Clinical and Therapeutic Pearls in Medical Dermatology

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).