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July 2019

Jul 18
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What’s New in Itch

By Medical Dermatology, ODAC Sessions No Comments
ODAC Dermatology Conference faculty image

Dermatologists are well aware of the difficulty in managing itchy patients. Itch can be caused by a number of cutaneous and extracutaneous diseases. Regardless of the etiology, itch is one of the most frustrating symptoms of patients and management dilemmas for dermatologists. At the 16th Annual ODAC conference, Dr. Brian Berman reviewed some of the emerging therapies for the treatment of itch and the etiologies for which they are currently under investigation.

Nemolizumab is a monoclonal antibody directed at the IL-31 receptor A. It is currently being studied for use in atopic dermatitis. Recent phase II data have shown improvement for itch in atopic dermatitis over 64 weeks1. A few of the less common side effects that were seen in this study included peripheral edema and elevations in blood CPK levels.

Tapinarof cream is a first-in-class, naturally derived, non-steroidal topical agent. It is currently being investigated for use in psoriasis and atopic dermatitis. Tapinarof is a therapeutic aryl hydrocarbon modulating agent (or TAMA) and inhibits specific proinflammatory mediators, including IL-6 and IL-17A2.  One of the more interesting targets of tapinarof is nuclear factor-erythroid 2-related factor-2 (Nrf2), which happens to be one of the mechanisms through which coal tar produces its beneficial effects.

Hypochlorous acid gel is being used for its anti-inflammatory properties. This topical has potential utility for atopic and seborrheic dermatitis-related itch.

Serlopitant is an oral NK1 receptor antagonist. It is currently being investigated for use in chronic pruritus, pruritus in psoriasis, and prurigo nodularis. Substance P binds to the NK1 receptor peripherally, in the ganglion and brain to cause/increase the perception of itch, and as such, NK1 receptor antagonists are an up and coming mechanistic target for itch. Phase II data appear to be promising3.

Remetinostat (previously referred to as SHAPE), a topical histone deacetylase inhibitor, is currently under investigation for treating pruritus in patients with stage IA-IIA mycosis fungoides4. Preliminary data are promising as the topical route of the medication appears to decrease itch while limiting side effects compared to systemic histone deacetylase inhibitors.

Omalizumab, an anti-IgE monoclonal antibody, is approved for use for chronic idiopathic or chronic spontaneous urticaria5. It is notable that in the pivotal, phase 3 study published in the New England Journal of Medicine, the primary endpoint was itch-severity score rather than urticarial lesion counts. The use of this endpoint highlights the magnitude of itch in urticaria.

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Jul 12
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Making Sense of Cosmeceuticals

By Aesthetic Dermatology, ODAC Sessions
Cosmeceuticals Image

Dermatology thought leader Hilary Baldwin, MD helps us make sense of cosmeceuticals by sharing her approach to them, including how to define them and evaluate their utility.

On a funny note, Dr. Baldwin confesses being a skeptic and a hypocrite when it comes to cosmeceuticals. She remains skeptical about some of the science but at the same time uses 5 cosmeceutical products herself. We love her honesty!

What is a cosmeceutical?

The term was accredited to Albert Kilgman in 1984 as the ill-defined realm between cosmetics and prescription skincare products. Like a cosmetic, it is topically applied; like a drug, it contains ingredients that influence biologic functioning of the skin.

Different meaning to different groups

Fortunately for the FDA, they have no comment (and we would prefer to keep it that way!). Cosmetic companies consider them to be well-studied actives with proven efficacy. For most dermatologists, they are not well studied, they have some data behind them and are products that may or may not live up to claims (some of which are quite grandiose!). Cosmeticdermatologists on the other hand, feel a little bit different and think these are products that may alter wound healing and may prolong the effects of cosmetic procedures. Patients, however, consider cosmeceuticals to be miracle cures, which Dr. Baldwin believes is the problem and where a disconnect exists. In the quest for medical cures, we don’t want patients to be dissatisfied and frustrated…and poor. It is unlikely that topicals, or at least a single topical, can fully address the complex process and major issues that causes the aging appearance, such as:

  • Pervasive cumulative sun damage
  • Loss of hormones (particularly estrogens)
  • Cell senescence
  • Fat depletion
  • Damage to DNA
  • Repetitive muscle movement
  • Genetics
  • Gravity

Dr. Baldwin notes that when patients come into the office, they have a couple of specific requests: “Do I need a face lift yet?”, “What can you do to fix my face?”. Sometimes they even ask if there is some magic cream they can put on their face to make them look less tired. Dr. Baldwin suggests to her patients to think of their face as an old couch in their living room that they no longer care for. Do they no longer care for it because it is sagging and actually has structural abnormalities, or do they not like it because the slipcovers are torn and stained? When we talk about cosmeceuticals, what we are talking about is slipcover repair, we are not talking about sagging skin because cosmeceuticals may be able to handle the drying on the sofa but they are not going to help with the sagging of the sofa.

Why do dermatologists need to be well-informed?

The average U.S. woman uses 15 different cosmetic products each day. If you figure that each of them contains 10-50 ingredients, the average woman is putting an awful lot of chemicals on her face every day, and it should be something that actually works, is safe, and non-irritating.

The truth is that patients dolike to use cosmeceuticals as feel they are doing something for themselves. Cosmeceuticals can make retinoids more tolerable and effective and can prolong or improve the results of cosmetic procedures.

Dr. Baldwin believes it is the job of dermatologists to help patients make reasonable choices and manage their expectations. How often does a patient come to you with a bunch of pieces of papers from magazines and newspapers and ask you about all these miracle cures? Or bring you a before and after picture saying, “Look at how much better she looks in the after picture” which is clearly a photographic cure, or perhapsthere is actually a cure there, but we can make no judgements based on these photographs which are just rampantin the magazines patients are looking at.

The fear of wrinkles, coupled with the fear of procedures, make some of Dr. Baldwin’s patients say that “they are looking for something better than Botox”. But is there a topical that is superior to fillers and neuromodulating agents? The magazines say there is…so it must be true, and then we have “friends” in the media who tell us every day there are products out there, one on Monday, a completely different one on Tuesday, yet a different one on Wednesday that will be life changing.

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Jul 10
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What’s New for Itch

By Medical Dermatology, ODAC Sessions
ODAC Dermatology Conference Dr. Berman Image

Source: Next Steps in Dermatology

Dermatologists are well aware of the difficulty in managing itchy patients. Itch can be caused by a number of cutaneous and extracutaneous diseases. Regardless of the etiology, itch is one of the most frustrating symptoms of patients and management dilemmas for dermatologists. At the 16th Annual ODAC conference, Dr. Brian Berman reviewed some of the emerging therapies for the treatment of itch and the etiologies for which they are currently under investigation.

Nemolizumab is a monoclonal antibody directed at the IL-31 receptor A. It is currently being studied for use in atopic dermatitis. Recent phase II data have shown improvement for itch in atopic dermatitis over 64 weeks1. A few of the less common side effects that were seen in this study included peripheral edema and elevations in blood CPK levels.

Tapinarof cream is a first-in-class, naturally derived, non-steroidal topical agent. It is currently being investigated for use in psoriasis and atopic dermatitis. Tapinarof is a therapeutic aryl hydrocarbon modulating agent (or TAMA) and inhibits specific proinflammatory mediators, including IL-6 and IL-17A2.  One of the more interesting targets of tapinarof is nuclear factor-erythroid 2-related factor-2 (Nrf2), which happens to be one of the mechanisms through which coal tar produces its beneficial effects.

Hypochlorous acid gel is being used for its anti-inflammatory properties. This topical has potential utility for atopic and seborrheic dermatitis-related itch.

Serlopitant is an oral NK1 receptor antagonist. It is currently being investigated for use in chronic pruritus, pruritus in psoriasis, and prurigo nodularis. Substance P binds to the NK1 receptor peripherally, in the ganglion and brain to cause/increase the perception of itch, and as such, NK1 receptor antagonists are an up and coming mechanistic target for itch. Phase II data appear to be promising3.

Remetinostat (previously referred to as SHAPE), a topical histone deacetylase inhibitor, is currently under investigation for treating pruritus in patients with stage IA-IIA mycosis fungoides4. Preliminary data are promising as the topical route of the medication appears to decrease itch while limiting side effects compared to systemic histone deacetylase inhibitors.

Omalizumab, an anti-IgE monoclonal antibody, is approved for use for chronic idiopathic or chronic spontaneous urticaria5. It is notable that in the pivotal, phase 3 study published in the New England Journal of Medicine, the primary endpoint was itch-severity score rather than urticarial lesion counts. The use of this endpoint highlights the magnitude of itch in urticaria.

Physician assurance reduces itch. In a recent study6, a physician administered a histamine skin prick to 76 participants. After 3 minutes, half of the randomly selected participants were assured by the physician in the following way. “From this point forward your allergic reaction will start to diminish, and your rash and irritation will go away.” In the assured group, it was found that over the next 15 minutes, itchiness of the area declined significantly faster than the group not assured by the physician.

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