Tag

medical dermatology

Fine Tune Staging Risk for SCC

By Medical Dermatology, ODAC Sessions
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

By Medical Dermatology, ODAC Sessions
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

By Medical Dermatology, ODAC Sessions, Patient Care
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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Hot Topics in Infectious Disease

By Medical Dermatology, ODAC Sessions
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?

By Medical Dermatology, ODAC Sessions
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.”

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ODAC Dermatology Conference Returns to Orlando, Florida

By Aesthetic Dermatology, Medical Dermatology, ODAC Sessions, Patient Care, Surgical Dermatology
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.

Five Pearls Target Wound Healing

By Medical Dermatology, ODAC Sessions, Patient Care, Surgical Dermatology
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

By Medical Dermatology, ODAC Sessions
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

By Medical Dermatology, ODAC Sessions
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

By Medical Dermatology, ODAC Sessions, Patient Care
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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