Skin Microbiome and Acne: Connecting the Dots

By | Medical Dermatology, Patient Care | No Comments
skin microbiome

When we think about skin, a few things come to mind: protection, temperature regulation, sensation. However, there is growing interest in the microbiome of the skin. Our skin flora can be likened to an invisible ecosystem. Similar to fingerprints, it is unique to each individual. The complexity of the skin microbiome is continuing to be researched. This research is paving the way to improve our understanding of the relationship between acne and dysbiosis.

At the GW Virtual Appraisal of Advances in Acne Conference, Dr. Adam Friedman discussed Microbiome Manipulation in the Management of Acne. His lecture provided insight on the microenvironment of the skin and how the diversity in skin flora can affect disease processes such as acne.

First, let me share a few pearls from Dr. Friedman’s lecture.

The skin is a physical barrier against invasion by pathogenic organisms and foreign substances. The skin is also an ecosystem, host to a variety of microorganisms that are typically harmless.

The habitat of the skin varies topographically and there are several factors that contribute to this unique variation among individuals.

The cutaneous immune system modulates and can be modulated by these commensal microorganisms. Dysbiosis, which directly refers to decreased microbial diversity, is directly linked to dysregulation of the skin immune response is evident in several skin disorders.

When we think about the skin barrier, we usually think about the hydrophilic corneocytes and hydrophobic lipids that make up this security guard for your skin. However, we do not necessarily think about the invisible barrier that protects the skin, which is composed of numerous microorganisms. Both of these components are vital to the structural stability of the skin barrier. If this invisible barrier is disrupted, this may lead to skin disease. Why are these commensal organisms so important?

Role of commensal organisms on the skin:

  • Inhibit colonization of foreign pathogens
  • Maintain the pH balance of the skin
  • Inhibit inflammation

We all have a unique skin microbiome. What contributes to the variability of the skin microbiome?

Factors contributing to individual variations in skin microflora:

  • Gender
  • Age
  • Environment
  • Lifestyle
  • Genetics
  • Underlying medical conditions

Read more….

Free Virtual Conference: GW Virtual Acne Appraisal Conference

By | Medical Dermatology, Patient Care | No Comments
GW Virtual Appraisal of Advances in Acne

Hosted by George Washington University, in Partnership with ODAC Dermatology, Aesthetic & Surgical Conference and Next Steps in Derm

Even during a global pandemic we cannot forget that Acne Vulgaris is one of if not THE most common skin condition afflicting our patients and the general populace. With the disruption of clinics and conferences, innovative vehicles for the dissemination of the most up to date data and expert anecdote are certainly and sorely needed.

Enter the GW Virtual Acne Appraisal Conference: A 3 hour program that promises to pander to your pimple popping practices with short but sweet lectures from the acne gurus covering the gamut of the big A. From treatments to treats, from considering the microbiome to unique treatment approaches in specific patient populations, we will cover it all. And if that wasn’t enough, we will round it out with a perusal of the therapeutic pipeline. It will be all that and a bag of chips (which may or may not cause acne…you need to tune in to find out).

Agenda

8:00 – 8:15 – Introduction and Welcome
8:15 – Topical Management of Acne– James Q. Del Rosso, DO, FAOCD, FAAD
8:30 – Use of Hormonal Therapies in Acne– Julie Harper, MD
8:50 – Use of Antibiotics in Acne – Neal Bhatia, MD
9:10 – Issues with Isotretinoin: Fact vs. Fiction – Jenna C. Lester, MD
9:30 – Microbiome Manipulation for the Management of Acne – Adam Friedman, MD, FAAD
9:45 –  Diet and Alternative Therapies: What to know for Acne management – Vivian Shi, MD
10:00 – Management Considerations for Skin of Color Patients with Acne –Andrew Alexis, MD, MPH
10:20 – Managing Acne in the LGBTQ+ Population – Angelo Landriscina, MD
10:40 – New and Emerging Therapies for Acne – Leon Kircik, MD

View On-Demand: Starting Your Own Dermatology Practice: Expert Panel Discussion

By | Aesthetic Dermatology, Medical Dermatology, Patient Care, Video Pearls | No Comments

This webinar was previously recorded on July 1, 2020 and is now available on demand.

Hosted by ODAC
In Partnership with The Journal of Drugs in Dermatology
ODAC in partnership with the JDD, invite you to join your dermatology colleagues as we discuss strategies, steps and best practices for starting your own dermatology practice. Expert panelists will discuss their experiences with securing financing, choosing devices, hiring contractors and running a practice. They will give insights into what they wish they knew before beginning their practice, offer practical tips and much more!
MODERATOR
Aanand N. Geria, MD, FAAD (Founder, Geria Dermatology – Rutherford, NJ)
PANELISTS
Matthew J. Elias, DO, FAAD (Co-Founder, Elias Dermatology – Fort Lauderdale, FL)
Rishi K. Gandhi, MD, FAAD (CEO & Director, Ohio Skin Surgery and Cosmetic Center – Dayton, OH)
Chesahna Kindred, MD, MBA, FAAD (Founder, Kindred Hair & Skin Center – Columbia, MD)
Omar N. Qutub, MD FAAD (Founder, Dermatology By Design LLC – Portland, OR)

The Business of Dermatology: A Must Read

By | Aesthetic Dermatology, Medical Dermatology | No Comments
The Business of Dermatology Cover Image

Business intellect, a vital aspect of managing a practice, is not taught in residency. From the infancy of their training, dermatologists are trained to think broadly and scrupulously, using each clue, each corporeal sense, and each available tool to accurately diagnose and manage a plethora of cutaneous conditions. After residency, dermatologists set out armed with the knowledge and drive to deliver expert care to their future patients. However, despite their education and best intentions, lack of business acumen can hinder even the brightest and most motivated of practitioners. In order to enlighten oneself in the complicated field of business management, clinicians are left to fend for themselves, often learning as they go, sometimes making unnecessary mistakes, and adjusting their business practices reactively. Retrospective “trial and error” learning is time-consuming, cumbersome, and costly. Why not short track and get the goods without the trial and error, making costly mistakes and taking years. The new book, The Business of Dermatology is a cornerstone achievement in the standardization of business education for dermatologists.

Edited by Drs. Jeffrey S. Dover and Kavita Mariwalla, and authored by impressive experts in the field, The Business of Dermatology offers a comprehensive guide to opening, maintaining, and sustaining a practice. To start, the power of this textbook fundamentally lies in the experience and scope of its authorship. The authors were hand-selected by the editors ensuring that each chapter was written by a tried and true expert in that subject. Unlike other textbooks in the field of business management and administration that are primarily written by individuals from the business world, some of whom have no insight into the inner machinations of the medical world, or hands-on experience, the authors of this book are well-known, respected dermatologists that hail from thriving practices of their own. The reader has an unprecedented opportunity to learn from the firsthand experiences of top authorities who live and breathe dermatology. Using conversational prose, the authors depict their experiences, trials, and errors, employing specific real-world examples and scenarios while tackling each subject.

A notable forte of The Business of Dermatology is the sheer breadth and range of topics discussed in the textbook by medical as well as surgical dermatologists. Opening and managing a practice is a daunting endeavor with twists, turns, and hidden hurdles that one cannot foresee until stumbling across them. The Business of Dermatology unveils those twists, turns, and hurdles for the reader, taking the “guessing game” out of the equation. Fifty-five chapters elucidate every aspect of running a practice, covering all practice-relevant topics, including office space and equipment, managing financials, diverse practice models, human resources, employment considerations, patient issues, pricing, essential surgical tools/supplies, marketing, and much more. The Business of Dermatology lays bare every facet of handling a dermatologic practice, so much so that even a well-run, seasoned practice stands to learn new tools and tips to elevate itself to a higher level.

And now more than ever in the “Time of Covid” we are in desperate need of information from The Business of Dermatology. Many of us are inventing the wheel with the significant changes that are occurring in Dermatology, and the practice of our specialty.

The wealth of knowledge endowed in each chapter is written and formatted in such a style that renders each chapter extremely easy to read and comprehend. First, the prose used in the chapters is conversational – as such, the reader is fully immersed in each topic as if he/she were having a face-to-face chat with the authors. Furthermore, references are used only when absolutely necessary. The reader is not bogged down by superfluous references and discussions that may dim the vital discussion points of the chapters. Finally, embedded within each chapter are practical tips that are immediately implementable and a Top Ten list that highlights the key take-home points, making “reading on the run” possible. The novice practice owner need not fear the residency dogma of “trying to drink from a gushing fire hydrant” with this easy-to-read, catchy and focused textbook.

Read More….

Dr. Adam Friedman Discusses 2021 ODAC Dermatology Conference Program

By | Aesthetic Dermatology, Medical Dermatology, ODAC Sessions, Patient Care, Surgical Dermatology, Video Pearls | No Comments

ODAC Dermatology, Aesthetic & Surgical Conference’s Medical Director, Dr. Adam Friedman, discusses the ODAC 2021 program, reasons to attend and more!

To view the full agenda, click here: https://orlandoderm.org/agenda/

ODAC Dermatology Conference is the premier clinical dermatology conference expertly curated to provide comprehensive, annual updates and fresh pearls in medical, aesthetic and surgical dermatology. Check out our blog and media coverage.
The 2021 ODAC dermatology conference focuses on new uses for old treatments, incorporating new treatments, products and treatment lines, critical updates in diagnosis guidelines, as well as advanced techniques for enhancing your surgical and nonsurgical patient outcomes.

BLACK LIVES MATTER | A MESSAGE FROM OUR CEO

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Black Lives Matter

NEW YORK, (June 3, 2020) –  Shelley Tanner, SanovaWorks (parent company of ODAC) CEO/President

The below was sent to the employees of SanovaWorks.

This is an issue we should all be aware of, we should all be engaged in, and we should all be actively fighting together against for a solution. Each company, as a collective of humans, has a responsibility to do everything we can to protect our fellow humans and ensure that we all have access to the things we hold dear. We cannot stand by knowing that our fellow Americans are being targeted unjustly from all angles.

On the heels of the global and national devastation of the coronavirus pandemic, we are witness to the glaring evidence of an epidemic that has existed for hundreds of years in the USA, and that is the systematic racism and injustice against black Americans. The devastation that results from this affects lives in literally every facet: education, careers, health, families, finances, safety, etc.

The pandemic unveiled in clear numbers the disparity between black and white communities in this country, where only 13% of the population are African American, yet represent 23% of the deaths. In some states, like Georgia, African Americans make up little more than 30% of the population, yet almost 50% of deaths are from within this group.

On May 25th this year George Floyd, a black man from Minneapolis who is also a brother, a cousin, a nephew, a friend, a boyfriend, a son, and a fellow human, was murdered in a horrific incident that has reinvigorated people to stand up and say that this is not acceptable, spurring the nationwide protests that are not only just, but also necessary to demand change for a reality that has been accepted through complacency and inaction.

What can we do?

For our employees who are impacted by this, we need to support you. As a team and your friends we are here to back you up.

If you don’t already know how you can personally help, I hope you will take the time to learn what we can all be doing at this time to be a part of the solution. You might feel helpless or overwhelmed by this matter, and feel like there is nothing you can do, but this is part of the problem. Doing nothing is a choice and an action. The support we show for one another matters. One of my friends sent me this article on the weekend, for which I was extremely grateful, as it outlines many things we can all be doing for racial justice.

READ What White People Can do for Racial Justice

President Barack Obama

On June 1, President Obama published an article on how he believes we can use what is happening now as a turning point for real change that is definitely worth the read. In this article there is a link to a very detailed report and toolkit developed while he was in office by the Leadership Conference on Civil and Human Rights, along with a dedicated site of resources and organizations to learn about and get involved with.

READ How to Make this Moment The Turning Point for Real Change

Grassroots Organizations

Below is a list of grassroots organizations supporting this cause. I have personally donated, and I encourage you all to consider doing the same. There are many more that I have read about and perhaps that speak to you more personally. I encourage you to look up some of these groups and read about what they are doing.

https://minnesotafreedomfund.org/

https://www.blackvisionsmn.org/

https://www.reclaimtheblock.org/home

https://www.northstarhealthcollective.org/

On Wednesday June 3rd

We as a company will take a moment of silence at 1:30pm ET to reflect on these injustices, and how we personally might help. I would like us all to pause together and show solidarity. For those who choose to sit on their own, know we are with you.

I am committed to ensuring that this is not the end of the conversation for SanovaWorks. Stay tuned for more information and please get in touch with me directly if you have thoughts on this. I welcome all ideas and feedback.

And finally. To ALL of our friends of color: know that we see you, we appreciate you, and we will do everything we can to support you.

Shelley N. Tanner
President/CEO

Therapeutic Updates in Melanoma

By | Medical Dermatology, ODAC Sessions, Patient Care, Video Pearls | No Comments

ODAC Dermatology Conference, in partnership with Next Steps in Derm, interviewed Dr. David Miller, Instructor in Dermatology and Medicine at Harvard Medical School and member of the Department of Dermatology and the Department of Medicine at Massachusetts General Hospital, where he is co-director of the Merkel cell carcinoma treatment program. Watch as he shares important updates on Immuno-Oncology (IO) strategies for melanoma.

COVID-19: The Invisible Impact on Team Members

By | COVID-19 Resources | No Comments
COVID 19 Impact on Team Members
Register Now

Date: Wednesday, May 13th

Time: 8:00 – 8:45 PM

Join colleagues and thought leaders as we examine the emotional and logistical impact of COVID-19 on team members. Panelists will discuss job loss, mental wellbeing, team member’s top concerns and communication surrounding the global coronavirus pandemic.
Experts will discuss ways to offset anxiety and depression, steps to take care of your emotional well-being and logistical challenges such as homeschooling and balancing the ever-changing priorities during this crisis. There will also be discussion surrounding manager communication strategies, what works, what does not work, and ways employers can calm team’s fears during the pandemic.
MODERATOR
Brandon Thompson

Brandon Thompson

Co-Founder of BNB Aesthetic Innovations

PANELISTS
Aaron Burton

Aaron Burton

CEO, Sciton

John Connors

John Connors

CEO & President, Jan Marini Skin Research

Richard G. Fried, MD, PhD

Richard G. Fried, MD, PhD

Board Certified Dermatologist & Clinical Psychologist, Clinical Director, Yardley Dermatology Associates

Jenna Mons Anderson

Jenna Mons Anderson

CEO, AccessElite

Mark Wilkins

Mark Wilkins

Executive Vice President and U.S. General Manager - Prollenium Medical Technologies

Register Now
PLEASE NOTE
Due to technical limitations, this webinar will be open for the first 1000 participants that join the webinar. If you miss the webinar, it will be archived for on demand viewing on JDDonline.com by the end of the week.
If you missed previous installments of our COVID-19 webinar series, you can watch them here: https://jddonline.com/jdd-webinars

COVID-19: The Invisible Impact on Dermatologists and Dermatology Practices

By | COVID-19 Resources | No Comments
COVID webinar promotion invisible impact

DATE: Wednesday, May 13th

TIME: 7:00 – 7:45 PM EST

Join your dermatology colleagues and thought leaders as we examine the hidden impact of COVID-19 on dermatologists and providers, including new and small private practices, emotional wellbeing and the evolving priorities placed on providers during the global coronavirus pandemic. Panelists will discuss their first-hand, personal experience living with COVID-19 and ways it has impacted their physical and emotional health, practice and personal life.
Discussion and guidance will be given on simple steps you can take in the wellness sphere, crisis management and return to practice concepts for both large and small dermatology practices.
Moderator:
Richard G. Fried, MD, PhD (Board Certified Dermatologist & Clinical Psychologist, Clinical Director, Yardley Dermatology Associates)
Panelists:
Evan Rieder, MD (Board Certified Dermatologist & Psychiatrist, NYU Langone Health)
Paul Jarrod Frank, MD (Chief Medical Officer & Founder, PFRANKMD)
Melissa Kanchanapoomi Levin, MD (Founder, Entière Dermatology)

Melasma: Treatment Pearls from the Expert

By | Medical Dermatology, ODAC Sessions, Video Pearls | No Comments

Next Steps in Derm, in partnership with ODAC Dermatology, Aesthetic and Surgical Conference, interviewed Dr. Vic Ross, Director of the Scripps Clinic Laser and Cosmetic Dermatology Center in San Diego, CA, on his approach and the various interventions he uses for the treatment of Melasma. Watch as he shares fresh practical pearls immediately useful in your practice.

Read More…

Full-Field Ablative Resurfacing: Is the Pendulum Swinging Back?

By | Aesthetic Dermatology, ODAC Sessions | No Comments

According to ODAC Vice-Chair Dr. Joel Cohen, Director of AboutSkin Dermatology (Greenwood Village and Lone Tree, Colorado),  and Associate Clinical Professor at the University of California at Irvine, the pendulum is swinging back to heavy resurfacing in areas such as around the mouth and around the eyes that really need it. He uses full-field erbium resurfacing and shares why this is the way to go.

Read More….

COVID-19: How to Support Your Dermatologist (NP or PAs)

By | COVID-19 Resources | 2 Comments
Register Now

Webinar Details:

Date: April 23, 2020

Time 7:00 PM – 8:30 PM EST

National Academy of Dermatology Nurse Practitioners invite you to attend this webinar panel to examine how nurse practitioners and physician assistants can support their employing dermatologist during the global coronavirus pandemic.

Over the course of the 1.5 hours, panelists will join together to provide discussion, guidance and practical steps for supporting your dermatologist and the practice. In addition, panelists will answer the most pressing questions that are on the minds of practitioners impacted by COVID-19.

 

This panel discussion is part of a webinar series designed to assist NP and PA employed by dermatologists during COVID-19. The previous recordings can be found here.

Moderator:

Debra Shelby, PhD, DNP, FNP-BC, DCNP, FACDNP, FAANP
Managing Member, CEO and Clinical Director: DistinctlyDerm, New Mexico Specialty Medical Services, LLC, Florida Specialty Medical Services, LLC, Dermatology Division and Dermstaffing
Managing member and Co-CEO: CoreMedSource

President, National Academy of Dermatology Nurse Practitioners
Board Director, American College of Dermatology Nurse Practitioners
Panelists:
Ken Greenwood, BSE
Kevin Harrington, APRN, FNP-C
Maria Ann Kolarsick, DNP APN FNP-BC DCNP
Marisa McGeorge, NP-C, CANS
Becky Naughton, MSN, FNP-C, WCC
Debra Shelby, PhD, DNP, FNP-BC, DCNP, FACDNP, FAANP

Hydroxychloroquine, Pentoxifylline, and Colchicine: Off-Label is ON in Dermatology

By | Medical Dermatology, ODAC Sessions, Video Pearls | No Comments

So many diseases, so few FDA approved indications. Between the mind-numbing time and cost from bench to bottle, it is no surprise that dermatologists, as masters of the integument are the off-label bandits, marrying their wealth of knowledge on the pathophysiology of skin diseases to the mechanisms by which medications work to create an evidenced-based armament of therapies for both common and rare diseases alike. Where a primary care physician sees a blood pressure medication, a dermatologist sees an effective medication for acne. A medication for malaria you say? They use it for a plethora of complex diseases ranging from Lupus to scarring hair loss. The lengthy list of medications used off-label in dermatology continues to grow and for good reason and fortune.

Next Steps in Derm, in partnership with ODAC Dermatology, Aesthetic and Surgical Conference interviewed Dr. Adam Friedman, Professor, Interim Chair of Dermatology, and Residency Program Director at George Washington University, who shared off-label uses of drugs such as Hydroxychloroquine (currently under investigation for the treatment of patients with COVID-19), Pentoxifylline, and Colchicine. A wealth of clinical pearls you don’t want to miss!

Additional video pearls can be found here.

Webinar Series Held to Assist Dermatology Practitioners During COVID-19

By | COVID-19 Resources | No Comments

Click here to view the on-demand recordings.

 

On April, 1, 2020, the Journal of Drugs in Dermatology (JDD) and SanovaWorks brands, including ODAC launched Part I of the webinar series: COVID-19: Urgent Dermatology and Aesthetic Issues for Dermatology.

Over the course of the 2 hours, Joel L. Cohen, MD and 6 different thought leaders joined the COVID-19 conversation, discussing the pressing questions that are on the minds of many dermatologists and providers in the country. The initial broadcast attracted 1,900 registrants and nearly 800 attendees comprised of physicians, residents, fellows, nurse practitioners and physician assistants.  Attendees were interested and engaged throughout the entire 2 hours with a 76% average attentiveness and 72% average interest rating.

The on-demand broadcast has attracted over 500 registrants as of April 9th and is available on JDDonline.com.

On April 7, 2020, Part II of the webinar series was broadcasted: COVID-19: Your Questions Answered. Dermatology experts and thought leaders examined the legal and financial concerns of dermatology providers during the global coronavirus pandemic. Experts discussed furlough vs. layoffs; mortgage and rent relief programs; the CARES Act; the pros and cons of leveraging NPs or PAs for teledermatology and more. Then, hear questions answered by our panel of experts; discussed practical tips you can use in your practice right now; and how to move forward with patient care. Part II attracted 1,300 registrants with nearly 700 attendees. Attendees were engaged and interested throughout with an 82% attentiveness average and 75+% interest rating.

The on-demand broadcast of Part II will be available on April 11, 2020 on JDDonline.com.

Is COVID-19 an Indication to Temporarily Modify Dermatological Management Plans?

By | COVID-19 Resources, Medical Dermatology, Patient Care | No Comments
Coronavirus image

Source: Journal of Drugs in Dermatology

While the world lives under the shadow of the novel coronavirus (COVID-19) pandemic, dermatologists wonder if the current situation calls for a temporary change in the management of skin conditions.

Immunosuppressive drugs are used ubiquitously in the modern treatment of inflammatory and autoimmune skin diseases like psoriasis, bullous diseases, connective tissue diseases, and many others. Treatment of these conditions is based on the suppression of the patient’s immune system using steroids, steroid-sparing drugs, and biological agents.1

While the effects of the novel coronavirus on the body and its immune system are still being studied, there is overwhelming evidence that the virus could directly or indirectly affect the immune system. In one study, lymphocytopenia was reported in 83.2% of the admitted patients and might be associated with a worse prognosis.2In another study, a steady decline in the lymphocyte counts was recorded in a group of patients who did not survive the infection.3

While the coexisting comorbid medical conditions (such as diabetes or heart disease) are considered as independent predictors of an adverse outcome of the novel coronavirus infection,4 it could be assumed that the chronic inflammatory and autoimmune skin diseases like psoriasis by themselves might imply an additional risk factor of developing more serious symptoms of the novel virus due to their chronicity and effects on the immune system.5

The use of immunosuppressive to treat these conditions can amplify this effect, and it might leave the patient vulnerable to more serious complications should an infection with the novel coronavirus be established. Hence, it may be wise to restrict temporarily the use of immunosuppressive agents including systemic steroids, steroid-sparing agents, and biologics in dermatology daily practice until more evidence is available about their safety in the current pandemic.6As a relates point, the International Psoriasis Council declared an urgent statement on March 11, 2020 that the physician should be alert to the potentially harmful effects of COVID-19 infection on patients with psoriasis and to immediately discontinue or postpone immunosuppressant medications for psoriasis patients diagnosed with COVID-19 disease.7

Read More….. 

Clinical Photography: Pearls from the ODAC Dermatology Conference

By | Medical Dermatology, ODAC Sessions, Video Pearls | No Comments

Clinical photography is a critical tool for the dermatologist and has rapidly become standard of care in the digital era.  While a point-and-click approach to photography is sufficient for some circumstances, there are some simple tricks and techniques that will elevate your photography to a new level of professionalism.

Next Steps in Derm, in partnership with ODAC Dermatology, Aesthetic and Surgical Conference interviewed Dr. Justin Finch, Associate Professor of Dermatology at UConn and Co-Founder of Central Connecticut Dermatology who shared his top 3 pearls for improving clinical photography in your practice.

Read More…..

Dermatology During COVID-19 [FREE WEBINAR]

By | COVID-19 Resources | No Comments
COVID-19 & Dermatology Webinar

This webinar was previously recorded on April 1st, 2020 and is now available on demand. Click here to access the on-demand recording.

Join Dermatology Leadership Discussion of COVID-19

ODAC and JDD invite you to attend a webinar panel to provide discussion, guidance, and leadership for dermatologists and dermatology practices during the global coronavirus pandemic.

Over the course of the 2 hours, 8 different thought leaders will join the conversation, discussing questions that are on the mind of many dermatologists in the country. Click here to register.

MODERATOR
Joel L. Cohen, MD (Director, About Skin Dermatology & Associate Clinical Professor, University of California at Irvine)

AGENDA
6:00-7:00PM
Neal Bhatia, MD (Vice President-elect of the AAD & Director of Clinical Dermatology, Therapeutics Clinical Research)
Adam Friedman, MD (Professor and Interim Chair of Dermatology, GW School of Medicine & Health Sciences)
William D. Humphries (President, Ortho Dermatologics)
Mark Kaufman, MD (Associate Clinical Professor, Icahn School of Medicine at Mount Sinai)

7:00-8:00PM
Sue Ellen Cox, MD (Founder, Aesthetic Solutions)
Kavita Mariwalla, MD (Founder, Mariwalla Dermatology)
Carrie Strom (Senior Vice President, US Medical Aesthetics at Allergan)

ARCHIVED RECORDING
This webinar will be archived for on demand viewing on JDDonline.com by end of day Friday April 3rd.

Remote Work and Benefits of Video Conference

By | COVID-19 Resources | No Comments
Remote work on phone

Source: ODAC Dermatology Conference’s Parent Company, SanovaWorks

NEW YORK, (Mar. 26, 2020) – Shelley Tanner, SanovaWorks CEO/President

In the wake of COVID 19, I wrote a article about the Top Immediate Needs of a Remote Employee

Regular communication through video conference calls was at the top of my list. I asked the team what their thoughts were and received a great response from Nick.

Nick Gillespie, Assistant Publisher

Use video conference tools, not the phone.

Sometimes staff can feel that it’s an imposition, but the quality of meetings for those participating via video is infinitely better than just via phone

I would say the most important tip is to embrace the video component of remote working.

People quickly become used to the video interface, to the point where it becomes no different from meeting face to face in the office.

Gaging facial expressions and body language is very important for effective communication.

I think if you are a manager in a company, you should make video attendance mandatory for all. 

Some links about the benefits of face to face meetings (even remote ones):

https://timemanagementninja.com/2012/10/5-reasons-why-meeting-face-to-face-is-best/

https://medium.com/@shannonkelly_80469/steve-jobs-on-the-importance-of-face-to-face-meetings-even-in-the-age-of-iphones-a5a4b83621a6

https://sebastiancorp.com/10-reasons-video-conferencing-is-better-than-a-conference-call/

COVID-19 News & Resource Center

By | COVID-19 Resources | No Comments
COVID-19 Dermatology resources and news

Source: Next Steps in Derm

Each week, Next Steps in Derm will be compiling the top news and updates surrounding COVID-19 to keep you up-to-date and informed.

HIPAA Compliance During COVID-19 Pandemic

Learn what information can be shared about individuals who have contracted COVID-19, those suspected of exposure to the 2019 Novel Coronavirus, and those with whom information can be shared.

For any questions you have related to the response to HIPAA compliance during coronavirus crisis call (800) 231-4096.

JDD CME library offers virtual learning during COVID-19

The JDD CME library is now updated to accommodate a growing demand for online CME resources. We expect this demand to grow in light of the cancellation of some medical meetings due to the global COVID-19 situation. Access the CME library here.

Medicare Telemedicine Health Care Provider Fact Sheet

Source: Centers for Medicare & Medicaid Services
The Centers for Medicare & Medicaid Services (CMS) has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility.

 

The American Academy of Dermatology strongly recommends that patients should not stop biologic therapy without consulting their physicians. Read their interim recommendations here.

AAD Coronavirus Resources

Managing your practice through the COVID-19 outbreak

Legislation and regulation

Teledermatology

Managing your business

American Medical Association (AMA) COVID-19
Resource Center for Physicians

AMA Physician’s Guide to COVID-19

  • Prepare your practice
  • Address patient concerns
  • Answer your most pressing questions

COVID-19: Frequently asked questions

  • Patient-physician relationship questions
  • Clinical questions
  • Practice management questions
  • Ethical Questions

Read More….

The Two Most Important Aspects of Communication While Working Remotely

By | COVID-19 Resources | No Comments
Remote-Work-SanovaWorks

Source: ODAC Dermatology Conference’s Parent Company, SanovaWorks

NEW YORK, (Mar. 23, 2020) Signe Pihlstrand, Vice President, SanovaWorks

In the wake of COVID-19 and the need for social distancing, many companies are having their staff work from home, and a great portion of them don’t have a routine remote policy or have remote processes set up. SanovaWorks has been successfully 100% remote for over six years now, and we gave ourselves many months of preparing, the better part of a year, before launching our remote work culture. These companies unfortunately don’t have that luxury and need to keep their workforce productive and the wheels rolling with an abrupt start to their remote experience. When I think about the most important things a company can do to lay the right foundation for their remote procedures, the plan for how you will communicate regularly is the first thing that comes to mind.

Working remotely requires clear communication and clear expectations.

If your team isn’t used to working remotely, you can’t assume that everyone will be on the same page about how to connect. Setting up defined guidelines for when and how you will communicate is so important.

  1. When – This has the tendency to go both ways: It’s not productive to be bombarded with IMs and emails throughout the day, and radio silence can leave you wondering if anything is getting accomplished. Set up and communicate a clear plan for when you expect to hear from your staff, or colleagues – for instance, a 15-minute touch-base call every morning, emails returned within 24-hours, or maybe a daily end-of-day report from your staff.
  2. How – Pick the ways that your team will communicate and get everyone on the same tools. You don’t want to have to check numerous places for messages. Plus, decide what is communicated by each. Short, occasional messages are best for IMs, while longer messages can be via email – while longer yet should be done in a conversation by video chat.

These ideas may seem obvious, but if not set up to make sure everyone has the same idea about what communication looks like, it can really wreck productivity. If everyone is left to their own devices, you could be fielding phone calls, texts, IMs, video chats, and emails from whatever program someone has on their phone or laptop, at all times of the day, or not at all. Remote working requires its own set of procedures, just like you have at the office.

At SanovaWorks we train everyone on our designated tools and procedures and make it a priority to use video chats whenever possible for the best communication and team member connections!

Statement From Our President and CEO Regarding COVID-19

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Sanovaworks Logo

NEW YORK (Mar. 13, 2020) – A Note from Shelley Tanner, SanovaWorks CEO/President

First and foremost, in light of the rapidly evolving global COVID-19 situation, we hope that you and your family are safe and healthy. We send companywide thoughts and prayers to the individuals, families, and other groups who have been impacted by this situation, and hope that things will improve very soon.

While many things are uncertain surrounding this virus, as an organization, SanovaWorks believes in taking action early. We are dedicated to providing the best care and support we can to all our employees and business partners.

We have the extremely good fortune to be functioning already as a virtual company and because of this we hope to be able to provide support and resources to our entire network who might not have the experience we have. Please check our blog for our tips and recommendations for transitioning to and being successful in a remote work environment:https://sanovaworks.com/2020/03/11/top-immediate-needs-of-remote-employees/

In addition to this, in order to protect our teams and others, until further notice, we have issued a complete restriction on all business-related travel. While the CDC has not placed restrictions on domestic travel, they have recently posted travel warnings on their website: https://www.cdc.gov/coronavirus/2019-ncov/travelers/travel-in-the-us.html?mod=article_inline

The CDC also provide general recommendations that we should all be following to prevent the spread of this disease:https://www.cdc.gov/coronavirus/2019-ncov/about/prevention.html

We will be working diligently as teams to connect with many of you so that we can share some very interesting ways to accomplish our results in this new, virtual environment. We have many years of experience transitioning traditional programs to digital programs, and launching successful virtual programs. Because we are already positioned as a remote company that produces virtual programs, we hope that we are able to support your own initiatives and bridge the gap this global situation has caused.

And last but not least, with a shout out to Jim Collins who introduced me to the Stockdale Paradox in his book Good To Great, we all need to look squarely at the facts, but have confidence that together we will prevail, as we balance realism with optimism.

 

Together.

Shelley and the entire SanovaWorks Team

Long Term Use of Novel Therapeutic for Topical Treatment of Primary Axillary Hyperhidrosis in Pediatric Subjects

By | Medical Dermatology, ODAC Sessions | No Comments

Source: ODAC Dermatology, Aesthetic & Surgical Conference (ODAC) Discovery in Dermatology Poster Session

At the 17th Annual ODAC Dermatology, Aesthetic, and Surgical Conference (ODAC) held January 17-20 in Orlando, FL, Brandon Kirsch, MD, Janet DuBois, MD, Martin N. Zaiac, MD and Deepak Chadha, MS, MBA, RAC presented scientific research of long term data with a novel therapeutic for topical treatment of primary axillary hyperhidrosis in pediatric subjects.

Discovery in Dermatology
The use of retro-metabolically designed drugs in dermatology is novel and has the potential for providing significant therapeutic benefit to pediatric and adult patients.

Sofpironium bromide is an ester analogue of glycopyrrolate that inhibits muscarinic receptors in sweat glands. It was developed according to the principles of retro-metabolic drug design, in which the goal is to create an active compound that is metabolized in vivo to an inactive moiety in a single, predictable reaction. Retro-metabolically designed drugs are rapidly metabolized in the bloodstream, potentially allowing for optimal therapeutic effect at application sites with minimal systemic side effects.

Brickell Bio Ped Data

Introduction
~2.1% of the US population aged <18 years has primary hyperhidrosis (HH); ~65% have axillary HH. Long-term safety/tolerability and efficacy of topical HH treatments have rarely been studied in pediatric patients. Sofpironium bromide is a retro-metabolically designed analog of glycopyrrolate (anticholinergic) in development for topical treatment of primary axillary HH. Absorbed drug is rapidly metabolized, potentially allowing optimal local therapeutic effect with minimal systemic effects..

Procedures
21 of 25 subjects (age 9-16 yrs) with primary axillary HH of ≥6 months duration, completing a previous 1-week safety and pharmacokinetic (PK) study (BBI-4000-CL-105), were enrolled. Objectives were to assess safety/tolerability and PK, and explore efficacy of sofpironium bromide gel, 15% applied to both axillae for 24 weeks.

Results
Mean age (SD) 13.3 (2.29) years. 16 subjects completed this 24-week study. 7 had treatment emergent adverse events (TEAEs); 4 with AEs related to study drug, including expected systemic anticholinergic AEs (blurred vision, dry mouth, dry eyes, mydriasis) and local events (pain, pruritus, rash, erythema). 2 subjects discontinued due to TEAEs, including dry eye, dry mouth, local pruritus, local rash. The majority (52.4%) of subjects did not have any local symptoms/signs, and none observed were severe in nature. PK did not show evidence of drug/major metabolite accumulation, with most subjects having concentrations not quantifiable. The validated patient-reported outcome, Hyperhidrosis Disease Severity Measure-Axillary (HDSM-Ax), showed mean (SD) change from baseline (from previous study) to Week 24 of this study of -1.91 (1.038). A -1.00 change shows clinically meaningful improvement.

Conclusion
In this 24-week study in pediatric subjects sofpironium bromide, 15% was safe/well tolerated. Majority of subjects had no TEAE, and there were no severe or serious AEs. There was no evidence of drug accumulation. There was indication of clinically meaningful improvement in axillary HH.

Top Immediate Needs of Remote Employees

By | COVID-19 Resources | No Comments
Remote-Work-SanovaWorks

Source: ODAC Dermatology Conference’s Parent Company, SanovaWorks

NEW YORK (Mar. 11, 2020) – A Note from Shelley Tanner, SanovaWorks CEO/President

SanovaWorks transitioned into a 100% virtual company at the end 2012 at the same time press was reporting market leaders like Yahoo and Best Buy stopped all remote work at their companies. To the outside world, it seemed like we were making a crazy decision, heading in the opposite direction from global brand in terms of office culture and environment. We were convinced of the many benefits, so without hesitation we transitioned from two floors of a small office building on Park Avenue South in Manhattan, to a completely remote workforce.

I realize that due to the Coronavirus outbreak many companies are forced to transition some or all of their teams into remote teams without a solid plan, and so I felt compelled to share some of my thoughts on this matter.

The main things remote employees need in the short term are:

  1. Access to information immediately
  2. Regular communication
  3. Clear visibility of priority and goals

For this reason, I am including some of my “must-haves”:

  • Use video conference tools, not the phone. It take more internet bandwidth, but it provides a more engaged experience of meetings. If you don’t know what I’m talking about watch this live enactment of a conference call by phone: https://www.youtube.com/watch?v=DYu_bGbZiiQ
  • Use online project management tools for collaboration and project tracking. We use Wrike.com but there are many other options like Asana or Basecamp.
  • Use online file storage for easy access to documents. We use Egnyte, but there are options like Dropbox and Google also.
  • Ask for feedback. Don’t be afraid to ask what people think. Communicate that this is new and you are figuring it out, but want to support your teams and accomplish results in this new environment. Your teams will give valuable insight into accomplishing results.
  • Commute time turns into connect time: With a remote culture – everything can feel like a meeting. Be prepared for a feeling of meeting fatigue and get out ahead of it making meetings meaningful with clear agendas and timekeeping, etc.

If anyone has specific questions please comment on the Linked In post or direct message me and if I can’t answer, I will ask one of my extremely competent virtual team.

Best to all during these challenging times,

Shelley

What’s New in Treatments for Hair Loss with Amy McMichael, MD

By | Aesthetic Dermatology, Medical Dermatology, ODAC Sessions, Video Pearls | No Comments

During the 2020 ODAC Dermatology, Aesthetic and Surgical Conference, Dr. Amy McMichael, Professor and Chair of Dermatology at the Wake Forest University School of Medicine, sat down with Next Steps in Derm to share important updates regarding treatments on the horizon for the most common forms of hair loss. Dr. McMichael will be presenting at Skin of Color Update 2020 with lectures including Hair & Scalp Disorders in SOC: Diagnostic Approaches and Hot Topics & Controversies in Photoprotection: Making sense of it all.

Read More…..

ODAC and JDD Help Identify Need for Disaster Preparation in Dermatology

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JDD ODAC Disaster preparedness Adam Friedman

Source: George Washington University, ODAC and JDD

A new study from the George Washington University found that many dermatologists are unprepared to respond to biological disasters and that the specialty would benefit from formal preparedness training.

WASHINGTON (Jan. 30, 2020) — The dermatology community is inadequately prepared for a biological disaster and would benefit from a formal preparedness training program, according to a study from the George Washington University (GW). The article is published in the Journal of Drugs in Dermatology.

Natural and man-made disasters can cause a range of dermatologic conditions due to environmental exposures, such as secondary infections following a flood, irritation from blistering agents used in chemical warfare, and acute and chronic effects of cutaneous radiation syndrome. A 2003 survey revealed that 88% of dermatologists felt unprepared to respond to a biological attack — this new survey shows that the need for training still exists.

“Recognizing and diagnosing the conditions that can arise following a disaster requires diagnostic acumen, knowledge on reporting, and short- and long-term management strategies,” said Adam Friedman, MD, interim chair of the Department of Dermatology at the GW School of Medicine and Health Sciences and senior author on the study.

This current survey from an interdisciplinary team of dermatology and emergency medicine researchers, led by Emily Murphy, a research fellow in the GW Department of Dermatology, examines whether the field of dermatology has advanced in its bioterrorism preparedness.

The survey, disseminated via the ODAC Dermatology, Aesthetic & Surgical conference listserv, found that only 28.9% of respondents received training in disaster preparedness and response. The respondents to the survey frequently commented that they felt dermatologists should be prepared for bioterrorism-related cutaneous diseases, such as anthrax or smallpox-related diseases, as well as infections resulting from natural disasters.

Similar to the 2003 survey, the authors found that few dermatologists received adequate bioterrorism preparedness training. Even among those who had reported training, many indicated they felt ill prepared to manage patients affected by disasters, especially biological attacks and nuclear or radiological events.

“While few respondents to the survey were trained in disaster preparedness, it is encouraging that 75% reported that it should be included in dermatology training,” Friedman said. “It is a necessary tool to advance the field.”

James Phillips, MD, section chief of disaster and operational medicine in the GW Department of Emergency Medicine, director of the GW Disaster Medicine Fellowship, and co-author on the study, agreed: “My fellows and I found great value in partnering with our dermatology colleagues for this project. It is my firm belief that, while disaster medicine and emergency management primarily fall within the scope of emergency medicine and trauma surgery, education, and training for other specialties is of great value and is virtually unexplored. In an increasingly complex disaster environment, we welcome such research collaborations with other GW specialists.”

###

The article, titled “A Survey of Dermatologists’ Preparedness for Natural and Man-made Disasters,” is published in the Journal of Drugs in Dermatology and can be found at jddonline.com/articles/dermatology/S1545961620P0016X/1.

New and Emerging Therapies for Advanced Non-Melanoma Skin Cancer

By | Medical Dermatology, ODAC Sessions | No Comments
Advanced non-melanoma skin cancer patient image

Source: Next Steps in Dermatology 

At the 17th Annual ODAC Dermatology, Aesthetic, and Surgical Conference (ODAC) held January 17-20 in Orlando, FL, Dr. Desiree Ratner led a discussion on new and emerging therapies for advanced non-melanoma skin cancer discussion.

Treatment Options
The session covered several treatments for patients including patidegib gel 2% and 4% applied once or twice daily in patients with basal cell carcinoma. Patidegib is a topical hedgehog inhibitor made by PellePharm and its mechanism of action is to block Smo signaling, thereby inhibiting the hedgehog pathway that contributes to the development of basal cell carcinomas. This treatment has several advantages in that it does not contribute to hair loss, taste loss, or muscle cramps. It has the potential to treat and mitigate facial basal cell carcinomas in basal cell nevus patients. It is being studied in randomized clinical trials enrolling patients with Gorlin’s syndrome (basal cell nevus syndrome) in the United States and in Europe.

Hedgehog pathway inhibitor resistance is unusual but may occur as “rebound” tumor growth after drug cessation or secondarily after long-term smoothened inhibitor therapy. Resistance to hedgehog pathway inhibitors is classified into primary and secondary resistance. Primary resistance has been postulated to bypass mechanisms of genes downstream of smoothened, such as the G497 W mutation. Secondary resistance in patients who showed an initial response has actually been thought to be due to de novo mutations located on regions in smoothened to which hedgehog pathway inhibitors bind or selective clonal expansion of minority clones in the pre-treated tumor. Further studies are definitely needed to elucidate what drives resistance to hedgehog pathway inhibitors and how basal cell carcinoma resistance may be overcome by other novel, emerging therapies.

Patient Cases
Dr. Ratner presented a number of interesting patient cases with advanced basal cell carcinomas sometimes so large that patients lose mobility and function of a body part or organ. In most cases, locally advanced BCCs respond well to oral hedgehog inhibitors, which can be used for long-term control or neoadjuvantly prior to surgery. In the case of one patient, an aggressive orbital BCC caused contraction of the tissues around his eye, such that he was not able to open it. Despite treatment with an oral hedgehog inhibitor, his tumor continued to grow, resulting in destruction of his orbit and locoregional metastasis.

Samples of his tumor and normal skin were sent to Stanford University, which performed whole exome sequencing. In the studies of these samples, it became evident that the tumor should have responded to vismodegib but had developed resistance due to another as yet unknown mechanism. Therapies designed to override resistance such as second-generation smoothened inhibitors are under development.

Read more. 

Deciding When to Perform Mohs: ODAC Q&A

By | ODAC Sessions, Surgical Dermatology | No Comments
Patel at ODAC Mohs

Source: The Dermatologist

The following is an excerpt from The Dermatologist as coverage from ODAC Dermatology, Aesthetic & Surgical 2020 where Sailesh Konda, MD, and Vishal Patel, MD, reviewed the guidelines and discussed considerations for when and when not to perform MMS.

Mohs micrographic surgery (MMS) is considered the gold standard of treatment for many skin cancers. However, this option is not always appropriate for every situation and every patient. Several factors should be considered when determining which option to use, including tumor size, patient age, and aesthetic outcomes, for treating skin cancer.

The Dermatologist: What are the guidelines for determining what tumors should and should not be treated with MMS?

Dr Konda: The appropriate use criteria (AUC) for MMS was developed in 2012 by an ad hoc task force.2 In general, MMS may be considered as a treatment option for tumors on the head, neck, hands, feet, pretibial surface, ankles, and genitalia; aggressive tumors of any location; tumors greater than 2 cm on trunk or extremities; recurrent tumors, and tumors arising in patients with a history of immunosuppression, radiation, or genetic syndromes.

An AUC score is assigned to tumors based on their characteristics. Tumors with scores of 7 to 9 are appropriate, 4 to 6 are uncertain (in extenuating circumstances, MMS may be considered), and 1 to 3 are inappropriate.

However, practitioners should remember that these are only guidelines! Even if a tumor meets criteria for MMS, the physician and patient should still discuss all available treatment options—both surgical and nonsurgical— and take into consideration associated cure rates; long-term clinical and aesthetic outcome; the patient’s age and comorbidities; and risks, benefits, and adverse effects before deciding on a treatment.

The Dermatologist: What tumors often deemed appropriate for MMS might not actually require MMS, and why?

Dr Konda: Superficial basal cell carcinoma and squamous cell carcinoma in situ are tumors that have been deemed appropriate for MMS. However, these tumors may also be treated with topical therapy (imiquimod and 5-fluorouracil), local destruction, fusiform or disc excision, photodynamic therapy, and lasers (CO2 +/- diode for follicular extension). These treatment modalities may provide cure rates lower than but approaching those of MMS, and may be preferred by physicians and patients in certain circumstances. When discussing treatment options, patients should be made aware of any therapies that may be used off-label or are not FDA-approved.

Additionally, lentigo maligna (melanoma in situ) and lentigo maligna melanoma may be treated with either MMS (frozen sections), staged excision with central debulk and complete margin assessment (permanent sections), or wide local excision (permanent sections).

Read more….

Safety and Patient Sunscreen Questions Answered at ODAC

By | Medical Dermatology, ODAC Sessions, Patient Care | No Comments
Friedman SPF T ODAC

Source: Dermatology News

The following is an excerpt from Dermatology News Expert Analysis, Conference Coverage from ODAC.  

ORLANDO – Dermatologists should be well versed in addressing common concerns that patients, family members, and the media have about photoprotection, Adam Friedman, MD, advised at the ODAC Dermatology, Aesthetic, & Surgical Conference.

“Know the controversies. Be armed and ready when these patients come to your office with questions,” Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, said in an interview at the meeting, where he presented on issues related to photoprotection.

Which SPF to choose and the impact of sunscreen on vitamin D are among the issues patients may be asking about. Sunscreen SPFs above 50 don’t technically provide a “meaningful” increase in ultraviolet protection, given that this value relates to filtering about 98% of UVB, but they still can provide some benefit, which has to do with real-world human error, Dr. Friedman said.

Read more. 

Systemic Therapy Options for Pediatric Skin Diseases are Improving

By | Medical Dermatology, ODAC Sessions | No Comments
Kirkorian Pediatric Systemic Disease ODAC

Source: Dermatology News

The following is an excerpt from Dermatology News Expert Analysis, Conference Coverage from ODAC.  

ORLANDO – Because Food and Drug Administration–approved treatment options for children and adolescents with severe dermatologic diseases are limited, systemic therapies for these patients often require the use of off-label medications. However, this scenario is changing, A. Yasmine Kirkorian, MD, said at the ODAC Dermatology, Aesthetic & Surgical Conference.

“I really would like to emphasize that children with severe disease need to be treated,” added Dr. Kirkorian, a pediatric dermatologist at George Washington University, Washington, and Children’s National Health System, where she is interim chief of the division of dermatology.

Current on-label systemic therapies for pediatric skin disease include etanercept for psoriasis (4 years and older), ustekinumab for psoriasis (12 years and older), adalimumab for hidradenitis suppurativa (12 years and older), and omalizumab for chronic idiopathic urticaria (12 years and older). A new addition to the list is dupilumab, which was approved for children and adolescents with atopic dermatitis (AD) aged 12 years and older in 2019, she noted.

Read more…. 

Tips for Treating Male Aesthetic Patients: Q&A with ODAC Faculty

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Terrence Keaney Male Aesthetics at ODAC

Source: The Dermatologist

The following is an excerpt from The Dermatologist article on Q&A with ODAC Dermatology, Aesthetic and Surgical conference faculty, Terrence Keaney, MD.  

More and more men are seeking cosmetic procedures to improve their appearance and slow the aging process. In addition to anatomical differences, men have different concerns about how they look compared with women. Terrence Keaney, MD, discussed these concerns and trends among male aesthetic patients, and also shared pearls for treating this patient population at ODAC Dermatology, Aesthetic and Surgical conference in Orlando, FL.

Dr Keaney is founder and director of SkinDC and an assistant clinical professor of dermatology at George Washington University School of Medicine.

The Dermatologist: What are some common trends among male aesthetic patients?

Dr Keaney: Like broader trends in aesthetics, there is no cookie cutter technique for treating men. Gender is just one data point, albeit a fairly important one because it affects biology, anatomy, behavioral expectations, etc. When evaluating a new cosmetic patient, gender, age, ethnicity, and other patient factors play a role in creating a customized treatment plan.

Understanding aesthetic procedures among male patients has not been well-studied and has not been on the top of many aesthetic providers minds, most likely because men occupy a smaller percentage of cosmetic patients. However, the number of men seeking minimally invasive procedures is growing.

As more men seek cosmetic treatment, it is important that physicians and practitioners know how to approach these patients from a treatment perspective, as well as how to discuss complications from these procedures because these scenarios may be different compared with female patients.

The Dermatologist: What are some of the differences between male and female patients that dermatologists should keep in mind?

Dr Keaney: The number one difference between men and women is anatomy. Anatomy really dictates how a provider will perform a procedure, especially fillers.

The facial anatomy of men is very different than women. For example, the distribution of fat is different between the sexes. Men have less subcutaneous fat in the face, especially in the medial cheeks and middle of the cheek, and do not have high cheekbones, which dictates where a filler would be placed. The apex of the cheek tends to be lower and more towards the middle in men, whereas the apex tends to be high and lateral in women and is considered a very feminine feature.

Behaviors, such as goals and expectations of cosmetic procedures, differ between men and women as well. Men care about different factors than women. Specifically, men worry about 3 areas: the hairline, eyeline, and jawline. When discussing aesthetic procedures and performing a full-face analysis of male patients, I often refer back to these 3 areas because I know men tend to worry about them the most.

However, this does not mean I do not use fillers on the cheeks or the mid-face. When I use a filler, I explain to the patient so they understand how this procedure may influence how their jaw looks or their eyes look. Otherwise, they may not be interested in that treatment option.

Other major concerns among men include hair loss and body contouring.

Read more….

Dr. Landriscina on Caring for LGBTQ+ Patients

By | ODAC Sessions, Patient Care | No Comments
ODAC dermatology conference session image

Source: Next Steps in Derm

At the 17th ODAC -Aesthetic, Surgical and Clinical Dermatology Conference held January 17-20, 2020 in Orlando, FL, Dr. Angelo Landriscina led a session on developing new approaches to caring for LGBTQ+ patients.

Next Steps correspondent Dr. Anna Chacon reports back on highlights and pearls from the session which covered the following:

Why this topic?
Updating Our Understanding of SGM Patients
Caring for Transgender Patients
Aesthetic Treatments for Transgender Patients
Creating A Competent Clinical Environment
Why this topic?

It is difficult to determine how many people identify as LGTBQ+ in the United States. Right now, our best estimate is about 4% based on survey data. These patients tend to cluster into different areas, but it’s likely that you will see 2-3 patients per day who are a part of these communities.

Using the appropriate terminology is also key. There is a difference between sexual orientation and gender identity. Sexual orientation describes an individual’s emotional, romantic or sexual attraction to others while gender identity can be male, female or neither, and it can change over time.

What does LGTBQ+ stand for?

The acronym stands for lesbian, gay, bisexual, transgender, queer and questioning but can even be longer (LGBTQQ2SIAA)! There are other terminologies that can also be included such as intersex, gender fluid, and gender queer. Intersex describes: a variation in sex characteristics including chromosomes, gonads, or genitals that do not allow an individual to be distinctly identified as male or female. Gender fluid describes a person who doesn’t identify with a fixed gender at all times. And genderqueer is an umbrella term for gender identities that are not exclusively masculine or feminine identities which are thus outside of the gender binary and cisnormativity.

Queer is a blanket term that can describe all of these but has a loaded history since it used to be use as a slur. SGM stands for sexual and gender minority, which is an easy clinical and scientific term to use when talking about this population. While it is helpful to become familiar with the appropriate terminology, it is also important to be mindful of which particular terms to avoid when talking to patients such as: homosexual, sexual preference, “lifestyle,” and “sex change.”.

When it comes to pronouns, it is best to ask patients which they prefer. In situations where this may be unclear, the singular pronoun “they” may be your best friend – it was Merriam-Webster’s 2019 word of the year!

Additional tips for the dermatologist include being comfortable with not knowing everything, allowing your patients to define themselves, and recognizing that sexual orientation and gender identity are independent of each other.

Read more. 

Practical Dermoscopy with Sima Jain, MD: In-depth Conference Coverage

By | Medical Dermatology, ODAC Sessions | No Comments
Dermoscopy tool image

Source: Next Steps in Derm

Dermoscopy, also known as epiluminescence microscopy, epiluminoscopy or skin surface microscopy, is an important way to visualize subsurface structures in the epidermis and dermis. In a 2-part series, Dr. Sima Jain reviews the evaluation of pigmented lesions, and the different vessel morphologies and patterns along with a discussion of specific findings in select cutaneous infections.

Read part 1 here

Read part 2 here

If you want to learn more about dermoscopy, make sure to register for the upcoming ODAC Dermatology, Aesthetic & Surgical Conference where Dr. Sima Jain will lead the following dermoscopy sessions:

The Utility of Dermoscopy in Challenging Clinical Cases

During this session, Dr. Jain will present challenging clinical cases and explore how dermoscopic evaluation can significantly increase clinical acumen.

Attendees will:

  1. Learn how to use dermoscopy to help differentiate types of alopecia
  2.  Learn how to use dermoscopic features to differentiate between melanoma and pigmented basal cell carcinoma
  3. Learn the dermoscopic features seen in cutaneous lupus and other rashes with follicular plugging.
PEARL ALERT!

Perifollicular scaling and fibrotic white dots are seen in lichen planopilaris. Orthogonal white streaks can be seen in melanoma. Glomerular vessels are often seen in Bowen’s disease.

Dermoscopy Essentials for Residents & Practicing Physicians

During this session, Dr. Jain will review the basics of dermoscopy and how it can be used to help diagnose both pigmented and non-pigmented skin lesions.

Attendees will:

  1. Learn how to correlate the colors seen on dermoscopic exam with histopathology.
  2. Learn how to distinguish non-melanocytic growths from melanocytic growths.
  3. Learn how to use vessel morphology to help diagnose cutaneous malignancies.
PEARL ALERT!

White streaks can be seen in melanoma and basal cell carcinoma. Telangiectasias, leaf-like areas and spoke wheel pigmentation are seen in basal cell carcinomas. The delta wing jet with contrail is specific for scabies.

Dr. Susan Weinkle Receives ODAC JDD Award

By | Aesthetic Dermatology, Patient Care | No Comments
Susan Weinkle MD image from ODAC Dermatology conference

Source: Practical Dermatology

Susan Weinkle, MD, has been awarded the Outstanding Educator and Mentor in Dermatology Award by the ODAC Dermatology, Aesthetics & Surgical Conference, in partnership with the Journal of Drugs in Dermatology (JDD).

The award recognizes Dr. Weinkle for her long-standing commitment to educating and mentoring the next generation of dermatologists and for devoting a major portion of her professional life to enhancing the practice and profession of dermatology through education.

“Susan has given all of us in aesthetics so much of her time and energy, and I am honored to present this award to her.”“It is a pleasure and an honor to recognize the tireless work of exceptional leaders in dermatology,” said Shelley Tanner, CEO and president of SanovaWorks, which produces the JDD, ODAC, Derm In-Review, and Next Steps in Dermatology. “Not only do these dermatology leaders dedicate their entire lives to benefiting patients every day, but after the ‘work day’ ends, they spend countless hours involved in activities to improve the specialty’s future. We congratulate Dr. Weinkle for being chosen for this award.”

Read More….

Susan Weinkle, M.D., Presented JDD Outstanding Educator Award

By | Aesthetic Dermatology, Patient Care | No Comments
Susan Weinkle MD image from ODAC Dermatology conference

Source: DermatologyTimes

A south Florida practitioner’s contribution to dermatology is not going unnoticed at the 2020 Orlando Dermatology, Aesthetic & Surgical Conference (ODAC) with the recent presentation of the Journal of Drugs in Dermatology (JDD) Outstanding Educator & Mentor in Dermatology Award to Susan Weinkle, M.D, Tampa, Fla.

Dr. Weinkle, an assistant clinical professor of dermatology at the University of South Florida, was recognized for her dedication to mentoring and educating future dermatologists, and commitment to advancing the dermatology industry through education.

Aside from being an educator, Dr. Weinkle specializes in cosmetic surgery and Mohs Micrographic Surgery at her private practice in Bradenton, Fla.

She was also the president of the American Society for Dermatological Surgery and the Women’s Dermatological Society. Additionally, she was previously a committee chair and board of directors member at numerous dermatology organizations including the Florida Society of Dermatology and Dermatologic Surgery, American Academy of Dermatology and Dermatology Foundation.

Read More….

Dr. Stratman to Present MOC Certlink at ODAC 2020

By | ODAC Sessions | No Comments
Erik Stratman MD faculty image from ODAC 2020

Source: SanovaWorks

NEW YORK  – Erik J. Stratman, MD, 2019 President of the American Board of Dermatology (ABD), to present on Maintenance of Certification (MOC) CertLink in January at ODAC Dermatology, Aesthetic and Surgical conference.

Changes to MOC
A major shift in continuing certification is coming for board-certified dermatologists in January. Erik J. Stratman, MD will present, “Changes to Your MOC Requirements: What Every Dermatologist Should Know about CertLink,” on January 17th, 2020 at the J.W. Marriot in Orlando, Florida.

Workshop Description
Dr. Stratman will walk-through the CertLink® MOC program and demonstrate its design, rationale and navigation. According to the ABD, CertLink provides the utmost flexibility in MOC and provides an alternative to the one-time, sit-down, high stakes in-person MOC examination. Dermatologists will be able to go online and take test questions in the convenience of their own home or office at various times throughout the year.

ABD MOC CertLink®
CertLink® is a longitudinal testing platform. The platform is designed to test and build medical knowledge in a “test to competence” type model. In addition, CertLink® will keep dermatologists up to date by providing the latest articles from dermatology subspecialties. CertLink™ assessment platform is powered by American Board of Medical Specialties (ABMS).

Registration and Fees
The pre-conference workshop is provided complimentary for dermatologists registered for ODAC 2020.

About ODAC
Attend ODAC to stay connected, informed, and up-to-date in dermatology. ODAC (previously Orlando Derm) is one of the largest and most prestigious conferences of the year. ODAC attracts a national audience of over 650 US Dermatology Physicians, Dermatology Residents, Nurse Practitioners and Physician Assistants.

Visit orlandoderm.org to register for ODAC and attend this workshop. ODAC is a product of SanovaWorks.

Hormonal Acne with Sima Jain, MD

By | Medical Dermatology, ODAC Sessions | No Comments
Sima Jain faculty image

Source: Next Steps in Dermatology

ODAC speaker, Sima Jain, MD provides a two-part series on Hormonal Acne for Next Steps in Derm.

Dermatologists should be able to distinguish which patients presenting with acne may need further evaluation for a possible underlying endocrinopathy. In this two-part series, Dr. Jain will be focuses on hormonal acne specifically related to PCOS, including the exam, work up, diagnosis, treatment and long-term implications of this syndrome.

PCOS is a complex disorder affecting 5-10% of reproductive-age women and is characterized by a state of hyperandrogenism and often hyperinsulinemia. It is the most common endocrine disorder in women and is a major cause of infertility due to lack of ovulation. Patients can present with a wide range of symptoms, which may make the precise diagnosis difficult.

Acne is a common skin manifestation but other potential findings may include hirsutism (increased terminal hairs in a male-pattern distribution, scalp alopecia, acanthosis nigricans and less frequently seborrheic dermatitis. Non-dermatologic symptoms and signs may include irregular menses (oligomenorrhea), insulin resistance, polycystic ovaries and infertility.

Since a dermatologist may be the first or only physician a young female patient with hormonal acne sees, it is imperative for us to be aware of the clinical clues that suggest hyperandrogenism. First, it is important to inquire if the patient’s menstrual cycles are regular to screen for oligomenorrhea and potential anovulation. Be mindful if the patient is on an oral contraceptive pill, as this can mask underlying oligomenorrhea since the external hormones are essentially regulating the menstrual cycle. In addition to discussing the menstrual history, it is important to inquire about potential hirsutism by asking if the patient has noticed increased hair growth to the face (sideburn area, chin, upper cutaneous lip), chest, abdomen and/or inner thighs. Many patients do not realize that increased hair growth may be related to acne and often feel embarrassed to bring it up on their own. A third important feature to be aware of is hair loss to the scalp. It is not uncommon for patients to say they have noticed thinning of their hair or increased shedding, especially to the front of their scalp.

Visit Next Steps in Derm to read the series or attend ODAC to learn more.

Hormonal Acne with Sima Jain, MD: Part 2

By | Medical Dermatology, ODAC Sessions, Video Pearls | No Comments
Hormonal Acne Patient Image

Source: Next Steps in Dermatology

ODAC speaker, Sima Jain, MD provides a two-part series on Hormonal Acne for Next Steps in Derm.

Dermatologists should be able to distinguish which patients presenting with acne may need further evaluation for a possible underlying endocrinopathy. In this two-part series, Dr. Jain will be focuses on hormonal acne specifically related to PCOS, including the exam, work up, diagnosis, treatment and long-term implications of this syndrome.

PCOS is a complex disorder affecting 5-10% of reproductive-age women and is characterized by a state of hyperandrogenism and often hyperinsulinemia. It is the most common endocrine disorder in women and is a major cause of infertility due to lack of ovulation. Patients can present with a wide range of symptoms, which may make the precise diagnosis difficult.

Acne is a common skin manifestation but other potential findings may include hirsutism (increased terminal hairs in a male-pattern distribution, scalp alopecia, acanthosis nigricans and less frequently seborrheic dermatitis. Non-dermatologic symptoms and signs may include irregular menses (oligomenorrhea), insulin resistance, polycystic ovaries and infertility.

Since a dermatologist may be the first or only physician a young female patient with hormonal acne sees, it is imperative for us to be aware of the clinical clues that suggest hyperandrogenism. First, it is important to inquire if the patient’s menstrual cycles are regular to screen for oligomenorrhea and potential anovulation. Be mindful if the patient is on an oral contraceptive pill, as this can mask underlying oligomenorrhea since the external hormones are essentially regulating the menstrual cycle. In addition to discussing the menstrual history, it is important to inquire about potential hirsutism by asking if the patient has noticed increased hair growth to the face (sideburn area, chin, upper cutaneous lip), chest, abdomen and/or inner thighs. Many patients do not realize that increased hair growth may be related to acne and often feel embarrassed to bring it up on their own. A third important feature to be aware of is hair loss to the scalp. It is not uncommon for patients to say they have noticed thinning of their hair or increased shedding, especially to the front of their scalp.

Visit Next Steps in Derm to read the full series or attend ODAC to learn more.

CBD for Psoriasis?

By | Medical Dermatology, Patient Care | No Comments
CBD Oil for Psoriasis

Source: Next Steps in Dermatology

Health recently wrote an article asking if CBD oil can relieve psoriasis symptoms.

In recognition of Psoriasis Awareness Month, I consulted Adam Friedman, MD, FAAD, professor and interim chair of dermatology at the George Washington School of Medicine and Health Sciences. Dr. Friedman is also the residency program director, director of translational research and director of the Supportive Oncodermatology Clinic. In addition, Dr. Friedman serves as Medical Director for ODAC -Dermatology, Aesthetic & Surgical Conference.

Can CBD help relieve psoriasis symptoms? 

We have only begun to scratch the surface of the unbridled potential of cannabinoids as therapeutic agents. Interestingly enough, psoriasis is one of the listed indications for medical cannabis in the great state of Connecticut, though little is really known on this and many other spaces in dermatology.

Let’s take a step back and first talk about CBD. CBD stands for cannabidiol, one of about 120 different molecules that come from the cannabis plant. It’s the second most prevalent active ingredient in cannabis – tetrahydrocannabinol (THC) is the first. But unlike other cannabinoids – such as THC — CBD does not produce a euphoric “high” or psychoactive effect. That said, it has tremendous biological reactivity through binding to a multitude of receptors, including the cannabinoid specific receptor, CB2r, which is expressed by practically every immune cell (as opposed to CB1r, which is most heavily expressed in the peripheral and central nervous system), regulating skin physiology by being anti-inflammatory, lipostatic and antiproliferative.

Now back to the original question. Inflammatory skin conditions such as psoriasis result from a number of aberrant responses of the immune cells and immune signaling in the skin. Looking at psoriasis specifically, dysregulation of the skin immune system results in marked proliferation and keratinization of epidermal cells. Overactivation of Th1 and Th17 inflammatory responses in psoriasis produces cytokines like IL-17 and IL-22 that set off cascades of events resulting in increased keratinocyte proliferation, expression of keratins 6 and 16, and inflammatory cell infiltration. Because of its role in regulating the inflammatory response of keratinocytes and dermal immune cells, the endocannabinoid system offers potential targets for the management of many inflammatoryskin conditions, but the data to date is rather limited, mostly to cell bases, ex vivo and animal models.

This is what we know:Activation of the endocannabinoid system in the skin reduces inflammation through a number of mechanisms, such as shifting the pro-inflammatory Th1 response to an anti-inflammatory Th2 response via CB2r activation (thank you, CBD). The endocannabinoid system also plays a role in regulating keratinocyte proliferation and differentiation, which are pathologically increased in psoriasis. For example, CB1r activation by cannabinoids such as anandamide (AEA) inhibits keratinocyte differentiation and decreases production of keratin K6, a marker of keratinocyte hyperproliferation. The potential therapeutic effects of CBD in psoriasis also include activation of non-cannabinoid receptors such as GPR55, which reduces inflammation caused by nerve growth factor, and PPARα and PPARγ which reduces epidermal hyperplasia via suppressed proliferation of keratinocytes.

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.

Read More…

Making Sense of Cosmeceuticals

By | Aesthetic Dermatology, ODAC Sessions | No Comments
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.

Read More….

What’s New for Itch

By | Medical Dermatology, ODAC Sessions | No Comments
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.

Read More…..

Sentinel Lymph Node Biopsy for Melanoma

By | Medical Dermatology, ODAC Sessions, Surgical Dermatology | No Comments
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 | No Comments
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.

Read more. 

SLNB for Melanoma

By | Medical Dermatology, ODAC Sessions, Surgical Dermatology | No Comments
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.

Read More….

Hyperhydrosis: Where are we?

By | Medical Dermatology, ODAC Sessions | No Comments
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

Read More…

Pathophysiology and Management of Rosacea

By | Medical Dermatology, ODAC Sessions | No Comments
Dermatology Patient with Rosacea

Source: Next Steps in Derm

This information was presented by Dr. Adam Friedman at the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference held January 18th-21st, 2019 in Orlando, FL. The  highlights from his lecture were written and compiled by Dr. InYoung Kim.

If you’re a coffee drinker, you may be relieved to know that there was an inverse association between caffeine intake and risk of rosacea in a recent study.  That was a huge relief for me for sure! Unfortunately, we can’t prescribe caffeine for rosacea and call it a day. So, what works?

High-yield pearls on the pathophysiology and management of rosacea are shared by Dr. Adam Friedman – 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. Here are the highlights.

New Approach to Diagnosis and Categorization of Rosacea

First, let’s talk about diagnosis.  Rather than categorizing into 4 classic subtypes that we learned in the textbook, rosacea may be better defined by “phenotypes”.  Diagnostic phenotypes include 1) having fixed centrofacial erythema in a characteristic pattern that may periodically intensify or 2) phymatous changes.  In the absence of these, the presence of 2 or more major features may be diagnostic, including papules/pustules, flushing, telangiectasia, ocular symptoms.  Some secondary phenotypes that may help with diagnosis are burning/stinging, edema, dry appearance, and ocular rosacea.

Rosacea in Skin of Color – Rosacea Does Not Discriminate!

While rosacea has widely been considered a disorder selectively affecting the Caucasian population, this is not true! Perhaps due to this bias, delayed diagnosis has been reported in substantial numbers.  In fact, the prevalence of rosacea in skin of color is as high as 10%!  That is significant.  Please spread the word!  So how do they present differently than Caucasian patients? While you may not see the persistent facial erythema (which is common in whites), the granulomatous subtype and papules/pustules are more common in skin of color.  Asking about the secondary phenotypes noted above (burning/stinging, edema, dry appearance, and ocular rosacea) may also be helpful in diagnosis.

Therapeutic Options – Combo is King!

While many prescription treatment options exist (outlined below), patient education concerning proper general skin care is of utmost importance.  Make sure to include these in your counseling: daily sunscreen, gentle moisturizers, gentle cleansers, avoid triggers.

A list of FDA-approved topical therapies that you may choose from:

  • Azelaic acid (15% gel/foam)
  • Metronidazole (0.75% and 1%)
  • Sodium sulfacetamide 10% and sulfur 5%
  • Brimonidine (0.33% gel)
  • Ivermectin 1%
  • Oxymetazoline (1% cream)

What would a typical daily plan look like for a moderate-to-severe rosacea patient?  Here are Dr. Friedman’s tips:

Read More….

Platelet-Rich Plasma for Skin Rejuvenation

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PRP Injection in Patient

Source: Next Steps in Derm

Dr. Deirdre Hooper, an expert aesthetic and medical dermatologist, discussed the emerging use of Platelet-rich Plasma in the treatment of alopecia and skin rejuvenation at the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference. Dr. Nikhil Shyam shares his takeaways and pearls from this lecture.

Platelet-rich plasma (PRP) is rapidly gaining popularity amongst dermatologists for its potential use in treating hair loss, acne scarring and facial rejuvenation. However, there is significant variability in the processing of PRP and there are currently no established treatment protocols.

Evidence for PRP in Treating Hair Loss and Skin Rejuvenation

  • The literature review for the use of PRP in androgenetic alopecia shows significant benefit without any serious complications. However, the data also reveals wide ranging processing systems for PRP and treatment protocols.
  • PRP may be used topically or intradermally in combination with fractional ablative laser resurfacing to enhance skin rejuvenation and acne scarring with faster recovery between treatments.
  • PRP has also been shown to improve the cosmetic outcome of striae with high patient satisfaction.

Practical Tips for Using PRP in Hair Loss:

  • Use about 5 – 7 ml PRP
  • Inject intradermally or in the deep subcutaneous tissue
  • Inject 0.3 to 0.5 cc per area using a 27- or 30-gauge needle
  • Typically perform 3-4 treatment sessions every 4-6 weeks
  • Maintenance treatments every 6 to 9 months

Practical Tips for Using PRP in Skin Rejuvenation:

  • Apply topical numbing medication to the target areas.
  • Inject PRP using a 1 cc syringe and a 25 or 27 gauge, 1.5” cannula.
  • Utilize a fanning technique to inject in the problem area.
  • Alternatively, use a 30-31-gauge needle and inject intradermal blebs.
  • Perform 3-4 treatment sessions in 4-6 week intervals.
  • Maintenance treatments every 6 to 9 months.

Patient Instructions After Treatment:

  • May experience some burning or stinging 5-15 minutes post procedure.
  • May result in potential “bleeding” appearance and recommend patients bring hats.
  • Avoid strenuous exercise for about 24 hours post procedure.

Overall, PRP is increasingly being utilized for hair loss, scarring and facial rejuvenation. Currently, PRP appears to be safe with no long-term side effects noted. It may be used synergistically with existing treatment options with added benefit. Further research is required to establish the optimal PRP processing technique and to establish standardized treatment protocols.

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Dr. Jean Bolognia’s Approach to Atypical Nevi

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Atypical Nevi on Patient leg

Source: Next Steps in Derm

This information was presented by Dr. Jean Bolognia at the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference held January 18th-21st, 2019 in Orlando, FL.  The highlights from her lecture were written and compiled by Dr. Daniel Yanes.

Despite being one of the more common reasons for consulting a dermatologist, the diagnosis and management of atypical nevi remain nuanced and can often be challenging. I had the opportunity to learn from Dr. Jean Bolognia on her approach to atypical nevi, and walked away with many pearls to share.

1. Identify the patient’s signature nevus and come up with a plan.

Sometimes it can be overwhelming to know where to begin when tasked with the patient who has numerous and atypical nevi. The first step is to identify the patient’s signature nevus. Do they tend to grow fried egg nevi, eclipse nevi, or cockade nevi? Are their signature moles all pink with little brown pigment, or are they pitch black with a wafer of scale? Identifying the signature nevus assists in determining the ugly duckling, and it will also help you develop a practical approach. In addition, if the patient has primarily pink nevi, palpation for induration versus soft flabbiness is helpful as banal intradermal melanocytic nevi can be pink in color.  If the patient has primarily small flat black nevi, you should hone in on the presence of inflammation that is not simply due to acne or folliculitis. Creating an individualized plan is the key to a successful examination.

2. Nevi change, and sometimes it is simply an aging phenomenon.

In addition to identifying the signature nevus, it is also essential to understand how melanocytic nevi evolve over time. While nevi classically progress from junctional to compound and then to dermal, sometimes they simply fade away. In the case of fried egg nevi, the “yolk” becomes more raised and softer over time while the “white” of the egg gradually fades (figure 1). This results in multiple large dermal nevi on the trunk in an older patient. Patients can be taught that when a nevus elevates, determining if the lesion is firm versus soft can assist in distinguishing between the need for evaluation versus an aging phenomenon. Although not all changing nevi are concerning nevi, it is still essential to give the patient’s nevus of concern special attention, even if it doesn’t catch your eye at first.

Continue reading. 

Systemic Therapies for Melanoma: What Every Dermatologist Needs to Know

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List of current melanoma therapies

Source: Next Steps in Derm

This information was presented by Dr. Jean Bolognia at the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference held January 18th-21st, 2019 in Orlando, FL.  The highlights from her lecture were written and compiled by Dr. Daniel Yanes, one of the 5 residents selected to participate in the Sun Resident Career Mentorship Program (a program supported by an educational grant from Sun Pharmaceutical Industries, Inc.). Dr. Yanes was paired with Dr. Jean Bolognia as his mentor.  

The world of melanoma is evolving, and dermatologists need to be equipped with the knowledge to help their patients navigate this landscape. Newer therapies for patients with more advanced stages of melanoma have not only drastically improved survival, but we as dermatologists must be prepared to recognize and treat the cutaneous side effects of these medications. This is a brief summary of common systemic therapies for melanoma with which every dermatologist should become familiar.

MAP Kinase Pathway Inhibitors

Selective BRAF Inhibitors

Melanoma tumor cells often have activating mutations that lead to constitutive activation of the MAP kinase pathway (See figure). Such activation can then lead to unregulated cell growth and proliferation. The most commonly detected mutation in BRAF results in the substitution of glutamic acid (E) for valine (V) at the 600th position in the BRAF protein and is referred to as BRAF V600E. Selective BRAF inhibitors, e.g. dabrafenib, encorafenib and vemurafenib, specifically target altered BRAF proteins. You can easily recognize these medications from their names, with raf indicating they target (B)RAF and nib identifying them as inhibitors. They are administered orally and chronically and lead to rapid responses but unfortunately tumor resistance commonly develops, often within six months. There are cutaneous side effects that the dermatologist should recognize, including morbilliform and folliculocentric eruptions, UVA photosensitivity (e.g. vemurafenib), keratoacanthomas/squamous cell carcinomas, and changes in melanocytic nevi (eruptive, enlargement, involution).

MEK Inhibitors

When mechanisms of resistance to selective BRAF inhibitors were investigated, a common finding was re-activation of the MAP kinase pathway via activation of MEK, another kinase that is downstream from BRAF. MEK inhibitors, e.g. binimetinib, cobimetinib, trametinib, were then combined with selective BRAF inhibitors to reduce the development of tumor resistance. These drugs are identified by the presence of a -metinib suffix. Interestingly, compared to BRAF inhibitors alone, combination BRAF+MEK therapy is associated with significantly less, not additive, cutaneous side effects – a real benefit to the patient.

Immunotherapy – Checkpoint Inhibitors

Immunotherapy is designed to stimulate the immune system to attack immunogenic melanoma cells. These monoclonal antibodies inhibit inhibitory signals that normally downregulate the immune system and thus act as immune checkpoints. These drugs model after the saying “the enemy of my enemy is my friend,” only it’s now “the inhibitor of the immune inhibitor is the immune stimulator.” CTLA4 is a receptor on regulatory T cells that plays an important role in diminishing immune responses. By blocking the inhibitory function of CTLA4 during the priming phase, the anti-CTLA4 antibody ipilimumab increases T cell immune activity. Peripherally, when the PD-1 receptor on T cells binds to its ligand, PD-L1, on tumor cells, an inhibitory signal results. In a similar fashion, the anti-PD-1 monoclonal antibodies approved for melanoma – nivolumab and pembrolizumab – can increase anti-tumor immune activity. Anti-PD-L1 monoclonal antibodies (e.g. avelumab, atezolizumab, durvalumab) have been approved to treat other malignancies, including Merkel cell carcinoma.

Read more. 

Dr. Jean Bolognia and the Many Faces of Lupus

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Dr. Jean Bolognia presenting at ODAC Dermatology Conference

Source: Next Steps in Derm

This information was presented by Dr. Jean Bolognia at the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference held January 18th-21st, 2019 in Orlando, FL.  The highlights from her lecture were written and compiled by Dr. Daniel Yanes.

Just as systemic lupus erythematosus (LE) can have protean systemic manifestations, cutaneous LE can present in many different ways. When confronted with the many faces of mucocutaneous LE, the following pearls can be valuable.

1. Be Aware of the SLICC Criteria

In 2012, the Systemic Lupus International Collaborating Clinics (SLICC) developed a set of clinical and immunologic criteria to assist in the diagnosis of systemic LE.

To view the original image full size image, click here.

To meet criteria for systemic LE, a patient must fulfill at least four criteria, with at least one clinical criterion and one immunological criterion OR have biopsy-proven lupus nephritis in the presence of ANA or anti-dsDNA antibodies. Of the 11 clinical criteria, 4 are mucocutaneous: (1) acute or subacute cutaneous LE; (2) chronic cutaneous lupus; (3) non-scarring alopecia; and (4) oral or nasal ulcers. Of note, the dermatologist doesn’t just establish the diagnosis of cutaneous LE, but can also determine the specific types of autoantibodies the patient is forming as well as if the patient has systemic involvement (e.g. hematologic or renal abnormalities). Remember the latter requires a urinalysis in addition to bloodwork. Acute cutaneous LE is more closely associated with systemic LE than subacute cutaneous LE, which in turn is more closely associated with systemic LE than discoid LE. The cutaneous manifestations of LE per the SLICC classification scheme are as follows:

Acute cutaneous lupus

  • Lupus malar rash (does not count if malar discoid)
  • Bullous eruption of systemic LE
  • Toxic epidermal necrolysis variant of systemic LE [also sometimes referred to as acute syndrome of apoptotic pan-epidermolysis (ASAP)]
  • Maculopapular lupus rash
  • Photosensitive lupus rash in the absence of dermatomyositis

Subacute cutaneous lupus

Chronic cutaneous lupus

  • Classic discoid LE
  • localized (above the neck)
  • disseminated (above and below the neck)
  • Hypertrophic (verrucous) LE
  • Mucosal LE
  • Lupus panniculitis (profundus)
  • LE tumidus
  • Chilblain lupus
  • Discoid LE/lichen planus overlap

2. A Positive ANA Does Not Equate to Systemic LE.

While ANA titer is positive in nearly all patients with systemic LE, not all patients with a positive ANA titer have LE.

Continue reading. 

Dermatology Contract Negotiations and Legal Tips

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Dermatology Business deal

Source: Next Steps in Derm

If you are navigating the confusing landscape of contract negotiations or considering partnership in a private practice after years of employment, then take note! Ron Lebow, Senior Counsel in the Health Law practice group at Greenspoon Marder LLP, led a fantastic workshop at the 2019 ODAC conference. He covered common concerns when negotiating employment agreements with dermatology practices, as well as issues to address when it comes time to become a partner.

The most important point and recurring theme of Ron Lebow’s workshop was simply this:

“Make sure everything you want is in writing. Nothing is inferred. Everything is written and agreed upon by both parties.”

This point was stressed time and time again and will continue to be the overarching theme throughout the many parts of contract negotiations. With this in mind, here are some of the main takeaways and important questions we, dermatologists, should constantly keep in mind.

What Do I Do When Searching For A Job?

Surround yourself with experts! Find people who have your back. Make sure you find a lawyer who deals with medical professionals (particularly your specialty) for a living. You may need to find an accountant to work with you depending on your situation. Lastly, it may be in your best interest to work through recruiters. Some recruiters are better than others, and Ron Lebow recommends Dermatology Authority as an organization that provides good recruiting services for dermatologists.

Can I Negotiate When Looking For A Job?

When dealing with negotiations, it is important to recognize the many aspects of the process. With respect to the job you are offered:

  • They expect you to negotiate. It’s not rude to negotiate. It is part of the process.
  • They aren’t doing you a favor by hiring you. They are making a profit on you and therefore, you do have some leverage in the process. You can negotiate because they want you.
  • They will (almost) never take the offer away. The only instance in which they may take an offer away is if you ask for something, they say no, and then you continue to ask for something that is already off the table.
  • Don’t negotiate before you bring a lawyer in to help with the contract and negotiation. It may already be too late for them to be useful.
  • Don’t sign term sheet/offer letter until you have spoken with a lawyer who has reviewed the information. Again, it may already be too late for them to be useful.
  • The term of the contract, the length of time you sign for, is a non-issue. The real term of the contract is actually the notice you have to give before leaving, not the actual term of the contract itself. For example, if you sign a two-year contract but the notice you must give is three months, the term for all intents and purposes is three months from the time you decide you want to break your contact.
  • Make sure it is spelled out when partnership will be happening if that is on the table. Three years is a common timetable for partnership to be offered. If partnership is a possibility, make sure there is something written in the contract in case ownership changes between the time you start and the time you would have been allowed to start buying into partnership (e.g. if the group sells to private equity).

Compensation and Bonuses

Continue reading. 

Actinic Keratosis and Squamous Cell Carcinoma: Pearls from ODAC

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Dr. Patel presenting at ODAC Dermatology Conference

Source: Next Steps in Derm

In a 20-minute lecture presented at the 16th Annual ODAC conference, Dr. Patel reviewed the appropriate management of actinic keratoses and squamous cell carcinoma. Grabbing the attention of the audience early on, Dr. Patel quoted the staggering statistics for squamous cell carcinoma – calling the growing epidemic “a public health crisis.”  He challenged dermatologists to lead the charge in a more sophisticated approach to disease stratification.

Data are conflicting regarding the risk of progression of actinic keratoses to squamous cell carcinoma. Despite Dr. Patel’s expertise, he admitted even he finds it impossible to predict which lesions will progress. Instead, he takes a more astute approach and taking a step back to focus on the burden of disease.

Twenty is the magic number – over 20 actinic keratoses increase the risk of squamous cell carcinoma.

With the groundwork firmly laid, Dr. Patel delved into the crux of his talk. He posed a thought-provoking question to captivated listeners:  Are actinic keratoses a disease or a symptom? In the same way hypertension leads to stroke, actinic keratoses lead to squamous cell carcinoma.

Actinic keratoses are a field disease, as such we should focus on field treatment.

Dr. Patel drove his point home with several instructive clinical cases. With each patient, Dr. Patel calls dermatologists to first discern field disease from invasive disease. Once invasive disease has been excluded, hyperkeratotic lesions should be debrided, and a strict regimen of topical 5-fluorouracil instituted for 4 weeks. This regimen should be followed by photodynamic therapy in 3 months.

Continue reading. 

Facial Anatomy: ODAC Coverage with Susan Weinkle, MD

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Patient receiving injections

Source: Next Steps in Derm

This information was presented by Dr. Susan Weinkle at the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference held January 18th-21st, 2019 in Orlando, FL. The highlights from her lecture and live demonstrations were written and compiled by Dr Nikhil Shyam.

Dr. Susan Weinkle, an expert in the field of aesthetic and surgical dermatology, shares important anatomical concepts to consider when using neurotoxins and fillers safely.

The face can be split into 3 zones – the upper 1/3rd, the middle 1/3rd and the lower 1/3rd. Knowing the important vessels and nerves in each zone as well as their corresponding depth in the skin is crucial in order to minimize injury and utilize a safe technique when injecting neurotoxins and fillers.

Figure 1: D corresponds to areas where deeper injections are safer to avoid vasculature and nerves. S corresponds to areas where superficial (intradermal injections) are safer to avoid vasculature and nerves. Vessels shown are cartoon depictions of some of the more common arteries including the supraorbital, supratrochlear, superficial temporal, facial and superior and inferior labial arteries. Also depicted are the supraorbital, infraorbital and mental foramen that are located along the medial limbus.

Important Landmarks for the Upper 1/3rd of the Face

  • A line drawn vertically along the medial limbus denotes the anatomical locations of the supraorbital, infraorbital and mental foramen.
  • The supraorbital notch or foramen is the exit aperture for the supraorbital neurovascular bundle (NVB). While the vessels here initially lie deep in the skin, they become more superficial about 1.5 cm superior to the supraorbital foramen as they supply the forehead.
  • The supratrochlear NVB lies about 8-12 mm medial to the supraorbital NVB. The vessels are similarly deep initially and gradually become more superficial as they traverse superiorly to supply the forehead.
  • The supraorbital nerve, after exiting through its foramen, runs laterally and then superiorly about 1 cm medial to the temporal fusion line. It lies deep within the skin in this region.

Key Concepts for Upper 1/3rd Facial Injections and more.

Fine Tune Staging Risk for SCC

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Patel at ODAC Mohs

Source: Dermatology News

When caring for individuals with sun-damaged skin, dermatologists need comfort with the full spectrum of photo-related skin disease. From assessment and treatment of actinic keratoses (AKs) and field cancerization, to long-term follow-up of cutaneous squamous cell carcinomas (SCCs), appropriate treatment and staging can improve patient quality of life and reduce health care costs, Vishal Patel, MD, said at the Orlando Dermatology Aesthetic and Clinical Conference.

“Actinic keratosis/squamous cell carcinoma in situ is not a disease; it’s a symptom of cutaneous carcinogenesis or field cancerization,” said Dr. Patel, director of cutaneous oncology at George Washington University Cancer Center, Washington. On the other hand, he added, “field disease can be a marker for invasive squamous cell carcinoma risk, and it requires field treatment.” Treatment that reduces field disease is primary prevention because it decreases the formation of invasive SCC, he noted.

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Fungus Among US: Practical Case-Based Dermatophytosis

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Patient with fungus on foot

Source: Next Steps in Derm

This information was presented by Dr. Adam Friedman at the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference held January 18th-21st, 2019 in Orlando, FL.

Dermatophytosis constitutes a big chunk of “bread and butter” in dermatology.  In fact, an average of 4.1 million visits a year were due to dermatophytosis from 1995 to 2004! Nevertheless, these fungi can still stump the most seasoned dermatologist, and misdiagnosis can be surprisingly common. Dr. Adam Friedman, Professor, Interim Chair, and Program Director of Dermatology at George Washington School of Medicine and Health Sciences, recently presented interesting cases and practical pearls on how to diagnose and treat dermatophytosis. Here are some highlights.

Make the Diagnosis

Here’s the golden rule: if there is scale, scrape it! KOH preparation is first line in diagnosis of dermatophytosis.  Do you follow this rule? A recent survey showed that the percentages of dermatologists who scrape when suspicious of dermatophytosis were only 20-30% (always) and 30-40% (very often). Next, histology can be helpful in diagnosing nail fungus and Majocci’s granuloma (where KOH is usually negative).  Fungal culture be helpful to guide anti-fungal therapy, especially for tinea capitis in children. 

Tinea Pedis

Tinea pedis is the most common form of skin fungal infection, and there are 4 types: moccasin, interdigital, bullous, and ulcerative.

Don’t forget that non-dermatophytes (S. dimidiatum; S. hyalinum) can cause identical findings!  Also, an exuberant dermatophytid (or “id”) reaction, an inflammatory response to the fungal infection, can accompany findings of dermatophytosis. When you see a 2-hand-1-foot (or vice-versa) involvement, this can be another clue for diagnosing tinea pedis.

While topical azoles (econazole, other azoles) and allylamines (terbinafine, naftifine) and antifungal powder/spray weekly to shoes have been the mainstay treatment, there are some new topical options available.  Luliconazole 1% cream (daily for 2 week) for moist macerated web space; naftifine 2% gel and cream (daily for 2 week) for dry, scaling plaques; and urea 40% cream for moccasin tinea pedis have shown efficacy.

What about systemic anti-fungal therapy? The moccasin type and vesicular type may warrant oral terbinafine 250mg BID for 2-6 weeks and 2 weeks, respectively.  Since the vesicular type may have superimposed bacterial infection, an oral antibiotic may also be considered.

For more Tinea, click here.

ODAC and JDD Award Dr. Alan Menter

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Dr. Mentor Presenting at ODAC

Source: Practical Dermatology

Alan Menter, MD, has been awarded the Outstanding Researcher and Educator in Psoriatic Disease Award by the ODAC Dermatology, Aesthetics & Surgical Conference, in partnership with the Journal of Drugs in Dermatology (JDD).

The award recognizes Dr. Menter’s significant contribution and lifetime commitment to the advancement of psoriatic disease research as well as his work guiding the next generation of psoriasis experts and researchers.

“Dr. Menter has dedicated his career to improving psoriasis treatment options and standards of care while also pouring countless hours into up-and-coming psoriasis experts and researchers, ensuring his legacy will continue for generations to come,” said Shelley Tanner, CEO and president of SanovaWorks, which produces the JDD and ODAC.

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Male vs. Female Aesthetic Consultation – ODAC Dermatology Conference

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Terrence Keaney Male Aesthetics at ODAC

Source: Dermatology News

The first time a man walks in for an aesthetic consultation, he probably doesn’t know what to expect, according to Terrence Keaney, MD, a dermatologist in private practice in Arlington, Va. And he may not even be sure what he’s looking for.

However, he probably knows what he doesn’t like about his appearance. When men are questioned, the three areas they are most concerned about is their hairline, their eyes, and their jawline, said Dr. Keaney, speaking at the Orlando Dermatology Aesthetic and Clinical Conference.

It’s important to evaluate men differently, not just for anatomic differences from women, but also for behavioral and psychological factors unique to men as aesthetic patients, he noted.

Hot Topics in Infectious Disease

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Justin Finch MD Presenting at ODAC Dermatology Conference

Source: Dermatology News

New tricks from ticks, near-zero Zika, and the perils of personal grooming: Dermatologists have a lot to think about along the infectious disease spectrum in 2019, according to Justin Finch, MD, speaking at the Orlando Dermatology Aesthetic and Clinical Conference.

Anaphylaxis from alpha-gal syndrome is on the rise, caused in part by the geographic spread of the Lone Star tick. Beginning in 2006, isolated cases of an anaphylactic reaction to cetuximab, the epidermal growth factor receptor antagonist used to treat certain cancers, began to be seen in a curious geographic distribution. “The anaphylaxis cases were restricted to the southeastern United States, the home of the Lone Star tick,” said Dr. Finch, of the department of dermatology at the University of Connecticut, Farmington.

With some detective work, physicians and epidemiologists eventually determined that patients were reacting to an oligosaccharide called galactose-alpha–1,3-galactose (alpha-gal) found in cetuximab. This protein is also found in the meat of nonprimate mammals; individuals in the southeastern United States, where the Lone Star tick is endemic, had been sensitized via exposure to alpha-gal from Lone Star tick bites.

“Alpha-gal syndrome is on the rise,” said Dr. Finch, driven by the increased spread of this tick. Individuals who are sensitized develop delayed anaphylaxis 2-7 hours after ingesting red meat such as beef, pork, or lamb. “Ask about it,” said Dr. Finch, in patients who develop urticaria, dyspnea, angioedema, or hypotension without a clear offender. Because of the delay between allergen ingestion and anaphylaxis, it can be hard to connect the dots.

 

Hyperhydrosis: Where Are We Now?

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Video of Dr. Adam Friedman

Source:Dermatology News

When you extend your hand to a new patient, and he reflexively wipes his palm before shaking hands, be alert. It’s possible you’re seeing primary hyperhidrosis, a condition that’s both more common and more disabling than once thought.

“Looking at the biology of sweating, normally, it’s a good thing – we need it to survive. However, hyperhidrosis is too much of a good thing – it’s an excess of what is needed for normal biology,” said Adam Friedman, MD, speaking at the Orlando Dermatology Aesthetic and Clinical Conference.

Recent data, he pointed out, show that hyperhidrosis is more prevalent than previously thought – about 4.8% of individuals may have the condition, with about half having axillary hyperhidrosis. Symptoms peak in early adulthood, with adults aged 18-54 most affected. “These are the prime working years,” he said.

About 2% of teens are affected, and many adults report that symptoms began before they were 12 years old. Hand hyperhidrosis is a factor for computer and electronic device work, sports, and even handling paper and pencils, noted Dr. Friedman, professor of dermatology at George Washington University, Washington.

“Does it affect quality of life? Yes. We have data to support the impact. The adverse impact is actually greater than that of eczema and psoriasis,” he said, adding that patients won’t always bring up their concerns about sweating. “Often, it’s the patient who apologizes for having sweaty palms or who sticks to the paper on the exam table. It’s worth asking these patients if they are bothered by excessive sweating.”

Read More….

ODAC Dermatology Conference Returns to Orlando, Florida

By | Aesthetic Dermatology, Medical Dermatology, ODAC Sessions, Patient Care, Surgical Dermatology | No Comments
Orlando Florida Hotel

Source: Dermatology Times

The Orlando Dermatology Aesthetic & Clinical Conference (ODAC), formerly known as Orlando Derm, is scheduled for January 18-21 at the JW Marriott in Orlando.

This year’s meeting will open with presentations from physicians who will address advances in treating skin of color, hot topics in surgical dermatology and cutaneous malignancy, the latest on photodynamic therapy, and a year in review from the Journal of Drugs in Dermatology, among others.

Drs. Eric Bernstein and Jason Pozner will host a panel discussion on “My Top Picks for Laser and Energy Based Treatments.” And, Dr. Joel Cohen will give an overview of facial arterial supply.

During the general session on Saturday, Jan. 19, Dr. Brian Berman will address managing urticaria, which will be followed by talks by Dr. Deirdre Hooper on platelet rich plasma for hair growth and skin rejuvenation; Dr. Andrew Alexis on keloids and disorders of hyperpigmentation in skin of color; and, Drs. Bernstein and Pozner will address advances in non-surgical skin tightening.

On Sunday, January 20, Dr. Jean Bolognia will open the day’s general session with a review of advances in systemic therapies for melanoma.

For more information, visit ODAC online at https://orlandoderm.org.

Vascular Compromise

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Dr. Joel Cohen presenting at ODAC dermatology conference

Source: Dermatology Times

Avoiding and treating vascular compromise with hyaluronic acid (HA) injections requires understanding the subtleties of underlying facial anatomy and keeping a well-stocked arsenal of treatments for impending necrosis, said an expert at the Orlando Dermatology Aesthetic and Clinical Conference (ODAC) in Miami.

“Some blood vessels may actually be in different locations than in some of the anatomic diagrams and cartoons that have long characterized their course,” said vice conference chair Joel L. Cohen, M.D., from Greenwood Village, Colorado, who serves on the teaching faculty for both the University of California, Irvine and the University of Colorado.

Although textbooks commonly depict the angular artery tracking adjacent to the nasofacial sulcus, he said, “it’s more common for the angular artery to be more lateral to that area, closer to the infraorbital distribution. In a recent cadaver study, only 19% of the time did the facial artery actually project upward along the side of the nose-cheek junction. But 32% of the time, the angular artery came off the facial artery earlier, and therefore coursed to more of the medial cheek area.”

The technique of aspirating before injecting is not foolproof. “There can be false negatives. A study indicates you probably have to pull back on the plunger for several seconds in order to physically be able to see if you’re in a vessel. We all surely realize that it is very difficult to have the needle in the exact spot you plan to inject, and then reposition your hand to pull back on the plunger of the syringe to try to aspirate, and then have your needle-tip remain in the exact same spot when you reposition again in order to inject. As you change your hand position to pull back on the plunger, you probably move a bit, maybe just a millimeter, from the original location to the location you later inject,” Dr. Cohen said.

A recent report also shows that it is possible to puncture and get into a vessel with small cannulas — the injectors aspirated blood despite using a cannula.

Read More…..

Want to expand aesthetic dermatology business? Appeal to men

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Terrence Keaney Male Aesthetics at ODAC

Source: Dermatology Times

Bringing more men into an aesthetic dermatology practice can expand the patient population, increase business revenue, and pay long-term dividends in terms of patient loyalty and repeat business.

But men aren’t like women when it comes to aesthetic concerns, so the strategies used to market your aesthetic offerings to female patients might miss the mark with men, cautioned Terrence Keaney, MD.

Men are less cosmetically savvy and need more upfront education and counseling, Dr. Keaney said at the 2018 Orlando Dermatology Aesthetic and Clinical Conference.

“I spend more time explaining therapies and what might be best for them,” he noted. “I explain the scientific rationale and treatment mechanisms so they will be more comfortable.” Making sure they understand is important, because “men often nod and don’t ask questions.”

The extra effort up front can pay off.

“The beauty of men is when they get a great result and are happy with you, men are very physician loyal. Once they get a great result, they’re yours forever,” said Dr. Keaney, an assistant clinical professor of dermatology at George Washington University, Washington, and a private practice dermatologist in Arlington, Va.

Cost is the leading deterrent for men to embrace aesthetic procedures, a factor that also ranks first among women. Men are also concerned that results will not look natural and want information about safety and side effects, Dr. Keaney said. “These deterrents can be overcome with proper education and counseling.”

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Five Pearls Target Wound Healing

By | Medical Dermatology, ODAC Sessions, Patient Care, Surgical Dermatology | No Comments
Robert Kirsner at the ODAC Dermatology Conference

Source: Dermatology News

Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.

In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.

Avoid opioids for postoperative pain

“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”

Emerging evidence suggests opioids also impair wound healing (J Invest Dermatol. 2017;137:2646-9). This study of 715 patients with leg ulcers, for example, showed use of opioids the most strongly associated with nonhealing at 12 weeks. “We found if you took an opioid you were less likely to heal,” Dr. Kirsner said. They found opioids significantly impaired healing, even when the investigators controlled for ulcer area, duration, and patient gender.

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Best Practices Address Latest Trends in PDT, Skin Cancer Treatment

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ODAC Dermatology Conference Audience

Source: Dermatology News

Pearls for providers of photodynamic therapy (PDT) include tips on skin preparation, eye protection, and use of three new codes to maximize reimbursement. Also trending in medical dermatology are best practices for intralesional injections of 5-FU to treat the often challenging isomorphic squamous cell carcinomas (SCCs) or keratoacanthomas on the lower leg, as well as use of neoadjuvant hedgehog inhibitors to shrink large skin cancer lesions, according to Glenn David Goldman, MD.

“This talk is about what you can do medically as a dermatologic surgeon,” Dr. Goldman said at the Orlando Dermatology Aesthetic and Clinical Conference.

Use new billing codes for photodynamic therapy

There are now three new PDT billing codes. “Make sure your coders are using these properly. They are active now, and if you don’t use them, you won’t get paid properly,” said Dr. Goldman, professor and medical director of dermatology at the University of Vermont, Burlington. Specifically, 96567 is for standard PDT applied by staff; 96573 is for PDT applied by a physician; and 96574 is for PDT and curettage performed by a physician.

“Be involved, don’t delegate,” Dr. Goldman added. “If you do, you will get paid half as much as you used to, which means you will lose money on every single patient you treat.”

What type of PDT physicians choose to use in their practice remains controversial. “Do you do short-contact PDT, do you do daylight PDT? We’ve gone back and forth in our practice,” Dr. Goldman said. “I’m not impressed with daylight PDT. I know this is at odds with some of the people here, but at least in Vermont, it doesn’t work very well.”

The way PDT was described in the original trials (a photosensitizer applied in the office followed by PDT) “works the best, with one caveat,” Dr. Goldman said. The caveat is that dermatologists should aim for a PDT clearance that approaches the efficacy of 5-fluorouracil (5-FU). “If you can get to that – which is difficult by the way – I think your patients will really appreciate this.”

An additional PDT pearl Dr. Goldman shared involves skin preparation: the use of acetone to defat the skin, even in patients with very thick lesions. Apply acetone with gauze to the site for 5 minutes and “all of that hyperkeratosis just wipes away,” curette off any residual hyperkeratosis – and consider a ring anesthetic block to control pain for the patient with severe disease, he advised.

Another tip is to forgo the goggles that come with most PDT kits. Instead, purchase smaller, disposable laser eye shields for PDT patients, Dr. Goldman said. “They work better. You can get closer to the eye … and they are more comfortable for the patient.”

Dr. Goldman’s practice is providing more PDT and much less 5-FU for patient convenience. “I believe if someone is willing to go through 3 weeks of 5-FU or 12-16 weeks of imiquimod, they get the best results. However, most people don’t want to do that if they can sit in front of a light for 15 minutes.”

Consider intralesional injections for SCCs and KAs on the legs

An ongoing challenge in medical dermatology is preventing rapid recurrence of SCCs and/or keratoacanthomas (KAs) near sites of previous excision on the legs. “We all see this quite a bit. Often you get lesions on the leg, you cut them out, and they come right back” close to the excision site, Dr. Goldman said.

He does not recommend methotrexate injections for these lesions. “Methotrexate does not work. It doesn’t hurt, but I’ve injected methotrexate into squamous cell carcinomas many times and they’ve never gone away.” In contrast, 5-FU “works incredibly well. They go away, I’ve had tremendous success. This has changed the way we treat these lesions.” 5-FU is inexpensive and can be obtained from oncology pharmacies. One caveat is 5-FU injections can be painful and patients require anesthesia prior to injection.

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JDD honors Adam Friedman, M.D., for Educational Contributions

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Adam Friedman, MD faculty headshot

Source: Dermatology Times

Adam Friedman, M.D., was honored with the Innovations in Residency Training Award by the Journal of Drugs in Dermatology (JDD) at the Orlando Dermatology Aesthetic & Clinical Conference (ODAC) held in January. The award recognizes individuals who serve as exemplary role models for dermatology residents and innovate improvements in residency programs.

“Dr. Adam Friedman embodies the spirit of the award and more,” says Shelley Tanner, CEO and president of SanovaWorks, parent company of the JDD and ODAC. “He looks towards the future of dermatology and those who will carry it forward.”

Dr. Friedman is the residency program director and director of translational research at the George Washington University School of Medicine. He is also deputy chair of the American Academy of Dermatology’s Poster Task Force, senior editor of the Dermatology In-Review online workshop and cram pack, and director of the Oakstone Institute Dermatology Board Review.

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Understanding and Using Biosimilars

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Dr Leon Kircik at ODAC Dermatology Conference

Source: Dermatology Times

One of the only things the dermatology community knows about biosimilar use is that there are many unknowns. Still, biosimilars are on dermatologists’ radars as having the potential to lower the high costs of biologic treatments for chronic skin diseases, including psoriasis.

There also are misperceptions—even among dermatologists—about what biosimilars are and if these drugs can be used to treat patients, according to Leon H. Kircik, M.D., clinical associate professor of dermatology at Indiana University School of Medicine, Indianapolis; clinical associate professor of dermatology at Mount Sinai Medical Center, New York City; and medical director of Physicians Skin Care in Louisville, Ky. who presented “Biosimilars: What You Need to Know” at the Orlando Derm Aesthetic and Clinical conference in Miami, Fla., in January 2017.

Misperception number one

The first misperception is that biosimilars are generic biologics. They’re not, he says.

“You cannot have a generic of a biologic because every biologic is made differently. So, it is important for everybody to understand that biosimilars are not generics,” says Dr. Kircik,

As a result, the approval process for biosimilars is different for that of generics. Biosimilars came about because of the Biologics Price Competition and Innovation Act of 2009, which passed in Congress as a provision of the Affordable Care Act. Biosimilars have an abbreviated licensure pathway, but it’s a different pathway compared to a generic.

“Biopharmaceuticals are biopolymers of organic molecules that are manufactured in living systems. Function is based not only on the amino acid number and sequence but also on posttranslational modification (e.g. glycosylation) that are added by virtue of manufacture in living systems.”

Complexities and blurred lines

The FDA’s definition of a biosimilar, according to Dr. Kircik is, “A biological product that is highly similar to the reference product, notwithstanding minor differences in clinically inactive components. There are no clinically meaningful differences from the reference product in terms of the safety, purity, and potency”

“Those are very vague terms,” Dr. Kircik says.

The first biosimilar (not for use in dermatology), Zarxio [Sandoz], was FDA approved in March 2015. Zarxio is biosimilar to Neupogen (Amgen, filgrastim)1

More than a year later, the first biosimilar to have dermatologic indications received FDA approval—a biosimilar of infliximab, by the name of Inflectra (Celltrion). Interestingly, Inflectra, a biosimilar to Janssen Biotech’s Remicade, has an indication for psoriasis but no data on dermatologic disease, including psoriasis, Dr. Kircik says.

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Nasal Reconstruction After Surgery

By | Aesthetic Dermatology, Medical Dermatology, ODAC Sessions, Surgical Dermatology | No Comments
Explore By Region

Source: Dermatology Times

Options for repairing nasal defects after skin cancer surgery should be based on location, size and depth of the defect, as well as patient preference.

“If the defect is centrally located in the alar groove, you may want natural healing to occur,” says Joel L. Cohen, M.D., associate clinical professor of dermatology at the University of Colorado in Denver, and director of AboutSkin Dermatology in Greenwood Village and Lone Tree, Colo. He spoke with Dermatology Times prior to his presentation on skin cancer nasal reconstruction at the recent Orlando Dermatology Aesthetic & Clinical Conference (ODAC) in Miami.

“In such a case, the natural concavity is often recapitulated by simply letting the skin granulate, without the need for any sutured repair.”

However, in many instances of nasal reconstruction, dermatologists have to decide which procedure will achieve the best aesthetic outcome and also, the level of wound care that can be managed by the patient.

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Laser Resurfacing for Minimizing Post Surgery Scars

By | Aesthetic Dermatology, Medical Dermatology, ODAC Sessions, Patient Care, Surgical Dermatology | No Comments
Adam Friedman, MD at ODAC Dermatology Conference

Source: Dermatology News

In his practice, Joel L. Cohen, MD, spends a good part of his day doing Mohs surgery, “with the goal of cancer removal, and after surgery, having the patient look good,” he said at the Orlando Dermatology Aesthetic and Clinical Conference.

“Having resurfacing in my practice has allowed me to treat not only wrinkles and etched lines, but also help skin cancer patients by blending and minimizing their skin cancer scars,” said Dr. Cohen, an aesthetic dermatologist and Mohs surgeon in private practice in Denver.

For example, one of his patients was a kindergarten teacher who had a large rotation flap scar on her cheek after excision of a melanoma in situ. The children asked her about it all the time during the 2 months after the surgery, and she decided to come in for some laser sessions. “With three ablative fractional laser sessions, she really looked great just 3 months later and wasn’t even interested in wearing makeup at that point.”

Resurfacing in his practice using a variety of lasers is very helpful, Dr. Cohen said. He published a study in November that compared pulse dye laser, CO2 ablative fractional lasers, or a combination of both for modification of scars following Mohs surgery (J Drugs Dermatol. 2016 Nov 1;15[11]:1315-9).

The prospective, multicenter study revealed that although both monotherapy approaches were safe and effective, the combination of pulse dye laser and fractional ablative laser offered some synergy that was preferred by patients.

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FDA Approval: Corticosteroid-Sparing Topical for Eczema

By | Medical Dermatology, ODAC Sessions, Patient Care | No Comments
Dr. Friedman Presenting at the ODAC Dermatology Conference

Source: Dermatology Times

The FDA announced it has approved Eucrisa (Anacor Pharmaceuticals, crisaborole) ointment to treat mild to moderate eczema in patients two-years-of-age and older.

Applied twice daily, Eucrisa is a phosphodiesterase 4 (PDE-4) inhibitor. Its precise mechanism of action in atopic dermatitis, however, isn’t known, according to an FDA press release.

“We welcome this corticosteroid-sparing topical option,” says Elaine C. Siegfried, M.D., professor of pediatrics and dermatology at Saint Louis University, Cardinal Glennon Children’s Hospital, St. Louis, Mo. “The other two alternatives (pimecrolimus cream and tacrolimus ointment) carry black box warnings and labelled limitation on duration of use. Although most pediatric dermatologists prescribe these medications in infants and children without long-term safety concerns, prescribing Eucrisa is not hampered by this medicolegal burden. However, cost and access could be a limitation.”

Adam Friedman, M.D., associate professor of dermatology and director of translational research in dermatology at George Washington School of Medicine and Health Sciences, tells Dermatology Times that this most recent approval represents the exciting first of hopefully many new approved therapies for an exceedingly common disease state, which until recently was largely ignored.

“I envision crisaborole being used in a similar manner to calcineurin inhibitors, both as proactive treatment for affected delicate areas like the eyelids, face, body folds, groin or mild disease elsewhere. But, more importantly, [I envision it] as preventative maintenance therapy for disease areas that recur frequently after topical steroid use has been discontinued (though without the baggage of a black box warning and possible substance P induced burning at the onset of use),” he says.

Dr. Friedman, who is presenting on the topic of eczema at the January 16 to 19, 2017 Orlando Derm Aesthetic and Clinical conference in Miami, Fla., says this approval, however, should not overshadow the basic and requisite elements for properly managing this often chronic condition. These basics are: clear patient education on a broad range of topics, including realistic expectations; proper soap, moisturizer and treatment use; and myths about treatment safety, in order to gain the patient’s confidence, which in turn, increases the likelihood of regimen compliance, according to Dr. Friedman.

Taming Atopic Dermatitis and Managing Expectations

By | Medical Dermatology, ODAC Sessions, Patient Care | No Comments
Adam Friedman, MD faculty headshot

Source: Dermatology News

Tactics for managing patients with atopic dermatitis can go a long way to educate patients, set realistic expectations, and devise strategies for existing therapies, even as clinicians await some promising agents expected on the market soon.

“The good news is this is the Age of Eczema. In the last couple of years we’ve seen an explosion in the literature,” Adam Friedman, MD, of the department of dermatology, George Washington University, Washington, D.C., said at the Orlando Dermatology Aesthetic and Clinical Conference. Some of this research is spurring new therapeutics. a phosphodiesterase 4 inhibitor.

Crisaborole ointment, 2% (Eucrisa), a phosphodiesterase 4 inhibitor, was approved by the Food and Drug Administration in December 2016 for treating patients aged 2 years and older with mild to moderate AD, for example. It is a novel, nonsteroidal anti-inflammatory and the first prescription agent approved in the United States for atopic dermatitis in more than 10 years.

Dr. Friedman has no personal experience with crisaborole, which just became available. “But the data look encouraging. From what I’ve seen this may be a nonburning alternative to calcineurin inhibitors. It will be interesting to see how this will fit in our practices.”

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