WCH 2024 Conference Highlights

Join our esteemed Winter Clinical attendees and gain insights from the distinguished Nicholas Brownstone, MD, and Danny Zakria, MD, as they share their expertise during our captivating Welcome Reception!

Our first full day in Hawaii commenced with this favorite multispeaker session covering clinical pearls, novel treatments, and medication side effects. Clay Cockerell, MD, educated us on dermatoses with atypical histologic findings such as photodermatitis with minimal inflammatory infiltrate or a subepidermal blistering disorder in older patients with DIF-negative and cell poor findings often in relation to NSAID usage. He also detailed the shift to grade dysplastic nevi as low- or high-grade, the latter requiring excision and reevaluation. On all things hair loss, Dr Leavitt reviewed trichoscopy findings of androgenetic alopecia, lichen planopilaris, and CCCA. He recommended trialing minoxidil for at least 6 months for multiple subtypes of alopecia. One small trial (n=89) did not show significant impact on blood pressure. Joslyn Kirby, MD, recommended trialing adapalene 0.1% for acanthosis nigricans and gave us an easy tip for picking patients, including children with atopic dermatitis and adults with acne: hydrocolloid patches. N-acetyl cysteine, though it can cause GI upset, can also be used for picking patients dosed at 600 mg to 2400 mg daily. Dr Green gave us some tips on prescribing antibiotics for acne, including adding a probiotic after dosing, preferably the liquid formulations, and to minimize treatment to 3 months. Spironolactone may also be a viable antibiotic-sparing treatment even for nonhormonal acne. Dr Lebwohl showed us 2 multicenter RCTs using cantharidin in molluscum contagiosum with superior clearance response in the head/neck and groin regions. He also covered a review of laboratory tests in chronic urticaria and angioedema, which very rarely impact management. All doses of omalizumab significantly improved itch severity score in patients with antihistamine-refractory chronic urticaria and spontaneous urticaria, and the risk of anaphylaxis with this medication is estimated to be 0.2% from reports of about 57000 patients. For those with uremic pruritus or notalgia paresthetica, a new medication, difelikefalin, has dramatically impacted itch scores as soon as one week in multiple RCTs and may be useful in patients with refractory itch in atopic dermatitis.

In our first full day of lectures, Amy McMichael, MD, kicked off this update on alopecia areata with an examination of alopecia areata (AA) epidemiology. The disease is most prevalent in non-White females, including Asian, Black, and Hispanic women, and this trend carries through from the pediatric to adult population. Prevalence increases in patients with other atopic conditions, but AA also is associated with diabetes, thyroid disorders, hypertension, obesity, and depression. On dermoscopy, this condition is characterized by exclamation point hairs, which should be differentiated from pigtail hairs in tinea capitus, and yellow dots within the follicular ostium. She shifted gears to review treatments for alopecia areata, some decades old and some new to the marketplace in 2023. For refractory alopecia areata, contact immunotherapy such as topical squaric acid dibutyl ester has been used despite risk of cutaneous side effects, which can range from mild to severe. Like all treatments for alopecia areata, maintenance is required to reduce incidence of relapse. Dr McMichael showed 2 trials that used oral minoxidil. While on its own this hypertensive drug rarely led to significant hair growth in patients with AA, it may boost efficacy of other systemic agents, as one patient only responded to tofacitinib after its addition into the treatment regimen after a year of solo therapy. Another combination treatment that has been studied is methotrexate with low-dose prednisone, which allowed for complete regrowth in 7 of 35 patients with either alopecia totalis or universalis, despite many of the responders obtaining <25% hair regrowth with 6 months of methotrexate alone. There are some new prominent players in the treatment of alopecia areata, which is now understood to be a complex inflammatory condition. While topical ruxolitinib was not demonstrated to be effective, oral JAK inhibitors are nothing short of a monumental breakthrough for AA with the approval of barcitinib for adults, ritlecitinib for ages 12+, and deuruxolitinib currently in a long-term extension study. Dr McMichael recommended uptitrating to 4 mg in patients who do not respond to the 2-mg dose of baricitinib. Some emerging treatments to be on the lookout for include bempikibart (an IL-7 receptor inhibitor), ustekinumab, other JAK inhibitors, and dupilumab. Platelet-rich plasma and microneedling may also be powerful adjunct therapies.

Hidradenitis suppurativa is a life-altering diagnosis that impacts all aspects of a patient’s life from professional to psychosocial. In this presentation delivered by Joslyn Kirby, MD, the acting president of the Hidradenitis Suppurativa Foundation, emerging therapies that may change the landscape of this difficult-to-treat disease were covered along with clinical practice tips to assess treatment response. She recommended seeing patients every 4 to 6 months to assess for migratory lesions, which may indicate the need to switch treatment regimens, or persistent lesions, an indicator that procedures might be the next step. Beyond adalimumab and infliximab, secukinumab, an IL-17A inhibitor, 300 mg weekly for 5 weeks followed by a bimonthly dosing regimen, achieved 50% reduction in inflammatory lesion count by 16 weeks. Bimekizumab, which has high affinity for both IL-17A and IL-17F, also has demonstrated promising results. JAK inhibitors are another encouraging treatment path for this disease, though we still await results of ongoing clinical trials. Besides new biologic medications, other innovations in the field of HS include smartphone photos to harness artificial intelligence to aid in the diagnosis HS. Given the plethora of antimicrobials sometimes erroneously recommended to these patients, this technology could be useful for medical providers. Early prototypes detected moderate to severe HS with 79% sensitivity and 77% specificity. Dr Kirby also detailed up-to-date bench research on the genetics involved in HS, which may provide insight into its complex pathogenesis and potential therapeutic targets. Some things to be on the lookout for are the use of topical ruxolitinib cream and topical aryl hydrocarbon modulators for more mild disease, both of which are currently undergoing trials.

JAK inhibitors have flooded the dermatopharmacologic market with indications for many inflammatory dermatoses. Drs Golant and Del Rosso covered the physiology of this medication class along with important trials and safety data. As a quick reminder of the JAK STAT pathway, extracellular binding leads to JAK-receptor dimerization and phosphorylation of STAT proteins. Dimerized and phosphorylated STAT proteins translocate into the nucleus to activate target gene transcription. The dimerization of the JAK receptor is of particular importance as it is selective for a variety of interleukins and cytokines. While at high concentrations, JAK inhibitors likely would block all JAK receptors, they have selectivity: baricitinib is preferential for both JAK1 and JAK2, while abrocitinib and upadacitinib primarily inhibit JAK1 and secondarily JAK2.They moved on to review important trials on JAK inhibitors, like the MEASURE UP and JADE MONO trials, and the comparisons against dupilumab. Both doses of upadacitinib were effective in reducing EASI scores and, impressively, pruritus scores within 2 days of treatment in patients with atopic dermatitis. At 16 weeks, more than 60% of patients on upadacitinib 30 mg obtained an EASI 90 compared to <40% of those on dupilumab monotherapy. In JADE COMPARE, which compared abrocitinib and dupilumab while patients were utilizing topical steroids, efficacy between dupilumab and high- and low-dose abrocitinib was similar. JAK inhibitors have been able to achieve more stringent endpoints for atopic dermatitis compared to dupilumab, which may alter our patients’ expectations of treatment response. Safety is an extremely important topic when discussing JAK inhibitors with patients considering the class-wide black box warning for mortality and major cardiac events. This resulted from a post-marketing study in tofacitinib use for rheumatoid arthritis patients. In atopic dermatitis, acne, headache, and nasopharyngitis are the main adverse events related to treatments. For older patients, there is an increased incidence of herpes zoster, and age-appropriate vaccination should be encouraged. Recommended labs include CBC, CMP, and fasting lipid panel, along with pregnancy, hepatitis, and tuberculosis screening at baseline. CBC, CMP, lipids and CPK should be rechecked every few months.

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While blood work is often unnecessary to diagnose most alopecia subtypes, Dr. Leavitt did explore the association between vitamin D deficiency and insufficiency in CCCA which could be an easy target for supplementation if studies examine the impact on this progressive disease course. Linda F. Stein Gold, MD went through some clinical pearls on atopic dermatitis, reporting that patients often can complain of itch even after skin lesions resolve and that failing one biologic doesn’t necessarily preclude success with another. Shifting to skin and soft tissue infections, Dr. Tomecki recommended against antibiotics unless in a high-risk patient, severe or system, or otherwise complicated, preferring incision and drainage as first-line treatment. Further, compression stockings may prevent recurrent cellulitis.Some new medications covered in this section were sonidegib, a hedgehog pathway inhibitor, for advanced basal cell carcinoma, nemolizumab for prurigo nodularis, and dupilumab for chronic pruritus of unknown origin all presented by Dr. Lebwohl. Aphthous stomatitis was effectively treated with vitamin B12 and apremilast in two RCTs. Dr. Green also gave us some surgical tips like using intradermal sutures for closures on the back to improve closures and when, why, and how to document appropriate undermining.

In this multispeaker session, psoriasis, its subtypes and its treatments, were reviewed. The clinical treatment of palmoplantar psoriasis, which should be considered separately from plaque psoriasis with palmar involvement, was covered by E. James Song, MD, who laid out his algorithm for management, starting with cyclosporine often combined with phototherapy, topicals, retinoids, and biologics before switching to methotrexate to maintain response. To mitigate adverse reactions with methotrexate, Dr. Song recommended increasing folic acid, splitting the daily dose, or adding ondansetron for GI intolerance, while nonspecific complaints may be helped by adding dextromethorphan on dosing days. He emphasized that treatment can’t be expected to mimic psoriasis vulgaris, and that monotherapy is often inadequate. JAK-inhibitors may be a promising new treatment for refractory disease as shown in a case series of 7 patients on tofacitinib.Next a thought-provoking case series on patients with psoriasis developing spongiotic dermatitis following IL-17 inhibitor treatment was presented by Alice Gottlieb, MD. One patient discussed in particular failed subsequent anti-IL-23 treatment and, in the end, responded to upadacitinib, which also improved their psoriatic arthritis. Conversely, Dr. Gottlieb presented data on a small subset of patients with AD treated with dupilumab who developed enthesitis, arthritis and/or tenosynovitis suggestive of psoriatic arthritis (26 of 470). Symptoms ranged from mild, which could be treated with temporary discontinuation, dose reduction, or NSAIDs, to moderate-to-severe, which persisted for months despite reduction or discontinuation of dupilumab. Mark Lebwohl, MD gave us some actionable tips to prescribe oral PDE4 inhibitors for our patients and managing associated side effects. In a pooled analysis of patients with psoriasis (ESTEEM 1&2 trials) and psoriatic arthritis (PALACE 1 trial), treatment-associated diarrhea more commonly began within 1 week of starting apremilast and lasted for 1 to 2 weeks, compared to placebo-reported diarrhea. Taking apremilast with food and avoiding caffeine may be enough to ameliorate GI symptoms, but loperamide and fiber supplements are options for persistent or severe symptoms. His next tip focused on clinical administration of spesolimab for GPP, reminding us to assess for active infection, including WBC counts and/or CRP, if clinically indicated, prior to initiation in addition to tuberculosis testing. Dr. Lebwohl’s last pearl shed light onto psychiatric concerns with brodalumab for psoriasis patients with a history of depression. While vigilance is always recommended, detailed analysis of RCTs did not incur a causal relationship between completed suicides and brodalumab and in fact demonstrated improvements in Hospital Anxiety and Depression Scales with treatment.

Mark Lebwohl, MD kicked off a summary of the newest developments in the world of psoriasis with a review of two newly approved therapeutics: bimekizumab and spesolimab. In the BE VIVID trial (n=567), bimekizumab, the IL-17A and IL-17F inhibitor, was superior to both placebo and ustekinumab with 85% of patients achieving PASI 90 at Week 16, compared to 5% and 50%, respectively. Even more remarkable is that almost 60% of patients on bimekizumab achieved a PASI 100 at Week 16. In the BE ACTIVE trial, all bimekizumab dosing arms achieved significant improvements in ARC scores, a marker of psoriatic arthritis, as early as week 12. Spesolimab, the newest biologic on the market for generalized pustular psoriasis, is an IL-36 receptor inhibitor that demonstrated rapid pustular clearance at one week in 54% of patients, compared to 6% treated with placebo. Further, research has demonstrated that high-dose spesolimab may be the key to preventing flares of this recalcitrant disease in a 48 week study. Dr. Lebwohl encouraged us to keep on the lookout for data from another IL-36 receptor inhibitor, imsidolimab, which was also recently trialed for use in GPP. The next part of his presentation covered exciting updates on more established biologic therapies for psoriasis: anti IL-23, anti IL-17, and anti-TNF molecules. Oral formulations of these inhibitors are now in trials, such as an oral IL-23 receptor antagonist that demonstrated significant efficacy in a phase 2 dose-ranging trial, FRONTIER 1. An oral IL-17A inhibitor is also on the horizon, with the higher 800mg BID dose causing a 40% improvement in PASI within one month in a small phase 1c trial for mild-to-moderate psoriasis. Lastly, an oral anti-TNF that inhibits only the TNFR1 signal by binding soluble TNFα, which is more involved in inflammation, demonstrated PASI improvements by week 2. Ending with other oral options for your psoriasis patients, Dr. Lebwohl reviewed new data on the TYK-2 inhibitor, deucravacitinib, and the PDE4 inhibitors, apremilast, roflumilast, and orismilast. Extension trials on deucravacitinib show maintenance of PASI and sPGA in week 16 PASI 75 responders over a 3 year observation period without notable laboratory trends, serious infections, or herpes zoster activation compared to placebo. Apremilast was also shown to be as safe as placebo in a large pooled analysis of patients with psoriasis, psoriatic arthritis, and Behcet’s syndrome in addition to being efficacious in a 16 week pediatric psoriasis trial. Lastly, Dr. Lebwohl covered cardiovascular implications in psoriasis, in particular data from a trial with roflumilast that showed a significant decrease in cardiometabolic parameters, including BMI, by week 12. This may provide an important added benefit for obese patients struggling with weight loss and psoriatic disease control.

Major developments in the treatment of acne and rosacea in the past year have changed the face of these two common clinical conditions. In this relevant update, Hilary Baldwin, MD started by refreshing us on a consensus shift in literature to phenotypes of rosacea rather than distinct subtypes, all of which maintain centrofacial erythema as the key diagnostic feature. Other features of rosacea such as telangectasias, flushing, papules, and ocular manifestations are not diagnostic in and of themselves but useful to assess severity when considered all together. The shift from subtypes to phenotypes is particularly important, Dr. Baldwin assured us, when considering treatment options and algorithms. Specifically, for papules and pustules, treatments remain focused on topical antimicrobials including ivermectin 1% cream, minocycline 1.5% foam, and microencapsulated benzoyl peroxide 5% with or without the addition of an oral tetracycline or isotretinoin. Oral options include sarecycline, which has narrower antimicrobial activity compared to other tetracyclines, and low-dose extended-release minocycline which showed superiority at all timepoints to the customary 40mg doxycycline. For persistent facial erythema, Dr. Baldwin recommended alpha agonists like brimonidine and oxymetazoline, beta blockers for flushing, and vascular lasers for telangiectasias. While the potent vasoconstriction by alpha agonists makes them a clear choice for any erythema acutely, a more recent study showed that the efficacy of oxymetazoline cream increased overtime as patients had improvement in even pre-application erythema severity scores at 52 weeks with consistent application. One clinical pearl is to target perilesional erythema by treating papules and pustules rather than targeting the erythema itself. She concluded the rosacea portion by reviewing some atypical treatments such as mast cell stabilizers and botulinum toxin, which also inhibits mast cell degranulation as well as decreasing substance P release and calcitonin gene-related peptide to decrease erythema. Acne, one of the most common conditions seen in the clinic, affects a wide range of ages and Fitzpatrick skin types. Dr. Baldwin reviewed some accessible topicals that have emerged for acne including microencapsulated benzoyl peroxide 3%/tretinoin 0.1%, which was more efficacious than either component alone without an increase in adverse events, and clascoterone 1% cream, a promising new androgen receptor inhibitor. Due to rapid metabolism in the skin into cortexelone, which has no anti-androgenic activity, it is considered safe for men, and results from a RCT demonstrated significant efficacy with about 20% of patients achieving an IGA score of 0 or 1 by week 12. Perhaps the most exciting novel treatment for acne vulgaris is the 1726nm Nd:YAG laser which destroys sebocytes and is safe for use in darker skin types. Dr. Baldwin concluded by presenting data in over 100 subjects with mostly moderate acne vulgaris who were treated with 3 total 30 minute monthly laser treatments. 80% of patients obtained a greater than 50% reduction in inflammatory lesion count 3 months after their final treatment. Overall, this session reviewed some practice-changing therapeutics for rosacea and acne vulgaris, which have taken center-stage of innovation in inflammatory skin disease.

Dr. Del Rosso led an engaging and data-driven session on new therapeutics and updated guidelines, though he did remind us that while new medications are constantly in development, many tried-and-true formulations remain the anchored in treatment algorithms. The art of medicine is determining when dupilumab, for example, remains an excellent choice, where topical corticosteroids fit into a regimen, and which patient needs something more nuanced. He started his presentation by reviewing topical medications for itchy and inflammatory conditions, such as topical ruxolitinib which shows significant impact on patient report of itch in AD in even 2 days. Topical tapinarof, an acrylic hydrocarbon receptor modulator, works by regulating Th2 cell differentiation as well as reducing resident memory T-cell generation. In 2023, an 8 week RCT in >= 2 year olds showed significant impact on IGA, EASI, and Itch scores in AD though follicular events are a pertinent side effect that can be minimized by avoiding normal skin and applying a thin layer of the ointment. Further, as a steroid sparing agent, tapinarof’s usage in intertriginous psoriasis in a phase 4 trial showing iPGA of 0 at week 12 in 65% of patients is particularly vital. Topical PDE4 inhibitors, which interrupt the inflammatory cAMP pathway, are another steroid-sparing agent, and roflumilast has shown efficacy in seborrheic dermatitis, psoriasis, and atopic dermatitis. A long-term open label extension study using roflumilast 0.15% twice weekly maintained efficacy in about 50% of patients, defined as an IGA of 0 or 1, with AD. For psoriasis, the cream at 0.3% achieved PASI 75 in 40.3% and a PASI-HD-75 in almost 60%, a more precise assessment of severity when BSA<10%. Roflumilast 0.3% foam was also used effectively for skin and scalp seborrheic dermatitis. No relation to diarrhea has been seen with the topical formulations.Systemic players are nemolizumab, the IL-31 inhibitor, which interrupts the itch cycle at the immune and nervous system level, lebrikizumab, the IL-13 inhibitor that is a promising new injection for atopic dermatitis, and bimekizumab, the IL-17A and IL-17F inhibitor that shows dramatic clinical efficacy rapidly in plaque psoriasis, with 90% of patients achieving PASI 90 by week 16. While medications for inflammatory conditions can lessen symptoms and signs, many patients, after achieving control, wonder if treatment can be stopped and remain in remission. Dr. Del Rosso addressed this question starting with dupilumab, which has data to support prolonging dosing to every 4 weeks if atopic dermatitis is well controlled. However, new systemic medications may be able to target memory T cells which perpetuate eczema flares in atopic, but normal appearing, skin. Rocatinlimab, the OX-40 inhibitor, is one of these potentially disease-modifying drugs, as the OX40 pathway promotes differentiation of activated effector T cells into memory cells. Amlitelimab, the OX-40L inhibitor, is another such medication currently under study with 40% and 60% of patients achieving an EASI 75 at Week 16 and Week 24 respectively. These pathways may not be as rapid as JAK inhibitors, but more data is required to assess if they can truly lead to a period of disease-free remission after dosing.

For the final round of 60 tips in 60 minutes, inflammatory skin diseases, rare infectious diseases, and with a few general life pearls were delivered. Mark Lebwohl, MD reviewed a few highly recalcitrant disease treatments including penicillin to decrease recurrence of cellulitis and timolol gel for chronic venous leg ulcers. Timolol ophthalmic solution (0.5%) applied topically can also be used for hypergranulation seen in hidradenitis suppurativa, Dr. Kirby told us. Other tips in the management of HS include utilizing the HS foundation website which has prior authorization templates for a variety of systemic drugs and laser hair removal. Dr. Stein Gold covered two RCTs for topical atopic dermatitis medications: roflumilast and tapinarof. She also reviewed promising long-term results from the 1726nm laser for acne in 104 subjects followed for 12 months. Lesion clearance and IGA were improved at the 12 month mark post treatment even compared to 3 months after completion of the regimen. A few new infectious etiologies were brought to our attention by Dr. Tomecki, including Orf virus, a pox virus, which leads to contagious ecthyma contracted from sheep, goats, oxen, and reindeer, as well as talaromycosis, a soil-dwelling fungus. Our hair loss pearls in this session were delivered by Dr. Leavitt who covered dutasteride in depth. He started by reviewing a series of patients with frontal fibrosing alopecia (n=224) who were followed for at least 12 months while on dutasteride or another systemic therapy, such as hydroxychloroquine, doxycycline, and isotretinoin. Those on dutasteride had higher stabilization rates than the other groups, around 60% in all scalp regions. Dutasteride for androgenic alopecia was also deemed superior to finasteride and minoxidil, but he recommended combination therapy for maximal benefit. Dr. Siegel gave us a helpful clinical pearl to scrape rather than clip nails for a KOH prep. Leaving us with a few real life warnings, he recommended backing up our documents and photos often and taking steps, like ultra-wideband technologies in tags and cards, to prevent us from losing our electronic devices for those of us who seem to misplace things all too often.

Keeping up with cosmeceuticals can feel like a full time job as the field has grown to include everything from botanicals to exosomes. To make things more challenging, our patients increasingly desire clarification on postulates consumed on social media regarding myriad products and techniques. Emmy Graber, MD walked us through the data to ensure we have all the information to answer our patients’ questions and contextualize the newest skincare trends. The current on-trend ingredient list she covered includes niacinamide, snail mucin, alternative retinoids, which differ from their prescribed counterparts as they do not bind directly to nuclear retinoid receptors, and mushrooms. Niacinamide has shown substantial growth in the past few years for its seemingly innumerable benefits by inhibiting sebum production and inflammatory cytokines, increasing production of collagen and skin barrier lipids thereby reducing transepidermal water loss, and decreasing melanosome transfer to keratinocytes. One placebo-controlled split-face trial (n=50) showed decreased fine lines, hyperpigmentation spots, and redness with the use of niacinamide 5% in middle-aged women in 12 weeks. Another split-face trial (n=50) in patients with rosacea also demonstrated improvement in a variety of features including inflammatory lesions and erythema by week 4. Snail mucin, another hot topic in the cosmeceutical industry, contains secretions from cryptomphalus aspersa which, in a 14 week split-face RCT, demonstrated significant improvement in periocular rhytides that persisted 2 weeks after discontinuation of this anti-photoaging product. Alternative retinols, or “bio-retinols”, such as bakuchiol have been touted to be less irritating, and this was supported by a RCT in which patients applied either bakuchiol 0.5% cream twice daily or retinol 0.5% cream daily. Bakuchiol users did report less skin scaling and stinging without significant impact to grading of rhytides. The last popular ingredient Dr. Graber discussed was mushrooms, which may be referred to as “adaptogens”. One study on veratric acid, which can be derived from medicinal mushrooms, reported significant impact on rhytides by modulating matrix metalloproteinases and epidermal layer integrity. More studies are required to ascertain efficacy against alternative options. She concluded by addressing an emerging concern of visible light in photoaging by inducing reactive oxygen species. An adequate method to mitigate this is opting for a sunscreen product with antioxidants.

This is always a favorite multispeaker session that provides useful pearls on a wide range of dermatologic diagnoses and therapeutics. Boni Elewski, MD kicked off this session by discussing a popular option for alopecia, minoxidil, which in a combined review of 17 studies and over 630 patients showed efficacy in androgenic alopecia, telogen effluvium, lichen planoilaris/frontal fibrosing alopecia, alopecia areata, and chemotherapy induced hair loss. A larger review (n=1404) of adverse events with low-dose minoxidil highlighted hypertrichosis and effects related to the drugs impact on blood pressure like light-headedness, tachycardia, and fluid retention (all <2%), the latter of which Dr. Elewski recommended could be ameliorated with the addition of spironolactone. Rarely, the drug has been linked to generalized anasarca including pericardial and pleural effusion. The next pearls focused on treatment of actinic keratoses and the efficacy of PDT, imiquimod, 5-FU, and other treatments. Dr. Pariser delved into the reasons behind different reported reduction rates between trials including patient adherence, the addition of curettage before PDT, and the grades of AKs studied. Other PDT pearls to enhance efficacy are to use heat, “thermal PDT”, prior to treatment and occlusion on the extremities. He also covered a novel phase 3 trial that used PDT for superficial BCC successfully.Giving answer to an pertinent clinical question, Dawn Merritt, DO presented data from a prospective multicenter study examining patch test results before and during dupilumab treatment (n=36); results were 83% congruent with 3.6% turning negative i.e. patch tests maintain reproducibility. She also covered chronic urticaria and reported that omalizumab can be uptitrated to 600mg or dosed every 2 weeks for uncontrolled patients. For patients with 6-9 months without attacks, she recommended decreasing dosage by 150mg monthly until the patient is on 150mg monthly at which point the interval can be widened to 6 weeks before stopping entirely. After discontinuation, if the patient does flare, luckily there is a strong recapture rate at normal dosing levels. For the clinician, tips for practice were to use a scribe both to minimize charting time and maximize patient volume, and to try placing steri-strips parallel to incisions to help brace external sutures in thin and friable tissue. Though research on biotin supplements is conflicting, many patients take these vitamins, sometimes in high doses which can impact various laboratory results. Dr. Elewski explained that high doses of biotin can lead to the misdiagnosis of hyperthyroidism by impacting streptavidin-biotin based immunoassays and cause both falsely low and high troponin levels, depending on the test used. Patients should halt supplements at least 72 hours prior to scheduled testing when possible. Dr. Nguyen covered a few unique treatment indications including dupilumab for bullous pemphigoid at standard AD dosing, apremilast for generalized granuloma annulare, and topical ruxolitinib for connective tissue diseases like CLE and dermatomyositis. He also proposed a few atypical medication formulations such as topical cyclosporine, 100mg capsules of which can be compounded with 100% vitamin E oil, for PG which improved both ulcers and patient symptoms in 6 of 7 patients in a case series. Another case series he presented treated toxic erythema of chemotherapy and radiation dermatitis with very high doses of vitamin D (50,000-100,000IU).

This has been a big year for botulinum toxin, with the approval of the touted longer-lasting daxibotulinum toxin A. Dr. Goldberg presented a summary of the updates in this principal dermatologic class. He started off by reviewing unit equivalence when diluted with 0.9% sodium chloride: 1U ONA: 1.5U INCA: 1.5U PRA: 2.5U ABO. Addressing a long-standing question on toxin use, he reviewed an open-label clinical trial using high dose (120U) of abobotulinum toxin for glabellar lines to assess impact on duration of effect. Patients were followed monthly for up to 11 months, and the >75% of subjects had a duration of >120 days of at least 1 point improvement on investigator IGA, long over what is considered its typical dose-duration. Enter daxibotulinum toxin, which has been approved by the FDA with a median duration of effect of 6 months. High dose and novel formulations of botulinum toxin will impact clinical care and potentially consistent results until they are adequately tested. In the second half of this presentation, Dr. Goldenberg focused on injection techniques discussing lateral brow lift via the orbicularis oculi and the medial frontalis, lip lift via the depressor anguli oris, and “gummy smile” via the levator labii superioris. Perhaps more importantly, he also reviewed danger zones that are rife with poor outcomes. Lastly, in a world where patients can increasingly obtain botulinum injections from outside a physician’s office, Dr. Goldenberg stressed the importance of marketing. Start with the cosmetic consultation, and your connection to the patient already in your office. After this, emailing prior patients with promotions and educational content is a good way to keep them coming back, while social media should present your “brand” consistently to newcomers.

Roger Ceilley, MD took us through a riveting review of the innovations in photodynamic therapy but not before completing an overview of its mechanism of action and some industry updates for clinical practice. Notably, a new red light laser (635nm) has garnered FDA approval with a flexible multipanel lamp for full face coverage, and CPT codes strictly dictate clinician involvement in PDT procedure: 96567 for no direct participation, 96573 for clinicians applying photosensitizer and initiating light illumination, and 96574 for the performance of curettage or debridement prior to PDT. He emphasized the importance of setting expectations, especially surrounding one of the major disadvantages of PDT which is the discomfort and erythema that remains post-procedure. While compliance with PDT remains much higher than that for topicals in the treatment of actinic keratoses, Dr. Ceilley proposed multiple methods to mediate patient discomfort. One split-face study that compared blue light PDT with two photosensitizers, 10% ALA-gel and 20% ALA solution, demonstrated that the gel formulation was associated with significantly less local skin reactions. Other options to mitigate pain include fans, cold compresses, antihistamines, and topical or local anesthesia, though modifications to the actual treatment regimen, i.e. shorter incubation times or lower irradiance, may be the most effective. Even immediate irradiance, “simultaneous PDT”, for 30 – 60 minutes after application of ALA could be a promising option to dramatically lower pain scores while maintaining almost identical clearance rates to conventional PDT in another, albeit small (n=23), split-face study. Moving on to treating the extremities and trunk, Dr. Ceilley showed that efficacy can be increased with the addition of occlusion dressing during the incubation period or with pretreatment of adapalene for 7 days in two RCT trials. Microneedling prior to treatment with ALA appeared to have less dramatic results, with improved AK clearance after 20-minute incubation but not for 10-minute incubation. While simultaneous PDT may be effective for the face, he recommended sticking to an incubation time of at least 2-3 hours for the extremities. Other tricks to increase efficacy of PDT include adding cryotherapy before incubation and warming the extremities before irradiance, called “thermal” PDT. New frontiers include the use of PDT for alternative conditions like photodamage, which has already shown promising results, inflammatory conditions like acne and psoriasis, and cutaneous T-cell lymphoma.

While assessing and diagnosing a problem, educating the patient, and picking an appropriate treatment are essential pieces of almost every new patient encounter, ensuring the patient actually acquires this treatment can be an entirely separate battle. G. Michael Lewitt, MD, took us to the front lines to highlight key challenges in obtaining biologic medications for both our patients and our offices. Dermatologists are often hindered by a lack of knowledge and significant time required, which may be compounded if the practice lacks a “biologic coordinator”. Dr. Lewitt’s first tip is to find a biologic mentor who can recommend a good specialty pharmacy, provide examples of prior authorization letters, and support when denials inevitably return. Patients can be discouraged by the prior authorization process as well because it requires adequate medical literacy to negotiate insurance claims, seek a provider who is willing to prescribe treatment, and switch pharmacies. Despite these hurdles, Dr. Lewitt encouraged us to stick with the process not only because there is significant demand and a paucity of providers, but because patient improvement can be dramatic. Consider that before biologics, most generic medications for inflammatory conditions consisted of topical steroids. For patients with severe disease, the amount they can progress with a shift from topicals to biologics is life-changing. While biologics may make up only ~10% of prior authorizations, in a study from a single academic center, they take up almost 25% of staff time. Some options that exist to assist patients in obtaining needed medications are copay cards and assistance programs. Copay cards are used to place payment ceilings on drugs for commercially-insured patients, and is set nationally, whereas patient assistance programs (PAPs) are unique to each pharmaceutical company. PAPs may be a good option for low-income individuals who are uninsured or insured but denied coverage; they can also assist Medicare Part D enrollees by operating outside of the Part D benefit. Lastly, bridge programs are generally short-lived programs during coverage caps or delays for newer medications. Dr. Lewitt also reviewed some important terminology in the approval process: accumulators, maximizers, and step therapy. Accumulator programs apply only to medications without biosimilars or generic alternatives and work to exclude a patient’s copay cards or any manufacturer support in their contribution to their deductible or out-of-pocket maximum as a way to control drug spending. However, an important lawsuit in September 2023 may lead to the appeal of this rule which could have far-reaching impact on patients and manufacturers alike. Maximizers set an individual’s cost-sharing amount as the maximum manufacturer copay assistance either broken into even monthly intervals or frontloaded into the early months, after which the maximizer would cover the full cost of the drug. The last definition he reviewed was step therapy which is implemented by insurance companies to start patients on the most cost-saving drug options, however he emphasized that documentation is the best offense in this situation.

It is essential to understand billing and coding to run a successful practice, and Mark Kauffman, MD delivered a rigorous session to get us up to speed on coding strategies and the current fiscal physician landscape. He informed us of the dramatic decrease in physician reimbursement throughout the 2000s. While lobbying, legislation, and larger bureaucratic changes are required to truly fight inflation’s impact on physician salary, there are some small steps to take in your practice right now. He warned us to be aware of E/M leveling as payers begin to lump diagnoses into specific complexity levels robbing clinicians of the ability to make appropriate claims. These leveled claims should be appealed if necessary. Perhaps one of the most actionable tips Dr. Kauffman gave us is that suture removals can now be billed to capture clinic supplies required for these minor procedures. Explicitly, 15853 should be used for removing sutures or staples, whereas 15854 should be used for sutures and staples. However, both of these codes are for 0-global day procedures or can be used when outside of a global period when an E/M service is performed in the office setting, such as reviewing pathology results. They can never be reported during a global period of any procedure. A few notable changes to the 2024 Current Procedural Terminology book: 96920-96922 for the treatment of psoriasis with excimer laser now requires both a specific diagnosis and specific laser for billing. Dr. Kauffman ended this session by reminding us to use the entire fee schedule including facility fees or J codes when a drug requires an infusion or injection. In practices with multiple subtypes of dermatologists, such as pediatric, procedural, and dermatopathologic, each physician can bill and be paid without regard to their membership in the same group. Important dermatologic taxonomies are as follows: Dermatology 207N00000X, Mohs Surgery 207ND0101X, Clinical and Lab Derm Immunology 207NI0002X, Pediatric Dermatology 207NP0225X, Procedural Derm 20NSO135X, and Dermatopathology 207ND0900X.

April Armstrong, MD filled this jam-packed session with treatments and techniques to use in difficult dermatoses. She started by detailing a multi-sectioned retrograde injection of certolizumab (total 60mg in 0.3mL) every 4 weeks for 3 months for refractory lupus pernio, and then moved on to another resistant disease, palmoplantar pustulosis. Guselkumab, risankizumab, and brodalumab are all approved for palmoplantar pustulosis internationally, though topical steroids remain the most commonly prescribed treatment in a review of almost 200 patients. In a case report, tocilizumab, an IL-6 receptor inhibitor, was used for corticosteroid-refractory immune checkpoint inhibitor-induced generalized morphea. Botulinum toxin A was used to treat primary palmar hyperhidrosis but effectively cleared concomitant yellow nail syndrome in another case report. Another few case reports showed promising results of JAK-inhibitors for novel indications. Netherton syndrome, a rare autosomal recessive skin disease characterized by hair shaft defects and ichthyosis, was treated successfully with abrocitinib, while a patient with epidermolysis bullosa acquisita who failed high dose prednisolone and methotrexate was treated successfully with tofacitinib, allowing him to taper prednisolone to 5mg at 20 months. Severe lupus miliaris disseminatus, a facial granulomatous skin disease, that was unresponsive to oral doxycycline and topical ivermectin, responded to topical ruxolitinib 1.5% cream. Moving on to more common clinical syndromes, Dr. Armstrong detailed a needle-free injection technique of 5-flurouracil for verruca vulgaris which involves paring with a scalpel without reaching bleeding point and then using a spring loaded mixture of 5-FU and lidocaine into each wart. Two treatments led to complete resolution without hyperpigmentation. She also covered the hot topic of venous thromboembolism in atopic dermatitis patients on JAK-inhibitors. In a meta-analysis of 466,993 patients of patients with AD, 3 of 5722 (0.05%) on JAK inhibitors experienced VTE compared with 1 of 3065 (0.03%) receiving placebo or dupilumab, indicating no increased risk of VTE in AD patients.

In an exhilarating review of what is new in dermatologic surgery, Brett Coldiron, MD took us through topics that he found to be noteworthy in 2023. He started by reviewing treatments for basal cell carcinoma, including a small study from Sweden demonstrating efficacy of Mohs surgery as an initial treatment and another that compared curettage and cryosurgery. Out of 228 superficial basal cells in 97 patients, those who received cryosurgery had no recurrence at 1 year while 5 of 115 that were treated with curettage demonstrated histopathologically verified recurrence. While superficial basal cells do well with a variety of treatments, squamous cell carcinoma has numerous reports of bone invasion mostly on the skull emphasizing the importance of completely clear margins. Rounding out the discussion of skin cancers with melanoma, Dr. Coldiron reviewed a large cohort study that examined the impact of time between diagnostic excision biopsy and sentinel lymph node biopsy. In short, out of over 10,000 patients, no significant association was seen in overall survival and time until SN biopsy or SN positivity. With the advent of PD-1 inhibitors, treatment algorithms for primary melanoma may be changing. One study from JAMA Dermatology on stage-specific risk of melanoma highlighted the inaccuracy of TMN staging on predicting overall survival and pushed for an increase in PET scans for thicker lesions or immunotherapy with resultant high risk gene analysis. In the second half of this presentation, he covered a few rare cancers and distinguished pearls. Cutaneous leiomyosarcoma may have more clinical variability due to different muscular origins. More aggressive varieties are TP53 +, RB1 +, and MYOCD amplification. Recurrence should be minimized by wider margins and potentially Mohs. One study published in JAAD showed a significant risk of recurrence and disease-specific death when postoperative radiation was delayed more than 8 weeks for Merkel cell carcinoma. Dr. Coldiron also presented some odd factoids to be aware of such as a 10% increased skin cancer risk in patients taking statin medications and a lack of bleeding complications with patients on novel oral anticoagulants during Mohs micrographic surgery, especially compared to aspirin. Other insights included the environmental burden of procedures occurring in hospital operating rooms which may make an argument to move them to the office setting when appropriate and the increasing use of AI in all aspects of dermatology, specifically as a tool for detecting skin cancer.