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.
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
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.
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.
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.
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.”
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.
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.
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.
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:
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).