshatch the fusiform design before surgery, because once you make the incision, they may open up and everything gets distorted, particularly when a patient’s lying down,” he said. “We have to put these markings on while the patient is sitting. Then, when you put your sutures in, you can use those lines to line everything up, so that you end up with a scar that fits in how you designed it when the patient was upright.” The rule is a 3:1 or 4:1 ratio for length/width when designing a fusiform incision for excision of a lesion.
Incisions are made perpendicular to the surface of the skin instead of beveled. “Repair in tension” rather than layers, Dr. Gotkin said. “It’s important when you put a needle in the skin, pronate so that the needle goes in at 90 degrees from the skin surface,” he explained. “Follow the curve of the needle through and supinate as you’re putting the needle through. That way, you get the right amount of tension and the right amount of tissue in the grasp of the needle.”
When tying sutures, Dr. Gotkin said he uses a hand tie in addition to an instrument tie, everting the skin edges as he closes subcuticular and cuticular sutures.
During surgery, gentle handling of tissues with forceps that have teeth, rather than a smooth surface, will help avoid crushing the skin. “That’s very important in plastic surgery, and it’s very important in any surgical procedure that you do,” he said.
These technical factors are “completely under the control of the surgeon,” but above all, a good surgical plan following an accurate diagnosis is most likely to yield the best result for patients, Dr. Gotkin said. “An architect wouldn’t build a house without blueprints, so you have to do the same thing when you’re doing surgery.”
Dr. Gotkin reported no relevant financial disclosures.
EXPERT ANALYSIS FROM ODAC 2020
‘Natural is not always good’ when it comes to treatments for alopecia
ORLANDO – Biotin is the most popular consumer supplement for alopecia and highly popular online, but should patients be taking it?
Patients may want something “natural” to treat their hair loss, but “natural is not always good,” Amy McMichael, MD, professor and chair of the department of dermatology at Wake Forest Baptist Health, Winston-Salem, N.C., said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
Dosages of commercially available biotin supplements can vary significantly, with some doses as high as 10,000 mcg, making supraphysiological dosing possible. Dr. McMichael said that, not only is biotin unlikely to help with a patient’s alopecia, but a high intake of biotin can interfere with certain assays that use streptavidin-biotin capture techniques (Clin Chem Lab Med. 2017 May 1;55[6]:817-25). This could present a problem for a patient who experiences an MI or has a thyroid disorder where a high level of biotin could affect lab results, she noted.
Dr. McMichael advises patients that there is a
Questioning side effects of 5-alpha reductase inhibitors
Research in the early 2010s associated the 5-alpha reductase inhibitor finasteride with persistent sexual side effects and depression. But a later meta-analysis of the Prostate Cancer Prevention Trial and other trials did not find evidence of persistent sexual side effects or depression in men on finasteride, and the authors said that double-blind, placebo-controlled studies were needed (J Clin Aesthet Dermatol. 2014 Dec;7[12]:51-5).
However, two meta-analyses of 34 clinical trials published in 2015 found that none of the clinical trials evaluating finasteride treatment in patients with androgenic alopecia had accurate safety reporting (JAMA Dermatol. 2015 Jun;151[6]:600-6). Another study published by the same group in 2017 found that 0.8% of men aged 16-42 years to exposed to a 5-alpha reductase inhibitor developed persistent erectile dysfunction after a longer duration of exposure (median, 1,534 days). compared with a shorter duration of exposure (PeerJ. 2017 Mar 9;5:e3020).
The bottom line when considering use of 5-alpha reductase inhibitors in men is to discuss the outlier data on persistent sexual dysfunction in the studies, ask patients whether they have a history of sexual dysfunction and depression, and then only treat appropriate patients with no such history, Dr. McMichael said.
Use of 5-alpha reductase inhibitors also appears to be related to an increased risk of type 2 diabetes in men with benign prostatic hyperplasia, according to more recent data. In a study of patients in the U.K. Clinical Practice Research Datalink and Taiwanese National Health Insurance Research Database who received dutasteride, finasteride, or the alpha blocker tamsulosin, there was a slightly increased risk of type 2 diabetes among those who took the two 5-alpha reductase inhibitors, compared with those on tamsulosin (BMJ. 2019;365:l1204). In light of these results, Dr. McMichael advised clinicians to be aware of these risks and to consider screening patients for type 2 diabetes and ask them about their family history, but the results shouldn’t affect patients at risk for type 2 diabetes or metabolic disorder.
JAK inhibitors for alopecia areata
Within the past few years, promising results for Janus kinase (JAK) inhibitors like tofacitinib and ruxolitinib for alopecia areata have been reported, but they are currently not a first-line therapy, Dr. McMichael said. Consider methotrexate first in older adolescents and adults with more than 50% hair loss, followed by a JAK inhibitor if there is no improvement or methotrexate is not tolerated well.
Clinicians can consider enrolling their patients in a clinical trial to give them access to JAK inhibitors as a treatment option, she noted, and if a trial is not available, it may be worth appealing to an insurance company using an article titled “Alopecia areata is a medical disease” coauthored by Dr. McMichael and others (Am Acad Dermatol. 2018 Apr;78[4]:832-4). After two denials by insurance, the manufacturer’s patient assistance program (Xelsource) may be helpful in obtaining tofacitinib (Xeljanz) through a letter and references. There are adolescent data on JAK inhibitors for alopecia, but “absolutely no data” in very young children, so prior to adolescence, she would not recommend this treatment. In a study of 13 adolescents with alopecia areata, totalis, or universalis, those treated with tofacitinib for a mean of 6.5 months, 9 had significant hair regrowth with treatment and adverse events were mild (J Am Acad Dermatol. 2017 Jan;76[1]:29-32).
Dr. McMichael reports being an investigator for Allergan, Intendis, Proctor & Gamble, Samumed, Cassiopia, Concert, Aclaris, and Incyte; and is a consultant for Johnson & Johnson, Proctor & Gamble, Allergan, Bayer, Galderma, Incyte, Samumed, Aclaris, Anacor, Pfizer, Nutrafol, Bioniz, and Almirall.
ORLANDO – Biotin is the most popular consumer supplement for alopecia and highly popular online, but should patients be taking it?
Patients may want something “natural” to treat their hair loss, but “natural is not always good,” Amy McMichael, MD, professor and chair of the department of dermatology at Wake Forest Baptist Health, Winston-Salem, N.C., said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
Dosages of commercially available biotin supplements can vary significantly, with some doses as high as 10,000 mcg, making supraphysiological dosing possible. Dr. McMichael said that, not only is biotin unlikely to help with a patient’s alopecia, but a high intake of biotin can interfere with certain assays that use streptavidin-biotin capture techniques (Clin Chem Lab Med. 2017 May 1;55[6]:817-25). This could present a problem for a patient who experiences an MI or has a thyroid disorder where a high level of biotin could affect lab results, she noted.
Dr. McMichael advises patients that there is a
Questioning side effects of 5-alpha reductase inhibitors
Research in the early 2010s associated the 5-alpha reductase inhibitor finasteride with persistent sexual side effects and depression. But a later meta-analysis of the Prostate Cancer Prevention Trial and other trials did not find evidence of persistent sexual side effects or depression in men on finasteride, and the authors said that double-blind, placebo-controlled studies were needed (J Clin Aesthet Dermatol. 2014 Dec;7[12]:51-5).
However, two meta-analyses of 34 clinical trials published in 2015 found that none of the clinical trials evaluating finasteride treatment in patients with androgenic alopecia had accurate safety reporting (JAMA Dermatol. 2015 Jun;151[6]:600-6). Another study published by the same group in 2017 found that 0.8% of men aged 16-42 years to exposed to a 5-alpha reductase inhibitor developed persistent erectile dysfunction after a longer duration of exposure (median, 1,534 days). compared with a shorter duration of exposure (PeerJ. 2017 Mar 9;5:e3020).
The bottom line when considering use of 5-alpha reductase inhibitors in men is to discuss the outlier data on persistent sexual dysfunction in the studies, ask patients whether they have a history of sexual dysfunction and depression, and then only treat appropriate patients with no such history, Dr. McMichael said.
Use of 5-alpha reductase inhibitors also appears to be related to an increased risk of type 2 diabetes in men with benign prostatic hyperplasia, according to more recent data. In a study of patients in the U.K. Clinical Practice Research Datalink and Taiwanese National Health Insurance Research Database who received dutasteride, finasteride, or the alpha blocker tamsulosin, there was a slightly increased risk of type 2 diabetes among those who took the two 5-alpha reductase inhibitors, compared with those on tamsulosin (BMJ. 2019;365:l1204). In light of these results, Dr. McMichael advised clinicians to be aware of these risks and to consider screening patients for type 2 diabetes and ask them about their family history, but the results shouldn’t affect patients at risk for type 2 diabetes or metabolic disorder.
JAK inhibitors for alopecia areata
Within the past few years, promising results for Janus kinase (JAK) inhibitors like tofacitinib and ruxolitinib for alopecia areata have been reported, but they are currently not a first-line therapy, Dr. McMichael said. Consider methotrexate first in older adolescents and adults with more than 50% hair loss, followed by a JAK inhibitor if there is no improvement or methotrexate is not tolerated well.
Clinicians can consider enrolling their patients in a clinical trial to give them access to JAK inhibitors as a treatment option, she noted, and if a trial is not available, it may be worth appealing to an insurance company using an article titled “Alopecia areata is a medical disease” coauthored by Dr. McMichael and others (Am Acad Dermatol. 2018 Apr;78[4]:832-4). After two denials by insurance, the manufacturer’s patient assistance program (Xelsource) may be helpful in obtaining tofacitinib (Xeljanz) through a letter and references. There are adolescent data on JAK inhibitors for alopecia, but “absolutely no data” in very young children, so prior to adolescence, she would not recommend this treatment. In a study of 13 adolescents with alopecia areata, totalis, or universalis, those treated with tofacitinib for a mean of 6.5 months, 9 had significant hair regrowth with treatment and adverse events were mild (J Am Acad Dermatol. 2017 Jan;76[1]:29-32).
Dr. McMichael reports being an investigator for Allergan, Intendis, Proctor & Gamble, Samumed, Cassiopia, Concert, Aclaris, and Incyte; and is a consultant for Johnson & Johnson, Proctor & Gamble, Allergan, Bayer, Galderma, Incyte, Samumed, Aclaris, Anacor, Pfizer, Nutrafol, Bioniz, and Almirall.
ORLANDO – Biotin is the most popular consumer supplement for alopecia and highly popular online, but should patients be taking it?
Patients may want something “natural” to treat their hair loss, but “natural is not always good,” Amy McMichael, MD, professor and chair of the department of dermatology at Wake Forest Baptist Health, Winston-Salem, N.C., said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
Dosages of commercially available biotin supplements can vary significantly, with some doses as high as 10,000 mcg, making supraphysiological dosing possible. Dr. McMichael said that, not only is biotin unlikely to help with a patient’s alopecia, but a high intake of biotin can interfere with certain assays that use streptavidin-biotin capture techniques (Clin Chem Lab Med. 2017 May 1;55[6]:817-25). This could present a problem for a patient who experiences an MI or has a thyroid disorder where a high level of biotin could affect lab results, she noted.
Dr. McMichael advises patients that there is a
Questioning side effects of 5-alpha reductase inhibitors
Research in the early 2010s associated the 5-alpha reductase inhibitor finasteride with persistent sexual side effects and depression. But a later meta-analysis of the Prostate Cancer Prevention Trial and other trials did not find evidence of persistent sexual side effects or depression in men on finasteride, and the authors said that double-blind, placebo-controlled studies were needed (J Clin Aesthet Dermatol. 2014 Dec;7[12]:51-5).
However, two meta-analyses of 34 clinical trials published in 2015 found that none of the clinical trials evaluating finasteride treatment in patients with androgenic alopecia had accurate safety reporting (JAMA Dermatol. 2015 Jun;151[6]:600-6). Another study published by the same group in 2017 found that 0.8% of men aged 16-42 years to exposed to a 5-alpha reductase inhibitor developed persistent erectile dysfunction after a longer duration of exposure (median, 1,534 days). compared with a shorter duration of exposure (PeerJ. 2017 Mar 9;5:e3020).
The bottom line when considering use of 5-alpha reductase inhibitors in men is to discuss the outlier data on persistent sexual dysfunction in the studies, ask patients whether they have a history of sexual dysfunction and depression, and then only treat appropriate patients with no such history, Dr. McMichael said.
Use of 5-alpha reductase inhibitors also appears to be related to an increased risk of type 2 diabetes in men with benign prostatic hyperplasia, according to more recent data. In a study of patients in the U.K. Clinical Practice Research Datalink and Taiwanese National Health Insurance Research Database who received dutasteride, finasteride, or the alpha blocker tamsulosin, there was a slightly increased risk of type 2 diabetes among those who took the two 5-alpha reductase inhibitors, compared with those on tamsulosin (BMJ. 2019;365:l1204). In light of these results, Dr. McMichael advised clinicians to be aware of these risks and to consider screening patients for type 2 diabetes and ask them about their family history, but the results shouldn’t affect patients at risk for type 2 diabetes or metabolic disorder.
JAK inhibitors for alopecia areata
Within the past few years, promising results for Janus kinase (JAK) inhibitors like tofacitinib and ruxolitinib for alopecia areata have been reported, but they are currently not a first-line therapy, Dr. McMichael said. Consider methotrexate first in older adolescents and adults with more than 50% hair loss, followed by a JAK inhibitor if there is no improvement or methotrexate is not tolerated well.
Clinicians can consider enrolling their patients in a clinical trial to give them access to JAK inhibitors as a treatment option, she noted, and if a trial is not available, it may be worth appealing to an insurance company using an article titled “Alopecia areata is a medical disease” coauthored by Dr. McMichael and others (Am Acad Dermatol. 2018 Apr;78[4]:832-4). After two denials by insurance, the manufacturer’s patient assistance program (Xelsource) may be helpful in obtaining tofacitinib (Xeljanz) through a letter and references. There are adolescent data on JAK inhibitors for alopecia, but “absolutely no data” in very young children, so prior to adolescence, she would not recommend this treatment. In a study of 13 adolescents with alopecia areata, totalis, or universalis, those treated with tofacitinib for a mean of 6.5 months, 9 had significant hair regrowth with treatment and adverse events were mild (J Am Acad Dermatol. 2017 Jan;76[1]:29-32).
Dr. McMichael reports being an investigator for Allergan, Intendis, Proctor & Gamble, Samumed, Cassiopia, Concert, Aclaris, and Incyte; and is a consultant for Johnson & Johnson, Proctor & Gamble, Allergan, Bayer, Galderma, Incyte, Samumed, Aclaris, Anacor, Pfizer, Nutrafol, Bioniz, and Almirall.
EXPERT ANALYSIS FROM ODAC 2020
Consider allergic contact dermatitis in children with AD with disease flares, new rash
ORLANDO – Do you have ? Consider patch testing to assess whether they have allergic contact dermatitis.
“Of the patients who are sent to me by local pediatric dermatologists, 50% of them are positive” for allergens, said Jonathan H. Zippin, MD, PhD, director of the contact, occupational, and photodermatitis service at Cornell University, New York.
Speaking at the ODAC Dermatology, Aesthetic, and Surgical Conference, Dr. Zippin noted the prevalence of allergen sensitization is between 13% and 25% among children who are asymptomatic, while the prevalence of sensitization to at least one allergen among children with suspected allergic contact dermatitis (ACD) is between 25% and 96%. In 2014, a study from the National American Contact Dermatitis Group (NACDG) showed that of 883 children who were patch tested, 56.7% had at least one relevant positive patch test (RPPT) result.
“The take-home message here is that pediatric contact dermatitis is common, much more common than a lot of people realize,” Dr. Zippin said.
He described three common scenarios to keep in mind: a worsening rash, a new rash, and failure of a rash to improve after the patient avoids all of his or her positive allergens.
When a rash worsens, patch testing is likely to offer answers. In an analysis of 1,142 patients with suspected ACD aged 18 years or younger (mean age, 10.5 years; 64% female) in the Pediatric Contact Dermatitis Registry study database, 65% had at least one positive patch test, and 48% had at least 1 RPPT (Dermatitis 2016; 27[5] 293-302).
But not all patch testing is the same: The study also found that 24% of the RPPT cases would have been missed if assessed with the T.R.U.E. TEST compared with extended patch testing. If a T.R.U.E. TEST fails to explain generalized atopic dermatitis, the patient should be sent for more comprehensive testing where available, Dr. Zippin advised.
Pediatric patients also have unique allergens clinicians should consider. In the same study, children had a number of allergens similar to those of adults as reported in previous studies, such as nickel, cobalt, and neomycin. However, propylene glycol and cocamidopropyl betaine were allergens identified as unique to the pediatric population.
Another study looking at the same group of patients found that compared with children who did not have AD, children with AD had 7.4 times higher odds of having an RPPT to cocamidopropyl betaine, 7.6 times higher odds of having an RPPT to parthenolide, 5.3 times higher odds of having an RPPT to tixocortol pivalate, 4.2 times higher odds of having an RPPT to wool alcohols, and 4 times higher odds of having an RPPT to lanolin (JAMA Dermatology 2017;153[8]:765-70).
All of these are components of topical medicaments used to treat AD, “either components of emollients that we recommend, or components of steroids that we recommend,” Dr. Zippin pointed out.
One of these allergens could be the culprit when a child develops a new rash but there are no new apparent changes in products, exposures, and activities. Lanolin, also called wool grease, is used in many skin care products, for example. Dr. Zippin described the case of a 6-year-old girl with a history of AD, who presented with a new rash on her scalp and behind her ears, not explained by any obvious changes to products, exposures, or activities. Subsequent patch testing determined that the rash was caused by baby shampoo, which contained cocamidopropyl betaine, which is used in hypoallergenic products. The rash resolved after a different shampoo was used.
“Sometimes, we really have to be thinking when the rash is getting worse, is there something they’re being exposed to that might be an allergen?” Dr. Zippin said.
In patients who have avoided all their positive allergens but a rash has not improved, clinicians should consider systemic contact dermatitis (SCD). Patients can develop SCD through different types of exposures, including transepidermal, transmucosal, oral, intravenous, subcutaneous, intramuscular, inhalation, and implantation routes.
SCD also has a variety of presentations, including pompholyx/dyshidrosis/vesicular dermatitis, maculopapular eruption, chronic pruritus, exfoliative erythroderma/toxiderma, chronic urticaria, erythema multiforme and vasculitis, hyperkeratotic papules of the elbows, acute generalized exanthematous pustulosis, and pruritus ani, according to Dr. Zippin.
SCD should be considered when a patient has a positive patch test to an allergen that is known to cause SCD, and does not clear after avoiding cutaneous exposure to the allergen, Dr. Zippin advised.
Patients will most often develop SCD from plants and herbs, Dr. Zippin noted. Chrysanthemums and chamomile tea are common culprits for compositae allergy and can trigger SCD; other causes are Anacardiaceae, Balsam of Peru, and propolis. Metals (nickel, cobalt, gold, and chromium), medications (aminoglycosides, corticosteroids, and ethylenediamine), and other sources (formaldehyde, propylene glycol in frozen foods, gallates, and methylisothiazolinone) can cause SCD as well.
Methylisothiazolinone in particular is a very common sensitizer, Dr. Zippin said. “If you have a patient who is positive to this, it’s almost always the cause of their problem.”
Balsam of Peru is in a number of different foods, and patients who need to follow a diet free of Balsam of Peru should avoid a long list of foods including citrus; bakery goods; Danish pastry; candy; gum; spices such as cinnamon, cloves, vanilla, curry, allspice, anise, and ginger; spicy condiments such as ketchup, chili sauce, barbecue sauce; chili, pizza, and foods with red sauces; tomatoes; pickles; alcohol (wine, beer, gin, vermouth); tea (perfumed or flavored); tobacco; chocolate and ice cream; and soft drinks (cola or spiced soft drinks).
Patients starting a nickel-free diet should avoid soy, peanuts and other nuts, legumes, chocolate, cocoa, oats, fish, and whole wheat flours. Any elimination diet should last for 3 months but should at least be tried for 3-4 weeks, with gradual reintroduction of foods suspected as triggers once per week. Any type I allergies that are discovered or suspected can be referred to an allergist for allergen challenge and desensitization therapy.
For more information, Dr. Zippin recommended the American Contact Dermatitis Society website for more information.
Dr. Zippin reported that he is the founder and holds stock options at CEP Biotech; is on the medical advisory board and receives stock options from YouV Labs., is a paid consultant and performs industry-sponsored research for Pfizer, receives stock options from Regeneron, and is on the medical advisory board for Hoth Therapeutics Inc. He is on the board of directors for the American Contact Dermatitis Society.
ORLANDO – Do you have ? Consider patch testing to assess whether they have allergic contact dermatitis.
“Of the patients who are sent to me by local pediatric dermatologists, 50% of them are positive” for allergens, said Jonathan H. Zippin, MD, PhD, director of the contact, occupational, and photodermatitis service at Cornell University, New York.
Speaking at the ODAC Dermatology, Aesthetic, and Surgical Conference, Dr. Zippin noted the prevalence of allergen sensitization is between 13% and 25% among children who are asymptomatic, while the prevalence of sensitization to at least one allergen among children with suspected allergic contact dermatitis (ACD) is between 25% and 96%. In 2014, a study from the National American Contact Dermatitis Group (NACDG) showed that of 883 children who were patch tested, 56.7% had at least one relevant positive patch test (RPPT) result.
“The take-home message here is that pediatric contact dermatitis is common, much more common than a lot of people realize,” Dr. Zippin said.
He described three common scenarios to keep in mind: a worsening rash, a new rash, and failure of a rash to improve after the patient avoids all of his or her positive allergens.
When a rash worsens, patch testing is likely to offer answers. In an analysis of 1,142 patients with suspected ACD aged 18 years or younger (mean age, 10.5 years; 64% female) in the Pediatric Contact Dermatitis Registry study database, 65% had at least one positive patch test, and 48% had at least 1 RPPT (Dermatitis 2016; 27[5] 293-302).
But not all patch testing is the same: The study also found that 24% of the RPPT cases would have been missed if assessed with the T.R.U.E. TEST compared with extended patch testing. If a T.R.U.E. TEST fails to explain generalized atopic dermatitis, the patient should be sent for more comprehensive testing where available, Dr. Zippin advised.
Pediatric patients also have unique allergens clinicians should consider. In the same study, children had a number of allergens similar to those of adults as reported in previous studies, such as nickel, cobalt, and neomycin. However, propylene glycol and cocamidopropyl betaine were allergens identified as unique to the pediatric population.
Another study looking at the same group of patients found that compared with children who did not have AD, children with AD had 7.4 times higher odds of having an RPPT to cocamidopropyl betaine, 7.6 times higher odds of having an RPPT to parthenolide, 5.3 times higher odds of having an RPPT to tixocortol pivalate, 4.2 times higher odds of having an RPPT to wool alcohols, and 4 times higher odds of having an RPPT to lanolin (JAMA Dermatology 2017;153[8]:765-70).
All of these are components of topical medicaments used to treat AD, “either components of emollients that we recommend, or components of steroids that we recommend,” Dr. Zippin pointed out.
One of these allergens could be the culprit when a child develops a new rash but there are no new apparent changes in products, exposures, and activities. Lanolin, also called wool grease, is used in many skin care products, for example. Dr. Zippin described the case of a 6-year-old girl with a history of AD, who presented with a new rash on her scalp and behind her ears, not explained by any obvious changes to products, exposures, or activities. Subsequent patch testing determined that the rash was caused by baby shampoo, which contained cocamidopropyl betaine, which is used in hypoallergenic products. The rash resolved after a different shampoo was used.
“Sometimes, we really have to be thinking when the rash is getting worse, is there something they’re being exposed to that might be an allergen?” Dr. Zippin said.
In patients who have avoided all their positive allergens but a rash has not improved, clinicians should consider systemic contact dermatitis (SCD). Patients can develop SCD through different types of exposures, including transepidermal, transmucosal, oral, intravenous, subcutaneous, intramuscular, inhalation, and implantation routes.
SCD also has a variety of presentations, including pompholyx/dyshidrosis/vesicular dermatitis, maculopapular eruption, chronic pruritus, exfoliative erythroderma/toxiderma, chronic urticaria, erythema multiforme and vasculitis, hyperkeratotic papules of the elbows, acute generalized exanthematous pustulosis, and pruritus ani, according to Dr. Zippin.
SCD should be considered when a patient has a positive patch test to an allergen that is known to cause SCD, and does not clear after avoiding cutaneous exposure to the allergen, Dr. Zippin advised.
Patients will most often develop SCD from plants and herbs, Dr. Zippin noted. Chrysanthemums and chamomile tea are common culprits for compositae allergy and can trigger SCD; other causes are Anacardiaceae, Balsam of Peru, and propolis. Metals (nickel, cobalt, gold, and chromium), medications (aminoglycosides, corticosteroids, and ethylenediamine), and other sources (formaldehyde, propylene glycol in frozen foods, gallates, and methylisothiazolinone) can cause SCD as well.
Methylisothiazolinone in particular is a very common sensitizer, Dr. Zippin said. “If you have a patient who is positive to this, it’s almost always the cause of their problem.”
Balsam of Peru is in a number of different foods, and patients who need to follow a diet free of Balsam of Peru should avoid a long list of foods including citrus; bakery goods; Danish pastry; candy; gum; spices such as cinnamon, cloves, vanilla, curry, allspice, anise, and ginger; spicy condiments such as ketchup, chili sauce, barbecue sauce; chili, pizza, and foods with red sauces; tomatoes; pickles; alcohol (wine, beer, gin, vermouth); tea (perfumed or flavored); tobacco; chocolate and ice cream; and soft drinks (cola or spiced soft drinks).
Patients starting a nickel-free diet should avoid soy, peanuts and other nuts, legumes, chocolate, cocoa, oats, fish, and whole wheat flours. Any elimination diet should last for 3 months but should at least be tried for 3-4 weeks, with gradual reintroduction of foods suspected as triggers once per week. Any type I allergies that are discovered or suspected can be referred to an allergist for allergen challenge and desensitization therapy.
For more information, Dr. Zippin recommended the American Contact Dermatitis Society website for more information.
Dr. Zippin reported that he is the founder and holds stock options at CEP Biotech; is on the medical advisory board and receives stock options from YouV Labs., is a paid consultant and performs industry-sponsored research for Pfizer, receives stock options from Regeneron, and is on the medical advisory board for Hoth Therapeutics Inc. He is on the board of directors for the American Contact Dermatitis Society.
ORLANDO – Do you have ? Consider patch testing to assess whether they have allergic contact dermatitis.
“Of the patients who are sent to me by local pediatric dermatologists, 50% of them are positive” for allergens, said Jonathan H. Zippin, MD, PhD, director of the contact, occupational, and photodermatitis service at Cornell University, New York.
Speaking at the ODAC Dermatology, Aesthetic, and Surgical Conference, Dr. Zippin noted the prevalence of allergen sensitization is between 13% and 25% among children who are asymptomatic, while the prevalence of sensitization to at least one allergen among children with suspected allergic contact dermatitis (ACD) is between 25% and 96%. In 2014, a study from the National American Contact Dermatitis Group (NACDG) showed that of 883 children who were patch tested, 56.7% had at least one relevant positive patch test (RPPT) result.
“The take-home message here is that pediatric contact dermatitis is common, much more common than a lot of people realize,” Dr. Zippin said.
He described three common scenarios to keep in mind: a worsening rash, a new rash, and failure of a rash to improve after the patient avoids all of his or her positive allergens.
When a rash worsens, patch testing is likely to offer answers. In an analysis of 1,142 patients with suspected ACD aged 18 years or younger (mean age, 10.5 years; 64% female) in the Pediatric Contact Dermatitis Registry study database, 65% had at least one positive patch test, and 48% had at least 1 RPPT (Dermatitis 2016; 27[5] 293-302).
But not all patch testing is the same: The study also found that 24% of the RPPT cases would have been missed if assessed with the T.R.U.E. TEST compared with extended patch testing. If a T.R.U.E. TEST fails to explain generalized atopic dermatitis, the patient should be sent for more comprehensive testing where available, Dr. Zippin advised.
Pediatric patients also have unique allergens clinicians should consider. In the same study, children had a number of allergens similar to those of adults as reported in previous studies, such as nickel, cobalt, and neomycin. However, propylene glycol and cocamidopropyl betaine were allergens identified as unique to the pediatric population.
Another study looking at the same group of patients found that compared with children who did not have AD, children with AD had 7.4 times higher odds of having an RPPT to cocamidopropyl betaine, 7.6 times higher odds of having an RPPT to parthenolide, 5.3 times higher odds of having an RPPT to tixocortol pivalate, 4.2 times higher odds of having an RPPT to wool alcohols, and 4 times higher odds of having an RPPT to lanolin (JAMA Dermatology 2017;153[8]:765-70).
All of these are components of topical medicaments used to treat AD, “either components of emollients that we recommend, or components of steroids that we recommend,” Dr. Zippin pointed out.
One of these allergens could be the culprit when a child develops a new rash but there are no new apparent changes in products, exposures, and activities. Lanolin, also called wool grease, is used in many skin care products, for example. Dr. Zippin described the case of a 6-year-old girl with a history of AD, who presented with a new rash on her scalp and behind her ears, not explained by any obvious changes to products, exposures, or activities. Subsequent patch testing determined that the rash was caused by baby shampoo, which contained cocamidopropyl betaine, which is used in hypoallergenic products. The rash resolved after a different shampoo was used.
“Sometimes, we really have to be thinking when the rash is getting worse, is there something they’re being exposed to that might be an allergen?” Dr. Zippin said.
In patients who have avoided all their positive allergens but a rash has not improved, clinicians should consider systemic contact dermatitis (SCD). Patients can develop SCD through different types of exposures, including transepidermal, transmucosal, oral, intravenous, subcutaneous, intramuscular, inhalation, and implantation routes.
SCD also has a variety of presentations, including pompholyx/dyshidrosis/vesicular dermatitis, maculopapular eruption, chronic pruritus, exfoliative erythroderma/toxiderma, chronic urticaria, erythema multiforme and vasculitis, hyperkeratotic papules of the elbows, acute generalized exanthematous pustulosis, and pruritus ani, according to Dr. Zippin.
SCD should be considered when a patient has a positive patch test to an allergen that is known to cause SCD, and does not clear after avoiding cutaneous exposure to the allergen, Dr. Zippin advised.
Patients will most often develop SCD from plants and herbs, Dr. Zippin noted. Chrysanthemums and chamomile tea are common culprits for compositae allergy and can trigger SCD; other causes are Anacardiaceae, Balsam of Peru, and propolis. Metals (nickel, cobalt, gold, and chromium), medications (aminoglycosides, corticosteroids, and ethylenediamine), and other sources (formaldehyde, propylene glycol in frozen foods, gallates, and methylisothiazolinone) can cause SCD as well.
Methylisothiazolinone in particular is a very common sensitizer, Dr. Zippin said. “If you have a patient who is positive to this, it’s almost always the cause of their problem.”
Balsam of Peru is in a number of different foods, and patients who need to follow a diet free of Balsam of Peru should avoid a long list of foods including citrus; bakery goods; Danish pastry; candy; gum; spices such as cinnamon, cloves, vanilla, curry, allspice, anise, and ginger; spicy condiments such as ketchup, chili sauce, barbecue sauce; chili, pizza, and foods with red sauces; tomatoes; pickles; alcohol (wine, beer, gin, vermouth); tea (perfumed or flavored); tobacco; chocolate and ice cream; and soft drinks (cola or spiced soft drinks).
Patients starting a nickel-free diet should avoid soy, peanuts and other nuts, legumes, chocolate, cocoa, oats, fish, and whole wheat flours. Any elimination diet should last for 3 months but should at least be tried for 3-4 weeks, with gradual reintroduction of foods suspected as triggers once per week. Any type I allergies that are discovered or suspected can be referred to an allergist for allergen challenge and desensitization therapy.
For more information, Dr. Zippin recommended the American Contact Dermatitis Society website for more information.
Dr. Zippin reported that he is the founder and holds stock options at CEP Biotech; is on the medical advisory board and receives stock options from YouV Labs., is a paid consultant and performs industry-sponsored research for Pfizer, receives stock options from Regeneron, and is on the medical advisory board for Hoth Therapeutics Inc. He is on the board of directors for the American Contact Dermatitis Society.
EXPERT ANALYSIS FROM ODAC 2020
Measles, scarlet fever among infectious diseases to watch for in 2020
ORLANDO – – leading into 2020, Justin Finch, MD, said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
While group A streptococcus has declined over the past century, there has been “an unprecedented” resurgence in severe, invasive group A streptococcal infections and severe epidemics of scarlet fever worldwide, including in industrialized regions like the United Kingdom. Shedding some light on why this may be occurring, Dr. Finch referred to a recently published population-based molecular epidemiologic study identified a new dominant emm1UK lineage of Streptococcus pyogenes associated with such cases in England (Lancet Infect Dis. 2019 Nov;19(11):1209-18). This new lineage of S. pyogenes was genotypically distinct from other emm1 isolates and had greatly increased expression of the streptococcal pyrogenic exotoxin A, one of the exotoxins responsible for the clinical features of scarlet fever.
“We have not, to my knowledge, seen the strain yet in the United States,” said Dr. Finch, of Central Connecticut Dermatology in Cromwell. “Have it on your radar. With all of the worldwide travel patterns, I expect that you will see this in the United States at some point in the not-too-distant future.”
Also in 2019, promising data on the safety and effectiveness of the recombinant herpes zoster vaccine in immunocompromised patients became available for the first time. A randomized clinical trial published in JAMA of 1,846 patients who were immunosuppressed after autologous hematopoietic stem cell transplantation and received two doses of a recombinant zoster vaccine found that the patients had a reduced incidence of herpes zoster after a median follow-up of 21 months (JAMA. 2019 Jul 9;322[2]:123-33). The study found that the recombinant vaccine was both safe and effective in these immunocompromised patients, “so we can easily generalize this to our dermatology population as well,” Dr. Finch said. In comparing the live attenuated and recombinant vaccines, he noted the recombinant vaccine requires two doses but appears to be slightly more effective. “The number needed to treat to prevent [one case] of zoster is about half as high as that for the live vaccine, and most importantly for us is, it’s safe in immunocompromised patients.”
2019 also saw a record high in the number of measles cases in the United States, the highest since 1993, Dr. Finch pointed out. Most cases were seen in the area in and around New York City, but the percentage of people across the United States who are vaccinated against measles is below the threshold for herd immunity to protect immunocompromised patients. Measles requires a population vaccination rate of 94%, and less than half of U.S. counties in 2014 and 2015 reached that vaccination rate.
“Furthermore, if we look at that over the last 20 years, comparing the domestic measles cases to imported measles cases, we are increasingly breeding these measles epidemics right here at home, whereas they used to be imported from throughout the world,” said Dr. Finch. Patients with measles can be treated with vitamin A, he added, referring to a Cochrane review showing that 200,000 units of vitamin A given daily for 2 days decreased the mortality rate of measles by about 80%. Measles is on the Centers for Disease Control and Prevention’s list of reportable diseases, so should be reported to local health authorities, and will be followed up with confirmatory testing.
In 2019, a study examining herd protection of oral human papillomavirus infection in men and women compared the prevalence of oral HPV infection based on the 4 HPV types present in the quadrivalent HPV vaccine with 33 nonvaccine types from 2009 to 2016. There was no change in the prevalence of nonvaccine type oral HPV infections among men who were unvaccinated, but the prevalence of oral HPV infections because of the four strains in the quadrivalent HPV vaccine declined from 2.7% in 2009-2010 to 1.6% in 2015-2016 (JAMA. 2019 Sep 10;322[10]:977-9). Among unvaccinated women, the prevalence of nonvaccine- and vaccine-type oral HPV infections did not change between the two time periods.
“Notably, this only occurred in men,” Dr. Finch said. Herd immunity is being achieved in men “because we’re vaccinating all women, [but] we’re not seeing that herd immunity in women. Which begs the question: Why are we still vaccinating only half of our population?”
One study published in 2019 (Br J Dermatol. 2019 Nov;181[5]:1093-5) described a patient with CARD9 mutations, which predispose individuals to deep invasive infections – a disseminated Microsporum infection in this case, Dr. Finch said. “You shouldn’t see that,” he added, noting that these mutations are known to predispose individuals to severe Trichophyton infections and familial candidiasis.
“What I think is interesting about this is that, as we look forward to 2020, we’re going to increasingly see studies like this that are identifying specific mutations in our community that underlie a lot of these weird infections,” he added. “I wouldn’t be surprised if within the span of our careers, we find that a lot of those severe treatment-refractory reports that so commonly plague your everyday clinic have some underlying, specific immunity.”
Dr. Finch reported no relevant conflicts of interest.
ORLANDO – – leading into 2020, Justin Finch, MD, said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
While group A streptococcus has declined over the past century, there has been “an unprecedented” resurgence in severe, invasive group A streptococcal infections and severe epidemics of scarlet fever worldwide, including in industrialized regions like the United Kingdom. Shedding some light on why this may be occurring, Dr. Finch referred to a recently published population-based molecular epidemiologic study identified a new dominant emm1UK lineage of Streptococcus pyogenes associated with such cases in England (Lancet Infect Dis. 2019 Nov;19(11):1209-18). This new lineage of S. pyogenes was genotypically distinct from other emm1 isolates and had greatly increased expression of the streptococcal pyrogenic exotoxin A, one of the exotoxins responsible for the clinical features of scarlet fever.
“We have not, to my knowledge, seen the strain yet in the United States,” said Dr. Finch, of Central Connecticut Dermatology in Cromwell. “Have it on your radar. With all of the worldwide travel patterns, I expect that you will see this in the United States at some point in the not-too-distant future.”
Also in 2019, promising data on the safety and effectiveness of the recombinant herpes zoster vaccine in immunocompromised patients became available for the first time. A randomized clinical trial published in JAMA of 1,846 patients who were immunosuppressed after autologous hematopoietic stem cell transplantation and received two doses of a recombinant zoster vaccine found that the patients had a reduced incidence of herpes zoster after a median follow-up of 21 months (JAMA. 2019 Jul 9;322[2]:123-33). The study found that the recombinant vaccine was both safe and effective in these immunocompromised patients, “so we can easily generalize this to our dermatology population as well,” Dr. Finch said. In comparing the live attenuated and recombinant vaccines, he noted the recombinant vaccine requires two doses but appears to be slightly more effective. “The number needed to treat to prevent [one case] of zoster is about half as high as that for the live vaccine, and most importantly for us is, it’s safe in immunocompromised patients.”
2019 also saw a record high in the number of measles cases in the United States, the highest since 1993, Dr. Finch pointed out. Most cases were seen in the area in and around New York City, but the percentage of people across the United States who are vaccinated against measles is below the threshold for herd immunity to protect immunocompromised patients. Measles requires a population vaccination rate of 94%, and less than half of U.S. counties in 2014 and 2015 reached that vaccination rate.
“Furthermore, if we look at that over the last 20 years, comparing the domestic measles cases to imported measles cases, we are increasingly breeding these measles epidemics right here at home, whereas they used to be imported from throughout the world,” said Dr. Finch. Patients with measles can be treated with vitamin A, he added, referring to a Cochrane review showing that 200,000 units of vitamin A given daily for 2 days decreased the mortality rate of measles by about 80%. Measles is on the Centers for Disease Control and Prevention’s list of reportable diseases, so should be reported to local health authorities, and will be followed up with confirmatory testing.
In 2019, a study examining herd protection of oral human papillomavirus infection in men and women compared the prevalence of oral HPV infection based on the 4 HPV types present in the quadrivalent HPV vaccine with 33 nonvaccine types from 2009 to 2016. There was no change in the prevalence of nonvaccine type oral HPV infections among men who were unvaccinated, but the prevalence of oral HPV infections because of the four strains in the quadrivalent HPV vaccine declined from 2.7% in 2009-2010 to 1.6% in 2015-2016 (JAMA. 2019 Sep 10;322[10]:977-9). Among unvaccinated women, the prevalence of nonvaccine- and vaccine-type oral HPV infections did not change between the two time periods.
“Notably, this only occurred in men,” Dr. Finch said. Herd immunity is being achieved in men “because we’re vaccinating all women, [but] we’re not seeing that herd immunity in women. Which begs the question: Why are we still vaccinating only half of our population?”
One study published in 2019 (Br J Dermatol. 2019 Nov;181[5]:1093-5) described a patient with CARD9 mutations, which predispose individuals to deep invasive infections – a disseminated Microsporum infection in this case, Dr. Finch said. “You shouldn’t see that,” he added, noting that these mutations are known to predispose individuals to severe Trichophyton infections and familial candidiasis.
“What I think is interesting about this is that, as we look forward to 2020, we’re going to increasingly see studies like this that are identifying specific mutations in our community that underlie a lot of these weird infections,” he added. “I wouldn’t be surprised if within the span of our careers, we find that a lot of those severe treatment-refractory reports that so commonly plague your everyday clinic have some underlying, specific immunity.”
Dr. Finch reported no relevant conflicts of interest.
ORLANDO – – leading into 2020, Justin Finch, MD, said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
While group A streptococcus has declined over the past century, there has been “an unprecedented” resurgence in severe, invasive group A streptococcal infections and severe epidemics of scarlet fever worldwide, including in industrialized regions like the United Kingdom. Shedding some light on why this may be occurring, Dr. Finch referred to a recently published population-based molecular epidemiologic study identified a new dominant emm1UK lineage of Streptococcus pyogenes associated with such cases in England (Lancet Infect Dis. 2019 Nov;19(11):1209-18). This new lineage of S. pyogenes was genotypically distinct from other emm1 isolates and had greatly increased expression of the streptococcal pyrogenic exotoxin A, one of the exotoxins responsible for the clinical features of scarlet fever.
“We have not, to my knowledge, seen the strain yet in the United States,” said Dr. Finch, of Central Connecticut Dermatology in Cromwell. “Have it on your radar. With all of the worldwide travel patterns, I expect that you will see this in the United States at some point in the not-too-distant future.”
Also in 2019, promising data on the safety and effectiveness of the recombinant herpes zoster vaccine in immunocompromised patients became available for the first time. A randomized clinical trial published in JAMA of 1,846 patients who were immunosuppressed after autologous hematopoietic stem cell transplantation and received two doses of a recombinant zoster vaccine found that the patients had a reduced incidence of herpes zoster after a median follow-up of 21 months (JAMA. 2019 Jul 9;322[2]:123-33). The study found that the recombinant vaccine was both safe and effective in these immunocompromised patients, “so we can easily generalize this to our dermatology population as well,” Dr. Finch said. In comparing the live attenuated and recombinant vaccines, he noted the recombinant vaccine requires two doses but appears to be slightly more effective. “The number needed to treat to prevent [one case] of zoster is about half as high as that for the live vaccine, and most importantly for us is, it’s safe in immunocompromised patients.”
2019 also saw a record high in the number of measles cases in the United States, the highest since 1993, Dr. Finch pointed out. Most cases were seen in the area in and around New York City, but the percentage of people across the United States who are vaccinated against measles is below the threshold for herd immunity to protect immunocompromised patients. Measles requires a population vaccination rate of 94%, and less than half of U.S. counties in 2014 and 2015 reached that vaccination rate.
“Furthermore, if we look at that over the last 20 years, comparing the domestic measles cases to imported measles cases, we are increasingly breeding these measles epidemics right here at home, whereas they used to be imported from throughout the world,” said Dr. Finch. Patients with measles can be treated with vitamin A, he added, referring to a Cochrane review showing that 200,000 units of vitamin A given daily for 2 days decreased the mortality rate of measles by about 80%. Measles is on the Centers for Disease Control and Prevention’s list of reportable diseases, so should be reported to local health authorities, and will be followed up with confirmatory testing.
In 2019, a study examining herd protection of oral human papillomavirus infection in men and women compared the prevalence of oral HPV infection based on the 4 HPV types present in the quadrivalent HPV vaccine with 33 nonvaccine types from 2009 to 2016. There was no change in the prevalence of nonvaccine type oral HPV infections among men who were unvaccinated, but the prevalence of oral HPV infections because of the four strains in the quadrivalent HPV vaccine declined from 2.7% in 2009-2010 to 1.6% in 2015-2016 (JAMA. 2019 Sep 10;322[10]:977-9). Among unvaccinated women, the prevalence of nonvaccine- and vaccine-type oral HPV infections did not change between the two time periods.
“Notably, this only occurred in men,” Dr. Finch said. Herd immunity is being achieved in men “because we’re vaccinating all women, [but] we’re not seeing that herd immunity in women. Which begs the question: Why are we still vaccinating only half of our population?”
One study published in 2019 (Br J Dermatol. 2019 Nov;181[5]:1093-5) described a patient with CARD9 mutations, which predispose individuals to deep invasive infections – a disseminated Microsporum infection in this case, Dr. Finch said. “You shouldn’t see that,” he added, noting that these mutations are known to predispose individuals to severe Trichophyton infections and familial candidiasis.
“What I think is interesting about this is that, as we look forward to 2020, we’re going to increasingly see studies like this that are identifying specific mutations in our community that underlie a lot of these weird infections,” he added. “I wouldn’t be surprised if within the span of our careers, we find that a lot of those severe treatment-refractory reports that so commonly plague your everyday clinic have some underlying, specific immunity.”
Dr. Finch reported no relevant conflicts of interest.
REPORTING FROM ODAC 2020
Systemic therapy options for pediatric skin diseases are improving
ORLANDO – Because Food and Drug Administration–approved treatment options for medications. However, this scenario is changing, A. Yasmine Kirkorian, MD, said at the ODAC Dermatology, Aesthetic & Surgical Conference.
“I really would like to emphasize that children with severe disease need to be treated,” added Dr. Kirkorian, a pediatric dermatologist at George Washington University, Washington, and Children’s National Health System, where she is interim chief of the division of dermatology.
Current on-label systemic therapies for pediatric skin disease include etanercept for psoriasis (4 years and older), ustekinumab for psoriasis (12 years and older), adalimumab for hidradenitis suppurativa (12 years and older), and omalizumab for chronic idiopathic urticaria (12 years and older). A new addition to the list is dupilumab, which was approved for children and adolescents with atopic dermatitis (AD) aged 12 years and older in 2019, she noted.
Dupilumab is currently being studied in children aged 6 months to 12 years, and other clinical trials are evaluating more options for pediatric patients with AD, alopecia areata, and psoriasis. They include a clinical trial of the oral Janus kinase 3 (JAK3) inhibitor PF-06651600 in patients aged 12 years and older with alopecia areata. Six biologic therapies are being evaluated for psoriasis in patients beginning at 6 years: ixekizumab, secukinumab, ustekinumab, guselkumab, brodalumab, and apremilast.
Some systemic therapies are off-label “but used all the time” for dermatologic diseases in pediatrics, Dr. Kirkorian noted. One example is methotrexate, which is approved by the FDA for acute lymphoblastic leukemia, meningeal leukemia, and juvenile idiopathic arthritis down to infancy. Having existing efficacy and safety data for a medication in a pediatric population, even for a different disease, can be helpful when counseling parents of children with severe dermatologic disease. “If you have something, even in an older population of children, it can be reassuring, or you can use evidence from other diseases,” she said.
While methotrexate is a cheap option and approved by the FDA for other pediatric indications down to infancy, the cons of using it to treat AD in pediatric patients are numerous. Treatment requires a number of blood draws for lab testing, which can be discouraging for younger patients, and the reported adverse effect profile may be concerning to some parents, while “in practice doesn’t really occur,” she said. Methotrexate is a teratogen so is not appropriate for teenagers who are sexually active and not using contraception.
The “biggest problem,” though, is the issue of whether methotrexate is effective, since it doesn’t always work for AD, Dr. Kirkorian said. “Even at the highest doses, I often feel that we fail the atopic children,” as opposed to using it to treat psoriasis, “where you know I’m going to get you on something that works.”
In contrast, cyclosporine is FDA approved down to infancy, and works quickly as a bridge to other therapy, and is not expensive, Dr. Kirkorian said. Cons include the need for blood draws, blood pressure checks, drug interactions, and adverse effects, she noted, adding that she tries to use cyclosporine as a bridge to on-label and off-label dupilumab.
Even with FDA approval for dupilumab down to age 12 years, she said it can be difficult to get insurance approval for the on-label treatment for patients in this age group with AD, before they first fail other therapies (even with off-label systemic drugs). For patients under age 12 years, getting approval is even more challenging and requires rigorous documentation of what therapies the child has failed, and how it has affected their quality of life, she said.
“If you send in a letter to the insurance company without an IGA [Investigator Global Assessment] or SCORAD, you’re going to get rejected,” Dr. Kirkorian said. In addition to those two measures, she provides “everything else,” including the impact of the disease on quality of life of patients, and school, she said, adding, “Did they miss school, did they get hospitalized for infections? And do they have comorbid diseases that might help you get approval?”
In pediatric patients with psoriasis, common issues are more likely to be about how insurance dictates step therapy. She has often found that young children may stop responding to etanercept after a few years, which can justify a switch to ustekinumab or a new treatment in a clinical trial, she said. Adolescents with psoriasis can receive ustekinumab, which is approved for psoriasis in patients aged 12-17 years, she said, noting that the infrequent ustekinumab dosing schedule is often beneficial in this population.
When all other approved options fail for young patients with psoriasis, justifying off-label use isn’t always easy. “You just have to make a justification based on the literature, even though it’s off label,” citing available safety information for other diseases, and “demonstrate over and over the impact on quality of life,” which works “most of the time,” Dr. Kirkorian said.
She reported having no conflicts of interest.
ORLANDO – Because Food and Drug Administration–approved treatment options for medications. However, this scenario is changing, A. Yasmine Kirkorian, MD, said at the ODAC Dermatology, Aesthetic & Surgical Conference.
“I really would like to emphasize that children with severe disease need to be treated,” added Dr. Kirkorian, a pediatric dermatologist at George Washington University, Washington, and Children’s National Health System, where she is interim chief of the division of dermatology.
Current on-label systemic therapies for pediatric skin disease include etanercept for psoriasis (4 years and older), ustekinumab for psoriasis (12 years and older), adalimumab for hidradenitis suppurativa (12 years and older), and omalizumab for chronic idiopathic urticaria (12 years and older). A new addition to the list is dupilumab, which was approved for children and adolescents with atopic dermatitis (AD) aged 12 years and older in 2019, she noted.
Dupilumab is currently being studied in children aged 6 months to 12 years, and other clinical trials are evaluating more options for pediatric patients with AD, alopecia areata, and psoriasis. They include a clinical trial of the oral Janus kinase 3 (JAK3) inhibitor PF-06651600 in patients aged 12 years and older with alopecia areata. Six biologic therapies are being evaluated for psoriasis in patients beginning at 6 years: ixekizumab, secukinumab, ustekinumab, guselkumab, brodalumab, and apremilast.
Some systemic therapies are off-label “but used all the time” for dermatologic diseases in pediatrics, Dr. Kirkorian noted. One example is methotrexate, which is approved by the FDA for acute lymphoblastic leukemia, meningeal leukemia, and juvenile idiopathic arthritis down to infancy. Having existing efficacy and safety data for a medication in a pediatric population, even for a different disease, can be helpful when counseling parents of children with severe dermatologic disease. “If you have something, even in an older population of children, it can be reassuring, or you can use evidence from other diseases,” she said.
While methotrexate is a cheap option and approved by the FDA for other pediatric indications down to infancy, the cons of using it to treat AD in pediatric patients are numerous. Treatment requires a number of blood draws for lab testing, which can be discouraging for younger patients, and the reported adverse effect profile may be concerning to some parents, while “in practice doesn’t really occur,” she said. Methotrexate is a teratogen so is not appropriate for teenagers who are sexually active and not using contraception.
The “biggest problem,” though, is the issue of whether methotrexate is effective, since it doesn’t always work for AD, Dr. Kirkorian said. “Even at the highest doses, I often feel that we fail the atopic children,” as opposed to using it to treat psoriasis, “where you know I’m going to get you on something that works.”
In contrast, cyclosporine is FDA approved down to infancy, and works quickly as a bridge to other therapy, and is not expensive, Dr. Kirkorian said. Cons include the need for blood draws, blood pressure checks, drug interactions, and adverse effects, she noted, adding that she tries to use cyclosporine as a bridge to on-label and off-label dupilumab.
Even with FDA approval for dupilumab down to age 12 years, she said it can be difficult to get insurance approval for the on-label treatment for patients in this age group with AD, before they first fail other therapies (even with off-label systemic drugs). For patients under age 12 years, getting approval is even more challenging and requires rigorous documentation of what therapies the child has failed, and how it has affected their quality of life, she said.
“If you send in a letter to the insurance company without an IGA [Investigator Global Assessment] or SCORAD, you’re going to get rejected,” Dr. Kirkorian said. In addition to those two measures, she provides “everything else,” including the impact of the disease on quality of life of patients, and school, she said, adding, “Did they miss school, did they get hospitalized for infections? And do they have comorbid diseases that might help you get approval?”
In pediatric patients with psoriasis, common issues are more likely to be about how insurance dictates step therapy. She has often found that young children may stop responding to etanercept after a few years, which can justify a switch to ustekinumab or a new treatment in a clinical trial, she said. Adolescents with psoriasis can receive ustekinumab, which is approved for psoriasis in patients aged 12-17 years, she said, noting that the infrequent ustekinumab dosing schedule is often beneficial in this population.
When all other approved options fail for young patients with psoriasis, justifying off-label use isn’t always easy. “You just have to make a justification based on the literature, even though it’s off label,” citing available safety information for other diseases, and “demonstrate over and over the impact on quality of life,” which works “most of the time,” Dr. Kirkorian said.
She reported having no conflicts of interest.
ORLANDO – Because Food and Drug Administration–approved treatment options for medications. However, this scenario is changing, A. Yasmine Kirkorian, MD, said at the ODAC Dermatology, Aesthetic & Surgical Conference.
“I really would like to emphasize that children with severe disease need to be treated,” added Dr. Kirkorian, a pediatric dermatologist at George Washington University, Washington, and Children’s National Health System, where she is interim chief of the division of dermatology.
Current on-label systemic therapies for pediatric skin disease include etanercept for psoriasis (4 years and older), ustekinumab for psoriasis (12 years and older), adalimumab for hidradenitis suppurativa (12 years and older), and omalizumab for chronic idiopathic urticaria (12 years and older). A new addition to the list is dupilumab, which was approved for children and adolescents with atopic dermatitis (AD) aged 12 years and older in 2019, she noted.
Dupilumab is currently being studied in children aged 6 months to 12 years, and other clinical trials are evaluating more options for pediatric patients with AD, alopecia areata, and psoriasis. They include a clinical trial of the oral Janus kinase 3 (JAK3) inhibitor PF-06651600 in patients aged 12 years and older with alopecia areata. Six biologic therapies are being evaluated for psoriasis in patients beginning at 6 years: ixekizumab, secukinumab, ustekinumab, guselkumab, brodalumab, and apremilast.
Some systemic therapies are off-label “but used all the time” for dermatologic diseases in pediatrics, Dr. Kirkorian noted. One example is methotrexate, which is approved by the FDA for acute lymphoblastic leukemia, meningeal leukemia, and juvenile idiopathic arthritis down to infancy. Having existing efficacy and safety data for a medication in a pediatric population, even for a different disease, can be helpful when counseling parents of children with severe dermatologic disease. “If you have something, even in an older population of children, it can be reassuring, or you can use evidence from other diseases,” she said.
While methotrexate is a cheap option and approved by the FDA for other pediatric indications down to infancy, the cons of using it to treat AD in pediatric patients are numerous. Treatment requires a number of blood draws for lab testing, which can be discouraging for younger patients, and the reported adverse effect profile may be concerning to some parents, while “in practice doesn’t really occur,” she said. Methotrexate is a teratogen so is not appropriate for teenagers who are sexually active and not using contraception.
The “biggest problem,” though, is the issue of whether methotrexate is effective, since it doesn’t always work for AD, Dr. Kirkorian said. “Even at the highest doses, I often feel that we fail the atopic children,” as opposed to using it to treat psoriasis, “where you know I’m going to get you on something that works.”
In contrast, cyclosporine is FDA approved down to infancy, and works quickly as a bridge to other therapy, and is not expensive, Dr. Kirkorian said. Cons include the need for blood draws, blood pressure checks, drug interactions, and adverse effects, she noted, adding that she tries to use cyclosporine as a bridge to on-label and off-label dupilumab.
Even with FDA approval for dupilumab down to age 12 years, she said it can be difficult to get insurance approval for the on-label treatment for patients in this age group with AD, before they first fail other therapies (even with off-label systemic drugs). For patients under age 12 years, getting approval is even more challenging and requires rigorous documentation of what therapies the child has failed, and how it has affected their quality of life, she said.
“If you send in a letter to the insurance company without an IGA [Investigator Global Assessment] or SCORAD, you’re going to get rejected,” Dr. Kirkorian said. In addition to those two measures, she provides “everything else,” including the impact of the disease on quality of life of patients, and school, she said, adding, “Did they miss school, did they get hospitalized for infections? And do they have comorbid diseases that might help you get approval?”
In pediatric patients with psoriasis, common issues are more likely to be about how insurance dictates step therapy. She has often found that young children may stop responding to etanercept after a few years, which can justify a switch to ustekinumab or a new treatment in a clinical trial, she said. Adolescents with psoriasis can receive ustekinumab, which is approved for psoriasis in patients aged 12-17 years, she said, noting that the infrequent ustekinumab dosing schedule is often beneficial in this population.
When all other approved options fail for young patients with psoriasis, justifying off-label use isn’t always easy. “You just have to make a justification based on the literature, even though it’s off label,” citing available safety information for other diseases, and “demonstrate over and over the impact on quality of life,” which works “most of the time,” Dr. Kirkorian said.
She reported having no conflicts of interest.
EXPERT ANALYSIS FROM ODAC 2020
Be ready for patient questions on sunscreen safety, SPF choice
ORLANDO – Dermatologists should be well versed in addressing common concerns that patients, family members, and the media have about photoprotection, Adam Friedman, MD, advised at the ODAC Dermatology, Aesthetic, & Surgical Conference.
“Know the controversies. Be armed and ready when these patients come to your office with questions,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview at the meeting, where he presented on issues related to photoprotection.
Sunscreen SPFs above 50 don’t technically provide a “meaningful” increase in ultraviolet protection, given that this value relates to filtering about 98% of UVB, but they still can provide some benefit, which has to do with real-world human error, Dr. Friedman said.
“Most people don’t use sunscreens the right way,” meaning they don’t apply enough to achieve the SPF listed, he added in the interview. “A higher SPF is meaningful, because if they apply less [sunscreen], they actually still are in that safety window,” with the higher SPF sunscreen. (The American Academy of Dermatology recommends an SPF of 30 or higher.) Several studies have shown that a SPF of 70 or 100 is superior to 50, likely because of this “dilutional” effect.
Patients may have concerns about the effects of sunscreen on vitamin D production, the environment, and hair loss, and whether they have endocrine disrupting effects, added Dr. Friedman, who is also the medical director of the meeting.
Inhibition of cutaneous vitamin D synthesis after using sunscreen can vary, based on whether a person has properly applied sunscreen, the season, latitude, and an individual’s age and obesity level. Patients with low vitamin D levels can use a vitamin D supplement to achieve sufficient levels, and patients concerned about the impact of sunscreen and vitamin D can be advised to take 600 IU of vitamin D3 a day, according to Dr. Friedman. Some studies have suggested that UVB exposure and risk of certain cancers are inversely correlated, implicating cutaneous vitamin D synthesis (J Clin Transl Endocrinol. 2014 Oct 5;1[4]:179-86). But correlation does not equal causation, he pointed out.
Other concerns stem from the potential for oxybenzone, a UVA/UVB filter in more than 70% of sunscreens, to act as an endocrine disruptor in people and whether it is potentially damaging the environment. The data driving these concerns “stem from the bench, not the real world,” Dr. Friedman said. While topical application of oxybenzone can result in systemic absorption, and even though it’s been detected in waters that are heavily populated or where people go on vacation, there is no evidence demonstrating toxicity to humans or the coral reefs. “At least the information we have to date says they don’t,” he added.
In a randomized clinical trial recently published in JAMA, Food and Drug Administration investigators found that systemic skin absorption with geometric mean plasma concentrations greater than 0.5 ng/mL with six active ingredients in sunscreen that were tested, including oxybenzone (JAMA. 2020;323[3]:256-7). The study was part of an FDA proposed rule requesting additional information on sunscreen ingredients; the plasma concentrations exceeded the level at which further safety studies could potentially be waived.
The study, Dr. Friedman said, “only demonstrated the ability to detect these UV filters at very small concentrations in the blood. They have yet to show any meaningful biologic correlation to these findings.”
For those patients who prefer not to use chemical filters, Dr. Friedman suggests recommending mineral-based sunscreens, of which he said micro- and nanoparticulate formulations offer the best cosmesis by sitting more evenly on the skin, being more amenable to thinner and less-lipophilic vehicles, and limiting visible light scattering (thereby limiting the unsightly white appearance) – while maintaining UV scattering efficacy. However, controversy has emerged as there are past studies that posit the theoretical danger of nanoparticles in sunscreens, given their potential to penetrate the skin and enter cells.
But continually emerging evidence has shown that commercially available nanosunscreens are safe, with no toxicity even at the cellular level when applied to the skin in sunscreen or in cosmetics. “All evidence to date suggests they do not do this,” Dr. Friedman said, noting that, in Europe, the European Commission’s Scientific Committee on Consumer Safety has stated that nanoparticles below a concentration of 25% in sunscreens is safe, “just don’t put them in aerosolized forms.”
Lastly, while some recent studies have detected titanium dioxide on the hair shafts of patients with and without frontal fibrosing alopecia, Dr. Friedman noted more evidence is needed before recommending that these patients avoid using sunscreen (Br J Dermatol. 2019 Jul;181[1]:216-7). “Correlation does not mean causation, and the current dogma is that there’s no connection between these two,” he commented.
Dr. Friedman reported consulting and advisory board relationships with numerous companies; he also reported speaking for Regeneron, Abbvie, and Dermira, and receiving grants with Pfizer and DF Pharma.
ORLANDO – Dermatologists should be well versed in addressing common concerns that patients, family members, and the media have about photoprotection, Adam Friedman, MD, advised at the ODAC Dermatology, Aesthetic, & Surgical Conference.
“Know the controversies. Be armed and ready when these patients come to your office with questions,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview at the meeting, where he presented on issues related to photoprotection.
Sunscreen SPFs above 50 don’t technically provide a “meaningful” increase in ultraviolet protection, given that this value relates to filtering about 98% of UVB, but they still can provide some benefit, which has to do with real-world human error, Dr. Friedman said.
“Most people don’t use sunscreens the right way,” meaning they don’t apply enough to achieve the SPF listed, he added in the interview. “A higher SPF is meaningful, because if they apply less [sunscreen], they actually still are in that safety window,” with the higher SPF sunscreen. (The American Academy of Dermatology recommends an SPF of 30 or higher.) Several studies have shown that a SPF of 70 or 100 is superior to 50, likely because of this “dilutional” effect.
Patients may have concerns about the effects of sunscreen on vitamin D production, the environment, and hair loss, and whether they have endocrine disrupting effects, added Dr. Friedman, who is also the medical director of the meeting.
Inhibition of cutaneous vitamin D synthesis after using sunscreen can vary, based on whether a person has properly applied sunscreen, the season, latitude, and an individual’s age and obesity level. Patients with low vitamin D levels can use a vitamin D supplement to achieve sufficient levels, and patients concerned about the impact of sunscreen and vitamin D can be advised to take 600 IU of vitamin D3 a day, according to Dr. Friedman. Some studies have suggested that UVB exposure and risk of certain cancers are inversely correlated, implicating cutaneous vitamin D synthesis (J Clin Transl Endocrinol. 2014 Oct 5;1[4]:179-86). But correlation does not equal causation, he pointed out.
Other concerns stem from the potential for oxybenzone, a UVA/UVB filter in more than 70% of sunscreens, to act as an endocrine disruptor in people and whether it is potentially damaging the environment. The data driving these concerns “stem from the bench, not the real world,” Dr. Friedman said. While topical application of oxybenzone can result in systemic absorption, and even though it’s been detected in waters that are heavily populated or where people go on vacation, there is no evidence demonstrating toxicity to humans or the coral reefs. “At least the information we have to date says they don’t,” he added.
In a randomized clinical trial recently published in JAMA, Food and Drug Administration investigators found that systemic skin absorption with geometric mean plasma concentrations greater than 0.5 ng/mL with six active ingredients in sunscreen that were tested, including oxybenzone (JAMA. 2020;323[3]:256-7). The study was part of an FDA proposed rule requesting additional information on sunscreen ingredients; the plasma concentrations exceeded the level at which further safety studies could potentially be waived.
The study, Dr. Friedman said, “only demonstrated the ability to detect these UV filters at very small concentrations in the blood. They have yet to show any meaningful biologic correlation to these findings.”
For those patients who prefer not to use chemical filters, Dr. Friedman suggests recommending mineral-based sunscreens, of which he said micro- and nanoparticulate formulations offer the best cosmesis by sitting more evenly on the skin, being more amenable to thinner and less-lipophilic vehicles, and limiting visible light scattering (thereby limiting the unsightly white appearance) – while maintaining UV scattering efficacy. However, controversy has emerged as there are past studies that posit the theoretical danger of nanoparticles in sunscreens, given their potential to penetrate the skin and enter cells.
But continually emerging evidence has shown that commercially available nanosunscreens are safe, with no toxicity even at the cellular level when applied to the skin in sunscreen or in cosmetics. “All evidence to date suggests they do not do this,” Dr. Friedman said, noting that, in Europe, the European Commission’s Scientific Committee on Consumer Safety has stated that nanoparticles below a concentration of 25% in sunscreens is safe, “just don’t put them in aerosolized forms.”
Lastly, while some recent studies have detected titanium dioxide on the hair shafts of patients with and without frontal fibrosing alopecia, Dr. Friedman noted more evidence is needed before recommending that these patients avoid using sunscreen (Br J Dermatol. 2019 Jul;181[1]:216-7). “Correlation does not mean causation, and the current dogma is that there’s no connection between these two,” he commented.
Dr. Friedman reported consulting and advisory board relationships with numerous companies; he also reported speaking for Regeneron, Abbvie, and Dermira, and receiving grants with Pfizer and DF Pharma.
ORLANDO – Dermatologists should be well versed in addressing common concerns that patients, family members, and the media have about photoprotection, Adam Friedman, MD, advised at the ODAC Dermatology, Aesthetic, & Surgical Conference.
“Know the controversies. Be armed and ready when these patients come to your office with questions,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview at the meeting, where he presented on issues related to photoprotection.
Sunscreen SPFs above 50 don’t technically provide a “meaningful” increase in ultraviolet protection, given that this value relates to filtering about 98% of UVB, but they still can provide some benefit, which has to do with real-world human error, Dr. Friedman said.
“Most people don’t use sunscreens the right way,” meaning they don’t apply enough to achieve the SPF listed, he added in the interview. “A higher SPF is meaningful, because if they apply less [sunscreen], they actually still are in that safety window,” with the higher SPF sunscreen. (The American Academy of Dermatology recommends an SPF of 30 or higher.) Several studies have shown that a SPF of 70 or 100 is superior to 50, likely because of this “dilutional” effect.
Patients may have concerns about the effects of sunscreen on vitamin D production, the environment, and hair loss, and whether they have endocrine disrupting effects, added Dr. Friedman, who is also the medical director of the meeting.
Inhibition of cutaneous vitamin D synthesis after using sunscreen can vary, based on whether a person has properly applied sunscreen, the season, latitude, and an individual’s age and obesity level. Patients with low vitamin D levels can use a vitamin D supplement to achieve sufficient levels, and patients concerned about the impact of sunscreen and vitamin D can be advised to take 600 IU of vitamin D3 a day, according to Dr. Friedman. Some studies have suggested that UVB exposure and risk of certain cancers are inversely correlated, implicating cutaneous vitamin D synthesis (J Clin Transl Endocrinol. 2014 Oct 5;1[4]:179-86). But correlation does not equal causation, he pointed out.
Other concerns stem from the potential for oxybenzone, a UVA/UVB filter in more than 70% of sunscreens, to act as an endocrine disruptor in people and whether it is potentially damaging the environment. The data driving these concerns “stem from the bench, not the real world,” Dr. Friedman said. While topical application of oxybenzone can result in systemic absorption, and even though it’s been detected in waters that are heavily populated or where people go on vacation, there is no evidence demonstrating toxicity to humans or the coral reefs. “At least the information we have to date says they don’t,” he added.
In a randomized clinical trial recently published in JAMA, Food and Drug Administration investigators found that systemic skin absorption with geometric mean plasma concentrations greater than 0.5 ng/mL with six active ingredients in sunscreen that were tested, including oxybenzone (JAMA. 2020;323[3]:256-7). The study was part of an FDA proposed rule requesting additional information on sunscreen ingredients; the plasma concentrations exceeded the level at which further safety studies could potentially be waived.
The study, Dr. Friedman said, “only demonstrated the ability to detect these UV filters at very small concentrations in the blood. They have yet to show any meaningful biologic correlation to these findings.”
For those patients who prefer not to use chemical filters, Dr. Friedman suggests recommending mineral-based sunscreens, of which he said micro- and nanoparticulate formulations offer the best cosmesis by sitting more evenly on the skin, being more amenable to thinner and less-lipophilic vehicles, and limiting visible light scattering (thereby limiting the unsightly white appearance) – while maintaining UV scattering efficacy. However, controversy has emerged as there are past studies that posit the theoretical danger of nanoparticles in sunscreens, given their potential to penetrate the skin and enter cells.
But continually emerging evidence has shown that commercially available nanosunscreens are safe, with no toxicity even at the cellular level when applied to the skin in sunscreen or in cosmetics. “All evidence to date suggests they do not do this,” Dr. Friedman said, noting that, in Europe, the European Commission’s Scientific Committee on Consumer Safety has stated that nanoparticles below a concentration of 25% in sunscreens is safe, “just don’t put them in aerosolized forms.”
Lastly, while some recent studies have detected titanium dioxide on the hair shafts of patients with and without frontal fibrosing alopecia, Dr. Friedman noted more evidence is needed before recommending that these patients avoid using sunscreen (Br J Dermatol. 2019 Jul;181[1]:216-7). “Correlation does not mean causation, and the current dogma is that there’s no connection between these two,” he commented.
Dr. Friedman reported consulting and advisory board relationships with numerous companies; he also reported speaking for Regeneron, Abbvie, and Dermira, and receiving grants with Pfizer and DF Pharma.
EXPERT ANALYSIS FROM ODAC 2020
Dermatologists are uniquely suited to help sexual-, gender-minority patients
ORLANDO – There is a these patients, Angelo Landriscina, MD, said at the ODAC Dermatology, Aesthetic, & Clinical Conference.
“Our knowledge lagging behind is really to our own detriment,” said Dr. Landriscina, chief resident of dermatology at George Washington University, Washington. “The unique comorbidities and lived experiences of queer patients can impact their dermatologic disease. In addition to that, we are in a really unique position to provide life-changing care for these patients.”
The topic of dermatologic care for SGM patients has been discussed with interest in the dermatology community, but it has not been well studied. In one of two papers recently published in Pediatric Dermatology, Markus D. Boos, MD, PhD, from the University of Washington, Seattle, and Seattle Children’s Hospital, and coauthors noted that there is a particular knowledge gap in how to care for SGM pediatric and adolescent patients (Pediatr Dermatol. 2019 Sep;36[5]:581-6; 587-93).
In his presentation, Dr. Landriscina outlined the differences between sexual orientation – an emotional, romantic, or sexual attraction to others – and gender identity, or how one perceives their own gender. Lesbian, gay, transgender, and queer/questioning are classical definitions, but SGM patients may also self-identify in any number of other ways. Some SGM patients may identify as gender-fluid or nonbinary, while genderqueer is an umbrella term for individuals who don’t identify with typical gender roles. On the topic of pronouns, asking SGM patients how they want to be referred to is ideal, but the singular they is considered a gender-neutral term that should work for most situations.
There are also terms to avoid: “Homosexual” may be acceptable to some SGM patients, but is from an era when same-sex attraction was pathologized; “sexual preference” characterizes sexuality as a choice; the term “lifestyle” perpetuates the idea that all SGM patients are the same; and referring to transgender patients as "pre-op" or "post-op" is problematic as these terms imply that transgender identity is defined by a medical transition. Using transgender or gay as a noun, or the word transsexual, is offensive and shouldn’t be used at all, according to Dr. Landriscina.
As these terms continue to change and be redefined, dermatologists are likely to encounter terms they are unfamiliar with in the clinic, but he emphasized that attendees need not know every term to care for these patients. “The easiest way to be right in all of these situations is to let your patients define themselves,” he said, but noted that “assumptions are your worst enemy. You’re going to have to ask the hard questions.”
Updating understanding of SGM patients
Much of the medical community’s understanding of SGM patients hasn’t been updated in decades, Dr. Landriscina said. For example, medical school students typically learn about SGM risk factors that only apply to men who have sex with men (MSM), but there is new interest in caring for transgender patients within dermatology. The focus on classical notions for treating MSM can be reductive, Dr. Landriscina explained. “It boils a whole community of people down to one disease process. I think that we need to expand the thought that there are other associations here. There are other risks these patients face.”
In contrast, dermatologists who strive to understand their patients can better see them as a whole person, can engage in a better differential diagnosis, are aware of the current comorbidities SGM patients face that affect dermatologic disease, and can even work with the patient toward preventative care.
“It’s been decades since we’ve had a paradigm shift about this, and I think it’s time,” he said.
Overall, SGM patients have a higher likelihood of suffering from mental illness and suicidal ideation, with 10%-20% of lesbian, gay, and bisexual patients attempting suicide. Gender-minority patients have a significantly higher rate of attempting suicide at 40%. SGM patients are also more likely to be homeless and uninsured, and have the highest rates of tobacco, alcohol, and illicit drug use. In the SGM population, there is a higher likelihood of being victimized, and discriminated against, with this risk being much higher in transgender patients.
For MSM, there is a high risk of HIV and other STIs such as herpes simplex virus type 2 (HSV2), human papillomavirus (HPV), gonorrhea, and chlamydia, Dr. Landriscina said. They are also at risk for hepatitis A, B, and C; clusters of meningococcal meningitis; and human herpes virus 8. While MSM are more likely to use sunscreen, they also are more likely to use tanning beds and not wear protective clothing outdoors, and are at a greater risk of skin cancer. The risks of body dysmorphia and eating disorders are also increased for MSM.
While there is not as much research on risk factors for women who have sex with women (WSW), they are still at risk for HIV, HSV, and HPV and are less likely to engage in safe sex practices. For women who have sex with both men and other women, there is an even greater risk of STIs. While WSW are more likely to perceive less need for screening, they should be given the same screening as all other women, and dermatologists can help by ensuring these patients are connected with primary care providers, he said.
Dermatologic sequelae for transgender patients
For patients who transition from male to female, there is little information on their sexual risk from studies, but their care should be managed similarly to MSM, Dr. Landriscina said. When seeing transgender patients, dermatologists should be aware of issues of gender dysphoria, but not offer any intervention without first having a conversation about the patient’s hopes and goals. “Not every patient will have the means or desire to have everything that you can offer,” he said.
For patients who choose to undergo a female-to-male transition, dermatological sequelae may include classical manifestations of androgen excess from hormone therapy such as acne and androgenic alopecia; acne, miliaria, tinea corporis, contact dermatitis from chest binding; and surgical scars and keloids. For acne, isotretinoin is an option if a case is severe, but dermatologists should be aware these patients may still be able to become pregnant. There is no consensus on treatment for androgenic alopecia, but use of finasteride might block wanted secondary sex characteristics, Dr. Landriscina noted.
Patients who undergo a male-to-female transition may develop melasma or asteatotic eczema while receiving estrogen therapy; unwanted facial or body hair; and complications from illicit “filler” injections that may cause foreign-body granulomas, bacterial or atypical mycobacterial infection, lymphedema, and scarring.
Transgender patients may choose to undergo aesthetic treatments that can affirm their gender and decrease their gender dysphoria, augment the effects of hormone therapy and gender-confirmation surgery, and improve their quality of life. “While this has classically fallen under the purview of plastic surgery, I feel like we’re uniquely positioned to provide really life-changing aesthetic services to these patients,” Dr. Landriscina said.
Creating an inclusive environment is key to successfully caring for SGM patients. Any practice policies should have SGM-inclusive language, employees should receive mandatory LGBTQ+ focused training, and a point person should oversee LGBTQ+ matters, according to the Joint Commission’s LGBT Guide. Practices should also begin collecting data on sexual orientation and gender identity, which may help patients who are reluctant to vocally disclose their sexual orientation and gender identity and expand understanding of SGM patients. “Before you even walk into that visit, you know what the patient’s identity is, how they want to be addressed,” said Dr. Landriscina. “It also shows patients that you value what their identities are and that you’re competent in taking care of them.”
Dr. Landriscina encouraged attendees to take the information they learned in the session and “run with it.”
“Go for it. Keep learning,” he said. “There’s more about this topic than I even had the chance to include. Your patients are going to appreciate your dedication to them.”
In an interview, Adam Friedman, MD, professor and interim chair of dermatology at George Washington University and medical director of ODAC, acknowledged the large gaps in care for SGM patients and the unique role dermatologists can play in their care, both in terms of medical and surgical procedures.
“There are specific considerations that we as dermatologists need to think about in terms of just quality of life, potentially mental disease, homelessness, access to care. I think if we consider the whole picture, we can not only provide dermatologic care, but maybe serve as a pivot point to direct them to other specialists, and other physicians, and even nonphysicians who play a role in all facets of life to really get these individuals all the care, in broader senses, that they need,” he said.
Dr. Landriscina reported no relevant conflicts of interest.
ORLANDO – There is a these patients, Angelo Landriscina, MD, said at the ODAC Dermatology, Aesthetic, & Clinical Conference.
“Our knowledge lagging behind is really to our own detriment,” said Dr. Landriscina, chief resident of dermatology at George Washington University, Washington. “The unique comorbidities and lived experiences of queer patients can impact their dermatologic disease. In addition to that, we are in a really unique position to provide life-changing care for these patients.”
The topic of dermatologic care for SGM patients has been discussed with interest in the dermatology community, but it has not been well studied. In one of two papers recently published in Pediatric Dermatology, Markus D. Boos, MD, PhD, from the University of Washington, Seattle, and Seattle Children’s Hospital, and coauthors noted that there is a particular knowledge gap in how to care for SGM pediatric and adolescent patients (Pediatr Dermatol. 2019 Sep;36[5]:581-6; 587-93).
In his presentation, Dr. Landriscina outlined the differences between sexual orientation – an emotional, romantic, or sexual attraction to others – and gender identity, or how one perceives their own gender. Lesbian, gay, transgender, and queer/questioning are classical definitions, but SGM patients may also self-identify in any number of other ways. Some SGM patients may identify as gender-fluid or nonbinary, while genderqueer is an umbrella term for individuals who don’t identify with typical gender roles. On the topic of pronouns, asking SGM patients how they want to be referred to is ideal, but the singular they is considered a gender-neutral term that should work for most situations.
There are also terms to avoid: “Homosexual” may be acceptable to some SGM patients, but is from an era when same-sex attraction was pathologized; “sexual preference” characterizes sexuality as a choice; the term “lifestyle” perpetuates the idea that all SGM patients are the same; and referring to transgender patients as "pre-op" or "post-op" is problematic as these terms imply that transgender identity is defined by a medical transition. Using transgender or gay as a noun, or the word transsexual, is offensive and shouldn’t be used at all, according to Dr. Landriscina.
As these terms continue to change and be redefined, dermatologists are likely to encounter terms they are unfamiliar with in the clinic, but he emphasized that attendees need not know every term to care for these patients. “The easiest way to be right in all of these situations is to let your patients define themselves,” he said, but noted that “assumptions are your worst enemy. You’re going to have to ask the hard questions.”
Updating understanding of SGM patients
Much of the medical community’s understanding of SGM patients hasn’t been updated in decades, Dr. Landriscina said. For example, medical school students typically learn about SGM risk factors that only apply to men who have sex with men (MSM), but there is new interest in caring for transgender patients within dermatology. The focus on classical notions for treating MSM can be reductive, Dr. Landriscina explained. “It boils a whole community of people down to one disease process. I think that we need to expand the thought that there are other associations here. There are other risks these patients face.”
In contrast, dermatologists who strive to understand their patients can better see them as a whole person, can engage in a better differential diagnosis, are aware of the current comorbidities SGM patients face that affect dermatologic disease, and can even work with the patient toward preventative care.
“It’s been decades since we’ve had a paradigm shift about this, and I think it’s time,” he said.
Overall, SGM patients have a higher likelihood of suffering from mental illness and suicidal ideation, with 10%-20% of lesbian, gay, and bisexual patients attempting suicide. Gender-minority patients have a significantly higher rate of attempting suicide at 40%. SGM patients are also more likely to be homeless and uninsured, and have the highest rates of tobacco, alcohol, and illicit drug use. In the SGM population, there is a higher likelihood of being victimized, and discriminated against, with this risk being much higher in transgender patients.
For MSM, there is a high risk of HIV and other STIs such as herpes simplex virus type 2 (HSV2), human papillomavirus (HPV), gonorrhea, and chlamydia, Dr. Landriscina said. They are also at risk for hepatitis A, B, and C; clusters of meningococcal meningitis; and human herpes virus 8. While MSM are more likely to use sunscreen, they also are more likely to use tanning beds and not wear protective clothing outdoors, and are at a greater risk of skin cancer. The risks of body dysmorphia and eating disorders are also increased for MSM.
While there is not as much research on risk factors for women who have sex with women (WSW), they are still at risk for HIV, HSV, and HPV and are less likely to engage in safe sex practices. For women who have sex with both men and other women, there is an even greater risk of STIs. While WSW are more likely to perceive less need for screening, they should be given the same screening as all other women, and dermatologists can help by ensuring these patients are connected with primary care providers, he said.
Dermatologic sequelae for transgender patients
For patients who transition from male to female, there is little information on their sexual risk from studies, but their care should be managed similarly to MSM, Dr. Landriscina said. When seeing transgender patients, dermatologists should be aware of issues of gender dysphoria, but not offer any intervention without first having a conversation about the patient’s hopes and goals. “Not every patient will have the means or desire to have everything that you can offer,” he said.
For patients who choose to undergo a female-to-male transition, dermatological sequelae may include classical manifestations of androgen excess from hormone therapy such as acne and androgenic alopecia; acne, miliaria, tinea corporis, contact dermatitis from chest binding; and surgical scars and keloids. For acne, isotretinoin is an option if a case is severe, but dermatologists should be aware these patients may still be able to become pregnant. There is no consensus on treatment for androgenic alopecia, but use of finasteride might block wanted secondary sex characteristics, Dr. Landriscina noted.
Patients who undergo a male-to-female transition may develop melasma or asteatotic eczema while receiving estrogen therapy; unwanted facial or body hair; and complications from illicit “filler” injections that may cause foreign-body granulomas, bacterial or atypical mycobacterial infection, lymphedema, and scarring.
Transgender patients may choose to undergo aesthetic treatments that can affirm their gender and decrease their gender dysphoria, augment the effects of hormone therapy and gender-confirmation surgery, and improve their quality of life. “While this has classically fallen under the purview of plastic surgery, I feel like we’re uniquely positioned to provide really life-changing aesthetic services to these patients,” Dr. Landriscina said.
Creating an inclusive environment is key to successfully caring for SGM patients. Any practice policies should have SGM-inclusive language, employees should receive mandatory LGBTQ+ focused training, and a point person should oversee LGBTQ+ matters, according to the Joint Commission’s LGBT Guide. Practices should also begin collecting data on sexual orientation and gender identity, which may help patients who are reluctant to vocally disclose their sexual orientation and gender identity and expand understanding of SGM patients. “Before you even walk into that visit, you know what the patient’s identity is, how they want to be addressed,” said Dr. Landriscina. “It also shows patients that you value what their identities are and that you’re competent in taking care of them.”
Dr. Landriscina encouraged attendees to take the information they learned in the session and “run with it.”
“Go for it. Keep learning,” he said. “There’s more about this topic than I even had the chance to include. Your patients are going to appreciate your dedication to them.”
In an interview, Adam Friedman, MD, professor and interim chair of dermatology at George Washington University and medical director of ODAC, acknowledged the large gaps in care for SGM patients and the unique role dermatologists can play in their care, both in terms of medical and surgical procedures.
“There are specific considerations that we as dermatologists need to think about in terms of just quality of life, potentially mental disease, homelessness, access to care. I think if we consider the whole picture, we can not only provide dermatologic care, but maybe serve as a pivot point to direct them to other specialists, and other physicians, and even nonphysicians who play a role in all facets of life to really get these individuals all the care, in broader senses, that they need,” he said.
Dr. Landriscina reported no relevant conflicts of interest.
ORLANDO – There is a these patients, Angelo Landriscina, MD, said at the ODAC Dermatology, Aesthetic, & Clinical Conference.
“Our knowledge lagging behind is really to our own detriment,” said Dr. Landriscina, chief resident of dermatology at George Washington University, Washington. “The unique comorbidities and lived experiences of queer patients can impact their dermatologic disease. In addition to that, we are in a really unique position to provide life-changing care for these patients.”
The topic of dermatologic care for SGM patients has been discussed with interest in the dermatology community, but it has not been well studied. In one of two papers recently published in Pediatric Dermatology, Markus D. Boos, MD, PhD, from the University of Washington, Seattle, and Seattle Children’s Hospital, and coauthors noted that there is a particular knowledge gap in how to care for SGM pediatric and adolescent patients (Pediatr Dermatol. 2019 Sep;36[5]:581-6; 587-93).
In his presentation, Dr. Landriscina outlined the differences between sexual orientation – an emotional, romantic, or sexual attraction to others – and gender identity, or how one perceives their own gender. Lesbian, gay, transgender, and queer/questioning are classical definitions, but SGM patients may also self-identify in any number of other ways. Some SGM patients may identify as gender-fluid or nonbinary, while genderqueer is an umbrella term for individuals who don’t identify with typical gender roles. On the topic of pronouns, asking SGM patients how they want to be referred to is ideal, but the singular they is considered a gender-neutral term that should work for most situations.
There are also terms to avoid: “Homosexual” may be acceptable to some SGM patients, but is from an era when same-sex attraction was pathologized; “sexual preference” characterizes sexuality as a choice; the term “lifestyle” perpetuates the idea that all SGM patients are the same; and referring to transgender patients as "pre-op" or "post-op" is problematic as these terms imply that transgender identity is defined by a medical transition. Using transgender or gay as a noun, or the word transsexual, is offensive and shouldn’t be used at all, according to Dr. Landriscina.
As these terms continue to change and be redefined, dermatologists are likely to encounter terms they are unfamiliar with in the clinic, but he emphasized that attendees need not know every term to care for these patients. “The easiest way to be right in all of these situations is to let your patients define themselves,” he said, but noted that “assumptions are your worst enemy. You’re going to have to ask the hard questions.”
Updating understanding of SGM patients
Much of the medical community’s understanding of SGM patients hasn’t been updated in decades, Dr. Landriscina said. For example, medical school students typically learn about SGM risk factors that only apply to men who have sex with men (MSM), but there is new interest in caring for transgender patients within dermatology. The focus on classical notions for treating MSM can be reductive, Dr. Landriscina explained. “It boils a whole community of people down to one disease process. I think that we need to expand the thought that there are other associations here. There are other risks these patients face.”
In contrast, dermatologists who strive to understand their patients can better see them as a whole person, can engage in a better differential diagnosis, are aware of the current comorbidities SGM patients face that affect dermatologic disease, and can even work with the patient toward preventative care.
“It’s been decades since we’ve had a paradigm shift about this, and I think it’s time,” he said.
Overall, SGM patients have a higher likelihood of suffering from mental illness and suicidal ideation, with 10%-20% of lesbian, gay, and bisexual patients attempting suicide. Gender-minority patients have a significantly higher rate of attempting suicide at 40%. SGM patients are also more likely to be homeless and uninsured, and have the highest rates of tobacco, alcohol, and illicit drug use. In the SGM population, there is a higher likelihood of being victimized, and discriminated against, with this risk being much higher in transgender patients.
For MSM, there is a high risk of HIV and other STIs such as herpes simplex virus type 2 (HSV2), human papillomavirus (HPV), gonorrhea, and chlamydia, Dr. Landriscina said. They are also at risk for hepatitis A, B, and C; clusters of meningococcal meningitis; and human herpes virus 8. While MSM are more likely to use sunscreen, they also are more likely to use tanning beds and not wear protective clothing outdoors, and are at a greater risk of skin cancer. The risks of body dysmorphia and eating disorders are also increased for MSM.
While there is not as much research on risk factors for women who have sex with women (WSW), they are still at risk for HIV, HSV, and HPV and are less likely to engage in safe sex practices. For women who have sex with both men and other women, there is an even greater risk of STIs. While WSW are more likely to perceive less need for screening, they should be given the same screening as all other women, and dermatologists can help by ensuring these patients are connected with primary care providers, he said.
Dermatologic sequelae for transgender patients
For patients who transition from male to female, there is little information on their sexual risk from studies, but their care should be managed similarly to MSM, Dr. Landriscina said. When seeing transgender patients, dermatologists should be aware of issues of gender dysphoria, but not offer any intervention without first having a conversation about the patient’s hopes and goals. “Not every patient will have the means or desire to have everything that you can offer,” he said.
For patients who choose to undergo a female-to-male transition, dermatological sequelae may include classical manifestations of androgen excess from hormone therapy such as acne and androgenic alopecia; acne, miliaria, tinea corporis, contact dermatitis from chest binding; and surgical scars and keloids. For acne, isotretinoin is an option if a case is severe, but dermatologists should be aware these patients may still be able to become pregnant. There is no consensus on treatment for androgenic alopecia, but use of finasteride might block wanted secondary sex characteristics, Dr. Landriscina noted.
Patients who undergo a male-to-female transition may develop melasma or asteatotic eczema while receiving estrogen therapy; unwanted facial or body hair; and complications from illicit “filler” injections that may cause foreign-body granulomas, bacterial or atypical mycobacterial infection, lymphedema, and scarring.
Transgender patients may choose to undergo aesthetic treatments that can affirm their gender and decrease their gender dysphoria, augment the effects of hormone therapy and gender-confirmation surgery, and improve their quality of life. “While this has classically fallen under the purview of plastic surgery, I feel like we’re uniquely positioned to provide really life-changing aesthetic services to these patients,” Dr. Landriscina said.
Creating an inclusive environment is key to successfully caring for SGM patients. Any practice policies should have SGM-inclusive language, employees should receive mandatory LGBTQ+ focused training, and a point person should oversee LGBTQ+ matters, according to the Joint Commission’s LGBT Guide. Practices should also begin collecting data on sexual orientation and gender identity, which may help patients who are reluctant to vocally disclose their sexual orientation and gender identity and expand understanding of SGM patients. “Before you even walk into that visit, you know what the patient’s identity is, how they want to be addressed,” said Dr. Landriscina. “It also shows patients that you value what their identities are and that you’re competent in taking care of them.”
Dr. Landriscina encouraged attendees to take the information they learned in the session and “run with it.”
“Go for it. Keep learning,” he said. “There’s more about this topic than I even had the chance to include. Your patients are going to appreciate your dedication to them.”
In an interview, Adam Friedman, MD, professor and interim chair of dermatology at George Washington University and medical director of ODAC, acknowledged the large gaps in care for SGM patients and the unique role dermatologists can play in their care, both in terms of medical and surgical procedures.
“There are specific considerations that we as dermatologists need to think about in terms of just quality of life, potentially mental disease, homelessness, access to care. I think if we consider the whole picture, we can not only provide dermatologic care, but maybe serve as a pivot point to direct them to other specialists, and other physicians, and even nonphysicians who play a role in all facets of life to really get these individuals all the care, in broader senses, that they need,” he said.
Dr. Landriscina reported no relevant conflicts of interest.
EXPERT ANALYSIS FROM ODAC 2020