In this multispeaker session, David M. Pariser, MD, Daniela Kroshinsky, MD, MPH, and Ron Vender, MD, FRCPC, provided many great clinical pearls for the medical dermatologists in the audience. Dr Pariser kicked off the session with a tip for using botulinum toxin for Hailey-Hailey disease. Double-blind, placebo-controlled studies have demonstrated efficacy of intralesional onabotulinumtoxin A for Hailey-Hailey. Dr Pariser’s next pearl centered on the use of glycopyrronium cloths for palmar hyperhidrosis. While more commonly used for axillary hyperhidrosis, the cloths can be used on the hands if patients follow a strict protocol of wiping with the cloth, covering the hands with cotton gloves for 30 minutes, then thoroughly washing hands. Pupillary dilation can occur if patients touch their face and eyes. For hyperhidrosis of the palms and soles, Dr Pariser recommended using ice and pressure for pain management when injecting botulinum toxin into the palms and soles.

Continuing, Dr Kroshinsky gave the audience some practical pearls for the use of cyclosporine. While not used quite as frequently as it used to be, cyclosporine remains an important medication for dermatologists to feel comfortable using. Cyclosporine is available as capsules and solution, and the solution can be mixed with apple juice or milk. Common dosing of cyclosporine is 3 to 5 mg/kg/day divided twice daily. The American Academy of Dermatology limits continuous use to less than one year. Cyclosporine can interact with grapefruit juice, NSAIDs, and a number of antibiotics, so Dr Kroshinsky recommended performing a thorough medication history. Renal toxicity and hypertension are two of the most common side effects of cyclosporine. Dr Kroshinsky discussed strategies for managing both adverse events such as dose reduction and introducing calcium channel blockers for hypertension.

To conclude, Dr Vender discussed paradoxical TNF-a inhibitor–induced psoriasis. Up to 2% to 5% of patients receiving TNFa-inhibitors will develop paradoxical psoriasis. It has also been reported with ustekinumab, an IL-12/23 inhibitor, and IL-17 inhibitors, although it is rarer than with TNF-a inhibitors. Paradoxical psoriasis often shows immunological features of acute, early-phase psoriasis with higher levels of interferon alpha (IFN-a), and it is thought that the imbalance of IFN-a to TNF-a may lead to paradoxical psoriasis. For treatment, Dr Vender recommended treating through with topical therapy or nbUVB or switching to a different biologic class, such as an IL-17 or IL-23 inhibitor. Depending on the indication for the TNF-a inhibitor, comanagement with gastroenterology or rheumatology may be necessary.