TBD Meeting (2839-20)

LAHAINA, HAWAII – Recent data on the roles of caffeinated coffee and two types of Demodex species play in rosacea were discussed by Linda Stein Gold, MD, at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

When considering rosacea triggers, the role of coffee has been difficult to determine, according to Dr. Stein Gold, director of dermatology research at the Henry Ford Health System in Detroit.

“We know that caffeine can vasoconstrict, it also has anti-inflammatory properties so ... that might help rosacea,” while the heat from a hot cup of coffee may cause vasodilation “and make rosacea worse,” she noted.

But a recent study of data from the Nurses’ Health Study II that evaluated intake of coffee, tea, soda, and chocolate every 4 years in over 82,000 women shed some light on the role coffee may play (JAMA Dermatol. 2018 Dec 1;154[12]:1394-1400). There were almost 5,000 cases of physician-diagnosed rosacea in the cohort. When the investigators looked at caffeinated coffee consumption, “the more caffeine and the more coffee they drank each day, the more likely it was for them not to have rosacea,” she said.

Those who consumed four or more servings of caffeinated coffee a day had a significantly lower risk of rosacea, compared with those who consumed one or fewer servings per month (hazard ratio, 0.77; 95% confidence interval, 0.69-0.87; P less than .001).

But there was no significant association with decaffeinated coffee or with edibles that contained caffeine such as tea, soda, and chocolate, “so something about caffeinated coffee seems to be protective for the development of rosacea,” Dr. Stein Gold said.

Demodex mites

A few years ago, “we really didn’t think much of Demodex, but now we know Demodex tends to be a key player” in people with rosacea, Dr. Stein Gold said.

National Rosacea Society

In adults, the colonization rate of Demodex ranges from 70% to 100%, but the skin of people with rosacea have a particularly high density of Demodex: About 35%-50% of patients with rosacea have an increased Demodex load above 5 mites per cm², as measured with a standard skin surface biopsy, she noted. The density of Demodex in the skin of patients with rosacea has been measured at sixfold higher, compared with age-matched controls.

There also are two different Demodex species: Demodex folliculorum, which are longer, and Demodex brevis, which are short, and there is evidence that each “may cause an individual reaction,” Dr. Stein Gold said.

She referred to a study that found a difference in the Demodex population in patients with highly inflammatory disease with a high level of Demodex, mild rosacea patients who did not have a lot of Demodex, and people with no rosacea (Dermatol Reports. 2019 Jan 23;11[1]:7675).

“Those people who had really severe, inflammatory rosacea had Demodex folliculorum,” and the patients with the more mild disease or those with clear skin had Demodex brevis, she said, so “different species of Demodex might cause a different inflammatory reaction within individual rosacea patients.”

Dr. Stein Gold reported that she has served as a consultant, investigator, or speaker for Galderma, Dermira, Foamix Pharmaceuticals, Valeant (now Bausch Health), Allergan, Actavis, and Roche.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

LAHAINA, HAWAII – Recent data on the roles of caffeinated coffee and two types of Demodex species play in rosacea were discussed by Linda Stein Gold, MD, at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

When considering rosacea triggers, the role of coffee has been difficult to determine, according to Dr. Stein Gold, director of dermatology research at the Henry Ford Health System in Detroit.

“We know that caffeine can vasoconstrict, it also has anti-inflammatory properties so ... that might help rosacea,” while the heat from a hot cup of coffee may cause vasodilation “and make rosacea worse,” she noted.

But a recent study of data from the Nurses’ Health Study II that evaluated intake of coffee, tea, soda, and chocolate every 4 years in over 82,000 women shed some light on the role coffee may play (JAMA Dermatol. 2018 Dec 1;154[12]:1394-1400). There were almost 5,000 cases of physician-diagnosed rosacea in the cohort. When the investigators looked at caffeinated coffee consumption, “the more caffeine and the more coffee they drank each day, the more likely it was for them not to have rosacea,” she said.

Those who consumed four or more servings of caffeinated coffee a day had a significantly lower risk of rosacea, compared with those who consumed one or fewer servings per month (hazard ratio, 0.77; 95% confidence interval, 0.69-0.87; P less than .001).

But there was no significant association with decaffeinated coffee or with edibles that contained caffeine such as tea, soda, and chocolate, “so something about caffeinated coffee seems to be protective for the development of rosacea,” Dr. Stein Gold said.

Demodex mites

A few years ago, “we really didn’t think much of Demodex, but now we know Demodex tends to be a key player” in people with rosacea, Dr. Stein Gold said.

National Rosacea Society

In adults, the colonization rate of Demodex ranges from 70% to 100%, but the skin of people with rosacea have a particularly high density of Demodex: About 35%-50% of patients with rosacea have an increased Demodex load above 5 mites per cm², as measured with a standard skin surface biopsy, she noted. The density of Demodex in the skin of patients with rosacea has been measured at sixfold higher, compared with age-matched controls.

There also are two different Demodex species: Demodex folliculorum, which are longer, and Demodex brevis, which are short, and there is evidence that each “may cause an individual reaction,” Dr. Stein Gold said.

She referred to a study that found a difference in the Demodex population in patients with highly inflammatory disease with a high level of Demodex, mild rosacea patients who did not have a lot of Demodex, and people with no rosacea (Dermatol Reports. 2019 Jan 23;11[1]:7675).

“Those people who had really severe, inflammatory rosacea had Demodex folliculorum,” and the patients with the more mild disease or those with clear skin had Demodex brevis, she said, so “different species of Demodex might cause a different inflammatory reaction within individual rosacea patients.”

Dr. Stein Gold reported that she has served as a consultant, investigator, or speaker for Galderma, Dermira, Foamix Pharmaceuticals, Valeant (now Bausch Health), Allergan, Actavis, and Roche.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

LAHAINA, HAWAII – Recent data on the roles of caffeinated coffee and two types of Demodex species play in rosacea were discussed by Linda Stein Gold, MD, at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

When considering rosacea triggers, the role of coffee has been difficult to determine, according to Dr. Stein Gold, director of dermatology research at the Henry Ford Health System in Detroit.

“We know that caffeine can vasoconstrict, it also has anti-inflammatory properties so ... that might help rosacea,” while the heat from a hot cup of coffee may cause vasodilation “and make rosacea worse,” she noted.

But a recent study of data from the Nurses’ Health Study II that evaluated intake of coffee, tea, soda, and chocolate every 4 years in over 82,000 women shed some light on the role coffee may play (JAMA Dermatol. 2018 Dec 1;154[12]:1394-1400). There were almost 5,000 cases of physician-diagnosed rosacea in the cohort. When the investigators looked at caffeinated coffee consumption, “the more caffeine and the more coffee they drank each day, the more likely it was for them not to have rosacea,” she said.

Those who consumed four or more servings of caffeinated coffee a day had a significantly lower risk of rosacea, compared with those who consumed one or fewer servings per month (hazard ratio, 0.77; 95% confidence interval, 0.69-0.87; P less than .001).

But there was no significant association with decaffeinated coffee or with edibles that contained caffeine such as tea, soda, and chocolate, “so something about caffeinated coffee seems to be protective for the development of rosacea,” Dr. Stein Gold said.

Demodex mites

A few years ago, “we really didn’t think much of Demodex, but now we know Demodex tends to be a key player” in people with rosacea, Dr. Stein Gold said.

National Rosacea Society

In adults, the colonization rate of Demodex ranges from 70% to 100%, but the skin of people with rosacea have a particularly high density of Demodex: About 35%-50% of patients with rosacea have an increased Demodex load above 5 mites per cm², as measured with a standard skin surface biopsy, she noted. The density of Demodex in the skin of patients with rosacea has been measured at sixfold higher, compared with age-matched controls.

There also are two different Demodex species: Demodex folliculorum, which are longer, and Demodex brevis, which are short, and there is evidence that each “may cause an individual reaction,” Dr. Stein Gold said.

She referred to a study that found a difference in the Demodex population in patients with highly inflammatory disease with a high level of Demodex, mild rosacea patients who did not have a lot of Demodex, and people with no rosacea (Dermatol Reports. 2019 Jan 23;11[1]:7675).

“Those people who had really severe, inflammatory rosacea had Demodex folliculorum,” and the patients with the more mild disease or those with clear skin had Demodex brevis, she said, so “different species of Demodex might cause a different inflammatory reaction within individual rosacea patients.”

Dr. Stein Gold reported that she has served as a consultant, investigator, or speaker for Galderma, Dermira, Foamix Pharmaceuticals, Valeant (now Bausch Health), Allergan, Actavis, and Roche.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

LAHAINA, HAWAII – Multiple studies, including meta-analyses, have shown that dermoscopy improves sensitivity for diagnosing melanoma, without lowering specificity, but there are still some “nonbelievers,” Ashfaq A. Marghoob, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

In fact, not one study has shown that dermoscopy is less sensitive than the naked eye alone, and at clinics where dermoscopy is used, “two-thirds of the melanomas being detected now lack the classic ABCD features of melanoma,” added Dr. Marghoob, director of clinical dermatology at Memorial Sloan Kettering in Hauppauge, N.Y.

Dr. Marghoob cited a meta-analysis of 9 prospective trials, which concluded that dermoscopy was more accurate in diagnosing melanoma than the naked eye alone and did not lower specificity, with a sensitivity and specificity of 90%, compared with 71% and 81%, respectively for the naked eye (Br J Dermatol. 2008 Sep;159[3]:669-76).

“And at least from an evidence-based standpoint ... the Cochrane library has basically endorsed that, yes, dermoscopy does indeed improve your diagnostic accuracy,” Dr. Marghoob said.

He referred to a 2018 Cochrane review on 104 dermoscopy studies, with and without visual inspection, for diagnosing melanoma in adults (Cochrane Database Syst Rev. 2018 Dec 4;12:CD011902). The review authors concluded that “the evidence suggests that melanomas will be missed if visual inspection is used on its own,” and despite limitations in the evidence, “dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants.”

As for the question of specificity, Dr. Marghoob said studies have found that dermoscopy results in the detection of more melanomas and reduces the number of biopsies of benign lesions and “every study looking into this has shown that, yes, it does improve” specificity.

A 10-year multicenter survey of about 300,000 cases, which included 17,172 melanomas and 283,043 melanocytic nevi, found that the number-needed-to-excise (NNE) values improved over time in specialized clinics where newer diagnostic techniques like dermoscopy were used (from 12.8 to 6.8), but the NNE did not appear to change in the nonspecialized settings (J Am Acad Dermatol. 2012 Jul;67[1]:54-9).

Looking at the benign-to-malignant ratio, there was no change among those not using dermoscopy, where the ratio remained at about 30 to 1. When dermoscopy was used, this ratio started to improve over the 10-year period, to about 5 to 1. In addition, “the dermoscopy users were finding many more melanomas than the non–dermoscopy users,” Dr. Marghoob added. And over the 10 years, the number of nevi being removed did not change among those not using dermoscopy but dropped among those using dermoscopy.

Adding photography with the ability to digitally monitor patients helps bring this ratio down further, Dr. Marghoob noted. He referred to a study that instead evaluated the ratio of melanoma to nonmelanomas diagnosed among dermatologists in three groups: those with no digital dermoscopy with little dermoscopy training (group A, the reference group), no digital dermoscopy but more dermoscopy training (group B), and those using digital dermoscopy (group C). In the group that used digital dermoscopy, that ratio was about 1 to 2.4, compared with about 1 to 8 in group B, and about 1 to 10.7 in group A (Br J Dermatol. 2012;167[4]778-86).

The use of dermoscopy is also associated with thinner tumors. Among dermoscopy users, the thickness of the tumors detected drops, and the proportion of thin to thick lesions detected increases, Dr. Marghoob said.

For example, in one study, the mean thickness in melanomas detected with dermoscopy was 1.4 mm versus 2.59 mm when dermoscopy was not used (J Eur Acad Dermatol Venereol. 2015 Jan; 29[1]:102-8). About 55% of the tumors detected with dermoscopic examination were 1 mm or less in thickness versus 23.4% of those detected without dermoscopy, “so the dermoscopy users from a proportion standpoint were also finding thinner tumors,” Dr. Marghoob said. Dermoscopy was also identified as an independent predictor of finding thinner tumors.

Even without a study, it could be assumed that the use of dermoscopy would reduce costs, since dermoscopy increases sensitivity and the total number of melanomas detected, decreases the number of benign nevi removed, and helps detect disease earlier. But there are data showing that dermoscopy reduces health care costs, Dr. Marghoob said.* For example, a Belgian study that looked at dermoscopy in two cohorts of melanoma patients concluded that adequate dermoscopy training was cost effective (Eur J Cancer. 2016 Nov;67:38-45).

It has also been shown that adding dermoscopy to a primary care setting has cost benefits, Dr. Marghoob said. He cited a study of Dutch general practices that found that the probability of a correct diagnosis was 1.25 times higher when dermoscopy was used to evaluate suspicious skin lesions and concluded that the use of dermoscopy appeared to be cost effective (J Eur Acad Dermatol Venereol. 2014 Nov;28[11]:1442-9).

Dr. Marghoob had no disclosures relevant to this presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

*Correction, 2/28/20: An earlier version of this article mischaracterized the cost implications of dermoscopy use.

emechcatie@mdedge.com

LAHAINA, HAWAII – Multiple studies, including meta-analyses, have shown that dermoscopy improves sensitivity for diagnosing melanoma, without lowering specificity, but there are still some “nonbelievers,” Ashfaq A. Marghoob, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

In fact, not one study has shown that dermoscopy is less sensitive than the naked eye alone, and at clinics where dermoscopy is used, “two-thirds of the melanomas being detected now lack the classic ABCD features of melanoma,” added Dr. Marghoob, director of clinical dermatology at Memorial Sloan Kettering in Hauppauge, N.Y.

Dr. Marghoob cited a meta-analysis of 9 prospective trials, which concluded that dermoscopy was more accurate in diagnosing melanoma than the naked eye alone and did not lower specificity, with a sensitivity and specificity of 90%, compared with 71% and 81%, respectively for the naked eye (Br J Dermatol. 2008 Sep;159[3]:669-76).

“And at least from an evidence-based standpoint ... the Cochrane library has basically endorsed that, yes, dermoscopy does indeed improve your diagnostic accuracy,” Dr. Marghoob said.

He referred to a 2018 Cochrane review on 104 dermoscopy studies, with and without visual inspection, for diagnosing melanoma in adults (Cochrane Database Syst Rev. 2018 Dec 4;12:CD011902). The review authors concluded that “the evidence suggests that melanomas will be missed if visual inspection is used on its own,” and despite limitations in the evidence, “dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants.”

As for the question of specificity, Dr. Marghoob said studies have found that dermoscopy results in the detection of more melanomas and reduces the number of biopsies of benign lesions and “every study looking into this has shown that, yes, it does improve” specificity.

A 10-year multicenter survey of about 300,000 cases, which included 17,172 melanomas and 283,043 melanocytic nevi, found that the number-needed-to-excise (NNE) values improved over time in specialized clinics where newer diagnostic techniques like dermoscopy were used (from 12.8 to 6.8), but the NNE did not appear to change in the nonspecialized settings (J Am Acad Dermatol. 2012 Jul;67[1]:54-9).

Looking at the benign-to-malignant ratio, there was no change among those not using dermoscopy, where the ratio remained at about 30 to 1. When dermoscopy was used, this ratio started to improve over the 10-year period, to about 5 to 1. In addition, “the dermoscopy users were finding many more melanomas than the non–dermoscopy users,” Dr. Marghoob added. And over the 10 years, the number of nevi being removed did not change among those not using dermoscopy but dropped among those using dermoscopy.

Adding photography with the ability to digitally monitor patients helps bring this ratio down further, Dr. Marghoob noted. He referred to a study that instead evaluated the ratio of melanoma to nonmelanomas diagnosed among dermatologists in three groups: those with no digital dermoscopy with little dermoscopy training (group A, the reference group), no digital dermoscopy but more dermoscopy training (group B), and those using digital dermoscopy (group C). In the group that used digital dermoscopy, that ratio was about 1 to 2.4, compared with about 1 to 8 in group B, and about 1 to 10.7 in group A (Br J Dermatol. 2012;167[4]778-86).

The use of dermoscopy is also associated with thinner tumors. Among dermoscopy users, the thickness of the tumors detected drops, and the proportion of thin to thick lesions detected increases, Dr. Marghoob said.

For example, in one study, the mean thickness in melanomas detected with dermoscopy was 1.4 mm versus 2.59 mm when dermoscopy was not used (J Eur Acad Dermatol Venereol. 2015 Jan; 29[1]:102-8). About 55% of the tumors detected with dermoscopic examination were 1 mm or less in thickness versus 23.4% of those detected without dermoscopy, “so the dermoscopy users from a proportion standpoint were also finding thinner tumors,” Dr. Marghoob said. Dermoscopy was also identified as an independent predictor of finding thinner tumors.

Even without a study, it could be assumed that the use of dermoscopy would reduce costs, since dermoscopy increases sensitivity and the total number of melanomas detected, decreases the number of benign nevi removed, and helps detect disease earlier. But there are data showing that dermoscopy reduces health care costs, Dr. Marghoob said.* For example, a Belgian study that looked at dermoscopy in two cohorts of melanoma patients concluded that adequate dermoscopy training was cost effective (Eur J Cancer. 2016 Nov;67:38-45).

It has also been shown that adding dermoscopy to a primary care setting has cost benefits, Dr. Marghoob said. He cited a study of Dutch general practices that found that the probability of a correct diagnosis was 1.25 times higher when dermoscopy was used to evaluate suspicious skin lesions and concluded that the use of dermoscopy appeared to be cost effective (J Eur Acad Dermatol Venereol. 2014 Nov;28[11]:1442-9).

Dr. Marghoob had no disclosures relevant to this presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

*Correction, 2/28/20: An earlier version of this article mischaracterized the cost implications of dermoscopy use.

emechcatie@mdedge.com

LAHAINA, HAWAII – Multiple studies, including meta-analyses, have shown that dermoscopy improves sensitivity for diagnosing melanoma, without lowering specificity, but there are still some “nonbelievers,” Ashfaq A. Marghoob, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

In fact, not one study has shown that dermoscopy is less sensitive than the naked eye alone, and at clinics where dermoscopy is used, “two-thirds of the melanomas being detected now lack the classic ABCD features of melanoma,” added Dr. Marghoob, director of clinical dermatology at Memorial Sloan Kettering in Hauppauge, N.Y.

Dr. Marghoob cited a meta-analysis of 9 prospective trials, which concluded that dermoscopy was more accurate in diagnosing melanoma than the naked eye alone and did not lower specificity, with a sensitivity and specificity of 90%, compared with 71% and 81%, respectively for the naked eye (Br J Dermatol. 2008 Sep;159[3]:669-76).

“And at least from an evidence-based standpoint ... the Cochrane library has basically endorsed that, yes, dermoscopy does indeed improve your diagnostic accuracy,” Dr. Marghoob said.

He referred to a 2018 Cochrane review on 104 dermoscopy studies, with and without visual inspection, for diagnosing melanoma in adults (Cochrane Database Syst Rev. 2018 Dec 4;12:CD011902). The review authors concluded that “the evidence suggests that melanomas will be missed if visual inspection is used on its own,” and despite limitations in the evidence, “dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants.”

As for the question of specificity, Dr. Marghoob said studies have found that dermoscopy results in the detection of more melanomas and reduces the number of biopsies of benign lesions and “every study looking into this has shown that, yes, it does improve” specificity.

A 10-year multicenter survey of about 300,000 cases, which included 17,172 melanomas and 283,043 melanocytic nevi, found that the number-needed-to-excise (NNE) values improved over time in specialized clinics where newer diagnostic techniques like dermoscopy were used (from 12.8 to 6.8), but the NNE did not appear to change in the nonspecialized settings (J Am Acad Dermatol. 2012 Jul;67[1]:54-9).

Looking at the benign-to-malignant ratio, there was no change among those not using dermoscopy, where the ratio remained at about 30 to 1. When dermoscopy was used, this ratio started to improve over the 10-year period, to about 5 to 1. In addition, “the dermoscopy users were finding many more melanomas than the non–dermoscopy users,” Dr. Marghoob added. And over the 10 years, the number of nevi being removed did not change among those not using dermoscopy but dropped among those using dermoscopy.

Adding photography with the ability to digitally monitor patients helps bring this ratio down further, Dr. Marghoob noted. He referred to a study that instead evaluated the ratio of melanoma to nonmelanomas diagnosed among dermatologists in three groups: those with no digital dermoscopy with little dermoscopy training (group A, the reference group), no digital dermoscopy but more dermoscopy training (group B), and those using digital dermoscopy (group C). In the group that used digital dermoscopy, that ratio was about 1 to 2.4, compared with about 1 to 8 in group B, and about 1 to 10.7 in group A (Br J Dermatol. 2012;167[4]778-86).

The use of dermoscopy is also associated with thinner tumors. Among dermoscopy users, the thickness of the tumors detected drops, and the proportion of thin to thick lesions detected increases, Dr. Marghoob said.

For example, in one study, the mean thickness in melanomas detected with dermoscopy was 1.4 mm versus 2.59 mm when dermoscopy was not used (J Eur Acad Dermatol Venereol. 2015 Jan; 29[1]:102-8). About 55% of the tumors detected with dermoscopic examination were 1 mm or less in thickness versus 23.4% of those detected without dermoscopy, “so the dermoscopy users from a proportion standpoint were also finding thinner tumors,” Dr. Marghoob said. Dermoscopy was also identified as an independent predictor of finding thinner tumors.

Even without a study, it could be assumed that the use of dermoscopy would reduce costs, since dermoscopy increases sensitivity and the total number of melanomas detected, decreases the number of benign nevi removed, and helps detect disease earlier. But there are data showing that dermoscopy reduces health care costs, Dr. Marghoob said.* For example, a Belgian study that looked at dermoscopy in two cohorts of melanoma patients concluded that adequate dermoscopy training was cost effective (Eur J Cancer. 2016 Nov;67:38-45).

It has also been shown that adding dermoscopy to a primary care setting has cost benefits, Dr. Marghoob said. He cited a study of Dutch general practices that found that the probability of a correct diagnosis was 1.25 times higher when dermoscopy was used to evaluate suspicious skin lesions and concluded that the use of dermoscopy appeared to be cost effective (J Eur Acad Dermatol Venereol. 2014 Nov;28[11]:1442-9).

Dr. Marghoob had no disclosures relevant to this presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

*Correction, 2/28/20: An earlier version of this article mischaracterized the cost implications of dermoscopy use.

emechcatie@mdedge.com

LAHAINA, HAWAII – “Protect and prevent” by applying an antioxidant and sunscreen in the morning, and focus on repair using a retinoid in the evening. That’s the simple message about daily skin care that clinicians can offer patients, according to Brooke Sikora, MD.

“At a very basic level, you want to tell your patients [to] use an antioxidant and use your sunscreen” early in the day, said Dr. Sikora, who is in private practice in Chestnut Hill, Mass. “In the evening, it’s all about repairing their damage, so make sure they’re getting on a retinol,” and if they can’t tolerate prescription strength, try a nonprescription product, she noted at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

“Aging factors create oxidative stress on the skin that leads to the development of these reactive oxygen species on the skin,” decreasing collagen production and increasing collagen breakdown, she explained during a presentation on cosmeceuticals at the meeting. Applying an antioxidant to the skin, however, can help neutralize “a lot of these reactive oxygen species and help to slow the breakdown of collagen.”

There is good evidence that peptides and growth factors – although expensive – work well and are worth recommending for patients “who really want to take their skin care to the next level,” Dr. Sikora said. “Then you can add corrective products like hyperpigmentation or acne products to treat ... specific concerns” as needed.

In an interview at the meeting, Dr. Sikora discussed these recommendations, as well as vitamin C use in the daily skin care routine. (To listen to the interview, click on the play button below.)

Vitamin C is the best-studied antioxidant, she noted during her presentation, and in vivo studies have shown it can stimulate collagen synthesis, reduce erythema of rosacea (which is why she has all her rosacea patients on vitamin C), reduce post-UVB erythema, decrease facial wrinkles, and increase dermal papillae.

Dr. Sikora disclosed that she is a consultant to and on the advisory board of SkinCeuticals, La Roche–Posay, Silk Therapeutics, Galderma, Evolus, and Allergen. She is on the speakers bureau for SkinCeuticals, La Roche–Posay, Galderma, and Aclaris.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

To listen to the interview, click on the play button below.

emechcatie@mdedge.com

LAHAINA, HAWAII – “Protect and prevent” by applying an antioxidant and sunscreen in the morning, and focus on repair using a retinoid in the evening. That’s the simple message about daily skin care that clinicians can offer patients, according to Brooke Sikora, MD.

“At a very basic level, you want to tell your patients [to] use an antioxidant and use your sunscreen” early in the day, said Dr. Sikora, who is in private practice in Chestnut Hill, Mass. “In the evening, it’s all about repairing their damage, so make sure they’re getting on a retinol,” and if they can’t tolerate prescription strength, try a nonprescription product, she noted at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

“Aging factors create oxidative stress on the skin that leads to the development of these reactive oxygen species on the skin,” decreasing collagen production and increasing collagen breakdown, she explained during a presentation on cosmeceuticals at the meeting. Applying an antioxidant to the skin, however, can help neutralize “a lot of these reactive oxygen species and help to slow the breakdown of collagen.”

There is good evidence that peptides and growth factors – although expensive – work well and are worth recommending for patients “who really want to take their skin care to the next level,” Dr. Sikora said. “Then you can add corrective products like hyperpigmentation or acne products to treat ... specific concerns” as needed.

In an interview at the meeting, Dr. Sikora discussed these recommendations, as well as vitamin C use in the daily skin care routine. (To listen to the interview, click on the play button below.)

Vitamin C is the best-studied antioxidant, she noted during her presentation, and in vivo studies have shown it can stimulate collagen synthesis, reduce erythema of rosacea (which is why she has all her rosacea patients on vitamin C), reduce post-UVB erythema, decrease facial wrinkles, and increase dermal papillae.

Dr. Sikora disclosed that she is a consultant to and on the advisory board of SkinCeuticals, La Roche–Posay, Silk Therapeutics, Galderma, Evolus, and Allergen. She is on the speakers bureau for SkinCeuticals, La Roche–Posay, Galderma, and Aclaris.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

To listen to the interview, click on the play button below.

emechcatie@mdedge.com

LAHAINA, HAWAII – “Protect and prevent” by applying an antioxidant and sunscreen in the morning, and focus on repair using a retinoid in the evening. That’s the simple message about daily skin care that clinicians can offer patients, according to Brooke Sikora, MD.

“At a very basic level, you want to tell your patients [to] use an antioxidant and use your sunscreen” early in the day, said Dr. Sikora, who is in private practice in Chestnut Hill, Mass. “In the evening, it’s all about repairing their damage, so make sure they’re getting on a retinol,” and if they can’t tolerate prescription strength, try a nonprescription product, she noted at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

“Aging factors create oxidative stress on the skin that leads to the development of these reactive oxygen species on the skin,” decreasing collagen production and increasing collagen breakdown, she explained during a presentation on cosmeceuticals at the meeting. Applying an antioxidant to the skin, however, can help neutralize “a lot of these reactive oxygen species and help to slow the breakdown of collagen.”

There is good evidence that peptides and growth factors – although expensive – work well and are worth recommending for patients “who really want to take their skin care to the next level,” Dr. Sikora said. “Then you can add corrective products like hyperpigmentation or acne products to treat ... specific concerns” as needed.

In an interview at the meeting, Dr. Sikora discussed these recommendations, as well as vitamin C use in the daily skin care routine. (To listen to the interview, click on the play button below.)

Vitamin C is the best-studied antioxidant, she noted during her presentation, and in vivo studies have shown it can stimulate collagen synthesis, reduce erythema of rosacea (which is why she has all her rosacea patients on vitamin C), reduce post-UVB erythema, decrease facial wrinkles, and increase dermal papillae.

Dr. Sikora disclosed that she is a consultant to and on the advisory board of SkinCeuticals, La Roche–Posay, Silk Therapeutics, Galderma, Evolus, and Allergen. She is on the speakers bureau for SkinCeuticals, La Roche–Posay, Galderma, and Aclaris.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

To listen to the interview, click on the play button below.

emechcatie@mdedge.com

LAHAINA, HAWAII – Teledermatology and dermoscopy were made for each other, Trilokraj Tejasvi, MBBS, MD, declared at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

“If somebody is trying to start a practice in lesional teledermatology, I would recommend getting dermoscopy images with all of the teledermatology consults. The dermatoscope manufacturers make teledermoscopy systems with attachments for iPhones, iPads, and Android devices,” said Dr. Tejasvi, who is director of teledermatology services and also director of the cutaneous lymphoma program at the University of Michigan, Ann Arbor.

To make his point, he presented slides of six standard unenhanced teledermatologic photos of ambiguous pigmented skin lesions. When he asked the large audience which ones they’d want to biopsy and which they were confident were benign, there was absolutely no consensus. But when he followed up with teledermoscopic photos of the same lesions, the dermoscopists in the audience quickly voiced agreement that four of the lesions were benign and two were obvious melanoma. Based on that information, instead of having to bring in all six patients for biopsy of their indeterminant suspicious lesions, only two of the patients would need to come in promptly for treatment of their malignancy.

“Dermoscopy changes the whole triage system and the teledermoscopy concept model, because dermoscopy remains the same: it’s going to stay [two-dimensional] whether you’re going to see the images in the clinic or in teledermatology. So using teledermoscopy images actually makes it far better for your teledermatology services,” explained Dr. Tejasvi, who is also chief of the dermatology service at the Ann Arbor Veterans Affairs Hospital.

Why get into teledermatology?

The benefits of teledermatology include earlier diagnosis and treatment of skin cancers as documented in a Spanish study of 43,677 patients. The Spanish dermatologists reported that teledermatologically detected melanomas had a thinner Breslow depth and lower tumor stage because they were diagnosed earlier. Teledermatology also brought a twofold increase in the basal cell carcinoma detection rate and – most importantly – a reduction in time to biopsy for what turned out to be skin cancers (JAMA Dermatol. 2015 Dec 1;151[12]:1289-90).

In addition, teledermatology is an effective triage tool for busy clinicians whose appointment calendars are booked weeks or months in advance.

“Let’s say you are the only dermatologist in the surrounding five counties. You can use teledermatology to see which patients actually need to come to your clinic,” Dr. Tejasvri said. Just make sure the referring primary care providers know to send photos taken with the dermatoscope attachment.

Internet-based teledermatology also provides a way to follow patients with chronic conditions, including psoriasis, atopic dermatitis, and venous ulcers, he noted.
 

Before getting started

Dr. Tejasvri emphasized the importance of visiting the American Academy of Dermatology Teledermatology Task Force website as well as the American Telemedicine Association’s Teledermatology Special Interest Group, which he chairs. These resources, he stressed, are invaluable.

The AAD site, open to all academy members, includes a tool kit for getting started in teledermatology. It’s individually tailored for the dermatologist in solo, small group, academic, or multispecialty practice. This highly practical tool kit includes a checklist that aids in determining whether a dermatologist’s practice is suited for teledermatology, as well as the suggested optimal teledermatology practice model for that individual, the nuts and bolts of equipment, relevant state laws, and how to navigate legal concerns, among the most critical of which is to get in writing the malpractice insurer’s verbal reassurance that the policy covers telemedicine.

The American Telemedicine Association Teledermatology Special Interest Group provides best-practice guidelines (Telemed J E Health. 2016 Dec;22[12]:981-90)

Teledermatology practice model options

The most common teledermatology model is called “store-and-forward.” It relies upon transmission of still images of skin lesions. Its advantages are that it’s not dependent upon internet speed and it accommodates physicians working in different time zones. Most commonly, this is a consult model in which a remote primary care provider takes the photos and transmits them to the dermatologist specialist. The referring provider retains responsibility for patient care.

The other model entails creation of a virtual clinic with real-time videoconference-based communication using a HIPAA-compliant high-speed broadband internet connection. The advantages are that reimbursement is good – indeed, the same as for a face-to-face office visit – and it’s possible to ask questions of the patient and referring physician, although that’s generally not necessary for the straightforward evaluation of suspicious pigmented or nonpigmented skin lesions. However, the video image quality isn’t as good as with still photos, the virtual clinic requires dedicated scheduling, and the quality of the experience is highly dependent upon internet speed.

“If you have a bad internet speed the whole process becomes choppy. When you ask a question, the answer you get is the one to your previous question,” Dr. Tejasvi said.

Reimbursement

Currently 38 states and Washington, D.C., have laws governing private payer telehealth reimbursement policy.

Under the 2019 Medicare physician fee schedule, code number 99446 – interprofessional telephone/internet consult lasting 5-10 minutes – pays $18.36. A 99447, lasting 11-20 minutes, pays $36.36, and a 99448, representing a 21-30 minute interprofessional consult, pays $54.72.

“Reimbursement is poor. It’s not a lot at all. If you spend 5-10 minutes on a consult you get paid about 20 bucks. But it’s better than nothing, and it used to be that patients had to pay out of pocket,” the dermatologist commented.

And of course, the improved timely and efficient patient access to dermatologist evaluation of potential skin cancer that’s afforded via teledermatology helps out with the profession’s workforce shortage and responds to the common criticism that dermatologists are geographically maldistributed and treatment delayed is treatment denied.
 

How accurate is teledermatology?

Numerous studies have reported diagnostic concordance rates between teledermatology and face-to-face clinical diagnosis of 72.5%-90% for melanoma, dropping off markedly to 31.2%-62% for lentigines. However, teledermoscopic images greatly improved the diagnostic accuracy.

In one recent study involving teledermatology versus face-to-face evaluation of 293 index lesions, the face-to-face dermatologist examination turned up 131 incidental skin lesions, including 6 incidental melanomas not suspected or photographed by the consulting primary care providers. That worked out to a 2.6% risk of incidental melanoma per consult, which Dr. Tejasvi called “kind of scary.”

“All six of the incidental melanomas were located on the back, chest, or abdomen, so a good teaching point is that, if you’re doing a teledermatology consult, ask the primary care provider who’s sending you this consult to do a careful waist-up exam to look for other lesions,” he advised.

He added that more and larger studies are needed in order to determine the diagnostic concordance rate for nonpigmented lesions.

Dr. Tejasvi reported having no financial conflicts regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

LAHAINA, HAWAII – Teledermatology and dermoscopy were made for each other, Trilokraj Tejasvi, MBBS, MD, declared at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

“If somebody is trying to start a practice in lesional teledermatology, I would recommend getting dermoscopy images with all of the teledermatology consults. The dermatoscope manufacturers make teledermoscopy systems with attachments for iPhones, iPads, and Android devices,” said Dr. Tejasvi, who is director of teledermatology services and also director of the cutaneous lymphoma program at the University of Michigan, Ann Arbor.

To make his point, he presented slides of six standard unenhanced teledermatologic photos of ambiguous pigmented skin lesions. When he asked the large audience which ones they’d want to biopsy and which they were confident were benign, there was absolutely no consensus. But when he followed up with teledermoscopic photos of the same lesions, the dermoscopists in the audience quickly voiced agreement that four of the lesions were benign and two were obvious melanoma. Based on that information, instead of having to bring in all six patients for biopsy of their indeterminant suspicious lesions, only two of the patients would need to come in promptly for treatment of their malignancy.

“Dermoscopy changes the whole triage system and the teledermoscopy concept model, because dermoscopy remains the same: it’s going to stay [two-dimensional] whether you’re going to see the images in the clinic or in teledermatology. So using teledermoscopy images actually makes it far better for your teledermatology services,” explained Dr. Tejasvi, who is also chief of the dermatology service at the Ann Arbor Veterans Affairs Hospital.

Why get into teledermatology?

The benefits of teledermatology include earlier diagnosis and treatment of skin cancers as documented in a Spanish study of 43,677 patients. The Spanish dermatologists reported that teledermatologically detected melanomas had a thinner Breslow depth and lower tumor stage because they were diagnosed earlier. Teledermatology also brought a twofold increase in the basal cell carcinoma detection rate and – most importantly – a reduction in time to biopsy for what turned out to be skin cancers (JAMA Dermatol. 2015 Dec 1;151[12]:1289-90).

In addition, teledermatology is an effective triage tool for busy clinicians whose appointment calendars are booked weeks or months in advance.

“Let’s say you are the only dermatologist in the surrounding five counties. You can use teledermatology to see which patients actually need to come to your clinic,” Dr. Tejasvri said. Just make sure the referring primary care providers know to send photos taken with the dermatoscope attachment.

Internet-based teledermatology also provides a way to follow patients with chronic conditions, including psoriasis, atopic dermatitis, and venous ulcers, he noted.
 

Before getting started

Dr. Tejasvri emphasized the importance of visiting the American Academy of Dermatology Teledermatology Task Force website as well as the American Telemedicine Association’s Teledermatology Special Interest Group, which he chairs. These resources, he stressed, are invaluable.

The AAD site, open to all academy members, includes a tool kit for getting started in teledermatology. It’s individually tailored for the dermatologist in solo, small group, academic, or multispecialty practice. This highly practical tool kit includes a checklist that aids in determining whether a dermatologist’s practice is suited for teledermatology, as well as the suggested optimal teledermatology practice model for that individual, the nuts and bolts of equipment, relevant state laws, and how to navigate legal concerns, among the most critical of which is to get in writing the malpractice insurer’s verbal reassurance that the policy covers telemedicine.

The American Telemedicine Association Teledermatology Special Interest Group provides best-practice guidelines (Telemed J E Health. 2016 Dec;22[12]:981-90)

Teledermatology practice model options

The most common teledermatology model is called “store-and-forward.” It relies upon transmission of still images of skin lesions. Its advantages are that it’s not dependent upon internet speed and it accommodates physicians working in different time zones. Most commonly, this is a consult model in which a remote primary care provider takes the photos and transmits them to the dermatologist specialist. The referring provider retains responsibility for patient care.

The other model entails creation of a virtual clinic with real-time videoconference-based communication using a HIPAA-compliant high-speed broadband internet connection. The advantages are that reimbursement is good – indeed, the same as for a face-to-face office visit – and it’s possible to ask questions of the patient and referring physician, although that’s generally not necessary for the straightforward evaluation of suspicious pigmented or nonpigmented skin lesions. However, the video image quality isn’t as good as with still photos, the virtual clinic requires dedicated scheduling, and the quality of the experience is highly dependent upon internet speed.

“If you have a bad internet speed the whole process becomes choppy. When you ask a question, the answer you get is the one to your previous question,” Dr. Tejasvi said.

Reimbursement

Currently 38 states and Washington, D.C., have laws governing private payer telehealth reimbursement policy.

Under the 2019 Medicare physician fee schedule, code number 99446 – interprofessional telephone/internet consult lasting 5-10 minutes – pays $18.36. A 99447, lasting 11-20 minutes, pays $36.36, and a 99448, representing a 21-30 minute interprofessional consult, pays $54.72.

“Reimbursement is poor. It’s not a lot at all. If you spend 5-10 minutes on a consult you get paid about 20 bucks. But it’s better than nothing, and it used to be that patients had to pay out of pocket,” the dermatologist commented.

And of course, the improved timely and efficient patient access to dermatologist evaluation of potential skin cancer that’s afforded via teledermatology helps out with the profession’s workforce shortage and responds to the common criticism that dermatologists are geographically maldistributed and treatment delayed is treatment denied.
 

How accurate is teledermatology?

Numerous studies have reported diagnostic concordance rates between teledermatology and face-to-face clinical diagnosis of 72.5%-90% for melanoma, dropping off markedly to 31.2%-62% for lentigines. However, teledermoscopic images greatly improved the diagnostic accuracy.

In one recent study involving teledermatology versus face-to-face evaluation of 293 index lesions, the face-to-face dermatologist examination turned up 131 incidental skin lesions, including 6 incidental melanomas not suspected or photographed by the consulting primary care providers. That worked out to a 2.6% risk of incidental melanoma per consult, which Dr. Tejasvi called “kind of scary.”

“All six of the incidental melanomas were located on the back, chest, or abdomen, so a good teaching point is that, if you’re doing a teledermatology consult, ask the primary care provider who’s sending you this consult to do a careful waist-up exam to look for other lesions,” he advised.

He added that more and larger studies are needed in order to determine the diagnostic concordance rate for nonpigmented lesions.

Dr. Tejasvi reported having no financial conflicts regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

LAHAINA, HAWAII – Teledermatology and dermoscopy were made for each other, Trilokraj Tejasvi, MBBS, MD, declared at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

“If somebody is trying to start a practice in lesional teledermatology, I would recommend getting dermoscopy images with all of the teledermatology consults. The dermatoscope manufacturers make teledermoscopy systems with attachments for iPhones, iPads, and Android devices,” said Dr. Tejasvi, who is director of teledermatology services and also director of the cutaneous lymphoma program at the University of Michigan, Ann Arbor.

To make his point, he presented slides of six standard unenhanced teledermatologic photos of ambiguous pigmented skin lesions. When he asked the large audience which ones they’d want to biopsy and which they were confident were benign, there was absolutely no consensus. But when he followed up with teledermoscopic photos of the same lesions, the dermoscopists in the audience quickly voiced agreement that four of the lesions were benign and two were obvious melanoma. Based on that information, instead of having to bring in all six patients for biopsy of their indeterminant suspicious lesions, only two of the patients would need to come in promptly for treatment of their malignancy.

“Dermoscopy changes the whole triage system and the teledermoscopy concept model, because dermoscopy remains the same: it’s going to stay [two-dimensional] whether you’re going to see the images in the clinic or in teledermatology. So using teledermoscopy images actually makes it far better for your teledermatology services,” explained Dr. Tejasvi, who is also chief of the dermatology service at the Ann Arbor Veterans Affairs Hospital.

Why get into teledermatology?

The benefits of teledermatology include earlier diagnosis and treatment of skin cancers as documented in a Spanish study of 43,677 patients. The Spanish dermatologists reported that teledermatologically detected melanomas had a thinner Breslow depth and lower tumor stage because they were diagnosed earlier. Teledermatology also brought a twofold increase in the basal cell carcinoma detection rate and – most importantly – a reduction in time to biopsy for what turned out to be skin cancers (JAMA Dermatol. 2015 Dec 1;151[12]:1289-90).

In addition, teledermatology is an effective triage tool for busy clinicians whose appointment calendars are booked weeks or months in advance.

“Let’s say you are the only dermatologist in the surrounding five counties. You can use teledermatology to see which patients actually need to come to your clinic,” Dr. Tejasvri said. Just make sure the referring primary care providers know to send photos taken with the dermatoscope attachment.

Internet-based teledermatology also provides a way to follow patients with chronic conditions, including psoriasis, atopic dermatitis, and venous ulcers, he noted.
 

Before getting started

Dr. Tejasvri emphasized the importance of visiting the American Academy of Dermatology Teledermatology Task Force website as well as the American Telemedicine Association’s Teledermatology Special Interest Group, which he chairs. These resources, he stressed, are invaluable.

The AAD site, open to all academy members, includes a tool kit for getting started in teledermatology. It’s individually tailored for the dermatologist in solo, small group, academic, or multispecialty practice. This highly practical tool kit includes a checklist that aids in determining whether a dermatologist’s practice is suited for teledermatology, as well as the suggested optimal teledermatology practice model for that individual, the nuts and bolts of equipment, relevant state laws, and how to navigate legal concerns, among the most critical of which is to get in writing the malpractice insurer’s verbal reassurance that the policy covers telemedicine.

The American Telemedicine Association Teledermatology Special Interest Group provides best-practice guidelines (Telemed J E Health. 2016 Dec;22[12]:981-90)

Teledermatology practice model options

The most common teledermatology model is called “store-and-forward.” It relies upon transmission of still images of skin lesions. Its advantages are that it’s not dependent upon internet speed and it accommodates physicians working in different time zones. Most commonly, this is a consult model in which a remote primary care provider takes the photos and transmits them to the dermatologist specialist. The referring provider retains responsibility for patient care.

The other model entails creation of a virtual clinic with real-time videoconference-based communication using a HIPAA-compliant high-speed broadband internet connection. The advantages are that reimbursement is good – indeed, the same as for a face-to-face office visit – and it’s possible to ask questions of the patient and referring physician, although that’s generally not necessary for the straightforward evaluation of suspicious pigmented or nonpigmented skin lesions. However, the video image quality isn’t as good as with still photos, the virtual clinic requires dedicated scheduling, and the quality of the experience is highly dependent upon internet speed.

“If you have a bad internet speed the whole process becomes choppy. When you ask a question, the answer you get is the one to your previous question,” Dr. Tejasvi said.

Reimbursement

Currently 38 states and Washington, D.C., have laws governing private payer telehealth reimbursement policy.

Under the 2019 Medicare physician fee schedule, code number 99446 – interprofessional telephone/internet consult lasting 5-10 minutes – pays $18.36. A 99447, lasting 11-20 minutes, pays $36.36, and a 99448, representing a 21-30 minute interprofessional consult, pays $54.72.

“Reimbursement is poor. It’s not a lot at all. If you spend 5-10 minutes on a consult you get paid about 20 bucks. But it’s better than nothing, and it used to be that patients had to pay out of pocket,” the dermatologist commented.

And of course, the improved timely and efficient patient access to dermatologist evaluation of potential skin cancer that’s afforded via teledermatology helps out with the profession’s workforce shortage and responds to the common criticism that dermatologists are geographically maldistributed and treatment delayed is treatment denied.
 

How accurate is teledermatology?

Numerous studies have reported diagnostic concordance rates between teledermatology and face-to-face clinical diagnosis of 72.5%-90% for melanoma, dropping off markedly to 31.2%-62% for lentigines. However, teledermoscopic images greatly improved the diagnostic accuracy.

In one recent study involving teledermatology versus face-to-face evaluation of 293 index lesions, the face-to-face dermatologist examination turned up 131 incidental skin lesions, including 6 incidental melanomas not suspected or photographed by the consulting primary care providers. That worked out to a 2.6% risk of incidental melanoma per consult, which Dr. Tejasvi called “kind of scary.”

“All six of the incidental melanomas were located on the back, chest, or abdomen, so a good teaching point is that, if you’re doing a teledermatology consult, ask the primary care provider who’s sending you this consult to do a careful waist-up exam to look for other lesions,” he advised.

He added that more and larger studies are needed in order to determine the diagnostic concordance rate for nonpigmented lesions.

Dr. Tejasvi reported having no financial conflicts regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

LAHAINA, HAWAII – It’s important to counsel patients about the degree of improvement to expect with noninvasive skin tightening procedures, Nazanin Saedi, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Many devices are available that can be used for facial skin tightening, “but there are definitely limitations to what we can do noninvasively, and we really need to educate our patients about what we can do so that they have realistic expectations,” said Dr. Saedi, director of laser surgery and cosmetic dermatology at Sidney Kimmel Medical College, Philadelphia.

Treatment with these devices improve skin laxity, and some improve skin texture as well, she said. These devices are not an option for patients who want to have several inches of excess skin removed.

“You have to tell patients that this isn’t a replacement for a face-lift or a mini face-lift,” but patients can expect to see mild and modest improvement, and they’ll continue to see improvement for 3-6 months.

Patient selection is also important. Patients with mild to moderate laxity who do not want to undergo surgery and anesthesia are good candidates, as opposed to those who are older and have thin, sagging skin, Dr. Saedi said, noting that there still is no standard method of defining laxity.

She referred to a recent study illustrating the importance of counseling patients about what to expect. Of the 83 patients in a practice who had undergone microfocused ultrasound treatments and responded to an anonymous survey about the results of treatment, almost 80% reported at least mild improvement (14.5% said the improvement was significant, almost 28% said it was moderate, 37.3% said it was mild, and 20.5% said there was no improvement).

However, although about half (53.1%) reported being satisfied with their results, almost 45% said that the results did not meet their expectations (Lasers Surg Med. 2019;51[6]:495-9).

In an interview at the meeting, Dr. Saedi commented on these results and the importance of counseling.

Listen to the interview by clicking the play button at the end of this story.

During the presentation, Dr. Saedi, who is also codirector of cutaneous surgery in the department of dermatology and cutaneous biology at Sidney Kimmel Medical College, reviewed different technologies used for noninvasive skin tightening, including ablative and fractional laser resurfacing, radiofrequency, and microfocused ultrasound with visualization.

She disclosed serving on the advisory board and/or as a consultant for Aerolase, Alastin, Alma, Cartessa Aesthetics, Cynosure, and Vivo Capital, and that she has equipment from these companies, except for Vivo Capital and Alastin.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

To listen to the interview, click the play button below.
 

emechcatie@mdedge.com

LAHAINA, HAWAII – It’s important to counsel patients about the degree of improvement to expect with noninvasive skin tightening procedures, Nazanin Saedi, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Many devices are available that can be used for facial skin tightening, “but there are definitely limitations to what we can do noninvasively, and we really need to educate our patients about what we can do so that they have realistic expectations,” said Dr. Saedi, director of laser surgery and cosmetic dermatology at Sidney Kimmel Medical College, Philadelphia.

Treatment with these devices improve skin laxity, and some improve skin texture as well, she said. These devices are not an option for patients who want to have several inches of excess skin removed.

“You have to tell patients that this isn’t a replacement for a face-lift or a mini face-lift,” but patients can expect to see mild and modest improvement, and they’ll continue to see improvement for 3-6 months.

Patient selection is also important. Patients with mild to moderate laxity who do not want to undergo surgery and anesthesia are good candidates, as opposed to those who are older and have thin, sagging skin, Dr. Saedi said, noting that there still is no standard method of defining laxity.

She referred to a recent study illustrating the importance of counseling patients about what to expect. Of the 83 patients in a practice who had undergone microfocused ultrasound treatments and responded to an anonymous survey about the results of treatment, almost 80% reported at least mild improvement (14.5% said the improvement was significant, almost 28% said it was moderate, 37.3% said it was mild, and 20.5% said there was no improvement).

However, although about half (53.1%) reported being satisfied with their results, almost 45% said that the results did not meet their expectations (Lasers Surg Med. 2019;51[6]:495-9).

In an interview at the meeting, Dr. Saedi commented on these results and the importance of counseling.

Listen to the interview by clicking the play button at the end of this story.

During the presentation, Dr. Saedi, who is also codirector of cutaneous surgery in the department of dermatology and cutaneous biology at Sidney Kimmel Medical College, reviewed different technologies used for noninvasive skin tightening, including ablative and fractional laser resurfacing, radiofrequency, and microfocused ultrasound with visualization.

She disclosed serving on the advisory board and/or as a consultant for Aerolase, Alastin, Alma, Cartessa Aesthetics, Cynosure, and Vivo Capital, and that she has equipment from these companies, except for Vivo Capital and Alastin.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

To listen to the interview, click the play button below.
 

emechcatie@mdedge.com

LAHAINA, HAWAII – It’s important to counsel patients about the degree of improvement to expect with noninvasive skin tightening procedures, Nazanin Saedi, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Many devices are available that can be used for facial skin tightening, “but there are definitely limitations to what we can do noninvasively, and we really need to educate our patients about what we can do so that they have realistic expectations,” said Dr. Saedi, director of laser surgery and cosmetic dermatology at Sidney Kimmel Medical College, Philadelphia.

Treatment with these devices improve skin laxity, and some improve skin texture as well, she said. These devices are not an option for patients who want to have several inches of excess skin removed.

“You have to tell patients that this isn’t a replacement for a face-lift or a mini face-lift,” but patients can expect to see mild and modest improvement, and they’ll continue to see improvement for 3-6 months.

Patient selection is also important. Patients with mild to moderate laxity who do not want to undergo surgery and anesthesia are good candidates, as opposed to those who are older and have thin, sagging skin, Dr. Saedi said, noting that there still is no standard method of defining laxity.

She referred to a recent study illustrating the importance of counseling patients about what to expect. Of the 83 patients in a practice who had undergone microfocused ultrasound treatments and responded to an anonymous survey about the results of treatment, almost 80% reported at least mild improvement (14.5% said the improvement was significant, almost 28% said it was moderate, 37.3% said it was mild, and 20.5% said there was no improvement).

However, although about half (53.1%) reported being satisfied with their results, almost 45% said that the results did not meet their expectations (Lasers Surg Med. 2019;51[6]:495-9).

In an interview at the meeting, Dr. Saedi commented on these results and the importance of counseling.

Listen to the interview by clicking the play button at the end of this story.

During the presentation, Dr. Saedi, who is also codirector of cutaneous surgery in the department of dermatology and cutaneous biology at Sidney Kimmel Medical College, reviewed different technologies used for noninvasive skin tightening, including ablative and fractional laser resurfacing, radiofrequency, and microfocused ultrasound with visualization.

She disclosed serving on the advisory board and/or as a consultant for Aerolase, Alastin, Alma, Cartessa Aesthetics, Cynosure, and Vivo Capital, and that she has equipment from these companies, except for Vivo Capital and Alastin.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

To listen to the interview, click the play button below.
 

emechcatie@mdedge.com

LAHAINA, HAWAII – Two recent large, well-conducted, and persuasive studies provide much-needed clarity regarding the neurodevelopmental risks posed by general anesthesia in early childhood, Jessica Sprague, MD, said at the SDEF Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

“These two studies can be cited in conversation with parents and are very reassuring for a single episode of general anesthesia,” observed Dr. Sprague, a dermatologist at Rady Children’s Hospital and the University of California, both in San Diego.

“As a take home, I think we can feel pretty confident that single exposure to short-duration general anesthesia does not have any adverse neurocognitive effects,” she added.

In 2016, the Food and Drug Administration issued a drug safety communication that general anesthesia lasting for more than 3 hours in children aged less than 3 years, or repeated shorter-duration general anesthesia, may affect the development of children’s brains. This edict caused considerable turmoil among both physicians and parents. The warning was based upon animal studies suggesting adverse effects, including abnormal axon formation and other structural changes, impaired learning and memory, and heightened emotional reactivity to threats. Preliminary human cohort studies generated conflicting results, but were tough to interpret because of potential confounding issues, most prominently the distinct possibility that the very reason the child was undergoing general anesthesia might inherently predispose to neurodevelopmental problems, the dermatologist explained.

Enter the GAS trial, a multinational, assessor-blinded study in which 722 generally healthy infants undergoing hernia repair at 28 centers in the United States and six other countries were randomized to general anesthesia for a median of 54 minutes or awake regional anesthesia. Assessment via a detailed neuropsychological test battery and parent questionnaires at age 2 and 5 years showed no between-group differences at all. Of note, the GAS trial was funded by the FDA, the National Institutes of Health, and similar national health care agencies in the other participating countries (Lancet. 2019 Feb 16;393[10172]:664-77).

The other major recent research contribution was a province-wide Ontario study led by investigators at the Hospital for Sick Children in Toronto. This retrospective study included 2,346 sibling pairs aged 4-5 years in which one child in each pair received general anesthesia as a preschooler. All participants underwent testing using the comprehensive Early Development Instrument. Reassuringly, no between-group differences were found in any of the five domains assessed by the testing: language and cognitive development, physical health and well-being, emotional health and maturity, social knowledge and competence, and communication skills and general knowledge (JAMA Pediatr. 2019 Jan 1;173[1]:29-36).

These two studies address a pressing issue, since 10% of children in the United States and other developed countries receive general anesthesia within their first 3 years of life. Common indications in dermatology include excisional surgery, laser therapy for extensive port wine birthmarks, and diagnostic MRIs.

Dr. Sprague advised that, based upon the new data, “you definitely do not want to delay necessary imaging studies or surgeries, but MRIs can often be done without general anesthesia in infants less than 2 months old. If you have an infant who needs an MRI for something like PHACE syndrome [posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities], if you can get them in before 2 months of age sometimes you can avoid the general anesthesia if you wrap them tight enough. But once they get over 2 months ,there’s too much wiggle and it’s pretty impossible.”

Her other suggestions:
 

• Consider delaying nonurgent surgeries and imaging until at least age 6 months and ideally 3 years. “Parents will eventually want surgery to be done for a benign-appearing congenital nevus on the cheek, but it doesn’t necessarily need to be done before 6 months. The same with a residual hemangioma. I would recommend doing it before they go to kindergarten and before they get a sort of sense of what their self looks like, but you have some time between ages 3 and 5 to do that,” Dr. Sprague said.
• Seek out an anesthesiologist who has extensive experience with infants and young children, as is common at a dedicated children’s hospital. “If you live somewhere where the anesthesiologists are primarily seeing adult patients, they’re just not as good,” according to the pediatric dermatologist.
• Definitely consider a topical anesthesia strategy in infants who require multiple procedures, because there remains some unresolved concern about the potential neurodevelopmental impact of multiple bouts of general anesthesia.

Dr. Sprague reported having no financial conflicts regarding her presentation.

The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

LAHAINA, HAWAII – Two recent large, well-conducted, and persuasive studies provide much-needed clarity regarding the neurodevelopmental risks posed by general anesthesia in early childhood, Jessica Sprague, MD, said at the SDEF Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

“These two studies can be cited in conversation with parents and are very reassuring for a single episode of general anesthesia,” observed Dr. Sprague, a dermatologist at Rady Children’s Hospital and the University of California, both in San Diego.

“As a take home, I think we can feel pretty confident that single exposure to short-duration general anesthesia does not have any adverse neurocognitive effects,” she added.

In 2016, the Food and Drug Administration issued a drug safety communication that general anesthesia lasting for more than 3 hours in children aged less than 3 years, or repeated shorter-duration general anesthesia, may affect the development of children’s brains. This edict caused considerable turmoil among both physicians and parents. The warning was based upon animal studies suggesting adverse effects, including abnormal axon formation and other structural changes, impaired learning and memory, and heightened emotional reactivity to threats. Preliminary human cohort studies generated conflicting results, but were tough to interpret because of potential confounding issues, most prominently the distinct possibility that the very reason the child was undergoing general anesthesia might inherently predispose to neurodevelopmental problems, the dermatologist explained.

Enter the GAS trial, a multinational, assessor-blinded study in which 722 generally healthy infants undergoing hernia repair at 28 centers in the United States and six other countries were randomized to general anesthesia for a median of 54 minutes or awake regional anesthesia. Assessment via a detailed neuropsychological test battery and parent questionnaires at age 2 and 5 years showed no between-group differences at all. Of note, the GAS trial was funded by the FDA, the National Institutes of Health, and similar national health care agencies in the other participating countries (Lancet. 2019 Feb 16;393[10172]:664-77).

The other major recent research contribution was a province-wide Ontario study led by investigators at the Hospital for Sick Children in Toronto. This retrospective study included 2,346 sibling pairs aged 4-5 years in which one child in each pair received general anesthesia as a preschooler. All participants underwent testing using the comprehensive Early Development Instrument. Reassuringly, no between-group differences were found in any of the five domains assessed by the testing: language and cognitive development, physical health and well-being, emotional health and maturity, social knowledge and competence, and communication skills and general knowledge (JAMA Pediatr. 2019 Jan 1;173[1]:29-36).

These two studies address a pressing issue, since 10% of children in the United States and other developed countries receive general anesthesia within their first 3 years of life. Common indications in dermatology include excisional surgery, laser therapy for extensive port wine birthmarks, and diagnostic MRIs.

Dr. Sprague advised that, based upon the new data, “you definitely do not want to delay necessary imaging studies or surgeries, but MRIs can often be done without general anesthesia in infants less than 2 months old. If you have an infant who needs an MRI for something like PHACE syndrome [posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities], if you can get them in before 2 months of age sometimes you can avoid the general anesthesia if you wrap them tight enough. But once they get over 2 months ,there’s too much wiggle and it’s pretty impossible.”

Her other suggestions:
 

• Consider delaying nonurgent surgeries and imaging until at least age 6 months and ideally 3 years. “Parents will eventually want surgery to be done for a benign-appearing congenital nevus on the cheek, but it doesn’t necessarily need to be done before 6 months. The same with a residual hemangioma. I would recommend doing it before they go to kindergarten and before they get a sort of sense of what their self looks like, but you have some time between ages 3 and 5 to do that,” Dr. Sprague said.
• Seek out an anesthesiologist who has extensive experience with infants and young children, as is common at a dedicated children’s hospital. “If you live somewhere where the anesthesiologists are primarily seeing adult patients, they’re just not as good,” according to the pediatric dermatologist.
• Definitely consider a topical anesthesia strategy in infants who require multiple procedures, because there remains some unresolved concern about the potential neurodevelopmental impact of multiple bouts of general anesthesia.

Dr. Sprague reported having no financial conflicts regarding her presentation.

The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

LAHAINA, HAWAII – Two recent large, well-conducted, and persuasive studies provide much-needed clarity regarding the neurodevelopmental risks posed by general anesthesia in early childhood, Jessica Sprague, MD, said at the SDEF Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

“These two studies can be cited in conversation with parents and are very reassuring for a single episode of general anesthesia,” observed Dr. Sprague, a dermatologist at Rady Children’s Hospital and the University of California, both in San Diego.

“As a take home, I think we can feel pretty confident that single exposure to short-duration general anesthesia does not have any adverse neurocognitive effects,” she added.

In 2016, the Food and Drug Administration issued a drug safety communication that general anesthesia lasting for more than 3 hours in children aged less than 3 years, or repeated shorter-duration general anesthesia, may affect the development of children’s brains. This edict caused considerable turmoil among both physicians and parents. The warning was based upon animal studies suggesting adverse effects, including abnormal axon formation and other structural changes, impaired learning and memory, and heightened emotional reactivity to threats. Preliminary human cohort studies generated conflicting results, but were tough to interpret because of potential confounding issues, most prominently the distinct possibility that the very reason the child was undergoing general anesthesia might inherently predispose to neurodevelopmental problems, the dermatologist explained.

Enter the GAS trial, a multinational, assessor-blinded study in which 722 generally healthy infants undergoing hernia repair at 28 centers in the United States and six other countries were randomized to general anesthesia for a median of 54 minutes or awake regional anesthesia. Assessment via a detailed neuropsychological test battery and parent questionnaires at age 2 and 5 years showed no between-group differences at all. Of note, the GAS trial was funded by the FDA, the National Institutes of Health, and similar national health care agencies in the other participating countries (Lancet. 2019 Feb 16;393[10172]:664-77).

The other major recent research contribution was a province-wide Ontario study led by investigators at the Hospital for Sick Children in Toronto. This retrospective study included 2,346 sibling pairs aged 4-5 years in which one child in each pair received general anesthesia as a preschooler. All participants underwent testing using the comprehensive Early Development Instrument. Reassuringly, no between-group differences were found in any of the five domains assessed by the testing: language and cognitive development, physical health and well-being, emotional health and maturity, social knowledge and competence, and communication skills and general knowledge (JAMA Pediatr. 2019 Jan 1;173[1]:29-36).

These two studies address a pressing issue, since 10% of children in the United States and other developed countries receive general anesthesia within their first 3 years of life. Common indications in dermatology include excisional surgery, laser therapy for extensive port wine birthmarks, and diagnostic MRIs.

Dr. Sprague advised that, based upon the new data, “you definitely do not want to delay necessary imaging studies or surgeries, but MRIs can often be done without general anesthesia in infants less than 2 months old. If you have an infant who needs an MRI for something like PHACE syndrome [posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities], if you can get them in before 2 months of age sometimes you can avoid the general anesthesia if you wrap them tight enough. But once they get over 2 months ,there’s too much wiggle and it’s pretty impossible.”

Her other suggestions:
 

• Consider delaying nonurgent surgeries and imaging until at least age 6 months and ideally 3 years. “Parents will eventually want surgery to be done for a benign-appearing congenital nevus on the cheek, but it doesn’t necessarily need to be done before 6 months. The same with a residual hemangioma. I would recommend doing it before they go to kindergarten and before they get a sort of sense of what their self looks like, but you have some time between ages 3 and 5 to do that,” Dr. Sprague said.
• Seek out an anesthesiologist who has extensive experience with infants and young children, as is common at a dedicated children’s hospital. “If you live somewhere where the anesthesiologists are primarily seeing adult patients, they’re just not as good,” according to the pediatric dermatologist.
• Definitely consider a topical anesthesia strategy in infants who require multiple procedures, because there remains some unresolved concern about the potential neurodevelopmental impact of multiple bouts of general anesthesia.

Dr. Sprague reported having no financial conflicts regarding her presentation.

The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

LAHAINA, HAWAII – The list of nontraditional uses for botulinum toxin type A includes facial flushing, menopausal hot flashes, and androgenetic alopecia, Mark Rubin, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

There are data to support these uses, and there are data associating botulinum toxin treatment with improvement in depression, which suggest the effect may not be necessarily be related to improvement in appearance, said Dr. Rubin, who is in private practice in Beverly Hills, Calif., and is associate professor of dermatology at the University of California, San Diego.

Facial flushing: Very few people use botulinum toxin for facial flushing, but Dr. Rubin, who is among those who do not, described the data as “impressive.” Several trials, he noted, have found that very small doses can significantly reduce the amount of facial erythema, including an average 45% reduction after 60 days in one trial of 24 women (Acta Med Iran. 2016 Jul;54[7]:454-7).

In another study of 25 patients with facial erythema related to rosacea who were treated with 14-45 units intradermally to the nasal tip, bridge, and alae, there were statistically significant improvements in erythema 1, 2, and 3 months after treatment among the 15 with complete data (Dermatol Surg. 2015 Jan;41 Suppl 1:S9-16).

“If you’re using very small doses and they’re intradermal, there really is minimal risk you’re going to have a problem by inadvertently affecting musculature” in these patients, Dr. Rubin commented.

In another study of 9 patients with rosacea, treatment with incobotulinumtoxinA was associated with a significant reduction in erythema, papules, pustules, and telangiectasias, up to 15 weeks, compared with saline. The treatment patients also experienced less burning and stinging that did those who received saline (J Drugs Dermatol. 2017 Jun 1;16[6]:549-54.)

Menopausal hot flashes: Dr. Rubin described one study of 60 patients with severe hot flashes that compared saline with botulinum toxin, injected in 40 sites (2 units per site), including the neck, hairline, scalp, and chest. At 60 days’ follow-up, those treated with botulinum toxin had a significant reduction in sweating and in the number and severity of hot flashes; these women also had improved mood in terms of depression and irritability (Dermatol Surg. 2011 Nov;37[11]:1579-83).

Androgenetic alopecia: In a 60-week study of 50 men with androgenetic alopecia (Hamilton ratings of II-IV), 150 units of botulinum toxin A was injected into the scalp muscles (temporalis, frontalis, periauricular, and occipital), and repeated 6 months later (Plast Reconstr Surg. 2010 Nov;126[5]:246e-8e). Among the 40 patients who completed the trial, 75% had a response, and from baseline to 48 weeks, there was an 18% increase in mean hair counts in a 2 cm area, and a“profound” 39% reduction in hair loss (as measured by hair counts on the pillow in the morning), Dr. Rubin noted.

“Presumably, this is because if you’re relaxing the scalp muscles you’re getting increased blood flow into the scalp,” including increased oxygenation, which decreases the conversion of testosterone to dihydrotestosterone and increases the conversion of testosterone to estradiol, he said.

In another study, 8 of 10 patients with androgenic alopecia has “good to excellent” results 24 weeks after botulinum toxin injections with 5 units per site at 30 sites. Referring to the increasing popularity of platelet-rich plasma (PRP) injections for male pattern alopecia, Dr. Rubin said that in his opinion “PRP certainly doesn’t do any better” than botulinum toxin for male pattern alopecia and is a much more involved injection, “so this is definitely something worth considering if you have more people coming into your practice thinking about injections for male pattern alopecia.”

Pore size and sebum production: A 2019 review of published studies of botulinum toxin A looking at the effect on sebum and pore size, Dr. Rubin said, found that most studies “suggest it does actually reduce pore size and sebum production” (J Cosmet Dermatol. 2019 Apr;18[2]:451-7).

This can be considered an option for those patients concerned about pore size, who are not satisfied with results of retinoid or laser treatment, he commented. This approach may not have an effect in all patients, so he advised first treating a small trial area, and photographing patients to record their level of improvement. “It’s rarely profound, but it’s additive, it’s one more thing you can do.”

Depression: These data include a study of 30 patients with major depression, half who received one onabotulinumtoxinA injection in the glabellar area as adjunctive treatment of depression. After 6 weeks, those who were treated had an average of 47% reduction in depression scores on the Hamilton Depression Rating Scale, compared with an average 9% reduction among those on placebo (J Psychiatr Res. 2012 May;46[5]:574-81). Two recent studies have had similar results, according to Dr. Rubin.

Results of another study, he said, raise the question of whether patients are less depressed because they are pleased with the cosmetic effects or if there is another explanation (J Am Acad Dermatol. 2016 Jan;74[1]:171-3.e1). The study, which included 59 patients with depression treated in the glabellar areas with botulinum toxin injections, found no association between severity of the furrows and degree of depression or between the degree of furrow correction and degree of relief from depression after treatment. “So the patients who had the most improvement were not necessarily the ones who were the least depressed afterwards,” he said.

These data imply that something else may be occurring that is not necessarily muscle related, he said.

Dr. Rubin said he had no relevant disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

emechcatie@mdedge.com

LAHAINA, HAWAII – The list of nontraditional uses for botulinum toxin type A includes facial flushing, menopausal hot flashes, and androgenetic alopecia, Mark Rubin, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

There are data to support these uses, and there are data associating botulinum toxin treatment with improvement in depression, which suggest the effect may not be necessarily be related to improvement in appearance, said Dr. Rubin, who is in private practice in Beverly Hills, Calif., and is associate professor of dermatology at the University of California, San Diego.

Facial flushing: Very few people use botulinum toxin for facial flushing, but Dr. Rubin, who is among those who do not, described the data as “impressive.” Several trials, he noted, have found that very small doses can significantly reduce the amount of facial erythema, including an average 45% reduction after 60 days in one trial of 24 women (Acta Med Iran. 2016 Jul;54[7]:454-7).

In another study of 25 patients with facial erythema related to rosacea who were treated with 14-45 units intradermally to the nasal tip, bridge, and alae, there were statistically significant improvements in erythema 1, 2, and 3 months after treatment among the 15 with complete data (Dermatol Surg. 2015 Jan;41 Suppl 1:S9-16).

“If you’re using very small doses and they’re intradermal, there really is minimal risk you’re going to have a problem by inadvertently affecting musculature” in these patients, Dr. Rubin commented.

In another study of 9 patients with rosacea, treatment with incobotulinumtoxinA was associated with a significant reduction in erythema, papules, pustules, and telangiectasias, up to 15 weeks, compared with saline. The treatment patients also experienced less burning and stinging that did those who received saline (J Drugs Dermatol. 2017 Jun 1;16[6]:549-54.)

Menopausal hot flashes: Dr. Rubin described one study of 60 patients with severe hot flashes that compared saline with botulinum toxin, injected in 40 sites (2 units per site), including the neck, hairline, scalp, and chest. At 60 days’ follow-up, those treated with botulinum toxin had a significant reduction in sweating and in the number and severity of hot flashes; these women also had improved mood in terms of depression and irritability (Dermatol Surg. 2011 Nov;37[11]:1579-83).

Androgenetic alopecia: In a 60-week study of 50 men with androgenetic alopecia (Hamilton ratings of II-IV), 150 units of botulinum toxin A was injected into the scalp muscles (temporalis, frontalis, periauricular, and occipital), and repeated 6 months later (Plast Reconstr Surg. 2010 Nov;126[5]:246e-8e). Among the 40 patients who completed the trial, 75% had a response, and from baseline to 48 weeks, there was an 18% increase in mean hair counts in a 2 cm area, and a“profound” 39% reduction in hair loss (as measured by hair counts on the pillow in the morning), Dr. Rubin noted.

“Presumably, this is because if you’re relaxing the scalp muscles you’re getting increased blood flow into the scalp,” including increased oxygenation, which decreases the conversion of testosterone to dihydrotestosterone and increases the conversion of testosterone to estradiol, he said.

In another study, 8 of 10 patients with androgenic alopecia has “good to excellent” results 24 weeks after botulinum toxin injections with 5 units per site at 30 sites. Referring to the increasing popularity of platelet-rich plasma (PRP) injections for male pattern alopecia, Dr. Rubin said that in his opinion “PRP certainly doesn’t do any better” than botulinum toxin for male pattern alopecia and is a much more involved injection, “so this is definitely something worth considering if you have more people coming into your practice thinking about injections for male pattern alopecia.”

Pore size and sebum production: A 2019 review of published studies of botulinum toxin A looking at the effect on sebum and pore size, Dr. Rubin said, found that most studies “suggest it does actually reduce pore size and sebum production” (J Cosmet Dermatol. 2019 Apr;18[2]:451-7).

This can be considered an option for those patients concerned about pore size, who are not satisfied with results of retinoid or laser treatment, he commented. This approach may not have an effect in all patients, so he advised first treating a small trial area, and photographing patients to record their level of improvement. “It’s rarely profound, but it’s additive, it’s one more thing you can do.”

Depression: These data include a study of 30 patients with major depression, half who received one onabotulinumtoxinA injection in the glabellar area as adjunctive treatment of depression. After 6 weeks, those who were treated had an average of 47% reduction in depression scores on the Hamilton Depression Rating Scale, compared with an average 9% reduction among those on placebo (J Psychiatr Res. 2012 May;46[5]:574-81). Two recent studies have had similar results, according to Dr. Rubin.

Results of another study, he said, raise the question of whether patients are less depressed because they are pleased with the cosmetic effects or if there is another explanation (J Am Acad Dermatol. 2016 Jan;74[1]:171-3.e1). The study, which included 59 patients with depression treated in the glabellar areas with botulinum toxin injections, found no association between severity of the furrows and degree of depression or between the degree of furrow correction and degree of relief from depression after treatment. “So the patients who had the most improvement were not necessarily the ones who were the least depressed afterwards,” he said.

These data imply that something else may be occurring that is not necessarily muscle related, he said.

Dr. Rubin said he had no relevant disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

emechcatie@mdedge.com

LAHAINA, HAWAII – The list of nontraditional uses for botulinum toxin type A includes facial flushing, menopausal hot flashes, and androgenetic alopecia, Mark Rubin, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

There are data to support these uses, and there are data associating botulinum toxin treatment with improvement in depression, which suggest the effect may not be necessarily be related to improvement in appearance, said Dr. Rubin, who is in private practice in Beverly Hills, Calif., and is associate professor of dermatology at the University of California, San Diego.

Facial flushing: Very few people use botulinum toxin for facial flushing, but Dr. Rubin, who is among those who do not, described the data as “impressive.” Several trials, he noted, have found that very small doses can significantly reduce the amount of facial erythema, including an average 45% reduction after 60 days in one trial of 24 women (Acta Med Iran. 2016 Jul;54[7]:454-7).

In another study of 25 patients with facial erythema related to rosacea who were treated with 14-45 units intradermally to the nasal tip, bridge, and alae, there were statistically significant improvements in erythema 1, 2, and 3 months after treatment among the 15 with complete data (Dermatol Surg. 2015 Jan;41 Suppl 1:S9-16).

“If you’re using very small doses and they’re intradermal, there really is minimal risk you’re going to have a problem by inadvertently affecting musculature” in these patients, Dr. Rubin commented.

In another study of 9 patients with rosacea, treatment with incobotulinumtoxinA was associated with a significant reduction in erythema, papules, pustules, and telangiectasias, up to 15 weeks, compared with saline. The treatment patients also experienced less burning and stinging that did those who received saline (J Drugs Dermatol. 2017 Jun 1;16[6]:549-54.)

Menopausal hot flashes: Dr. Rubin described one study of 60 patients with severe hot flashes that compared saline with botulinum toxin, injected in 40 sites (2 units per site), including the neck, hairline, scalp, and chest. At 60 days’ follow-up, those treated with botulinum toxin had a significant reduction in sweating and in the number and severity of hot flashes; these women also had improved mood in terms of depression and irritability (Dermatol Surg. 2011 Nov;37[11]:1579-83).

Androgenetic alopecia: In a 60-week study of 50 men with androgenetic alopecia (Hamilton ratings of II-IV), 150 units of botulinum toxin A was injected into the scalp muscles (temporalis, frontalis, periauricular, and occipital), and repeated 6 months later (Plast Reconstr Surg. 2010 Nov;126[5]:246e-8e). Among the 40 patients who completed the trial, 75% had a response, and from baseline to 48 weeks, there was an 18% increase in mean hair counts in a 2 cm area, and a“profound” 39% reduction in hair loss (as measured by hair counts on the pillow in the morning), Dr. Rubin noted.

“Presumably, this is because if you’re relaxing the scalp muscles you’re getting increased blood flow into the scalp,” including increased oxygenation, which decreases the conversion of testosterone to dihydrotestosterone and increases the conversion of testosterone to estradiol, he said.

In another study, 8 of 10 patients with androgenic alopecia has “good to excellent” results 24 weeks after botulinum toxin injections with 5 units per site at 30 sites. Referring to the increasing popularity of platelet-rich plasma (PRP) injections for male pattern alopecia, Dr. Rubin said that in his opinion “PRP certainly doesn’t do any better” than botulinum toxin for male pattern alopecia and is a much more involved injection, “so this is definitely something worth considering if you have more people coming into your practice thinking about injections for male pattern alopecia.”

Pore size and sebum production: A 2019 review of published studies of botulinum toxin A looking at the effect on sebum and pore size, Dr. Rubin said, found that most studies “suggest it does actually reduce pore size and sebum production” (J Cosmet Dermatol. 2019 Apr;18[2]:451-7).

This can be considered an option for those patients concerned about pore size, who are not satisfied with results of retinoid or laser treatment, he commented. This approach may not have an effect in all patients, so he advised first treating a small trial area, and photographing patients to record their level of improvement. “It’s rarely profound, but it’s additive, it’s one more thing you can do.”

Depression: These data include a study of 30 patients with major depression, half who received one onabotulinumtoxinA injection in the glabellar area as adjunctive treatment of depression. After 6 weeks, those who were treated had an average of 47% reduction in depression scores on the Hamilton Depression Rating Scale, compared with an average 9% reduction among those on placebo (J Psychiatr Res. 2012 May;46[5]:574-81). Two recent studies have had similar results, according to Dr. Rubin.

Results of another study, he said, raise the question of whether patients are less depressed because they are pleased with the cosmetic effects or if there is another explanation (J Am Acad Dermatol. 2016 Jan;74[1]:171-3.e1). The study, which included 59 patients with depression treated in the glabellar areas with botulinum toxin injections, found no association between severity of the furrows and degree of depression or between the degree of furrow correction and degree of relief from depression after treatment. “So the patients who had the most improvement were not necessarily the ones who were the least depressed afterwards,” he said.

These data imply that something else may be occurring that is not necessarily muscle related, he said.

Dr. Rubin said he had no relevant disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

emechcatie@mdedge.com

LAHAINA, HAWAII – Consider the “mutant selection window” to reduce antibiotic resistance when treating acne, Hilary E. Baldwin, MD, advised at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Dermatologists continue to write a disproportionate number of prescriptions for antibiotics, particularly tetracyclines, noted Dr. Baldwin, medical director of the Acne Treatment and Research Center in New York. In addition to limiting unnecessary use of antimicrobials, strategies for slowing antimicrobial resistance include using anti-inflammatory doses of doxycycline; using more retinoids, isotretinoin, spironolactone, and oral contraceptives; and improving patient compliance with treatment.

Dermatologists can also “pay attention to the bug we are treating and ... make sure the concentration of the drug that we are using is appropriate to the bug we’re trying to kill,” while also targeting resistant organisms. Dr. Baldwin referred to a paper in the infectious disease literature titled: “The mutant selection window and antimicrobial resistance,” which points out that a drug concentration range exists for which mutant strains of bacteria are selected most frequently (J Antimicrob Chemother. 2003 Jul;52[1]:11-7). The dimensions of this range, or “window,” are characteristic of each pathogen-antimicrobial combination. A high enough drug concentration will eliminate both resistant and sensitive strains of the pathogen.

The paper notes that the minimum inhibitory concentration (MIC) is the lowest concentration that will inhibit the visible growth of a microorganism. The mutant prevention concentration (MPC) is the minimum drug concentration needed to prevent the growth of resistant strains, Dr. Baldwin said. The mutant selection window is the concentration range that extends from the MIC up to the MPC, the range “within which resistant mutants are likely to emerge.” If the antimicrobial concentration falls within this window, a mutant strain is likely to develop and “you’re going to add to the problem of antibiotic resistance,” she explained. “So the goal is to treat low or to treat high, but not right in the middle.”

“This is not theoretical,” and has been shown over and over again, with, for example, Streptococcus pneumonia and moxifloxacin, she said (J Antimicrob Chemother. 2003 Oct;52[4]:616-22.).

When the therapeutic window does not extend all the way to the MPC, “toxicity starts to kick in before you can get high enough to kill off the whole group of organisms,” in which case a low-dose strategy would reduce the development of resistant organisms, she noted.

“We’re doing this already,” with topical antifungals, Dr. Baldwin pointed out, asking when the last time anyone heard that a fungus developed resistance to topical antifungal therapy. “Never, because we use our antifungals in such a high dose, that we’re 500 times the MPC.”

Using an anti-inflammatory dose of doxycycline for treating acne or rosacea is a low-dose strategy, and the 40-mg delayed-release dose stays “way below” the antimicrobial threshold, she said, but the 50-mg dose falls “right in the middle of that mutant selection window.”

As more treatments become available, it will be important to determine how to dose topical antibiotics so that they do not fall within the mutant selection window and avoid what happened with clindamycin and erythromycin, “where the topical use of these medications led to the development of resistance such that they no longer work for the treatment” of Cutibacterium acnes.

Dr. Baldwin disclosures included being on the speakers bureau, serving as an advisor, and/or an investigator for companies that include Almirall, BioPharmx, Foamix, Galderma, Ortho Dermatologics, Sun Pharmaceuticals, Johnson & Johnson, and La Roche–Posay.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

emechcatie@mdedge.com

LAHAINA, HAWAII – Consider the “mutant selection window” to reduce antibiotic resistance when treating acne, Hilary E. Baldwin, MD, advised at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Dermatologists continue to write a disproportionate number of prescriptions for antibiotics, particularly tetracyclines, noted Dr. Baldwin, medical director of the Acne Treatment and Research Center in New York. In addition to limiting unnecessary use of antimicrobials, strategies for slowing antimicrobial resistance include using anti-inflammatory doses of doxycycline; using more retinoids, isotretinoin, spironolactone, and oral contraceptives; and improving patient compliance with treatment.

Dermatologists can also “pay attention to the bug we are treating and ... make sure the concentration of the drug that we are using is appropriate to the bug we’re trying to kill,” while also targeting resistant organisms. Dr. Baldwin referred to a paper in the infectious disease literature titled: “The mutant selection window and antimicrobial resistance,” which points out that a drug concentration range exists for which mutant strains of bacteria are selected most frequently (J Antimicrob Chemother. 2003 Jul;52[1]:11-7). The dimensions of this range, or “window,” are characteristic of each pathogen-antimicrobial combination. A high enough drug concentration will eliminate both resistant and sensitive strains of the pathogen.

The paper notes that the minimum inhibitory concentration (MIC) is the lowest concentration that will inhibit the visible growth of a microorganism. The mutant prevention concentration (MPC) is the minimum drug concentration needed to prevent the growth of resistant strains, Dr. Baldwin said. The mutant selection window is the concentration range that extends from the MIC up to the MPC, the range “within which resistant mutants are likely to emerge.” If the antimicrobial concentration falls within this window, a mutant strain is likely to develop and “you’re going to add to the problem of antibiotic resistance,” she explained. “So the goal is to treat low or to treat high, but not right in the middle.”

“This is not theoretical,” and has been shown over and over again, with, for example, Streptococcus pneumonia and moxifloxacin, she said (J Antimicrob Chemother. 2003 Oct;52[4]:616-22.).

When the therapeutic window does not extend all the way to the MPC, “toxicity starts to kick in before you can get high enough to kill off the whole group of organisms,” in which case a low-dose strategy would reduce the development of resistant organisms, she noted.

“We’re doing this already,” with topical antifungals, Dr. Baldwin pointed out, asking when the last time anyone heard that a fungus developed resistance to topical antifungal therapy. “Never, because we use our antifungals in such a high dose, that we’re 500 times the MPC.”

Using an anti-inflammatory dose of doxycycline for treating acne or rosacea is a low-dose strategy, and the 40-mg delayed-release dose stays “way below” the antimicrobial threshold, she said, but the 50-mg dose falls “right in the middle of that mutant selection window.”

As more treatments become available, it will be important to determine how to dose topical antibiotics so that they do not fall within the mutant selection window and avoid what happened with clindamycin and erythromycin, “where the topical use of these medications led to the development of resistance such that they no longer work for the treatment” of Cutibacterium acnes.

Dr. Baldwin disclosures included being on the speakers bureau, serving as an advisor, and/or an investigator for companies that include Almirall, BioPharmx, Foamix, Galderma, Ortho Dermatologics, Sun Pharmaceuticals, Johnson & Johnson, and La Roche–Posay.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

emechcatie@mdedge.com

LAHAINA, HAWAII – Consider the “mutant selection window” to reduce antibiotic resistance when treating acne, Hilary E. Baldwin, MD, advised at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Dermatologists continue to write a disproportionate number of prescriptions for antibiotics, particularly tetracyclines, noted Dr. Baldwin, medical director of the Acne Treatment and Research Center in New York. In addition to limiting unnecessary use of antimicrobials, strategies for slowing antimicrobial resistance include using anti-inflammatory doses of doxycycline; using more retinoids, isotretinoin, spironolactone, and oral contraceptives; and improving patient compliance with treatment.

Dermatologists can also “pay attention to the bug we are treating and ... make sure the concentration of the drug that we are using is appropriate to the bug we’re trying to kill,” while also targeting resistant organisms. Dr. Baldwin referred to a paper in the infectious disease literature titled: “The mutant selection window and antimicrobial resistance,” which points out that a drug concentration range exists for which mutant strains of bacteria are selected most frequently (J Antimicrob Chemother. 2003 Jul;52[1]:11-7). The dimensions of this range, or “window,” are characteristic of each pathogen-antimicrobial combination. A high enough drug concentration will eliminate both resistant and sensitive strains of the pathogen.

The paper notes that the minimum inhibitory concentration (MIC) is the lowest concentration that will inhibit the visible growth of a microorganism. The mutant prevention concentration (MPC) is the minimum drug concentration needed to prevent the growth of resistant strains, Dr. Baldwin said. The mutant selection window is the concentration range that extends from the MIC up to the MPC, the range “within which resistant mutants are likely to emerge.” If the antimicrobial concentration falls within this window, a mutant strain is likely to develop and “you’re going to add to the problem of antibiotic resistance,” she explained. “So the goal is to treat low or to treat high, but not right in the middle.”

“This is not theoretical,” and has been shown over and over again, with, for example, Streptococcus pneumonia and moxifloxacin, she said (J Antimicrob Chemother. 2003 Oct;52[4]:616-22.).

When the therapeutic window does not extend all the way to the MPC, “toxicity starts to kick in before you can get high enough to kill off the whole group of organisms,” in which case a low-dose strategy would reduce the development of resistant organisms, she noted.

“We’re doing this already,” with topical antifungals, Dr. Baldwin pointed out, asking when the last time anyone heard that a fungus developed resistance to topical antifungal therapy. “Never, because we use our antifungals in such a high dose, that we’re 500 times the MPC.”

Using an anti-inflammatory dose of doxycycline for treating acne or rosacea is a low-dose strategy, and the 40-mg delayed-release dose stays “way below” the antimicrobial threshold, she said, but the 50-mg dose falls “right in the middle of that mutant selection window.”

As more treatments become available, it will be important to determine how to dose topical antibiotics so that they do not fall within the mutant selection window and avoid what happened with clindamycin and erythromycin, “where the topical use of these medications led to the development of resistance such that they no longer work for the treatment” of Cutibacterium acnes.

Dr. Baldwin disclosures included being on the speakers bureau, serving as an advisor, and/or an investigator for companies that include Almirall, BioPharmx, Foamix, Galderma, Ortho Dermatologics, Sun Pharmaceuticals, Johnson & Johnson, and La Roche–Posay.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

emechcatie@mdedge.com

LAHAINA, HAWAII – Individuals with vitiligo demonstrated a markedly reduced rate of internal malignancies in a recent first-of-its-kind “big data” study from South Korea, Iltefat Hamzavi, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

Previous studies by Dr. Hamzavi and others have established that vitiligo patients have a reduced risk of melanoma and perhaps nonmelanoma skin cancers as well. But the South Korean national study of 101,078 vitiligo patients matched by age and sex to twice as many vitiligo-free controls was the first large examination of the association between vitiligo and internal malignancies. The findings suggest that immunosurveillance in patients with the disease is not merely a skin-deep phenomenon, noted Dr. Hamzavi, of the MultiCultural Dermatology Center at Henry Ford Hospital in Detroit.

“Vitiligo is probably a systemic disease in which there may be increased immunosurveillance. The point here is that as we suppress the disease, we have to be careful that we’re not going to increase cancer rates,” the dermatologist explained in an interview. “This is big data, and something to be aware of, but don’t act on it yet in clinical practice. I just want people to be aware that all of these autoimmune diseases are there for a reason. There are lower rates of melanoma and internal cancers in patients who have vitiligo, but what that means for our new therapies that are coming up we don’t know yet.”

He predicted that the study will open up an active new research domain, but it will take time to find definitive answers as to whether emerging immunomodulatory therapies for patients with vitiligo might, in some instances, increase their current favorably lower risk of internal malignancies. In the meantime, physicians interested in treating vitiligo off label with, for example, Janus kinase (JAK) inhibitors will want to be particularly cautious in patients with a strong history of skin cancer or internal malignancies.

The retrospective, population-based study utilized data from the Korean National Health Insurance claims database. The investigators found that the incidence rate of internal malignancies was 612.9 per 100,000 person-years in the vitiligo group and 708.9 per 100,000 person-years in controls, for a statistically significant and clinically meaningful 14% relative risk reduction after adjustment for age, sex, and comorbid conditions.

Among the most striking organ-specific findings: the vitiligo group had a 38% relative risk reduction in colorectal cancer, a 25% reduction in the risk of lung cancer, and a 38% decrease in ovarian cancer. In contrast, they had a 20% increase in the risk of thyroid cancer (J Clin Oncol. 2019 Apr 10;37[11]:903-11).

Despite the fact that vitiligo is a common disease that affects 0.5%-1% of the population worldwide, for decades it has been something of a pharmacotherapeutic backwater. That’s changed recently and in dramatic fashion as a result of new understanding of the disease pathogenesis. The JAK inhibitors are now under active investigation for the treatment of vitiligo. Indeed, ruxolitinib cream, a potent JAK-1 and -2 inhibitor, is now in phase 3 investigation following a highly successful phase 2 trial. Interleukin-15 blockade is another promising avenue.

Dr. Hamzavi reported serving as a consultant to AbbVie, Aclaris, Novartis, and Pfizer, and receiving research funding from Estee Lauder, Clinuvel Pharmaceuticals, Incyte, and Pfizer. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

LAHAINA, HAWAII – Individuals with vitiligo demonstrated a markedly reduced rate of internal malignancies in a recent first-of-its-kind “big data” study from South Korea, Iltefat Hamzavi, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

Previous studies by Dr. Hamzavi and others have established that vitiligo patients have a reduced risk of melanoma and perhaps nonmelanoma skin cancers as well. But the South Korean national study of 101,078 vitiligo patients matched by age and sex to twice as many vitiligo-free controls was the first large examination of the association between vitiligo and internal malignancies. The findings suggest that immunosurveillance in patients with the disease is not merely a skin-deep phenomenon, noted Dr. Hamzavi, of the MultiCultural Dermatology Center at Henry Ford Hospital in Detroit.

“Vitiligo is probably a systemic disease in which there may be increased immunosurveillance. The point here is that as we suppress the disease, we have to be careful that we’re not going to increase cancer rates,” the dermatologist explained in an interview. “This is big data, and something to be aware of, but don’t act on it yet in clinical practice. I just want people to be aware that all of these autoimmune diseases are there for a reason. There are lower rates of melanoma and internal cancers in patients who have vitiligo, but what that means for our new therapies that are coming up we don’t know yet.”

He predicted that the study will open up an active new research domain, but it will take time to find definitive answers as to whether emerging immunomodulatory therapies for patients with vitiligo might, in some instances, increase their current favorably lower risk of internal malignancies. In the meantime, physicians interested in treating vitiligo off label with, for example, Janus kinase (JAK) inhibitors will want to be particularly cautious in patients with a strong history of skin cancer or internal malignancies.

The retrospective, population-based study utilized data from the Korean National Health Insurance claims database. The investigators found that the incidence rate of internal malignancies was 612.9 per 100,000 person-years in the vitiligo group and 708.9 per 100,000 person-years in controls, for a statistically significant and clinically meaningful 14% relative risk reduction after adjustment for age, sex, and comorbid conditions.

Among the most striking organ-specific findings: the vitiligo group had a 38% relative risk reduction in colorectal cancer, a 25% reduction in the risk of lung cancer, and a 38% decrease in ovarian cancer. In contrast, they had a 20% increase in the risk of thyroid cancer (J Clin Oncol. 2019 Apr 10;37[11]:903-11).

Despite the fact that vitiligo is a common disease that affects 0.5%-1% of the population worldwide, for decades it has been something of a pharmacotherapeutic backwater. That’s changed recently and in dramatic fashion as a result of new understanding of the disease pathogenesis. The JAK inhibitors are now under active investigation for the treatment of vitiligo. Indeed, ruxolitinib cream, a potent JAK-1 and -2 inhibitor, is now in phase 3 investigation following a highly successful phase 2 trial. Interleukin-15 blockade is another promising avenue.

Dr. Hamzavi reported serving as a consultant to AbbVie, Aclaris, Novartis, and Pfizer, and receiving research funding from Estee Lauder, Clinuvel Pharmaceuticals, Incyte, and Pfizer. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

LAHAINA, HAWAII – Individuals with vitiligo demonstrated a markedly reduced rate of internal malignancies in a recent first-of-its-kind “big data” study from South Korea, Iltefat Hamzavi, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

Previous studies by Dr. Hamzavi and others have established that vitiligo patients have a reduced risk of melanoma and perhaps nonmelanoma skin cancers as well. But the South Korean national study of 101,078 vitiligo patients matched by age and sex to twice as many vitiligo-free controls was the first large examination of the association between vitiligo and internal malignancies. The findings suggest that immunosurveillance in patients with the disease is not merely a skin-deep phenomenon, noted Dr. Hamzavi, of the MultiCultural Dermatology Center at Henry Ford Hospital in Detroit.

“Vitiligo is probably a systemic disease in which there may be increased immunosurveillance. The point here is that as we suppress the disease, we have to be careful that we’re not going to increase cancer rates,” the dermatologist explained in an interview. “This is big data, and something to be aware of, but don’t act on it yet in clinical practice. I just want people to be aware that all of these autoimmune diseases are there for a reason. There are lower rates of melanoma and internal cancers in patients who have vitiligo, but what that means for our new therapies that are coming up we don’t know yet.”

He predicted that the study will open up an active new research domain, but it will take time to find definitive answers as to whether emerging immunomodulatory therapies for patients with vitiligo might, in some instances, increase their current favorably lower risk of internal malignancies. In the meantime, physicians interested in treating vitiligo off label with, for example, Janus kinase (JAK) inhibitors will want to be particularly cautious in patients with a strong history of skin cancer or internal malignancies.

The retrospective, population-based study utilized data from the Korean National Health Insurance claims database. The investigators found that the incidence rate of internal malignancies was 612.9 per 100,000 person-years in the vitiligo group and 708.9 per 100,000 person-years in controls, for a statistically significant and clinically meaningful 14% relative risk reduction after adjustment for age, sex, and comorbid conditions.

Among the most striking organ-specific findings: the vitiligo group had a 38% relative risk reduction in colorectal cancer, a 25% reduction in the risk of lung cancer, and a 38% decrease in ovarian cancer. In contrast, they had a 20% increase in the risk of thyroid cancer (J Clin Oncol. 2019 Apr 10;37[11]:903-11).

Despite the fact that vitiligo is a common disease that affects 0.5%-1% of the population worldwide, for decades it has been something of a pharmacotherapeutic backwater. That’s changed recently and in dramatic fashion as a result of new understanding of the disease pathogenesis. The JAK inhibitors are now under active investigation for the treatment of vitiligo. Indeed, ruxolitinib cream, a potent JAK-1 and -2 inhibitor, is now in phase 3 investigation following a highly successful phase 2 trial. Interleukin-15 blockade is another promising avenue.

Dr. Hamzavi reported serving as a consultant to AbbVie, Aclaris, Novartis, and Pfizer, and receiving research funding from Estee Lauder, Clinuvel Pharmaceuticals, Incyte, and Pfizer. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

LAHAINA, HAWAII – Hyperhidrosis affects nearly 5% of the U.S. population, and in a survey of U.S. teenagers, about 17% reported excessive sweating, Jashin Wu, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

In an interview with MDedge reporter Bruce Jancin, Dr. Wu, founder of the Dermatology Research and Education Foundation, Irvine, Calif., discussed the off-label use of oral agents to treat hyperhidrosis. Dr. Wu said he is a fan of oral glycopyrrolate in particular, which he tends to use even earlier than suggested in the International Hyperhidrosis Society guidelines.

Glycopyrrolate is available in 1 mg and 2 mg tablets; Dr. Wu starts patients at a dose of 1 mg twice a day, escalating by 1 mg per week until the “desired effects occur” or the patient has problems tolerating treatment because of side effects.

Other oral options include oxybutynin and propranolol. Sofpironium bromide, an analog of glycopyrrolate, is in the pipeline, he said.

During the interview, Dr. Wu discussed mydriasis, an adverse effect associated with both topical and systemic anticholinergic treatment. In the two pivotal phase 3 randomized trials of prescription glycopyrronium cloth (Qbrexza) for axillary hyperhidrosis, the incidence of mydriasis was 6.8% in 463 patients on active treatment for 4 weeks. Three-quarters of cases were unilateral. The mydriasis resolved without permanent treatment discontinuation in 27 of the 31 patients (J Am Acad Dermatol. 2019 Jan;80[1]:128-138.e2).

“The most important point is that patients need to be educated that they need to wash their hands very well after they apply it to the affected areas” to prevent accidental medication contact with the eyes, he advised.

Alarm bells can go off when a patient with anticholinergic therapy–induced mydriasis presents to an ED without mentioning their treatment status, Dr. Wu observed.

Dr. Wu had no relevant disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

To listen to the interview, click the play button below.

LAHAINA, HAWAII – Hyperhidrosis affects nearly 5% of the U.S. population, and in a survey of U.S. teenagers, about 17% reported excessive sweating, Jashin Wu, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

In an interview with MDedge reporter Bruce Jancin, Dr. Wu, founder of the Dermatology Research and Education Foundation, Irvine, Calif., discussed the off-label use of oral agents to treat hyperhidrosis. Dr. Wu said he is a fan of oral glycopyrrolate in particular, which he tends to use even earlier than suggested in the International Hyperhidrosis Society guidelines.

Glycopyrrolate is available in 1 mg and 2 mg tablets; Dr. Wu starts patients at a dose of 1 mg twice a day, escalating by 1 mg per week until the “desired effects occur” or the patient has problems tolerating treatment because of side effects.

Other oral options include oxybutynin and propranolol. Sofpironium bromide, an analog of glycopyrrolate, is in the pipeline, he said.

During the interview, Dr. Wu discussed mydriasis, an adverse effect associated with both topical and systemic anticholinergic treatment. In the two pivotal phase 3 randomized trials of prescription glycopyrronium cloth (Qbrexza) for axillary hyperhidrosis, the incidence of mydriasis was 6.8% in 463 patients on active treatment for 4 weeks. Three-quarters of cases were unilateral. The mydriasis resolved without permanent treatment discontinuation in 27 of the 31 patients (J Am Acad Dermatol. 2019 Jan;80[1]:128-138.e2).

“The most important point is that patients need to be educated that they need to wash their hands very well after they apply it to the affected areas” to prevent accidental medication contact with the eyes, he advised.

Alarm bells can go off when a patient with anticholinergic therapy–induced mydriasis presents to an ED without mentioning their treatment status, Dr. Wu observed.

Dr. Wu had no relevant disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

To listen to the interview, click the play button below.

LAHAINA, HAWAII – Hyperhidrosis affects nearly 5% of the U.S. population, and in a survey of U.S. teenagers, about 17% reported excessive sweating, Jashin Wu, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

In an interview with MDedge reporter Bruce Jancin, Dr. Wu, founder of the Dermatology Research and Education Foundation, Irvine, Calif., discussed the off-label use of oral agents to treat hyperhidrosis. Dr. Wu said he is a fan of oral glycopyrrolate in particular, which he tends to use even earlier than suggested in the International Hyperhidrosis Society guidelines.

Glycopyrrolate is available in 1 mg and 2 mg tablets; Dr. Wu starts patients at a dose of 1 mg twice a day, escalating by 1 mg per week until the “desired effects occur” or the patient has problems tolerating treatment because of side effects.

Other oral options include oxybutynin and propranolol. Sofpironium bromide, an analog of glycopyrrolate, is in the pipeline, he said.

During the interview, Dr. Wu discussed mydriasis, an adverse effect associated with both topical and systemic anticholinergic treatment. In the two pivotal phase 3 randomized trials of prescription glycopyrronium cloth (Qbrexza) for axillary hyperhidrosis, the incidence of mydriasis was 6.8% in 463 patients on active treatment for 4 weeks. Three-quarters of cases were unilateral. The mydriasis resolved without permanent treatment discontinuation in 27 of the 31 patients (J Am Acad Dermatol. 2019 Jan;80[1]:128-138.e2).

“The most important point is that patients need to be educated that they need to wash their hands very well after they apply it to the affected areas” to prevent accidental medication contact with the eyes, he advised.

Alarm bells can go off when a patient with anticholinergic therapy–induced mydriasis presents to an ED without mentioning their treatment status, Dr. Wu observed.

Dr. Wu had no relevant disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

To listen to the interview, click the play button below.