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Dermbits

Which patients are recommended for treatment with spesolimab, and are there any exclusions? 

What spesolimab-associated hypersensitivity reactions should patients be monitored for? 

Can patients treated with spesolimab receive live vaccines? 

What is the recommended dosing regimen for spesolimab?

Join the leading experts as they go in-depth on some of the most important topics in dermatology. In this special feature, they give their invaluable insights into the mechanism of disease of psoriasis.

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Discourses in Dermatology

Psoriasis mechanism of disease: Genetic, environmental, and lifestyle factors

<p>In this installment of <i>Discourses in Dermatology</i>, Dr. George Han, Director of Clinical Research at Northwell Health in New York, sits down with Dr. Andrew Blauvelt, Investigator at Oregon Medical Research Center, to discuss the genetic, environmental, and lifestyle factors that influence psoriasis. They also explore the comorbidities associated with psoriasis and how they play into the role of psoriatic disease.</p><p><strong>The role of genetics in psoriasis</strong></p><p>Dr. Han begins by asking Dr. Blauvelt what role genetics really plays in the development of psoriasis.</p><p>Dr. Blauvelt references the first genetic study published on psoriasis, spearheaded by Danish researchers in the Faroe Islands in 1963, which found evidence of a genetic component to psoriasis in the local island population. &nbsp;</p><p>He also comments on a key study examining identical twins that revealed strong evidence in favor of a genetic component to psoriasis.</p><p>Dr. Blauvelt notes that while there is a genetic component to psoriasis, it’s not a Mendelian disease. Rather, there are 70 to 80 susceptibility genes that have been identified that either confer a risk for psoriasis or confer some protection.</p><p>With those factors considered, he explains to his patients that while there is indeed a significant genetic component, it does not account for the entire picture of psoriasis. He estimates that approximately 40% of patients have a family history of the condition but suggests that even those without a family history may still have a genetic predisposition due to a combination of genes inherited from their parents.&nbsp;</p><p>To summarize, he reiterates that psoriasis is a complex condition with a genetic component with other factors also involved in its development.</p><p><strong>Key points</strong></p><ul><li>A seminal study demonstrating the genetics of psoriasis was conducted by Danish researchers on the Faroe Islands in 1963</li><li>Twin studies have also revealed strong evidence in favor of a genetic component to psoriasis</li><li>Psoriasis is not a Mendelian disease, but is influenced by 70 to 80 susceptibility genes</li><li>While there is a significant genetic component to psoriasis, it does not account for the entire picture</li></ul><p><strong>Environmental influences on psoriasis</strong></p><p>Dr. Han continues the conversation by asking Dr. Blauvelt about the environmental influences on psoriasis that may encourage psoriasis in susceptible individuals.</p><p>Dr. Blauvelt replies by giving more background on the genetics of psoriasis, explaining that there are 2 types of psoriasis as it relates to genetics. The first type is a result of genes that tend to run in families, with HLA-Cw6 being the most common. With this type, there is usually an earlier onset in the late teens or early 20s.&nbsp;</p><p>The second type tends to manifest in the early 40s, and those patients tend not to have a family history of the condition. Rather, this type of psoriasis tends to be more associated with metabolic syndrome, diabetes, or hypertension.</p><p>Dr. Blauvelt then begins delving into some of the well-known influences on psoriasis, including stress, infections like strep throat, and certain medications. He specifically mentions lithium and interferon stimulators, remarking that Aldara cream can stimulate psoriasis locally.</p><p>He comments that the most common influences on psoriasis he has seen in his career have been strep throat, stress, and cold weather. He advises patients that any kind of stressor on the body, whether emotional or physical stress from temperature, medication, or infection, can trigger the psoriasis immune response.</p><p><strong>Key points</strong></p><ul><li>Influences on psoriasis can include stress, infections, and certain medications</li><li>Lithium and interferon stimulators can affect psoriasis</li><li>Cold weather can also trigger the psoriasis immune response</li></ul><p><strong>Comorbidities of psoriasis</strong></p><p>Dr. Blauvelt comments that the list of comorbidities associated with psoriasis has become quite long and can be overwhelming for healthcare providers who are unsure how to counsel patients on this topic.</p><p>He describes his approach to speaking with patients and how he always discusses the 2 most important psoriasis comorbidities, psoriatic arthritis and heart disease, at their first visit. When discussing psoriatic arthritis, he explains that it is the most common comorbidity and will affect treatment choice, and that is an important facet for patients to consider and understand. In his experience, some patients with psoriasis are unaware that they are at risk for arthritis and thus it should be discussed early on.</p><p>Dr. Blauvelt also makes sure to discuss heart disease with his patients and emphasize the seriousness of it. He references the literature that is now available on psoriasis as an independent risk factor for heart disease and says it also suggests that the risk of heart disease can be reduced if an impact can be made on the skin.</p><p>He mentions large databases that suggest TNF blockers may reduce the risk of cardiovascular events but that we don’t yet have that same kind of data for IL-17s and IL-23s. He also references studies conducted at the NIH that put patients on biologics for one year and measured their atherosclerotic plaques. Those studies demonstrated that IL-17 blockers were the best class of drugs in terms of improving atherosclerosis in patients with psoriasis. While they don’t prevent heart attack and stroke, it’s strong evidence that these therapies are having positive outcomes.</p><p><strong>Key points</strong></p><ul><li>The long list of comorbidities associated with psoriasis can make it overwhelming to counsel patients</li><li>The 2 most important comorbidities to discuss with patients are psoriatic arthritis and heart disease</li><li>Psoriatic arthritis should be discussed with patients at their first visit, since it’s the most common comorbidity and can affect treatment choice</li><li>Literature suggests that psoriasis is an independent risk factor for heart disease and that the risk of heart disease can be reduced if an impact can be made on the skin</li><li>Large databases suggest TNF blockers may reduce risk of cardiovascular events</li><li>NIH studies demonstrated that IL-17 blockers were the best class of drugs in improving atherosclerosis in patients with psoriasis</li></ul><p><strong>Mental health as a comorbidity of psoriasis</strong></p><p>Dr. Han continues the conversation by asking Dr. Blauvelt his thoughts on mental health and psoriasis and how he approaches this discussion with patients.</p><p>Dr. Blauvelt references his involvement in one of the first multidisciplinary clinics for psoriasis in the United States that included dermatology, rheumatology, and psychiatry. When he asked patients about their mental health, they often reported they were depressed and anxious due to the condition. He found many were hesitant to be referred to the psychiatry clinic because they felt that if their psoriasis cleared, their mental health would improve, which demonstrates there is a component to the condition that can cause angst and depression.</p><p>He remarks that practitioners can assume quality of life is impaired for patients with psoriasis and that patients are likely to score poorly on quality-of-life measures and depression scales. He emphasizes that this should not be ignored and that it’s important to listen to patients and monitor for signs of severe depression and suicidal ideation.&nbsp;</p><p>Dr. Han concludes by agreeing on the importance of listening and caring for the whole patient.</p><p><strong>Key points</strong></p><ul><li>There is a component to psoriasis that can cause angst and depression among patients with the condition</li><li>Patients with psoriasis will often have impaired quality of life and score poorly on quality-of-life measures and depression scales</li><li>It’s vital to listen to patients and monitor them for signs of severe depression and suicidal ideation</li></ul>

Join Nicholas Brownstone, MD, as he gets to know your colleagues and gets tips on topics like time management, communicating with patients, and more!

Under Your Skin Interviews with Top Dermatologists

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Under Your Skin

Interview with Andrea T. Murina, MD

<p>In this installment of <i>Under Your Skin</i>, host Nicholas Brownstone, MD, chats with Andrea Murina, MD, to get tips on time management and dealing with demanding patients. Dr Murina also shares her thoughts on what condition dermatology still needs better treatments for.&nbsp;</p><h5>What’s your favorite time management technique in clinic?&nbsp;</h5><p>Dr. Murina finds that getting an early start to her day helps her to best manage her time. She also provides some tips on writing notes. She shares her technique of setting aside a block of time to work on them; if she doesn’t finish her notes within that block, she moves the remainder of that task to the next day. She finds that unfinished work makes her more focused the next day and helps increase her efficiency.&nbsp;</p><h5>How do you deal with demanding patients?&nbsp;</h5><p>Dr. Murina values challenging patients because they teach valuable lessons. One such lesson she has learned from her demanding patients is the importance of listening. She finds that taking the time to sit down and actively listen is the best way to bring down the intensity of a demanding patient.&nbsp;</p><h5>What condition in dermatology do we still need better treatments for?&nbsp;</h5><p>Dr. Murina feels the biggest gap in dermatology currently is treatment for hidradenitis suppurativa. There is currently only one FDA-approved biologic for this condition, and all other treatments for it are off label. She emphasizes that dermatology needs more FDA-approved medications in this area.</p>

Interview with Natasha Atanaskova Mesinkovska, MD, PhD

<p>In this installment of<i> Under Your Skin</i>, Dr. Nick Brownstone chats with Dr. Mesinkovska about her favorite disease to treat and which innovations in dermatology she’s most excited about. He also gets a helpful tip on one way to increase efficiency in the office.&nbsp;</p><h5>What is your favorite disease to treat and why?&nbsp;</h5><p>Dr. Mesinkovska replies that her favorite disease to treat is alopecia areata because dermatologists finally have a treatment for it. With JAK inhibitors revolutionizing the field, she finds it very satisfying to be able to assure her patients that there is now a treatment available.&nbsp;</p><p>She also notes the positive effects of dupilumab for children with atopic dermatitis.&nbsp;</p><p>She comments that with the development of baricitinib, the field of alopecia areata has experienced a game-changing event. She also reflects on the positive developments for other types of alopecia that have benefitted from the development of oral minoxidil. She remarks that she’s hopeful more JAK inhibitors will enter the market.&nbsp;</p><h5>What innovations in dermatology are you most excited about?&nbsp;</h5><p>Dr. Mesinkovska remarks that she’s happy treatment for chronic inflammatory diseases has shifted from injectables to oral treatments taken daily and that dermatologists are able to treat people more effectively with fewer injections.&nbsp;</p><p>In the realm of aesthetic devices, she is also pleased about the development of micro-coring technology, which uses needles big enough to puncture skin and remove tissue but heal without a scar. She remarks that this technology can likely help tighten not only faces, but bodies as well.&nbsp;</p><h5>In the past 5 years, what is 1 thing you’ve done to increase your efficiency in the office?&nbsp;</h5><p>Dr. Mesinkovska explains that she realizes what she likes to do and how many people she wants to see, and she accomplishes this by recognizing her own worth. She comments on the urge doctors often have to be people-pleasers but recognizes that she can raise her own value by raising her prices and choosing to see 1 patient instead of 3. This allows her to dedicate more time to that patient and leave the exam room feeling less burnt out while not sacrificing any value monetarily.</p>

Interview with Gabriela Maloney, DO

<p>In this episode of <i>Under Your Skin</i>, Dr. Nick Brownstone chats with Dr. Gabriela Maloney about her journey from Brazil to Wisconsin, her favorite thing about being a dermatologist, tips for staying efficient in the clinic, and how she counsels patients on a common misperception in dermatology.</p><h5>What was your journey like from growing up in Brazil to practicing dermatology in Wisconsin?</h5><p>Dr. Maloney explains that when she was 15, she received a scholarship to become a high school exchange student and later also received a college scholarship. She wanted to pursue medical school but first needed to save some money. After working for 2 years at a biotech company, she saved enough to apply to medical school. After medical school, she had an opportunity to work in Wisconsin, which she describes as a family-friendly place with very nice people.</p><h5>What’s your favorite thing about being a dermatologist?</h5><p>Dr. Maloney explains that she loves the variety of patients dermatologists see, from newborns to the elderly. With a wide array of conditions to treat surgically, cosmetically, and medically, there are no repetitive days in dermatology. With many systemic diseases that can show up in the skin, she feels dermatology especially encourages doctors to retain and use the knowledge they learned in medical school daily. She finds it very rewarding to make a positive impact on patients’ quality of life.</p><h5>How do you stay efficient in clinic?</h5><p>Dr Maloney notes that to stay efficient in clinic, she makes sure to look at her schedule ahead of time, highlight potential derailments, and prepare her staff. She schedules surgeries 10 minutes ahead of when she wants patients to arrive, so if they are late, it doesn’t impact her daily schedule and they have sufficient time to get checked in, prepped, and consented. She also does her large cosmetic procedures right before lunch; with this tactic, if patients have a vasovagal episode or need more recovery time, they can be safely kept in the room without derailing the day.</p><h5>What’s a common misperception you hear from patients, and how do you address it?</h5><p>Dr. Maloney finds that many patients with melasma think they don’t need daily sunscreen because they don’t spend much time outside. She explains to patients that even if they think they don’t go outside, we all inevitably take the trash out, walk our dogs, get the mail, or chat with a neighbor, all of which add to daily sun exposure contributing to melasma. She counsels patients to keep their sunscreen next to their toothbrushes to encourage daily application.</p>

Interview with Jane S. Bellet, MD

<p>In this episode of <i>Under Your Skin</i>, Dr. Nick Brownstone sits down with Dr. Jane Bellet to hear about a common misperception she hears from her patients, her best tip for treating hemangiomas in pediatric patients, and her opinion on what condition we need better treatments for in dermatology.</p><h5>What is the most common misperception you hear from your patients?</h5><p>The most common misperception Dr. Bellet hears from her patients is that they shouldn’t apply sunscreen to babies under 6 months of age. She advises her patients that while babies should still be shaded and wear protective clothing outside, it’s essential to use a physical blocker with zinc oxide or titanium dioxide to prevent sunburn.</p><h5>What is your best tip for treating pediatric patients with hemangiomas?</h5><p>Dr Bellet advises that the most important thing to do when treating a hemangioma in pediatric patients is to treat early. She emphasizes that doctors should not delay referring patients to a pediatric dermatologist as young as possible since treatments for hemangiomas work better when the patients are younger.</p><h5>Which conditions do we need better therapies for in dermatology?</h5><p>In Dr. Bellet’s opinion, dermatology needs better therapies for nail lichen planus. Dermatologists often struggle to treat it, and she hopes that in the future, better treatment options will develop.<br>&nbsp;</p>

Join host Nicholas Brownstone, MD, as he chats with colleagues about the most common misperceptions heard in dermatology, and get tips on how to bust these myths for your patients!

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Dermbusters

Dermbusters: G. Michael Lewitt, MD

<p>In this installment of Dermbusters, Dr. Nick Brownstone sits down with Dr. G. Michael Lewitt to get his thoughts on blood monitoring for patients prescribed biologics and to discuss how he advises patients who believe tretinoin must be applied at night.&nbsp;</p><h5>Do dermatologists have to check CBCs and LFTs with all biologics?&nbsp;</h5><p>Dr. Lewitt explains that from looking at the data, it’s likely not necessary to monitor CBCs and LFTs for patients who are prescribed a biologic. He estimates that half of the biologic prescribers across the US do this type of monitoring for patients taking a biologic, and the other half do not.&nbsp;</p><p>He recalls that when the IL-17s came out, there were a few incidences of neutropenia and leukopenia observed which led to a trend of blood monitoring every 6 months; however, he then found he did not see any more abnormalities across the following 2 years and felt that as a result, this type of monitoring was wasting his time and patients’ healthcare funds. He now checks CBCs and LFTs annually for patients taking a biologic.&nbsp;</p><p>When counseling his patients on this topic, he emphasizes to them that they have a chronic skin condition and should receive age- and disease-state-appropriate blood monitoring, like TSH and fasting limit profiles, at intervals recommended by their primary care physicians.&nbsp;</p><p>In sum, he emphasizes that the necessity of checking CBCs and LFTs for patients taking a biologic is largely a myth.&nbsp;</p><h5>Do topical retinoids have to be applied at night?&nbsp;</h5><p>Dr. Lewitt explains that of the 4 current generations of retinoids, the original tretinoin and tretinoin derivates were photolabile, while generations 2 though 4 are photostable. Historically, patients were encouraged to apply retinoids at night because as soon as they were exposed to sun in the morning, the medication became inactivated.&nbsp;</p><p>Even though the newer generations of retinoids are photostable, Dr. Lewitt still prefers nighttime application. With the most common side effect being retinoid dermatitis or irritation, he finds that with evening application, he can then troubleshoot in the mornings to ensure there isn’t any scale appearing on his nose or eyes. However, from a pharmacodynamic standpoint, generations 2 though 4 do not need to be applied at night.&nbsp;</p><p>He advises his patients that the best time to apply it is whenever they can best remember and recommends applying it at the same time they brush their teeth to establish a routine.</p>

Dermbusters: Carly Elston, MD

<h5>Do patients with skin of color need sunscreen?</h5><p>First, Dr. Brownstone asks Dr. Elston how to advise patients with skin of color who believe they don’t need sunscreen. Dr. Elston references studies that show not only do patients with skin of color get skin cancer, they also tend to get diagnosed later and have higher mortality.</p><p>She details a study that examined melanoma survival among White, Hispanic, Asian, and Black women, which demonstrated that those with skin of color had lower survival rates, with Black women having the lowest.</p><p>To encourage sunscreen use among her patients with skin of color, Dr. Elston recommends products that will be more cosmetically favorable on pigmented skin; some of the physical blockers can be challenging, so she often recommends sunscreens that are in a clear- or a gel-base that will rub in.</p><h5>If a topical medication isn’t burning, does that mean it’s not working?</h5><p>Next, Dr. Brownstone chats with Dr. Elston on a common misperception heard from patients—if a topical medication isn’t burning, it isn’t working.</p><p>Dr. Elston explains that many medications burn or sting because of what’s in the vehicle, like lactic acid affecting patients who are sensitive to cosmetic products or propylene glycol causing an irritant effect. She explains to patients that the resulting stinging is not a result of the products’ efficacy. She also explains that other drugs cause burning because of the drug effect, for example, topical calcineurin inhibitors causing a capsaicin-like burning reaction that often gets better the longer patients use them. She helps dispel this common misconception by advising patients that these medications work just as well when the burning stops.</p>

Dermbusters: Aaron Farberg, MD

<p>In this episode of <i>Dermbusters</i>, Dr. Nick Brownstone chats with Dr. Aaron Farberg how he busts myths often heard from patients surrounding sunscreen use and scarring.</p><h5>Is a higher SPF sunscreen always better?</h5><p>First, Dr. Brownstone asks Dr. Farberg how he counsels patients who believe a higher SPF sunscreen is always better. Dr. Farberg explains that when he chats with patients about sunscreen use, he emphasizes that the best sunscreen is whichever one they will use consistently.</p><p>He tells his patients that an SPF of 30 is sufficient if they are using it correctly; however, he notes that most people do not, either by not applying enough or not reapplying their sunscreen. Considering that, he advises his patients to select the highest SPF sunscreen they can find to give themselves a margin of safety.</p><h5>Is a barely noticeable scar the mark of a good surgeon?</h5><p>Next, Dr. Brownstone inquires about a misconception regarding scarring that he often hears from patients: that a barely noticeable scar is the mark of a good surgeon. Dr. Farberg emphasizes that for patients who hold this belief, managing expectations is key and advises them that they should expect a scar.</p><p>He describes his system of measuring scars by distance—whether the scar is visible from 3 feet, 30 feet, or 300 feet—and that he explains to his patients that he aims for scars that can only be visible from 3 feet away.</p>

Dermbusters: Dawn L. Sammons, DO

<p>In this episode of <i>Dermbusters</i>, Dr. Nick Brownstone asks Dr. Dawn Sammons how she dispels myths often heard from patients about tanning and tretinoin use.</p><h5><br>Does a base tan prevent sunburn?</h5><p><br>First, Dr. Brownstone asks Dr. Sammons what she says to patients who believe getting a base tan prevents sunburn and the need for sunscreen. She explains to her patients that while a base tan may provide a very slight level of SPF, it does not prevent the need for sunscreen, and pretanning ultimately increases the amount of sun damage patients get. For patients still desiring the look of a base tan, she advises a spray tan.&nbsp;</p><p>She notes that with social media often promoting misconceptions about base tans, dermatologists must work to help dispel these notions among their patients.</p><h5><br>Does tretinoin make you more sun-sensitive?</h5><p><br>Next, Dr. Brownstone chats with Dr. Sammons on the belief that tretinoin makes the skin more sun-sensitive. She states that while true, the slight decrease in minimum effective dose associated with topical retinoid use is not time-sensitive, and that skin won’t be any more sensitive in the daylight hours than in the evening. Considering this, she questions the reasoning dermatologists have for instructing patients to apply retinoid at night.&nbsp;</p><p><br>Dr. Sammons explains that she encourages patients to apply their retinoid at whatever time they are most likely to adhere to. In her experience, her younger patients tend to have more consistent routines in the morning as opposed to at bedtime.</p><p><br>She concludes by explaining that historically, retinoids were photolabile and thus deactivated by sunlight. As a result, dermatologists instructed patients to apply retinoids at night. Currently, however, all preparations are micronized and photostable for up to 8 hours, which is sufficient time for retinoid to be absorbed.</p>

Tune in to hear insights and updates on some of the hot topics in dermatology. In this series, we showcase expert updates on featured conditions, KOL discussions, and much more!

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Topical Conversations

Perspectives on Vitiligo: Insights From the Global VALIANT Study

<p>In this installment of <i>Topical Conversations</i>, Dr. Iltefat Hamzavi sits down to discuss the results of the VALIANT study, which explored the natural treatment history of vitiligo and was published in the <i>British Journal of Dermatology</i> in July 2023.</p><h5>Vitiligo and the VALIANT study</h5><p>The VALIANT (<u>V</u>itiligo <u>a</u>nd <u>L</u>ife <u>I</u>mpact <u>A</u>mong Inter<u>n</u>a<u>t</u>ional Communities) aimed to investigate the natural treatment history of vitiligo, a pigmentary disorder causing color loss in areas of the skin that can be socially stigmatizing for patients. The study focused on understanding the patient and healthcare provider experiences related to this condition.</p><p>The study was based on a survey distributed globally across Africa, Asia, Latin America, North America, and Europe. Around 3,500 patients participated in a 25-minute survey, and around 1,200 clinicians (primary care physicians and dermatologists) completed a 30-minute survey. Results were then compared across the different populations.</p><h5>Patient profiles</h5><p>Among the 3,541 patients who completed the full analysis, the average age was 38, and 59% of participants reported Fitzpatrick skin types I-III. The mean duration of the disease was 12.7 years, taking 2.4 years to receive a diagnosis. In survey participants, lesions appeared on the hands and face in about 40% and 38% of cases, respectively.</p><h5>Physician profiles</h5><p>Of the 1203 clinicians who completed the survey, 91% specialize in dermatology and 8% are primary care physicians or other care physicians. Around 60% identified themselves as vitiligo specialists. Clinician respondents had on average 8 years of experience treating vitiligo.&nbsp;</p><h5>Survey results: misdiagnoses</h5><p>Of the patients surveyed, 44% reported being misdiagnosed. Patients with vitiligo occurring on more than 5% of their body surface, patients with darker skin, and patients with facial lesions particularly noted difficulty with receiving a diagnosis.</p><p>Misdiagnoses included sun damage, fungal infections, and atopic dermatitis. About 17% of both primary care physicians and dermatologists reported encountering patients referred to them who were misdiagnosed.&nbsp;</p><p>While there were geographic variations among these findings, similar results were found globally.</p><h5>Survey results: treatment</h5><p>Fifty-seven percent of patients reported being told by their healthcare practitioner that their vitiligo could not be treated, and 44% reported they had given up on finding an effective treatment. Treatments that were reported to be used or suggested by the primary care physician or dermatologist were topical medications, photoprotection, laser therapy, and surgical options.</p><h5>Survey results: effective care</h5><p>Two-thirds of patients reported receiving effective care, defined by the patient as a reduction or cessation of spread and repigmentation.</p><p>A core element that patients sought to achieve was a reduction of the psychological burden of vitiligo, with mental effects of the disease going well beyond just what is happening in the skin.</p><h5>Implications for dermatology</h5><p>The results of the VALIANT study show that there is a profound burden associated with vitiligo with nearly half of patients reporting greater than 5% body surface area affected and a time of 2.4 years to diagnosis for a condition that should be easy to identify.</p><p>The survey results also revealed that there is a common misperception that vitiligo cannot be treated. Although many publications have disproved this, it is nonetheless a widely held belief among both the patient community and healthcare practitioners.</p><p>With these factors considered, this global survey emphasizes the significant frustration that is mounting among patients and the practitioners who treat them that can hopefully be addressed with future developments and advances in vitiligo education and management.</p><p>To read the full study published in the <i>British Journal of Dermatology</i>, click <a target="_blank" rel="noopener noreferrer" href="https://watermark.silverchair.com/ljad245.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAA2EwggNdBgkqhkiG9w0BBwagggNOMIIDSgIBADCCA0MGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMX5V9-MHsh4UtmQYyAgEQgIIDFGv2S4nMY1oqmdJqAc47hiyKl2BFRZp7HtQoN7ABGUGRybwdmWBOmG86sQh5u1StnaFuElQuzuV8FAlO6hPzuf7JDeqDF1kliJmPdkDq1awxpqAa9mxDuUDdxJs9MDu63G5W1VFZGk3ULW_mR_ByNxXiDq-HMlhH9aESceVPkuHi61qj6PutyptC3NDBNpLRVPgzY_Gf_J_mQasVqVYyMizb_nt37cypxpAN3saqAOOhnLIAI-f4KLNgqGOTU0ifJp1XRBJFwe9fI8ern3fWjxDbS5t3RBe2BNu-U9r1jW6QrbzszivU4gmx1sb5JJk5f2Ce0o1_jy_EjGyj2RZX2_FPfJH91lpLehUcfmXbmoNKNnXo0onaGYG4NVs0tChMTZLRp_3OMBlS6E5V97efZ2NFi1dykQwUUVDRGkZsBc_R6yUlAExRTVXuALp45Lz0U2F7yXDcv4S05iDtjySYixnKffB1D6fNEtsNriG4CYvoGA5Y70z6vIN--HREWAdDI3edtfWX60KjZmhs3xBwTGIpQ2Damkzao3jCALB4zFxiuLV0HpBNr7ytKA8qI24BB2nQtROy9LRzgLYhzS0zllaTjztz1dAj1LQZLYPzSGFLBYsMSRNL9YcrsvOZ4Buq60M0Pg8g6MyGBiyKntz4NXhwocbTHxnC2gAc7ndzHAGyHBfV6_GOkVrOIjNwTjD8qmU1g_VXZQrsvOWNXazM6U_87toGM7wtfwMCQaFxNXJ0QV-QR6eGkd7loYWljWUa_uWQtSxWhndhu6tzWL7-Qg0k8C4YYYnMrPrOibTcQXl9044B1_B3Sxc_GQiTDJ-8NKWQiPGqB42k-nwYDr5Iq7COyB0sEesVfuwrOAet2fvHDEn8ODVk-eONNUI6mCi_ALw7Bh7mw6d3-7nH3oM5zbxeXRlCgNqPO3yK4wdcFYkjOShm9FXH6g6JcrJTS2J3VK8VLxtcogqWOg34plnCbxqyua3d5RN7Ci-dy8xoFAdBoLovqO0g0k87CPhkzHmf5ibMH6HAr9awuSAPtpDs-2Qrg3dp">here</a>.</p><p>Key points from the VALIANT study</p><ul><li>It is the first global survey to explore the natural history and treatment of vitiligo from both a patient and HCP perspective</li><li>3,541 patients and 1,203 were surveyed</li><li>Mean time to diagnosis was 2.4 years</li><li>45.2% of patients had &gt;5% affected BSA</li><li>44.9% of patients reported an initial misdiagnoses</li><li>Reported rates of misdiagnoses were greater among patients with darker skin, &gt;5% affected BSA, and facial lesions</li><li>56.7% of patients reported being told vitiligo could not be treated</li><li>26.3% of HCPs did not believe an effective therapy for vitiligo exists</li><li>44.6% of patients reported giving up on finding an effective therapy</li><li>HCPs most commonly recommended prescription topicals, sun protection, and phototherapy, but comparatively few patients reported using these</li><li>34.4% of patients reported having surgery or other procedures, but only 14% of surveyed HCPS recommended surgery<br>&nbsp;</li></ul>

A Barrier Repair Formulation for Radiation Dermatitis

<p>Anyway, today we're going to be talking about EpiCeram controlled release, skin barrier emulsion and Leon, this brings back memories of years ago because we did a lot of work on this. We wrote some publications, evaluated data, were involved with some clinical studies. But to bring everybody up to date, EpiCeram control release skin barrier emulsion is really a standard for how a barrier formulations were put together. It's fragrance free, it's not a corticosteroid, it contains ceramide. We'll talk a little bit about a ceremide called the pseudo ceramide, which it does contain, which many other formulations contain pseudo ceramides. Importantly, the fatty acids specifically conjugated linoleic acid, and it also contains palmitic acid and those are very important physiologic lipids. And then cholesterol balanced to simulate the intercellular lipid membrane of the skin barrier of the stratum corneum. 3-1-1 ratios, ceramides to fatty acids to cholesterol. Importantly, a couple of other things is in purified water, it has phenoxyethanol as its preservative, which has a very low rate of irritancy and contact dermatitis. Some other components, like glycerin, which is obviously important for humectancy, dimethicone, are very important emollient that's very popular for emollientcy. So it's formulated extremely well, but we're going to be focusing on what its indication is. And Leon, can you give us a little bit of background before we do that about the type of product this is and how these got introduced initially?&nbsp;</p><p>So couple of important points, as you know the 510(k) device, and when we go back to the history of 510(k) device approvals, it actually goes back to the very first product that came to US, which is not in the market anymore as far as I know, and it was a trolamine based product that was approved for radiation dermatitis in France. And then it came back to US, with that same indication, ironically. However, in dermatology, you know, we are keen on atopic derm and skin barrier functions, so we always use those products for atopic dermatitis, but the history goes back to radiation dermatitis.&nbsp;</p><p>And that brings us to the indications, which for EpiCeram specifically, to treat dry skin conditions, which is a broad indication, right. And also manage really and relieve symptoms. It's not, you know, approved for a specific disease state. It's to manage symptoms associated with various dermatoses. That gives you a lot of leeway. It does mention atopic dermatitis, irritant contact dermatitis, and radiation dermatitis as examples, but it's primarily to relieve the symptoms like burning and itching, so that gives you a lot of leeway in where you can use this particular formulation, correct?&nbsp;</p><p>Yes, and Jim, one thing to mention in addition to all those indications. And you mentioned the ingredients of the product really in a very elaborated way. But one thing we have to emphasize on the multi-celled release option, right? It is a patented time release system that no other product in this field that I know of it has. It's the multi-cell neolipids are release system that gives 24 hour barrier repair benefits that is very, very important with just one application a day. And the multi-celled system is a multi-component, multi-compartment microencapsulation that allows the release of different ingredients that you mentioned, including the conjugated linoleic acid, the pseudo ceramide and the cholesterol in a timely fashion, little by little. And that when the emulsion is dropped on the skin, the initial other 30 micron-nanosphere shell dissolves and it helps the release of the submicron spheres, infused with the CLA and the release of the content slowly over time. So basically it's a very practical way of getting the benefit of the product over 24 hours with one application only.&nbsp;</p><p>So the thing that's really important that you said, it's actually a 2 sphere system. There's that outer shell sphere. And then once that basically dissolves away, there are those submicron spheres that contain the cholesterol, contain the conjugated linoleic acid, which is important to encapsulate. Because when those fatty acids, like the CLA and the palmitic acid get released and they get oxidized, there can be odor and this system prevents that, where generic versions I've heard people complain about the odor. Well, make sure the patients getting the right one cause this does not have any malodor that people have noticed with it. You know, the palmitic acid and the CLA they reduce transepidermal water loss. We know, this formulation certainly does. The CLA also increases ceramide synthesis and what I found in literature, there has been CLA conjugated linoleic acid used post fractionated laser procedures that have significant improvement in reducing inflammation, irritation and swelling. So the conjugated linoleic acid is a very important part of this formulation, but the bottom line is it's simulating the natural intercellular lipid membrane, as you mentioned. I do want to point out something that you did mention. The label does say twice daily application, but the data does show that once daily provides that moisturization over 24 hours. So that's a very important point. Do you have any final comments you want to make about this particular formulation? I think we need to talk a little bit about radiation dermatitis because we know that when patients utilize an alkaline soap or they go from a the humid climate like where you are in Louisville out, you get off the plane in Las Vegas or in Scottsdale you can immediately feel the transepidermal water loss in the skin getting dry and symptomatic. With ultraviolet light exposure chronic photodamage, it's slower, you know, but there is barrier impairment with increased transepidermal water loss. With radiation dermatitis, the literature shows that you have barrier impairment. You gotta remember the burn if you will, is deeper. It's deeper in in the dermis and secondarily it affects more superficially with transepidermal water loss. You have transepidermal water loss and barrier impairment much earlier than you see the radiation dermatitis. Radiation dermatitis visibly can take 10 days to three weeks, but the barrier impairment is earlier, so it makes sense to me, and I'd love to you for you to give a final comment on it, that you start treating that radiation dermatitis early on. You don't wait to see the problem in order to try to help that patient.&nbsp;</p><p>I think absolutely you brought up a very important point that unfortunately it takes about a good 10 to 11 days for the radiation dermatitis patients to see this clinical signs of that dryness of the itching and burning, all the clinical signs of the epidermal barrier dysfunction, unlike in atopic dermatitis, where we deal with in our practices, right? So it is important for these patients to start the treatment early on from get go, maybe not even day one, but even before to prepare the skin because the other thing is in addition to the radiation, they also have to deal with the daily challenges of washing just with the water, tap water, which is the pH is neutral, right? So the formulation here is pH of five, acidic pH is very important to keep the pH of the skin on top of what's going on with the radiation, right? With the salt, the cleanser, the tap water. You're looking at the pages of above acidic numbers, and that's really important.&nbsp;</p><p>Yeah, the acid mantle, the skin. That's extremely important. We often forget about pH. Maintaining consistent with the skins natural pH has everything to do with epidermal barrier function, right and the wrong pH can just rail everything else we're trying to do so all of that is extremely important. We want to stay ahead of the problem. One caveat with radiation dermatitis that the package insert does state is it they recommend not to have the patient apply the EpiCeram within 4 hours before the radiation treatment, but to use it after. So I think that's an important thing. And also you brought up a great point. That's why I love talking to you, Leon. You're brilliant. That the other aspects, the gentle cleanser, the you know, in addition to these products, doing everything we can to help the skin barrier is going to help the patient. So thank you, Leon, for joining us today, and I hope this helps listeners understand this product and this disease state better for their patients.&nbsp;</p><p>Thank you for the invite. Thank you. For including me. Bye bye.</p>

<h6>Summary</h6><p>In this video discussion, Dr Jim Del Rosso and Dr Leon Kircik talk about EpiCeram controlled release skin barrier emulsion. They highlight its formulation, which includes ceramides, fatty acids (conjugated linoleic acid [CLA] and palmitic acid), and cholesterol in a 3:1:1 ratio to simulate the intercellular lipid membrane of the skin barrier. &nbsp;</p><p>They then discuss the indications for EpiCeram, which include treatment of dry skin conditions and managing symptoms associated with various dermatoses like atopic dermatitis, irritant contact dermatitis, and radiation dermatitis.&nbsp;</p><p>Dr Kircik emphasizes the importance of EpiCeram's unique patented time-release system, which provides 24-hour barrier repair benefits with just one application a day. Dr Del Rosso and Dr Kircik explain the product's 2-sphere system and how the microsphere structure stabilizes the lipids from premature oxidation that can cause malodor in generic versions.&nbsp;</p><p>Dr Del Rosso highlights the important role of CLA in the formulation of EpiCeram by referencing literature that has shown CLA used post-fractionated laser procedures has demonstrated significant improvement in inflammation, irritation, and swelling.</p><p class="MsoNormal">Dr Del Rosso and Dr Kircik then focus their conversation on radiation dermatitis and the ensuing barrier impairment. They emphasize the importance of treating radiation dermatitis early, since while the clinical signs of radiation dermatitis may take up to 3 weeks to appear, the barrier impairment can begin sooner. They conclude by highlighting the importance of maintaining the skin’s pH level to support epidermal barrier function.<o:p></o:p></p><h6>Key Points</h6><ul><li>EpiCeram formulation includes ceramides, fatty acids, and cholesterol in a 3:1:1 ratio to simulate the intercellular lipid membrane of the skin barrier</li><li>EpiCeram has broad indications, including managing symptoms associated with various dermatoses like atopic dermatitis, irritant contact dermatitis, and radiation dermatitis</li><li>EpiCeram uses a patented time-release system which provides 24-hour barrier repair benefits with one application a day</li><li>While the product label recommends twice-daily application, data shows that once-daily application provides moisturization over 24 hours</li><li>EpiCeram's 2-sphere system prevents malodor by stabilizing lipids from premature oxidation</li><li>Early treatment is essential for radiation dermatitis, as barrier impairment can occur before clinical signs appear</li><li>Maintaining the skin's pH level is crucial for epidermal barrier function</li><li>EpiCeram should not be applied within 4 hours before radiation treatment, as recommended in the package insert</li></ul>

Advancements in Treating Vitiligo

Combination Therapy for Vitiligo

Watch short highlight videos summarizing information presented at FCPANP 2023 in Orlando!

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FCPANP 2023 Conference Highlights

What's New in Pediatric Dermatology

<p>In this session, Adelaide A. Hebert, MD, shares some important pearls for evaluating rare pediatric disorders as well as new therapies for some of the most common ones. She begins by discussing helpful resources to confirm a diagnosis of icthyosis or epidermolysis bullosa (EB). Dr. Hebert then updates the audience on a new treatment for dystrophic EB, topical beremagene geperpavec, which was approved by the FDA in May 2022. Patients as young as 6 months old have been treated weekly without any safety concerns. Next, Dr. Hebert discusses the treatment of infantile hemangiomas, which, if left untreated, have the potential to cause complications such as severe consumptive hypothyroidism or breast hypoplasia depending on the location. She recommends treatment with propranolol between weeks 3 and 8 of life twice or three times daily after feeding with dosing of 0.5 mg/kg/day for week 1, 1.0 mg/kg/day for week 2, and 2.0 mg/kg/day for week 3.</p><p>Next, Dr. Hebert reviews PIK3CA-related overgrowth spectrum disorders. Alpelisib has shown promise in the treatment of PIK3CA-mutated, hormone receptor-positive advanced breast cancer. Alpelisib can also be used to treat Klippel-Trenaunay syndrome. However, Dr. Hebert emphasizes that you must monitor for hyperglycemia, pneumonitis, and severe diarrhea. She then discusses the efficacy of selumetinib for neurofibromatosis. In the clinical trials, 40% of patients had a partial response and 71% of patients had clinically meaningful improvement. The side effects are all dermatologic, ranging from dermatitis acneiformis to maculopapular eruption and eczema. Dr. Hebert finishes the session by discussing new investigational treatment options for molluscum contagiosum. This includes berdazimer gel 10.3% and VP-102 which have shown promise in phase 3 trials.</p>

JAKs and TYKs - What You Need to Know

<p>In the ever-expanding world of systemic dermatologic treatments, busy clinicians may struggle to keep up with all of the recent approvals. In this session, Neal Bhatia, MD, provides an in-depth look at the efficacy and safety data of several Janus Kinase (JAK) inhibitors for a variety of inflammatory diseases including psoriasis, atopic dermatitis, alopecia areata, and hidradenitis suppurativa. Dr. Bhatia begins with an overview of the mechanism of action of JAK inhibitors as well as their safety profile and how to address the dreaded black box warning. He also highlights the increasingly common side effect of acne, colloquially known as “JAKne”. For upadacitinib, 13% of patients on the 15 mg dose and 17% of patients on the 30 mg dose developed acne, which was mild in two-thirds of cases. For abrocitinib, 2.9% of patients on the 100 mg dose and 6.6% of patients on the 200 mg dose developed acne that was mild to moderate in all cases. For baricitinib, 2.9% of patients developed acne across all doses.</p><p>Next, Dr. Bhatia reviews efficacy data from several pivotal trials. He starts with upadacitinib and its quick onset. By week 2 of the Measure Up 1 and 2 phase 3 trials, 38% of patients experienced EASI-75 by week 2. With regard to itch, 16% of patients experienced a numerical rating score (NRS) improvement of at least 4 points by day 2. This is important because breaking the itch-scratch cycle earlier than biologics leads to improved quality of life much quicker. In the abrocitinib phase 3 pivotal trials, 62.7% of patients on the 200 mg dose and 39.7% of patients on the 100 mg dose achieved EASI-75 at 12 weeks, compared with just 11.8% of patients on placebo.</p><p>Dr. Bhatia wraps up the session highlighting several medications that are in the pipeline as well as off label uses. This includes Jaktinib for atopic dermatitis, rilzabrutinib for atopic dermatitis and pemphigus, ritlecitinib and brepocitinib for alopecia areata, and deucravacitinib for lupus.</p>

Topical Management of Atopic Dermatitis and Psoriasis: Clinical Insights for Dermatology PAs and NPs

<p>Topical corticosteroids were once the mainstay of treatment for atopic dermatitis (AD) and psoriasis. Now, there are several non-steroidal topical therapies with proven efficacy and safety. In this session, James Q. Del Rosso, DO, and Linda F. Stein Gold, MD, give a thorough overview of these treatments and how to incorporate them into your practice. These include ruxolitinib 1.5% cream, a JAK inhibitor approved for mild to moderate AD in patients 12 and older, tapinarof 1% cream, an AhR-modulating agent approved for plaque psoriasis in patients 18 and older, and roflumilast 0.3% ream, PDE-4 inhibitor approved for plaque psoriasis in patients 12 and older.</p><p>Drs. Del Rosso and Stein Gold begin by reviewing several real cases where these medications made a dramatic difference for their patients. In particular, they discuss whether these non-steroidal topical therapies work quickly enough to be used as monotherapy. They show that with tapinarof 1% once daily monotherapy, patients experienced significant reductions in both itch and PASI score. Overall, in the two phase 3 pivotal trials, 35.4% and 40.2% of patients on tapinarof 1% once daily achieved an investigator global assessment (PGA) of 0 or 1 with at least a 2-point improvement, compared to 6.0% and 6.3% of patients on placebo, respectively. Importantly, they note that tapinraof was well tolerated and had a benign safety profile, even when applied to intertriginous areas. The most common adverse effects (AE) were folliculitis, contact dermatitis, headache, pruritus, and dermatitis.</p><p>Drs. Del Rosso and Stein Gold then present phase 3 clinical trial data for roflumilast 0.3% cream. In the parallel trials, 42.4% and 37.5% of patients on roflumilast achieved the primary endpoint of IGA success at week 8, defined as clear or almost clear skin with at least a 2-point IGA improvement, compared to 6.1% and 6.9% of patients on placebo, respectively. Notably, roflumilast was very effective for typically hard-to-treat intertriginous areas, with 71.2% and 68.1% achieving IGA success at week 8. Roflumilast was also well tolerated, with very low rates of application site reactions and no treatment-related serious adverse events.</p><p>Finally, Drs. Del Rosso and Stein Gold switch gears and discuss the efficacy and safety of non-steroidal topicals for AD. We know that the itch-scratch cycle can be very debilitating for patients with AD, so quick and effective treatment is critical. Dr. Del Rosso discusses a case of a 15-year-old student who failed multiple topical agents but achieved significant improvement in her itch after just two days of twice daily ruxolitinib 1.5% cream. This isn’t uncommon, as Dr. Stein Gold points out that 11.2% of patients achieved a 4-point improvement in itch after just 36 hours and 30.4% of patients achieved a 4-point improvement after 7 days in the pivotal trials. Additionally, up to 53.8% of patients on ruxolitinib 1.5% cream achieved IGA of 0 or 1 with at least 2-point improvement compared to just 15.1% on placebo. They close the session by discussing exciting new data for tapinarof cream and roflumilast cream for AD.</p>

Using Surgical and Medical Techniques to Manage Your Hidradenitis Suppurativa Patients

<p>Hidradenitis suppurativa (HS) can be very debilitating for patients and difficult for providers to effectively treat. In this session, Jennifer Hsiao, MD discussed both medical and surgical techniques to manage this disease. She began by reviewing the Hurley staging system, common HS comorbidities, and key considerations when deciding how to approach treatment. She reiterates that optimal management of HS involves a multifaceted approach, which includes managing friction/irritation, metabolic dysfunction, hormones, dysbiosis, follicular occlusion, and immune dysregulation.</p><p>Next, Dr. Hsiao focused on specific treatments for mild HS. She highlighted the importance of lifestyle modifications such as smoking cessation, weight loss, and avoidance of tight-fitting clothes. For topical treatments, she recommended clindamycin 1% gel or lotion and resorcinol 15% ointment. For increased efficacy, she suggested combining these with antiseptic washes such as chlorhexidine or benzoyl peroxide washes. Dr. Hsiao then discussed several systemic medications for mild HS, including oral doxycycline or minocycline 100 mg twice daily for 8-12 weeks, oral dapsone 50 to 100 mg daily, and oral clindamycin 300 mg twice daily with rifampin 300 mg twice daily for 12 weeks.</p><p>For moderate-to-severe HS, Dr. Hsiao shared that she likes to use biologics, especially adalimumab which is FDA approved for HS, and infliximab and secukinumab which are not yet approved for HS. In the clinical trial for adalimumab, at week 12 up to 58.9% of patients on weekly adalimumab achieved HiSCR, defined as at least a 50% reduction in inflammatory lesion count (abscesses + inflammatory nodules) and no increase in abscesses or draining fistulas when compared with baseline, compared to 27.6% on placebo. Two phase 3 clinical trials for secukinumab are underway, and so far, more patients have achieved HiSCR at week 16 than placebo.</p><p>Dr. Hsiao concludes the session with procedural management of HS. Her recommendations included intralesional triamcinolone 10 mg/mL – 40 mg/mL, incision and drainage for acute relief of abscesses, botulinum toxin injections, laser therapy, and deroofing or wide local excision. She also teases a few emerging medical therapies for HS, including anti-IL-1, anti-IL-36, and kinase inhibitors.</p>