ODAC Sessions

Jul 18

What’s New in Itch

By Dana Turner 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.

Making Sense of Cosmeceuticals

By Dana Turner Aesthetic Dermatology, ODAC Sessions

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.

What’s New for Itch

By Dana Turner Medical Dermatology, ODAC Sessions

ODAC Dermatology Conference Dr. Berman Image

Source: Next Steps in Dermatology

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.

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

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.

Sentinel Lymph Node Biopsy for Melanoma

By Dana Turner Medical Dermatology, ODAC Sessions, Surgical Dermatology

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 progression, in 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.

Perioral Combination Pearls from the Expert – Joel Cohen, MD

By Dana Turner Aesthetic Dermatology, ODAC Sessions

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.

SLNB for Melanoma

By Dana Turner Medical Dermatology, ODAC Sessions, Surgical Dermatology

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.

Hyperhydrosis: Where are we?

By Dana Turner Medical Dermatology, ODAC Sessions

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

Pathophysiology and Management of Rosacea

By Dana Turner Medical Dermatology, ODAC Sessions

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:

Platelet-Rich Plasma for Skin Rejuvenation

By Dana Turner Aesthetic Dermatology, ODAC Sessions, Patient Care

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 16^th 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.

Dr. Jean Bolognia’s Approach to Atypical Nevi

By Dana Turner Medical Dermatology, ODAC Sessions

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 18^th-21^st, 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.

What’s New in Itch

Making Sense of Cosmeceuticals

What is a cosmeceutical?

Different meaning to different groups

Why do dermatologists need to be well-informed?

What’s New for Itch

Sentinel Lymph Node Biopsy for Melanoma

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

Which theory is correct?

Perioral Combination Pearls from the Expert – Joel Cohen, MD

Dr. Cohen’s Approach

SLNB for Melanoma

Hyperhydrosis: Where are we?

Did You Know?

Know Your Sweaters: First, Diagnose

Treatment Options

Pathophysiology and Management of Rosacea

New Approach to Diagnosis and Categorization of Rosacea

Rosacea in Skin of Color – Rosacea Does Not Discriminate!

Therapeutic Options – Combo is King!

Platelet-Rich Plasma for Skin Rejuvenation

Evidence for PRP in Treating Hair Loss and Skin Rejuvenation

Practical Tips for Using PRP in Hair Loss:

Practical Tips for Using PRP in Skin Rejuvenation:

Patient Instructions After Treatment:

Dr. Jean Bolognia’s Approach to Atypical Nevi

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

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

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