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.