Treating Keloids Pragmatic Tips & Advances

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Vol. 2, No. 1 | January 2021 Treating Keloids Pragmatic Tips & Advances

INSIDE: Practice Management Marketing in pandemic days Integrative Medicine Diet and dermatology Outside-the-Box Thinking

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DERMAVANT.COM THE Contents www.thedermdigest.com Volume 2, Number 1 | January 2021

2 13 Ted Talks Pediatrics Will COVID-19 Lice are still out in force mark the end of live during the pandemic. medical education and Here is a look at conventions? treatment options

6 33 Literature Lessons Getting teens to comply with acne treatments can 23 Research updates in take a delicate approach Cover Article cutaneous oncology, rosacea, new drugs and devices, itch, psoriasis, Five pearls infectious diseases, for treating and more tricky keloid scars

continued on page 3

January 2021 | 1 Ted Talks “ Lord! How sad a sight it is to see the streets empty of people…and about us, two shops in three, if not more, generally shut up.” —Samuel Pepys’ diary, August 16, 1665

Samuel Pepys, high ranking administrator in the British Admiralty and also a member of Parliament, kept a detailed diary during a period when London was experiencing an outbreak of bubonic plague. Despite the passage of three and a half centuries, many of his clever observations could easily apply to the present- day COVID-19 pandemic. For example, he noted that businesses were closed and people were not socializing as they had before. Ted Rosen, MD, FAAD With the advent of COVID-19, we essentially Editor-in-Chief saw the demise of live continuing medical This is Ted's take. education conferences. They have largely been What's yours? supplanted in 2020 by virtual medical educa- [email protected] tion events. Some have featured pre-recorded talks, while others have included presentations given in real time, but only to an online audience. With COVID-19 cases still appearing worldwide, including second or third waves, ing the significant financial burdens and time it remains uncertain when (or even if) we can commitment barriers that may make traveling (or will) return to the days of in-person CME to meetings difficult for some. Virtual atten- events, often held in desirable destinations. dance is also efficient and comfortable. I dare However, one might legitimately ask if this is say that sitting in a crowded ballroom chair indeed a laudable goal! In fact, there are many for hours on end can become both painful and unequivocal advantages to approaching CME soporific, no matter the quality of the 4:30 pm via the virtual route. speaker. Most online symposia also typically Online conventions can certainly still convey allow adequate time for live question-and-an- important content. If the core purpose of such swer periods. Participants may be even more meetings is to disseminate new and emerging likely to ask questions when they don’t have to medical information, then virtual seminars stand up in front of hundreds of their peers. do work. There have even been provisions for The fact that virtual content is most frequently online product theaters and virtual tours of ex- archived for later access facilitates convenient hibit halls to insure vital interactions with our viewing—and reviewing if so desired—by reg- pharmaceutical partners. Moreover, online at- istrants. Urgent and emergent patient care also tendance “levels the playing field” by eliminat- does not suffer because providers no longer continued on page 4 2 | The Dermatology Digest Contents continued from page 1

17 Literature Update Does hair oil complicate scalp cultures? You may be surprised

28 Cosmetic Corner One practice's experience with using broadband light to treat senile purpura

43 Psoriasis and Atopic Dermatitis 61 Tips to improve eczema patients' Practice Management outcomes and satisfaction What to do (and what NOT to do) to reach patients during the COVID-19 pandemic 49 Crystal Ball How strong is the link between diet and skin health?

53 General Dermatology New hyperhidrosis treatments emerge to give patients better quality of life

C3 37 Diagnose This Zebra Surgical Corner A patient returns from a Surgical glues work wonders, except safari with strange symptoms. when they provoke contact dermatitis Can you make the diagnosis?

January 2021 | 3 www.thedermdigest.com/TED_TALKS

continued from page 2 THE must be hundreds, or even thousands, of miles of learning occurs outside the lecture hall: away from their offices, clinics, or hospitals. physician to physician, physician to faculty From a pragmatic standpoint, an online con- and physician to industry.” Additionally, all ference may be able to attract many overseas noted another feature of live conferences that www.thedermdigest.com participants and/or international experts who is hard to emulate via the virtual route: the will bring somewhat different experiences and enjoyment aspect. As Dr. Wu put it, “In-person PUBLISHING & SALES viewpoints. In summary, when I started to re- meetings are far superior for socializing and AMY AMMON Executive Director, Publisher [email protected] DON BERMAN Executive Director, Digital Strategy [email protected] It seems to me that learning is enhanced when we remove ourselves GEORGE MARTIN, MD from our daily routine and place ourselves in a controlled learning Executive Director

EDITORIAL situation such as a live conference.” TERESA MCNULTY “ —Joe Fowler, MD Managing Editor SUSAN C. OLMSTEAD Editor ally think about this subject, I became increas- for networking.” Finally, it actually may be, as NANCY BITTEKER Creative Director ingly convinced that the old archetype of live several suggested, that distractions MICHAEL WESTFALL CME conferences was destined to follow the from learning are more likely to occur when Product Manager path of the dinosaur and simply disappear. attendees are “signing in” from home or the office, compared to when they have deliber- Nonetheless, to be fair and balanced, as well Print Circulation: ately chosen to come to a conference and 13,500 dermatologists USA as to ascertain others’ viewpoints, I contacted 2,800 dermatological NP/PA’s spend a block of time devoted to educational some of the directors of well-known, widely The Dermatology Digest ® is published endeavors. To quote Dr. Fowler, “It seems to monthly by The Dermatology Digest, attended dermatology conferences. I wanted LLC, 88 N Main Street, Pearl River, me that learning is enhanced when we remove NY 10965. to understand their positions on this hot topic. ourselves from our daily routine and place © 2020 The Dermatology Digest, LLC. After all, these are the very people who have All rights reserved. No part of this pub- ourselves in a controlled learning situation lication may be reproduced or trans- had to make difficult decisions and devise and mitted in any form or by any means, such as a live conference.” electronic or mechanical including by implement adjustments and modifications to photocopy, recording, or information We are certainly constrained by the current storage and retrieval without permis- a highly successful paradigm. I communicated sion in writing from the publisher. exigencies inherent to this dreadful global Authorization to photocopy items for with Drs. Joe Fowler, George Martin, Mark internal/educational or personal use, Nestor, Jay Wu, and Eric “Billy” Baum. All pandemic. In the immediate future, I seriously or the internal/educational or personal doubt that many totally live conferences will use of specific clients is granted by The readily acknowledged that online conferences Dermatology Digest, LLC. For uses occur. While the traditional CME conference beyond those listed above, please can be useful tools to provide high-quality direct your written request to Amy has been temporarily replaced by its virtual Ammon, Executive Director, Publisher CME. All were also pleasantly surprised that at: [email protected]. such meetings can be held without technologi- counterpart, there are certainly excellent POSTMASTER: Please send address reasons to eventually return to educational changes to The Dermatology Digest cal problems. Dr. Baum said, “I was dreading LLC, 88 N Main Street, Pearl River, NY meetings with live components. When per- 10965. Printed in the U.S.A. glitches deterring the quality of the presenta- sonal safety and public health concerns allow The Dermatology Digest ® does not tions. These never happened. Our meeting verify any claims or other information it, perhaps hybrid conferences will become appearing in any of the advertisements was seamless.” contained in the publication and cannot the norm, so that the unique benefits of each take any responsibility for any losses Despite being generally positive, however, or other damages incurred by readers model may be reaped by all involved.  in reliance on such content. these directors did share several concerns. The Dermatology Digest ® welcomes They pointed out one glaringly obvious fact: unsolicited articles, manuscripts, photographs, illustrations and other virtual conferences lack the opportunity for materials, but cannot be held responsible for their safekeeping or return. instant and impromptu educational interac- tion. As Dr. Nestor astutely said, “A great deal

4 | The Dermatology Digest THE

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EDITORIAL BOARD

EDITOR-IN-CHIEF

TED ROSEN, MD JIM TREAT, MD SANDY TSAO, MD Houston, Texas Philadelphia, Pennsylvania Boston, Massachusetts

STEPHEN TYRING, MD, PhD ASSOCIATE EDITORS CONTRIBUTING EDITORS Houston, Texas

BRIAN BERMAN, MD, PhD LUCIA DIAZ, MD GUY WEBSTER, MD, PhD Miami, Florida Austin, Texas Philadelphia, Pennsylvania

JOEL COHEN, MD HAYES GLADSTONE, MD Greenwood Village, Colorado San Ramon, California CONTRIBUTORS

SEEMAL DESAI, MD MICHAEL GOLD, MD NEAL BHATIA, MD Plano, Texas Nashville, Tennessee San Diego, California

SHEILA FRIEDLANDER, MD MITCHEL GOLDMAN, MD CHERYL BURGESS, MD San Diego, California San Diego, California Washington, DC

DAVID OZOG, MD ADITYA GUPTA, MD, PhD SUNEEL CHILUKURI, MD Detroit, Michigan Toronto, Canada Houston, Texas

MATT ZIRWAS, MD RAJANI KATTA, MD RISA GOLDMAN LUKSA Columbus, Ohio Bellaire, Texas San Diego, California

MARK KAUFMANN, MD RAEGAN HUNT, MD EDITORIAL BOARD New York, New York Houston, Texas

HILARY BALDWIN, MD ARTHUR KAVANAUGH, MD NEIL KORMAN, MD, PhD New York, New York San Diego, California Cleveland, Ohio

VALERIE CALLENDER, MD ROB KIRSNER, MD, PhD DAVID LAUB, MD Glenn Dale, Maryland Miami, Florida Mill Valley, California

LARRY EICHENFIELD, MD HENRY LIM, MD GEORGE MARTIN, MD San Diego, California Detroit, Michigan Kihei, Hawaii

WHITNEY HIGH, MD, JD NATASHA MESINKOVSKA, MD WENDY ROBERTS, MD Aurora, Colorado Irvine, California Rancho Mirage, California

SUZANNE KILMER, MD DANIEL SIEGEL, MD REENA RUPANI, MD Sacramento, California New York, New York New York, New York

BRUCE STROBER, MD, PhD LINDA STEIN GOLD, MD JONATHAN SILVERBERG, MD Cromwell, Connecticut Detroit, Michigan Washington, DC

January 2021 | 5 Off-label Pearl By Ted Rosen, MD, FAAD, Editor-in-Chief

Patients receiving epidermal growth factor receptor inhibitors for the treatment of cancer are prone to develop severe acneiform eruptions. This adverse event may be prevented or lessened in severity by prophylactic administration of oral tetracycline derivatives at typical therapeutic doses. TO READ MORE: Yu Z, et al. Evaluation of a comprehensive skin toxicity program for patients treated with epidermal growth factor receptor inhibitors at a cancer treatment center. JAMA Dermatol. 2020;Jul 1;e201795. doi: 10.1001/jamadermatol.2020.1795

Literature Lessons

COVID-19

It appears that patients who have recovered from COVID-19 can be reinfected, and that—at least—humoral immune response wanes over time. This calls into question the potential need for multiple vaccinations over time. TO READ MORE: Torres DA, et al. Reinfection of COVID-19 after 3 months with a distinct and more aggressive clinical presentation: case report. J Med Virol. 2020 Oct 28. https://pubmed.ncbi.nlm.nih. gov/33112002/; AlFehaidi A, et al. A case of SARS-CoV-2 re-infection. J Infect. 2020 Oct 25. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7585726/; Seow J, et al. Longitudinal observation and decline of neutralizing antibody responses in the three months following SARS- CoV-2 infection in humans. Nat Microbiol. 2020 Oct 26. https://pubmed. ncbi.nlm.nih.gov/33106674/

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INFECTIOUS DISEASES

Approved in the US in 2014, miltefosine is Alternating 0.1 ml intralesional injections of CANDIDA ANTIGEN AND PURI- an effective oral treatment for NEW WORLD FIED PROTEIN DERIVATIVE (PPD), given every 2 weeks for a total of LEISHMANIASIS. The dosage is 50 mg BID 3 months, led to com (body weight under 45 kg) or TID (body weight plete clearance of nearly over 45 kg) for 28 days. Significant numbers of patients develop nausea, vomiting, motion sickness and headache. The drug is contra % indicated in pregnancy. TO READ MORE: Chan CX, et al. Cutaneous 71 leishmaniasis successfully treated with OF COMMON WARTS. miltefosine. Cutis. 2020;106:206209. Alternating therapy https://www.mdedge.com/dermatology/ proved superior to either Candida antigen, PPD or saline placebo alone, given article/229918/infectiousdiseases/cutane on the same schedule. ousleishmaniasissuccessfullytreated?sso=true TO READ MORE: Nofal A, et al. Alternating intralesional purified protein derivative and Candida antigen versus either agent alone in the treatment of multiple common warts. J Am Acad Dermatol. 2020;83(1):208210. https://pubmed.ncbi.nlm.nih.gov/32006600/

What is a “NORMAL” TEMPERATURE? Is it really 98.6°F (37°C), as deter mined by measurements taken in Germany in 1851? Based on a 10year study done at Stanford University, it appears that the “normal” body tempera ture in industrialized countries has been falling every decade since 1860, and may be at (or near) 97.5°F (36.4°C) at present. TO READ MORE: Protsiv M, et al. Decreasing human body temperature in the United States since the industrial revolution. . 2020 Jan 7;9:e49555. In a small Iranian study, clarithromycin 500 mg Elife https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6946399/ BID proved equal in efficacy to intramuscular pentavalent antimony in the treatment of OLD WORLD LEISHMANIASIS. TO READ MORE: Zabolinejad N, et al. Evaluating the effect of oral clarithromycin on acute cutane ous leishmaniasis lesions compared with systemic glucantime. J Dermatolog Treat. 2020 Sep 24:16. https://pubmed.ncbi.nlm.nih.gov/32972289/

January 2021 | 7 PSORIASIS

While large-scale studies are lacking, there is PUSTULAR growing evidence that TOPICAL CANNABINOID PSORIASIS is products may be useful for the mitigation of signs composed of a and symptoms of inflammatory skin disorders variety of clinical such as psoriasis. For patients who prefer “nat- entities, most ural” products or who have insufficient response notably generalized or atrophy following the use of topical corticoste- pustular psoriasis, roids, a trial of readily available topical cannabi- palmoplantar noids may be warranted. psoriasis, and acrodermatitis TO READ MORE: Friedman AJ, Momeni K, Kogan continua of Hallopeau. M. Topical cannabinoids for the management of Unlike psoriasis psoriasis vulgaris. Report of a case and review of vulgaris, however, the literature. J Drugs Dermatol. 2020;19:794- these diseases have 795. https://pubmed.ncbi.nlm.nih.gov/32845594/ a monogenic etiology. Mutations in 3 genes, IL36RN, CARD14, and AP1S3, seem to be responsible for PSORIASIS IN SKIN OF COLOR may present with these distinct entities. more violaceous and less erythematous lesions, Identification of this reduced scaling, greater scalp involvement, and genetic etiology may much higher risk of post-inflammatory dyschromia. allow rational design TO READ MORE: Nicholas MN, et al. Psoriasis of tailored therapeutic in patients of color: differences in morphology, approaches which clinical presentation, and treatment. Cutis. will be better than 2020;106(suppl 2):7-10. https://pubmed.ncbi.nlm. currently available nih.gov/33104098/ drugs. TO READ MORE: Bachelez H. Pustular While endemic deep FUNGAL INFECTION has psoriasis: the dawn of been reported concomitant to the use of a new era. Acta Derm TNF-alpha inhibitors, there is no evidence that Venereol. 2020 Jan administration of IL-17, IL-12/IL-23 or IL-23 30;100(3):adv00034. inhibitors increases the risk of deep fungal doi: 10.2340/ infections. 00015555-3388. TO READ MORE: Lee MP, et al. Risk of deep fungal infections during IL-17 and IL-23 inhibitor therapy for psoriasis. Cutis. 2020;106:199-205. https://pubmed.ncbi.nlm.nih.gov/33186421/

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CONTACT DERMATITIS RHEUMATOLOGIC DISEASES Remember that CONTACT DERMATITIS can almost exactly mimic a wide MOISTURE- variety of skin conditions. These include, but are not limited to: eczematous ASSOCIATED SKIN Be careful when disorders, infectious conditions, cutaneous lymphoma, drug eruptions, and DAMAGE diagnosing nutritional deficiencies. When your treatment plan is not working, think: Could Moisture-associated PYODERMA this be a contact dermatitis? skin damage can GANGRENOSUM. occur with urinary or Cutaneous polyarteritis TO READ MORE: Elmas OF, et al. Contact dermatitis: a great imitator. fecal incontinence, can almost exactly Clin Dermatol. 2020 Mar-Apr;38:176-192. around stoma and mimic pyoderma https://pubmed.ncbi.nlm.nih.gov/32513398/ cutaneous wounds, gangrenosum and as intertriginous clinically. Biopsy and HIDRADENITIS SUPPURATIVA (HS) dermatitis. Meticulous clinical context may be A survey of over 700 hidradenitis patients was conducted online and at HS adherence to proper required to separate specialty clinics. Few (12%) felt that select foods improved the disease. But skin care can help the 2 entities. nearly one-third readily identified dietary components which aggravated HS alleviate these forms TO READ MORE: symptoms. Most commonly implicated were: of skin irritation. Pineider J, Woen SWEETS BREAD/PASTA/RICE DAIRY HIGH-FAT FOODS TO READ PRACTICAL J, West L, et al. AND EASILY Cutaneous polyarteritis % % % % IMPLEMENTED nodosa with clinical 67.9 51.1 50.6 44 TIPS, GO TO: features of pyoderma The inescapable conclusion is that “HS patients may benefit from receiving Fletcher J, Beeckman gangrenosum. JAAD dietary counseling as part of a comprehensive HS management plan.” D, Boyles A, et Case Reports. al. International TO READ MORE: Fernandez JM, et al. Alleviating and exacerbating foods Sep 2020. best practice https://www. in hidradenitis suppurativa. Dermatol Ther. 2020 Aug 29:e14246. recommendations: https://pubmed.ncbi.nlm.nih.gov/32860476/ jaadcasereports. prevention and org/article/S2352- management of 5126(20)30660-3/ ITCH moisture-associated fulltext According to a comprehensive meta-analysis of randomized controlled skin damage (MASD). studies, gabapentin is an effective management for UREMIC PRURITUS. Wounds International. Adverse events include dizziness, drowsiness, and somnolence. 2020. TO READ MORE: Eusebio-Alpapara KMV, et al. Gabapentin for uremic Available at www. puritus: a systematic review of randomized controlled trials. Int J Dermatol. woundsinternational. 2020;59:412-422. https://pubmed.ncbi.nlm.nih.gov/31777066/ com.

January 2021 | 9 DRUGS AND DEVICES GENERAL DERMATOLOGY

While several new topical agents are (or will The British Association of Dermatologists issued a third update on GENITAL soon be) available to treat HYPERHIDROSIS, LICHEN SCLEROSUS. Highlights include enumeration of co-morbidities and botulinum toxin injections may also be (females: thyroid disease; males: coronary artery disease and diabetes), used, these interventions are quite expensive. general recommendations to lose weight and discontinue smoking, and A retrospective review of 1658 patients treated validation of daily use of potent topical steroids for 1-3 months to gain over 12 years with oral oxybutynin suggests control. A ½ fingertip unit should be used per application. Maintenance that over 70% of hyperhidrosis patients can be involves application of low- to medium-potency steroid 1-2 times weekly. managed successfully with this inexpensive agent. The goals of therapy are to relieve symptoms, prevent scarring, preserve Oxybutynin, an anticholinergic drug, was effective sexual functioning, and prevent neoplasia. for all hyperhidrosis sites; the most common TO READ MORE: Lewis FM, et al. British Association of Dermatologists adverse event was dry mouth (25%). Considering guidelines for the management of lichen sclerosus, 2018. Br J Dermatol. that a month’s supply of this agent (at a dose 2018;178(4):839-853. https://pubmed.ncbi.nlm.nih.gov/29313888/ of 5 mg BID) can be obtained for less than $10, a trial might be considered. TO READ MORE: Wolosker N, et al. Long-term According to the most recent Medscape survey of 5250 physicians, results of the treatment of primary hyperhidrosis representing 29 specialties, with oxybutynin: follow-up of 1,658 cases. Int J felt that it was acceptable to become involved Dermatol. 2020;59:709-715. in a ROMANTIC/SEXUAL RELATIONSHIP https://pubmed.ncbi.nlm.nih.gov/32301117/ % WITH A PATIENT 6-12 months after the professional association was discontinued. 25 Only 12% felt this way in 2010.

In a cross-sectional, national interview study of nearly 24,000 patients, about 20% of those surveyed felt that their health care providers were insufficiently familiar with their CULTURE AND MEDICAL TRADITIONS. This led to a feeling of disrespect. The message here is to make an attempt to broaden one’s horizons and take into account ethnic health practices. TO READ MORE: Blewett LA, et al. Patient perspectives on the cultural competence of US health care professionals. JAMA Netw Open. 2019;2(11): e1916105. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902827/

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CUTANEOUS ONCOLOGY ACNE ROSACEA

Palliative therapy for inoperable NON-MELANOMA A study done at the University of Naples, Italy, SKIN CANCERS is a reasonable consideration, concluded that especially in older patients. For example, Hedge- hog pathway inhibitors may be utilized, not to “cure” advanced basal cell carcinoma, but rather % to improve quality of life, reduce morbidity, and preserve function when large tumors occur near 92 the facial orifices. OF ACNE PATIENTS WERE SATISFIED TO READ MORE: Lam C, et al. Palliative use of WITH MEDICAL CARE DELIVERED VIA Vismodegib. Dermatol Surg. 2020;46(2):272-276. TELEDERMATOLOGY. https://pubmed.ncbi.nlm.nih.gov/30789523/ The implication for our future practice is clear. TO READ MORE: Ruggiero A, et al. Telederma- NICOTINAMIDE tology for acne during COVID-19: high patients’ satisfaction in spite of the emergency. J Eur Acad 500 MG Dermatol Venereol. 2020 June 13. As is true with acne, https://www.ncbi.nlm.nih.gov/pmc/articles/ ROSACEA is often TWICE A DAY PMC7323158/ best managed with may well be a sustainable therapy for patients combination therapy. with large numbers of otherwise refractory Mixing topical alpha Are you aware of the “SKIN ACCEPTANCE MOVE- ACTINIC KERATOSIS. agonist with either MENT”? This largely social media-driven move- systemic or topical TO READ MORE: Paugam E, Dreno B. Is ment aims to remove the social stigma from acne, anti-inflammatory nicotinamide a sustainable therapy for resistant making it almost a “trendy” skin finding. While agents, followed by actinic keratoses? J Eur Acad Dermatol Venereol. there is clear benefit to making acne acceptable adjunctive energy- 2020;34(10):e624-e626. (and even “cool”) to have, there is a risk that it based therapies, https://pubmed.ncbi.nlm.nih.gov/32311791 might also discourage seeking treatment for a may be required to very responsive disorder! address the patient’s Using the SEER cancer database (1973- TO READ MORE: Yumeen S, Abrouk ME, Maderal constellation of signs 2014), researchers have noted that PRIMARY AD. Acne, the new trend? A discussion of the and symptoms. CUTANEOUS MELANOMA SURVIVORS are at emerging social movement to embrace acne TO READ MORE: increased risk for both ocular melanoma and vulgaris. Int J Dermatol. 2020;59:1276-1277. Stein-Gold L, other non-cutaneous malignancies. Secondary https://pubmed.ncbi.nlm.nih.gov/32506439/ Baldwin H, Harper malignancies occurred in a wide range of types. JC. Rationale for TO READ MORE: Vakharia PP, et al. Risks for use of combination noncutaneous second primary malignancy in therapy in rosacea. cutaneous malignant melanoma survivors: an J Drugs Dermatol. analysis of data from the Surveillance, Epide- 2020;19:929-934. miology, and End Results (SEER) program. Int J https://pubmed. Dermatol. 2020;59:463-468. ncbi.nlm.nih. https://pubmed.ncbi.nlm.nih.gov/31971260/ gov/33026776/

January 2021 | 11

PEDIATRICS PEDICULOSIS CAPITIS

Tackling lice: Pick your poison

By Cheryl Guttman Krader | Reviewed by Natasha Mesinkovska, MD, PhD

ost everyone would agree that thanks to the COVID-19 pandemic, 2020 Mhas been a pretty lousy year. How “lousy” a year it has been with respect to the prevalence of pediculosis capitis (head lice infestation) is unknown.

On the one hand, cases of head lice infestation may have become more troublesome as families NATASHA spend more time together indoors. Alternatively, it is possible that cases declined because of social MESINKOVSKA, distancing and shifts to remote learning. MD, PhD Associate Professor Even if there was a temporary drop in cases, it is likely that head lice remains a common problem, of Dermatology, given its high prevalence before the pandemic, said Natasha Mesinkovska, MD, PhD, Associate University of California Professor of Dermatology, University of California Irvine. Irvine She notes that primary treatment for head lice generally may not be seen by dermatologists as a chief complaint for a clinic visit. However, with telehealth visits increasing, these patients may be encountered more often. “Whether managing patients who failed previous treatment or those needing initial therapy, however, understanding the life cycle of the louse and the activity of available therapies is fundamental for successful intervention that will eradicate the infestation and prevent its spread,” Dr. Mesinkovska said.

January 2021 | 13 Lice: the facts may be overcome soon, however, as the FDA THE KEY 3 Head lice infestation is caused by the ectopar- granted approval for topical ivermectin lotion asite Pediculosis humanus capitis, and the life 0.5% to be sold without prescription.”3 High levels of cycle of this insect is comprised of 3 stages: Pharmacological treatments louse resistance egg, nymph, and adult.1,2 Eggs (also known as The most commonly used OTC products for to common OTC nits) are deposited and glued onto the hair shaft treating head lice contain pyrethrin or per- products create close to the scalp by the adult female louse. The methrin. These chemicals act as neurotoxins a challenge for eggs hatch after approximately 7 days, releasing to kill nymphs and adult lice, but are poorly treatment the nymphs that go through 3 molts as they ovicidal. “Because of these issues, permethrin grow to become mature adults approximately 7 and pyrethrin products need to be combined The forthcoming days after hatching. Then, the cycle restarts as with hair combing to physically remove the availability of topical adult female lice begin to lay 8 to 10 eggs a day nits and require repeat application 7 to 10 days ivermectin as an during their lifespan, which lasts for approxi- after the first treatment to kill the newly hatched OTC product holds mately 30 days. nymphs,” Dr. Mesinkovska said. “Adherence to promise for greater “Effective treatment of head lice requires inter- these instructions, however, may be suboptimal.” treatment success vention that will eradicate both the living lice Furthermore, a relatively recent study of and any viable eggs,” said Dr. Mesinkovska. Wet-hair combing lice collected from infested individuals in “Unfortunately, the active ingredients in the to remove nits is an 48 US states found that 100% of lice at 96% most commonly used OTC treatments—pyre- essential component of the 138 participating sites carried resistance thrin and permethrin—are associated with high 4 of any treatment genes to pyrethroids. The investigators noted levels of genetic-based louse resistance. Most are regimen that the increasing frequency of the genetic also minimally effective at eliminating the eggs. mutations correlated with findings from con- The issue of louse resistance to OTC treatment trolled studies reporting treatment failure with products containing pyrethrin or permethrin.

Day 0: Louse egg is laid Ivermectin, which has been available as a top- Day 33-35: on the hair shaft ical lotion by prescription, kills lice by neuro- The louse dies muscular paralysis of the insects’ feeding parts. It offers hope for more effective OTC treatment Days 19-32: because it appears to be effective against perme- Female lays Day 6-7: thrin-resistant lice.5 Although its labeling rec- 1-2 eggs Young louse ommends a single application, Dr. Mesinkovska after mating. hatches Female con- still advises that repeating the treatment after tinues to lay 7 days may be prudent. 4-8 eggs a day for Among the available prescription products 16 days indicated for treatment of head lice, spinosad topical suspension 0.9% is the only one that is

M both pediculicidal and ovicidal. Because of its Days 8-9: First molt dual activity, it may be a good choice for treat- F 2 days after ing treatment-refractory cases of head lice, said Days 17-19: hatching Dr. Mesinkovska. Male and slightly larger Malathion 0.5% is partially ovicidal, and while female begin to reproduce it has a good margin of safety, it can be irritat- Days 16-17: Days 11-12: ing to skin and is not recommended for use Third molt 10 days Second molt 5 days in children younger than age 6. It must be left after hatching after hatching

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on the head for 8 to 12 hours after application, which may be a practical issue limiting its use. A relatively recent study of lice Rounding out the prescription options is benzyl collected from alcohol 5% lotion. Dr. Mesinskovska said she has no personal experience with that product, infested individuals which acts as a suffocant. in 48 US states “Some individuals may feel more comfortable found that using benzyl alcohol versus one of the neurotoxin-based products, but benzyl alcohol may % be more irritating and still needs to be used twice because it is not ovicidal,” she said. 100

Non-pharmacological treatments It runs on a single AA battery, is used on dry OF LICE AT Patients or parents who balk at the idea of using hair, physically removes nits, and purportedly a “pesticide” as treatment for head lice and ask kills live nymphs and adult lice on contact by % for a “natural” alternative can be counseled that emitting a small electrical charge. by definition, any chemical product designed to 96 “Efficacy of this device for treating refractory repel or kill lice and nits is a pesticide, regard- OF THE 138 6 infestations was reported in a letter to the ed- less of its ingredients. PARTICIPATING itor of the Journal of the American Academy of SITES “I always support finding the least toxic treat- Dermatology by dermatologist Kenneth Resnik ment methodology. However, claims about lack in 2005.7 I am not aware, however, of any clini- carried resistance of toxicity for ‘natural’ products require sub- cal trial evidence showing its effectiveness,” Dr. genes to stantiation, and there is little scientific evidence Mesinkovska said. to substantiate efficacy for many non-phar- pyrethroids. macological treatments, including mineral As another alternative to OTC or prescrip- oil, coconut oil, or various essential oils,” Dr. tion pediculicides, Dr. Mesinkovska provides Mesinkovska said. instructions for using a combination method of gentle skin cleanser to patients who ask about If parents strongly object to using chemicals, this treatment. The “Nuvo” method involves Dr. Mesinkovska suggests trying a commercial- application of Cetaphil Gentle Skin Cleanser to ly available electric, fine-toothed metal comb the hair and was reported as being 96% effec- intended for treating head lice (RobiComb). tive by Dale Pearlman, MD, the physician who

Table 1. Pharmacological treatments for pediculosis capitis Product (brand name) Minimum age Applications per manufacturer (interval) OTC*

Pyrethrin shampoo (Rid) 2 years 2 (7-10 days)

Permethrin 1% cream rinse (Nix) 2 months 2 (7 days)

Ivermectin lotion 0.5% (Sklice) 6 months 1 Prescription

Spinosad 0.9% suspension (Natroba) 6 months 2 (7 days)

Benzyl alcohol 5% lotion (Ulesfia) 6 months 2 (7 days)

Malathion 0.5% lotion (Ovide) 6 years 2 (7-9 days) *Ivermectin lotion was approved by the FDA for OTC sale on October 27, 2020, but had not yet reached store shelves as of December 8, 2020.

January 2021 | 15 www.thedermdigest.com/PEDIATRICS

a great diagnostic and surveillance method for re-infection.” All family members and close contacts of a person with head lice should be checked for infestation. Although lice and eggs can be transferred onto fomites through direct contact with an infested head, the lice and eggs remain viable for a relatively short time when off the head. Although exhaustive cleaning of furniture and carpeting is probably not necessary, Dr. Mesinkovska strongly advises washing recently worn clothing, bedding, and hair-care items in hot water. In addition, plush toys should be enclosed in a plastic bag for 2 weeks or exposed to high heat in a dryer for 10 minutes. 

REFERENCES 1. Centers for Disease Control and Prevention. Parasites – Lice – Head I always Lice. Frequently Asked Questions (FAQs). https://www.cdc.gov/ parasites/lice/head/gen_info/faqs.html. Published September 1, 2015. 8 support finding described it in 2004. However, the study in Accessed December 7, 2020. which it was evaluated was not a randomized, 2. Devore CD, Schutze GE; AAP, Council on School Health, Committee the least toxic controlled trial. on Infectious Dis. Head Lice. Pediatrics. 2015;135(5):e1355-1365. “treatment 3. US Food and Drug Administration. FDA approves lotion for Dimethicone 4% lotion is available as an nonprescription use to treat head lice. Published October 27,2020. methodology.” OTC product (LiceMD), acts as a pediculicide Accessed December 7, 2020. https://www.fda.gov/news-events/ through a physical mode of action, and has press-announcements/fda-approves-lotion-nonprescription-use- treat-head-lice. been reported to be effective for curing head 9 4. Gellatly KJ, Krim S, Palenchar DJ, et al. Expansion of the knockdown lice and minimizing reinfestation. resistance frequency map for human head lice (Phthiraptera: Pediculidae) in the United States using quantitative sequencing. Supplemental measures J Med Entomol. 2016;53(3):653-659. Dr. Mesinkovska believes that wet-combing 5. Strycharz JP, Yoon KS, Clark JM. A new ivermectin formulation the hair with a fine-toothed comb and a condi- topically kills permethrin-resistant human head lice (Anoplura: tioner to remove unhatched eggs is an essential Pediculidae). J Med Entomol. 2008;45(1):75-81. component of any effective head lice treatment 6. United States Environmental Protection Agency. What is a Pesticide? https://www.epa.gov/minimum-risk-pesticides/what-pesticide. regimen. Although it can even be reasonably Accessed December 7, 2020. effective as a standalone modality, with a re- 7. Resnik KS. A non-chemical therapeutic modality for head lice. J Am ported cure rate of 38%,10 Dr. Mesinkovska Acad Dermatol. 2005;52(2):374. says she does not rely solely on wet combing. 8. Pearlman DL. A simple treatment for head lice: dry-on, suffocation- Some head lice treatment products are pack- based pediculicide. Pediatrics. 2004;114(3):e275-279. aged with combs, and another good option is 9. Kassiri H, Fahdani AE, Cheraghian B. Comparative efficacy of permethrin 1%, lindane 1%, and dimeticone 4% for the treatment the “LiceMeister” comb that is available for of head louse infestation in Iran. Environ Sci Pollut Res Int. 2020 Sep purchase online. 12. Epub ahead of print. 10. Roberts RJ, Casey D, Morgan DA, et al. Comparison of wet combing “Parents have to be vigilant about combing, with malathion for treatment of head lice in the UK: a pragmatic which should be done on wet hair every 2 to randomised controlled trial. Lancet. 2000;356(9229):540-544. 3 days for at least 2 weeks and perhaps even

continued weekly for another month in young- DISCLOSURES: Dr. Mesinkovska has no relevant financial interests er children,” Dr. Mesinkovska said. “It is also to disclose.

16 | The Dermatology Digest LITERATURE UPDATE TINEA CAPITIS

myth debunked: Hair oil and fungal cultures

By Cheryl Guttman Krader | Reviewed by Susan J. Bayliss, MD

hen fungal culture is indicated for diagnosis of suspected tinea Wcapitis, clinicians can feel confident about the reliability of the test results whether the patient’s scalp is dry or oily from the recent use of hair grooming products, according to the results of a recently published study in Pediatric Dermatology.1 SUSAN J. BAYLISS, MD Professor of Pediatrics and Internal Medicine Susan J. Bayliss, MD, Professor of Pediatrics and Internal Medicine (Dermatology), Washington (Dermatology), Washington University School of Medicine, St. Louis, Missouri, is principal investigator of the research University School that sought to determine whether hair oil affects the sensitivity of fungal cultures for detecting of Medicine, St. Louis, Missouri Trichophyton tonsurans in pediatric patients with suspected tinea capitis. She told The Dermatology Digest that she was taught during her dermatology residency that hair oil can affect fungal culture results. Therefore, patients who were known to be coming to the clinic for signs and symptoms suggesting tinea capitis would be instructed to shampoo their hair and refrain from using any hair grooming products prior to the visit.

January 2021 | 17 “The idea that hair oil can interfere with de- the hair oil used in the study was selected THE KEY 3 tection of fungus on culture has been perpetu- after canvassing several department employees ated over the years and led some dermatology about the hair grooming products they used. Tinea capitis is programs to ask patients not to apply hair oil common among She acknowledged, “It’s possible that the use before coming to clinic. However, the origins prepubertal children of some other hair oil products containing of the recommendation and the proposed and can lead to different ingredients might affect the sensitivity mechanism are unclear. Importantly, there permanent hair loss of fungal cultures.” is a lack of evidence to support its veracity,” Dr. Bayliss said. Culture results Application of “As a limitation, our study population was Of the 28 samples that were collected before cosmetic hair oil small. However, each patient served as his hair oil application, 16 (57%) were positive for is common in or her own control, and we feel that based T. tonsurans. Of the 16 patients with a positive the demographic on the results, clinicians should culture, 15 had a positive culture group with a higher feel free to get a swab for fungal using the sample taken after incidence of tinea culture whether the scalp is hair oil application. Of the capitis The idea that hair very oily or very dry.” 12 patients whose culture oil can interfere was negative using the scalp Findings from The study included patients with detection of specimen obtained prior to hair who presented to the pediatric a systematic “fungus on culture has oil application, 1 had a positive investigation debunk dermatology clinics at St. Louis culture after hair oil application. the belief that use Children’s Hospital and been perpetuated Dr. Bayliss noted that because of hair oil can Washington University School over the years.” it involved only a single child, influence the ability of Medicine with scalp scaling, the case in which the culture to obtain a positive non-scarring alopecia, positive changed from negative to positive following fungal culture lymph node swelling, or a high clinical suspicion for tinea capitis. Patients who presented with hair oil application does not raise concern heavy oil in their hair or whose scalp symptoms about interference from the hair oil. Howev- could be explained by another disease, such as er, it does underscore a recommendation to psoriasis or eczema, were excluded. repeat the culture if a child diagnosed with another condition is not responding to the All children had specimens collected from recommended treatment. the scalp using a cotton-tip applicator before and after 2 drops of cosmetic hair oil were Testing tips rubbed into the scalp for 5 minutes. The sam- Understanding best practices for diagnosis of ples were plated on appropriate dermatophyte this fungal infection is important considering test media and reviewed for fungal growth that it is a common infection in the pediatric for up to 4 weeks. population, particularly among prepubertal children, that can lead to permanent hair loss.2 The study included 28 patients, including 17 male and 11 female. The patients were aged Diagnosis of tinea capitis can be challenging 5.1 ±3.1 years, and 27 (98%) of the 28 children because it may present with subtle findings that were African American. can mimic other dermatologic conditions affect- ing the scalp, such as mild dandruff-like scaling. The hair oil used in the study was a commer- Therefore, further evaluation beyond physical cially available product that contained water, examination is needed to avoid misdiagnosis. coconut oil, propylene glycol, and jojoba oil as its main ingredients. Dr Bayliss said that “It can sometimes be difficult to differentiate

18 | The Dermatology Digest www.thedermdigest.com/LITERATURE_UPDATE

The hair oil used in the study was a commercially available product that contained water, coconut oil, propylene glycol, and jojoba oil as its main ingredients. between tinea capitis and scalp eczema or the scalp and therefore limit false negatives,” seborrheic dermatitis based on the clinical she explained. features, and it is also possible that the child Because of the delay in obtaining the micro- has tinea capitis comorbid with another biology report and considering that the oral scaling condition,” Dr. Bayliss said. antifungal agents used to treat tinea capitis in She noted that fungal culture is the gold stan- children are generally safe and well-tolerated, dard for diagnosing tinea capitis, and she cited Dr. Bayliss said that she will initiate antifun- several reasons why she prefers getting a swab gal treatment if she has strong suspicion for specimen for fungal culture rather than per- diagnosing tinea capitis, such as in a child who forming a potassium hydroxide (KOH) prep. presents with posterior lymphadenopathy in addition to scaling on the scalp. However, she “I do a KOH prep sometimes, but I always waits for the microbiology report in cases in do a culture. A downside of the KOH method which the diagnosis of tinea capitis is unclear, is that it is more time-consuming for the such as if the child appears to have eczema clinician during what is likely a busy clinic elsewhere on the body. day,” Dr. Bayliss said. A Wood’s lamp examination may also be used “Although the turnaround time for obtaining for diagnosing tinea capitis. However, it is the final culture results can be up to 4 weeks, generally not very fruitful because T. tonsurans a fungal culture is a more sensitive, reliable, does not fluoresce and the test is often misin- and inexpensive diagnostic tool compared terpreted in novice hands, Dr. Bayliss said.  with the KOH prep,” Dr. Bayliss said.

To increase the yield of the culture, Dr. Bayliss REFERENCES recommends moistening the tip of the swab 1. Wichterman CM, Kumar MG, Bayliss SJ. Pediatr Dermatol. using the culturette transport medium before 2020;37(5):977-978. rubbing it on the scalp. 2. Gupta AK, Mays RR, Versteeg SG, et al. Tinea capitis in children: a systematic review of management. J Eur Acad Dermatol Venereol. “This is a quick easy step that can help to 2018;32(12):2264-2274. increase isolation of the dermatophytes from

January 2021 | 19 www.thedermdigest.com/LITERATURE_UPDATE

continued from page 9 COMMENTARY Good news about hair oil

inea capitis continues to pose a significant are less consistently sensitive to terbinafine, public health concern worldwide, partic- which has supplanted griseofulvin as the Tularly in young preschool-age children. treatment of choice in many areas.2 A case The most frequently affected US population, of T. mentagrophytes has recently been iden- African Americans, often use hair oils as a tified as resistant to terbinafine, adding to routine hair care practice. This small, prospec- concerns regarding evolving dermatophyte Sheila Fallon tive, case-controlled study provides reassuring resistance patterns.3 Friedlander, MD information regarding our ability to obtain One aspect of tinea capitis has not changed, Professor Emeritus, reliable cultures in patient populations who and that is its predilection to preferentially Dermatology and Pediatrics, utilize hair oils. University of California, affect people of color. Many theories have been San Diego School of This study is a step in the right direction. None- postulated to explain this, including lower Medicine, staff member, theless, it has some shortcomings. The num- socioeconomic status, crowding, and hair-care Scripps Clinic, ber of patients is small, and patients who had practices such as tight braiding, straightening, San Diego, California “heavy oil present” initially were excluded. The and the use of hair oils. Multiple studies have results tell us about the effect of one application failed to support any of these as the sole cause. of oil, but not what chronic application of oil Quality or volume of sebum as important does to fungal culture sensitivity. In addition, contributors to disease risk have been supported we cannot state whether the routine use of hair by certain epidemiologic facts. Genetic data The results tell oils poses a risk for acquiring the infection. on dermatophyte infections and tinea capitis in particular provide support for a polygenic us about the Though tinea capitis has been a public health explanation for disease susceptibility for any effect of one problem throughout history, it has evolved patient population.4 “application of over time. In the US in the 1950s, a Wood’s lamp proved a useful diagnostic tool, as most More data are needed on this topic, but it is oil, but not what tinea capitis cases were caused by Microsporum nice to know that we can probably depend on chronic applica- audouinii, which fluoresces, and luckily this our fungal culture results, regardless of the tion of oil does Microsporum species was very sensitive to presence of hair oils.  griseofulvin. Fast forward to the latter part to fungal culture of the twentieth century, and Trichophyton REFERENCES sensitivity.” tonsurans appears to have made its way from 1. Elewski BE. Tinea capitis: a current perspective. J Am Acad Dermatol. Central/South America to the southwestern US, 2000;42(1 Pt 1):1-20;quiz 21-4. and Wood’s lamps were no longer useful while 2. Marcoux D, Dang J, Auguste H, et al. Emergence of African species of dermatophytes in tinea capitis: A 17-year experience in a Montreal 1 griseofulvin proved less and less effective. pediatric hospital. Pediatr Dermatol. 2018;35(3):323-328. More recently, immigration from African 3. Sacheli R, Harag S, Dehavay F, et al. Belgian national survey on tinea capitis: Epidemiological considerations and highlight of terbinafine-re- nations to Canada, Europe, and the US has sistant T. mentagrophytes with a mutation on SQLE gene. J Fungi introduced traditionally “African species” to the (Basel). 2020;6(4):195. rest of the world. Species such as T. soudanense 4. Abdel-Rahman SM. Genetic predictors of susceptibility to dermato- and T. violaceum present newer issues, as they phytoses. Mycopathologia. 2017;182(1-2):67-76.

20 | The Dermatology Digest Not an actual patient

HOW YOU PRESCRIBE TODAY, REDEFINES THEIR TOMORROW

The safety and efﬁ cacy of ORACEA® (doxycycline, USP) 40 mg* Capsules in the treatment of inﬂ ammatory lesions (papules and pustules) of rosacea was evaluated in two randomized, placebo-controlled, multi-centered, double-blind, 16- week Phase 3 trials involving 537 subjects (total of 269 subjects on ORACEA Capsules from the two trials) with rosacea (10 to 40 papules and pustules and two fewer nodules.)^1,2 Mean change in lesion count ORACEA Capsules vs Placebo : Study 1 -11.8 vs -5.9, Study 2 -9.5 vs -4.3 Most common adverse events (>2%) were nasopharyngitis, sinusitis, diarrhea, hypertension and aspartate aminotransferase increase.

MONTH 9

UNIQUE FORMULATION* SUPERIOR GI NO EVIDENCE OF WITH ANTI-INFLAMMATORY TOLERABILITY† VS BACTERIAL RESISTANCE EFFECTS EQUIVALENT TO DOXYCYCLINE 100 MG3 IN A 9-MONTH STUDY8 DOXYCYCLINE 100 MG1,3-7 †ORACEA Capsules did not include *30 mg immediate release and symptoms of nausea, diarrhea, 10 mg delayed release beads vomiting or abdominal pain1,2

Important Safety Information Indication: ORACEA® (doxycycline, USP) 40 mg* Capsules are indicated for the treatment of only infl ammatory lesions (papules and pustules) of rosacea in adult patients. ORACEA Capsules do not lessen the facial redness caused by rosacea. Adverse Events: In controlled clinical studies, the most commonly reported adverse events (>2%) in patients treated with ORACEA Capsules were nasopharyngitis, sinusitis, diarrhea, hypertension and aspartate aminotransferase increase. Warnings/Precautions: ORACEA Capsules should not be used to treat or prevent infections. ORACEA Capsules should not be taken by patients who have a known hypersensitivity to doxycycline or other tetracyclines. ORACEA Capsules should not be taken during pregnancy, by nursing mothers, or during tooth development (up to the age of 8 years). Although photosensitivity was not observed in clinical trials, ORACEA Capsules patients should minimize or avoid exposure to natural or artifi cial sunlight. The effi cacy of ORACEA Capsules treatment beyond 16 weeks and safety beyond 9 months have not been established. *30 mg immediate release and 10 mg delayed release beads You are encouraged to report negative side eff ects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

Please see brief summary of full Prescribing Information on next page. ORACEA®

©2020 Galderma Laboratories, L.P. All rights reserved. All trademarks are the property of their respective owners. Galderma Laboratories, L.P., 14501 N. Freeway Fort Worth, TX 76177 USMP/ORA/0011/0220 02/20 www.oracea.com

REFERENCES 1. ORACEA [package insert]. Fort Worth, TX: Galderma Laboratories, L.P.;2013. 2. Del Rosso JQ, et al. Two randomized phase Ill clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea.J Am Acad Dermatol. 2007;56(5):791–802. 3. Del Rosso JQ, et al. Comparison of anti-inflammatory dose doxycycline versus doxycycline 100 mg in the treatment of rosacea. J Drugs Dermatol. 2008;7(8):573-576. .4 Bhatia N. ORACEA 40 mg capsules for papulopustular rosacea. The Dermatologist. 2013;6(21s):1-4. Available at: https://pdfs.semantic scholar.org/363e/66311811307ccfdc9e9d8bd8b594bdaf4254.pdf. Accessed: October 2019. 5. Theobald K, et al. Anti-inflammatory dose doxycycline ( 40 mg controlled-release) confers maximum anti- inflammatory efficacy in rosacea. Skinmed. 2007;6(5):221-226. 6. Wise RD. Sub microbial doxycycline and rosacea. Compr Ther. 2007;33(2):78-81. 7. Etchegaray JP, Wagner N, Shah MS, Difalco RJ, inventors; Galderma S.A., Cerovene, Inc. assignees. Doxycycline formulations, and methods of treating rosacea. US Patent 8,652,516 Bl. February 18, 2014. 8. Preshaw PM, et al. Modified-release subantimicrobial dose doxycycline enhances scaling and root planning in subjects with periodontal disease. J Periodontal. 2008;79(3):440-452. THE DERMATOLOGIST’S GUIDE Pearl 1 TO TREATING KELOIDS: Use cryotherapy before intra lesional Kenalog injection (ILK) One of the challenges with treating keloids is they are firm, making it 5 pearls and difficult to inject them. “One of the pearls that I learned from Dr. Charles McDonald, who was the promising future founding chairman of Brown Medical School Department of Dermatology, is to gently paint the keloid with cryotherapy, or liquid nitrogen,” therapies Dr. Jagdeo said. Dr. Jagdeo sprays a diffuse stream of liquid nitrogen to gently freeze By Lisette Hilton | Reviewed by Jared Jagdeo, MD, MS the keloid, waits about 30 seconds to allow the keloid to thaw, then repeats the process before injecting the scar. Cryotherapy softens the keloid and makes it more amenable to treatment injections. Jared Jagdeo, MD, MS Associate Professor of Dermatology SUNY Downstate Medical Center Pearl 2 Brooklyn, New York Use a largegauge needle Presented at the for keloid injections Virtual Skin of Color Update Dermatologists often use a small September 2020 30-gauge needle to inject keloids. But Dr. Jagdeo typically recommends using a 25-gauge or 22-gauge needle. The larger gauge makes it easier for medication to enter the keloid and Treating keloid scars can be tricky. Perfect outcomes are helps improve comprehensive keloid elusive and multiple treatments are the norm. Dermatologists treatment. can achieve optimal outcomes and high patient satisfaction if they use the right techniques, according to Jared Jagdeo, MD, Pearl 3 MS, Associate Professor of Dermatology at SUNY Downstate Use personal protective equipment Medical Center in Brooklyn, New York. Dr. Jagdeo presented (PPE) while injecting keloids on keloid management in September at the virtual Skin of Most dermatologists are using PPE during the COVID-19 pandemic, but Color Update 2020, offering pearls and his take on promising there is another reason to wear PPE therapies in the pipeline. when injecting keloids.

January 2021 | 23 “There is a lot of pressure within the keloid. When you inject the anti-keloid medication, the medication can spray back onto the injector,” Dr. Jagdeo said. “By using PPE, especially gloves, facemasks, and eye protection, it helps keeps us safe while providing the best care to our patients.” Pearl 4 Set patient expectations Dermatologists should let keloid patients know they likely will need multiple treatments—usually at least 4 to 6 to improve the keloid dramatically. Treatment can take a while. Treatment results in improvement but not perfection. And keloids can return. “Aesthetically, one of the things that I let patients know is the keloid will never look like regular, normal skin. They can expect it to be flatter, less itchy or symptomatic, but it is unlikely that it will look perfect,” he said. Pearl 5

Consider carbon dioxide (CO2) laser-assisted drug delivery

Depending on the setting, CO2 laser therapy can safely decrease inflammation and pigmentary change post-laser and decrease keloid size, according to Dr. Jagdeo. He recommends applying triamcinolone ointment immediately post-fractionated ablative laser therapy to deliver medication to keloid fibroblasts. “Best results are achieved over a series of treatments spaced at least 1 month apart per treatment,” he said. For

24 | The Dermatology Digest www.thedermdigest.com/KELOIDS

skin of color patients, I recommend waiting at least 6 weeks between treatments to allow for the epidermis to heal before the next treatment.”

CO2 laser-assisted drug delivery helps dermatologists achieve optimal outcomes. Here, too, dermatologists should let patients know that they may need multiple treatments over a year or longer. One of the challenges of providing the treatment is dermatologists must have a fractionated

CO2 laser, he said. In a study published in 2015 in the Journal of Drugs in Dermatology (https://jddonline.com/articles/ dermatology/S1545961617P0925X), Dr. Jagdeo and coauthors reported factors associated with keloid on a 39-year-old African-American scarring, decreases collagen, and Treatment results man (Fitzpatrick skin type VI) with can melt away keloids. a 10-year keloid history who was in improvement successfully treated with 8 sessions “It is phenomenally impressive,” he but not perfection.” of fractionated CO laser immediately said “Some of the things that are nice 2 “ followed by laser-assisted delivery about it is that it is noninvasive, there is of topical triamcinolone acetonide no downtime and no recovery time, it ointment.1 is relatively inexpensive and easy to ad- minister, and is combinable with other Emerging treatments treatment options. It can be done at An emerging keloid treatment home or at the dermatologist’s office.” that excites Dr. Jagdeo is the use In a study published in 2015 in of light-emitting diode (LED) red Dermatologic Surgery, researchers light technology. irradiated primary keloid-derived “We have pioneered this treatment human skin fibroblasts using LED using Omnilux technology, which red light panels (https://insights. is the best LED light on the market ovid.com/pubmed?pmid=25485805). with the most power density and The researchers concluded, “Light- clinical trials and data supporting emitting diode-generated red light the technology’s use,” he said. “We can inhibit keloid fibroblast prolifera- have been using some of their tion in a dose-dependent manner handheld LED arrays for keloid without altering viability. Light- treatments, and Omnilux has full emitting diode-generated red light panel arrays that are either mountable has the potential to contribute to to a wall or placed on a trolley.” the treatment of keloids and other Dr. Jagdeo has authored research fibrotic skin diseases and is worthy showing LED red light treatment of further translational and clinical 2 helps decrease molecular and other investigation.”

January 2021 | 25 www.thedermdigest.com/KELOIDS

Dr. Jagdeo has authored research showing LED red light treatment helps decrease molecular and other factors associated with keloid scarring, decreases collagen, and can melt away keloids.

Clinical trials on LED therapy and by physicians.”3 In the end, keloid management scar prevention are ongoing, Dr. Botulinum toxin A is yet another po- is complicated. Jagdeo said. tential therapy option, Dr. Jagdeo said. “Experts should be in control of Keloid fibroblast proliferation and “There is a lot of opportunity to use keloid management. Skills needed function involve microRNA, he said. botulinum toxin therapy to treat scars. include surgical removal, injection And microRNA is an emerging option It relaxes some of the tension on the techniques, laser adjuvant treatments, in keloid treatment. scar and helps decrease some of the and expecting the unexpected,” said  “If we can selectively increase or factors associated with skin scarring. Dr. Jagdeo. modulate microRNA into a favorable It’s safe but expensive,” he said. REFERENCES milieu, then we might benefit and Dr. Jagdeo and coauthors reviewed improve keloids. This is on the hori- 1. Kraeva E, Ho D, Jagdeo J. Successful treatment of 11 basic science articles involving keloid with fractionated carbon dioxide (CO2) laser zon,” he said. botulinum toxin A treatment of keloids and laser-assisted drug delivery of triamcinolone In his study “The role of microRNAs and hypertrophic scars and published acetonide ointment in an African American man. J Drugs Dermatol. 2017;16(9):925-927. in skin fibrosis,” published 2013 their findings in 2018 in Dermatologic 2. Mamalis A, Jagdeo J. Light-emitting diode-generated in the Archives of Dermatological Surgery (https://insights.ovid.com/ red light inhibits keloid fibroblast proliferation.Dermatol Research (https://link.springer.com/ pubmed?pmid=29401161). Studies Surg. 2015;41(1):35-9. article/10.1007/s00403-013-1410-1), suggest botulinum toxin A might 3. Babalola O, Mamalis A, Lev-Tov H. et al. The role Dr. Jagdeo and coauthors wrote, “In reduce skin fibrosis by decreasing of microRNAs in skin fibrosis. Arch Dermatol Res. 2013;305:763-776. the treatment of skin fibrosis, anti- fibroblast proliferation, modulating 4. Austin E, Koo E, Jagdeo J. The cellular response of fibrotic miRNAs may be upregulated the activity of transforming growth keloids and hypertrophic scars to botulinum toxin A: using mimics and viral vectors. factor-β, and reducing transcription a comprehensive literature review. Dermatol Surg. Conversely, profibrotic miRNAs may and expression of profibrotic cytokines 2018;44(2):149-157. be downregulated by employing in keloid-derived and hyper trophic anti-miRNAs, sponges, erasers, and scar-derived dermal fibroblasts. The DISCLOSURE: Dr. Jagdeo received National masks. We believe that miRNA-based neurotoxin might modulate collagen Institutes of Health funding to study LEDs for keloid prevention and treatment. He is on the therapies hold promise as important deposition but the evidence on specific advisory board for Global Med Tech and is a treatments and may transform the mechanisms of action is lacking, consultant for UV Biotek. management of fibrotic skin diseases according to the study.4

26 | The Dermatology Digest Say Hello again to

Not Actual Size

Most eligible commercially $ per prescription insured patients pay as little as 20at any pharmacy* * Certain restrictions apply. The LEO Pharma CONNECT program may reduce out-of-pocket expenses. Must be 12 years of age or older to be eligible, and a legal guardian over 18 years of age must redeem the card for patients aged 12 to 17. You are not eligible if you are enrolled or you participate in any state or federally funded health care program (eg, Medicare, Medicaid, etc). Full details of the LEO Pharma CONNECT program are available at www.FinaceaFoam.com/hcp or may be obtained by calling 1-877-678-7494 between 8:30 AM and 8:30 PM (Eastern), Monday through Friday.

The LEO Pharma logo, LEO Pharma, and Finacea are registered trademarks of LEO Pharma A/S. www.FinaceaFoam.com ©2020 LEO Pharma Inc. All rights reserved. March 2020 MAT-32481 COSMETIC CORNER SENILE PURPURA

Targeting senile purpura with broadband light

By Bob Kronemyer | Reviewed by Robyn Siperstein, MD

Robyn Siperstein, MD Founder, Siperstein Dermatology Group Boca Raton and Boynton Beach, Florida

Presented at Annual meeting of the American Society for Dermatologic Surgery (ASDS) Held virtually in October 2020

roadband light is an efficacious modality to treat senile purpura Bthat causes only limited pain and requires minimal downtime. “The purpura slowly goes away over the course of 24 to 48 hours,” said Robyn Siperstein, MD, founder of Siperstein Dermatology Group in Boca Raton and Boynton Beach, Florida, who presented the results of a pilot study using broadband light to treat senile purpura at the annual meeting of the American Society for Dermatologic Surgery (ASDS), which was held virtually in October 2020. Unlike skin resurfacing, broadband light therapy does not require the patient to stay inside afterward. “Patients may appear a little red and feel slightly hot for a couple of hours after treatment,” said Dr. Siperstein, “And if patients have sun damage, the sun damage becomes darker, then flakes off.” Senile purpura is a common condition in Florida, due to sun exposure, and is particularly prevalent in Boynton Beach because of the many communities for people aged 55 and older. People who currently take steroids or blood thinners are also at higher risk of acquiring the skin condition. Dr. Siperstein prefers the term “senile purpura” or “dermatoporosis,” as opposed to “actinic purpura,” because this term denotes that the purpura is from sun damage only, when in reality sun damage is not the only cause.

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“Currently, there are limited treatment options However, lesions on the legs are much harder for senile purpura,” said Dr. Siperstein. The to treat, as legs take much longer to heal. 3 most common topical options are retinol, Study details arnica, and vitamin K, “But studies have been inconclusive for efficacy,” she said. “Some of Dr. Siperstein was principal investigator of a the studies did not have a control group, which 10-patient study that compared 5 subjects over is important because multiple studies have the age of 65 with ecchymotic lesions measur- shown improvements with just a base vehicle ing over 1 cm on each forearm to 5 younger cream. Other studies had controls but had subjects under 35 years of age without any contradictory findings.” ecchymotic lesions. Dr. Siperstein started using the Sciton broad- All patients were treated at Dr. Siperstein’s prac- band light 5 years ago on patients who were tice by her and Jennifer Richter, PA-C, in 2018. bruising after cosmetic procedures. Shortly The protocol consisted of 4 weekly sessions of thereafter, one of her female patients being broadband light treatment. Photographs were treated for bruising after a cosmetic procedure taken before treatment and 1 month after the asked the doctor if she could treat the senile completion of the final session. Skin biopsies purpura on her arms as well. taken 1 day after the final session were analyzed. That was Dr. Siperstein’s first patient with The number of ecchymoses on the treated vs senile purpura to be treated with broadband untreated arm were significantly reduced (P = light, for which results on the arms were 0.02), with an average reduction of 3.5 lesions. “miraculous,” according to Dr. Siperstein. “Not only did treatment get rid of the bruises The square area of ecchymoses on the treated she had on her arms, but regular treatments vs untreated arm was also significantly reduced prevented new bruises.” (P = 0.04), with an average reduction of 12.7 cm.

80 The epidermal thickness in older untreated skin (red) was on average 15.81% thinner than in younger untreated skin (blue) 70 P=0.0153 at baseline: 45.31µm vs 53.82 µm.

60 Broadband light treatment of older skin with senile purpura (green) also resulted in a 21.14% increase in epidermal thick- 50 ness compared to untreated older skin (P = 0.0153, 2-tailed, 40 paired t-test).

30 Treatment significantly increased epidermal thickness in elderly subjects (green) to levels comparable with young subjects Epidermal Thickness (µm) 20 (blue): 54.89 µm vs 53.82 µm.

0 Young Old Old IPL untreated

January 2021 | 29 Control forearm beginning of study Control forearm end of study

Treated forearm beginning of study Treated forearm end of study

Figure 1: Complete clearance of purpura and photodamage on the treated arm 1 month after 4 broadband light treatments. This patient was a 70-year-old woman on inhaled corticosteroids.

Control forearm beginning of study Control forearm end of study

Treated forearm beginning of study Treated forearm end of study

Figure 2: Substantial clearance of purpura, photodamage, and hemosiderin deposition on the treated arm 1 month after 4 broadband light treatments. This patient was a 77-year-old male smoker on blood thinners.

All subjects, even those on blood thinners patients. “Nearly all patients have responded and inhaled or injected corticosteroids, had to treatment,” she said. “All patients on blood at least a 50% reduction in the total square thinners and inhaled or injectable steroids did area of ecchymoses. well. The only patients I find that do not do as well are those on oral steroids in high doses No side effects lasted more than 30 days. and for long periods of time.” To date, Dr. Siperstein has used broadband Patients without much sun damage are treated light to treat senile purpura in roughly 30 once a week for a total of 4 to 8 sessions, with

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both arms taking approximately 15 to 20 minutes per session. Treatment technique Treatment comprises several filters of broad- A lot of band light, starting with multiple passes of a Sciton SkinTyte filter from 800 nm to 1400 nm studies show at 150 watts in continuous motion, followed by the therapy 2 passes with a 590-nm filter at a lower energy “can increase setting, then a slightly higher energy setting of 2 passes with the same 590-nm filter. The final collagen, step is 2 passes with a 560-nm filter. increase Each subsequent treatment session is tailored very important when treating this condition epidermal based on results of the previous treatment to ensure there is no friction.” thickness, session. Maintenance therapy is also required In addition, patients are instructed to not once every 3 to 6 months. directly expose themselves to the sun 24 hours and remove “I have found that multiple passes, first at before treatment and to apply sunscreen both vascular a lower energy, then increasing the energy, before and after therapy. “The more sun dam- lesions.” as well as changing to different filters to age that is in the skin, the more the broadband ensure that we are targeting different depths light will be attracted to the pigment instead of the skin, help in senile purpura because of the bruising,” said Dr. Siperstein, who is also a volunteer associate professor of dermatology at the University of Miami. All subjects had at least a Sciton broadband light is a good investment for a dermatology practice, according to Dr. % Siperstein, because the device can be used to 50 treat a wide range of conditions, ranging from REDUCTION hair removal to removal of vascular lesions, in the total square area of ecchymoses. sun damage, and brown spots. “I believe broadband light will become that condition has bruises in many different the treatment of choice for senile purpura,” stages,” Dr. Siperstein said. “There are often Dr. Siperstein said. “There are a lot of multiple colors that we are treating. Bruises studies that show the therapy can increase can be purple, pink, red, yellow, or green.” collagen, increase epidermal thickness, and remove vascular lesions. Combining those Too high of an energy setting will cause the 3 advantages make broadband light ideal for skin to blister. senile purpura because it is a condition of Dr. Siperstein shaves patients before treatment decreased skin thickness, increased bruising, so that the energy is delivered deep into the and decreased collagen.” skin and does not become trapped in the hair. Moreover, broadband light has a much broader Ultrasound gel is also applied on the skin to treatment area than a laser, for much quicker glide the broadband light. “If you do not use treatment.  gel and you glide something very quickly over someone’s arm with senile purpura, you will DISCLOSURE: Dr. Siperstein has received research funding from actually cause more bruising,” she said. “It is Sciton Inc.

January 2021 | 31 www.thedermdigest.com/COSMETIC_CORNER

COMMENTARY Best outcomes for senile purpura

hen treating senile purpura, it is size, 7 msec and a pulse duration of 10 Hz. important to promote moisture reten- One treatment session is sufficient for most W tion of the skin, according to Suneel patients. Some patients undergo a follow-up Chilukuri, MD, the dermatologist at Refresh laser treatment 2 days later, with the exact Dermatology in Houston, Texas. “Anything same settings, followed immediately by com- that rehydrates the skin and improves the bined radiofrequency (RF) and ultrasound water barrier will improve the overall health (Exilis Ultra). of the skin,” he said. Suneel Chilukuri, MD Dermatologist, Refresh “These technologies improve blood flow Three inexpensive, over-the-counter products Dermatology, and help remove extravasated red blood cells,” that are quite effective for senile purpura are Houston, Texas Dr. Chilukuri said. CeraVe, Cetaphil, and Aveeno. However, at Refresh Dermatology, Epionce is the favored A 650-microsecond 1064-nm Nd:YAG laser moisturizer. is also often used to treat purpura and ecchymoses. “I like this laser because it is safe in “Epionce uses natural botanical ingredients to all skin types, whereas the pulse dye laser is most effectively rehydrate and heal skin,” Dr. These mostly reserved for skin types I through III,” Chilukuri said. “We also sometimes mix reti- technologies stated Dr. Chilukuri. Settings for the Nd:YAG nol with one of these 4 emollients for a great- laser are dependent on the patient’s skin type. er enhancement of the overall thickness of the improve blood upper dermis.” The combination therapy not “flow and As with the pulse dye laser, patients schedule only helps resolve the purpura more quickly, help remove 1 or 2 sessions of the Nd:YAG laser, spaced but also prevents some future bruises. about 2 days apart. “With 1 or 2 treatments, extravasated the bruise is gone within anywhere from For Epionce extreme barrier cream, patients 24 hours to 96 hours,” Dr. Chilukuri said. are instructed to mix in a pea-size drop of red blood cells.” retinol before applying, once a day at night. For either laser, a treatment session lasts Then in the morning, they apply either 3 to 4 minutes. Epionce, CeraVe, Cetaphil, or Aveeno. Broadband light is also part of the mix at “With this protocol, patients will typically Refresh Dermatology, consisting again of notice less bruising within about 8 to 12 1 or 2 sessions, spaced about 2 days apart. weeks,” Dr. Chilukuri said. “I believe we have some great choices to treat For patients with extreme cases of bruising, senile purpura,” Dr. Chilukuri said. “Once Refresh Dermatology offers laser and light- you get familiar with your light source, you based therapy that allows for rapid resolution can effectively enhance your patients’ results of bruises. and experience.”  Dr. Chilukuri’s laser of choice for purpura is a 595-nm pulse dye laser, with a 6-mm spot DISCLOSURES: Dr. Chilukuri reports no relevant financial disclosures.

32 | The Dermatology Digest OUTSIDE-THE-BOX Getting teens on board with acne treatment plans It’s not the products but the approach

By Lisette Hilton | Reviewed by Elizabeth A. Kiracofe, MD

t often takes outside-the-box thinking to get teenagers to agree Iwith anything, including acne treatment adherence.

Chicago-based dermatologist Elizabeth A. building a plan that teen is most likely to use. Kiracofe, MD, who specializes in adolescent ELIZABETH A. “Acne adherence is such an important factor. To acne, said that reaching teens and getting their KIRACOFE, MD me, adherence is different than compliance. If buy-in on acne treatment regimens is less about Founder, I give a patient a plan that does not make sense Airia Comprehensive what to use, than it is about how to get teens to for them in their life, it is not their fault if they Dermatology, correctly use what their dermatologist pre- Chicago are not compliant with it,” Dr. Kiracofe said. scribes and suggests. “They need to adhere to a plan that works for All in the approach them, and The approach when talking with a teen patient it is my fault if I don’t ask them the right ques- about acne includes listening, learning, and tions to make sure that a plan works.”

January 2021 | 33 or older than them, or if you know more than them,” Dr. Kiracofe said. “Teenagers are trying to fix their acne with YouTube videos and blog posts. They are slathering their entire faces with honey. They are doing wild things. But we do them a disservice if we shame them for those things. The perfect acne plan doesn’t matter if the patient is not able to follow through on it. So instead of focusing on the perfect plan, I focus on: What is the patient actually willing to do? What can they commit to, and how do we build on that?” Where the detective work comes in Teenagers are After a few minutes with a patient, Dr. Kiracofe trying to fix learns what regimen is most likely to work with their acne Dr. Kiracofe’s recipe for adolescent him or her. “with YouTube acne treatment success She starts with, “You wake up in the morning Dr. Kiracofe’s staff asks each new adolescent and then what happens?” Sometimes getting videos and blog acne patient to throw everything in a bag that to what is important takes some back and forth. posts. They are has touched his or her face in the past 30 days For example, the teen might respond with, and to bring that bag to the first appointment. “I have breakfast.” slathering their The exercise engages teens and helps them “I say, ‘You wake up and immediately go down- entire faces realize how many different things they might stairs and have breakfast?’ And they are like, have tried to treat their acne. with honey. ‘Oh. No, I get dressed and go to the bathroom They are doing Going through the products is a conversation and brush my teeth and go have breakfast.’ I say, starter, aimed at engaging, not shaming, teen ‘When you go brush your teeth, do you have wild things. patients. Dr. Kiracofe uses it as a way to show your shirt on, you’re dressed?’” But we do them respect to the teen. She starts the conversation If a teen says yes to being dressed, Dr. Kiracofe with, “Wow, it’s clear to me that you obviously a disservice knows that is not a patient that she wants to be really care about your skin ….” She then points using a benzoyl peroxide wash in the morning. if we shame out examples of some problems that her previ- Benzoyl peroxide will likely stain their clothes. them for those ous patients have had with specific products things.” or when learning from YouTube tutorials. The other clue from that conversation is the teen suggested he or she does not shower She assures patients that does not mean they in the morning. are wrong, but they should understand why she has some concerns about the products or “I love benzoyl peroxide washes, but I like them approaches they might be using. only in the shower. I am specific with patients about that,” she said. “I’ve heard from many teens that their doctors do not feel their input matters; that they just Planning means tracing the patient’s routine need to do what doctors say. Of course there is and building an acne program around it. some truth in that, but it also ignores human COVID-19 has changed routines for many nature. Whether teens or adults, no one likes to teens who are home schooling. Dr. Kiracofe do something only given the rationale ‘because tells those patients to keep topical acne prod- I said so.’ They are not going to do what you ucts next to their laptops instead of in the bath- say if you act like you are better than them, room. Patients apply their products between

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classes while sitting at their laptops. She has acting like they do not give a hoot, we have to patients post small sticky notes with instruc- remember that is because they are teenagers. tions for use on their laptops. We have to push through that and engage them,” she said. “The deal with teens and “My main emphasis is to build the plan around pre-teens is just that it’s very uncool to act like the patient’s life, instead of making the patient you care or to let something bother you. Their build their life around my plan. Quite frankly, default is ‘If I cannot change it or don’t feel like it just does not work as well the other way,” I can make a difference, then I will just act like she said. I don’t care, because then I am cool again.’” Parental involvement may Plan for a slow start hinder treatment Dr. Kiracofe does not schedule her first fol- Dr. Kiracofe lets parents know what the data low-up appointment with teen acne patients has shown: parents’ involvement in their at the traditional 3 months. Her follow-ups child’s acne routine is inversely correlated are much sooner. with success. Most patients do not have all their medicines “The more they remind their children what when they leave the office, so she gives them a to do, the less they are going to do it,” she said. week to get their medicines (generally a mix of “I tell them that pretty emphatically and in OTC and prescription) and schedules a tele- front of the patient. I just say, ‘Look, I know medicine call at one week for a quick review. you want what is best, but this is Sarah’s plan, and Sarah needs to want her plan to work.’” “It may not even be 5 minutes. It achieves Every patient 2 things: It makes sure they have collected that comes in Dr. Kiracofe explains that patients need to let all their medicine. It also gives accountability their parents know when they are running for acne gets to them and their parents,” she said. out of medication or are having side effects “3 face photos and need to see the dermatologist. In essence, She also uses the call to help patients learn parents’ roles are to support, not to police. to correctly apply their medicines. And every visit so whether in the office or via telemedicine, she we can see The dermatologist makes it clear that if the does it right along with them. This is especially patient needs policing, he or she might not their progress. important when using topical retinoids (a be ready for an acne plan. She has patients critical component of most acne treatment Patients need verbally agree during the first appointment plans) because many teens and their parents to take ownership of the plan. to see it. They are convinced they are allergic to topical “When we have completed the plan, I have retinoids because in the past they’ve experi- get excited to them agree—literally, I ask for a ‘verbal yes’ look back on like they do when sitting in the exit row of an old photos.” airplane. They agree 1) that they understand the plan, 2) that it’s doable, and 3) that they are going to take the plan and tape it to their bathroom mirror for 2 weeks. Then, I even have them send me a picture of it there!” Dr. Kiracofe said. Teens might act wild and crazy at times, but they are smart. And the far-out things they try to get rid of acne show they care. “Even though they are sitting in our offices,

January 2021 | 35 www.thedermdigest.com/ACNE

ANOTHER PEARL: Dr. Kiracofe loves to use salicylic acid peels in her treatment routines for many teen acne patients, referring to them as a jumpstart. However, she does not use the term “peels,” because she does not want parents or patients to confuse the treatment with something that is cosmetic or to think that peeling is required for success. She calls it an in-office acne treatment or an acne boost, and said that the treatment helps to boost results.

enced significant dryness or even a retinoid The process is part of the fun dermatitis. However, the truth is, at least with Dr. Kiracofe said she enjoys the process of all her patients to date, they simply never getting teens on board with acne treatment learned to apply them correctly or started off and experiencing success with her patients. with a product that was too strong, according “We do acne mug shots in my office. Every to Dr. Kiracofe. patient that comes in for acne gets 3 face “I like to show them the difference between photos every visit so we can see their progress. how much of their topical retinoid and how Patients need to see it. They get excited to look much of their moisturizer is appropriate. back on old photos,” she said. Then I let them know if they are ever feeling She sees patients again after the 6-week dry or uncomfortable that is because they appointment at 3 months. need a stronger moisturizer, and I let them know what that is,” she said. “I tell them the “Once I know that they are on a good routine, entire point of our plan is to get them to be I tell them that they are on autopilot. We check able to tolerate and use the topical retinoid in when they need me or at least 2 [times a every day of the week. And the rest of the year] if they are on prescription meds,” she plan supports that goal.” explained. “Parents share with me that they see the independence and confidence-building Patients know if their skin is dry, they should with their kids starting to take hold. Certainly, not stop the topical retinoid for 3 or 4 days; I see skin improvement, but what I really love rather, they stop the benzoyl peroxide wash is how proud they are of themselves. Some- for a couple of days and build back up to the times, the biggest problem is the patients do regular routine. not want to come back for their follow-up By the 6-week in-person follow-up, teen pa- because they are doing so much better and do tients are engaged and talking, and their acne not understand why they have to come back is visibly improved, according to Dr. Kiracofe. in. That’s a problem I’m ok with having.”  “I hear so often from parents that I ‘really know how to talk to teenagers.’ It is not that I know DISCLOSURES: Dr. Kiracofe has no relevant financial interests to disclose. how to talk to teenagers. I just treat them with respect. And they can feel that,” she said.

36 | The Dermatology Digest SURGICAL CORNER SURGICAL GLUES

Surgical glues: A sticky subject?

By John Jesitus | Reviewed by Hayes B. Gladstone, MD

he watertight, bactericidal, and aesthetically advantageous properties Tof surgical glues have made them popular in dermatologic surgery and beyond. However, a reported association between cyanoacrylate, the chemical cornerstone of these products, and contact dermatitis (CD) in some patients has attracted attention, including a suggestion that HAYES B. GLADSTONE, dermatologic surgeons perhaps should forgo surgical glues. MD Dermatologist and Mohs surgeon In a series of 102 consecutive breast-recon- However, experts have told The Dermatology President and Founder, Gladstone Clinic struction patients treated with surgical glues Digest that when surgical glues are used appro- San Ramon, California in 2018, Nigro et al. report that 14 patients priately, these products remain a safe, effective (of 100 evaluated) developed CD.1 Four of element of the therapeutic armamentarium. them exhibited reactions at the time of their Two surgeons’ experiences nipple delay procedure, 2 weeks before their mastectomies and first-stage reconstruction. “In dermatologic surgery,” said Hayes B. All reactions were confirmed with scratch test- Gladstone, MD, “cyanoacrylate glue plays ing. The study was published in January 2020 a significant role in pediatric cutaneous in Plastic and Reconstructive Surgery. wounds and reconstruction after Mohs surgery and certain aesthetic procedures such Mechanistically, write authors Nigro et al., ROD J. ROHRICH, as facelifts. It is not painful, more time-efficient degradation products of cyanoacrylate glues, MD, FACS than sutures, may be bacteriostatic, and may such as formaldehyde and cyanoacetate, Clinical Professor improve cosmetic results in certain patients.” of Plastic Surgery, can induce inflammation and/or reactions, Dr. Gladstone is a dermatologist and Mohs Baylor College of Medicine, particularly in areas of thin skin or open surgeon and President and Founder of the Past Chair/Distinguished wounds. Study patients who reported prior Gladstone Clinic in San Ramon, California. Teaching Professor surgical-glue exposure were slightly more of Plastic Surgery Rod J. Rohrich, MD, FACS, said that Nigro University of Texas likely to develop CD than were those without Southwestern, prior exposure. However, this trend did not et al.’s 14% CD rate is higher than he has seen Founding partner, reach statistical significance (P = 0.0732). reported or in his clinical experience, but the Dallas Plastic Surgery study is well done and published in the top Institute Because the 14% incidence rate exceeds the 7% rate found by a prior retrospective case plastic surgery journal. He is a Clinical review of surgical glue used mainly in the Professor of Plastic Surgery at Baylor College abdominal area,2 Nigro et al. suggest that of Medicine, past Chair/Distinguished surgeons reconsider cyanoacrylate glues Teaching Professor of Plastic Surgery at the altogether. University of Texas Southwestern, and founding partner of the Dallas Plastic Surgery Institute.

January 2021 | 37 A B C Copyright © 2015 R. W. Knackstedt et al. W. Copyright © 2015 R. Figure 1 Progression of rash in patient (33-year-old woman after bilateral reduction mammoplasty). (A) Patient at initial follow-up on postoperative day 6 with bilateral swelling, blisters, and erythema. (B) Patient at postoperative day 11 after 5 days of steroid taper. Steroid taper was subsequently terminated due to gastrointestinal intolerance. Rash had spread bilaterally since initial presentation. (C) Resolution of rash at postoperative day 19.7

“I use Dermabond (2-octyl cyanoacrylate, with antihistamines or steroids, said Dr. Rohrich, Ethicon) on almost every body and breast they do not affect healing. contouring surgery because it avoids the need “Though there is definitely a risk for contact I usually ask for skin sutures,” said Dr. Rohrich. In well over dermatitis when using cyanoacrylate glue,” 1000 such procedures, he said, only 1 or 2 patients if they Dr. Gladstone said, “the study by Nigro et al. patients developed CD. have allergies is very narrow since it only examines breast “in general. Dr. Gladstone occasionally uses surgical glue reconstruction patients.” The breast may be for skin grafts and rarely for facelift closures. an especially sensitive area because it involves If someone Even a 7% CD rate appears high, he said, as the more easily irritated skin, lower vascularity has asthma, reported overall complication rate for Mohs sur- compared to the face, and post-surgical mac- 3 allergies, and a gery is 1.64%. A few of his patients have devel- eration, he explained. Moreover, breast recon- oped minor irritation after exposure to surgical struction itself is a complex, often multi-stage history of atopic glue, he said, but none have developed CD. procedure that disrupts various skin layers and can provoke significant inflammation. dermatitis, then Dr. Gladstone added that any type of chemical I most likely can cause skin irritation or an immune reaction Additionally, Dr. Gladstone disagreed with would abstain and inflammation. Significant inflammation Nigro et al.’s inference that because affect- often inhibits wound healing and may raise the ed patients reacted to both Dermabond and from using risk of local infection, hinder healing, and cre- LiquiBand (Advanced Medical Solutions Ltd.), surgical glue.” ate prolonged scar erythema. “That’s why Nigro their findings apply to all cyanoacrylate glues.1 et al. bring this up—not just because it’s causing At best, said Dr. Gladstone, the findings may a rash,” he said. However, these authors report be generalizable to breast reconstruction. no delayed healing in their series. Safe usage Similarly, Nakagawa et al. note in a September Drs. Gladstone and Rohrich said that the 2018 Plastic and Reconstructive Surgery—Global Nigro et al. publication will not significantly Open publication that some patients treated with alter their clinical approaches. Safe use of surgi- surgical glues can experience severe allergic re- cal glue starts with a thorough patient history. 2 actions that may require systemic steroids. Drs. “If there’s any history of allergies to glues or Rohrich and Gladstone said that such reactions cyanoacrylate,” said Dr. Rohrich, “I don’t use it.” are uncommon. And if addressed immediately In closing surgical wounds, he added, cyano-

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acrylate glues currently available in the United In my experience,” Dr. Rohrich States should go no deeper than the dermis. added, “the benefits of surgical Dr. Gladstone said, “I usually ask patients glue outweigh the risks.” if they have allergies in general. If someone has asthma, allergies, and a history of atopic “ dermatitis, then I most likely would abstain from using surgical glue.” He may begin several formulations are available in Europe. asking patients specifically about reactions “It’s very appealing that you would be able to to cyanoacrylate glues such as those used with close a wound and get it to heal without having false nails and eyelashes. a drain.” However, he said, these products will require extensive FDA trials, and formulations Essentially, said Dr. Gladstone, Nigro and col- available to date have proven less promising leagues drew an overreaching conclusion from than cyanoacrylate-based glues.  a very narrowly focused study. Yet drawing firm conclusions about surgical glues remains difficult because evidence consists largely of REFERENCES 1. Nigro LC, Parkerson J, Nunley J, et al. Should we stick with surgical small case series. Larger prospective, random- glues? the incidence of dermatitis after 2-octyl cyanoacrylate ized studies are needed, Dr. Gladstone said, exposure in 102 consecutive breast cases. Plast Reconstr Surg. but unlikely to occur. 2020;145(1):32-37. 2. Nakagawa S, Uda H, Sarukawa S, et al. Contact dermatitis caused Pragmatically, he added, most dermatologic by Dermabond Advanced use. Plast Reconstr Surg Glob Open. surgeons still use sutures because they are 2018;6(9):e1841. comfortable with them. Along with increasing 3. Cook JL, Perone JB. A prospective evaluation of the incidence of complications associated with Mohs micrographic surgery. Arch operative time, sutures may provoke infections, Dermatol. 2003;139(2):143-152. and most sutures require subsequent removal. 4. Ge L, Chen S. Recent advances in tissue adhesives for clinical Comparatively, he said, surgical glue represents medicine. Polymers (Basel). 2020;12(4):939-961. an advance—no matter how imperfect—as 5. Bhagat V, Becker ML. Degradable adhesives for surgery and tissue surgeons continue seeking better ways to close engineering. Biomacromolecules. 2017;18(10):3009-3039. acute cutaneous wounds. 6. Ghosh D, Urie R, Chang A, et al. Light-activated tissue- integrating sutures as surgical nanodevices. Adv Healthc Mater. “In my experience,” Dr. Rohrich added, “the 2019;8(14):e1900084. benefits of surgical glue outweigh the risks.” 7. Knackstedt RW, et al. Rash with DERMABOND PRINEO skin closure system use in bilateral reduction mammoplasty: Meanwhile, use of fibrin glues is increasing. a case series. Case Rep Med. 2015:Article ID 642595. https://doi.org/10.1155/2015/642595 Composed mainly of fibrinogen and thrombin, these adhesives are less likely than cyanoac- DISCLOSURES: Dr. Gladstone reports no relevant financial interests. rylates to provoke CD, said Dr. Gladstone. Dr. Rohrich is editor-in-chief of Plastic and Reconstructive Surgery. Additional approaches under study include He reports no other relevant financial interests. light-activated nanosutures, laser-assisted tissue welding, and animal-inspired biomimetic adhesives.4-6 “That’s where we’re headed,” he said. “It will be a totally new paradigm. For many patients, surgical glue is at least is a step in the right direction.” Use of deep-tissue glues for indications such as facelifts and abdominal surgeries is clearly on the horizon, said Dr. Rohrich, who added that

January 2021 | 39 Dermatologists weigh in on DefenAge’s 8-in-1 BioSerum: Patient outcomes, optimal use

oday’s dermatologists may be which are broad targeted anti-immune scratching their heads trying to medications, but now we know the Tdifferentiate and ultimately rec- pathway and are more and more spe- ommend cosmeceuticals in a market- cific in targeting specific inhibitors of place crowded with skin rejuvenation the psoriasis pathway. options. With DefenAge, you are getting a very One topical that seems to stand out specific portion of the antiaging process among dermatologists and patients turned on: specific stem cells, located in is the 8-in-1 BioSerum, which fea- the hair follicle, that create a new epi- tures antiaging active defensin-mole- dermis and are basically unused and are cules and is the iconic product in the sequestered. These cells are turned on DefenAge Skincare line. by defensins and create new epidermal cells. The old way of using many differ- Unique mechanism of action ent growth factors and hoping to turn The 8-in-1 has a unique mechanism of on growth is less specific. And, if it does action, according to dermatologist Amy turn on stem cells, they are in the basal Forman Taub, MD, Medical Director layer and have been subject to the same and Managing Partner of Advanced toxic environment that the epidermis Dermatology in Lincolnshire, Illinois. has—unlike the sequestered stem cells.” “I often liken it to a biologic for pso- All in all, the 8-in-1 BioSerum is a more riasis,” Dr. Taub said. “In the old days advanced targeted cosmetic therapy we used cyclosporine or methotrexate, with an established scientific mecha-

Amy Forman Taub, MD Vivian Bucay, MD Anne Chapas, MD Medical Director and Bucay Center for Dermatology Director, Union Square Laser Managing Partner of and Aesthetics Dermatology, and Instructor Advanced Dermatology San Antonio, Texas of Dermatology, Mount Sinai Lincolnshire, Illinois Medical Center, New York City

40 | The Dermatology Digest This content is provided by DefenAge nism of action. And the product of- with pigmentation issues, skin barrier, BHT/BHA, or parabens. It does not fers great results for patients quickly, and skin immunity by protecting the have formaldehyde or propylene glycol. according to Dr. Taub, who co-led Langerhans cells. Niacinamide also That is an important differential,” Dr. DefenAge’s largest clinical study pub- helps prevent acne, she said. Bucay said. lished in the Journal of Drugs in Derma- “So, using this product helps me feel Dermatologist Anne Chapas, MD, tology (https://jddonline.com/articles/ confident that the patient will be less Director, Union Square Laser Derma- dermatology/S1545961618P0426X). likely to break out with acne post treat- tology, and Instructor of Dermatol- Another author of the original research ment,” Dr. Bucay said. “The defensins ogy, Mount Sinai Medical Center, New paper, dermatologist Vivian Bucay, MD, of Bucay Center for Dermatol- ogy and Aesthetics, in San Antonio, Using this product helps me feel Texas, said the positive results from us- confident that the patient will be less likely ing defensins in the clinical study have “ panned out over the years at her clinic. to break out with acne post treatment,” The 8-in-1 BioSerum is her go-to prod- Dr. Bucay said. uct in the line because it has 5 times as much of the defensins as the line’s bar- stimulate Lgr6-positive stem cells that York City, has been using and recom- rier cream. It is the only product with are dormant and will then repopulate mending the 8-in-1 BioSerum for years. such a high concentration of defensins. the epidermis. What we are looking for She was drawn to the products because “It is especially lightweight—you can’t is re-epithelialization after a procedure, of their unique mechanism of action. even feel it when you’re wearing it,” Dr. so it makes sense to use a product that “DefenAge wasn’t just repackaging Bucay said. works specifically off those cells that retinol or vitamin C or something else,” help produce a new healthy epidermis.” Dr. Bucay not only recommends the Dr. Chapas said. BioSerum as a part of patients’ daily Dr. Bucay embraces the BioSerum for Defensins are immunological mol- skincare but also uses it to achieve opti- what it has and does not have in its in- ecules that are some of the first line in mal outcomes after procedures she does gredient list. the body’s immune system defenses. in the office, including microneedling. “There is a really strong trend toward “There are defensins in the skin, and Niacinamide is another active ingredi- clean beauty. The BioSerum does not they play an important role in the mi- ent in the 8-in-1 BioSerum, which helps have mineral oil, phthalates, BPA,

Angela Bowers, MD Kathleen M. Welsh, MD Steven Swengel, MD Southlake Dermatology Bay Area Cosmetic Dermatology RefinedMD Southlake, Texas San Francisco Los Gatos, California

This content is provided by DefenAge January 2021 | 41 crobiome of our skin and in eczema Texas. “Even some of the other antiox- being that those stem cells are still reac- and other skin diseases. There also are idants and peptides out there can be a tive and still work with DefenAge, even gut defensins that play a role in the little irritating to the eyes and lip area. at an older age.” immune system in our gut. What was All skin types tolerate the DefenAge.” interesting was [researchers] found Still other uses that the gut defensins are active on the Patients give it a thumbs-up Dermatologist Kathleen M. Welsh, MD, skin and work to make new stem cells, and want more of Bay Area Cosmetic Dermatology in which is quite a difficult thing to do,” The BioSerum is a hit with patients be- San Francisco, said the BioSerum is not Dr. Chapas said. cause it works in a way that patients only for the face, neck, and chest. can see within a few weeks, according DefenAge is not a stem cell treatment. “DefenAge is my go-to for crepey to Dr. Bowers. Rather, defensins stimulate the body’s thin skin on the neck and arms,” Dr. own stem cells to grow more efficiently “Patients really are the biggest judge. I Welsh said. and to create thicker skin, which does have been in practice for about 21 years Dr. Welsh also has filler patients use interesting things like decrease pore size now and I’ve had all the skin care lines. it for 4 to 6 weeks before having filler and improve overall skin texture and The DefenAge by far has had the most procedures in the office to prep the skin quality, according to Dr. Chapas. impressive patient feedback of any new and enhance filler results. skincare line that we have offered,” Dr. Smoother pores, firmer skin, Bowers said. “I have hundreds of patients who could not be happier with the dramatic better skin quality and more Dr. Bowers has seen melasma patients Dr. Chapas uses the 8-in-1 BioSerum changes they see with DefenAge on improve with use of BioSerum, which as a rejuvenation cosmetic serum for their face. Within a month they are ask- she said was unexpected. Rosacea pa- patients who want smoother pores, ing if it can be used anywhere else. The tients who use it along with other treat- more skin firmness, or better overall first area I recommend is taking it down ments improve as well. skin quality. on the neck and décolleté. Very rapidly they see improvement in these areas too, but comment that they go through DefenAge is my go-to for crepey thin skin product a lot faster. So the new larger on the neck and arms,” Dr. Welsh said. size will be well received by this group “ of patients who are totally dedicated “It is also a product both men and Dr. Bowers recommends the BioSerum to their new DefenAge skin and want women like. DefenAge has come out with alone or in combination with other sk- a larger amount for those additional a fragrance-free version, and men tend incare products as a part of daily skin- areas,” said Steven Swengel, MD, of to prefer that one,” Dr. Chapas said. care for men and women. She also uses RefinedMD in Los Gatos, California. it in conjunction with microneedling or “Anywhere it is applied, you start see- Another big selling point is that the resurfacing procedures. ing fewer fine lines and more luminos- 8-in-1 BioSerum is not irritating like a ity and clarity.” retinol or acids would be, making it a “The interesting thing is when great option for patients with sensitive DefenAge first came out, we did some Dr. Swengel also encourages patients skin, Dr. Chapas said. half-and-half [studies]. We had several who are undergoing office-based skin people do one hand (usually the worst treatments to use DefenAge before “One of the key things [about the hand) and not the other hand with the and after those procedures. The 8-in-1 8-in-1 BioSerum] is it doesn’t tend to BioSerum,” Dr. Bowers said. “One of BioSerum primes their skin to respond irritate the skin. Women can use it our 73-year-old patients participated, more quickly and robustly, healing fast- around the eye and lip area without and we saw a marked difference at 2 er after ablative skin treatments. having any issues, unlike with retinol months in her hand that was using the or Retin-A (tretinoin),” said dermatol- “It truly is an amazingly unique, medi- BioSerum versus the other hand. That ogist Angela Bowers, MD, founder of cal-grade system with nothing else like was a real selling point for us. My point Southlake Dermatology in Southlake, it on the market,” Dr. Swengel said. ❍

42 | The Dermatology Digest This content is provided by DefenAge OUTSIDE-THE-BOX Tips for treating eczema and more

By Lisette Hilton | Reviewed by Peter A. Lio, MD

eter A. Lio, MD, has published extensively on simple things dermatologists can do Pto improve patient outcomes and satisfaction. These are among his tips.

The literature offers 2 or 3 evidence-based Moisturizers’ role in skin barrier repair treatment options for many of today’s most and how to get kids to use them frustrating dermatologic conditions, such as Dermatologists generally are comfortable with atopic dermatitis. When those do not work, the concept that moisturizers are helpful and do not work well, or are not accessible, what necessary for a variety of skin conditions. does the dermatologist do? The skin barrier’s microbiome, chemical, PETER A. LIO, MD “We want to try and stay conventional and physical, and immune functional layers are Clinical Assistant evidence-based whenever we can. But we are needed to maintain skin integrity, according Professor, Departments forced frequently to think outside the box,” to a paper by Dr. Lio and coauthors published of Dermatology said dermatologist Peter A. Lio, MD, Clinical June 2019 in Journal of Drugs in Dermatology and Pediatrics, Northwestern University Assistant Professor of Dermatology and (https://jddonline.com/articles/dermatology/ Feinberg School Pediatrics at Northwestern University Feinberg S1545961619P0581X).1 of Medicine, School of Medicine, Chicago. Chicago, Illinois Moisturizers can help maintain and restore Dr. Lio has published several papers on treat- the skin barrier to help prevent allergic sen- ment approaches and tips that help dermatolo- sitization, allergic sensitization, and contact gists help patients whose outcomes with tradi- dermatitis, they wrote. tional treatments have been less than optimal. It gets dicey when dermatologists are faced These and other simple strategies send a clear with the dilemma of which moisturizer to message to patients that dermatologists recommend. are not giving up on them, he said.

January 2021 | 43 “In an ideal product, each aspect of the skin barrier would be considered. Attributes such as avoiding preservatives that can damage the microbiota while perhaps even having pre- Dr. Lio said he often sees children, or probiotics to support the microbiota; using especially, with eczema who refuse pH-neutral and gentle ingredients to support to put anything on their skin because the chemical layer; combining occlusives, humectants, and emollients for the physical they say everything burns. barrier; and avoiding fragrance and common allergens and irritants to minimize the chance for immune activation are all desirable and should be considered when evaluating a potential moisturizer,” the authors wrote. But even the best products work only when patients use them correctly. Dr. Lio said he often sees children, especially, with eczema who refuse to put anything on their skin because they say everything burns. One of his outside-the-box tricks to get them to see that not everything burns is to get a placard and put dollops of different moisturizers on it. Wearing gloves, Dr. Lio will put a tiny bit of each of the moisturizers on the child’s arm or hands, with parents watching. He asks, “How does this one feel?” When and if the child says one of the moisturizers feels good, Dr. Lio, cel- ebrates having a winner and gives the parent or child a sample. The approach works and helps build a bond with patients, he said.

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Don’t forget the forgotten “colorful” therapies In a review analyzing mechanisms, applications and adverse effects of colorful dyes, including Castellani’s paint, gentian violet, potassium permanganate, as well as vibrant Dermatology (https:// topical creams vitamin B12 and indigo natu- practicaldermatology.com/ ralis, Dr. Lio and coauthors help make what is articles/2019-dec/what-about- old new again (https://link.springer.com/article diet-the-complex-relationship- /10.1007%2Fs40267-019-00665-1).2 between-food-and-atopic- Castellani’s paint, gentian violet, and potas- dermatitis?c4src= sium permanganate were once common, search:feed).3 studied, efficacious topical treatments for Eczema patients tend to be cutaneous infections. frustrated, suffering, and miserable. “Moreover, topical vitamin B12 and topical “They will often seek alternative medicine indigo naturalis creams for atopic dermatitis practitioners. And one of the things that and psoriasis have been extensively studied comes up a lot in alternative medicine is diet,” through multiple controlled trials and may Dr. Lio said. “I believe that for most of our also be effective, with minimal adverse effects,” patients with atopic dermatitis, food is not wrote authors of the review, published August generally a major contributing factor unless 9, 2019 in Drugs and Therapies Perspectives. they are truly allergic to a food and then, of Sometimes, thinking outside the box means course, should avoid it.” picking an old box, according to Dr. Lio. That does not mean that dermatologists “These treatments still have purpose and can should avoid the topic. Rather, they should serve certain patients in certain situations,” anticipate that someone—an alternative he said. practitioner, family member, or friend— has suggested dietary changes to help treat Gentian violet, for example, is anti-yeast the condition. and anti-fungal. Dr. Lio often uses it to treat oral thrush or intertrigo. The same goes for Castellani’s paint. “I have treated severe intertrigo in older patients who are heavy set. If we just paint the Castellani’s on a couple of times, it can turn things around in cases that are just brutal. I have also used it for pitted keratolysis of the feet,” he said. Talk about diet and eczema because patients are thinking about it The topic of food and eczema is complex and nuanced, according to Dr. Lio, who coauthored an article on exploring the clinical implications of what is currently known about diet and eczema, published December 2019 in Practical

January 2021 | 45 “By bringing it up and anticipating their they all share application site pain as an interest in it, it puts us in a tremendous posi- important adverse effect,” wrote Dr. Lio and tion of therapeutic alliance with the patient,” coauthors in a review published September Dr. Lio said. 2020 in Dermatology (https://www.karger. com/Article/FullText/508771).5 Overall, patients are grateful that Dr. Lio brings up diet, even if he is unlikely to agree The pain, stinging, or burning can be so trau- that diet will help or cure their skin condition. matic for children—especially when applying these therapies to lesions on the face—that “On the other hand, I think some dietary they do not want to come back to the dermatol- counseling for patients who are not eating ogist’s office, according to Dr. Lio. a healthy diet can be transformative for a lot of patients if it is done in a nonjudgmental, Based on available evidence and the authors’ supportive way,” Dr. Lio said. “There is no experience, they suggested strategies for doubt that the effect of changing to a healthy helping patients lessen pain associated with diet is far-reaching.” applying these medicines, including using a topical corticosteroid for a few days to reduce Consider black tea compresses inflammation before starting steroid-sparing for facial dermatitis agents; using steroid-sparing treatments stra- A paper published February 3, 2019, in the tegically; applying moisturizer (stored in the Journal of Dermatological Treatment caught refrigerator) before applying the steroid-spar- Dr. Lio’s attention as offering a powerful ing topicals; recommending that patients apply outside-the-box treatment for facial dermatitis the topical to dry rather than damp skin; and It is so (https://www.tandfonline.com/doi/full/10.1080/ considering aspirin when needed. 09546634.2019.1573306).4 powerful; it is Patients and parents are grateful for the tips. almost like a German researchers conducted a prospective, open, uncontrolled before and after study “When I talk about these things with patients, “medicine” they say no one talks about this stuff,” he said. of 22 patients with atopic or contact facial dermatitis. They treated the patients with Different boxes, entirely: black tea dressings and an emollient cream acupuncture, hypnosis over 6 days. Hypnosis has shown promising results for The authors described a dramatic and highly patients who have had difficulty responding significant reduction of disease activity in to more conventional therapies, according to the first 3 days of treatment. Patients contin- a paper coauthored by Dr. Lio and published ued to improve between days 3 and 6, with March 2020 in Practical Dermatology (https:// no side effects. practicaldermatology.com/articles/2020-mar/ the-role-of-hypnosis-in-dermatology- more- “It is so powerful; it is almost like a medicine,” than-mere-suggestion).6 Dr. Lio said. Hypnotherapy has the power to not only make Pain, pain go away patients feel better, but also get better. Dr. Lio Tacrolimus, pimecrolimus, and crisaborole refers some patients for hypnotherapy or rec- are effective therapies that many patients with ommends they read a book on self-hypnosis. atopic dermatitis and other inflammatory dermatoses do not take due to application “It can be very transformative for everything site pain. from itch to atopic dermatitis to warts. I use it a lot for warts that are refractory,” Dr. Lio said. “While these agents lack the common side effects associated with topical corticosteroids, He also uses acupuncture or acupressure to

46 | The Dermatology Digest www.thedermdigest.com/ECZEMA

I spent 2 years learning about acupuncture and Chinese herbology because I wanted to “offer patients who continued to be frustrated by dermatological conditions other options.”

help patients who have not achieved good by the crease of the elbow. outcomes with traditional therapies. Dr. Lio “They just use their fingertip and we have them spent 2 years learning about acupuncture and do it in the office, then do it at home,” Dr. Lio said. Chinese herbology because he became frustrated that many patients were not improving and Using acupressure at LI11 improved pruritus remained unsatisfied with the explanations of and lichenification, according to the authors.  conventional medicine.

He said he would think: Is this all we know about REFERENCES atopic dermatitis and other skin conditions? 1. Strugar TL, Kuo A, Seité S, Lin M, Lio P. Connecting the dots: from skin barrier dysfunction to allergic sensitization, and the “So, I spent 2 years learning about acupuncture role of moisturizers in repairing the skin barrier. J Drugs Derma- and Chinese herbology because I wanted to tol. 2019;18(6):581. offer patients who continued to be frustrated 2. Agnihotri G, Gandhi S, Lio PA. Colorful dyes and other vibrant topical creams as treatments for dermatological conditions. by dermatological conditions other options,” Drugs Ther Perspect. 2019;35:491-499. Dr. Lio said. 3. Bilimoria SN, Lio PA. What about diet? The complex relationship between food and atopic dermatitis. Practical Derm. 2019:76. While he generally refers patients to an 4. Witte M, Krause L, Zillikens D, Shimanovich I. Black tea d acupuncturist because he does not practice ressings: a rapidly effective treatment for facial dermatitis. enough to be as proficient as those who devote J Dermatolog Treat. 2019;30(8):785-789. 5. Madsen S, Price KN, Shi VY, Lio PA. Pearls in mitigating application pain of topical nonsteroidal agents. Dermatology. When I talk about these things 2020;236(5):477-480. 6. Turowski M, Lio PA. The role of hypnosis in dermatology: more with patients, they say no one than mere suggestion. Practical Derm. 2020;March:56-60. 7. Lee KC, Keyes A, Hensley JR, et al. Effectiveness of acupressure talks about this stuff.” on pruritus and lichenification associated with atopic dermatitis: “ a pilot trial. Acupunct Med. 2012;30(1):8-11. their career to acupuncture, Dr. Lio also educates patients about how they can perform DISCLOSURES: Dr. Lio reports research grants/funding from AbbVie, the National Eczema Association, and Regeneron/Sanofi acupressure on their own trigger points to ease Genzyme; is on the speaker’s bureau for Galderma, L’Oreal, Pfiz- discomfort, including itch. er, and Regeneron/Sanofi Genzyme; reports consulting/advisory boards for AbbVie, Amyris, AOBiome, Arbonne, Bodewell, Burt’s He was among the authors on a paper about Bees, Dermavant, Dermira, Eli Lilly, Exeltis, Franklin Bioscience/ acupressure for pruritus and lichenification Altus Labs (stock options), Galderma, IntraDerm, Johnson & Johnson, Kiniksa, La Roche Posay/L’Oreal, LEO Pharmaceuticals, associated with atopic dermatitis, published Level Ex, Menlo Therapeutics, Micreos (stock options), Pfizer, March 2012 in Acupuncture in Medicine Pierre-Fabre, Realm Therapeutics, Regeneron/Sanofi Genzyme, (https://pubmed.ncbi.nlm.nih.gov/22207450/).7 Theraplex, TopMD, UCB, Unilever, Verrica, YobeeCare (stock options).

In the small study, patients with atopic dermati- In addition, Dr. Lio has a patent pending for a Theraplex product tis were instructed to apply pressure for 3 min- with royalties paid and is a board member and scientific adviso- utes, 3 times a week for 4 weeks. The pressure ry committee member of the National Eczema Association and an investor at LearnSkin. point, called the large intestine (LI) 11 point, is

January 2021 | 47 www.thedermdigest.com/DIAGNOSE_THIS_ZEBRA

Continued from inside back cover A SOUVENIR FROM AN EXOTIC TRIP

DISCUSSION estimation, this patient most likely had South African tick bite fever (SA-TBF). First, she was The most striking almost exclusively in urban settings, whereas thing to consider African tick bite fever (ATBF) is more typically in this case is the acquired following long-term exposure to a prominent facial rural setting. Moreover, while she was exposed eschar. The differ- to dogs and a breeding kennel, classic sources ential diagnosis of of the vector tick for SA-TBF, she had virtually a cutaneous eschar, no exposure to cattle or other livestock, the while extensive, can characteristic hosts for the vector tick of ATBF. be rapidly narrowed. There was no history of Her rash involved the palms and soles, areas renal or cardiovascular disease, reducing the often affected by the eruption associated with likelihood of calciphylaxis or embolic phenom- SA-TBF but not that associated with ATBF; The patient enon. The eschar could not be drug-related, as and her illness was relatively severe, which had signs and the patient was not on an anticoagulant. There contrasts with the more mild disorder associated was no antecedent tumor which could have symptoms with ATBF. undergone necrosis. She had signs and symp- highly toms highly suggestive of an infection, and How would you treat this patient? therefore many entities could be considered. suggestive Fortunately, the antibiotic doxycycline can These include, but are not limited to: bacte- of an infection, effectively treat most human rickettsial infec- rial sepsis, including ecthyma gangrenosum; tions, regardless of exact etiology. The patient and therefore fungemia; mucormycosis; tularemia; scrub was given doxycycline 100 mg BID. Her sys- typhus; plague; and anthrax. However, one many entities temic symptoms rapidly disappeared and her must always put the potential diagnostic pos- eschar eventually healed with only a minimal could be sibilities into proper context. In this case, that depressed, atrophic scar. considered. context included a very recent trip to South Africa. Two rather obscure rickettsioses thus Several key points can be gleaned from this become reasonable to consider: African tick “zebra” case. When evaluating a patient with bite fever (due to R. africae) and South African a febrile illness of uncertain etiology in con- tick bite fever (due to R. conorii). Both can junction with cutaneous findings, clinicians cause a febrile illness and an eschar. should obtain a thorough travel history, ask What would you do next? about exposure to vectors such as insects and animals, and consider diseases common to the Multiple laboratory methods can confirm tick- region the patient recently visited. Clinical and borne rickettsial diseases. However, specific epidemiologic clues are critical for establishing rapid diagnostic tests are usually not available, such challenging diagnoses and support initi- even in the United States. An enzyme-linked ating appropriate anti-infective therapy based immunosorbent assay for the detection of IgG upon a presumptive diagnosis.  class antibody directed against the “spotted fever group” rickettsia showed a positive titer. SUGGESTED READING Serologic tests, cultures, and polymerase chain Dunn C, Rosen T. The rash that leads to eschar formation. Clin Dermatol. reaction tests, as available, were negative for 2019;37(2):99-108. all other potential infectious etiologies. In my Lowery K, Rosen T. Probable African tick bite fever in the United States. Yale J Biol Med. 2020;93(1):49-54.

48 | The Dermatology Digest CRYSTAL BALL INTEGRATIVE MEDICINE

Food and skin health: How strong is the link?

By Mary Beth Nierengarten | Reviewed by Rajani Katta, MD

he idea that diet can and does affect the skin is not new. Dermatologists Thave long known that vitamin deficiencies may cause a number of skin conditions.1 What is relatively new is the growing evidence on the extent to which diet can affect skin, both as a trigger for exacerbating conditions such as acne and atopic dermatitis as well as a means to help ease these RAJANI KATTA, MD and other conditions. Baylor College of Medicine McGovern Medical School Houston

Rajani Katta, MD, a dermatologist on the clinical faculty at the Baylor College of Medicine and Click to listen to a the McGovern Medical School, Houston, who has written extensively on this topic, emphasized podcast inteview with that dermatologists should know the evidence on how diet affects skin to help guide patients as Jonette Keri, MD, PhD, well as to dispel common myths and misconceptions about this association. (For more informa- on original research tion, see Dr. Katta’s site: https://www.doctorkatta.com/diet-skin.) on chocolate/sugar/ “In the past, dermatologists would refer patients to primary care doctors or nutritionists with glycemic diet in acne at www.thedermdigest.com/ questions about diet,” she said. “I don’t think that is good enough anymore because of the massive keri_podcast amount of information on the internet about this, much of it misleading or biased, along with the lack of evidence, particularly with certain supplements, that patients need to be aware of.”

January 2021 | 49 While Dr. Katta strongly urges dermatologists Current evidence to talk to patients about the evidence or lack of In a 2019 review article on skin and diet, Dr. evidence on the link between diet and certain Katta and a colleague provide information on skin conditions, she underscores that patients 5 major skin conditions for which there is ongo- need to understand that diet is just one compo- ing research and some evidence that diet plays a nent of skin health. “I always emphasize to my treatment role.2 The article lays out the evidence patients that dietary change is just one aspect in terms of what foods, nutrients, or dietary hab- of treatment,” she said. “It may be a part of I always its may act as triggers for specific skin conditions the treatment plan, but typically diet does not emphasize to and the utility of avoiding or eliminating those replace other medical therapies.” my patients foods from a patient’s diet, as well as evidence on foods, nutrients, or dietary habits that may help Emphasizing that much is still unknown about “that dietary to treat specific skin conditions. Table 1 synthe- diet and dermatology, Jeremy Hugh, MD, sizes this information. Assistant Professor and Co-Director of Medical change is just Education, University of Colorado Department one aspect Dr. Katta underscored that there are other areas of Dermatology, Aurora, also cautioned that of treatment.” in which diet may also play a role in skin care, diet is only a small component of skin care. including skin cancer prevention, and high- “I’m okay with patients trying to alter their diet lighted recent evidence showing the potential in order to improve their skin if it doesn’t hurt benefit of nicotinamide (vitamin B3) supple- them,” he said. “However, I do emphasize that mentation on reducing the risk of non-melano- this alone is unlikely to improve their skin in ma skin cancer in people at high risk for it.3 many cases.” He does believe that much of the connection between diet and dermatology just can’t yet be proven. So what is currently known?

It is better to get nutrients from whole foods versus supplements because “there is so much more synergy and nutrients in whole foods.”

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Table 1 Skin Condition Triggers Evidence: Benefits

Acne High-glycemic-load diets Some data suggest improvement in acne following a low-glycemic diet. Other data show a weak link between acne and dairy consumption (perhaps more strongly with skim milk). Overall, limited data from human trials disallow recommending specific foods or nutrients with any certainty. Research on probiotics, omega-3 fatty acids, and zinc suggests some promise but is preliminary.

Atopic Food allergies may result in immediate Synbiotics (a combination of probiotics and prebiotics) found in supplements or foods are dermatitis hypersensitivity reactions or delayed showing promise as treatment. eczematous reactions. The 6 most common More research is needed on the optimal dose, type of bacterial strain, and duration of trigger foods are milk, eggs, wheat, soy, treatment needed to confer a benefit. seafood, and nuts. Keeping a food diary is Limited evidence exists on the benefit of vitamin D or fish oil supplements in the absence recommended. of deficiency.

Psoriasis* Smoking and increased alcohol intake Dietary changes to reduce weight should be recommended to those who are overweight or obese, based on evidence showing that weight loss may improve disease severity and Gluten-containing foods in those with celiac improve response to systemic treatments. disease or gluten antibodies Further research is needed on the benefits of specific dietary or supplement recommendations, with some limited data showing promising results with vitamin D and fish oil supplements.

Rosacea Spicy food, hot sauce, tomatoes, chocolate, Evidence suggests a possible gut-skin connection, with research showing an increased citrus, alcohol, hot coffee, hot tea prevalence of small intestinal bacterial overgrowth (SIBO), celiac disease, Crohn’s disease, ulcerative colitis, Helicobacter pylori infection, and irritable bowel syndrome in patients with rosacea compared to those without. Case studies have shown a benefit of antibiotic treatment as well as increased fiber intake in those with SIBO.

Aging Foods and food cooking or processing Antioxidants found in a range of foods (eg, fruits, vegetables, tea leaves, seeds, spices, methods (such as deep frying) that result in herbs) have shown a benefit in laboratory and animal studies by limiting the effects of the production of advanced glycation end cutaneous damage from ultraviolet radiation. products (known as AGEs), such as sugary or Research shows that antioxidants from foods differ from those found in supplements. high-glycemic foods.

* Diet should be emphasized for all patients with psoriasis who are at a higher risk of comorbid conditions (ie, diabetes, hypertension, and cardiovascular disease) that diet can help prevent or ameliorate.2

Dr. Hugh also expressed interest in She emphasized, however, that as a rule of nicotinamide. “There are limited data to thumb she encourages patients to get their nu- suggest it can reduce new skin cancers, and trients from whole foods. “Eat power,” she says, it’s something we’ve used in conjunction with referring to foods rich in powerful nutrients. other medications to treat things like blistering “It is better to get nutrients from whole foods skin disorders,” he said, “so hopefully it has a versus supplements because there is so much meaningful role.” more synergy and nutrients in whole foods,” she said, saying that the role of supplements is Other supplements under investigation that to correct deficiencies. “Beyond that, you really Dr. Katta thinks hold promise include zinc for need more research before we can recommend acne and synbiotics for atopic dermatitis.4 supplements,” she said.

January 2021 | 51 www.thedermdigest.com/CRYSTAL_BALL

Using the evidence in clinical practice to yet provide definitive recommendations Dr. Katta uses a framework to break down the on the exact role of diet. Rather, the benefits role of diet in dermatology into 3 main areas suggested in Table 1 can be considered general (Table 2). recommendations that may be helpful within T a more broad treatment approach. Table 2. Diet in dermatology: Dr. Hugh said that he typically counsels the three big questions patients on diet if he thinks it has a meaningful Are there any systemic comorbidities that may role in their condition. “For instance, in 1. benefit from a change of diet? those with a higher body mass index at baseline, weight loss (more in the form of Are there any foods, nutrients, or eating patterns calorie restriction rather than a specific diet) that may act as a trigger for skin disease or make may improve things such as psoriasis and 2. it worse? hidradenitis suppurativa.” Are there any foods, nutrients, or eating patterns However, he cautions patients about the limita- 3. that may help in the treatment of skin disease? tions of what diet can achieve. “When patients ask how diet may affect their skin with things such as eczema, where the data are very weak, When Dr. Katta thinks diet may be playing a I tell them they are welcome to adjust [their role in a patient’s skin condition, she considers diet] as they please, but that I’m not sure it will the evidence (such as provided in Table 1) on change their skin dramatically.” the dietary benefits, but emphasized again that including diet in the treatment plan is only 1 “I think allowing patients to try [diet chang- component and should not be considered the es] is important, but knowing the limitations 2 main myths about main focus. associated with that is even more important,” he said.  skin and diet She said that she often tells her patients about the 2 main myths about skin and diet. One is Diet has that diet has no impact on the skin, and the REFERENCES no impact 1. Basavaraj KH, Seemanthini C, Rashmi R. Diet in dermatology. Indian other is that diet is the cause of all skin prob- J Dermatol. 2010;55:205-210. https://www.ncbi.nlm.nih.gov/pmc/ 1 on the skin lems. “I see people at both extremes, and so articles/PMC2965901/ I talk about diet as only one aspect, trigger or 2. Katta R, Kramer MJ. Skin and diet: an update on the role of dietary helper, when approaching a patient with skin change as treatment strategy for skin disease. Skin Therapy Letter. Diet is the 2018;23:1-5. https://www.skintherapyletter.com/dermatology/ disease,” she said. cause of all diet-change-treatment-skin-disease/ skin problems Among the most common misconceptions 3. Chen AC, Martin AJ, Choy B, et al. A phase 3 randomized trial of 2 nicotinamide for skin-cancer chemoprevention. N Eng J Med. about diet and skin is the broadly held belief 2015;373:1618-1626. https://www.nejm.org/doi/full/10.1056/ that dairy or gluten allergies are the main nejmoa1506197 culprits. “We need to educate people that some 4. Chang YS, Trivedi MK, Jha A, et al. Synbiotics for prevention and people may be allergic to those foods, but most treatment of atopic dermatitis. JAMA Pediatr. 2016;170:299. https://pubmed.ncbi.nlm.nih.gov/26810481/ people with skin disease are not reacting to those foods,” she said. “We have to think about this systematically and customize our approach for the particular skin condition and particular medical profile of each patient.” Although more evidence is emerging on the many ways that diet can influence skin, Dr. Katta underscored that the data are too limited

52 | The Dermatology Digest GENERAL DERMATOLOGY HYPERHIDROSIS

Less sweat, better quality of life

By Lisette Hilton | Reviewed by Dee Anna Glaser, MD

Dee Anna Glaser, MD President and Founding Member of the International Hyperhidrosis Society and Professor and Interim Chair of Dermatology at St. Louis University School of Medicine

Presented at Fall Clinical Dermatology Conference in 2020

ith a growing list of hyperhidrosis treatment options, it is becoming Wmore important that dermatologists understand how to optimally use individual therapies, combine treatments, and minimize side effects to improve patients’ quality of life, according to Dee Anna Glaser, MD, President and Founding Member of the International Hyperhidrosis Society and Professor and Interim Chair of Dermatology at St. Louis University School of Medicine.

Dr. Glaser, who presented on hyperhidrosis at the Fall Clinical Dermatology Conference in 2020, shared treatment pearls from that talk with The Dermatology Digest. Look beyond sweat to recommend individualized treatment Dermatologists have limited options for treating and managing hyperhidrosis. “You can use topical antiperspirants. There is the new topical glycopyrronium cloth. There are old favorites like iontophoresis devices, botulinum toxin, and oral medications, which can be used off label. There are local [surgical] procedures, and microwave thermolysis is an FDA-cleared device,” Hear the full interview at Dr. Glaser said. www.thedermdigest. com/glaser_podcast Sometimes, a therapy that seems ideal initially is not. Dr. Glaser described a young man with severe hyperhidrosis involving his face, scalp, and underarms. He had excessive sweating

January 2021 | 53 Other examples of combination therapies that address specific areas of concern: microwave thermolysis for the underarms, which uses microwave technology to permanently destroy the sweat glands; and iontophoresis for excessive sweating of the hands and feet. Or using focal treatments such as botulinum toxin for underarms, forehead, and scalp, and a clinical strength antiperspirant or the glycopyrronium cloth for the underarms. Treatment efficacy can vary with treatment Dr. Glaser location. For example, botulinum toxin injec- determines tions into the axilla provide “amazingly good control,” according to Dr. Glaser. if a patient of the back, chest, groin, palms, and soles. has excessive “But when we inject it off label in the palms or A patient with multiple excessive sweating sites forehead or scalp, it may provide good control sweating by would appear to be an ideal candidate for but not that amazing type of control of the how his or systemic therapy. But this patient worked out- sweating,” she said. doors and played sports and needed to sweat Mitigate side effects her sweating to regulate body temperature, she said. affects daily In some cases, the best option is an oral Dr. Glaser and the patient decided instead to anticholinergic. Oral anticholinergic medica- functions of combine compounded topical anticholinergics tions have potential side effects including dry living. that the patient would use on face and scalp. mouth, dry eyes, enlarged pupils, constipation, Those were the areas that bothered him most, bronchodilation, and more. In severe cases, which brings up another pearl: First ask each oral anticholinergics can cause genitourinary patient what bothers the patient most, so you symptoms. can focus treatment on those areas, she said. “If it is an excessive dose of anticholinergics, “Then, we talked about possibly adding patients may not even be able to urinate at all, propranolol, which can be very effective for which is an urgent situation. There are also sweating that the patient notices with a specific cardiac arrythmias. For especially young or event—things like going on a job interview older patients, there can be side effects like or meeting new people,” she said. “Sometimes confusion or excitement,” Dr. Glaser said. using propranolol 30 to 60 minutes prior to that situation can really help to reduce the When appropriate, Dr. Glaser uses glycopyrro- sweating at that time.” late because it is less likely to cross the blood- brain barrier and can mitigate side effects. Still, Using propranolol she educates patients that systemic therapies are likely to cause side effects that they might be able to manage with simple things. For exam- 30 to 60 ple, drinking more water can help with dry MINUTES mouth. Nasal sprays or eye drops can help with dry nasal passages or eyes. And extra fiber can prior to a stressful situation help with mild constipation. can help reduce sweating

54 | The Dermatology Digest www.thedermdigest.com/GENERAL_DERMATOLOGY

“I think it is becoming more recognized and more accepted that this is not just a lifestyle problem but a medical “condition that deserves treatment.”

Set reasonable expectations A bright future Improvement is the goal when managing Among the drugs in the hyperhidrosis treat- hyperhidrosis. The way Dr. Glaser often puts ment pipeline is sofpironium bromide it: She hopes patients’ episodes of excessive (Brickell), a topical, quickly metabolized sweating will be less often and less severe and anticholinergic in phase 3 research. that they will feel like they sweat more like the “The [topical anticholinergic] that we currently “normal” population. have is an individually packaged cloth and it “I remind the patients with hyperhidrosis that has a little alcohol in it. [The packets] are easy we all sweat. It helps maintain our body tem- and convenient, but the alcohol sometimes is perature and all of us tend to sweat more than a little bit irritating to the underarm,” she said. we want, especially when we are anxious and “[Sofpironium bromide] will be more of a cream- are in an environment that is uncomfortable based topical that will reduce the chance of sys- for us,” she said. temic anticholinergic side effects, so it will be nice to have more than one product to choose from.” Dr. Glaser determines if a patient has excessive sweating by how his or her sweating affects What excites Dr. Glaser most is that derma- daily functions of living. The need for treatment tologists and other health care providers are is obvious in many cases. “I have had some developing a better understanding of hyper- patients with severe palm sweating who have hidrosis’ potential impact and the need for shorted out their electronic devices. They can’t individualized treatment. function at work. I’ve had nurses who have had “I think it is becoming more recognized and difficulty changing IV bags or giving injec- more accepted that this is not just a lifestyle tions,” she said. problem but a medical condition that deserves In other cases, the impact of excessive sweating treatment,” she said. on a person’s life is not so apparent. A teenager, for Dermatologists can learn more at SweatHelp. example, with excessive underarm sweating may org, which offers treatment videos, examples spend a lot of time thinking about it and trying for coding and billing, and more.  to hide it. “They may never raise their hand to answer a question in the classroom. They might DISCLOSURES: not socialize. It can affect all domains of quality Dr. Glaser is an advisor or has received research funding from Allergan, Brickell, Dermira, Ferndale, Forest Research, Galderma, of life for these patients,” she said. Miramar, Revance, Ulthera, and Unilever.

January 2021 | 55 A new treatment looks promising

By Lisette Hilton | Reviewed by Joel L. Cohen, MD

nvestigational sofpironium bromide gel (Brickell Biotech) offers sustained Ireductions in sweating severity without many of the side effects associated with systemic anticholinergic therapy for axillary hyperhidrosis, according to the study “Efficacy and safety of topical sofpironium bromide gel for the treatment of axillary hyperhidrosis: A phase II, randomized, controlled, JOEL L. COHEN, MD double-blinded trial,” published in the Journal of the American Academy Director, AboutSkin Dermatology and of Dermatology. AboutSkin Research Greenwood Village and Lone Tree, Colorado We know that hyperhidrosis affects about 4% to 5% of the US population, which is more than 15 million Americans. About 10 million Americans suffer specifically from axillary hyperhidrosis. This has a significant negative impact on people’s social life and quality of life,” said study author Joel L. Cohen, MD, director of AboutSkin Dermatology as well as AboutSkin Research in Greenwood Village and Lone Tree, Colorado. “There is a lot of excitement about this particular drug and how it works.” Listen for more of Dr. Cohen’s hyperhidrosis advice at www.thedermdigest. com/cohen_ hyperhidrosis_podcast

About 10 million Americans suffer specifically from axillary hyperhidrosis. This has a significant negative impact on people’s“ social life and quality of life.”

56 | The Dermatology Digest www.thedermdigest.com/GENERAL_DERMATOLOGY

PHASE 2 TRIAL

Researchers randomized 227 participants to 1 of 3 doses of the gel or vehicle, with daily treatment for 42 days Percentage of participants exhibiting 1 or greater points of improvement in the Hyperhidrosis Disease Severity Measure-Axillary score

5% GEL 10% GEL 15% GEL VEHICLE GROUP 70% 79% 76% 54%

Sofpironium bromide is an analog of the anti In the phase 2 trial, researchers randomized 227 cholinergic agent glycopyrrolate. It is retro participants to 1 of 3 doses of the gel or vehicle, metabolic, which means the molecules are with daily treatment for 42 days. They found the designed to rapidly metabolize, limiting the risk percentage of participants exhibiting 1 or great of systemic side effects, such as dry mouth, pu er points of improvement in the Hyperhidrosis pil dilation, constipation, urinary retention, and Disease Severity MeasureAxillary score were more, Dr. Cohen told The Dermatology Digest. 70% in the 5% gel group, 79% in the 10% gel group, 76% in the 15% gel group, and 54% in If approved, sofpironium bromide will be in the the vehicle group. mix of hyperhidrosis treatments among alumi num chloride topical antiperspirant agents, the “In terms of the local potential skin reactions topical glycopyrronium cloth, botulinum toxin, with this type of product, some people might the microwave thermolysis device, and surgery. have mild dermatitis and irritation of the skin, some may just have some redness. Some people “Sofpironium bromide is a topical designed to have a little bit of itching or an eczematous type have specific efficacy in the eccrine, apoeccrine, pattern,” Dr. Cohen said. and apocrine glands that we know become more mature as people hit adolescence and US researchers began phase 3 trials looking at seem to be more of a problem in terms of sofpironium bromide in October 2020.  stimulation for people who suffer from axillary hyperhidrosis,” he said. DISCLOSURE: Dr. Cohen has been an investigator for Brickell Biotech.

January 2021 | 57 Most commercially insured patients pay as little as $20* An experience worth noticing. With clinical e cacy and safety proﬁ le in a once-daily spray foam, choose the Enstilar® Foam experience for your patients with plaque psoriasis.1

In adults, patients achieved "Clear" or "Almost Clear" skin as measured by IGA1,2†: • 53.3% vs 4.8% for vehicle at Week 4 (P<0.001) • 26.4% vs 1.9% for vehicle at Week 2

*Valid for up to 12 prescription ﬁ lls per calendar year. Patients are not eligible if they are enrolled in or eligible for any state or federally funded health care program (eg, Medicare, Medicaid). Additional restrictions and limitations apply; see www.leopharmaconnect.com. † A randomized clinical trial with 426 patients, ≥18 years of age, that investigated the e ectiveness of Enstilar® or the vehicle alone for the treatment of psoriasis vulgaris on the trunk and/or limbs. E cacy was assessed using a 5-point IGA at Week 4, with treatment success deﬁ ned as the percentage of patients who achieved at least a 2-step improvement to reach "Clear" or "Almost Clear" disease severity. Patients with "Mild" disease were required to be "Clear" to be considered a treatment success.1,2 IGA=Investigator’s Global Assessment. Not an actual patient. Image is a representation of plaque psoriasis. Individual results may vary. References: 1. Enstilar® [prescribing information]. LEO Pharma Inc. 2. Leonardi C, Bagel J, Yamauchi P, et al. E cacy and safety of calcipotriene plus betamethasone dipropionate aerosol foam in patients with psoriasis vulgaris — a randomized phase III study (PSO-FAST). J Drugs Dermatol. 2015;14(12):1468-1477. INDICATION AND USAGE Enstilar® (calcipotriene and betamethasone dipropionate) Foam is indicated for the topical treatment of plaque psoriasis in patients 12 years and older. Apply Enstilar Foam to a ected areas once daily for up to 4 weeks. Discontinue use when control is achieved. Instruct patients not to use more than 60 grams every 4 days. IMPORTANT SAFETY INFORMATION For topical use only. Enstilar Foam is not for oral, ophthalmic or intravaginal use and should not be applied on the face, groin or axillae or if skin atrophy is present at the treatment site. Do not use with occlusive dressings. Patients should wash hands after application. Please see Brief Summary of Prescribing Information on following page.

The LEO Pharma logo, LEO Pharma, and Enstilar are registered trademarks of LEO Pharma A/S. ©2020 LEO Pharma Inc. All rights reserved. March 2020 MAT-29982 ENSTILAR® (calcipotriene and betamethasone dipropionate) foam, for topical use Clinical Trials Conducted in Subjects 18 years and older with Psoriasis Rx Only The rates of adverse reactions described below were from three randomized, BRIEF SUMMARY OF PRESCRIBING INFORMATION. multicenter, vehicle and/or active-controlled clinical trials in adult subjects with plaque psoriasis. Subjects applied study product once daily for 4 weeks, and the INDICATIONS AND USAGE ® median weekly dose of Enstilar Foam was 25 grams. Adverse reactions reported in Enstilar (calcipotriene and betamethasone dipropionate) Foam is indicated for the <1% of adult subjects treated with Enstilar Foam included: application site irritation, topical treatment of plaque psoriasis in patients 12 years and older. application site pruritus, folliculitis, skin hypopigmentation, hypercalcemia, urticaria, DOSAGE AND ADMINISTRATION and exacerbation of psoriasis. Instruct patients to shake can prior to using Enstilar Foam and to wash their hands Clinical Trials Conducted in Subjects 12 to 17 years with Psoriasis after applying the product. Apply Enstilar Foam to affected areas once daily for up to In one uncontrolled clinical trial, 106 subjects aged 12 to 17 years with plaque 4 weeks. Rub in Enstilar Foam gently. Discontinue Enstilar Foam when control is psoriasis of the scalp and body applied Enstilar Foam once daily for up to 4 weeks. achieved. The median weekly dose was 40 grams. Adverse reactions reported in <1% of Patients should not use more than 60 grams every 4 days. pediatric subjects treated were acne, erythema, application site pain, and skin Enstilar Foam should not be: reactions. • Used with occlusive dressings unless directed by a healthcare provider. Postmarketing Experience • Used on the face, groin, or axillae, or if skin atrophy is present at the treatment Because adverse reactions are reported voluntarily from a population of uncertain site. size, it is not always possible to reliably estimate their frequency or establish a Enstilar Foam is not for oral, ophthalmic, or intravaginal use. causal relationship to drug exposure. DOSAGE FORMS AND STRENGTHS Postmarketing reports for local adverse reactions to topical corticosteroids included Enstilar Foam: 0.005%/0.064% - each gram contains 50 mcg calcipotriene and atrophy, striae, telangiectasia, dryness, perioral dermatitis, secondary infection, and 0.643 mg of betamethasone dipropionate in a white to off-white opalescent liquid in miliaria. a pressurized aluminum spray can with a continuous valve and actuator. At Ophthalmic adverse reactions of cataracts, glaucoma, increased intraocular pressure, administration the product is a white to off-white foam after evaporation of the and central serous chorioretinopathy have been reported with the use of topical propellants. corticosteroids, including topical betamethasone products. CONTRAINDICATIONS USE IN SPECIFIC POPULATIONS None. Pregnancy WARNINGS AND PRECAUTIONS Risk Summary Flammability Available data with Enstilar Foam are not sufficient to evaluate a drug-associated The propellants in Enstilar Foam are flammable. Instruct the patient to avoid fire, risk for major birth defects, miscarriages, or adverse maternal or fetal outcomes. flame, and smoking during and immediately following application. Although there are no available data on use of the calcipotriene component in Hypercalcemia and Hypercalciuria pregnant women, systemic exposure to calcipotriene after topical administration of Hypercalcemia and hypercalciuria have been observed with use of Enstilar Foam. Enstilar Foam is likely to be low. If hypercalcemia or hypercalciuria develop, discontinue treatment until parameters Observational studies suggest an increased risk of having low birth weight infants of calcium metabolism have normalized. The incidence of hypercalcemia and with the maternal use of potent or super potent topical corticosteroids. Advise hypercalciuria following Enstilar Foam treatment of more than 4 weeks has not been pregnant women that Enstilar Foam may increase the potential risk of having a low evaluated. birth weight infant and to use Enstilar Foam on the smallest area of skin and for the Effects on Endocrine System shortest duration possible. Hypothalamic-Pituitary-Adrenal Axis Suppression In animal reproduction studies, oral administration of calcipotriene to pregnant rats Systemic absorption of topical corticosteroids can cause reversible hypothalamic- during the period of organogenesis resulted in an increased incidence of minor pituitary-adrenal (HPA) axis suppression with the potential for clinical skeletal abnormalities, including enlarged fontanelles and extra ribs. Oral administration glucocorticosteroid insufficiency. This may occur during treatment or upon of calcipotriene to pregnant rabbits during the period of organogenesis had no withdrawal of treatment. Factors that predispose a patient to HPA axis suppression apparent effects on embryo-fetal development. Subcutaneous administration of include the use of high-potency steroids, large treatment surface areas, prolonged betamethasone dipropionate to pregnant rats and rabbits during the period of use, use of occlusive dressings, altered skin barrier, liver failure, and young age. organogenesis resulted in fetal toxicity, including fetal deaths, reduced fetal weight, Evaluation for HPA axis suppression may be done by using the adrenocorticotropic and fetal malformations (cleft palate and crooked or short tail). The available data hormone (ACTH) stimulation test. If HPA axis suppression is documented, gradually do not allow the calculation of relevant comparisons between the systemic withdraw Enstilar Foam, reduce the frequency of application, or substitute with a exposures of calcipotriene and betamethasone dipropionate observed in animal less potent corticosteroid. studies to the systemic exposures that would be expected in humans after topical use of Enstilar® Foam. The following trials evaluated the effects of Enstilar Foam on HPA axis suppression: The estimated background risk of major birth defects and miscarriage of the • In a trial evaluating the effects of Enstilar Foam on the HPA axis, 35 adult indicated population is unknown. All pregnancies have a background risk of birth subjects applied Enstilar Foam on the body and scalp. Adrenal suppression defect, loss, or other adverse outcomes. In the U.S. general population, the was not observed in any subjects after 4 weeks of treatment. In another trial, estimated background risk of major birth defects and miscarriage in clinically 33 pediatric subjects age 12 to 17 years applied Enstilar Foam on the body and recognized pregnancies is 2% to 4% and 15% to 20%, respectively. scalp. Adrenal suppression occurred in 3 (9%) of the subjects. Data Cushing’s Syndrome and Hyperglycemia Human Data Systemic effects of topical corticosteroids may also include Cushing’s syndrome, Available observational studies in pregnant women did not identify a drug- hyperglycemia, and glucosuria. associated risk of major birth defects, preterm delivery, or fetal mortality with Additional Considerations for Endocrine Adverse Reactions the use of topical corticosteroids of any potency. However, when the dispensed Pediatric patients may be more susceptible to systemic toxicity due to their larger amount of potent or super potent topical corticosteroids exceeded 300 grams skin surface to body mass ratios. during the entire pregnancy, maternal use was associated with an increased risk of Use of more than one corticosteroid-containing product at the same time may low birth weight in infants. increase the total systemic corticosteroid exposure. Animal Data Allergic Contact Dermatitis Embryo-fetal development studies with calcipotriene were performed by the oral Allergic contact dermatitis has been observed with topical calcipotriene and topical route in rats and rabbits. Pregnant rats received dosages of 0, 6, 18, or 54 mcg/kg/day corticosteroids. Allergic contact dermatitis to a topical corticosteroid is usually (0, 36, 108, and 324 mcg/m2/day, respectively) on days 6-15 of gestation (the diagnosed by observing a failure to heal rather than a clinical exacerbation. period of organogenesis). There were no apparent effects on maternal survival, Corroborate such an observation with appropriate diagnostic patch testing. behavior, or body weight gain, no effects on litter parameters, and no effects on Ophthalmic Adverse Reactions the incidence of major malformations in fetuses. Fetuses from dams dosed at Use of topical corticosteroids, including Enstilar® Foam, may increase the risk 54 mcg/kg/day exhibited a significantly increased incidence of minor skeletal of posterior subcapsular cataracts and glaucoma. Cataracts and glaucoma have abnormalities, including enlarged fontanelles and extra ribs. been reported with the postmarketing use of topical corticosteroid products. Avoid Pregnant rabbits were dosed daily with calcipotriene at exposures of 0, 4, 12, or contact with Enstilar Foam with eyes. Enstilar Foam may cause eye irritation. Advise 36 mcg/kg/day (0, 48, 144, and 432 mcg/m2/day, respectively) on days 6-18 of patients to report any visual symptoms and consider referral to an ophthalmologist gestation (the period of organogenesis). Mean maternal body weight gain was for evaluation. reduced in animals dosed at 12 or 36 mcg/kg/day. The incidence of fetal deaths was ADVERSE REACTIONS increased in the group dosed at 36 mcg/kg/day; reduced fetal weight was also Clinical Trials Experience observed in this group. The incidence of major malformations among fetuses was Because clinical trials are conducted under widely varying conditions, adverse not affected. An increase in the incidence of minor skeletal abnormalities, including reaction rates observed in the clinical trials of a drug cannot be directly compared to incomplete ossification of sternebrae, pubic bones, and forelimb phalanges, was rates in the clinical trials of another drug and may not reflect the rates observed in observed in the group dosed at 36 mcg/kg/day. practice.

Embryo-fetal development studies with betamethasone dipropionate were NONCLINICAL TOXICOLOGY performed via subcutaneous injection in mice and rabbits. Pregnant mice were Carcinogenesis, Mutagenesis, Impairment of Fertility administered doses of 0, 156, 625, or 2500 mcg/kg/day (0, 468, 1875, and When calcipotriene was applied topically to mice for up to 24 months at dosages of 7500 mcg/m2/day, respectively) on days 7 through 13 of gestation (the period of 3, 10, and 30 mcg/kg/day (9, 30, and 90 mcg/m2/day, respectively), no significant organogenesis). Betamethasone dipropionate induced fetal toxicity, including fetal changes in tumor incidence were observed when compared to control. deaths, reduced fetal weight, malformations (increased incidence of the cleft palate A 104-week oral carcinogenicity study was conducted with calcipotriene in male and crooked or short tail), and minor skeletal abnormalities (delayed ossification of and female rats at doses of 1, 5, and 15 mcg/kg/day (6, 30, and 90 mcg/m2/day, vertebra and sternebrae). Fetal toxicity was observed at the lowest exposure that respectively). Beginning week 71, the dosage for high-dose animals of both genders was evaluated (156 mcg/kg/day). was reduced to 10 mcg/kg/day (60 mcg/m2/day). A treatment-related increase in Pregnant rabbits were injected subcutaneously at dosages of 0, 0.625, 2.5, and benign C-cell adenomas was observed in the thyroid of females that received 10 mcg/kg/day (0, 7.5, 30, and 120 mcg/m2/day, respectively) on days 6 through 18 15 mcg/kg/day. A treatment-related increase in benign pheochromocytomas was of gestation (the period of organogenesis). Betamethasone dipropionate induced observed in the adrenal glands of males that received 15 mcg/kg/day. No other fetal toxicity, including fetal deaths, reduced fetal weight, external malformations statistically significant differences in tumor incidence were observed when compared (including malformed ears, cleft palate, umbilical hernia, kinked tail, club foot, and to control. The relevance of these findings to patients is unknown. club hand), and skeletal malformations (including absence of phalanges of the first When betamethasone dipropionate was applied topically to CD-1 mice for up to digit and cranial dysplasia) at dosages of 2.5 mcg/kg/day and above. 24 months at dosages approximating 1.3, 4.2, and 8.5 mcg/kg/day in females, and Calcipotriene was evaluated for effects on peri- and post-natal development when 1.3, 4.2, and 12.9 mcg/kg/day in males (up to 26 mcg/m2/day and 39 mcg/m2/day, orally administered to pregnant rats at dosages of 0, 6, 18 or 54 mcg/kg/day in females and males, respectively), no significant changes in tumor incidence were (0, 36, 108, and 324 mcg/m2/day, respectively) from gestation day 15 through day 20 observed when compared to control. postpartum. No remarkable effects were observed on any parameter, including When betamethasone dipropionate was administered via oral gavage to male and survival, behavior, body weight, litter parameters, or the ability to nurse or rear pups. female Sprague Dawley rats for up to 24 months at dosages of 20, 60, and Betamethasone dipropionate was evaluated for effects on peri- and post-natal 200 mcg/kg/day (120, 360, and 1200 mcg/m2/day, respectively), no significant development when orally administered to pregnant rats at dosages of 0, 100, 300, changes in tumor incidence were observed when compared to control. and 1000 mcg/kg/day (0, 600, 1800, and 6000 mcg/m2/day, respectively) from Calcipotriene did not elicit any genotoxic effects in the Ames mutagenicity assay, the gestation day 6 through day 20 postpartum. Mean maternal body weight was mouse lymphoma TK locus assay, the human lymphocyte chromosome aberration significantly reduced on gestation day 20 in animals dosed at 300 and 1000 mcg/kg/day. test, or the mouse micronucleus test. Betamethasone dipropionate did not elicit any The mean duration of gestation was slightly, but statistically significantly, increased genotoxic effects in the Ames mutagenicity assay, the mouse lymphoma TK locus at 100, 300, and 1000 mcg/kg/day. The mean percentage of pups that survived to assay, or in the rat micronucleus test. day 4 was reduced in relation to dosage. On lactation day 5, the percentage of pups Studies in rats with oral doses of up to 54 mcg/kg/day (324 mcg/m2/day) of with a reflex to right themselves when placed on their back was significantly reduced calcipotriene indicated no impairment of fertility or general reproductive performance. at 1000 mcg/kg/day. No effects on the ability of pups to learn were observed, and Studies in male rats at oral doses of up to 200 mcg/kg/day (1200 mcg/m2/day), and the ability of the offspring of treated rats to reproduce was not affected. in female rats at oral doses of up to 1000 mcg/kg/day (6000 mcg/m2/day), of Lactation betamethasone dipropionate indicated no impairment of fertility. Risk Summary PATIENT COUNSELING INFORMATION There is no information regarding the presence of topically administered calcipotriene Flammability and betamethasone dipropionate in human milk, the effects on the breastfed infant, Instruct patients that Enstilar Foam is flammable; avoid heat, flame, or smoking or the effects on milk production. Concentrations of calcipotriene in plasma are low when applying this medication. after topical administration, and therefore, concentrations in human milk are likely to be low. It is not known whether topical administration of large amounts of Administration Instructions betamethasone dipropionate could result in sufficient systemic absorption to • Shake before use and spray the foam by holding the can in any orientation produce detectable quantities in human milk. The developmental and health benefits except horizontally. of breastfeeding should be considered along with the mother’s clinical need for • Do not use more than 60 grams every 4 days. Enstilar® Foam and any potential adverse effects on the breastfed child from • Discontinue therapy when control is achieved unless directed otherwise by the Enstilar Foam or from the underlying maternal condition. healthcare provider. • Avoid use of Enstilar Foam on the face, underarms, groin or eyes. If this Clinical Considerations medicine gets on face or in mouth or eyes, wash area right away. To minimize potential exposure to the breastfed infant via breast milk, use Enstilar • Do not occlude the treatment area with a bandage or other covering unless Foam on the smallest area of skin and for the shortest duration possible while directed by the healthcare provider. Instruct the patients not to use other breastfeeding. Advise breastfeeding women not to apply Enstilar Foam directly to products containing calcipotriene or a corticosteroid with Enstilar Foam without the nipple and areola to avoid direct infant exposure. first talking to the healthcare provider. Pediatric Use • Wash hands after application. The safety and effectiveness of Enstilar Foam for the treatment of mild to severe Local Reactions and Skin Atrophy plaque psoriasis have been established in pediatric patients age 12 to 17 years. The Advise patients that local reactions and skin atrophy are more likely to occur with use of Enstilar Foam for this indication is supported by evidence from adequate and occlusive use, prolonged use or use of higher potency corticosteroids. well-controlled trials in adults and from one uncontrolled trial in 106 adolescents age 12 to 17 years with psoriasis of the body and scalp. Calcium metabolism was Hypercalcemia and Hypercalciuria evaluated in all pediatric subjects and no cases of hypercalcemia or clinically Advise patients that hypercalcemia and hypercalciuria have been observed with the relevant changes in urinary calcium were reported. Hypothalamic pituitary adrenal use of Enstilar Foam. (HPA) axis suppression was evaluated in a subset of 33 pediatric subjects with HPA Axis Suppression, Cushing’s Syndrome, and Hyperglycemia moderate plaque psoriasis of the body and scalp (mean body surface area Advise patients that Enstilar Foam can cause HPA axis suppression, Cushing’s involvement of 16% and mean scalp area involvement of 56%). After 4 weeks of syndrome, and/or hyperglycemia. once daily treatment with a mean weekly dose of 47 grams, HPA axis suppression Ophthalmic Adverse Reactions was observed in 3 of 33 subjects (9%). Advise patients to avoid contact of Enstilar Foam with eyes and to report any visual Because of a higher ratio of skin surface area to body mass, children under the age symptoms. of 12 years are at particular risk of systemic adverse effects when they are treated Pregnancy and Lactation with topical corticosteroids. Pediatric patients are, therefore, also at greater risk of • Advise pregnant women that Enstilar® Foam may increase the potential risk of HPA axis suppression and adrenal insufficiency with the use of topical corticosteroids having a low birth weight infant and to use Enstilar Foam on the smallest area of including Enstilar Foam. skin and for the shortest duration possible. Cushing’s syndrome, linear growth retardation, delayed weight gain, and intracranial • Advise breastfeeding women not to apply Enstilar Foam directly to the nipple and hypertension have been reported in pediatric patients treated with topical areola to avoid direct infant exposure. corticosteroids. Manufactured by: LEO Laboratories Ltd., 285 Cashel Road, Dublin 12, Ireland Local adverse reactions including striae have been reported with use of topical or corticosteroids in pediatric patients. Colep Laupheim GmbH & Co. KG, Fockestraße 12, 88471 Laupheim, Germany (DE) The safety and effectiveness of Enstilar Foam in pediatric patients less than 12 years Distributed by: LEO Pharma Inc., Madison, NJ 07940, USA of age have not been established. Geriatric Use Of the total number of subjects in the controlled clinical studies of Enstilar Foam, 97 subjects were 65 years and over, and 21 were 75 and over.

No overall differences in safety or effectiveness of Enstilar Foam were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. MAT-32588 March 2020 PRACTICE MANAGEMENT

Instinctively, dermatologists DOS, DON’TS might think it best to slow or stop practice marketing during FOR PRACTICE pandemic shutdowns and MARKETING through the uncertainty. But marketing pro Risa Goldman DURING THE Luksa tells The Dermatology Digest she recommends that PANDEMIC dermatology practices rev up some aspects of their marketing By Lisette Hilton campaigns while limiting others to maximize profit potential and minimize expenses.

“Marketing during this pandemic is extremely important. It is actually more important than ever to have really good, open, transparent lines of com munication with your patients that you can keep updated,” said Goldman Luksa, founder and president of Goldman Marketing Group, a professional consult ing firm specializing in medical marketing and business development almost exclusively to derma tology and cosmetic surgery practices.

Risa Goldman Luksa These extraordinary times call for nimble, impactful marketing approaches, including on practice websites, through social media channels, and by email. “The pandemic has taught us that things change fast and we need to be able to react and pivot quickly, so having all your marketing channels in place to be able to get the message out is more important than ever,” Goldman Luksa said. Hear the full interview at www.thedermdigest.com/ Pandemic marketing may look different pandemic_marketing. During a pandemic or soon in its aftermath, dermatology practices should focus on marketing tactics that offer a quick conversion to potential patients and should put some more expensive longterm branding efforts on hold, according to Goldman Luksa.

January 2021 | 61 For example, print advertising tends to be best for branding a practice and capturing the attention of a specific audience. But it also tends to be expensive and could be put on hold until things ease up. Another way for a practice to reduce the money it spends on marketing is to look at things that cost money and can easily be turned on and off, such as Google Pay Per Click advertising. “If you are not open, are not accepting new appointments, or are booked out for a very long time, Google Ad Words is an easy thing that you can turn off without jeopardizing your long-term success because you could easily turn it back on,” Goldman Luksa said. Embrace innovation and use it to educate Now is the time to virtually educate, do Zoom DO presentations about the latest in at-home skin- The pandemic has taught us that things care, and more, according to Goldman Luksa. change fast and we need to be able to “I think people are looking for virtual opportunities more “react and pivot quickly.” than ever before,” she said. She recommends that dermatology practices offer online Dermatology practices should focus their pandemic booking on their websites and 2-way texting for people who marketing efforts on the lines of communication with want to communicate electronically easily and quickly. their patients. Generally, the 3 best ways to stay in touch Dermatology practices should consider hosting virtual with patients and others are the practice website, email events, since it may be awhile before people feel comfortable marketing, and social media platforms. about indoor gatherings. Practices should make sure their websites are active “I’ve actually seen tremendous success with virtual events, and updated with COVID-19 protocols and other timely with being able to reach a far bigger audience than you ever information. People go to social media platforms and would inside your practice,” Goldman Luksa said. email for immediate information, and practices should use those channels to not only update people but also differentiate themselves. Consider new revenue lines Among the questions to answer: Are you open? What are such as online shopping your COVID protocols? What should patients expect? Why DO There is little downside and much potential for should they feel comfortable still coming to see you? What increasing a practice’s bottom line when offering e-com- is an urgent need requiring an office visit and what can wait? merce skincare solutions, according to Goldman Luksa. What can be done over telemedicine or virtually? Can skincare products be purchased online? Dermatologists can use platforms that do the selling for them or build their own online stores. Practices should make sure their Yelp pages are updated as well as Google My Business and RealSelf. “If patients can shop online for skincare, that can also help you with virtual consults. You can send them products, for Automated communications with patients might need to example, to modify their skincare regimen before or after a be modified during a pandemic. One example: reminders medical procedure or cosmetic procedure in the office,” she to make office appointments at 3 months for cosmetic said. “I definitely think online shopping is here to stay and neuromodulator injections. is worth the investment.”

62 | The Dermatology Digest www.thedermdigest.com/PRACTICE_MANAGEMENT

Market blindly: Measure, measure, measure DON’T Dermatologists who measure their “You don’t want your social media vendor tracking marketing efforts have a clear picture of what works and what separately than your website vendor than someone else doesn’t. And in many cases, measuring is easy. because really they are all working toward the same goal. At the end of the day, the most important statistic is how For example, options in call tracking software use specific many new patient leads you got every month. Then to phone numbers for tracking different marketing tactics. take it a step further, how many of those actually converted All calls go the practice’s front desk. And, at the back end, to become patients?” Goldman Luksa said. practice administrators can log in to see how many people called due to the Yelp page, practice website, print ad, Dermatology practices can track those numbers with radio spot, etc. customer relationship management software and strategic marketing tracking efforts, she said. Programs such as Google Tag Manager and Goals in Google Analytics can track email inquiries and online booking forms. Look at pandemic marketing as key to surviving, thriving DO “I have seen some incredible innovation and I’ve actually seen tremendous success people rising above during the pandemic. You can make with virtual events, with being able yourself stand apart from everyone else,” Goldman Luksa to reach a far bigger audience than you said. “Are you innovating quickly to accommodate social distancing? [Are you accommodating] your patients’ new- “ever would inside your practice.” found needs and desires and their wish lists by rolling out things like online scheduling, ecommerce skincare, texting? If you can do that and keep in touch with patients and help Consider a quarterback ensure that they feel supported … it will definitely come for your marketing plan back 2-fold, 10-fold in the future, when everything does go DO It is important to stay on top of marketing back to normal. I think people are going to remember the efforts, especially during a pandemic when things can stores, vendors, colleagues, the people that stood by them rapidly change. So Goldman Luksa recommends that during the harder times.”  dermatologists delegate the quarterbacking of the mar-

keting plan to someone in the office who can work with Ms. Goldman Luksa can be reached at [email protected]. different vendors, or to an outside professional.

January 2021 | 63 Advanced Topical Therapy

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Research using the proprietary delivery technology is also ongoing to determine the potential for: INNOVATIVE topical skin medications across a diverse pipeline IMPROVEMENTS in the tolerability of topical dermatological drug products NOVEL FIXED-DOSE combinations of 2 otherwise incompatible drug substances to be delivered in the same formulation

See how Sol-Gel is transforming topical treatment www.Sol-Gel.com/technology @SolGelDerm

By Ted Rosen, MD, FAAD, Editor-in-Chief

CASE HISTORY

A previously healthy 70-year-old white woman, a retired insurance agent, presented with influenza- like symptoms and an eschar on her nose shortly after completing a 2-week-long tour of South Africa. During her trip, she denied visiting any other African country, and said she had visited urban, rather than rural, destinations. She did go on a full-day photographic safari, but never TED ROSEN, MD, FAAD walked in the high grasses surrounding the safari vehicle. One interesting stop was a visit to Editor-in-Chief a kennel that bred and exported dogs native to the region (Boerboels and Rhodesian Ridgebacks). Six days after the patient returned to the United States, she developed fever (documented to 102.4∘F), chills, headache, and diffuse myalgia. Shortly thereafter, she noticed a faint rash on her palms and soles and a large, tender pustule on her nose. She presented to her dermatologist 9 days after her return from Africa because the nasal pustule had evolved into an unsightly eschar (Figure 1). She did not recall an overt insect bite or anyone else from the group with similar symptoms while still in, or on the way back from, South Africa. She had no other notable medical problems and did not take any medications. She was a non-smoker, non-drinker and did not use illicit drugs. She denied any sexual activity for at least 6 months before the trip and during the excursion. Past medical history was significant only for many actinic keratoses and several basal cell carcinomas. Laboratory studies disclosed an increased white blood cell count of 12,800 cells/mm3, but all other routine labs were within normal limits. RPR was non-reactive. She refused a skin biopsy.

What is your differential diagnosis? FIGURE 1.

For more on this case, turn to page 48 

January 2021 | C3 we are committed to the relentless pursuit of science that can improve the lives of patients and make a difference in healthcare.

In Dermatology, our research and development efforts are focused on immune-mediated dermatologic conditions with a high, unmet medical need, including atopic dermatitis, vitiligo, and hidradenitis suppurativa.

To learn more, visit Incyte.com/dermatology and stay in touch