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Desmoplastic trichoepithelioma may co-occur with BCC
SYDNEY, AUSTRALIA – Watchful waiting may not be the safest approach for managing patients with desmoplastic trichoepithelioma, according to a speaker at the annual meeting of the Australasian College of Dermatologists, who described five cases of the benign tumor combined with basal cell carcinoma.
Desmoplastic trichoepithelioma (DTE), a rare benign tumor that typically presents as a small, slow-growing, asymptomatic, skin-colored lesion on the face, with a depressed nonulcerated center and often raised edges, is managed with watchful waiting or local excision. While its key histopathologic features are narrow cords or strands of basaloid cells, numerous small keratin-filled cysts, and a surrounding desmoplastic core, DTE can be confused with morpheaform basal cell carcinoma (BCC), Tristan Blake, MD, dermatology registrar at Royal Brisbane and Womens’ Hospital, Brisbane, Australia, said at the meeting.
“At this stage, there’s no way to confidently say, looking at the slides, if those cases were desmoplastic trichoepithelioma arising in basal cell carcinoma or vice versa, or if they were a single tumor with divergent differentiation, or an occlusion of two separate tumors,” he said.
Dr. Blake added that this was the first time, to his knowledge, that such a combination had been reported, and that the finding had the potential to change the way DTE is managed.
“How can you now confidently elect to leave or watch the desmoplastic trichoepithelioma patients you have, knowing that not an insignificant portion might also harbor BCC or develop BCC in the future?” he said. This dilemma is made more acute by the fact that DTEs are typically found in younger patients and on the face, he added.
Two dermatopathologists involved in the retrospective review of cases reported that histochemistry was not particularly useful in differentiating DTE from other tumors, he noted.
Patients in the study were also interviewed about their tumors and reported no symptoms; when asked how long the lesions had been there prior to diagnosis, those who could recall said the lesions had likely been present for decades.
In an interview, Dr. Blake said that the discovery of coexisting DTE and BCC was a surprise, and cast doubt on the practice of watchful waiting.
No conflicts of interest were declared.
SYDNEY, AUSTRALIA – Watchful waiting may not be the safest approach for managing patients with desmoplastic trichoepithelioma, according to a speaker at the annual meeting of the Australasian College of Dermatologists, who described five cases of the benign tumor combined with basal cell carcinoma.
Desmoplastic trichoepithelioma (DTE), a rare benign tumor that typically presents as a small, slow-growing, asymptomatic, skin-colored lesion on the face, with a depressed nonulcerated center and often raised edges, is managed with watchful waiting or local excision. While its key histopathologic features are narrow cords or strands of basaloid cells, numerous small keratin-filled cysts, and a surrounding desmoplastic core, DTE can be confused with morpheaform basal cell carcinoma (BCC), Tristan Blake, MD, dermatology registrar at Royal Brisbane and Womens’ Hospital, Brisbane, Australia, said at the meeting.
“At this stage, there’s no way to confidently say, looking at the slides, if those cases were desmoplastic trichoepithelioma arising in basal cell carcinoma or vice versa, or if they were a single tumor with divergent differentiation, or an occlusion of two separate tumors,” he said.
Dr. Blake added that this was the first time, to his knowledge, that such a combination had been reported, and that the finding had the potential to change the way DTE is managed.
“How can you now confidently elect to leave or watch the desmoplastic trichoepithelioma patients you have, knowing that not an insignificant portion might also harbor BCC or develop BCC in the future?” he said. This dilemma is made more acute by the fact that DTEs are typically found in younger patients and on the face, he added.
Two dermatopathologists involved in the retrospective review of cases reported that histochemistry was not particularly useful in differentiating DTE from other tumors, he noted.
Patients in the study were also interviewed about their tumors and reported no symptoms; when asked how long the lesions had been there prior to diagnosis, those who could recall said the lesions had likely been present for decades.
In an interview, Dr. Blake said that the discovery of coexisting DTE and BCC was a surprise, and cast doubt on the practice of watchful waiting.
No conflicts of interest were declared.
SYDNEY, AUSTRALIA – Watchful waiting may not be the safest approach for managing patients with desmoplastic trichoepithelioma, according to a speaker at the annual meeting of the Australasian College of Dermatologists, who described five cases of the benign tumor combined with basal cell carcinoma.
Desmoplastic trichoepithelioma (DTE), a rare benign tumor that typically presents as a small, slow-growing, asymptomatic, skin-colored lesion on the face, with a depressed nonulcerated center and often raised edges, is managed with watchful waiting or local excision. While its key histopathologic features are narrow cords or strands of basaloid cells, numerous small keratin-filled cysts, and a surrounding desmoplastic core, DTE can be confused with morpheaform basal cell carcinoma (BCC), Tristan Blake, MD, dermatology registrar at Royal Brisbane and Womens’ Hospital, Brisbane, Australia, said at the meeting.
“At this stage, there’s no way to confidently say, looking at the slides, if those cases were desmoplastic trichoepithelioma arising in basal cell carcinoma or vice versa, or if they were a single tumor with divergent differentiation, or an occlusion of two separate tumors,” he said.
Dr. Blake added that this was the first time, to his knowledge, that such a combination had been reported, and that the finding had the potential to change the way DTE is managed.
“How can you now confidently elect to leave or watch the desmoplastic trichoepithelioma patients you have, knowing that not an insignificant portion might also harbor BCC or develop BCC in the future?” he said. This dilemma is made more acute by the fact that DTEs are typically found in younger patients and on the face, he added.
Two dermatopathologists involved in the retrospective review of cases reported that histochemistry was not particularly useful in differentiating DTE from other tumors, he noted.
Patients in the study were also interviewed about their tumors and reported no symptoms; when asked how long the lesions had been there prior to diagnosis, those who could recall said the lesions had likely been present for decades.
In an interview, Dr. Blake said that the discovery of coexisting DTE and BCC was a surprise, and cast doubt on the practice of watchful waiting.
No conflicts of interest were declared.
AT ACDASM 2017
Key clinical point: Watchful waiting may no longer be the obvious choice for desmoplastic trichoepithelioma, with evidence that the benign tumor may co-occur with basal cell carcinoma.
Major finding: Researchers reported five cases in which both DTE and BCC were identified in the same pathology specimen.
Data source: A retrospective review of 27 patients with DTE, which included reexamination of specimens.
Disclosures: No conflicts of interest were declared.
Mupirocin plus chlorhexidine halved Mohs surgical-site infections
SYDNEY – All patients undergoing Mohs surgery should be treated with intranasal mupirocin and a chlorhexidine body wash for 5 days before surgery, without any requirement for a nasal swab positive for Staphylococcus aureus, according to Dr. Harvey Smith.
He presented data from a randomized, controlled trial investigating the prevention of surgical-site infection in 1,002 patients undergoing Mohs surgery who had a negative nasal swab result for S. aureus. Patients were randomized to intranasal mupirocin ointment twice daily and chlorhexidine body wash daily for the 5 days before surgery, or no intervention, said Dr. Smith, a dermatologist in group practice in Perth, Australia.
The results add to earlier studies by the same group. The first study – Staph 1 – showed that swab-positive nasal carriage of S. aureus was a greater risk factor for surgical-site infections in Mohs surgery than the Wright criteria, and that decolonization with intranasal mupirocin and chlorhexidine body wash for a few days before surgery reduced the risk of infection in these patients from 12% to 4%.
The second previous study – Staph 2 – showed that using mupirocin and chlorhexidine before surgery was actually superior to the recommended treatment of stat oral cephalexin in reducing the risk of surgical-site infection.
“So, our third paper has been wondering what to do about the silent majority: These are the two-thirds of patients on whom we operate who have a negative swab for S. aureus,” Dr. Harvey said.
A negative nasal swab was not significant, he said, because skin microbiome studies had already demonstrated that humans carry S. aureus in several places, particularly the feet and buttocks.
“What we’re basically saying is we don’t think you need to swab people, because they’ve got it somewhere,” Dr. Harvey said in an interview. “We don’t think risk stratification is useful anymore, because we’ve shown it’s a benefit to everybody.”
The strategy of treating all patients with mupirocin and chlorhexidine, regardless of nasal carriage, rather than using the broad-spectrum cephalexin, fits with the World Health Organization’s global action plan on antimicrobial resistance, Dr. Harvey explained.
While there had been cases of mupirocin resistance in the past, Dr. Harvey said these had been seen in places where the drug had previously been available over the counter, such as New Zealand. However, there was no evidence of resistance developing for such a short course of use as employed in this setting, he said.
An audience member asked about whether there were any side effects from the mupirocin or chlorhexidine. Dr. Harvey said the main potential adverse event from the treatment was the risk of chlorhexidine toxicity to the cornea. However, he said that patients were told not to get the wash near their eyes.
Apart from one or two patients with eczema who could not tolerate the full 5 days of the chlorhexidine, Dr. Harvey said they had now treated more than 4,000 patients with no other side effects observed.
The study was supported by the Australasian College of Dermatologists. No conflicts of interest were declared.
SYDNEY – All patients undergoing Mohs surgery should be treated with intranasal mupirocin and a chlorhexidine body wash for 5 days before surgery, without any requirement for a nasal swab positive for Staphylococcus aureus, according to Dr. Harvey Smith.
He presented data from a randomized, controlled trial investigating the prevention of surgical-site infection in 1,002 patients undergoing Mohs surgery who had a negative nasal swab result for S. aureus. Patients were randomized to intranasal mupirocin ointment twice daily and chlorhexidine body wash daily for the 5 days before surgery, or no intervention, said Dr. Smith, a dermatologist in group practice in Perth, Australia.
The results add to earlier studies by the same group. The first study – Staph 1 – showed that swab-positive nasal carriage of S. aureus was a greater risk factor for surgical-site infections in Mohs surgery than the Wright criteria, and that decolonization with intranasal mupirocin and chlorhexidine body wash for a few days before surgery reduced the risk of infection in these patients from 12% to 4%.
The second previous study – Staph 2 – showed that using mupirocin and chlorhexidine before surgery was actually superior to the recommended treatment of stat oral cephalexin in reducing the risk of surgical-site infection.
“So, our third paper has been wondering what to do about the silent majority: These are the two-thirds of patients on whom we operate who have a negative swab for S. aureus,” Dr. Harvey said.
A negative nasal swab was not significant, he said, because skin microbiome studies had already demonstrated that humans carry S. aureus in several places, particularly the feet and buttocks.
“What we’re basically saying is we don’t think you need to swab people, because they’ve got it somewhere,” Dr. Harvey said in an interview. “We don’t think risk stratification is useful anymore, because we’ve shown it’s a benefit to everybody.”
The strategy of treating all patients with mupirocin and chlorhexidine, regardless of nasal carriage, rather than using the broad-spectrum cephalexin, fits with the World Health Organization’s global action plan on antimicrobial resistance, Dr. Harvey explained.
While there had been cases of mupirocin resistance in the past, Dr. Harvey said these had been seen in places where the drug had previously been available over the counter, such as New Zealand. However, there was no evidence of resistance developing for such a short course of use as employed in this setting, he said.
An audience member asked about whether there were any side effects from the mupirocin or chlorhexidine. Dr. Harvey said the main potential adverse event from the treatment was the risk of chlorhexidine toxicity to the cornea. However, he said that patients were told not to get the wash near their eyes.
Apart from one or two patients with eczema who could not tolerate the full 5 days of the chlorhexidine, Dr. Harvey said they had now treated more than 4,000 patients with no other side effects observed.
The study was supported by the Australasian College of Dermatologists. No conflicts of interest were declared.
SYDNEY – All patients undergoing Mohs surgery should be treated with intranasal mupirocin and a chlorhexidine body wash for 5 days before surgery, without any requirement for a nasal swab positive for Staphylococcus aureus, according to Dr. Harvey Smith.
He presented data from a randomized, controlled trial investigating the prevention of surgical-site infection in 1,002 patients undergoing Mohs surgery who had a negative nasal swab result for S. aureus. Patients were randomized to intranasal mupirocin ointment twice daily and chlorhexidine body wash daily for the 5 days before surgery, or no intervention, said Dr. Smith, a dermatologist in group practice in Perth, Australia.
The results add to earlier studies by the same group. The first study – Staph 1 – showed that swab-positive nasal carriage of S. aureus was a greater risk factor for surgical-site infections in Mohs surgery than the Wright criteria, and that decolonization with intranasal mupirocin and chlorhexidine body wash for a few days before surgery reduced the risk of infection in these patients from 12% to 4%.
The second previous study – Staph 2 – showed that using mupirocin and chlorhexidine before surgery was actually superior to the recommended treatment of stat oral cephalexin in reducing the risk of surgical-site infection.
“So, our third paper has been wondering what to do about the silent majority: These are the two-thirds of patients on whom we operate who have a negative swab for S. aureus,” Dr. Harvey said.
A negative nasal swab was not significant, he said, because skin microbiome studies had already demonstrated that humans carry S. aureus in several places, particularly the feet and buttocks.
“What we’re basically saying is we don’t think you need to swab people, because they’ve got it somewhere,” Dr. Harvey said in an interview. “We don’t think risk stratification is useful anymore, because we’ve shown it’s a benefit to everybody.”
The strategy of treating all patients with mupirocin and chlorhexidine, regardless of nasal carriage, rather than using the broad-spectrum cephalexin, fits with the World Health Organization’s global action plan on antimicrobial resistance, Dr. Harvey explained.
While there had been cases of mupirocin resistance in the past, Dr. Harvey said these had been seen in places where the drug had previously been available over the counter, such as New Zealand. However, there was no evidence of resistance developing for such a short course of use as employed in this setting, he said.
An audience member asked about whether there were any side effects from the mupirocin or chlorhexidine. Dr. Harvey said the main potential adverse event from the treatment was the risk of chlorhexidine toxicity to the cornea. However, he said that patients were told not to get the wash near their eyes.
Apart from one or two patients with eczema who could not tolerate the full 5 days of the chlorhexidine, Dr. Harvey said they had now treated more than 4,000 patients with no other side effects observed.
The study was supported by the Australasian College of Dermatologists. No conflicts of interest were declared.
Key clinical point: Treat all patients undergoing Mohs surgery with intranasal mupirocin and a chlorhexidine body wash for 5 days before surgery, without the need for a nasal swab for Staphylococcus aureus.
Major finding: Treating patients undergoing Mohs surgery with intranasal mupirocin and a chlorhexidine body wash for 5 days before surgery halved the risk of surgical-site infections, even if the patients did not have a positive nasal swab for S. aureus.
Data source: A randomized, controlled trial in 1,002 patients with a negative nasal swab for S. aureus undergoing Mohs surgery.
Disclosures: The study was partly supported by the Australasian College of Dermatologists. No conflicts of interest were declared.
Physical treatment plus antifungal best for chromoblastomycosis, review finds
SYDNEY – Chromoblastomycosis is best managed with a combination of surgery or cryotherapy, with an antifungal, based on a systematic review of 37 studies.
The results of these studies, none of which was randomized or controlled, highlighted challenges in the management of chromoblastomycosis, such as low cure rates and high relapse rates, particularly with chronic and extensive disease. “This is due to the indolent nature of the disease, which leads to a delayed diagnosis, so then the patient develops lymphedema and fibrosis, and the drug isn’t able to penetrate the sites of the lesion,” said Antonia Laino, MD, of the dermatology research center, University of Queensland (Australia).
Noncompliance was also found to be an issue because of side effects and the cost of long-term treatment.
Surgical and pharmacologic options were among the treatments used. Based on the results, Dr. Laino said surgery was recommended as the best treatment for small lesions, and could achieve cure rates of 100% for very small lesions. Cryotherapy was also used to treat chromoblastomycosis lesions, with variable success rates that were dependent on the size of the lesion and the frequency of freezing cycles. However, she suggested that larger lesions should be treated in serial sections, and warned of the risk of retractile scars with treatment over joints.
The most commonly reported drug therapies for chromoblastomycosis were itraconazole and terbinafine. With itraconazole, cure rates ranged from 15% to 80% over an average of 8.5 months of treatment. Pulsed itraconazole therapy, involving 1 week on and 3 weeks off treatment, achieved cure rates of 67%-100% across the studies. With terbinafine treatment, cure rates ranged from 40% to 75% over an average of 9 months of treatment.
In an interview, Dr. Laino said randomized controlled trials were needed to establish best practices for the treatment of chromoblastomycosis.
“I would also say that an antifungal plus a physical method [surgery or cryotherapy] is the way to go,” she said in the interview. As for pharmacotherapy, currently, “there’s the most support for use of itraconazole,” she said, but other antifungals that are being developed will also probably become good options, as studies of those become available. Refractory cases and very severe disease could be treated with a combination of itraconazole and terbinafine.
Chromoblastomycosis is a subcutaneous mycotic infection that is endemic worldwide, but is more common in tropical regions. It usually develops after injury to the skin, which allows entry of any one of several fungal pathogens including Fonsecaea pedrosoi, Phialophora verrucosa, and Cladophialophora carrionii. “Chromoblastomycosis can present with many different lesions, but the early lesions usually resemble a dermatophyte infection or begin as a papule,” Dr. Laino said. “Over time, the lesions will progress into the nodular, tumorous verrucous, cicatricial, and plaque types, and in advanced cases … you’ll see a lot of different lesions in one patient.”
No conflicts of interest were declared.
SYDNEY – Chromoblastomycosis is best managed with a combination of surgery or cryotherapy, with an antifungal, based on a systematic review of 37 studies.
The results of these studies, none of which was randomized or controlled, highlighted challenges in the management of chromoblastomycosis, such as low cure rates and high relapse rates, particularly with chronic and extensive disease. “This is due to the indolent nature of the disease, which leads to a delayed diagnosis, so then the patient develops lymphedema and fibrosis, and the drug isn’t able to penetrate the sites of the lesion,” said Antonia Laino, MD, of the dermatology research center, University of Queensland (Australia).
Noncompliance was also found to be an issue because of side effects and the cost of long-term treatment.
Surgical and pharmacologic options were among the treatments used. Based on the results, Dr. Laino said surgery was recommended as the best treatment for small lesions, and could achieve cure rates of 100% for very small lesions. Cryotherapy was also used to treat chromoblastomycosis lesions, with variable success rates that were dependent on the size of the lesion and the frequency of freezing cycles. However, she suggested that larger lesions should be treated in serial sections, and warned of the risk of retractile scars with treatment over joints.
The most commonly reported drug therapies for chromoblastomycosis were itraconazole and terbinafine. With itraconazole, cure rates ranged from 15% to 80% over an average of 8.5 months of treatment. Pulsed itraconazole therapy, involving 1 week on and 3 weeks off treatment, achieved cure rates of 67%-100% across the studies. With terbinafine treatment, cure rates ranged from 40% to 75% over an average of 9 months of treatment.
In an interview, Dr. Laino said randomized controlled trials were needed to establish best practices for the treatment of chromoblastomycosis.
“I would also say that an antifungal plus a physical method [surgery or cryotherapy] is the way to go,” she said in the interview. As for pharmacotherapy, currently, “there’s the most support for use of itraconazole,” she said, but other antifungals that are being developed will also probably become good options, as studies of those become available. Refractory cases and very severe disease could be treated with a combination of itraconazole and terbinafine.
Chromoblastomycosis is a subcutaneous mycotic infection that is endemic worldwide, but is more common in tropical regions. It usually develops after injury to the skin, which allows entry of any one of several fungal pathogens including Fonsecaea pedrosoi, Phialophora verrucosa, and Cladophialophora carrionii. “Chromoblastomycosis can present with many different lesions, but the early lesions usually resemble a dermatophyte infection or begin as a papule,” Dr. Laino said. “Over time, the lesions will progress into the nodular, tumorous verrucous, cicatricial, and plaque types, and in advanced cases … you’ll see a lot of different lesions in one patient.”
No conflicts of interest were declared.
SYDNEY – Chromoblastomycosis is best managed with a combination of surgery or cryotherapy, with an antifungal, based on a systematic review of 37 studies.
The results of these studies, none of which was randomized or controlled, highlighted challenges in the management of chromoblastomycosis, such as low cure rates and high relapse rates, particularly with chronic and extensive disease. “This is due to the indolent nature of the disease, which leads to a delayed diagnosis, so then the patient develops lymphedema and fibrosis, and the drug isn’t able to penetrate the sites of the lesion,” said Antonia Laino, MD, of the dermatology research center, University of Queensland (Australia).
Noncompliance was also found to be an issue because of side effects and the cost of long-term treatment.
Surgical and pharmacologic options were among the treatments used. Based on the results, Dr. Laino said surgery was recommended as the best treatment for small lesions, and could achieve cure rates of 100% for very small lesions. Cryotherapy was also used to treat chromoblastomycosis lesions, with variable success rates that were dependent on the size of the lesion and the frequency of freezing cycles. However, she suggested that larger lesions should be treated in serial sections, and warned of the risk of retractile scars with treatment over joints.
The most commonly reported drug therapies for chromoblastomycosis were itraconazole and terbinafine. With itraconazole, cure rates ranged from 15% to 80% over an average of 8.5 months of treatment. Pulsed itraconazole therapy, involving 1 week on and 3 weeks off treatment, achieved cure rates of 67%-100% across the studies. With terbinafine treatment, cure rates ranged from 40% to 75% over an average of 9 months of treatment.
In an interview, Dr. Laino said randomized controlled trials were needed to establish best practices for the treatment of chromoblastomycosis.
“I would also say that an antifungal plus a physical method [surgery or cryotherapy] is the way to go,” she said in the interview. As for pharmacotherapy, currently, “there’s the most support for use of itraconazole,” she said, but other antifungals that are being developed will also probably become good options, as studies of those become available. Refractory cases and very severe disease could be treated with a combination of itraconazole and terbinafine.
Chromoblastomycosis is a subcutaneous mycotic infection that is endemic worldwide, but is more common in tropical regions. It usually develops after injury to the skin, which allows entry of any one of several fungal pathogens including Fonsecaea pedrosoi, Phialophora verrucosa, and Cladophialophora carrionii. “Chromoblastomycosis can present with many different lesions, but the early lesions usually resemble a dermatophyte infection or begin as a papule,” Dr. Laino said. “Over time, the lesions will progress into the nodular, tumorous verrucous, cicatricial, and plaque types, and in advanced cases … you’ll see a lot of different lesions in one patient.”
No conflicts of interest were declared.
AT ACDASM 2017
Key clinical point:
Major finding: Surgery in combination with an antifungal was the most effective management approach for chromoblastomycosis.
Data source: A systematic review of 37 studies of patients with chromoblastomycosis.
Disclosures: No conflicts of interest were declared.
Treatment challenges for lichen planopilaris
SYDNEY – Responses to treatments for lichen planopilaris varied widely, and decreased with second- and third-line therapies, in a retrospective study, Karolina Kerkemeyer, MD, said at the annual meeting of the Australasian College of Dermatologists.
An analysis of computerized medical records for 32 patients who had been treated for lichen planopilaris at a tertiary referral hair center in Australia was conducted from 2012 to 2016 by Dr. Kerkemeyer of the University of Notre Dame Australia, Werribee, and Jack Green, MD, of the Skin and Cancer Foundation and St. Vincent’s Hospital in Melbourne. The study excluded patients with a dual diagnosis, or those followed for less than 12 months.
The most common treatment was topical steroids, used to treat 31 patients, followed by tetracyclines – minocycline or doxycycline – used to treat 21 patients, and hydroxychloroquine, used to treat 18 patients. Some patients were also treated with steroid-sparing immunosuppressants, including methotrexate, mycophenolate, and cyclosporine. Fourteen patients were also treated with intralesional steroids, and seven were treated with topical tacrolimus.
The researchers used a graded four-point scale to assess patients’ response to treatment, which corresponded to remission, partial improvement, no change, and worsening of disease, based on patients’ clinical signs, symptoms, and extent of alopecia.
Only a small proportion – about 15% – of patients achieved remission, which was seen with topical steroids, hydroxychloroquine, and doxycycline. About one-third of patients treated with doxycycline actually showed a worsening of symptoms.
The greatest proportion (75%) of patients with partial remission was among those treated with systemic acitretin, although the numbers were low (three of four patients who received this therapy).
In addition, one of the seven patients treated with minocycline achieved partial remission during this therapy, one showed a worsening of the condition, and the remaining five were unchanged. Among those treated with an immunosuppressant, the 3 patients treated with mycophenolate had no change in the condition; 4 of the 10 patients treated with methotrexate achieved partial remission, 4 were unchanged, and 2 experienced a worsening of the condition. One of the three patients treated with cyclosporine achieved partial remission while the other two remained unchanged. With topical tacrolimus, two patients achieved partial remission, two showed a worsening of the condition, and the remaining three were unchanged.
The response rates to treatment significantly decreased with subsequent therapies: 18 of the 32 patients responded to first-line treatments, compared with 7 of 19 who received second-line treatment and only 1 of 9 patients who received third-line treatment. “Many patients were not responsive to therapy, highlighting the difficulty of treating this scarring alopecia,” Dr. Kerkemeyer said.
In an interview, she said that topical or intralesional steroids seemed to be the best first-line option because they are associated with fewer side effects than other options. “They were easier to start off in patients first,” and for those who do not respond, switching to another treatment, such as topical tacrolimus, if they wanted a topical option, or an oral treatment, such as an immunosuppressant like methotrexate, she noted.
No conflicts of interest were declared.
SYDNEY – Responses to treatments for lichen planopilaris varied widely, and decreased with second- and third-line therapies, in a retrospective study, Karolina Kerkemeyer, MD, said at the annual meeting of the Australasian College of Dermatologists.
An analysis of computerized medical records for 32 patients who had been treated for lichen planopilaris at a tertiary referral hair center in Australia was conducted from 2012 to 2016 by Dr. Kerkemeyer of the University of Notre Dame Australia, Werribee, and Jack Green, MD, of the Skin and Cancer Foundation and St. Vincent’s Hospital in Melbourne. The study excluded patients with a dual diagnosis, or those followed for less than 12 months.
The most common treatment was topical steroids, used to treat 31 patients, followed by tetracyclines – minocycline or doxycycline – used to treat 21 patients, and hydroxychloroquine, used to treat 18 patients. Some patients were also treated with steroid-sparing immunosuppressants, including methotrexate, mycophenolate, and cyclosporine. Fourteen patients were also treated with intralesional steroids, and seven were treated with topical tacrolimus.
The researchers used a graded four-point scale to assess patients’ response to treatment, which corresponded to remission, partial improvement, no change, and worsening of disease, based on patients’ clinical signs, symptoms, and extent of alopecia.
Only a small proportion – about 15% – of patients achieved remission, which was seen with topical steroids, hydroxychloroquine, and doxycycline. About one-third of patients treated with doxycycline actually showed a worsening of symptoms.
The greatest proportion (75%) of patients with partial remission was among those treated with systemic acitretin, although the numbers were low (three of four patients who received this therapy).
In addition, one of the seven patients treated with minocycline achieved partial remission during this therapy, one showed a worsening of the condition, and the remaining five were unchanged. Among those treated with an immunosuppressant, the 3 patients treated with mycophenolate had no change in the condition; 4 of the 10 patients treated with methotrexate achieved partial remission, 4 were unchanged, and 2 experienced a worsening of the condition. One of the three patients treated with cyclosporine achieved partial remission while the other two remained unchanged. With topical tacrolimus, two patients achieved partial remission, two showed a worsening of the condition, and the remaining three were unchanged.
The response rates to treatment significantly decreased with subsequent therapies: 18 of the 32 patients responded to first-line treatments, compared with 7 of 19 who received second-line treatment and only 1 of 9 patients who received third-line treatment. “Many patients were not responsive to therapy, highlighting the difficulty of treating this scarring alopecia,” Dr. Kerkemeyer said.
In an interview, she said that topical or intralesional steroids seemed to be the best first-line option because they are associated with fewer side effects than other options. “They were easier to start off in patients first,” and for those who do not respond, switching to another treatment, such as topical tacrolimus, if they wanted a topical option, or an oral treatment, such as an immunosuppressant like methotrexate, she noted.
No conflicts of interest were declared.
SYDNEY – Responses to treatments for lichen planopilaris varied widely, and decreased with second- and third-line therapies, in a retrospective study, Karolina Kerkemeyer, MD, said at the annual meeting of the Australasian College of Dermatologists.
An analysis of computerized medical records for 32 patients who had been treated for lichen planopilaris at a tertiary referral hair center in Australia was conducted from 2012 to 2016 by Dr. Kerkemeyer of the University of Notre Dame Australia, Werribee, and Jack Green, MD, of the Skin and Cancer Foundation and St. Vincent’s Hospital in Melbourne. The study excluded patients with a dual diagnosis, or those followed for less than 12 months.
The most common treatment was topical steroids, used to treat 31 patients, followed by tetracyclines – minocycline or doxycycline – used to treat 21 patients, and hydroxychloroquine, used to treat 18 patients. Some patients were also treated with steroid-sparing immunosuppressants, including methotrexate, mycophenolate, and cyclosporine. Fourteen patients were also treated with intralesional steroids, and seven were treated with topical tacrolimus.
The researchers used a graded four-point scale to assess patients’ response to treatment, which corresponded to remission, partial improvement, no change, and worsening of disease, based on patients’ clinical signs, symptoms, and extent of alopecia.
Only a small proportion – about 15% – of patients achieved remission, which was seen with topical steroids, hydroxychloroquine, and doxycycline. About one-third of patients treated with doxycycline actually showed a worsening of symptoms.
The greatest proportion (75%) of patients with partial remission was among those treated with systemic acitretin, although the numbers were low (three of four patients who received this therapy).
In addition, one of the seven patients treated with minocycline achieved partial remission during this therapy, one showed a worsening of the condition, and the remaining five were unchanged. Among those treated with an immunosuppressant, the 3 patients treated with mycophenolate had no change in the condition; 4 of the 10 patients treated with methotrexate achieved partial remission, 4 were unchanged, and 2 experienced a worsening of the condition. One of the three patients treated with cyclosporine achieved partial remission while the other two remained unchanged. With topical tacrolimus, two patients achieved partial remission, two showed a worsening of the condition, and the remaining three were unchanged.
The response rates to treatment significantly decreased with subsequent therapies: 18 of the 32 patients responded to first-line treatments, compared with 7 of 19 who received second-line treatment and only 1 of 9 patients who received third-line treatment. “Many patients were not responsive to therapy, highlighting the difficulty of treating this scarring alopecia,” Dr. Kerkemeyer said.
In an interview, she said that topical or intralesional steroids seemed to be the best first-line option because they are associated with fewer side effects than other options. “They were easier to start off in patients first,” and for those who do not respond, switching to another treatment, such as topical tacrolimus, if they wanted a topical option, or an oral treatment, such as an immunosuppressant like methotrexate, she noted.
No conflicts of interest were declared.
Key clinical point: Lichen planopilaris is a scarring alopecia that is particularly difficult to treat, and a significant number of patients may have refractory disease.
Major finding:
Data source: A retrospective analysis of 32 patients with lichen planopilaris.
Disclosures: No conflicts of interest were declared.
Skin cancer risk similar for liver and kidney transplant recipients
SYDNEY – The risk of developing nonmelanoma skin cancer among liver transplant recipients is similar to that among kidney transplant recipients, but the former tend to have more skin cancer risk factors at baseline, according to a longitudinal cohort study reported at the annual meeting of the Australasian College of Dermatologists.
Liver transplant recipients have been thought to be at a lower risk of developing nonmelanoma skin cancers than are other solid organ transplant recipients, said Ludi Ge, MD, of the department of dermatology at the University of Sydney and Royal Prince Alfred Hospital, Sydney. However, data from a longitudinal cohort study of 230 kidney or liver transplant patients suggest the risk of nonmelanoma skin cancer is similar – if not greater – among liver transplant recipients, compared with kidney transplant recipients.
Over a 5-year period, 47% of liver transplant recipients developed at least one nonmelanoma skin cancer, compared with 33% of renal transplant recipients, representing a 78% greater risk among liver transplant recipients. However, Dr. Ge said the confidence intervals were wide, and the difference lost statistical significance in the multivariate analysis.
The researchers also noted that the liver transplant recipients in the study tended to be older at baseline, with a history of more sun exposure and more previous skin cancers, and were more likely to have a high risk skin type that sunburns easily.
In an interview, Dr. Ge said the findings had implications for the screening and follow-up of liver transplant recipients.
“Previously, we always thought that liver transplant recipients were at lower risk, and, possibly, they’re not screened as much so not followed up as much,” she said. “I think they really should be thought ... as high risk as renal transplant patients and the heart and lung transplant patients.”
The study showed that, while the renal transplant patients developed fewer skin cancers, they developed 1.9 lesions per year on average, compared with liver transplant patients, who developed 1.4 lesions per year.
The majority of skin cancers in both groups were squamous cell carcinomas and basal cell carcinomas, with a small number of keratoacanthomas. There was a similar ratio of squamous cell carcinomas to basal cell carcinomas between the two groups of transplant recipients – 1.7:1 in renal transplant recipients and 1.6:1 in liver recipients – which differed from the previously reported ratios of about 3:1, Dr. Ge said at the meeting.
She noted that this may have been because not every squamous cell carcinoma in situ was biopsied because of the sheer number of tumors, so many were treated empirically and, therefore, not entered into the clinic database.
Dr. Ge also pointed out that the evidence for the 3:1 ratio was around 10 years old.
“I think there’s been quite a change in the immunosuppressants that are used by transplant physicians, so, more and more, we’re seeing the use of sirolimus and everolimus, which are antiangiogenic,” she said.
Dr. Ge also strongly recommended that dermatology clinics specifically manage organ transplant recipients and commented that this could revolutionize the management of these patients, who tend to get lost to follow-up in standard dermatology clinics. “They’re very difficult to look after, they develop innumerable skin cancers that can result in death, and you need to intervene quite early,” she said in the interview.
No conflicts of interest were declared.
SYDNEY – The risk of developing nonmelanoma skin cancer among liver transplant recipients is similar to that among kidney transplant recipients, but the former tend to have more skin cancer risk factors at baseline, according to a longitudinal cohort study reported at the annual meeting of the Australasian College of Dermatologists.
Liver transplant recipients have been thought to be at a lower risk of developing nonmelanoma skin cancers than are other solid organ transplant recipients, said Ludi Ge, MD, of the department of dermatology at the University of Sydney and Royal Prince Alfred Hospital, Sydney. However, data from a longitudinal cohort study of 230 kidney or liver transplant patients suggest the risk of nonmelanoma skin cancer is similar – if not greater – among liver transplant recipients, compared with kidney transplant recipients.
Over a 5-year period, 47% of liver transplant recipients developed at least one nonmelanoma skin cancer, compared with 33% of renal transplant recipients, representing a 78% greater risk among liver transplant recipients. However, Dr. Ge said the confidence intervals were wide, and the difference lost statistical significance in the multivariate analysis.
The researchers also noted that the liver transplant recipients in the study tended to be older at baseline, with a history of more sun exposure and more previous skin cancers, and were more likely to have a high risk skin type that sunburns easily.
In an interview, Dr. Ge said the findings had implications for the screening and follow-up of liver transplant recipients.
“Previously, we always thought that liver transplant recipients were at lower risk, and, possibly, they’re not screened as much so not followed up as much,” she said. “I think they really should be thought ... as high risk as renal transplant patients and the heart and lung transplant patients.”
The study showed that, while the renal transplant patients developed fewer skin cancers, they developed 1.9 lesions per year on average, compared with liver transplant patients, who developed 1.4 lesions per year.
The majority of skin cancers in both groups were squamous cell carcinomas and basal cell carcinomas, with a small number of keratoacanthomas. There was a similar ratio of squamous cell carcinomas to basal cell carcinomas between the two groups of transplant recipients – 1.7:1 in renal transplant recipients and 1.6:1 in liver recipients – which differed from the previously reported ratios of about 3:1, Dr. Ge said at the meeting.
She noted that this may have been because not every squamous cell carcinoma in situ was biopsied because of the sheer number of tumors, so many were treated empirically and, therefore, not entered into the clinic database.
Dr. Ge also pointed out that the evidence for the 3:1 ratio was around 10 years old.
“I think there’s been quite a change in the immunosuppressants that are used by transplant physicians, so, more and more, we’re seeing the use of sirolimus and everolimus, which are antiangiogenic,” she said.
Dr. Ge also strongly recommended that dermatology clinics specifically manage organ transplant recipients and commented that this could revolutionize the management of these patients, who tend to get lost to follow-up in standard dermatology clinics. “They’re very difficult to look after, they develop innumerable skin cancers that can result in death, and you need to intervene quite early,” she said in the interview.
No conflicts of interest were declared.
SYDNEY – The risk of developing nonmelanoma skin cancer among liver transplant recipients is similar to that among kidney transplant recipients, but the former tend to have more skin cancer risk factors at baseline, according to a longitudinal cohort study reported at the annual meeting of the Australasian College of Dermatologists.
Liver transplant recipients have been thought to be at a lower risk of developing nonmelanoma skin cancers than are other solid organ transplant recipients, said Ludi Ge, MD, of the department of dermatology at the University of Sydney and Royal Prince Alfred Hospital, Sydney. However, data from a longitudinal cohort study of 230 kidney or liver transplant patients suggest the risk of nonmelanoma skin cancer is similar – if not greater – among liver transplant recipients, compared with kidney transplant recipients.
Over a 5-year period, 47% of liver transplant recipients developed at least one nonmelanoma skin cancer, compared with 33% of renal transplant recipients, representing a 78% greater risk among liver transplant recipients. However, Dr. Ge said the confidence intervals were wide, and the difference lost statistical significance in the multivariate analysis.
The researchers also noted that the liver transplant recipients in the study tended to be older at baseline, with a history of more sun exposure and more previous skin cancers, and were more likely to have a high risk skin type that sunburns easily.
In an interview, Dr. Ge said the findings had implications for the screening and follow-up of liver transplant recipients.
“Previously, we always thought that liver transplant recipients were at lower risk, and, possibly, they’re not screened as much so not followed up as much,” she said. “I think they really should be thought ... as high risk as renal transplant patients and the heart and lung transplant patients.”
The study showed that, while the renal transplant patients developed fewer skin cancers, they developed 1.9 lesions per year on average, compared with liver transplant patients, who developed 1.4 lesions per year.
The majority of skin cancers in both groups were squamous cell carcinomas and basal cell carcinomas, with a small number of keratoacanthomas. There was a similar ratio of squamous cell carcinomas to basal cell carcinomas between the two groups of transplant recipients – 1.7:1 in renal transplant recipients and 1.6:1 in liver recipients – which differed from the previously reported ratios of about 3:1, Dr. Ge said at the meeting.
She noted that this may have been because not every squamous cell carcinoma in situ was biopsied because of the sheer number of tumors, so many were treated empirically and, therefore, not entered into the clinic database.
Dr. Ge also pointed out that the evidence for the 3:1 ratio was around 10 years old.
“I think there’s been quite a change in the immunosuppressants that are used by transplant physicians, so, more and more, we’re seeing the use of sirolimus and everolimus, which are antiangiogenic,” she said.
Dr. Ge also strongly recommended that dermatology clinics specifically manage organ transplant recipients and commented that this could revolutionize the management of these patients, who tend to get lost to follow-up in standard dermatology clinics. “They’re very difficult to look after, they develop innumerable skin cancers that can result in death, and you need to intervene quite early,” she said in the interview.
No conflicts of interest were declared.
AT ACDASM 2017
Key clinical point: Liver transplant recipients should be screened and followed for the development of nonmelanoma skin cancers as closely as are kidney transplant recipients.
Major finding: Over 5 years, 47% of liver transplant recipients developed at least one nonmelanoma skin cancer, compared with 33% of renal transplant recipients, a difference that was not statistically significant after a multivariate analysis was done.
Data source: A longitudinal cohort study of 230 kidney or liver transplant recipients attending a dermatology clinic affiliated with an organ transplant unit.
Disclosures: No conflicts of interest were disclosed.
Topical tretinoin resolves inflammatory symptoms in rosacea, in small study
SYDNEY, AUSTRALIA – Treatment with topical tretinoin resulted in complete resolution of rosacea symptoms in a significant number of patients, in a small retrospective study presented at the annual meeting of the Australasian College of Dermatologists.
“As an intermediary step between topical antibiotics and oral isotretinoin, we propose that topical tretinoin may be effective in the management and reduction of rosacea symptoms,” Emily Forward, MD, of the University of Sydney, said at the meeting. There has been recent discussion regarding the use of low-dose isotretinoin in the treatment of rosacea, but safety with long-term use is an issue, she noted.
More than 80% of patients had complete or excellent resolution of papules and pustules, with only one patient showing no benefit. Of the patients with erythema as the primary feature of their rosacea, 42% achieved complete resolution, 33% achieved excellent resolution, 17% achieved a good response, and 8% showed no benefit, Dr. Forward reported.
Among patients with telangiectasia, 40% achieved complete resolution, while 37% of those with flushing achieved complete resolution.
Topical tretinoin should be considered among the treatment options for rosacea “as it is effective, well tolerated, and has synergistic benefits in the prevention of photoaging,” Dr. Forward said. The ideal patient candidate would be someone with inflammatory features such as papules, pustules, or erythema, she added.
No patients experienced worsening of their symptoms with treatment, although one patient stopped treatment because of adverse effects. Dr. Forward also stressed that tretinoin is a known teratogen, so it should not be used during pregnancy or breastfeeding, or in patients trying to conceive.
In an interview, Dr. Forward said that she and her associates were surprised at the degree of improvement with topical tretinoin, particularly for erythema symptoms. However, she said it was important to educate patients about how to use topical tretinoin. “You use a pea-sized amount, at night, and in the beginning we advise them to use it every second or third day, and if they tolerate it they can increase the amount,” she said.
No conflicts of interest were declared.
SYDNEY, AUSTRALIA – Treatment with topical tretinoin resulted in complete resolution of rosacea symptoms in a significant number of patients, in a small retrospective study presented at the annual meeting of the Australasian College of Dermatologists.
“As an intermediary step between topical antibiotics and oral isotretinoin, we propose that topical tretinoin may be effective in the management and reduction of rosacea symptoms,” Emily Forward, MD, of the University of Sydney, said at the meeting. There has been recent discussion regarding the use of low-dose isotretinoin in the treatment of rosacea, but safety with long-term use is an issue, she noted.
More than 80% of patients had complete or excellent resolution of papules and pustules, with only one patient showing no benefit. Of the patients with erythema as the primary feature of their rosacea, 42% achieved complete resolution, 33% achieved excellent resolution, 17% achieved a good response, and 8% showed no benefit, Dr. Forward reported.
Among patients with telangiectasia, 40% achieved complete resolution, while 37% of those with flushing achieved complete resolution.
Topical tretinoin should be considered among the treatment options for rosacea “as it is effective, well tolerated, and has synergistic benefits in the prevention of photoaging,” Dr. Forward said. The ideal patient candidate would be someone with inflammatory features such as papules, pustules, or erythema, she added.
No patients experienced worsening of their symptoms with treatment, although one patient stopped treatment because of adverse effects. Dr. Forward also stressed that tretinoin is a known teratogen, so it should not be used during pregnancy or breastfeeding, or in patients trying to conceive.
In an interview, Dr. Forward said that she and her associates were surprised at the degree of improvement with topical tretinoin, particularly for erythema symptoms. However, she said it was important to educate patients about how to use topical tretinoin. “You use a pea-sized amount, at night, and in the beginning we advise them to use it every second or third day, and if they tolerate it they can increase the amount,” she said.
No conflicts of interest were declared.
SYDNEY, AUSTRALIA – Treatment with topical tretinoin resulted in complete resolution of rosacea symptoms in a significant number of patients, in a small retrospective study presented at the annual meeting of the Australasian College of Dermatologists.
“As an intermediary step between topical antibiotics and oral isotretinoin, we propose that topical tretinoin may be effective in the management and reduction of rosacea symptoms,” Emily Forward, MD, of the University of Sydney, said at the meeting. There has been recent discussion regarding the use of low-dose isotretinoin in the treatment of rosacea, but safety with long-term use is an issue, she noted.
More than 80% of patients had complete or excellent resolution of papules and pustules, with only one patient showing no benefit. Of the patients with erythema as the primary feature of their rosacea, 42% achieved complete resolution, 33% achieved excellent resolution, 17% achieved a good response, and 8% showed no benefit, Dr. Forward reported.
Among patients with telangiectasia, 40% achieved complete resolution, while 37% of those with flushing achieved complete resolution.
Topical tretinoin should be considered among the treatment options for rosacea “as it is effective, well tolerated, and has synergistic benefits in the prevention of photoaging,” Dr. Forward said. The ideal patient candidate would be someone with inflammatory features such as papules, pustules, or erythema, she added.
No patients experienced worsening of their symptoms with treatment, although one patient stopped treatment because of adverse effects. Dr. Forward also stressed that tretinoin is a known teratogen, so it should not be used during pregnancy or breastfeeding, or in patients trying to conceive.
In an interview, Dr. Forward said that she and her associates were surprised at the degree of improvement with topical tretinoin, particularly for erythema symptoms. However, she said it was important to educate patients about how to use topical tretinoin. “You use a pea-sized amount, at night, and in the beginning we advise them to use it every second or third day, and if they tolerate it they can increase the amount,” she said.
No conflicts of interest were declared.
AT ACDASM 2017
Key clinical point: Topical tretinoin may be useful in treating erythema and the inflammatory symptoms of rosacea.
Major finding: More than 80% of patients with rosacea had complete or excellent resolution of papules and pustules with topical tretinoin 0.05%.
Data source: A retrospective study of 25 patients with mild to severe rosacea.
Disclosures: No conflicts of interest were declared.
Survey: Botulinum toxin achieves durable improvements in hyperhidrosis
SYDNEY, AUSTRALIA – Botulinum toxin therapy achieved substantial and durable improvements in symptoms in the majority of patients with axillary hyperhidrosis, in a retrospective study presented at the annual meeting of the Australasian College of Dermatologists.
Sydney dermatologist Robert Rosen, MMed, and his associates analyzed survey data from 200 patients with primary axillary hyperhidrosis who had been treated with 100 units of botulinum toxin at a hyperhidrosis referral center between 2006 and 2016. Patients were aged 12 years or older, and had had axillary hyperhidrosis for 6 months or longer that had not responded to treatment with 20% topical aluminum chloride.
Of these patients, 96% reported at least moderate satisfaction with the results of their treatment with botulinum toxin, with a mean satisfaction rating of 3.41 on a four-point scale that ranged from 1 (slight improvement) to 4 (complete abolition of signs and symptoms).
Durability of effect increased with successive treatments, according to 42% of the patients. There was no change in durability among 44% of the survey respondents, and 14% reported a shortened durability with successive treatments.
More than 80% of patients reported life-changing or substantial improvements in their quality of life after treatment with botulinum toxin, 14% reported some improvement, and 3% reported no improvement.
Only 6.5% of patients reported compensatory sweating elsewhere on the body, a rate similar to that of 5% reported in other studies, Dr. Rosen pointed out. This was in contrast to the 85%-90% rate of compensatory hyperhidrosis after surgical sympathectomy reported in other studies.
“That’s a big procedure and if you have compensatory hyperhidrosis elsewhere, you wouldn’t be terribly satisfied,” he said.
Dr. Rosen and his associates also looked at prognostic factors that might predict response to botulinum toxin. “People who did better with durability were those people who had sweating elsewhere, so they had more than one site of primary hyperhidrosis,” or they had failed other treatments, he said at the meeting.
In an interview, Dr. Rosen said that any treatment with a success rate greater than 90% was extraordinary. “It’s something that we as dermatologists can do where we have a lot of patient gratitude and satisfaction,” he noted. “Before we had this therapy, our other therapies were not great and people were quite desperate and had surgery, and the problem with surgery … is that they got compensatory hyperhidrosis elsewhere.”
Dr. Rosen, of Southern Suburbs Dermatology in Sydney, disclosed serving as a consultant for Allergan and Galderma unrelated to this research. No other conflicts of interest were declared.
SYDNEY, AUSTRALIA – Botulinum toxin therapy achieved substantial and durable improvements in symptoms in the majority of patients with axillary hyperhidrosis, in a retrospective study presented at the annual meeting of the Australasian College of Dermatologists.
Sydney dermatologist Robert Rosen, MMed, and his associates analyzed survey data from 200 patients with primary axillary hyperhidrosis who had been treated with 100 units of botulinum toxin at a hyperhidrosis referral center between 2006 and 2016. Patients were aged 12 years or older, and had had axillary hyperhidrosis for 6 months or longer that had not responded to treatment with 20% topical aluminum chloride.
Of these patients, 96% reported at least moderate satisfaction with the results of their treatment with botulinum toxin, with a mean satisfaction rating of 3.41 on a four-point scale that ranged from 1 (slight improvement) to 4 (complete abolition of signs and symptoms).
Durability of effect increased with successive treatments, according to 42% of the patients. There was no change in durability among 44% of the survey respondents, and 14% reported a shortened durability with successive treatments.
More than 80% of patients reported life-changing or substantial improvements in their quality of life after treatment with botulinum toxin, 14% reported some improvement, and 3% reported no improvement.
Only 6.5% of patients reported compensatory sweating elsewhere on the body, a rate similar to that of 5% reported in other studies, Dr. Rosen pointed out. This was in contrast to the 85%-90% rate of compensatory hyperhidrosis after surgical sympathectomy reported in other studies.
“That’s a big procedure and if you have compensatory hyperhidrosis elsewhere, you wouldn’t be terribly satisfied,” he said.
Dr. Rosen and his associates also looked at prognostic factors that might predict response to botulinum toxin. “People who did better with durability were those people who had sweating elsewhere, so they had more than one site of primary hyperhidrosis,” or they had failed other treatments, he said at the meeting.
In an interview, Dr. Rosen said that any treatment with a success rate greater than 90% was extraordinary. “It’s something that we as dermatologists can do where we have a lot of patient gratitude and satisfaction,” he noted. “Before we had this therapy, our other therapies were not great and people were quite desperate and had surgery, and the problem with surgery … is that they got compensatory hyperhidrosis elsewhere.”
Dr. Rosen, of Southern Suburbs Dermatology in Sydney, disclosed serving as a consultant for Allergan and Galderma unrelated to this research. No other conflicts of interest were declared.
SYDNEY, AUSTRALIA – Botulinum toxin therapy achieved substantial and durable improvements in symptoms in the majority of patients with axillary hyperhidrosis, in a retrospective study presented at the annual meeting of the Australasian College of Dermatologists.
Sydney dermatologist Robert Rosen, MMed, and his associates analyzed survey data from 200 patients with primary axillary hyperhidrosis who had been treated with 100 units of botulinum toxin at a hyperhidrosis referral center between 2006 and 2016. Patients were aged 12 years or older, and had had axillary hyperhidrosis for 6 months or longer that had not responded to treatment with 20% topical aluminum chloride.
Of these patients, 96% reported at least moderate satisfaction with the results of their treatment with botulinum toxin, with a mean satisfaction rating of 3.41 on a four-point scale that ranged from 1 (slight improvement) to 4 (complete abolition of signs and symptoms).
Durability of effect increased with successive treatments, according to 42% of the patients. There was no change in durability among 44% of the survey respondents, and 14% reported a shortened durability with successive treatments.
More than 80% of patients reported life-changing or substantial improvements in their quality of life after treatment with botulinum toxin, 14% reported some improvement, and 3% reported no improvement.
Only 6.5% of patients reported compensatory sweating elsewhere on the body, a rate similar to that of 5% reported in other studies, Dr. Rosen pointed out. This was in contrast to the 85%-90% rate of compensatory hyperhidrosis after surgical sympathectomy reported in other studies.
“That’s a big procedure and if you have compensatory hyperhidrosis elsewhere, you wouldn’t be terribly satisfied,” he said.
Dr. Rosen and his associates also looked at prognostic factors that might predict response to botulinum toxin. “People who did better with durability were those people who had sweating elsewhere, so they had more than one site of primary hyperhidrosis,” or they had failed other treatments, he said at the meeting.
In an interview, Dr. Rosen said that any treatment with a success rate greater than 90% was extraordinary. “It’s something that we as dermatologists can do where we have a lot of patient gratitude and satisfaction,” he noted. “Before we had this therapy, our other therapies were not great and people were quite desperate and had surgery, and the problem with surgery … is that they got compensatory hyperhidrosis elsewhere.”
Dr. Rosen, of Southern Suburbs Dermatology in Sydney, disclosed serving as a consultant for Allergan and Galderma unrelated to this research. No other conflicts of interest were declared.
AT ACDASM 2017
Key clinical point: Botulinum toxin therapy achieves substantial and durable improvements in axillary hyperhidrosis symptoms in a majority of patients with hyperhidrosis.
Major finding: Almost all patients (96%) reported moderate improvement or better with botulinum toxin treatment of primary axillary hyperhidrosis.
Data source: A retrospective review of 200 patients with primary axillary hyperhidrosis, treated over a decade.
Disclosures: Dr. Rosen declared consultancies with Allergan and Galderma unrelated to this research. No other conflicts of interest were declared.
Consider strongyloidiasis before giving oral steroids
SYDNEY – Think twice before prescribing oral steroids for patients who have urticarial dermatitis, diarrhea, and cough, especially if they have lived in or recently traveled to tropical areas, Ian McCrossin, MD, said at the annual meeting of the Australasian College of Dermatologists.
Strongyloides stercoralis, or threadworm, infection can flare dramatically when patients take oral steroids. “You get thousands of worms, and they punch their way through the bowel wall and take the bowel organisms with them; that’s when you get septicaemia,” Dr. McCrossin, a dermatologist from Liverpool Hospital, Sydney, said in an interview.
Dr. McCrossin cited an Australian study that found a strongyloides infection was present in 11.6% of 309 Vietnam veterans living in South Australia.
Risk factors for Strongyloides hyperinfection include compromised immunity, human T-cell lymphotropic virus type 1, alcohol use disorder, malnutrition, and oral steroid use. Mortality rates from the resulting sepsis are as high as 87%, Dr. McCrossin said.
IgG ELISA is a reliable test for established strongyloidiasis, but is less effective for recent infection, hyperinfection, and in patients who are immunosuppressed. Eosinophilia has a poor predictive value. Light microscopy of stool samples may require evaluation of multiple stool samples unless the patient had hyperinfection.
Treatment generally consists of ivermectin, 200 mcg/kg orally for 1-2 days. Follow-up stool exams should be performed 2-4 weeks after treatment to confirm clearance of infection. In those patients with hyperinfections, ivermectin 200 mcg/kg orally is given daily until stool and/or sputum exams are negative for 2 weeks.
Dr. McCrossin declared no conflicts of interest.
SYDNEY – Think twice before prescribing oral steroids for patients who have urticarial dermatitis, diarrhea, and cough, especially if they have lived in or recently traveled to tropical areas, Ian McCrossin, MD, said at the annual meeting of the Australasian College of Dermatologists.
Strongyloides stercoralis, or threadworm, infection can flare dramatically when patients take oral steroids. “You get thousands of worms, and they punch their way through the bowel wall and take the bowel organisms with them; that’s when you get septicaemia,” Dr. McCrossin, a dermatologist from Liverpool Hospital, Sydney, said in an interview.
Dr. McCrossin cited an Australian study that found a strongyloides infection was present in 11.6% of 309 Vietnam veterans living in South Australia.
Risk factors for Strongyloides hyperinfection include compromised immunity, human T-cell lymphotropic virus type 1, alcohol use disorder, malnutrition, and oral steroid use. Mortality rates from the resulting sepsis are as high as 87%, Dr. McCrossin said.
IgG ELISA is a reliable test for established strongyloidiasis, but is less effective for recent infection, hyperinfection, and in patients who are immunosuppressed. Eosinophilia has a poor predictive value. Light microscopy of stool samples may require evaluation of multiple stool samples unless the patient had hyperinfection.
Treatment generally consists of ivermectin, 200 mcg/kg orally for 1-2 days. Follow-up stool exams should be performed 2-4 weeks after treatment to confirm clearance of infection. In those patients with hyperinfections, ivermectin 200 mcg/kg orally is given daily until stool and/or sputum exams are negative for 2 weeks.
Dr. McCrossin declared no conflicts of interest.
SYDNEY – Think twice before prescribing oral steroids for patients who have urticarial dermatitis, diarrhea, and cough, especially if they have lived in or recently traveled to tropical areas, Ian McCrossin, MD, said at the annual meeting of the Australasian College of Dermatologists.
Strongyloides stercoralis, or threadworm, infection can flare dramatically when patients take oral steroids. “You get thousands of worms, and they punch their way through the bowel wall and take the bowel organisms with them; that’s when you get septicaemia,” Dr. McCrossin, a dermatologist from Liverpool Hospital, Sydney, said in an interview.
Dr. McCrossin cited an Australian study that found a strongyloides infection was present in 11.6% of 309 Vietnam veterans living in South Australia.
Risk factors for Strongyloides hyperinfection include compromised immunity, human T-cell lymphotropic virus type 1, alcohol use disorder, malnutrition, and oral steroid use. Mortality rates from the resulting sepsis are as high as 87%, Dr. McCrossin said.
IgG ELISA is a reliable test for established strongyloidiasis, but is less effective for recent infection, hyperinfection, and in patients who are immunosuppressed. Eosinophilia has a poor predictive value. Light microscopy of stool samples may require evaluation of multiple stool samples unless the patient had hyperinfection.
Treatment generally consists of ivermectin, 200 mcg/kg orally for 1-2 days. Follow-up stool exams should be performed 2-4 weeks after treatment to confirm clearance of infection. In those patients with hyperinfections, ivermectin 200 mcg/kg orally is given daily until stool and/or sputum exams are negative for 2 weeks.
Dr. McCrossin declared no conflicts of interest.
EXPERT ANALYSIS AT ACDASM 2017