SDEF Las Vegas Dermatology Seminar

LAS VEGAS – Bothersome and even disfiguring for some, acne keloidalis nuchae (AKN) is a mysterious but common skin disorder mostly affecting men of African descent.

But an accurate clinical diagnosis and a flexible treatment approach can boost treatment success, said Dr. Andrew F. Alexis, chair of the department of dermatology, and director of the Skin of Color Center, Mount Sinai St Luke’s and Mount Sinai Roosevelt, New York.

Speaking at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar, Dr. Alexis that the diagnosis can be made clinically, without the need for biopsies or skin scrapings. The condition is characterized by fibrotic, follicular papules, usually at the nape of the neck and on the occipital scalp. However, in more severe cases, the papules coalesce into a larger plaque. Occasionally, the characteristic scarring alopecia and keloidlike papules can be seen more toward the vertex of the scalp.

“We don’t really, truly know what the etiology of acne keloidalis nuchae is,” said Dr. Alexis, noting that many etiologies have been proposed. Some say it’s an epithelial elimination disorder, or a variant of lichen simplex chronicus. Many lay people may feel this is an ingrown hair disorder, but histopathologic studies have refuted this theory. These studies have also found no evidence of bacterial overgrowth in affected areas.

A newer and leading hypothesis is that AKN’s primary mechanism is fibrosis secondary to a mechanically induced folliculitis. At the very least, mechanical forces, even if they don’t cause the disorder, “certainly can exacerbate acne keloidalis nuchae, and short haircuts using electrical clippers may be a factor,” Dr. Alexis said. Support for this hypothesis can be found in two South African cross-sectional studies of nearly 2,000 men and boys: 86% of those with AKN reported receiving short haircuts with clippers. Among the adults reporting at least one episode of bleeding during a haircut, the odds ratio for having AKN was 3.45 (Int J Dermatol. 2011 Oct;50[10]:1212-6).

Therapy is multimodal, with some behavioral components, including avoidance of mechanical factors that can exacerbate AKN. In addition to low haircuts, tight-fitting caps and picking or scratching at the papules can worsen the condition.

Few studies exist to support one treatment regime over another for AKN, Dr. Alexis said. One small open label study of 20 individuals evaluated clobetasol 0.05% foam twice daily for two cycles of 2 weeks on and 2 weeks off treatment. Patients with persistent disease were then stepped down to 2 weeks of betamethasone valerate 0.12% foam twice daily. Overall, the mean papule/pustule count dropped by more than half, from 25 at baseline to 10 at 12 weeks, Dr. Alexis said (Cutis. 2005;75:317-21).

For larger papules and coalescent plaques, Dr. Alexis recommends intralesional triamcinolone acetonide at a concentration of 20-40mg/mL. “Don’t undertreat” and be sure to inject into, rather than under the lesion, he said. Concomitant topical class 1 or class 2 corticosteroids, such as clobetasol or fluocinonide, can be used along with injections. Addition of a topical antibiotic such as clindamycin can also accelerate resolution in his anecdotal experience.

Further recommendations based on practice experience include once-daily chlorhexidine washes of the affected area, as well as the addition of an oral tetracycline, such as doxycycline, when pustules are present or with more severe cases, Dr. Alexis said.

For some severely affected patients, surgical therapy may become the best treatment option. “You can inject all day long and still have disfiguring keloidlike plaque” in some patients with severe disease, he noted. Case series of both primary closure and healing by secondary intention have both shown good results. “Whichever camp you belong to, the key is to use a horizontal ellipse that includes the posterior hairline, and the depth of the excision must be down to the dermal-subcutaneous junction,” he said.

More recently, laser hair removal has been studied as a treatment alternative for AKN, Dr. Alexis pointed out. In a pilot study of 16 patients with AKN who received five sessions of laser hair removal, all had a marked reduction in papules and pustules at one year of follow-up (Eur J Dermatol. 2012 Sep-Oct;22[5]:645-50).

Another novel treatment approach used targeted UVB light with good results in a small split-scalp study. Pathology suggested the targeted skin was undergoing active matrix remodeling as a result of the UVB therapy (Br J Dermatol. 2014 Nov;171[5]:1156-63).

Dr. Alexis disclosed that he has received grants and research support from Allergan and Novartis, and speaker honoraria from Cipla. He has received consulting fees from Acclaris Therapeutics, Allergan, Amgen, Anacor, Bayer, Galderma, Johnson & Johnson, Leo, L’Oreal, Roche, Schick, Suneva, and Valeant.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Bothersome and even disfiguring for some, acne keloidalis nuchae (AKN) is a mysterious but common skin disorder mostly affecting men of African descent.

But an accurate clinical diagnosis and a flexible treatment approach can boost treatment success, said Dr. Andrew F. Alexis, chair of the department of dermatology, and director of the Skin of Color Center, Mount Sinai St Luke’s and Mount Sinai Roosevelt, New York.

Speaking at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar, Dr. Alexis that the diagnosis can be made clinically, without the need for biopsies or skin scrapings. The condition is characterized by fibrotic, follicular papules, usually at the nape of the neck and on the occipital scalp. However, in more severe cases, the papules coalesce into a larger plaque. Occasionally, the characteristic scarring alopecia and keloidlike papules can be seen more toward the vertex of the scalp.

“We don’t really, truly know what the etiology of acne keloidalis nuchae is,” said Dr. Alexis, noting that many etiologies have been proposed. Some say it’s an epithelial elimination disorder, or a variant of lichen simplex chronicus. Many lay people may feel this is an ingrown hair disorder, but histopathologic studies have refuted this theory. These studies have also found no evidence of bacterial overgrowth in affected areas.

A newer and leading hypothesis is that AKN’s primary mechanism is fibrosis secondary to a mechanically induced folliculitis. At the very least, mechanical forces, even if they don’t cause the disorder, “certainly can exacerbate acne keloidalis nuchae, and short haircuts using electrical clippers may be a factor,” Dr. Alexis said. Support for this hypothesis can be found in two South African cross-sectional studies of nearly 2,000 men and boys: 86% of those with AKN reported receiving short haircuts with clippers. Among the adults reporting at least one episode of bleeding during a haircut, the odds ratio for having AKN was 3.45 (Int J Dermatol. 2011 Oct;50[10]:1212-6).

Therapy is multimodal, with some behavioral components, including avoidance of mechanical factors that can exacerbate AKN. In addition to low haircuts, tight-fitting caps and picking or scratching at the papules can worsen the condition.

Few studies exist to support one treatment regime over another for AKN, Dr. Alexis said. One small open label study of 20 individuals evaluated clobetasol 0.05% foam twice daily for two cycles of 2 weeks on and 2 weeks off treatment. Patients with persistent disease were then stepped down to 2 weeks of betamethasone valerate 0.12% foam twice daily. Overall, the mean papule/pustule count dropped by more than half, from 25 at baseline to 10 at 12 weeks, Dr. Alexis said (Cutis. 2005;75:317-21).

For larger papules and coalescent plaques, Dr. Alexis recommends intralesional triamcinolone acetonide at a concentration of 20-40mg/mL. “Don’t undertreat” and be sure to inject into, rather than under the lesion, he said. Concomitant topical class 1 or class 2 corticosteroids, such as clobetasol or fluocinonide, can be used along with injections. Addition of a topical antibiotic such as clindamycin can also accelerate resolution in his anecdotal experience.

Further recommendations based on practice experience include once-daily chlorhexidine washes of the affected area, as well as the addition of an oral tetracycline, such as doxycycline, when pustules are present or with more severe cases, Dr. Alexis said.

For some severely affected patients, surgical therapy may become the best treatment option. “You can inject all day long and still have disfiguring keloidlike plaque” in some patients with severe disease, he noted. Case series of both primary closure and healing by secondary intention have both shown good results. “Whichever camp you belong to, the key is to use a horizontal ellipse that includes the posterior hairline, and the depth of the excision must be down to the dermal-subcutaneous junction,” he said.

More recently, laser hair removal has been studied as a treatment alternative for AKN, Dr. Alexis pointed out. In a pilot study of 16 patients with AKN who received five sessions of laser hair removal, all had a marked reduction in papules and pustules at one year of follow-up (Eur J Dermatol. 2012 Sep-Oct;22[5]:645-50).

Another novel treatment approach used targeted UVB light with good results in a small split-scalp study. Pathology suggested the targeted skin was undergoing active matrix remodeling as a result of the UVB therapy (Br J Dermatol. 2014 Nov;171[5]:1156-63).

Dr. Alexis disclosed that he has received grants and research support from Allergan and Novartis, and speaker honoraria from Cipla. He has received consulting fees from Acclaris Therapeutics, Allergan, Amgen, Anacor, Bayer, Galderma, Johnson & Johnson, Leo, L’Oreal, Roche, Schick, Suneva, and Valeant.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Bothersome and even disfiguring for some, acne keloidalis nuchae (AKN) is a mysterious but common skin disorder mostly affecting men of African descent.

But an accurate clinical diagnosis and a flexible treatment approach can boost treatment success, said Dr. Andrew F. Alexis, chair of the department of dermatology, and director of the Skin of Color Center, Mount Sinai St Luke’s and Mount Sinai Roosevelt, New York.

Speaking at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar, Dr. Alexis that the diagnosis can be made clinically, without the need for biopsies or skin scrapings. The condition is characterized by fibrotic, follicular papules, usually at the nape of the neck and on the occipital scalp. However, in more severe cases, the papules coalesce into a larger plaque. Occasionally, the characteristic scarring alopecia and keloidlike papules can be seen more toward the vertex of the scalp.

“We don’t really, truly know what the etiology of acne keloidalis nuchae is,” said Dr. Alexis, noting that many etiologies have been proposed. Some say it’s an epithelial elimination disorder, or a variant of lichen simplex chronicus. Many lay people may feel this is an ingrown hair disorder, but histopathologic studies have refuted this theory. These studies have also found no evidence of bacterial overgrowth in affected areas.

A newer and leading hypothesis is that AKN’s primary mechanism is fibrosis secondary to a mechanically induced folliculitis. At the very least, mechanical forces, even if they don’t cause the disorder, “certainly can exacerbate acne keloidalis nuchae, and short haircuts using electrical clippers may be a factor,” Dr. Alexis said. Support for this hypothesis can be found in two South African cross-sectional studies of nearly 2,000 men and boys: 86% of those with AKN reported receiving short haircuts with clippers. Among the adults reporting at least one episode of bleeding during a haircut, the odds ratio for having AKN was 3.45 (Int J Dermatol. 2011 Oct;50[10]:1212-6).

Therapy is multimodal, with some behavioral components, including avoidance of mechanical factors that can exacerbate AKN. In addition to low haircuts, tight-fitting caps and picking or scratching at the papules can worsen the condition.

Few studies exist to support one treatment regime over another for AKN, Dr. Alexis said. One small open label study of 20 individuals evaluated clobetasol 0.05% foam twice daily for two cycles of 2 weeks on and 2 weeks off treatment. Patients with persistent disease were then stepped down to 2 weeks of betamethasone valerate 0.12% foam twice daily. Overall, the mean papule/pustule count dropped by more than half, from 25 at baseline to 10 at 12 weeks, Dr. Alexis said (Cutis. 2005;75:317-21).

For larger papules and coalescent plaques, Dr. Alexis recommends intralesional triamcinolone acetonide at a concentration of 20-40mg/mL. “Don’t undertreat” and be sure to inject into, rather than under the lesion, he said. Concomitant topical class 1 or class 2 corticosteroids, such as clobetasol or fluocinonide, can be used along with injections. Addition of a topical antibiotic such as clindamycin can also accelerate resolution in his anecdotal experience.

Further recommendations based on practice experience include once-daily chlorhexidine washes of the affected area, as well as the addition of an oral tetracycline, such as doxycycline, when pustules are present or with more severe cases, Dr. Alexis said.

For some severely affected patients, surgical therapy may become the best treatment option. “You can inject all day long and still have disfiguring keloidlike plaque” in some patients with severe disease, he noted. Case series of both primary closure and healing by secondary intention have both shown good results. “Whichever camp you belong to, the key is to use a horizontal ellipse that includes the posterior hairline, and the depth of the excision must be down to the dermal-subcutaneous junction,” he said.

More recently, laser hair removal has been studied as a treatment alternative for AKN, Dr. Alexis pointed out. In a pilot study of 16 patients with AKN who received five sessions of laser hair removal, all had a marked reduction in papules and pustules at one year of follow-up (Eur J Dermatol. 2012 Sep-Oct;22[5]:645-50).

Another novel treatment approach used targeted UVB light with good results in a small split-scalp study. Pathology suggested the targeted skin was undergoing active matrix remodeling as a result of the UVB therapy (Br J Dermatol. 2014 Nov;171[5]:1156-63).

Dr. Alexis disclosed that he has received grants and research support from Allergan and Novartis, and speaker honoraria from Cipla. He has received consulting fees from Acclaris Therapeutics, Allergan, Amgen, Anacor, Bayer, Galderma, Johnson & Johnson, Leo, L’Oreal, Roche, Schick, Suneva, and Valeant.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Technologies to address the many skin changes associated with photoaging run the gamut from nonablative to ablative – and choosing the right technology for a given patient is a balancing act, according to Dr. Mathew Avram.

“Basically, it’s a trade-off between increased efficacy and increased side effects and downtime,” Dr. Avram said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

Dr. Avram, director of the Massachusetts General Hospital dermatology, laser, and cosmetic center, Boston, said that traditional resurfacing remains the preferred method for repairing photodamaged skin. “One treatment provides reproducible, excellent results,” but at the cost of a significant amount of wound care and prolonged downtime. Potential adverse effects also include clear lines of demarcation with improper feathering, prolonged erythema, permanent hypopigmentation, infection, and scarring, he added.

For these reasons, the popularity of traditional resurfacing to treat photodamaged skin has declined over time as nonablative and intermediate techniques have arisen.

Intense pulsed light (IPL) is a nonlaser, nonablative technique that can produce overall skin rejuvenation, a “side effect” that patients often notice after they receive IPL for vascular lesions or hyperpigmentation. The benefits tend to be modest, even after several treatments, so this is not usually performed as a standalone technique for skin laxity or rhytides.

Nonablative fractional lasers act by creating thousands of microscopic wounds that are “columns of thermal coagulation,” leaving an intact stratum corneum, said Dr. Avram, who is also faculty director for laser and cosmetic training, Harvard Medical School, Boston.

The most common reason for treatment with a nonablative laser is mild to moderate wrinkles, though it can also be used for various pigmentation issues, as well as acne, surgical, and burn scars.

Although side effects are typically minor, the devices can be used off face, and there’s no worry about lines of demarcation; improvement is also more modest and will happen only with multiple treatments. “Fractional treatments give you fractional results,” Dr. Avram commented.

“You want to think about your treatment in terms of the pathology of what you’re treating,” he added, noting that fractional resurfacing can target both epidermal and dermal conditions. Examples of epidermal conditions that benefit from superficial treatment include dermatoheliosis, lentigines, and melasma.

Acne scars and deep wrinkles should receive deeper treatment in order to create thermal damage to the dermis proper, which, over a period of months, will trigger collagen remodeling and new collagen formation. Pulse energy will determine the depth and width of the zone of coagulation in the skin, so higher energy should be used with deeper skin pathology, Dr. Avram said.

Dermatologists also need to consider density of treatment – what percent of the skin is treated. “These devices go from about 5% to about 48% of skin coverage,” and increased density is really what increases the intensity of treatment, he noted. High-density treatment will result in more redness and swelling and has a greater potential for hyperpigmentation, but will not necessarily yield increased benefit in treatment outcomes, he added.

Pretreatment considerations should include assessing the patient’s expectations and availability for downtime post procedure. Treatment planning should also consider the patient’s skin type and probability for sun exposure. Patients should know they will see only partial improvement in wrinkles, scars, and pigmentation, and should expect some discomfort during the procedure and some side effects and healing time post procedure. Patients with a history of herpes labialis should receive valacyclovir 500 mg twice daily, beginning the day before treatment and continuing for 5-7 days, Dr. Avram said.

Cold-air cooling makes the treatment both safer and more comfortable, he pointed out. Topical compounded anesthesia including higher percentages of lidocaine and tetracaine can also be effective. Though local injected anesthesia can be effective in focal treatment of scars, the injection should be deep, and treatment should not begin immediately. This allows the lidocaine to disperse, minimizing the risk of ulceration from the thermal instability that a depot of lidocaine could cause, he said.

Fractional lasers can also be effective for treating background dermatoheliosis, as opposed to targeted treatment of individual lentigines. “Fractional is going to be great for clearing background damage,” Dr. Avram said.

A hybrid technique called ablative fractional photothermolysis creates tiny columns of ablation, while leaving the surrounding untreated tissue available as a reservoir for rapid healing. This technique will improve the more severe wrinkles that nonablative treatments don’t help, with less downtime than a fully ablative technique. Interestingly, patients have less postprocedure pain with this technique than with nonablative techniques, probably because the ablated channels offer a way for heat to escape the skin, he said

Dr. Avram disclosed that he is a paid consultant or has received honoraria from Invasix, Zeltiq Aesthetics, Galderma, and Kythera Biopharmaceuticals; that he is on the scientific advisory board of Cytrellis and Zeltiq; that he has intellectual property and royalty interests with Cytrellis; and that he has received research equipment from Cutera.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Technologies to address the many skin changes associated with photoaging run the gamut from nonablative to ablative – and choosing the right technology for a given patient is a balancing act, according to Dr. Mathew Avram.

“Basically, it’s a trade-off between increased efficacy and increased side effects and downtime,” Dr. Avram said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

Dr. Avram, director of the Massachusetts General Hospital dermatology, laser, and cosmetic center, Boston, said that traditional resurfacing remains the preferred method for repairing photodamaged skin. “One treatment provides reproducible, excellent results,” but at the cost of a significant amount of wound care and prolonged downtime. Potential adverse effects also include clear lines of demarcation with improper feathering, prolonged erythema, permanent hypopigmentation, infection, and scarring, he added.

For these reasons, the popularity of traditional resurfacing to treat photodamaged skin has declined over time as nonablative and intermediate techniques have arisen.

Intense pulsed light (IPL) is a nonlaser, nonablative technique that can produce overall skin rejuvenation, a “side effect” that patients often notice after they receive IPL for vascular lesions or hyperpigmentation. The benefits tend to be modest, even after several treatments, so this is not usually performed as a standalone technique for skin laxity or rhytides.

Nonablative fractional lasers act by creating thousands of microscopic wounds that are “columns of thermal coagulation,” leaving an intact stratum corneum, said Dr. Avram, who is also faculty director for laser and cosmetic training, Harvard Medical School, Boston.

The most common reason for treatment with a nonablative laser is mild to moderate wrinkles, though it can also be used for various pigmentation issues, as well as acne, surgical, and burn scars.

Although side effects are typically minor, the devices can be used off face, and there’s no worry about lines of demarcation; improvement is also more modest and will happen only with multiple treatments. “Fractional treatments give you fractional results,” Dr. Avram commented.

“You want to think about your treatment in terms of the pathology of what you’re treating,” he added, noting that fractional resurfacing can target both epidermal and dermal conditions. Examples of epidermal conditions that benefit from superficial treatment include dermatoheliosis, lentigines, and melasma.

Acne scars and deep wrinkles should receive deeper treatment in order to create thermal damage to the dermis proper, which, over a period of months, will trigger collagen remodeling and new collagen formation. Pulse energy will determine the depth and width of the zone of coagulation in the skin, so higher energy should be used with deeper skin pathology, Dr. Avram said.

Dermatologists also need to consider density of treatment – what percent of the skin is treated. “These devices go from about 5% to about 48% of skin coverage,” and increased density is really what increases the intensity of treatment, he noted. High-density treatment will result in more redness and swelling and has a greater potential for hyperpigmentation, but will not necessarily yield increased benefit in treatment outcomes, he added.

Pretreatment considerations should include assessing the patient’s expectations and availability for downtime post procedure. Treatment planning should also consider the patient’s skin type and probability for sun exposure. Patients should know they will see only partial improvement in wrinkles, scars, and pigmentation, and should expect some discomfort during the procedure and some side effects and healing time post procedure. Patients with a history of herpes labialis should receive valacyclovir 500 mg twice daily, beginning the day before treatment and continuing for 5-7 days, Dr. Avram said.

Cold-air cooling makes the treatment both safer and more comfortable, he pointed out. Topical compounded anesthesia including higher percentages of lidocaine and tetracaine can also be effective. Though local injected anesthesia can be effective in focal treatment of scars, the injection should be deep, and treatment should not begin immediately. This allows the lidocaine to disperse, minimizing the risk of ulceration from the thermal instability that a depot of lidocaine could cause, he said.

Fractional lasers can also be effective for treating background dermatoheliosis, as opposed to targeted treatment of individual lentigines. “Fractional is going to be great for clearing background damage,” Dr. Avram said.

A hybrid technique called ablative fractional photothermolysis creates tiny columns of ablation, while leaving the surrounding untreated tissue available as a reservoir for rapid healing. This technique will improve the more severe wrinkles that nonablative treatments don’t help, with less downtime than a fully ablative technique. Interestingly, patients have less postprocedure pain with this technique than with nonablative techniques, probably because the ablated channels offer a way for heat to escape the skin, he said

Dr. Avram disclosed that he is a paid consultant or has received honoraria from Invasix, Zeltiq Aesthetics, Galderma, and Kythera Biopharmaceuticals; that he is on the scientific advisory board of Cytrellis and Zeltiq; that he has intellectual property and royalty interests with Cytrellis; and that he has received research equipment from Cutera.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Technologies to address the many skin changes associated with photoaging run the gamut from nonablative to ablative – and choosing the right technology for a given patient is a balancing act, according to Dr. Mathew Avram.

“Basically, it’s a trade-off between increased efficacy and increased side effects and downtime,” Dr. Avram said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

Dr. Avram, director of the Massachusetts General Hospital dermatology, laser, and cosmetic center, Boston, said that traditional resurfacing remains the preferred method for repairing photodamaged skin. “One treatment provides reproducible, excellent results,” but at the cost of a significant amount of wound care and prolonged downtime. Potential adverse effects also include clear lines of demarcation with improper feathering, prolonged erythema, permanent hypopigmentation, infection, and scarring, he added.

For these reasons, the popularity of traditional resurfacing to treat photodamaged skin has declined over time as nonablative and intermediate techniques have arisen.

Intense pulsed light (IPL) is a nonlaser, nonablative technique that can produce overall skin rejuvenation, a “side effect” that patients often notice after they receive IPL for vascular lesions or hyperpigmentation. The benefits tend to be modest, even after several treatments, so this is not usually performed as a standalone technique for skin laxity or rhytides.

Nonablative fractional lasers act by creating thousands of microscopic wounds that are “columns of thermal coagulation,” leaving an intact stratum corneum, said Dr. Avram, who is also faculty director for laser and cosmetic training, Harvard Medical School, Boston.

The most common reason for treatment with a nonablative laser is mild to moderate wrinkles, though it can also be used for various pigmentation issues, as well as acne, surgical, and burn scars.

Although side effects are typically minor, the devices can be used off face, and there’s no worry about lines of demarcation; improvement is also more modest and will happen only with multiple treatments. “Fractional treatments give you fractional results,” Dr. Avram commented.

“You want to think about your treatment in terms of the pathology of what you’re treating,” he added, noting that fractional resurfacing can target both epidermal and dermal conditions. Examples of epidermal conditions that benefit from superficial treatment include dermatoheliosis, lentigines, and melasma.

Acne scars and deep wrinkles should receive deeper treatment in order to create thermal damage to the dermis proper, which, over a period of months, will trigger collagen remodeling and new collagen formation. Pulse energy will determine the depth and width of the zone of coagulation in the skin, so higher energy should be used with deeper skin pathology, Dr. Avram said.

Dermatologists also need to consider density of treatment – what percent of the skin is treated. “These devices go from about 5% to about 48% of skin coverage,” and increased density is really what increases the intensity of treatment, he noted. High-density treatment will result in more redness and swelling and has a greater potential for hyperpigmentation, but will not necessarily yield increased benefit in treatment outcomes, he added.

Pretreatment considerations should include assessing the patient’s expectations and availability for downtime post procedure. Treatment planning should also consider the patient’s skin type and probability for sun exposure. Patients should know they will see only partial improvement in wrinkles, scars, and pigmentation, and should expect some discomfort during the procedure and some side effects and healing time post procedure. Patients with a history of herpes labialis should receive valacyclovir 500 mg twice daily, beginning the day before treatment and continuing for 5-7 days, Dr. Avram said.

Cold-air cooling makes the treatment both safer and more comfortable, he pointed out. Topical compounded anesthesia including higher percentages of lidocaine and tetracaine can also be effective. Though local injected anesthesia can be effective in focal treatment of scars, the injection should be deep, and treatment should not begin immediately. This allows the lidocaine to disperse, minimizing the risk of ulceration from the thermal instability that a depot of lidocaine could cause, he said.

Fractional lasers can also be effective for treating background dermatoheliosis, as opposed to targeted treatment of individual lentigines. “Fractional is going to be great for clearing background damage,” Dr. Avram said.

A hybrid technique called ablative fractional photothermolysis creates tiny columns of ablation, while leaving the surrounding untreated tissue available as a reservoir for rapid healing. This technique will improve the more severe wrinkles that nonablative treatments don’t help, with less downtime than a fully ablative technique. Interestingly, patients have less postprocedure pain with this technique than with nonablative techniques, probably because the ablated channels offer a way for heat to escape the skin, he said

Dr. Avram disclosed that he is a paid consultant or has received honoraria from Invasix, Zeltiq Aesthetics, Galderma, and Kythera Biopharmaceuticals; that he is on the scientific advisory board of Cytrellis and Zeltiq; that he has intellectual property and royalty interests with Cytrellis; and that he has received research equipment from Cutera.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – For a physician starting a patient on a systemic agent to treat psoriasis, deciding on risk factor screening and management strategies can be confusing. Who gets checked for what? Why? How often?

With a dearth of evidence to guide them, physicians should use what they know about psoriasis itself, as well as patient risk factors and the inherent risks of a given systemic therapy to guide screening, according to Dr. Kristina Callis Duffin of the department of dermatology, University of Utah, Salt Lake City.

Courtesy of the Centers for Disease Control and Prevention (CDC)

Speaking at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar, Dr. Duffin said that in her practice, this means that all patients being considered for systemic therapy get baseline labs as recommended by the drug manufacturer, and risk-focused monitoring for cardiovascular disease, infection, and cancer. Basically, she noted, the strategy is, “How can we be effective at monitoring and surveying for those ‘bad guys’– those complications of therapy?”

“Some of this is really about using common sense and being a good physician,” she added.

To obtain a pertinent history, it’s worthwhile to formulate a directed intake questionnaire, Dr. Duffin said. Screening items should include history of recurrent infections; hepatitis, HIV, and TB status and risk; travel history; cardiovascular history, including lipid status; history of any liver or kidney problems; history and risk of diabetes mellitus; depression; personal or family history of multiple sclerosis; and history of cancer, including skin cancer, and blood disorders.

The social history should include pregnancy status and birth control method for women (as appropriate); and alcohol use for all patients. Patients should be current with age-appropriate recommended immunizations and cancer screenings.

Obtaining baseline lab tests for all patients before they start treatment with a systemic agent affords the opportunity to detect common metabolic abnormalities, such as diabetes, liver or kidney disease, and dyslipidemia, as well as rare but serious blood abnormalities, Dr. Duffin said. This approach respects the fact that “there is no question that cardiovascular risk factors are overrepresented in the moderate to severe psoriasis population.”

Published TB screening guidelines have universally recommended screening before initiating a biologic agent with a tuberculin skin test, unless the patient has had the BCG vaccine or is immunosuppressed. From there, interpretation of the tine test and further screening requires knowing the patient: “It’s all about pretest probability,” said Dr. Duffin, adding that physicians should not be afraid to use infectious disease consultants to help them sort out tricky cases.

In terms of ongoing management, communication and coordination are key. Continue to ask patients about symptoms of psoriatic arthritis, and make sure that you work with the patient’s primary care provider so that cardiovascular risk management, malignancy screening, and immunizations don’t fall through the cracks, she advised.

“Have a high index of suspicion for infection,” including deep fungal infections, she added. Though the literature does not report frequent cases of serious fungal infections, “there’s no question cases are unreported or numbers can be unclear in the registries.” Patients should know early signs of infection and know to seek care right away.

Patients should know to defer live vaccines, and the physician managing the care of psoriasis should be included in the planning and management process for any type of surgery, to oversee biologic administration. While probably slight, the risk of infection should be weighed against the risk of loss of efficacy in psoriasis or psoriatic arthritis treatment, Dr. Duffin said.

The baseline risk of solid tumors is elevated in patients with psoriasis, but “is not definitively elevated in patients on biologics,” she commented. The risk of nonmelanoma skin cancer, however, is definitely elevated for patients on biologic therapies, so an annual skin survey is a must for these patients, she said.

“Should we be discussing immunizations with our patients? Absolutely,”she added. All patients need the influenza vaccine and the pneumococcal vaccine, and for live virus immunizations, the dermatologist should coordinate administration with the primary care physician.

Managing these risks effectively can make a big difference in quality of life for patients who are able to start and stay on systemic therapy, said Dr. Duffin. The many risks of not treating psoriasis appropriately include not only the significant psychosocial impact, but also progression of psoriatic arthritis, progression of skin disease, and increased risk of heart disease and other cardiovascular comorbidities. “Our job is to treat to patient satisfaction and the best possible quality of life. A lot of this is about anticipation and communication,” she said.

Dr. Duffin reported receiving research support from and consulting for Amgen, Eli Lilly, Janssen, Stiefel, AbbVie, Bristol-Myers Squibb, Celgene, Novartis, and XenoPort; consulting and being on the scientific advisory board for Pfizer; and being on the scientific advisory board for Novartis, Eli Lilly, Janssen, Celgene, and XenoPort.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – For a physician starting a patient on a systemic agent to treat psoriasis, deciding on risk factor screening and management strategies can be confusing. Who gets checked for what? Why? How often?

With a dearth of evidence to guide them, physicians should use what they know about psoriasis itself, as well as patient risk factors and the inherent risks of a given systemic therapy to guide screening, according to Dr. Kristina Callis Duffin of the department of dermatology, University of Utah, Salt Lake City.

Courtesy of the Centers for Disease Control and Prevention (CDC)

Speaking at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar, Dr. Duffin said that in her practice, this means that all patients being considered for systemic therapy get baseline labs as recommended by the drug manufacturer, and risk-focused monitoring for cardiovascular disease, infection, and cancer. Basically, she noted, the strategy is, “How can we be effective at monitoring and surveying for those ‘bad guys’– those complications of therapy?”

“Some of this is really about using common sense and being a good physician,” she added.

To obtain a pertinent history, it’s worthwhile to formulate a directed intake questionnaire, Dr. Duffin said. Screening items should include history of recurrent infections; hepatitis, HIV, and TB status and risk; travel history; cardiovascular history, including lipid status; history of any liver or kidney problems; history and risk of diabetes mellitus; depression; personal or family history of multiple sclerosis; and history of cancer, including skin cancer, and blood disorders.

The social history should include pregnancy status and birth control method for women (as appropriate); and alcohol use for all patients. Patients should be current with age-appropriate recommended immunizations and cancer screenings.

Obtaining baseline lab tests for all patients before they start treatment with a systemic agent affords the opportunity to detect common metabolic abnormalities, such as diabetes, liver or kidney disease, and dyslipidemia, as well as rare but serious blood abnormalities, Dr. Duffin said. This approach respects the fact that “there is no question that cardiovascular risk factors are overrepresented in the moderate to severe psoriasis population.”

Published TB screening guidelines have universally recommended screening before initiating a biologic agent with a tuberculin skin test, unless the patient has had the BCG vaccine or is immunosuppressed. From there, interpretation of the tine test and further screening requires knowing the patient: “It’s all about pretest probability,” said Dr. Duffin, adding that physicians should not be afraid to use infectious disease consultants to help them sort out tricky cases.

In terms of ongoing management, communication and coordination are key. Continue to ask patients about symptoms of psoriatic arthritis, and make sure that you work with the patient’s primary care provider so that cardiovascular risk management, malignancy screening, and immunizations don’t fall through the cracks, she advised.

“Have a high index of suspicion for infection,” including deep fungal infections, she added. Though the literature does not report frequent cases of serious fungal infections, “there’s no question cases are unreported or numbers can be unclear in the registries.” Patients should know early signs of infection and know to seek care right away.

Patients should know to defer live vaccines, and the physician managing the care of psoriasis should be included in the planning and management process for any type of surgery, to oversee biologic administration. While probably slight, the risk of infection should be weighed against the risk of loss of efficacy in psoriasis or psoriatic arthritis treatment, Dr. Duffin said.

The baseline risk of solid tumors is elevated in patients with psoriasis, but “is not definitively elevated in patients on biologics,” she commented. The risk of nonmelanoma skin cancer, however, is definitely elevated for patients on biologic therapies, so an annual skin survey is a must for these patients, she said.

“Should we be discussing immunizations with our patients? Absolutely,”she added. All patients need the influenza vaccine and the pneumococcal vaccine, and for live virus immunizations, the dermatologist should coordinate administration with the primary care physician.

Managing these risks effectively can make a big difference in quality of life for patients who are able to start and stay on systemic therapy, said Dr. Duffin. The many risks of not treating psoriasis appropriately include not only the significant psychosocial impact, but also progression of psoriatic arthritis, progression of skin disease, and increased risk of heart disease and other cardiovascular comorbidities. “Our job is to treat to patient satisfaction and the best possible quality of life. A lot of this is about anticipation and communication,” she said.

Dr. Duffin reported receiving research support from and consulting for Amgen, Eli Lilly, Janssen, Stiefel, AbbVie, Bristol-Myers Squibb, Celgene, Novartis, and XenoPort; consulting and being on the scientific advisory board for Pfizer; and being on the scientific advisory board for Novartis, Eli Lilly, Janssen, Celgene, and XenoPort.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – For a physician starting a patient on a systemic agent to treat psoriasis, deciding on risk factor screening and management strategies can be confusing. Who gets checked for what? Why? How often?

With a dearth of evidence to guide them, physicians should use what they know about psoriasis itself, as well as patient risk factors and the inherent risks of a given systemic therapy to guide screening, according to Dr. Kristina Callis Duffin of the department of dermatology, University of Utah, Salt Lake City.

Courtesy of the Centers for Disease Control and Prevention (CDC)

Speaking at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar, Dr. Duffin said that in her practice, this means that all patients being considered for systemic therapy get baseline labs as recommended by the drug manufacturer, and risk-focused monitoring for cardiovascular disease, infection, and cancer. Basically, she noted, the strategy is, “How can we be effective at monitoring and surveying for those ‘bad guys’– those complications of therapy?”

“Some of this is really about using common sense and being a good physician,” she added.

To obtain a pertinent history, it’s worthwhile to formulate a directed intake questionnaire, Dr. Duffin said. Screening items should include history of recurrent infections; hepatitis, HIV, and TB status and risk; travel history; cardiovascular history, including lipid status; history of any liver or kidney problems; history and risk of diabetes mellitus; depression; personal or family history of multiple sclerosis; and history of cancer, including skin cancer, and blood disorders.

The social history should include pregnancy status and birth control method for women (as appropriate); and alcohol use for all patients. Patients should be current with age-appropriate recommended immunizations and cancer screenings.

Obtaining baseline lab tests for all patients before they start treatment with a systemic agent affords the opportunity to detect common metabolic abnormalities, such as diabetes, liver or kidney disease, and dyslipidemia, as well as rare but serious blood abnormalities, Dr. Duffin said. This approach respects the fact that “there is no question that cardiovascular risk factors are overrepresented in the moderate to severe psoriasis population.”

Published TB screening guidelines have universally recommended screening before initiating a biologic agent with a tuberculin skin test, unless the patient has had the BCG vaccine or is immunosuppressed. From there, interpretation of the tine test and further screening requires knowing the patient: “It’s all about pretest probability,” said Dr. Duffin, adding that physicians should not be afraid to use infectious disease consultants to help them sort out tricky cases.

In terms of ongoing management, communication and coordination are key. Continue to ask patients about symptoms of psoriatic arthritis, and make sure that you work with the patient’s primary care provider so that cardiovascular risk management, malignancy screening, and immunizations don’t fall through the cracks, she advised.

“Have a high index of suspicion for infection,” including deep fungal infections, she added. Though the literature does not report frequent cases of serious fungal infections, “there’s no question cases are unreported or numbers can be unclear in the registries.” Patients should know early signs of infection and know to seek care right away.

Patients should know to defer live vaccines, and the physician managing the care of psoriasis should be included in the planning and management process for any type of surgery, to oversee biologic administration. While probably slight, the risk of infection should be weighed against the risk of loss of efficacy in psoriasis or psoriatic arthritis treatment, Dr. Duffin said.

The baseline risk of solid tumors is elevated in patients with psoriasis, but “is not definitively elevated in patients on biologics,” she commented. The risk of nonmelanoma skin cancer, however, is definitely elevated for patients on biologic therapies, so an annual skin survey is a must for these patients, she said.

“Should we be discussing immunizations with our patients? Absolutely,”she added. All patients need the influenza vaccine and the pneumococcal vaccine, and for live virus immunizations, the dermatologist should coordinate administration with the primary care physician.

Managing these risks effectively can make a big difference in quality of life for patients who are able to start and stay on systemic therapy, said Dr. Duffin. The many risks of not treating psoriasis appropriately include not only the significant psychosocial impact, but also progression of psoriatic arthritis, progression of skin disease, and increased risk of heart disease and other cardiovascular comorbidities. “Our job is to treat to patient satisfaction and the best possible quality of life. A lot of this is about anticipation and communication,” she said.

Dr. Duffin reported receiving research support from and consulting for Amgen, Eli Lilly, Janssen, Stiefel, AbbVie, Bristol-Myers Squibb, Celgene, Novartis, and XenoPort; consulting and being on the scientific advisory board for Pfizer; and being on the scientific advisory board for Novartis, Eli Lilly, Janssen, Celgene, and XenoPort.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – In the treatment of eczema, the gap between evidence and practice can be broad.

Dermatologists who treat atopic dermatitis confront many challenges – patients may be severely atopic, have a hard time being compliant with therapies, and have frequent recurrences, Dr. Robert Sidbury said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. “It just is not easy,” he said.

However, even for challenging patients, physicians should be mindful of evidence-supported treatments and be attentive to practice gaps, said Dr. Sidbury, chief of the division of dermatology at the University of Washington’s Seattle Children’s Hospital.

Though the field is rapidly changing, the American Academy of Dermatology has issued practice guidelines that can help guide clinical treatment decisions, said Dr. Sidbury, who helped develop the AAD guidelines. He noted that prescribers may eventually feel the pain of the practice gap if AMA-driven performance measures are enforced.

At the meeting, Dr. Sidbury discussed areas in which many clinicians may have a practice gap in the treatment of eczema. Topping the list of non–evidence-based eczema care are overuse of steroids, oral antibiotics, and nonsedating antihistamines.

Practice gap: Many clinicians believe that topical steroids are more effective for atopic dermatitis when used twice daily.

Reality: “Randomized, controlled trials and a systematic review suggest that there is no benefit to twice-daily use of steroids,” over once-daily use, Dr. Sidbury said, though he admitted that he’s having a hard time breaking his own longstanding practice habit of prescribing twice- rather than once-daily dosing of topical corticosteroids. He pointed out that Dr. Hywel Williams, the director of the University of Nottingham’s Center of Evidence-Based Dermatology, England, calls this the “lowest-hanging fruit” in terms of cost savings, safety, and convenience to patients.

Practice gap: Unnecessary skin cultures can lead to overuse of systemic antibiotics in atopic dermatitis.

Reality: Colonization with Staphylococcus aureus occurs in more than 90% of adults with atopic dermatitis, but the vast majority of these patients are not infected. “Except for bleach baths in concert with intranasal mupirocin, no topical antistaphylococcal treatment has been shown to be clinically helpful in patients with atopic dermatitis,” Dr. Sidbury said.

“How do we know when eczema is infected? We know it when we see it. You are best served by using your clinical gestalt,” he added. Eczematous skin presents along a continuum, ranging from erythema, scaling, and crusting, to a frankly purulent appearance with clear infection, and clinical presentation and judgment should guide treatment. Barring frank infection, the evidence doesn’t support use of systemic antibiotics (Br J Dermatol. 2010 Jul;163 [1]:12-26).

Practice gap: Many patients with atopic dermatitis receive nonsedating antihistamines for itching.

Reality: There is no evidence that nonsedating antihistamines are beneficial unless the patient has concurrent rhinoconjunctivitis, so data don’t support their use “for the actual itch of eczema,” Dr. Sidbury said. In fact, the AMA-sponsored Physician Consortium for Performance Improvement nearly passed an overuse measure that would have penalized the prescription of nonsedating antihistamines in this setting, he said.

Practice gap: Systemic immunomodulatory therapy is used for pediatric atopic dermatitis, despite the lack of data that provide clear guidance.

Reality: The landscape here is a little more complicated, according to Dr. Sidbury. Among the systemic immunosuppressants, cyclosporine, methotrexate, azathioprine, and mycophenolate have the most evidence backing their use. However, there remains a lack of comparative studies and a lack of studies evaluating these therapies in the pediatric population, he said.

In general, Dr. Sidbury said that systemic therapy for atopic dermatitis is indicated only when control is inadequate despite truly optimized topical care, and the condition is having a “significant negative physical, psychological, or social impact” on the patient. Before beginning these potent systemic therapies, it’s important to assess that the patient and family are truly adherent to the topical treatment regime, and that adjunctive treatments like wet wraps and strict allergen avoidance are being followed. The Food and Drug Administration is beginning to include pediatric patients in clinical trials of systemic therapy for atopic dermatitis, so the quality of data should improve.

If systemic therapy is initiated, some clinical pearls can guide use, he said. Cyclosporine has the quickest onset of action and can be dosed at 3-6 mg/kg per day, divided into twice daily dosing. The maximum dose is 300 mg/day, and the microemulsion form is preferred. Overall, mycophenolate is the best-tolerated immunosuppressive. If methotrexate is chosen, it should be dosed at 0.2-0.7 mg/kg per week; liver function should be checked at 5-7 days after dosing, since methotrexate can cause a transient transaminitis. There are no standard recommendations to guide if or when to do liver biopsy recommendations in children receiving methotrexate. (J Am Acad Dermatol. 2014 Aug;71[2]:327-49).

Practice gap: Eczema appointments may only last 10-20 minutes.

Reality: “Proper eczema education takes much longer,” Dr. Sidbury said. Among patients and clinicians, there is still “rampant misinformation,” with persistence of fundamental knowledge gaps. “Studies repeatedly validate the role of education” in providing optimal care for eczema sufferers and their families, he emphasized (Pediatr Allergy Immunol. 2015 Jan 23. doi: 10.1111/pai.12338).

How is a busy physician to integrate all of these recommendations into practice and make sure patients are getting proper education? “Don’t reinvent the wheel – Google it!” Dr. Sidbury said. Resources from the National Eczema Association, among others, can help guide care. Eczema action plans that can be downloaded provide a roadmap for shared decision making; food allergy clinical practice guidelines help patients avoid allergens, and patients can further their knowledge when directed to reputable websites like the National Eczema Association and resources like www.eczemacenter.org, at Rady Children’s Hospital–San Diego.

Dr. Sidbury disclosed that he was a site principal investigator for an Anacor Pharmaceuticals–sponsored trial of a new topical anti-inflammatory agent for allergic dermatitis, and that he is on the Scientific Advisory Committee of the National Eczema Association.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – In the treatment of eczema, the gap between evidence and practice can be broad.

Dermatologists who treat atopic dermatitis confront many challenges – patients may be severely atopic, have a hard time being compliant with therapies, and have frequent recurrences, Dr. Robert Sidbury said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. “It just is not easy,” he said.

However, even for challenging patients, physicians should be mindful of evidence-supported treatments and be attentive to practice gaps, said Dr. Sidbury, chief of the division of dermatology at the University of Washington’s Seattle Children’s Hospital.

Though the field is rapidly changing, the American Academy of Dermatology has issued practice guidelines that can help guide clinical treatment decisions, said Dr. Sidbury, who helped develop the AAD guidelines. He noted that prescribers may eventually feel the pain of the practice gap if AMA-driven performance measures are enforced.

At the meeting, Dr. Sidbury discussed areas in which many clinicians may have a practice gap in the treatment of eczema. Topping the list of non–evidence-based eczema care are overuse of steroids, oral antibiotics, and nonsedating antihistamines.

Practice gap: Many clinicians believe that topical steroids are more effective for atopic dermatitis when used twice daily.

Reality: “Randomized, controlled trials and a systematic review suggest that there is no benefit to twice-daily use of steroids,” over once-daily use, Dr. Sidbury said, though he admitted that he’s having a hard time breaking his own longstanding practice habit of prescribing twice- rather than once-daily dosing of topical corticosteroids. He pointed out that Dr. Hywel Williams, the director of the University of Nottingham’s Center of Evidence-Based Dermatology, England, calls this the “lowest-hanging fruit” in terms of cost savings, safety, and convenience to patients.

Practice gap: Unnecessary skin cultures can lead to overuse of systemic antibiotics in atopic dermatitis.

Reality: Colonization with Staphylococcus aureus occurs in more than 90% of adults with atopic dermatitis, but the vast majority of these patients are not infected. “Except for bleach baths in concert with intranasal mupirocin, no topical antistaphylococcal treatment has been shown to be clinically helpful in patients with atopic dermatitis,” Dr. Sidbury said.

“How do we know when eczema is infected? We know it when we see it. You are best served by using your clinical gestalt,” he added. Eczematous skin presents along a continuum, ranging from erythema, scaling, and crusting, to a frankly purulent appearance with clear infection, and clinical presentation and judgment should guide treatment. Barring frank infection, the evidence doesn’t support use of systemic antibiotics (Br J Dermatol. 2010 Jul;163 [1]:12-26).

Practice gap: Many patients with atopic dermatitis receive nonsedating antihistamines for itching.

Reality: There is no evidence that nonsedating antihistamines are beneficial unless the patient has concurrent rhinoconjunctivitis, so data don’t support their use “for the actual itch of eczema,” Dr. Sidbury said. In fact, the AMA-sponsored Physician Consortium for Performance Improvement nearly passed an overuse measure that would have penalized the prescription of nonsedating antihistamines in this setting, he said.

Practice gap: Systemic immunomodulatory therapy is used for pediatric atopic dermatitis, despite the lack of data that provide clear guidance.

Reality: The landscape here is a little more complicated, according to Dr. Sidbury. Among the systemic immunosuppressants, cyclosporine, methotrexate, azathioprine, and mycophenolate have the most evidence backing their use. However, there remains a lack of comparative studies and a lack of studies evaluating these therapies in the pediatric population, he said.

In general, Dr. Sidbury said that systemic therapy for atopic dermatitis is indicated only when control is inadequate despite truly optimized topical care, and the condition is having a “significant negative physical, psychological, or social impact” on the patient. Before beginning these potent systemic therapies, it’s important to assess that the patient and family are truly adherent to the topical treatment regime, and that adjunctive treatments like wet wraps and strict allergen avoidance are being followed. The Food and Drug Administration is beginning to include pediatric patients in clinical trials of systemic therapy for atopic dermatitis, so the quality of data should improve.

If systemic therapy is initiated, some clinical pearls can guide use, he said. Cyclosporine has the quickest onset of action and can be dosed at 3-6 mg/kg per day, divided into twice daily dosing. The maximum dose is 300 mg/day, and the microemulsion form is preferred. Overall, mycophenolate is the best-tolerated immunosuppressive. If methotrexate is chosen, it should be dosed at 0.2-0.7 mg/kg per week; liver function should be checked at 5-7 days after dosing, since methotrexate can cause a transient transaminitis. There are no standard recommendations to guide if or when to do liver biopsy recommendations in children receiving methotrexate. (J Am Acad Dermatol. 2014 Aug;71[2]:327-49).

Practice gap: Eczema appointments may only last 10-20 minutes.

Reality: “Proper eczema education takes much longer,” Dr. Sidbury said. Among patients and clinicians, there is still “rampant misinformation,” with persistence of fundamental knowledge gaps. “Studies repeatedly validate the role of education” in providing optimal care for eczema sufferers and their families, he emphasized (Pediatr Allergy Immunol. 2015 Jan 23. doi: 10.1111/pai.12338).

How is a busy physician to integrate all of these recommendations into practice and make sure patients are getting proper education? “Don’t reinvent the wheel – Google it!” Dr. Sidbury said. Resources from the National Eczema Association, among others, can help guide care. Eczema action plans that can be downloaded provide a roadmap for shared decision making; food allergy clinical practice guidelines help patients avoid allergens, and patients can further their knowledge when directed to reputable websites like the National Eczema Association and resources like www.eczemacenter.org, at Rady Children’s Hospital–San Diego.

Dr. Sidbury disclosed that he was a site principal investigator for an Anacor Pharmaceuticals–sponsored trial of a new topical anti-inflammatory agent for allergic dermatitis, and that he is on the Scientific Advisory Committee of the National Eczema Association.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – In the treatment of eczema, the gap between evidence and practice can be broad.

Dermatologists who treat atopic dermatitis confront many challenges – patients may be severely atopic, have a hard time being compliant with therapies, and have frequent recurrences, Dr. Robert Sidbury said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. “It just is not easy,” he said.

However, even for challenging patients, physicians should be mindful of evidence-supported treatments and be attentive to practice gaps, said Dr. Sidbury, chief of the division of dermatology at the University of Washington’s Seattle Children’s Hospital.

Though the field is rapidly changing, the American Academy of Dermatology has issued practice guidelines that can help guide clinical treatment decisions, said Dr. Sidbury, who helped develop the AAD guidelines. He noted that prescribers may eventually feel the pain of the practice gap if AMA-driven performance measures are enforced.

At the meeting, Dr. Sidbury discussed areas in which many clinicians may have a practice gap in the treatment of eczema. Topping the list of non–evidence-based eczema care are overuse of steroids, oral antibiotics, and nonsedating antihistamines.

Practice gap: Many clinicians believe that topical steroids are more effective for atopic dermatitis when used twice daily.

Reality: “Randomized, controlled trials and a systematic review suggest that there is no benefit to twice-daily use of steroids,” over once-daily use, Dr. Sidbury said, though he admitted that he’s having a hard time breaking his own longstanding practice habit of prescribing twice- rather than once-daily dosing of topical corticosteroids. He pointed out that Dr. Hywel Williams, the director of the University of Nottingham’s Center of Evidence-Based Dermatology, England, calls this the “lowest-hanging fruit” in terms of cost savings, safety, and convenience to patients.

Practice gap: Unnecessary skin cultures can lead to overuse of systemic antibiotics in atopic dermatitis.

Reality: Colonization with Staphylococcus aureus occurs in more than 90% of adults with atopic dermatitis, but the vast majority of these patients are not infected. “Except for bleach baths in concert with intranasal mupirocin, no topical antistaphylococcal treatment has been shown to be clinically helpful in patients with atopic dermatitis,” Dr. Sidbury said.

“How do we know when eczema is infected? We know it when we see it. You are best served by using your clinical gestalt,” he added. Eczematous skin presents along a continuum, ranging from erythema, scaling, and crusting, to a frankly purulent appearance with clear infection, and clinical presentation and judgment should guide treatment. Barring frank infection, the evidence doesn’t support use of systemic antibiotics (Br J Dermatol. 2010 Jul;163 [1]:12-26).

Practice gap: Many patients with atopic dermatitis receive nonsedating antihistamines for itching.

Reality: There is no evidence that nonsedating antihistamines are beneficial unless the patient has concurrent rhinoconjunctivitis, so data don’t support their use “for the actual itch of eczema,” Dr. Sidbury said. In fact, the AMA-sponsored Physician Consortium for Performance Improvement nearly passed an overuse measure that would have penalized the prescription of nonsedating antihistamines in this setting, he said.

Practice gap: Systemic immunomodulatory therapy is used for pediatric atopic dermatitis, despite the lack of data that provide clear guidance.

Reality: The landscape here is a little more complicated, according to Dr. Sidbury. Among the systemic immunosuppressants, cyclosporine, methotrexate, azathioprine, and mycophenolate have the most evidence backing their use. However, there remains a lack of comparative studies and a lack of studies evaluating these therapies in the pediatric population, he said.

In general, Dr. Sidbury said that systemic therapy for atopic dermatitis is indicated only when control is inadequate despite truly optimized topical care, and the condition is having a “significant negative physical, psychological, or social impact” on the patient. Before beginning these potent systemic therapies, it’s important to assess that the patient and family are truly adherent to the topical treatment regime, and that adjunctive treatments like wet wraps and strict allergen avoidance are being followed. The Food and Drug Administration is beginning to include pediatric patients in clinical trials of systemic therapy for atopic dermatitis, so the quality of data should improve.

If systemic therapy is initiated, some clinical pearls can guide use, he said. Cyclosporine has the quickest onset of action and can be dosed at 3-6 mg/kg per day, divided into twice daily dosing. The maximum dose is 300 mg/day, and the microemulsion form is preferred. Overall, mycophenolate is the best-tolerated immunosuppressive. If methotrexate is chosen, it should be dosed at 0.2-0.7 mg/kg per week; liver function should be checked at 5-7 days after dosing, since methotrexate can cause a transient transaminitis. There are no standard recommendations to guide if or when to do liver biopsy recommendations in children receiving methotrexate. (J Am Acad Dermatol. 2014 Aug;71[2]:327-49).

Practice gap: Eczema appointments may only last 10-20 minutes.

Reality: “Proper eczema education takes much longer,” Dr. Sidbury said. Among patients and clinicians, there is still “rampant misinformation,” with persistence of fundamental knowledge gaps. “Studies repeatedly validate the role of education” in providing optimal care for eczema sufferers and their families, he emphasized (Pediatr Allergy Immunol. 2015 Jan 23. doi: 10.1111/pai.12338).

How is a busy physician to integrate all of these recommendations into practice and make sure patients are getting proper education? “Don’t reinvent the wheel – Google it!” Dr. Sidbury said. Resources from the National Eczema Association, among others, can help guide care. Eczema action plans that can be downloaded provide a roadmap for shared decision making; food allergy clinical practice guidelines help patients avoid allergens, and patients can further their knowledge when directed to reputable websites like the National Eczema Association and resources like www.eczemacenter.org, at Rady Children’s Hospital–San Diego.

Dr. Sidbury disclosed that he was a site principal investigator for an Anacor Pharmaceuticals–sponsored trial of a new topical anti-inflammatory agent for allergic dermatitis, and that he is on the Scientific Advisory Committee of the National Eczema Association.

SDEF and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes