Monthly Archives

May 2019

Sentinel Lymph Node Biopsy for Melanoma

By Medical Dermatology, ODAC Sessions, Surgical Dermatology
Dr. Zitelli Presenting at ODAC

Source: Next Steps in Derm

Backed by a mountain of evidence, Dr. Zitelli walked us through the new and changing role of sentinel lymph node biopsy for melanoma in a riveting 20-minute talk presented at the 16th annual ODAC conference. Here are the highlights.

“Let’s separate what’s really evidence based from what you’ve been told.”

Before delving in, Dr. Zitelli skillfully laid the framework for his lecture. The crux of sentinel lymph node biopsy is based on the theory of orderly progressionin which malignant melanoma cells leave the tumor and preferentially enter the lymphatics and the first lymph node. This theory is rivaled by the anatomic pathway, in which malignant melanoma cells may enter the lymphatics or  the blood stream, resulting in simultaneous dissemination.

Which theory is correct?

The overwhelming preponderance of evidence supports the latter anatomic theory – melanoma cells may enter the blood stream directly or the lymphatics, potentially bypassing the sentinel node. This anatomic theory is evidence based. It refutes the theory of orderly progression that the concept of sentinel lymph node biopsy is based on. Another common misconception is that lymph nodes are filters – they are not. Lymph nodes are sampling organs, sampling antigens in order to initiate an immune response.

With the groundwork laid, Dr. Zitelli went on to summarize the emerging evidence for sentinel lymph node biopsy. “This is what you need to know when you counsel a patient in order to obtain true informed consent.”

What you’ve been told: Sentinel lymph node biopsy improves survival
What the evidence shows: There is not a single solid tumor for which sentinel lymph node biopsy has been shown to provide a survival benefit.

We’ve been told that sentinel lymph node biopsy improves survival in intermediate thickness melanoma, because subclinical deposits are removed from the lymph nodes before they can grow. In fact, 33% of patients who underwent sentinel lymph node biopsy, did so because they thought it would improve their survival. Yet, there is not a single solid tumor – melanoma, gastric, renal, thyroid or otherwise – where electively removing normal lymph nodes, even in the case of microscopic involvement, has shown a survival benefit.

A cornerstone trial, the Multicenter Selective Lymphadenectomy Trial (MSLT-1), set out to prove the survival benefit of sentinel lymph node biopsy in melanoma. However, sentinel lymph node biopsy failed to improve melanoma specific survival. Subsequently, MSLT-2 looked at whether removing positive lymph nodes further down the line would improve survival in patients who had positive sentinel lymph nodes – this was also a negative study.

Read more. 

Perioral Combination Pearls from the Expert – Joel Cohen, MD

By Aesthetic Dermatology, ODAC Sessions
Perioral Combination Patient Image

Source: Next Steps in Derm

At the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference held January 18th-21st, 2019 in Orlando, FL, longtime meeting Vice Chair Dr. Joel L. Cohen from Denver Colorado, spoke on perioral combination therapy. His presentation outlined his approach to perioral rejuvenation with one main theme – combination treatment, combination treatment, combination treatment. Simply put, combination treatment for perioral rejuvenation yields the most optimal results.

Dr. Cohen’s Approach

Dr. Cohen’s approach to perioral rejuvenation begins by dividing his work into its requisite parts. If the patient has excessive animation, toxins are recommended. If the patient has only a few superficial etched lines, fillers are recommended. If the patient has more significant or many perioral rhytides, laser resurfacing is the tool of choice – but he emphasizes full-field erbium over fractional options for significant etched-lines (see figure 1). Overall, all three should be considered individually or in combination to yield the best results. A major take home point regarding perioral rhytides is that fillers and toxins are not the primary treatment for this condition — and patients with etched-lines on the upper lip really need laser resurfacing.

His presentation also highlighted the need to address the entire perioral area when treating cutaneous lip etching – such as fillers in the nasolabial folds, antero-medial cheek, secondary smile lines, marionette area, and pre-jowl sulcus.

When addressing the mucosal lips as far as lip volume, it is of the utmost importance to make sure patients have a realistic expectation of results. Dr. Cohen prefers to use the Merz lip fullness scale, one of the scales that he co-authored. With this scale, no patient should jump from a zero to a four. Patients should move one or two grades on the scale in order to keep the result looking natural – and to be honest, it often isn’t even realistic for someone with really skinny lips to augment to full grade 4 lips, the anatomy just doesn’t accommodate that type of change.

It’s also important to note that mucosal lip-augmentation often results in neo-collagenesis over time.  Therefore, it is important to get volume and proportions right in the first place, and not just simply squirt a lot of volume all over the lip or even uniformly throughout the lip. The medial lip should be fuller than the lateral lip.  And the lip should have tubercles of projection points.

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SLNB for Melanoma

By Medical Dermatology, ODAC Sessions, Surgical Dermatology
Melanoma on Patient

Source: Dermatology Times

Sentinel lymph node biopsy (SLNB) has classically been performed for regional disease control and to hopefully prevent disease metastasis; however, according to one expert, there has not been any good evidence to support this practice. As such, it is important for clinicians to focus on the evidence when planning the treatment and management of their advanced melanoma patients.

“Over the last decade or so, the role of SLNB has been changing, and there is no real consensus as to when to perform the procedure because it is a very rapidly changing field. The touted usefulness in survival benefit or prognosis of SLNB simply cannot be backed up by the available data, essentially rendering the appropriate use of SLNB in therapeutic limbo,” said John Zitelli, M.D., clinical associate professor, departments of dermatology & otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Penn., who spoke at the Orlando Dermatology and Aesthetic Conference.

According to Dr. Zitelli, the theory that SLNB would provide a survival benefit was debunked with the MSLT-1 research study1 recently published in the New England Journal of Medicine, and the idea that the procedure was to be considered as the most accurate prognostic test was also shown to be untrue. There usually is no need to do a SLNB, Dr. Zitelli said. The Breslow thickness, as well as all of the presenting clinical pathological morphologic features, such as ulceration of the tumor, is a wealth of information that the clinician can use to contemplate appropriate further treatment and management of the patient. Many clinicians still prefer to perform SLNB, Dr. Zitelli said, reasoning that waiting until the tumor is palpable would likely be synonymous with greater complications.

“The premise is off, because if you’re performing SLNB on a lot of people and the complication rate is low but the number of patients who are getting the procedure is high, the long-term complication rate in a group of people who you manage with SLNB actually have more complications than the smaller group of patients who have a complete node dissection from palpable disease,” Dr. Zitelli said.

Controversy revolving around the role of SLNB and its true usefulness in melanoma therapy and management continues today. The current contemporary wisdom is that SLNB should be performed because the results could help determine which patients would be more amenable to adjuvant therapy.

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Hyperhydrosis: Where are we?

By Medical Dermatology, ODAC Sessions
Hydrosis Chart

Source: Next Steps in Derm

Can you think of a skin condition that has a greater negative impact on quality of life than eczema or psoriasis?  That’s right, you guess it—hyperhidrosis!  I still remember my first hyperhidrosis patient who refused to shake people’s hands, go on dates, or attend social events due to his condition.  After his treatment, he was like a new man.  I can’t tell you how satisfying it was to see his life changed after treatment. That’s why I’m so excited to share what I learned from Dr. Adam Friedman at ODAC 2019 regarding hyperhidrosis.   Dr. Adam Friedman is Professor and Interim Chair of Dermatology, Residency Program Director, Director of Translational Research, and Director of the Supportive Oncodermatology Clinic in the Department of Dermatology at The George Washington University School of Medicine & Health Sciences.

Did You Know?

Nearly 5% of the world’s population suffers from hyperhidrosis—that’s 365 million people worldwide! In the U.S., 7.8 to 13.4 million people (2.8-4.8%) are estimated to be affected by hyperhidrosis—that’s comparable to the prevalence of psoriasis.  Spalding et al. showed that patients with hyperhidrosis reported a worse quality of life compared to those with atopic dermatitis or psoriasis (Value in Health 2003).  That made me raise my eyebrows for sure!

Hyperhidrosis stats
Spalding et al. Value in Health 2003;6(3):242(abstract)


Know Your Sweaters: First, Diagnose

Hyperhidrosis can be divided into primary (usually focal) and secondary (generalized).  For secondary hyperhidrosis, the underlying cause needs to be addressed, which may include drugs, cardiovascular disorders, respiratory failure, infections, malignancies, and metabolic disorders.  For primary hyperhidrosis, now, that’s where we dermatologists step in and save the day. So, what are our options?

Treatment Options

There are non-invasive, minimally invasive, and surgical options for the treatment of hyperhidrosis.  Here, we will discuss everything but surgical options and energy-based treatment.

  • Topical aluminum chloride, aluminum chloride hexahydrate, or aluminum zirconium trichlorohydrex
    • This is applied on skin overnight (to remain on skin for 6-8 hours, during non-sweating hours) and washed off in the morning before sweating begins
    • A non-medicated deodorant should be applied in the morning after showering
    • Can use topical steroids for skin irritation
    • Cons: itching and burning of skin, time-consuming, can damage fabrics, temporary relief
  • Inotophoresis
    • Need treatment for 20-30 minutes a session, 3-4 times a week. This can be effective (81-91% response), but who has time for that?
    • Cons: cumbersome, can be costly, long-term therapy, and again…time-consuming
  • Topical glycopyrronium tosylate (Qbrexa)—the new kid on the block! And he’s FDA-approved, too. Whoohoo!
    • This can be applied nightly onto clean skin and can be used in conjunction with an over-the-counter antiperspirant
    • Improvement can be expected in 1-3 weeks.
    • Can be used in kids (approved for >9 years of age)
    • Cons: anticholinergic side effects such as dry eyes, dry mouth, blurred vision (need to emphasize the need to wash hands thoroughly after use to minimize risk), long-term therapy, may be costly
  • Systemic anticholinergics: off-label use for hyperhidrosis
    • Glycopyrrolate
      • Can start at 1mg twice daily and increase up to 6mg a day, or until limited by anticholinergic side effects
    • Oxybutynin
      • Can start at 5 to 10mg daily and increase to 15 to 20mg daily
      • A study in kids showed a 90% response rate at 2mg daily.
    • Cons: again, anticholinergic side effects — ones listed above, as well as constipation, urinary retention, bradycardia, etc.
  • Beta-adrenergic blockers
    • This is great for patients with social phobias and performance anxiety!
    • Most can tolerate a dose of 10 to 20mg (to be taken 1 hour before). But don’t forget to check the resting blood pressure and heart rate beforehand!  Oh, and also, they need a “test run” at home, just to make sure all goes smoothly before the actual “showtime”.
    • Contraindications: bradycardia, AV block, asthma
  • Botulinum toxin injection
    • Before treatment: patients should avoid deodorants for 24 hours prior and rest comfortably for 30 minutes prior
    • Treatment: after making an outline of the area, inject at a depth of 2mm, at a 45 degree angle with the bevel up, 1-2cm apart
    • What to expect: onset is about 2-4 days and duration is 3-7 months
    • Other considerations
      • Topical analgesics help a ton!
      • Do not use sterile water—can sting
      • If you buy the toxin and inject, use the CPT code 64650 and J code J0585 (with units)
      • If you prescribe the toxin to a pharmacy, provider bills only for the injection service, and patient pays co-pay for both the toxin and injections
    • Cons: can be painful and expensive

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