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Treatment of several nail disorders reviewed
ORLANDO – at the ODAC Dermatology, Aesthetic, & Surgical Conference.
Dr. Hinshaw, professor of dermatology at the University of Wisconsin, Madison, reviewed several disorders and provided guidance on diagnosis, and achieving the best outcomes for patients.
Retronychia: This is an ingrowth of the proximal nail plate into the proximal nail fold, which mimics chronic paronychia, or nail inflammation. A key to the diagnosis is elevation of the proximal nail plate, Dr. Hinshaw said, along with yellowing of the nail. In some cases, a second or even third nail can be seen growing under the nail plate, she said.
“There has been traumatic lifting of the central portion of the nail plate over the matrix,” she explained. “The body thinks it needs to make a new nail plate, so it starts to do that while the primary nail plate has not yet let go.”
Sometimes, treatment with topical steroids will be effective, she said, but there might be secondary changes that require further treatment. She referred to a systematic review and a suggested treatment algorithm for retronychia, published in 2022, which can be helpful. “Even though this entity is not very well studied, there are at least some consensus approaches that the proximal nail plate needs to be removed, if not the entire nail plate,” she said.
Onycholysis: Essential to treatment of this disorder – separation of the nail from the nail bed – is knowing when it is secondary to another issue, whether it is a fungal infection, psoriasis, or tumor under the nail.
When a patient has primary onycholysis “and there’s nothing else going on in the nail, remember to try retinoids,” Dr. Hinshaw said. She suggested clipping back the nail and treating the nail bed every night with tretinoin 0.025%. If the nail bed becomes irritated, patients can pause treatment for a few days, she said.
If onycholysis has been present for 6-12 months, it can become permanent. But she said she has had success treating patients who’ve had it for a year or even a little longer, “so what we don’t want to do is give up hope for patients.”
Pyogenic granuloma (PG) in the nail: These are benign vascular tumors that can mimic more serious conditions, Dr. Hinshaw said. In adults, PG requires a histologic diagnosis, she said.
“So these all really should have a biopsy,” because of potential confusion with amelanotic melanoma or squamous cell carcinoma, she said, although in children, a biopsy is likely not necessary.
Treatment with topical beta-blockers can be effective for PG, she said, and avoids the scarring seen with surgical removal. “These are benign conditions – we want them to go away, but we want these patients to have a functional nail thereafter.”
Periungual or subungual warts: For these warts, which are alongside or under the nail, destructive approaches can cause scarring of the nail bed and are far from optimal, she said.
“We’d like to avoid that, of course.” Therefore, treatments such as lasers and liquid nitrogen “would be much further down, if at all, on my list,” she said.
Injections of the antiviral cidofovir, into the dermis right under the wart, can be highly effective, and one or two treatments is often enough, Dr. Hinshaw said. Sometimes, local anesthesia isn’t even needed for the injection, she said. “This is a wonderful option,” she added.
Dr. Hinshaw is co-owner and chief medical officer of Acure.
ORLANDO – at the ODAC Dermatology, Aesthetic, & Surgical Conference.
Dr. Hinshaw, professor of dermatology at the University of Wisconsin, Madison, reviewed several disorders and provided guidance on diagnosis, and achieving the best outcomes for patients.
Retronychia: This is an ingrowth of the proximal nail plate into the proximal nail fold, which mimics chronic paronychia, or nail inflammation. A key to the diagnosis is elevation of the proximal nail plate, Dr. Hinshaw said, along with yellowing of the nail. In some cases, a second or even third nail can be seen growing under the nail plate, she said.
“There has been traumatic lifting of the central portion of the nail plate over the matrix,” she explained. “The body thinks it needs to make a new nail plate, so it starts to do that while the primary nail plate has not yet let go.”
Sometimes, treatment with topical steroids will be effective, she said, but there might be secondary changes that require further treatment. She referred to a systematic review and a suggested treatment algorithm for retronychia, published in 2022, which can be helpful. “Even though this entity is not very well studied, there are at least some consensus approaches that the proximal nail plate needs to be removed, if not the entire nail plate,” she said.
Onycholysis: Essential to treatment of this disorder – separation of the nail from the nail bed – is knowing when it is secondary to another issue, whether it is a fungal infection, psoriasis, or tumor under the nail.
When a patient has primary onycholysis “and there’s nothing else going on in the nail, remember to try retinoids,” Dr. Hinshaw said. She suggested clipping back the nail and treating the nail bed every night with tretinoin 0.025%. If the nail bed becomes irritated, patients can pause treatment for a few days, she said.
If onycholysis has been present for 6-12 months, it can become permanent. But she said she has had success treating patients who’ve had it for a year or even a little longer, “so what we don’t want to do is give up hope for patients.”
Pyogenic granuloma (PG) in the nail: These are benign vascular tumors that can mimic more serious conditions, Dr. Hinshaw said. In adults, PG requires a histologic diagnosis, she said.
“So these all really should have a biopsy,” because of potential confusion with amelanotic melanoma or squamous cell carcinoma, she said, although in children, a biopsy is likely not necessary.
Treatment with topical beta-blockers can be effective for PG, she said, and avoids the scarring seen with surgical removal. “These are benign conditions – we want them to go away, but we want these patients to have a functional nail thereafter.”
Periungual or subungual warts: For these warts, which are alongside or under the nail, destructive approaches can cause scarring of the nail bed and are far from optimal, she said.
“We’d like to avoid that, of course.” Therefore, treatments such as lasers and liquid nitrogen “would be much further down, if at all, on my list,” she said.
Injections of the antiviral cidofovir, into the dermis right under the wart, can be highly effective, and one or two treatments is often enough, Dr. Hinshaw said. Sometimes, local anesthesia isn’t even needed for the injection, she said. “This is a wonderful option,” she added.
Dr. Hinshaw is co-owner and chief medical officer of Acure.
ORLANDO – at the ODAC Dermatology, Aesthetic, & Surgical Conference.
Dr. Hinshaw, professor of dermatology at the University of Wisconsin, Madison, reviewed several disorders and provided guidance on diagnosis, and achieving the best outcomes for patients.
Retronychia: This is an ingrowth of the proximal nail plate into the proximal nail fold, which mimics chronic paronychia, or nail inflammation. A key to the diagnosis is elevation of the proximal nail plate, Dr. Hinshaw said, along with yellowing of the nail. In some cases, a second or even third nail can be seen growing under the nail plate, she said.
“There has been traumatic lifting of the central portion of the nail plate over the matrix,” she explained. “The body thinks it needs to make a new nail plate, so it starts to do that while the primary nail plate has not yet let go.”
Sometimes, treatment with topical steroids will be effective, she said, but there might be secondary changes that require further treatment. She referred to a systematic review and a suggested treatment algorithm for retronychia, published in 2022, which can be helpful. “Even though this entity is not very well studied, there are at least some consensus approaches that the proximal nail plate needs to be removed, if not the entire nail plate,” she said.
Onycholysis: Essential to treatment of this disorder – separation of the nail from the nail bed – is knowing when it is secondary to another issue, whether it is a fungal infection, psoriasis, or tumor under the nail.
When a patient has primary onycholysis “and there’s nothing else going on in the nail, remember to try retinoids,” Dr. Hinshaw said. She suggested clipping back the nail and treating the nail bed every night with tretinoin 0.025%. If the nail bed becomes irritated, patients can pause treatment for a few days, she said.
If onycholysis has been present for 6-12 months, it can become permanent. But she said she has had success treating patients who’ve had it for a year or even a little longer, “so what we don’t want to do is give up hope for patients.”
Pyogenic granuloma (PG) in the nail: These are benign vascular tumors that can mimic more serious conditions, Dr. Hinshaw said. In adults, PG requires a histologic diagnosis, she said.
“So these all really should have a biopsy,” because of potential confusion with amelanotic melanoma or squamous cell carcinoma, she said, although in children, a biopsy is likely not necessary.
Treatment with topical beta-blockers can be effective for PG, she said, and avoids the scarring seen with surgical removal. “These are benign conditions – we want them to go away, but we want these patients to have a functional nail thereafter.”
Periungual or subungual warts: For these warts, which are alongside or under the nail, destructive approaches can cause scarring of the nail bed and are far from optimal, she said.
“We’d like to avoid that, of course.” Therefore, treatments such as lasers and liquid nitrogen “would be much further down, if at all, on my list,” she said.
Injections of the antiviral cidofovir, into the dermis right under the wart, can be highly effective, and one or two treatments is often enough, Dr. Hinshaw said. Sometimes, local anesthesia isn’t even needed for the injection, she said. “This is a wonderful option,” she added.
Dr. Hinshaw is co-owner and chief medical officer of Acure.
AT ODAC 2023
Developments in wound healing include different treatment options
ORLANDO – , Hadar Lev-Tov, MD, said at the ODAC Dermatology, Aesthetic & Surgery Conference.
At the meeting, Dr. Lev-Tov, associate professor of dermatology at the University of Miami, reviewed some of the latest developments in several conditions involving wound care.
Pyoderma gangrenosum (PG): In this condition, pustules or nodules become large ulcerations, and one-third of patients with PG have pathergy, exaggerated skin injury after a mild trauma such as a bump or a bruise.
“You want to look at the clues in the history because 20% of these patients had histories of PG elsewhere,” Dr. Lev-Tov said. “Ask them about other ulcers, maybe they had some wound dehiscence history.”
Criteria have been developed to help with the diagnosis of ulcerative PG, which includes one major criterion, a biopsy of the ulcer edge showing neutrophilic infiltrate, along with minor criteria, including exclusion of an infection, pathergy, and a history of inflammatory bowel disease or inflammatory arthritis.
“This is no longer a diagnosis of exclusion,” Dr. Lev-Tov said.
Cyclosporine and oral steroids have been found to work well, but it typically takes many months before healing occurs. Tacrolimus or topical steroids can work as well, but healing also takes a fairly long time with those medications, Dr. Lev-Tov said.
The tumor necrosis factor (TNF) blocker infliximab is another option. He had a patient who was referred to him who had been treated with cyclosporine for 3 years for PG on his feet, even though it had not been effective. Dr. Lev-Tov tried infliximab, and the wounds finally cleared, he said.
Apremilast, a phosphodiesterase 4 (PDE4)-inhibitor, is another option for treating PG, he said. “Anecdotally, I used apremilast on three patients with recurrent PG for long-term suppression, with success,” he noted.
Epidermal grafting using suction and heat is an approach that might deserve further exploration for PG, Dr. Lev-Tov suggested. With this procedure, described in an article in 2014, heat and suction are used to induce blistering to separate and remove the epidermis from the dermis at the dermal-epidermal junction, creating an epidermal graft is placed over the wound to promote healing. Patients with PG who are immunosuppressed but demonstrate pathergy do not tend to experience pathergy when epidermal skin grafting is performed, he said.
The heat-suction procedure is simple, painless, and scarless, but better controlled data on this approach are needed, he said.
Corona phlebectatica: This disease involving abnormally dilated veins near the ankle has received formal recognition as a sign of venous insufficiency, in a 2020 update of a classification system for describing patients with chronic venous disorders, Dr. Lev-Tov said.
“We knew about it for years, but now there’s some data that can actually predict the severity of disease,” and, he said, it is now a part of the diagnostic criteria for venous insufficiency .
Venous leg ulcers: These often painful sores on the inside of the leg typically take more than a month to heal. A systematic review of placebo-controlled studies of pentoxifylline as a treatment for venous leg ulcers, published in 2021, supports its use for healing venous leg ulcers, Dr. Lev-Tov said. “It improved the healing rate and increased what [the researchers] called ‘significant improvement,’ ” a category they created to account for the varying methods across the studies, he said.
Topical beta-blockers can improve epithelialization and fibroblast migration in wound healing, he said. A study on topical timolol for various wounds found that a 0.5% formulation of topical timolol, with one drop applied per square centimeter as frequently as possible, was effective in healing. But the healing process was prolonged – a median of 90 days, said Dr. Lev-Tov, one of the study authors.
“When you start this, I don’t want you to expect the wound to heal tomorrow,” he said. “You’ve got to educate your patient.”
Dr. Lev-Tov reports relevant financial relationships with Abbvie, Novartis, Pfizer and other companies.
ORLANDO – , Hadar Lev-Tov, MD, said at the ODAC Dermatology, Aesthetic & Surgery Conference.
At the meeting, Dr. Lev-Tov, associate professor of dermatology at the University of Miami, reviewed some of the latest developments in several conditions involving wound care.
Pyoderma gangrenosum (PG): In this condition, pustules or nodules become large ulcerations, and one-third of patients with PG have pathergy, exaggerated skin injury after a mild trauma such as a bump or a bruise.
“You want to look at the clues in the history because 20% of these patients had histories of PG elsewhere,” Dr. Lev-Tov said. “Ask them about other ulcers, maybe they had some wound dehiscence history.”
Criteria have been developed to help with the diagnosis of ulcerative PG, which includes one major criterion, a biopsy of the ulcer edge showing neutrophilic infiltrate, along with minor criteria, including exclusion of an infection, pathergy, and a history of inflammatory bowel disease or inflammatory arthritis.
“This is no longer a diagnosis of exclusion,” Dr. Lev-Tov said.
Cyclosporine and oral steroids have been found to work well, but it typically takes many months before healing occurs. Tacrolimus or topical steroids can work as well, but healing also takes a fairly long time with those medications, Dr. Lev-Tov said.
The tumor necrosis factor (TNF) blocker infliximab is another option. He had a patient who was referred to him who had been treated with cyclosporine for 3 years for PG on his feet, even though it had not been effective. Dr. Lev-Tov tried infliximab, and the wounds finally cleared, he said.
Apremilast, a phosphodiesterase 4 (PDE4)-inhibitor, is another option for treating PG, he said. “Anecdotally, I used apremilast on three patients with recurrent PG for long-term suppression, with success,” he noted.
Epidermal grafting using suction and heat is an approach that might deserve further exploration for PG, Dr. Lev-Tov suggested. With this procedure, described in an article in 2014, heat and suction are used to induce blistering to separate and remove the epidermis from the dermis at the dermal-epidermal junction, creating an epidermal graft is placed over the wound to promote healing. Patients with PG who are immunosuppressed but demonstrate pathergy do not tend to experience pathergy when epidermal skin grafting is performed, he said.
The heat-suction procedure is simple, painless, and scarless, but better controlled data on this approach are needed, he said.
Corona phlebectatica: This disease involving abnormally dilated veins near the ankle has received formal recognition as a sign of venous insufficiency, in a 2020 update of a classification system for describing patients with chronic venous disorders, Dr. Lev-Tov said.
“We knew about it for years, but now there’s some data that can actually predict the severity of disease,” and, he said, it is now a part of the diagnostic criteria for venous insufficiency .
Venous leg ulcers: These often painful sores on the inside of the leg typically take more than a month to heal. A systematic review of placebo-controlled studies of pentoxifylline as a treatment for venous leg ulcers, published in 2021, supports its use for healing venous leg ulcers, Dr. Lev-Tov said. “It improved the healing rate and increased what [the researchers] called ‘significant improvement,’ ” a category they created to account for the varying methods across the studies, he said.
Topical beta-blockers can improve epithelialization and fibroblast migration in wound healing, he said. A study on topical timolol for various wounds found that a 0.5% formulation of topical timolol, with one drop applied per square centimeter as frequently as possible, was effective in healing. But the healing process was prolonged – a median of 90 days, said Dr. Lev-Tov, one of the study authors.
“When you start this, I don’t want you to expect the wound to heal tomorrow,” he said. “You’ve got to educate your patient.”
Dr. Lev-Tov reports relevant financial relationships with Abbvie, Novartis, Pfizer and other companies.
ORLANDO – , Hadar Lev-Tov, MD, said at the ODAC Dermatology, Aesthetic & Surgery Conference.
At the meeting, Dr. Lev-Tov, associate professor of dermatology at the University of Miami, reviewed some of the latest developments in several conditions involving wound care.
Pyoderma gangrenosum (PG): In this condition, pustules or nodules become large ulcerations, and one-third of patients with PG have pathergy, exaggerated skin injury after a mild trauma such as a bump or a bruise.
“You want to look at the clues in the history because 20% of these patients had histories of PG elsewhere,” Dr. Lev-Tov said. “Ask them about other ulcers, maybe they had some wound dehiscence history.”
Criteria have been developed to help with the diagnosis of ulcerative PG, which includes one major criterion, a biopsy of the ulcer edge showing neutrophilic infiltrate, along with minor criteria, including exclusion of an infection, pathergy, and a history of inflammatory bowel disease or inflammatory arthritis.
“This is no longer a diagnosis of exclusion,” Dr. Lev-Tov said.
Cyclosporine and oral steroids have been found to work well, but it typically takes many months before healing occurs. Tacrolimus or topical steroids can work as well, but healing also takes a fairly long time with those medications, Dr. Lev-Tov said.
The tumor necrosis factor (TNF) blocker infliximab is another option. He had a patient who was referred to him who had been treated with cyclosporine for 3 years for PG on his feet, even though it had not been effective. Dr. Lev-Tov tried infliximab, and the wounds finally cleared, he said.
Apremilast, a phosphodiesterase 4 (PDE4)-inhibitor, is another option for treating PG, he said. “Anecdotally, I used apremilast on three patients with recurrent PG for long-term suppression, with success,” he noted.
Epidermal grafting using suction and heat is an approach that might deserve further exploration for PG, Dr. Lev-Tov suggested. With this procedure, described in an article in 2014, heat and suction are used to induce blistering to separate and remove the epidermis from the dermis at the dermal-epidermal junction, creating an epidermal graft is placed over the wound to promote healing. Patients with PG who are immunosuppressed but demonstrate pathergy do not tend to experience pathergy when epidermal skin grafting is performed, he said.
The heat-suction procedure is simple, painless, and scarless, but better controlled data on this approach are needed, he said.
Corona phlebectatica: This disease involving abnormally dilated veins near the ankle has received formal recognition as a sign of venous insufficiency, in a 2020 update of a classification system for describing patients with chronic venous disorders, Dr. Lev-Tov said.
“We knew about it for years, but now there’s some data that can actually predict the severity of disease,” and, he said, it is now a part of the diagnostic criteria for venous insufficiency .
Venous leg ulcers: These often painful sores on the inside of the leg typically take more than a month to heal. A systematic review of placebo-controlled studies of pentoxifylline as a treatment for venous leg ulcers, published in 2021, supports its use for healing venous leg ulcers, Dr. Lev-Tov said. “It improved the healing rate and increased what [the researchers] called ‘significant improvement,’ ” a category they created to account for the varying methods across the studies, he said.
Topical beta-blockers can improve epithelialization and fibroblast migration in wound healing, he said. A study on topical timolol for various wounds found that a 0.5% formulation of topical timolol, with one drop applied per square centimeter as frequently as possible, was effective in healing. But the healing process was prolonged – a median of 90 days, said Dr. Lev-Tov, one of the study authors.
“When you start this, I don’t want you to expect the wound to heal tomorrow,” he said. “You’ve got to educate your patient.”
Dr. Lev-Tov reports relevant financial relationships with Abbvie, Novartis, Pfizer and other companies.
AT ODAC 2023
Expert gives tips on less-discussed dermatologic diseases
ORLANDO – , according to Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington.
These semi-forsaken diseases are important not to miss and can “also be quite challenging when we think about their management,” he said at the ODAC Dermatology, Aesthetic & Surgical Conference.
Dr. Friedman, also director of the GW dermatology residency program, reviewed several of these diseases – along with tips for management – during a session at the meeting.
. It does not always have the classic ring pattern for which it is best known, he said. And in patients with darker skin tones, it is characterized by more of a brown or black color, rather than the pink-red color.
Dr. Friedman said that despite a kind of “Pavlovian response” linking GA with diabetes, this link might not be as strong as the field has come to believe, since the studies on which this belief was based included a patient population with narrow demographics. “Maybe GA and type 1 diabetes aren’t necessarily connected,” he said.
Dyslipidemia, on the other hand, has a strong connection with GA, he said. The disease is also linked to thyroid disease and is linked with malignancy, especially in older patients with generalized or atypical presentations of GA, he said.
Spontaneous resolution of the disease is seen within 2 years for 50% to 75% of patients, so “no treatment may be the best treatment,” but antimalarials can be effective, Dr. Friedman said. “I use antimalarials frequently in my practice,” he said. “The key is, they take time to work (4-5 months),” which should be explained to patients.
Antibiotics, he said, can be “somewhat effective,” but in the case of doxycycline at least, the disease can resolve within weeks but then may return when treatment is stopped.
There is some evidence to support using biologics and more recently, Janus kinase (JAK) inhibitors, off-label, to treat GA. Efficacy has been seen with the tumor necrosis factor (TNF) blocker infliximab and with the JAK inhibitor tofacitinib, he said.
Lichen planus (LP). This is another common disease that can go off-script with its presentation. The disease is often described with the “six P’s” indicating the following characteristics: pruritic, polygonal, planar or flat-topped, purple papules, and plaques. But LP “didn’t read the textbook,” Dr. Friedman said.
“The clinical presentation of lichen planus can be quite broad,” he said. “The P’s aren’t always followed as there are a variety of colors and configurations which can be witnessed.”
With LP, there is a clear association with dyslipidemia and diabetes, so “asking the right questions is going to be important” when talking to the patient. There is also a higher risk of autoimmune diseases, especially of the thyroid type, associated with LP, he said.
No treatment has been Food and Drug Administration approved for LP, but some are expected in the future, he said.
For now, he emphasized creativity in the management of patients with LP. “I love oral retinoids for this,” he said. Antimalarials and methotrexate are also options.
In one case Dr. Friedman saw, nothing seemed to work: light therapy for a year; metronidazole; isotretinoin; halobetasol/tazarotene lotion; and the TNF-blocker adalimumab either weren’t effective or resulted in complications in the patient.
Knowing the recent implication of the interleukin (IL)-17 pathway in the pathophysiology of LP, he then tried the anti-IL17 antibody secukinumab. “This patient had a pretty robust response to treatment,” Dr. Friedman said. “He was very excited. The problem, as always, is access, especially for off-label therapies.”
Tumid lupus erythematosus. This disease is characterized by erythematous, edematous, nonscarring plaques on sun-exposed sites. For treatment, Dr. Friedman said antimalarials can be up to 90% effective, sometimes with rapid resolution of the lesions.
“You want to dose below that 5 mg per kg of true body weight to limit the small potential for ocular toxicity over time,” he said. And, he emphasized, “always combine treatment with good sun-protective measures.”
Dr. Friedman reported financial relationships with Sanova, Pfizer, Novartis, and other companies.
ORLANDO – , according to Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington.
These semi-forsaken diseases are important not to miss and can “also be quite challenging when we think about their management,” he said at the ODAC Dermatology, Aesthetic & Surgical Conference.
Dr. Friedman, also director of the GW dermatology residency program, reviewed several of these diseases – along with tips for management – during a session at the meeting.
. It does not always have the classic ring pattern for which it is best known, he said. And in patients with darker skin tones, it is characterized by more of a brown or black color, rather than the pink-red color.
Dr. Friedman said that despite a kind of “Pavlovian response” linking GA with diabetes, this link might not be as strong as the field has come to believe, since the studies on which this belief was based included a patient population with narrow demographics. “Maybe GA and type 1 diabetes aren’t necessarily connected,” he said.
Dyslipidemia, on the other hand, has a strong connection with GA, he said. The disease is also linked to thyroid disease and is linked with malignancy, especially in older patients with generalized or atypical presentations of GA, he said.
Spontaneous resolution of the disease is seen within 2 years for 50% to 75% of patients, so “no treatment may be the best treatment,” but antimalarials can be effective, Dr. Friedman said. “I use antimalarials frequently in my practice,” he said. “The key is, they take time to work (4-5 months),” which should be explained to patients.
Antibiotics, he said, can be “somewhat effective,” but in the case of doxycycline at least, the disease can resolve within weeks but then may return when treatment is stopped.
There is some evidence to support using biologics and more recently, Janus kinase (JAK) inhibitors, off-label, to treat GA. Efficacy has been seen with the tumor necrosis factor (TNF) blocker infliximab and with the JAK inhibitor tofacitinib, he said.
Lichen planus (LP). This is another common disease that can go off-script with its presentation. The disease is often described with the “six P’s” indicating the following characteristics: pruritic, polygonal, planar or flat-topped, purple papules, and plaques. But LP “didn’t read the textbook,” Dr. Friedman said.
“The clinical presentation of lichen planus can be quite broad,” he said. “The P’s aren’t always followed as there are a variety of colors and configurations which can be witnessed.”
With LP, there is a clear association with dyslipidemia and diabetes, so “asking the right questions is going to be important” when talking to the patient. There is also a higher risk of autoimmune diseases, especially of the thyroid type, associated with LP, he said.
No treatment has been Food and Drug Administration approved for LP, but some are expected in the future, he said.
For now, he emphasized creativity in the management of patients with LP. “I love oral retinoids for this,” he said. Antimalarials and methotrexate are also options.
In one case Dr. Friedman saw, nothing seemed to work: light therapy for a year; metronidazole; isotretinoin; halobetasol/tazarotene lotion; and the TNF-blocker adalimumab either weren’t effective or resulted in complications in the patient.
Knowing the recent implication of the interleukin (IL)-17 pathway in the pathophysiology of LP, he then tried the anti-IL17 antibody secukinumab. “This patient had a pretty robust response to treatment,” Dr. Friedman said. “He was very excited. The problem, as always, is access, especially for off-label therapies.”
Tumid lupus erythematosus. This disease is characterized by erythematous, edematous, nonscarring plaques on sun-exposed sites. For treatment, Dr. Friedman said antimalarials can be up to 90% effective, sometimes with rapid resolution of the lesions.
“You want to dose below that 5 mg per kg of true body weight to limit the small potential for ocular toxicity over time,” he said. And, he emphasized, “always combine treatment with good sun-protective measures.”
Dr. Friedman reported financial relationships with Sanova, Pfizer, Novartis, and other companies.
ORLANDO – , according to Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington.
These semi-forsaken diseases are important not to miss and can “also be quite challenging when we think about their management,” he said at the ODAC Dermatology, Aesthetic & Surgical Conference.
Dr. Friedman, also director of the GW dermatology residency program, reviewed several of these diseases – along with tips for management – during a session at the meeting.
. It does not always have the classic ring pattern for which it is best known, he said. And in patients with darker skin tones, it is characterized by more of a brown or black color, rather than the pink-red color.
Dr. Friedman said that despite a kind of “Pavlovian response” linking GA with diabetes, this link might not be as strong as the field has come to believe, since the studies on which this belief was based included a patient population with narrow demographics. “Maybe GA and type 1 diabetes aren’t necessarily connected,” he said.
Dyslipidemia, on the other hand, has a strong connection with GA, he said. The disease is also linked to thyroid disease and is linked with malignancy, especially in older patients with generalized or atypical presentations of GA, he said.
Spontaneous resolution of the disease is seen within 2 years for 50% to 75% of patients, so “no treatment may be the best treatment,” but antimalarials can be effective, Dr. Friedman said. “I use antimalarials frequently in my practice,” he said. “The key is, they take time to work (4-5 months),” which should be explained to patients.
Antibiotics, he said, can be “somewhat effective,” but in the case of doxycycline at least, the disease can resolve within weeks but then may return when treatment is stopped.
There is some evidence to support using biologics and more recently, Janus kinase (JAK) inhibitors, off-label, to treat GA. Efficacy has been seen with the tumor necrosis factor (TNF) blocker infliximab and with the JAK inhibitor tofacitinib, he said.
Lichen planus (LP). This is another common disease that can go off-script with its presentation. The disease is often described with the “six P’s” indicating the following characteristics: pruritic, polygonal, planar or flat-topped, purple papules, and plaques. But LP “didn’t read the textbook,” Dr. Friedman said.
“The clinical presentation of lichen planus can be quite broad,” he said. “The P’s aren’t always followed as there are a variety of colors and configurations which can be witnessed.”
With LP, there is a clear association with dyslipidemia and diabetes, so “asking the right questions is going to be important” when talking to the patient. There is also a higher risk of autoimmune diseases, especially of the thyroid type, associated with LP, he said.
No treatment has been Food and Drug Administration approved for LP, but some are expected in the future, he said.
For now, he emphasized creativity in the management of patients with LP. “I love oral retinoids for this,” he said. Antimalarials and methotrexate are also options.
In one case Dr. Friedman saw, nothing seemed to work: light therapy for a year; metronidazole; isotretinoin; halobetasol/tazarotene lotion; and the TNF-blocker adalimumab either weren’t effective or resulted in complications in the patient.
Knowing the recent implication of the interleukin (IL)-17 pathway in the pathophysiology of LP, he then tried the anti-IL17 antibody secukinumab. “This patient had a pretty robust response to treatment,” Dr. Friedman said. “He was very excited. The problem, as always, is access, especially for off-label therapies.”
Tumid lupus erythematosus. This disease is characterized by erythematous, edematous, nonscarring plaques on sun-exposed sites. For treatment, Dr. Friedman said antimalarials can be up to 90% effective, sometimes with rapid resolution of the lesions.
“You want to dose below that 5 mg per kg of true body weight to limit the small potential for ocular toxicity over time,” he said. And, he emphasized, “always combine treatment with good sun-protective measures.”
Dr. Friedman reported financial relationships with Sanova, Pfizer, Novartis, and other companies.
AT ODAC 2023
Expert offers insights on pediatric dermatology emergencies
ORLANDO – The eruption spread away from the head and her transaminase levels were “dramatic,” in the 700s, said Kalyani S. Marathe, MD, MPH, associate professor of dermatology and pediatrics at the University of Cincinnati.
Dr. Marathe, director of the division of dermatology at Cincinnati Children’s Hospital, reviewed this case in a presentation on pediatric dermatologic emergencies at the ODAC Dermatology, Aesthetic & Surgery Conference, pointing out potential pitfalls and important aspects that might require swift action.
The patient was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS).
Facial involvement is common in pediatric cases of DRESS, but edema of the face is less common in children than adults, Dr. Marathe said.
Antiepileptic medications are the most common cause of DRESS, followed by antibiotics – most often, vancomycin and trimethoprim/sulfamethoxazole, she said. But sometimes the trigger is not clear, she noted, recalling a vexing case she once saw in which IV contrast was eventually identified as the cause.
When DRESS is suspected, she said, lab work should be done during the acute eruption and after resolution. This should include CBC, liver function tests, creatinine, and urinalysis, and human herpesvirus 6 (HHV-6) and thyroid testing.
Treatment typically includes supportive care, unless symptoms are systemic, or if there is impending liver failure, when steroids, cyclosporine, or IVIG can be used.
Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN): Mortality rates when these diseases overlap is 4%, Dr. Marathe said. Clues to diagnosing this other medication-induced condition include involvement of the palms and the soles of the feet; presence of the Nikolsky sign in which the top layers of the skin slip away from the lower layers when rubbed; mucosal involvement, which often precedes cutaneous involvement; and these symptoms occurring within the first 8 weeks of taking a medication, which are most commonly antibiotics and anti-epileptics.
Dr. Marathe underscored how important it is to get ophthalmology involved right away, because of the risk of vision loss. Amniotic membrane transfer to the eye at the time of diagnosis has been found to produce dramatically better outcomes, she said. The membrane has anti-inflammatory and antiscarring properties and can promote wound healing on the surface of the eye.
“I would recommend getting your ophthalmology team on board early because they have to advocate for these patients,” she said.
Corticosteroids and IVIG can improve ocular outcomes, but cyclosporine is associated with better mortality outcomes, she said. Emerging data on etanercept has also led to more use of that drug, she said.
Erythema multiforme (EM): unlike urticaria, multiforme EM can have mucosal involvement, Dr. Marathe said. Clinicians should look for three zones of color: A central duskiness, a rim of pallor, and a ring of erythema.
EM is triggered by a virus, which is usually herpes simplex virus (HSV). But she added that HSV is not always found. “So, there are certainly other triggers out there that we just haven’t identified,” she said.
If HSV is suspected, oral acyclovir is effective, she noted.
Other cases might not be as straightforward. Dr. Marathe said that during her fellowship, she saw a patient with EM that was controlled only by IVIG, so it was administered every 3 months. In that case, the trigger was never found.
Multisystem inflammatory syndrome in children (MIS-C): This syndrome can follow COVID-19 infection, and usually presents with 3-5 days of fever after COVID has resolved. It can include gastrointestinal, cardiorespiratory, and neurocognitive symptoms.
The skin presentation is mainly a morbilliform pattern, but clinicians might also see conjunctival involvement, mucosal involvement, and “COVID toes,” painful red or purple lesions on the toes.
Treatment is usually IVIG and systemic corticosteroids, with the treatment course depending on the severity.
MIS-C was initially thought to be Kawasaki’s disease, another autoinflammatory disorder, which is related but distinct, Dr. Marathe said.
Patients with MIS-C “are usually going to have COVID-positive antibodies,” she said. But since almost everybody may have COVID antibodies, “it’s not usually a helpful test for you now. But early on, that’s what we used as helpful indicator.”
Dr. Marathe reported no relevant financial relationships.
ORLANDO – The eruption spread away from the head and her transaminase levels were “dramatic,” in the 700s, said Kalyani S. Marathe, MD, MPH, associate professor of dermatology and pediatrics at the University of Cincinnati.
Dr. Marathe, director of the division of dermatology at Cincinnati Children’s Hospital, reviewed this case in a presentation on pediatric dermatologic emergencies at the ODAC Dermatology, Aesthetic & Surgery Conference, pointing out potential pitfalls and important aspects that might require swift action.
The patient was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS).
Facial involvement is common in pediatric cases of DRESS, but edema of the face is less common in children than adults, Dr. Marathe said.
Antiepileptic medications are the most common cause of DRESS, followed by antibiotics – most often, vancomycin and trimethoprim/sulfamethoxazole, she said. But sometimes the trigger is not clear, she noted, recalling a vexing case she once saw in which IV contrast was eventually identified as the cause.
When DRESS is suspected, she said, lab work should be done during the acute eruption and after resolution. This should include CBC, liver function tests, creatinine, and urinalysis, and human herpesvirus 6 (HHV-6) and thyroid testing.
Treatment typically includes supportive care, unless symptoms are systemic, or if there is impending liver failure, when steroids, cyclosporine, or IVIG can be used.
Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN): Mortality rates when these diseases overlap is 4%, Dr. Marathe said. Clues to diagnosing this other medication-induced condition include involvement of the palms and the soles of the feet; presence of the Nikolsky sign in which the top layers of the skin slip away from the lower layers when rubbed; mucosal involvement, which often precedes cutaneous involvement; and these symptoms occurring within the first 8 weeks of taking a medication, which are most commonly antibiotics and anti-epileptics.
Dr. Marathe underscored how important it is to get ophthalmology involved right away, because of the risk of vision loss. Amniotic membrane transfer to the eye at the time of diagnosis has been found to produce dramatically better outcomes, she said. The membrane has anti-inflammatory and antiscarring properties and can promote wound healing on the surface of the eye.
“I would recommend getting your ophthalmology team on board early because they have to advocate for these patients,” she said.
Corticosteroids and IVIG can improve ocular outcomes, but cyclosporine is associated with better mortality outcomes, she said. Emerging data on etanercept has also led to more use of that drug, she said.
Erythema multiforme (EM): unlike urticaria, multiforme EM can have mucosal involvement, Dr. Marathe said. Clinicians should look for three zones of color: A central duskiness, a rim of pallor, and a ring of erythema.
EM is triggered by a virus, which is usually herpes simplex virus (HSV). But she added that HSV is not always found. “So, there are certainly other triggers out there that we just haven’t identified,” she said.
If HSV is suspected, oral acyclovir is effective, she noted.
Other cases might not be as straightforward. Dr. Marathe said that during her fellowship, she saw a patient with EM that was controlled only by IVIG, so it was administered every 3 months. In that case, the trigger was never found.
Multisystem inflammatory syndrome in children (MIS-C): This syndrome can follow COVID-19 infection, and usually presents with 3-5 days of fever after COVID has resolved. It can include gastrointestinal, cardiorespiratory, and neurocognitive symptoms.
The skin presentation is mainly a morbilliform pattern, but clinicians might also see conjunctival involvement, mucosal involvement, and “COVID toes,” painful red or purple lesions on the toes.
Treatment is usually IVIG and systemic corticosteroids, with the treatment course depending on the severity.
MIS-C was initially thought to be Kawasaki’s disease, another autoinflammatory disorder, which is related but distinct, Dr. Marathe said.
Patients with MIS-C “are usually going to have COVID-positive antibodies,” she said. But since almost everybody may have COVID antibodies, “it’s not usually a helpful test for you now. But early on, that’s what we used as helpful indicator.”
Dr. Marathe reported no relevant financial relationships.
ORLANDO – The eruption spread away from the head and her transaminase levels were “dramatic,” in the 700s, said Kalyani S. Marathe, MD, MPH, associate professor of dermatology and pediatrics at the University of Cincinnati.
Dr. Marathe, director of the division of dermatology at Cincinnati Children’s Hospital, reviewed this case in a presentation on pediatric dermatologic emergencies at the ODAC Dermatology, Aesthetic & Surgery Conference, pointing out potential pitfalls and important aspects that might require swift action.
The patient was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS).
Facial involvement is common in pediatric cases of DRESS, but edema of the face is less common in children than adults, Dr. Marathe said.
Antiepileptic medications are the most common cause of DRESS, followed by antibiotics – most often, vancomycin and trimethoprim/sulfamethoxazole, she said. But sometimes the trigger is not clear, she noted, recalling a vexing case she once saw in which IV contrast was eventually identified as the cause.
When DRESS is suspected, she said, lab work should be done during the acute eruption and after resolution. This should include CBC, liver function tests, creatinine, and urinalysis, and human herpesvirus 6 (HHV-6) and thyroid testing.
Treatment typically includes supportive care, unless symptoms are systemic, or if there is impending liver failure, when steroids, cyclosporine, or IVIG can be used.
Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN): Mortality rates when these diseases overlap is 4%, Dr. Marathe said. Clues to diagnosing this other medication-induced condition include involvement of the palms and the soles of the feet; presence of the Nikolsky sign in which the top layers of the skin slip away from the lower layers when rubbed; mucosal involvement, which often precedes cutaneous involvement; and these symptoms occurring within the first 8 weeks of taking a medication, which are most commonly antibiotics and anti-epileptics.
Dr. Marathe underscored how important it is to get ophthalmology involved right away, because of the risk of vision loss. Amniotic membrane transfer to the eye at the time of diagnosis has been found to produce dramatically better outcomes, she said. The membrane has anti-inflammatory and antiscarring properties and can promote wound healing on the surface of the eye.
“I would recommend getting your ophthalmology team on board early because they have to advocate for these patients,” she said.
Corticosteroids and IVIG can improve ocular outcomes, but cyclosporine is associated with better mortality outcomes, she said. Emerging data on etanercept has also led to more use of that drug, she said.
Erythema multiforme (EM): unlike urticaria, multiforme EM can have mucosal involvement, Dr. Marathe said. Clinicians should look for three zones of color: A central duskiness, a rim of pallor, and a ring of erythema.
EM is triggered by a virus, which is usually herpes simplex virus (HSV). But she added that HSV is not always found. “So, there are certainly other triggers out there that we just haven’t identified,” she said.
If HSV is suspected, oral acyclovir is effective, she noted.
Other cases might not be as straightforward. Dr. Marathe said that during her fellowship, she saw a patient with EM that was controlled only by IVIG, so it was administered every 3 months. In that case, the trigger was never found.
Multisystem inflammatory syndrome in children (MIS-C): This syndrome can follow COVID-19 infection, and usually presents with 3-5 days of fever after COVID has resolved. It can include gastrointestinal, cardiorespiratory, and neurocognitive symptoms.
The skin presentation is mainly a morbilliform pattern, but clinicians might also see conjunctival involvement, mucosal involvement, and “COVID toes,” painful red or purple lesions on the toes.
Treatment is usually IVIG and systemic corticosteroids, with the treatment course depending on the severity.
MIS-C was initially thought to be Kawasaki’s disease, another autoinflammatory disorder, which is related but distinct, Dr. Marathe said.
Patients with MIS-C “are usually going to have COVID-positive antibodies,” she said. But since almost everybody may have COVID antibodies, “it’s not usually a helpful test for you now. But early on, that’s what we used as helpful indicator.”
Dr. Marathe reported no relevant financial relationships.
AT ODAC 2023
Dermatologists address cultural competence and unconscious biases in the specialty
ORLANDO – When he was applying for residency, Omar N. Qutub, MD, eagerly arrived at his first interview of the day. But he was quickly thrown off his game.
The interviewer, he said, spent a surprising amount of time asking about his ethnicity and his last name. “I think I spent about 3-5 minutes in the first interview talking about my last name,” said Dr. Qutub, who practices in Portland, Ore., during a session titled “unconscious bias and microaggressions in dermatology” at the ODAC Dermatology, Aesthetic and Surgical Conference. “I really would have rather talked about my research interests.” The interaction threw him off for the rest of the interview process, he said.
The experience is an example of how the field has a ways to go in acquiring cultural competence and in overcoming unconscious biases, said Dr. Qutub. In 2020, a review in Clinics in Dermatology referred to a report that dermatology was the second-least diverse medical specialty, only behind orthopedic surgery, because of its low numbers of residents and faculty from groups underrepresented in medicine.
“We really need to put cultural competency at the forefront in order to do better for our patients,” he said.
Adam Friedman, MD, professor and chair of dermatology and director of the residency program at George Washington University, Washington, who also spoke during the session, said that the process of diversifying the field has to go deeper than the resident interviewing process. “If we just focus on trying to increase the diversity of our applicant pool for residents, it’s too late.”
Nada Elbuluk, MD, associate professor of dermatology at the University of Southern California, Los Angeles, pointed to USC’s Derm RISES initiative, a service program that aims to reach inner-city students through education in the sciences, starting from kindergarten to 12th grade. The program also includes premed undergraduate and medical students, “with the goal of increasing exposure to the sciences, medicine, and dermatology,” according to the USC website. “It’s crucial to begin the process early to get a high yield of students who reach medical school and eventually dermatology, she said, because of the inevitable attrition at each level of the education process.
“It’s incredibly rewarding,” added Dr. Elbuluk, who is also director of the dermatology diversity and inclusion program at USC. “And we get these thank-you letters back from students who [say], ‘I didn’t know I could be a doctor.’ ”
In another presentation, Kavita Mariwalla, MD, who practices in West Islip, N.Y., provided tips on boosting cultural competence during aesthetic consults.
One was to “know your fillers,” she said, noting that fillers have different effects on different skin tones, because of differences in fibroblast content, and fat cells will interact with fillers in different ways across skin tones.
Another is to “understand the shortfall of facial canons,” the idea that you can divide a face into sections that can be viewed and enhanced discretely. This concept was based on a White European model and has to be expanded when considering other ethnicities, Dr. Mariwalla said.
Overgeneralizing categories is another pitfall, she said. “Asian” is a term that covers countries from India to Japan, but within that category are a multitude of notions and nuances about aesthetics, and dermatologists have to be sensitive to all of them.
When meeting with a patient, Dr. Mariwalla said, asking the typical “Where are you from?” is not a helpful question. Instead, she suggested asking: “What is your cultural background? Can you tell me more about what your expectations are?”
“I ask for pictures,” she said. “I want to know what they looked like as a kid. I want to know what their family looks like. And I always hand patients a mirror. Patients will say to me: ‘I want to do what you think.’ It’s not about what I think, because what I see, and what you see in your magnifying mirror, are totally different things.”
After the session ended, a member of the audience, Sharon Stokes, MD, a dermatologist in the Orlando area, provided her view of the presentations, noting that it was an important discussion.
“I think it’s past time in medicine for cultural diversity training and awareness for physicians to understand their patients better and getting to know them – and how to even approach the patient and not to offensively and microaggressively approach the patient,” she said.
Dr. Elbuluk reported relevant relationships with Avita, Incyte, Beiersdorf, and other companies. Dr. Friedman reported financial relationships with Sanova, Pfizer, Novartis and other companies. Dr. Mariwalla reported relevant financial relationships with Abbvie, Sanofi, Regeneron and other companies. Dr. Qutub reported no relevant financial relationships. Dr. Qutub is the ODAC director of equity, diversity, and inclusion.
ORLANDO – When he was applying for residency, Omar N. Qutub, MD, eagerly arrived at his first interview of the day. But he was quickly thrown off his game.
The interviewer, he said, spent a surprising amount of time asking about his ethnicity and his last name. “I think I spent about 3-5 minutes in the first interview talking about my last name,” said Dr. Qutub, who practices in Portland, Ore., during a session titled “unconscious bias and microaggressions in dermatology” at the ODAC Dermatology, Aesthetic and Surgical Conference. “I really would have rather talked about my research interests.” The interaction threw him off for the rest of the interview process, he said.
The experience is an example of how the field has a ways to go in acquiring cultural competence and in overcoming unconscious biases, said Dr. Qutub. In 2020, a review in Clinics in Dermatology referred to a report that dermatology was the second-least diverse medical specialty, only behind orthopedic surgery, because of its low numbers of residents and faculty from groups underrepresented in medicine.
“We really need to put cultural competency at the forefront in order to do better for our patients,” he said.
Adam Friedman, MD, professor and chair of dermatology and director of the residency program at George Washington University, Washington, who also spoke during the session, said that the process of diversifying the field has to go deeper than the resident interviewing process. “If we just focus on trying to increase the diversity of our applicant pool for residents, it’s too late.”
Nada Elbuluk, MD, associate professor of dermatology at the University of Southern California, Los Angeles, pointed to USC’s Derm RISES initiative, a service program that aims to reach inner-city students through education in the sciences, starting from kindergarten to 12th grade. The program also includes premed undergraduate and medical students, “with the goal of increasing exposure to the sciences, medicine, and dermatology,” according to the USC website. “It’s crucial to begin the process early to get a high yield of students who reach medical school and eventually dermatology, she said, because of the inevitable attrition at each level of the education process.
“It’s incredibly rewarding,” added Dr. Elbuluk, who is also director of the dermatology diversity and inclusion program at USC. “And we get these thank-you letters back from students who [say], ‘I didn’t know I could be a doctor.’ ”
In another presentation, Kavita Mariwalla, MD, who practices in West Islip, N.Y., provided tips on boosting cultural competence during aesthetic consults.
One was to “know your fillers,” she said, noting that fillers have different effects on different skin tones, because of differences in fibroblast content, and fat cells will interact with fillers in different ways across skin tones.
Another is to “understand the shortfall of facial canons,” the idea that you can divide a face into sections that can be viewed and enhanced discretely. This concept was based on a White European model and has to be expanded when considering other ethnicities, Dr. Mariwalla said.
Overgeneralizing categories is another pitfall, she said. “Asian” is a term that covers countries from India to Japan, but within that category are a multitude of notions and nuances about aesthetics, and dermatologists have to be sensitive to all of them.
When meeting with a patient, Dr. Mariwalla said, asking the typical “Where are you from?” is not a helpful question. Instead, she suggested asking: “What is your cultural background? Can you tell me more about what your expectations are?”
“I ask for pictures,” she said. “I want to know what they looked like as a kid. I want to know what their family looks like. And I always hand patients a mirror. Patients will say to me: ‘I want to do what you think.’ It’s not about what I think, because what I see, and what you see in your magnifying mirror, are totally different things.”
After the session ended, a member of the audience, Sharon Stokes, MD, a dermatologist in the Orlando area, provided her view of the presentations, noting that it was an important discussion.
“I think it’s past time in medicine for cultural diversity training and awareness for physicians to understand their patients better and getting to know them – and how to even approach the patient and not to offensively and microaggressively approach the patient,” she said.
Dr. Elbuluk reported relevant relationships with Avita, Incyte, Beiersdorf, and other companies. Dr. Friedman reported financial relationships with Sanova, Pfizer, Novartis and other companies. Dr. Mariwalla reported relevant financial relationships with Abbvie, Sanofi, Regeneron and other companies. Dr. Qutub reported no relevant financial relationships. Dr. Qutub is the ODAC director of equity, diversity, and inclusion.
ORLANDO – When he was applying for residency, Omar N. Qutub, MD, eagerly arrived at his first interview of the day. But he was quickly thrown off his game.
The interviewer, he said, spent a surprising amount of time asking about his ethnicity and his last name. “I think I spent about 3-5 minutes in the first interview talking about my last name,” said Dr. Qutub, who practices in Portland, Ore., during a session titled “unconscious bias and microaggressions in dermatology” at the ODAC Dermatology, Aesthetic and Surgical Conference. “I really would have rather talked about my research interests.” The interaction threw him off for the rest of the interview process, he said.
The experience is an example of how the field has a ways to go in acquiring cultural competence and in overcoming unconscious biases, said Dr. Qutub. In 2020, a review in Clinics in Dermatology referred to a report that dermatology was the second-least diverse medical specialty, only behind orthopedic surgery, because of its low numbers of residents and faculty from groups underrepresented in medicine.
“We really need to put cultural competency at the forefront in order to do better for our patients,” he said.
Adam Friedman, MD, professor and chair of dermatology and director of the residency program at George Washington University, Washington, who also spoke during the session, said that the process of diversifying the field has to go deeper than the resident interviewing process. “If we just focus on trying to increase the diversity of our applicant pool for residents, it’s too late.”
Nada Elbuluk, MD, associate professor of dermatology at the University of Southern California, Los Angeles, pointed to USC’s Derm RISES initiative, a service program that aims to reach inner-city students through education in the sciences, starting from kindergarten to 12th grade. The program also includes premed undergraduate and medical students, “with the goal of increasing exposure to the sciences, medicine, and dermatology,” according to the USC website. “It’s crucial to begin the process early to get a high yield of students who reach medical school and eventually dermatology, she said, because of the inevitable attrition at each level of the education process.
“It’s incredibly rewarding,” added Dr. Elbuluk, who is also director of the dermatology diversity and inclusion program at USC. “And we get these thank-you letters back from students who [say], ‘I didn’t know I could be a doctor.’ ”
In another presentation, Kavita Mariwalla, MD, who practices in West Islip, N.Y., provided tips on boosting cultural competence during aesthetic consults.
One was to “know your fillers,” she said, noting that fillers have different effects on different skin tones, because of differences in fibroblast content, and fat cells will interact with fillers in different ways across skin tones.
Another is to “understand the shortfall of facial canons,” the idea that you can divide a face into sections that can be viewed and enhanced discretely. This concept was based on a White European model and has to be expanded when considering other ethnicities, Dr. Mariwalla said.
Overgeneralizing categories is another pitfall, she said. “Asian” is a term that covers countries from India to Japan, but within that category are a multitude of notions and nuances about aesthetics, and dermatologists have to be sensitive to all of them.
When meeting with a patient, Dr. Mariwalla said, asking the typical “Where are you from?” is not a helpful question. Instead, she suggested asking: “What is your cultural background? Can you tell me more about what your expectations are?”
“I ask for pictures,” she said. “I want to know what they looked like as a kid. I want to know what their family looks like. And I always hand patients a mirror. Patients will say to me: ‘I want to do what you think.’ It’s not about what I think, because what I see, and what you see in your magnifying mirror, are totally different things.”
After the session ended, a member of the audience, Sharon Stokes, MD, a dermatologist in the Orlando area, provided her view of the presentations, noting that it was an important discussion.
“I think it’s past time in medicine for cultural diversity training and awareness for physicians to understand their patients better and getting to know them – and how to even approach the patient and not to offensively and microaggressively approach the patient,” she said.
Dr. Elbuluk reported relevant relationships with Avita, Incyte, Beiersdorf, and other companies. Dr. Friedman reported financial relationships with Sanova, Pfizer, Novartis and other companies. Dr. Mariwalla reported relevant financial relationships with Abbvie, Sanofi, Regeneron and other companies. Dr. Qutub reported no relevant financial relationships. Dr. Qutub is the ODAC director of equity, diversity, and inclusion.
AT ODAC 2023
Pigmentary disorder experts welcome research explosion
ORLANDO – , a panel of experts said in a session on this topic at the ODAC Dermatology, Aesthetic & Surgical Conference.
The arrival of ruxolitinib cream, a topical JAK inhibitor – and oral JAK inhibitors, including ritlecitinib, a JAK3/TEC (tyrosine kinase expressed in hepatocellular carcinoma) inhibitor in clinical trials – is a welcome development for treatment of vitiligo, said John E. Harris, MD, PhD, chair of dermatology and director of the Vitiligo Clinic and Research Center at the University of Massachusetts, Worcester. Also in the pipeline is a kit for melanocyte-keratinocyte transplantation, which involves transplanting epidermal cells from one part of the body to another. This can be a challenging procedure but a kit would make it easier for a wider range of practitioners. (Topical ruxolitinib was approved by the Food and Drug Administration for treating nonsegmental vitiligo in July, 2022.)
“In the last 10 years, it’s just blown up and people care about vitiligo now,” Dr. Harris said, noting that vitiligo is more than a cosmetic issue, like gray hair or wrinkles. “Vitiligo is an autoimmune disease and now is being treated as such.”
Nada Elbuluk, MD, MSc, associate professor of dermatology at the University of Southern California, Los Angeles, said she’s pleased at the increasing availability of treatment options for hyperpigmentation, aside from hydroquinone, which is associated with an increased risk of adverse effects.
“We have more and more nonhydroquinone agents ... which is really nice because it expands our treatment armamentarium and what we can use to cycle people off of hydroquinone,” she said.
Some of these options include tranexamic acid and products containing azelaic acid or vitamin C.
Iltefat H. Hamzavi, MD, senior staff physician at Henry Ford Health System, Detroit, said that pigmentary disorders are receiving the recognition they deserve.
“I’m excited just about the intersection of society and science, the awareness that pigmentary abnormalities mean something, and they mean something across our society,” he said.
Dr. Elbuluk said that hyperpigmentation has “profound effects on quality of life” for patients.
“They are often more bothered by the darkening of the skin than the primary process that caused it,” she said. “It’s not uncommon that the chief complaint will say ‘dark spots’ and I walk in a room and it’s a patient who has acne. They don’t even say they’re here for acne. They just put ‘dark spots’ [down] because that’s what bothers them. That’s what lasts for so long after the acne is gone.”
The experts offered suggestions for managing these cases. Among her tips, Dr. Elbuluk said that for hyperpigmentation, physicians should not be afraid to biopsy the face – but suggested small, 2-millimeter specimens. In addition, “you can get common conditions in uncommon places,” she noted. “If you see something that looks like melasma off the face, it actually could be, so keep that in your differential.”
Dr. Hamzavi, who spoke about hypopigmentation disorders, said clinicians need to use an algorithm for diagnosis, considering features such as localized or diffuse, scale or no scale, as well as patient history, and other factors. For instance, a hypopigmented area that is localized and has a reddish central papule might lead a clinician to a diagnosis of hypopigmented sarcoidosis.
Using the algorithms, “you actually have to categorize these and then use your own experience. ... All of these elements can help you become a really good taxonomist – ultimately that’s what physicians are.”
He said it’s also important to know when it’s time to reconsider a diagnosis, such as when patients do not respond to traditional treatments. “If they don’t respond, re-categorize,” he said.
Speaking about vitiligo, Dr. Harris said it’s crucial to differentiate active vitiligo from inactive vitiligo and if it’s active, steps need to be taken to keep it from worsening..
Four signs of active vitiligo are a “confetti” pattern of clustered tiny macules of depigmentation, which will coalesce quickly into huge patches; tri-chrome vitiligo that includes a hypopigmented zone; linear areas of depigmentation (Koebner’s phenomenon) that look like scratches on the skin; and inflammatory vitiligo, with an erythematous ring around the edges of a depigmented area.
Dr. Harris disclosed ties with Incyte, Pfizer, Abbvie, Genzyme/Sanofi and other companies. Dr. Elbuluk disclosed ties with Avita, Incyte, Beiersdorf, and other companies. Dr. Hamzavi disclosed ties with AbbVie, Pfizer, Incyte, and other companies.
ORLANDO – , a panel of experts said in a session on this topic at the ODAC Dermatology, Aesthetic & Surgical Conference.
The arrival of ruxolitinib cream, a topical JAK inhibitor – and oral JAK inhibitors, including ritlecitinib, a JAK3/TEC (tyrosine kinase expressed in hepatocellular carcinoma) inhibitor in clinical trials – is a welcome development for treatment of vitiligo, said John E. Harris, MD, PhD, chair of dermatology and director of the Vitiligo Clinic and Research Center at the University of Massachusetts, Worcester. Also in the pipeline is a kit for melanocyte-keratinocyte transplantation, which involves transplanting epidermal cells from one part of the body to another. This can be a challenging procedure but a kit would make it easier for a wider range of practitioners. (Topical ruxolitinib was approved by the Food and Drug Administration for treating nonsegmental vitiligo in July, 2022.)
“In the last 10 years, it’s just blown up and people care about vitiligo now,” Dr. Harris said, noting that vitiligo is more than a cosmetic issue, like gray hair or wrinkles. “Vitiligo is an autoimmune disease and now is being treated as such.”
Nada Elbuluk, MD, MSc, associate professor of dermatology at the University of Southern California, Los Angeles, said she’s pleased at the increasing availability of treatment options for hyperpigmentation, aside from hydroquinone, which is associated with an increased risk of adverse effects.
“We have more and more nonhydroquinone agents ... which is really nice because it expands our treatment armamentarium and what we can use to cycle people off of hydroquinone,” she said.
Some of these options include tranexamic acid and products containing azelaic acid or vitamin C.
Iltefat H. Hamzavi, MD, senior staff physician at Henry Ford Health System, Detroit, said that pigmentary disorders are receiving the recognition they deserve.
“I’m excited just about the intersection of society and science, the awareness that pigmentary abnormalities mean something, and they mean something across our society,” he said.
Dr. Elbuluk said that hyperpigmentation has “profound effects on quality of life” for patients.
“They are often more bothered by the darkening of the skin than the primary process that caused it,” she said. “It’s not uncommon that the chief complaint will say ‘dark spots’ and I walk in a room and it’s a patient who has acne. They don’t even say they’re here for acne. They just put ‘dark spots’ [down] because that’s what bothers them. That’s what lasts for so long after the acne is gone.”
The experts offered suggestions for managing these cases. Among her tips, Dr. Elbuluk said that for hyperpigmentation, physicians should not be afraid to biopsy the face – but suggested small, 2-millimeter specimens. In addition, “you can get common conditions in uncommon places,” she noted. “If you see something that looks like melasma off the face, it actually could be, so keep that in your differential.”
Dr. Hamzavi, who spoke about hypopigmentation disorders, said clinicians need to use an algorithm for diagnosis, considering features such as localized or diffuse, scale or no scale, as well as patient history, and other factors. For instance, a hypopigmented area that is localized and has a reddish central papule might lead a clinician to a diagnosis of hypopigmented sarcoidosis.
Using the algorithms, “you actually have to categorize these and then use your own experience. ... All of these elements can help you become a really good taxonomist – ultimately that’s what physicians are.”
He said it’s also important to know when it’s time to reconsider a diagnosis, such as when patients do not respond to traditional treatments. “If they don’t respond, re-categorize,” he said.
Speaking about vitiligo, Dr. Harris said it’s crucial to differentiate active vitiligo from inactive vitiligo and if it’s active, steps need to be taken to keep it from worsening..
Four signs of active vitiligo are a “confetti” pattern of clustered tiny macules of depigmentation, which will coalesce quickly into huge patches; tri-chrome vitiligo that includes a hypopigmented zone; linear areas of depigmentation (Koebner’s phenomenon) that look like scratches on the skin; and inflammatory vitiligo, with an erythematous ring around the edges of a depigmented area.
Dr. Harris disclosed ties with Incyte, Pfizer, Abbvie, Genzyme/Sanofi and other companies. Dr. Elbuluk disclosed ties with Avita, Incyte, Beiersdorf, and other companies. Dr. Hamzavi disclosed ties with AbbVie, Pfizer, Incyte, and other companies.
ORLANDO – , a panel of experts said in a session on this topic at the ODAC Dermatology, Aesthetic & Surgical Conference.
The arrival of ruxolitinib cream, a topical JAK inhibitor – and oral JAK inhibitors, including ritlecitinib, a JAK3/TEC (tyrosine kinase expressed in hepatocellular carcinoma) inhibitor in clinical trials – is a welcome development for treatment of vitiligo, said John E. Harris, MD, PhD, chair of dermatology and director of the Vitiligo Clinic and Research Center at the University of Massachusetts, Worcester. Also in the pipeline is a kit for melanocyte-keratinocyte transplantation, which involves transplanting epidermal cells from one part of the body to another. This can be a challenging procedure but a kit would make it easier for a wider range of practitioners. (Topical ruxolitinib was approved by the Food and Drug Administration for treating nonsegmental vitiligo in July, 2022.)
“In the last 10 years, it’s just blown up and people care about vitiligo now,” Dr. Harris said, noting that vitiligo is more than a cosmetic issue, like gray hair or wrinkles. “Vitiligo is an autoimmune disease and now is being treated as such.”
Nada Elbuluk, MD, MSc, associate professor of dermatology at the University of Southern California, Los Angeles, said she’s pleased at the increasing availability of treatment options for hyperpigmentation, aside from hydroquinone, which is associated with an increased risk of adverse effects.
“We have more and more nonhydroquinone agents ... which is really nice because it expands our treatment armamentarium and what we can use to cycle people off of hydroquinone,” she said.
Some of these options include tranexamic acid and products containing azelaic acid or vitamin C.
Iltefat H. Hamzavi, MD, senior staff physician at Henry Ford Health System, Detroit, said that pigmentary disorders are receiving the recognition they deserve.
“I’m excited just about the intersection of society and science, the awareness that pigmentary abnormalities mean something, and they mean something across our society,” he said.
Dr. Elbuluk said that hyperpigmentation has “profound effects on quality of life” for patients.
“They are often more bothered by the darkening of the skin than the primary process that caused it,” she said. “It’s not uncommon that the chief complaint will say ‘dark spots’ and I walk in a room and it’s a patient who has acne. They don’t even say they’re here for acne. They just put ‘dark spots’ [down] because that’s what bothers them. That’s what lasts for so long after the acne is gone.”
The experts offered suggestions for managing these cases. Among her tips, Dr. Elbuluk said that for hyperpigmentation, physicians should not be afraid to biopsy the face – but suggested small, 2-millimeter specimens. In addition, “you can get common conditions in uncommon places,” she noted. “If you see something that looks like melasma off the face, it actually could be, so keep that in your differential.”
Dr. Hamzavi, who spoke about hypopigmentation disorders, said clinicians need to use an algorithm for diagnosis, considering features such as localized or diffuse, scale or no scale, as well as patient history, and other factors. For instance, a hypopigmented area that is localized and has a reddish central papule might lead a clinician to a diagnosis of hypopigmented sarcoidosis.
Using the algorithms, “you actually have to categorize these and then use your own experience. ... All of these elements can help you become a really good taxonomist – ultimately that’s what physicians are.”
He said it’s also important to know when it’s time to reconsider a diagnosis, such as when patients do not respond to traditional treatments. “If they don’t respond, re-categorize,” he said.
Speaking about vitiligo, Dr. Harris said it’s crucial to differentiate active vitiligo from inactive vitiligo and if it’s active, steps need to be taken to keep it from worsening..
Four signs of active vitiligo are a “confetti” pattern of clustered tiny macules of depigmentation, which will coalesce quickly into huge patches; tri-chrome vitiligo that includes a hypopigmented zone; linear areas of depigmentation (Koebner’s phenomenon) that look like scratches on the skin; and inflammatory vitiligo, with an erythematous ring around the edges of a depigmented area.
Dr. Harris disclosed ties with Incyte, Pfizer, Abbvie, Genzyme/Sanofi and other companies. Dr. Elbuluk disclosed ties with Avita, Incyte, Beiersdorf, and other companies. Dr. Hamzavi disclosed ties with AbbVie, Pfizer, Incyte, and other companies.
AT ODAC 2023