Join Nick Brownstone, MD, and Jennifer Bares, MD, as they interview our attendees from the Welcome Reception!

Transport back to the 80s with our dance party!

Generalized pustular psoriasis (GPP) is a chronic, rare, and potentially life-threatening disease characterized by recurrent flares of widespread skin edema, erythema, and pustulation. Intravenous spesolimab, an anti-interleukin-36 receptor monoclonal antibody, is approved for GPP flare treatment; however, maintenance treatments are needed to prevent flares. This poster presents efficacy data from a study of subcutaneous spesolimab in preventing GPP flares. After 48 weeks of treatment, high-dose spesolimab, 600-mg loading dose followed by 300 mg every 4 weeks, led to sustained remission in 63.3% of patients compared to 29.0% of patients on placebo. Sustained pustular clearance was achieved by more patients in the high-dose spesolimab arm compared to placebo over 48 weeks (63.6% vs 25.8%). Spesolimab was found to be effective for the long-term management of GPP skin symptoms. 

Generalized pustular psoriasis (GPP) is a rare, chronic, neutrophilic skin disease characterized by recurring flares of widespread erythema, edema, coalescing pustules, and possible systemic symptoms that can be life-threatening; however, there is limited data on the mortality burden of GPP. This poster presents data from a claims database comparing all-cause mortality among patients with GPP with matched plaque psoriasis patients and the general population. At one year of follow-up, patients with GPP had a significantly higher mortality risk than the general population (HR 4.93, 95% CI 2.24-10.88) and patients with psoriasis only (HR 2.31, 95% CI 1.32-4.04). At maximum follow-up, the mortality risk for patients with GPP was almost 4 times higher than the general population and 1.5 times higher than the psoriasis population, reinforcing the need for awareness of the mortality burden of GPP. 

In this session, Gary Goldenberg, MD, took the audience on a whirlwind tour through the latest in treatment updates for common dermatologic conditions. Starting off with acne and rosacea, Dr Goldenberg reviewed efficacy data for a new fixed-dose combination product currently in clinical trials: clindamycin 1.2% + benzoyl peroxide 3.1% + adapalene 0.15% gel (IDP-126). In a Phase 2 study, IDP-126 gel showed superior efficacy in reducing inflammatory and noninflammatory lesions than other fixed-dose combination products (CLIN/BPO, BPO/ADAP, CLIN/ADAP). Dr Goldenberg also reviewed data for clascoterone 1% cream, a novel 1726 nm laser recently approved for mild, moderate, and severe acne and a photopneumatic acne therapy system.

Moving on to atopic dermatitis, Dr Goldenberg discussed the impressive efficacy of both upadacitinib and abrocitinib before introducing tapinarof cream 1%, which is currently under investigation for use in atopic dermatitis. Transitioning to new nonsteroidal topical treatments of psoriasis, tapinarof cream 1% daily led to 64% of patients achieving PASI-75 responses at any time point in a pooled Phase 3 trial analysis. Apremilast appears to be safe and efficacious for pediatric patients with moderate-to-severe plaque psoriasis, with 45.4% achieving PASI-75 at Week 16 compared to 16.1% of those on placebo. Dr Goldenberg concluded the discussion on psoriasis with an overview of recently released data for several biologic medications, including secukinumab, ixekizumab, and risankizumab.

Transitioning to medications currently under investigation, roflumilast foam 0.3% was shown to be effective for seborrheic dermatitis in Phase 2 trials. Monotherapy with nemolizumab, an IL-31R inhibitor, led to statistically significant improvements in itch scores compared to placebo in patients with prurigo nodularis in Phase 3 trials, and secukinumab was statistically superior to placebo in reducing abscesses and inflammatory nodules in hidradenitis suppurativa compared to placebo in Phase 3 trials. Dr Goldenberg concluded this action-packed session with an update on useful technology for dermatologists, including a pigmented lesion assay and electrical impedance spectroscopy machine to assist in melanoma diagnosis, as well as gene expression profiling tests to assist with risk stratification for patients with melanoma and cutaneous squamous cell carcinoma. With all of these new medications and technologies, it is certainly a great time to be a dermatologist!

Janus kinase (JAK) inhibitors are one of the hottest topics in dermatology today. In this session, Raj Chovatiya, MD, PhD, MSCI, reviewed the science behind JAK inhibitor therapy and the latest updates for JAK inhibitors on the market and in development. The Janus kinase family has 4 members: JAK1, JAK2, JAK3, and TYK2. These intracellular molecules play a central role in cell signaling for many different pathways. JAK1 and JAK3 play a role in immunity and metabolism, while TYK2 plays a role in immunity only. JAK2 has the widest range of influence, playing a role in immunity, metabolism, and hematopoiesis.

Currently, there are multiple JAK inhibitors on the market for a wide range of indications. While each JAK inhibitor has distinct chemistry and is generally considered selective for certain JAK molecules, there is overlap and cross-talk between all JAK molecules, leading to class-wide side effects such as infection, cytopenia, and hyperlipidemia. All JAK inhibitors have received a black box warning from the FDA for increased risk of serious infection, malignancy, mortality, thrombosis, and major adverse cardiovascular events, except deucravacitinib which is an oral selective TYK2 inhibitor. Dr Chovatiya discussed these boxed warnings and recent evidence showing no relationship between upadacitinib, a JAK1 inhibitor approved for atopic dermatitis, and increased risks of major adverse cardiovascular events or thrombosis in the atopic dermatitis population.

To conclude, Dr Chovatiya provided updates on the newer JAK inhibitors on the market. Ruxolitinib 1.5% cream, which is approved for atopic dermatitis and vitiligo, was found to decrease itch within 15 minutes of application in a Phase 2 open-label study. Upadacitinib is currently in Phase 3 clinical trials for hidradenitis suppurativa, with 38% of patients on upadacitinib 30 mg daily achieving HiSCR50 at Week 12 regardless of Hurley stage or prior TNF-a inhibitor use. Ritlecitinib, a JAK3/TEC inhibitor, and baricitinib, a JAK1/2 inhibitor, are both FDA approved for severe alopecia areata. Duration and severity of disease are inversely associated with therapeutic response, emphasizing the need for early intervention.

Hyperpigmentation has many different etiologies and can be a diagnostic and therapeutic challenge for dermatologists. In this session, Susan C. Taylor, MD, discussed tips for differentiating between the different types of hyperpigmentation and best strategies for treatment. Melasma and postinflammatory hyperpigmentation (PIH) are 2 common causes of facial hyperpigmentation. Melasma is usually found in sun-exposed areas on women of reproductive age, while patients with PIH should have a history of acne or another inflammatory facial dermatosis. Dr Taylor reviewed mimickers of melasma and PIH on the face, including exogenous ochronosis, lichen planus pigmentosus, maturational hyperpigmentation, drug-induced hyperpigmentation, and adrenal insufficiency. Nasal hyperpigmentation can be seen in a postviral state and has been reported following Chikungunya infection and COVID-19 infection.

Moving on, Dr Taylor discussed strategies for preventing hyperpigmentation, which starts with sun protection. Multiple studies have shown improved resolution of both PIH and melasma with the use of sunscreen. Visible light is now understood to contribute to the pathogenesis of hyperpigmentation and is not blocked by traditional UV filters. Tinted sunscreens containing iron oxides as well as a new formulation of sunscreen containing 5 antioxidants have all been shown to reduce hyperpigmentation from visible light.

Wrapping up with a review of treatment, Dr Taylor reviewed efficacy data for tretinoin for acne and acne-induced PIH as well as topical cysteamine 5% for PIH. Traditional triple therapy with combination tretinoin, fluocinolone, and hydroquinone has well-known efficacy for the treatment of melasma, although long-term use is limited by the risk of exogenous ochronosis. Dr Taylor introduced a novel triple-combination therapy for melasma containing isobutylamido thiazolyl resorcinol, tretinoin, and a corticosteroid. A 24-week randomized, double-blind, prospective clinical trial comparing the novel triple therapy with traditional triple therapy found a 63% reduction in melasma severity score for the novel combination versus 39% reduction with the traditional combination. Both oral and topical tranexamic acid as well as use of polypodium leucotomos extract has also shown benefit in the treatment of melasma.

With the recent approval of baricitinib and ritlecitinib, alopecia areata (AA) is one of the most talked-about diseases in dermatology today. During this session, Natasha A. Mesinkovska, MD, PhD, gave the audience the latest information on the pathogenesis and treatment of AA. Alopecia areata affects 2% of the global population, and the prevalence has been increasing over time. It has a complex pathogenesis, including genetics, environmental triggers, and loss of hair follicle immune privilege. Dr Mesinkovska discussed potential environmental triggers including infections, allergies, and vaccinations, including the COVID-19 vaccine.

Moving on to treatments, Dr Mesinkovska dove into the data behind baricitinib and ritlecitinib. Baricitinib is a selective JAK1/2 inhibitor approved for severe AA in patients 18 years and older. Ritlecitinib is a JAK3/TEC inhibitor approved for severe AA in patients 12 years and older. Similar to JAK molecules, TEC kinases play a role in intracellular signaling leading to downstream immunity and inflammation. For those taking baricitinib 4 mg daily in Phase 3 clinical trials, 18% of patients achieved SALT20 (equivalent to 80% scalp coverage) at Week 16; 28% of patients achieved SALT20 at Week 24 and 32% to 35% of patients achieved SALT20 at Week 36. Ritlecitinib 50 mg daily led to 23% of patients achieving SALT20 at Week 24 and 43% of patients achieving SALT20 at Week 48 in clinical trials.

To conclude, Dr Mesinkovska gave tips for real-world use of these medications. Once hair regrows with JAK inhibitors, treatment needs to continue otherwise hair will most likely be lost. Skipping pills can also result in worsening patchy AA. For patients who are hesitant about therapy, Dr Mesinkovska recommended trying the medication for 3 to 6 months instead of committing to long-term use. Regarding the black box warnings, Dr Mesinkovska discussed data showing low rates of major adverse cardiovascular events and malignancy but cautioned against use in current smokers, those with malignancy within the past 5 years, and those with prior episodes of venous thromboembolism.

Patients with moderate-to-severe atopic dermatitis (AD) often experience chronic pruritus, poor sleep, and decreased quality of life. Rocatinlimab, a monoclonal antibody that targets OX40, is being investigated for the treatment of moderate-to-severe AD. This poster presents patient-reported outcome data from a Phase 2b study of rocatinlimab for AD. Treatment with various doses of rocatinlimab over a 40-week period led to improvements in numerical rating scale (NRS) pruritus scores (ranging from -25.6% to -48.0% vs -6.0%) and NRS sleep disturbance scores (ranging from -41.6% to -7.0% vs +45.6%) compared to placebo. Treatment with rocatinlimab was discontinued from Week 40 to Week 56, and improvements in pruritus and sleep disturbance scores were maintained in the rocatinlimab groups until Week 56. Rocatinlimab showed significant improvements in patient-reported outcomes in patients with moderate-to-severe atopic dermatitis. 

This multispeaker session is always an audience favorite; this year, the panel included medical, surgical, as well as practice management tips. Erin Boh, MD, PhD, kicked off the session with a tip on identifying cutaneous T cell lymphoma (CTCL) in clinical practice. This can be difficult because CTCL can mimic psoriasis, atopic dermatitis, and drug eruptions, but Dr Boh emphasized the importance of early recognition to increase disease-specific survival. Dr Boh also discussed the use and monitoring of methotrexate in clinical practice as well as labs for a thorough work-up of prurigo nodularis. Dr Boh concluded with tips on the work-up of pretibial myxedema, which includes thyroid function studies and biopsy, as well as the early use of biopsies in dupilumab nonresponders after 3 to 4 months of therapy to rule out CTCL.

Sandra Lee, MD, discussed in-office procedural pearls, such as using a 15-blade in its wrapper for an inexpensive shave biopsy and covering cysts with a transparent film dressing prior to local anesthesia to prevent splashing. Dr Lee recommended using tumescent anesthesia for large lipoma excisions and attempting to aspirate large pilar cysts before excision as many can become liquified. Dr Lee concluded with a tip on a clinical maneuver to determine whether large lipomas are superficial or are lying underneath a muscle.

The next panelist, Lawrence F. Eichenfield, MD, began with a tip on using an otoscope or flashlight to evaluate for transillumination of cysts and look for calcification in pilomatricomas. Dr Eichenfield advised documenting body surface area involvement for all moderate-to-severe inflammatory skin diseases and told the audience that one thumb size is approximately 1% of the scalp when evaluating alopecia areata. For reducing pain during procedures or injections in children, Dr Eichenfield recommended lidocaine 4% cream, listening to music, utilizing the Zimmer cooler, and a wrapping technique for immobilizing smaller children.

Steven Wang, MD, continued the discussion with surgical tips for the office. Dr Wang recommended doing multiple scouting shave biopsies in a clock pattern on the periphery of large pigmented facial lesions suspected to be lentigo maligna. For nonsurgical treatment of lentigo maligna, Dr Wang gave tips on using imiquimod cream 5 times weekly for 12 weeks. Dr Wang’s next 2 tips were on the use of ferric subsulfate solution as a landmark for scalp biopsies that may need further surgical treatment and the use of heating packs to enhance aminolevulinic acid incubation prior to photodynamic therapy. Dr Wang concluded with a recommendation for weekly intralesional triamcinolone injections for keratoacanthomas on the lower extremities.

G. Michael Lewitt, MD, gave the audience a few medical pearls, the first being to check a Tb spot on patients who have an indeterminate QuantiFERON Gold test. For cases of psoriasiform dermatitis with overlapping eczematous features on the hands and feet, Dr Lewitt recommended treating with a systemic JAK inhibitor for rapid improvement. When using immunosuppressive medications, Dr Lewitt reminded the audience to avoid the concomitant use of live vaccines, including the MMR, rotavirus, and varicella vaccines. To conclude, Dr Lewitt recommended sticking to a strict order when performing total body skin exams, even when patients come in with a list of things to address.

David M. Pariser, MD, concluded the session with a few office efficiency and medical tips for the audience. Starting with office efficiency, Dr Pariser recommended getting a scribe for each provider and making sure they are well-trained in billing to help save time. Moving on to medical dermatology, Dr Pariser reviewed evidence for a novel targeted alkali thermolysis patch as an in-office treatment for axillary hyperhidrosis. In studies, a single 3-minute application led to reduction in excessive sweating for up to 3 months. Dr Pariser concluded with a discussion of efficacy of various field treatments for actinic keratoses and recommended occlusion of aminolevulinic acid for photodynamic therapy. 

To help the audience stay up to date on recent literature publications, Dirk Elston, MD, reviewed interesting articles published in the Journal of the American Academy of Dermatology (JAAD) over the past year. An open-label extension of upadacitinib for atopic dermatitis found that patients had improved outcomes when switched from dupilumab to upadacitinib regardless of prior dupilumab response. Bimekizumab, an IL-17 A/F inhibitor, achieved high clearance rates of psoriasis in clinical trials, with 74.8% of patients achieving PASI-100 at Week 48. There was no difference in survival rates for primary cutaneous Merkel cell carcinoma after Mohs micrographic surgery versus wide local excision.

Dr Elston highlighted a multicenter, randomized, double-blind, placebo-controlled trial of paroxetine 25 mg daily for refractory erythema of rosacea. Erythema assessment scores improved more in the paroxetine group compared to the placebo group (42.9% vs 20.8%, p = 0.02). Adverse events seen in the paroxetine group included dizziness, lethargy, nausea, dyspepsia, and muscle tremors. Risk of recurrence of nail unit melanoma was slightly lower after functional surgery versus amputation (21.5% vs 30.3%). In that study, a Breslow thickness of 0.8 mm was found to be an appropriate cut-off for stratifying recurrence risk after surgery. Other interesting articles discussed by Dr Elston included omalizumab as an effective treatment for solar urticaria, a review of risk factors for progression of discoid lupus erythematosus to severe systemic lupus erythematosus, anesthetic preferences for axillary laser hair removal, and local hyperthermia versus cryotherapy for warts. 

To round out the morning review of dermatology literature, Roger I. Ceilley, MD, delighted the audience with a look back at the past year for SKIN: The Journal of Cutaneous Medicine. SKIN is a peer-reviewed, open-access, online-only journal dedicated to providing free access globally to dermatologic knowledge. Readership of SKIN continues to grow, with over 68,000 reads in May 2023. Dr Ceilley highlighted important sections of SKIN, including a new Medical Educational in Dermatology section and the ever-popular SKINmages section. High-impact articles from 2023 included an expert consensus panel report on the use of gene expression profiling in melanoma management. The panel concluded that adding gene expression profiling results to AJCC classification improves prognostic assessment of patients with cutaneous melanoma. Dr Ceilley concluded with a look at the most-read articles of 2023, which included a review of makeup ingredients and their effects on acne cosmetica, a short communication about solutions for the lidocaine shortage, and an original research article on the use of ampicillin in acne vulgaris. 

The approval of multiple novel JAK inhibitors for inflammatory dermatoses such as atopic dermatitis and alopecia areata has left many dermatologists wondering how to deal with the FDA-mandated class-wide black box warning. All oral JAK inhibitors carry a warning for serious infection, malignancy, major adverse cardiovascular events (MACE), all-cause mortality, and thrombosis. Christopher G. Bunick, MD, PhD, used this session to bust some common myths associated with black box warnings. Contrary to popular belief, a causal relationship between a medication and an adverse event does have to be established for a drug to carry a specific warning. FDA application of black box warnings is increasing according to Dr Bunick, so dermatologists should become comfortable discussing them with patients.

Dr Bunick went on to discuss that medications with black box warnings can be purchased over the counter, as evidenced by ibuprofen, which carries a black box warning for cardiovascular thrombotic events and gastrointestinal events. There are many other medications commonly used in dermatology that carry boxed warnings, including TNF- inhibitors, isotretinoin, botulinum toxins, and multiple antimicrobials. To conclude, Dr Bunick reviewed safety data for JAK inhibitors compared with conventional immunosuppressives that have been commonly used for atopic dermatitis. A recent review found that both upadacitinib and abrocitinib have lower rates of malignancy, MACE, and thrombosis than methotrexate, cyclosporine, and systemic corticosteroids when used in patients with atopic dermatitis. Rates of malignancy, MACE, and thrombosis in patients with atopic dermatitis on JAK inhibitors are also equal to or lower than rates in patients with untreated moderate-to-severe atopic dermatitis.

Deucravacitinib, an oral selective, allosteric tyrosine kinase 2 inhibitor, is approved in the US, EU, and other countries for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy. This poster presents safety and efficacy data of deucravacitinib in a Phase 3 long-term extension (LTE) study for up to 3 years. Of the 1519 patients who received ≥1 dose of deucravacitinib, 513 received continuous deucravacitinib in the LTE. Exposure-adjusted incidence rate per 100 person-years were comparable, or decreased, between the 2-year and 3-year cumulative periods for adverse events and serious adverse events. Rates of herpes zoster, malignancies, major adverse cardiovascular events, venous thromboembolism, and deaths were also comparable or decreased and were all below 1.0 per 100 person-years. Response rates were maintained at 3 years, with 73.2% maintaining PASI-75 and 48.1% maintaining PASI-90. Deucravacitinib maintained a consistent safety profile and durable efficacy for up to 3 years.