DermNewsletter of the American OsteopathicLine College of Dermatology Winter 2018 Vol. 34, No. 1

Message from the President Dear AOCD members and friends, The New Year brings new beginnings and resolutions. The Board of Trustees is working behind the scenes on many important initiatives that I would like to share with you. First, the AOCD is exploring ways to reinvent ourselves in the upcoming era where our osteopathic specialty organizations no longer proctor residency training, under the ACGME “merger”, formally known as the Single Accreditation System. While overall, there are benefits to streamlining the education of future dermatologists, many fear that our osteopathic uniqueness will be lost. I believe that the osteopathic core principles will survive the house of medicine during this merger (it’s a two-way street, right), however it takes each and every one of us to remember our roots and continue to practice Dr. Still’s principles every day. It’s not just about manual manipulation, it’s also about the philosophy; the philosophy that makes the “DO Difference”. We must actively share as many of these values with our allopathic colleagues as we can, so that these principles permeate; it is about improving patient care and outcomes, after all. I encourage all of us to remember our roots and spread our knowledge, as this is the only choice we have to keep our specialty alive. The AOA is also exploring options for survivability, many of which include taking over administration of struggling specialty colleges membership and finances. The AOCD opposes this course of action, as we have made great strides in improving our CME offerings tailored to the practicing dermatologist and in no way view our college as struggling! The AOCD Board will be meeting later this month to discuss the new avatars of the AOCD. The foci will be creating the best CME meeting out there (get ready for the unveiling of TED talk style CME lectures) and community services. In these times, it’s best not to reinvent the wheel and divide resources. Instead the AOCD will actively partner with our sister organizations like the AAD, state societies, etc, on initiatives that they are already doing well such as advocacy and PAC’s. Most recently, the AOCD partnered with the AAD, FSDDS, ISHRS, and the ASDS to oppose legislation allowing electrologists to perform laser hair removal without physician supervision. We also joined the AOA and the NY State Osteopathic Society in supporting legislation banning the use of tanning devices in minors. These are the types of relationships I hope to continue building as there is a stronger voice in numbers and solidarity, and we all have something to offer each other, our members, and our patients. If you’re interested in seeing our advocacy projects, click here to browse our archive of letters from 2013 to present. I encourage you all to attend the upcoming meeting in West Palm Beach, marking our 60th Anniversary Celebration, to be commemorated with a Casino-themed night. Dressing the part is absolutely a must! Also, I believe the CME offerings and debut of the TED talks style will be out of this world. Finally, we will be offering the Florida required hours on Sunday. Hope to see you In this issue... all there! AOCD 60th Anniversary Commemorative Karthik Krishnamurthy, DO, FAOCD Yearbook Preview...pages 4-10 2017 AOCD Fall Meeting Highlights ...pages 17-49 Line DermNewsletter of the American Osteopathic College of Dermatology Board of Trustees Executive Director’s Report PRESIDENT by Marsha Wise, Executive Director Karthik Krishnamurthy, D.O., FAOCD PRESIDENT-ELECT Happy New Year Everyone! Daniel Ladd, D.O., FAOCD FIRST VICE-PRESIDENT 2017 is behind us and 2018 is here. It is AOCD’s 60th John P. Minni, D.O., FAOCD Anniversary year and we have some new, fresh, and exciting SECOND VICE-PRESIDENT changes and events happening this year. Join us in West Palm Reagan Anderson, D.O., FAOCD Beach for our Spring Meeting, March 21-25 and help the THIRD VICE-PRESIDENT AOCD celebrate. Our Celebration Gala on Friday, March David Cleaver, D.O., FAOCD 23 will be a “Casino Night”. Try your luck at the tables and IMMEDIATE PAST-PRESIDENT take home your own Casino Night Survival Bag sponsored by Alpesh Desai, D.O., FAOCD Aurora Diagnostics. If the game tables aren’t your thing, have TRUSTEES Danica Alexander, D.O., FAOCD your palm read, enjoy the DJ and live music, or grab your Steven Brooks, D.O., FAOCD friends and colleagues and visit the Photo Booth. Jonathan Crane, D.O., FAOCD Peter Saitta, D.O., FAOCD Amy Spizuoco, D.O., FAOCD Of course this meeting isn’t just for having fun. We have some serious CME sessions taking Michael Whitworth, D.O., FAOCD place, which includes the Florida Requirements Course on Sunday, March 25. SECRETARY-TREASURER Steven Grekin, D.O., FAOCD Take home your copy of the Anniversary book which you can pre-order now. In the next few EXECUTIVE DIRECTOR pages, you will find a little sneak peek. Marsha A. Wise, B.S. Editorial/Public Relations Committee May this New Year brings you a peace filled life, warmth and togetherness in your family and much prosperity! Happy New Year! CHAIR David Cleaver, D.O., FAOCD DERMLINE EDITOR Danica Alexander, D.O., FAOCD DERMLINE ASSOCIATE EDITOR Marsha Wise In Memoriam: MEMBERS Danica Alexander, D.O., FAOCD Jason Green, D.O., FAOCD Tracy Favreau, Susun Kim, D.O., FAOCD Albert Rivera, D.O., FAOCD Lawrence Schiffman, D.O., FAOCD DO, FAOCD Dustin Wilkes, D.O., FAOCD The American Osteoapthic College of

Corporate Partners Dermatology was deeply saddened to DIAMOND learn of the passing of Tracy Favreau, Galderma Laboratories Pfizer DO, FAOCD. Dr. Favreau passed PLATINUM away the morning of December 11, Lilly USA, LLC 2017 in Fort Lauderdale, FL. Dr. GOLD Favreau earned her medical degree AbbVie Valeant Pharmaceuticals from NOVASE in 2001. She completed Bronze her dermatology residency at NSUCOM/North Broward Hospital District, Allergan Dermatopathology Laboratory of Central States eventually serving as the director of the program from 2013 to 2015. Pearl Dr. Favreau was an active member of the AOCD, serving on a number of Aclaris Therapeutics, Inc. Dermpath Diagnostics committees, including the Board of Trustees from 2013 until 2017. Her service Novartis also included a terms on the Nominating Committee (2009-2010), the Program Sun Dermatology Director’s Committee (2013-2015) and the Public Relations Committee (2010- Contribute to DermLine 2017). In addition, she was a member of the Foundation for Osteopathic If you have a topic you would like to read about or an article you would like to write for the next issue of Dermatology’s Ulbrich Circle. DermLine, contact Marsha Wise by email at [email protected] or John Grogan at [email protected]. A blood drive will be held in her honor at the 2018 Spring Meeting on Friday, American Osteopathic College of Dermatology March 23 from 10:30 a.m. - 4:00 p.m. Click here to reserve a time slot if you P.O. Box 7525 would like to donate. 2902 N. Baltimore St. Kirksville, MO 63501 Our thoughts remain with her family, friends, past residents and colleagues Office: (660) 665-2184 | (800) 449-2623 Fax: (660) 627-2623 during this difficult time. She is missed. Web: http://www.aocd.org http://www.aobd.org

MILESTONES OF THE AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY

1957 An American Osteopathic 1960 July: It was voted to move 1964 October: Dr. Koprince and College of Dermatology (AOCD) annual meeting to be held in Dr. Elmets were both elected to the organizational meeting was held. conjunction with the American AOBD for three-year terms. The AOCD begins work to gain 501(c)(3) status. Dr. A. P. Ulbrich was elected Osteopathic Association (AOA). president. 1965 September: Members were 1961 January: The By-Laws divided into two membership 1958 The new American Committee was created. categories: Active and Affiliate. Osteopathic Board of Dermatology (AOBD) gave their first 1962 January: College newsletter 1966 November: Member certification exam in the fall of planned to be written on quarterly recruitment was the hot topic. 1958, in Washington, DC. Eight basis. applicants took the exam and all 1967 October: AOA control over passed. There were twenty-one 1963 January: Twenty-four active the osteopathic profession was board-certified members. members. Cash, $1,271.97. discussed. The board exam fee was October: Meetings began to be $200. Cash on hand, $2873.19. 1959 July: Only preceptorships held twice a year. Dr. Daniel were available to osteopathic Koprince was elected as secretary- 1968 February: The AOCD physicians for training. Cash in treasurer. began the process of attaining bank, $732.23. 501(c)(3) non-profit organization status. October: Cash on hand, $4534.87.

30 AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY 60TH ANNIVERSARY COMMEMORATIVE YEARBOOK 31 Page 4 MILESTONES OF THE AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY

1957 An American Osteopathic 1960 July: It was voted to move 1964 October: Dr. Koprince and College of Dermatology (AOCD) annual meeting to be held in Dr. Elmets were both elected to the organizational meeting was held. conjunction with the American AOBD for three-year terms. The AOCD begins work to gain 501(c)(3) status. Dr. A. P. Ulbrich was elected Osteopathic Association (AOA). president. 1965 September: Members were 1961 January: The By-Laws divided into two membership 1958 The new American Committee was created. categories: Active and Affiliate. Osteopathic Board of Dermatology (AOBD) gave their first 1962 January: College newsletter 1966 November: Member certification exam in the fall of planned to be written on quarterly recruitment was the hot topic. 1958, in Washington, DC. Eight basis. applicants took the exam and all 1967 October: AOA control over passed. There were twenty-one 1963 January: Twenty-four active the osteopathic profession was board-certified members. members. Cash, $1,271.97. discussed. The board exam fee was October: Meetings began to be $200. Cash on hand, $2873.19. 1959 July: Only preceptorships held twice a year. Dr. Daniel were available to osteopathic Koprince was elected as secretary- 1968 February: The AOCD physicians for training. Cash in treasurer. began the process of attaining bank, $732.23. 501(c)(3) non-profit organization status. October: Cash on hand, $4534.87.

30 AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY 60TH ANNIVERSARY COMMEMORATIVE YEARBOOK 31 Page 5 The first annual AOCD residents’ forum in 1978 included lectures from Drs. Howard S. Dr. James Bernard with Dr. Walter Willis. Kessler, Laurie M. Woll, and Charles G. Hughes.

1969 October: The AOCD 1973 October: Membership dues 1977 November: Holding donated $1,000 to the financially increased to $40. a midyear meeting seminar struggling AOBD to support the was approved. Cash on hand, Certifying Exam Committee. 1974 September: There were $16,939.38. forty-two members. Dr. Koprince 1970 October: The College’s served on the Program and 1978 October: A Life membership in the AOA was Trainee Review Council (PTRC). membership category was created. discussed and tabled. 1975 November: Seven candidates 1979 November: Dr. James 1971 November: The AOCD took the AOBD exam. Bernard was elected secretary- voted to reincorporate/reorganize treasurer. There were sixty-eight and move headquarters from 1976 November: Holding a members. California to Illinois. midyear meeting was discussed. 1972 October: The AOCD voted to stay in California. There were thirty-three active members.

32 AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY 60TH ANNIVERSARY COMMEMORATIVE YEARBOOK 33 Page 6 The first annual AOCD residents’ forum in 1978 included lectures from Drs. Howard S. Dr. James Bernard with Dr. Walter Willis. Kessler, Laurie M. Woll, and Charles G. Hughes.

1969 October: The AOCD 1973 October: Membership dues 1977 November: Holding donated $1,000 to the financially increased to $40. a midyear meeting seminar struggling AOBD to support the was approved. Cash on hand, Certifying Exam Committee. 1974 September: There were $16,939.38. forty-two members. Dr. Koprince 1970 October: The College’s served on the Program and 1978 October: A Life membership in the AOA was Trainee Review Council (PTRC). membership category was created. discussed and tabled. 1975 November: Seven candidates 1979 November: Dr. James 1971 November: The AOCD took the AOBD exam. Bernard was elected secretary- voted to reincorporate/reorganize treasurer. There were sixty-eight and move headquarters from 1976 November: Holding a members. California to Illinois. midyear meeting was discussed. 1972 October: The AOCD voted to stay in California. There were thirty-three active members.

32 AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY 60TH ANNIVERSARY COMMEMORATIVE YEARBOOK 33 Page 7 The incoming president, Charles Hughes, DO, presents a 1983–1984 AOCD officers, left to right: Joel Harris, DO; William plaque to the outgoing president, Roger Byrd, DO. Heckert, DO; Dudley Goetz, DO; Charles Hughes, DO; and James Bernard, DO.

1984 Minutes are missing from 1984.

1985 November: Executive Director Cathy Garris was hired for the AOCD.

1980–1982 Minutes are missing 1986 February: The AOCD Original letter from Dr. Steven Roberts selecting the winners of the first Koprince Awards in 1987. from 1980 to 1982. was incorporated in the state of Georgia. 1983 October: Discussion began November: The Dr. Daniel on hiring an executive director. Koprince Education Award was There were eighty-three members. established. Dr. A. P. Ulbrich announced his intent to retire after fifty years.

The AOCD’s first executive director, Cathy Garris, pictured with James Del Rosso, DO. The Koprince family, left to right: Janet Koprince, DO; Daniel Koprince, DO; and Mrs. Helen Koprince.

34 AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY 60TH ANNIVERSARY COMMEMORATIVE YEARBOOK 35 Page 8 The incoming president, Charles Hughes, DO, presents a 1983–1984 AOCD officers, left to right: Joel Harris, DO; William plaque to the outgoing president, Roger Byrd, DO. Heckert, DO; Dudley Goetz, DO; Charles Hughes, DO; and James Bernard, DO.

1984 Minutes are missing from 1984.

1985 November: Executive Director Cathy Garris was hired for the AOCD.

1980–1982 Minutes are missing 1986 February: The AOCD Original letter from Dr. Steven Roberts selecting the winners of the first Koprince Awards in 1987. from 1980 to 1982. was incorporated in the state of Georgia. 1983 October: Discussion began November: The Dr. Daniel on hiring an executive director. Koprince Education Award was There were eighty-three members. established. Dr. A. P. Ulbrich announced his intent to retire after fifty years.

The AOCD’s first executive director, Cathy Garris, pictured with James Del Rosso, DO. The Koprince family, left to right: Janet Koprince, DO; Daniel Koprince, DO; and Mrs. Helen Koprince.

34 AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY 60TH ANNIVERSARY COMMEMORATIVE YEARBOOK 35 Page 9 American Osteopathic College of Dermatology 60th Anniversary Commemorative Yearbook

Oh the places we’ve been and the places we’re going! The AOCD is celebrating our 60th Anniversary in 2018. To honor this milestone, a special edition commemorative yearbook is being prepared. This book will be a tribute to AOCD’s past, filled with historical information and photos and will contain a membership directory. This hardcover edition will be dedicated to all members in recognition of their contribution to dermatology and osteopathic medicine. A true keepsake you will be proud to display in your home or office. PRE-ORDER YOUR COPIES NOW! • Pre-Order your copies now for 40.00* each by Feb 1, 2018 • Also available on our online store at www.aocd.org * Price at meeting $50.00 ORDER FORM Please fill out and return with payment Please make checks payable to: Organization/Name

Address AOCD

City State Zip Quantity Phone S&H $10.00 per copy Email Total Due Members and Corporate friends are also invited to take part in this historic event by purchasing ad space to place an ad or a congratulatory note. Sizes available: Business Card (3 ½” W x 2” H) $150.00 Quarter Page (3 5/8” W x 5 3/8” H) $250.00 Half Page (7 ½” W x 5 3/8” H) $400.00 Or order online at Full Page (7 ½” W x 9 7/8” H) $800.00 www.aocd.org Contact the AOCD office for more information on ad placement. Corporate Spotlight By Shelley Wood, MaE, Administrative Grants Coordinator Corporate Sponsors Support 2017 AOCD Fall Meeting, New Orleans I appreciate having had the Biotech, Inc., Leo Pharma, Lilly USA, LLC, Novartis, Pfizer/ opportunity to thank several of Eucrisa, ProPath Services LLP, Sagis Diagnostics, Sensus Healthcare, our corporate sponsors for their Sun Dermatology, Tiemann Surgical, and Valeant Pharmaceuticals continued support of the College and to welcome new exhibitors at We hope that many of you had an opportunity to express your the 2017 AOCD Fall Meeting. The appreciation to our sponsors while you were in New Orleans. The AOCD is very fortunate to have fact that they continue to support the College, many of them corporate sponsors who join us as doing so for several years, speaks volumes about the value of their partners with a commitment to medical excellence. Our corporate commitment to our organization. sponsors remain committed to the College and continuing medical education (CME). It goes without saying that our corporate This year we asked attendees to let us know who had the best sponsors are critical to helping us accomplish our mission. customer service, was the most informative, and had the best display. We had several ties for these topics. The companies New and returning corporate sponsors are as follows: and booth attendees are listed below. Congratulations to these • Galderma, Pfizer (Diamond Level) companies and booth attendees. • Lilly USA, LLC (Platinum Level) • AbbVie, Valeant Pharmaceuticals (Gold Level) Best Customer Service Exhibit Booth • Allergan, DLCS (Bronze Level) Galderma Laboratories was voted as the “Best Customer Service” • Aclaris Therapeutics, Dermpath Diagnostics, Novartis, Sun at our Fall 2017 Current Concepts in Dermatology meeting in Dermatology (Pearl Level) New Orleans, LA. Representatives from Galderma Laboratories in attendance were Chris Townsend. The past couple of meetings, Sagis Diagnostics has sponsored our meeting lanyards. We would like to thank Dr. Cangelosi and his Most Informative Exhibit Booth crew for this sponsorship. Sun Dermatology received the most attendee votes as the “Most Informative Exhibit” at our Fall 2017 Current Concepts in The AOCD also appreciates Janssen Biotech, Inc., Lilly USA, LLC, Dermatology meeting in New Orleans, LA. Representatives from Novartis, Allergan, and Pfizer for providing Product Theaters for Sun Dermatology in attendance was Todd Bishop. our physicians. Best Exhibit Booth Display Exhibitors for the 2017 Fall Meeting were as follows: 3Gen, Galderma Laboratories and AbbVie tied as the “Best Exhibit Inc., AbbVie, Advanced Dermatology, Allergan, AOBD, Aurora Display” at our Fall 2017 Current Concepts in Dermatology meeting Diagnostics, Bayer Healthcare, Biofrontera, Inc., Brymill, Celgene, in New Orleans, LA. Representative from Galderma Laboratories Daavlin Company, DermOne, Dermpath Diagnostics, Encore in attendance was Chris Townsend. Representatives from AbbVie in Dermatology, EZDerm, Galderma Laboratories, Genentech, Janssen attendance were Tom Spooner, Kelley McWhirter, and Robin Berrett.

Confessions of a Dermatology Resident By Laura Jordan, DO We are now knee-deep in interview season. Sifting through piles of applicants, coaching our dermabees as it is their time to shine this year. Though it may have only been a few short years ago that we were in the same boat, it feels like decades. We were preoccupied with the idea of matching into derm so much that it became easy for many of us to lose perspective. Family, friends, our own health became secondary to this ultimate goal. How many holidays did we miss while interviewing, how many dental appointments postponed, and how much did Facebook seem like your arch nemesis as you saw other friends having fun? We made so many sacrifices to be the ones who now sit on the other side of the table, asking those questions we dreaded hearing… “Tell us about yourself”—a.k.a. “Try to sound human, and don’t recite your resume or ramble on in a tangential fashion for hours.” Seems so easy thinking about it now, but how hard it was back then when it felt like your entire future was on the line. So take a sip of that hard-earned cup of coffee as you sit before the incoming interview crew, and try to cut them a little slack remembering what it was like not so long ago 

Page 11 Resident Liaison Update By Brittany Hearn, D.O. Dear colleagues, ABD’s Exam of the Future For those of you in programs who are or are planning on becoming Happy holidays! I hope everyone has ACGME accredited, there is a new structure for the certifying had a great first half of the academic exam. Many of you have had questions regarding this new structure. year. Remember to enjoy this time Click here to learn more about the exam structure. The BASIC before the new year. We will be back Exam for 1st year dermatology residents will take place on Thursday, in the thick of things in no time! April 12th, 2018. The Online Practice Exam for nd2 & 3rd year dermatology residents will take place in a window between March Here are some updates for the 1-30, 2018. This exam can be either remotely or locally proctored. upcoming year: If there are any questions regarding the new format & how it will affect you, please e-mail me for more information. AAD Annual Meeting The AAD annual meeting will be held in sunny San Diego, CA If you are in a program that is not becoming ACGME accredited, from Feb 16-20, 2018. Discounted registration is currently open the AOCD is planning on offering an In-Training Exam. Stay tuned for residents/fellows at a rate of $215.00. Registration, housing for those details! & travel, and general information about this meeting can all be found at by clicking here. Board Review Attention 3rd year residents! Whether you plan on taking the AOBD, Remember to also register for Life After Residency: A Toolkit for ABD, or both exams, “board season” will soon be upon us. Remember Success! This popular program will take place Thursday, Feb 15, to take advantage of the most popular board review sessions throughout 2018 (the day preceding the annual meeting). It is geared towards the Spring. Registration is now open for the following: 2nd and 3rd year residents. To attend, you must register separately • Conquer the Boards: An Experiential Review- San Diego, CA- from the AAD annual meeting, but registration is absolutely free! Feb 16th, 2018 9:00 a.m. - 4:00 p.m. - $110 (You must be Please click here for more information. registered for the AAD Annual meeting to attend) • Barron Board Review- Rosemont, IL- April 20th - 22nd, 2018 - $375 AOCD Spring Meeting • Florida Dermatology & Dermatopathology Board Review The AOCD spring current concepts in dermatology meeting & 60th Course - Tampa, FL- May 10th - 13th, 2018 - $800 anniversary celebration will be held in sunny West Palm Beach, FL from March 21-25, 2018. Information regarding accommodations As always, if you have any questions, comments, or concerns & meeting schedule can be found on the AOCD website. There will I can be reached at the AOCD resident liaison email account: be a new format for this meeting which includes expert speakers, [email protected]. Have a happy holiday TED talk inspired lectures, and practice management revelations. season & a great new year! See you all in 2018! Click here for more details!

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If you are a US medical doctor with an active state license number, the value of the food, beverage, and/or educational item that you receive when attending this program may be disclosed on Eli Lilly and Company’s Physician Payment Registry and/or the National Physician Payment Transparency Program (NPPTP) Open Payments report under the federal Sunshine Act as a transfer of value made to you by Lilly. As a result of enacted state regulations, food and beverages will not be provided to healthcare professionals licensed in the states of Minnesota, Massachusetts, and Vermont. Additionally, educational items will not be provided to healthcare professionals licensed in Minnesota. Federal Veterans Affairs (VA) regulations and several states also prohibit state/government employees from receiving or being provided gift items, which may include educational materials and meals. Please consult your state regulations and ethics laws to see if such prohibition would apply to you. This medical presentation is intended only for invited healthcare professionals for whom the information to be presented is relevant to their practice. We regret that spouses or other guests cannot be accommodated. This is a promotional program and no continuing medical education (CME) credits are offered.

Taltz® is a registered trademark of Eli Lilly and Company. PP-IX-US-0377 03/2016 ©2016, LILLY USA, LLC. ALL RIGHTS RESERVED. Residents Update By John Grogan, Resident Coordinator Hello everyone, any extent by a pharmaceutical company or other commercial enterprise, should include a clear acknowledgment stating Happy New Year to all! I hope 2018 that a portion of its cost was underwritten and identifying the is off to a great start for each of you particular commercial company involved. and you all enjoyed a happy and • Trade name violations or failure to disclose commercial support safe holiday season with family and will result in the poster being denied acceptance for this AOCD friends. requirement. • The poster is to be submitted to the AOCD electronically, It was great to see all of you who you do not need to print a copy of the poster to bring to the were able to attend the Fall Meeting meeting. Simply submit the poster as a Powerpoint file. in historic New Orleans. I hope you found value in the lectures presented 2018 Dermatology Grand Rounds Schedule and had a great time in the Big Easy. A special thanks to Cassandra Each residency program, once again, is asked to provide a case for Beard, DO; Shane Swink, OMS-IV; and Rachel Giesey, OMS-IV, the Grand Rounds website. Click here to visit the Dermatology our student ambassadors for the Fall Meeting. They each did an Grand Rounds on our website. Please contact me for the sign-on outstanding job, going above and beyond, to help put on a great information to submit a case. The 2018 schedule is as follows: meeting. • January 5, 2018 • OPTI-West/Chino Valley Medical Center 2018 Resident Membership Renewal • February 5, 2018 With a new membership year approaching, it’s not too early to • Still OPTI/Northeast Regional Medical Center begin thinking about renewing your annual dues. These can be • March 5, 2018 paid online through your member account at www.aocd.org. You • PCOM/Lehigh Valley Health Network can quickly and conveniently renew your membership online using • April 5, 2018 these five easy steps: • CORE/O’Bleness Memorial Hospital 1. To get started, click sign in at the top of the homepage. • SCS/MSUCOM/Botsford Hospital 2. Enter your username and password, and click sign in. [Note: • May 5, 2018 If this is your first time signing in, you will be taken to a • LECOMT/Larkin Community Hospital Palm Springs screen prompting you to verify your member profile options. Campus Make any desired changes, click the Save Settings button, and • SCS/MSUCOM/Oakwood Southshore Medical Center proceed to Step 3.] • CEME/Palm Beach Consortium for GME 3. Click the yellow *** Renew Your Membership Now *** banner • June 5, 2018 4. You will be prompted to update your contact information. • NYCOMEC/St. Barnabas Hospital If you have any changes, enter updated information in the • LECOMT/St. John’s Episcopal Hospital appropriate field. When finished, click the Save Changes • July 5, 2018 button. • NSUCOM/Largo Medical Center 5. Enter your billing and payment information, and click the • Texas OPTI/UNTHSC Submit Securely button. If you have any problems logging in, • August 5, 2018 please contact us and we will help you. • PCOM/North Fulton Hospital Medical Campus • OMNEE/Sampson Regional Medical Center 2018 Spring Meeting 2nd Year Resident Posters • NYCOMEC/Palisades Medical Center Residents are required to submit a poster during the second • September 5, 2018 year of training at the Spring Meeting. This year, posters are due • MWU/OPTI/Advanced Desert Dermatology February 14, 2018. A completed poster submission forms [www. • MWU/OPTI/Affiliated Dermatology aocd.org/resource/resmgr/annualreports/poster-abstract-info.pdf] • October 5, 2018 must accompany your poster. A few things to keep in mind when • Texas OPTI/South Texas Osteopathic Dermatology preparing your poster: • NSUCOM/Larkin Community Hospital • This poster is an individual submission, not a group project. • Texas OPTI/Bay Area Corpus Christi Medical Center • If you are required to prepare a poster for your program, you • November 5, 2018 may submit a copy of that poster to meet this requirement. • OPTI-West/Aspen Dermatology If your program does not have this requirement, you should • SCS/MSUCOM/Lakeland Regional Medical Center follow the poster guidelines for either the AAD or the AOA in • December 5, 2018 preparing this poster. • OMNEE/LewisGale Hospital – Montgomery • Please submit completed copies of the Poster Submission Form • OPTI-West/Silver Falls Dermatology and Faculty Disclosure Form, along with your poster. • RMOPTI/Colorado Dermatology Institute • Avoidance of Commercialism: All poster exhibits must • OMNEE/Park Avenue Dermatology avoid commercialism. No trade names should be used for drugs, devices and/or instrumentation, including lasers. Any I look forward to seeing you all in West Palm Beach for the 2018 medications or other substances referred to in the presentation Spring Meeting. material must be identified by their scientific names only. In addition, poster exhibits, the cost of which is underwritten to

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2018 Fall Meeting Venue Offers Numerous Amenities, Entertainment and Shopping Options by Kristin Ayer Welcome back to our latest edition of looking to get some work done, the Tangent at of souvenir shops, cafes, coffee shops, burger DermLine! We have a few upcoming Westin is a 24/7 business center can be booked eats, a wine tasting room and even a cupcake meetings in excellent locations, where you to make your stay a bit more productive. shop—who doesn’t love cupcakes? What can come to earn your CME credits during else could you possibly ask for to create a the day and then venture out into the city for For attendees wanting to spend some time wonderful, relaxing, yet exciting adventure fun evenings of dining, shopping and events. away from the hotel in the evenings, the after a long day sitting in the classroom? Westin is located near incredible dining and Our Midyear Fall Meeting will be held in shopping experiences. The Westfield Horton Hopefully this has gotten the gears turning San Diego, CA at the Westin San Diego, Plaza is a shopping spot that has something with a few ideas for things to keep you busy Gaslamp Quarter. Their contact information for everyone. Their website is a great tool during our Midyear Fall Meeting in October will be listed below for your convenience. for planning out your trip to the Westfield 2018. The AOCD staff is working very Be watching our Facebook page and your Horton Plaza and lists the open hours and diligently to enhance your CME experience Thursday Bulletin emails for the group code also movies they have playing. Whether you and also to make AOCD meetings the to use when booking your hotel stay to are searching for new luggage, a new bedding meeting you look forward to attending. ensure you get our discounted rate. set or a new pair of blue jeans, the Westfield We are always open to suggestions and Horton Plaza is the place to start. constructive feedback. Email Kristin at The Westin San Diego looks to be a modern, [email protected] if you have anything luxurious beach hotel with a slew of amenities. Another great spot to spend a few hours you would like us to hear. Until next time! There is a high-end fitness studio open 24/7, at would be the Seaport Village. It has with cardio equipment, free weights and iPod 45 shops and stores right on the beach, as Westin San Diego, Gaslamp Quarter stations for the best workout away from home. well as a carousel and other family-friendly 910 Broadway Circle The Pure Body Spa features an outdoor pool attractions. This is definitely the type of place San Diego, CA 92101 and whirlpool, and professionally trained body to check out if you are wanting to venture (619) 239-2200 care specialists offering an array of treatments somewhere a bit less conventional than the for your relaxation. However, if you are mall atmosphere. Fresh ocean breeze, tons CME Cycle News Since 2018 is the last year in the current Physicians who register and stay for the to get this. The number of CME credits CME cycle, members should check their Sunday session that will be an extra 5, for a offered for this joint session have not yet CME reports regularly!! total of 35 Category 1A. been finalized. Details will be forthcoming.

To verify the CME requirement for your Fall 2018 in San Diego will have 25 in A maximum of 62 Category 1A CME will state, visit the Federation of State Medical person CME, with up to two extra credits be offered in 2018. To receive the maximum Boards, which was updated January 1, 2018. available for completing a post-test and amount of CME attendees must be present outcomes survey, for a grand total of 27 for all didactic sessions and participate in The 2018 Spring Meeting in West Palm will Category 1A CME credits available for the post-test and outcomes evaluations after have 28 in person CME, with up to two didactics held October 11-13. the meetings. extra credits available for completing a post- test and outcomes survey, for a grand total There will also be a joint session at OMED Additionally, the AOCD offers Category 1B of 30 Category 1A CME for Wednesday in San Diego on October 9, 2018. Please credit for reading the JAOCD and taking the through Saturday didactic sessions note you must register separately with AOA quiz. Click here to view all available quizzes.

The AOCD is exploring a potential partnership with the skin cancer prevention non- profit, The Shade Project. This organization helps to educate the public on skin cancer prevention, encourages annual skin checks by a dermatologist and promotes physical shade structures in schools and parks. For more information please contact Interim Executive Director Diane Morgan at [email protected]

Page 15 Innovation Spotlight Dr. Schreiber Shapes Future Medical Professionals Through Robust Student Program by Meghan McLaughlin

Las Vegas is often thought of as a land of gambling, nightlife and bright lights. But for Saul Schreiber, DO, it has served as the perfect place to shape future medical professionals. Located just one mile off the Las Vegas Strip, Dr. Schreiber’s practice, Advanced Dermatology, offers opportunities for high school, pre-med, medical assistant, medical and physician assistant students to gain experience in a medical setting. In practice for 31 years, Dr. Schreiber has valued helping students from the beginning.

“There are maybe 10,000 dermatologists in the United States, and only 250 are entering the field each year,” says Dr. Schreiber. “Real knowledge of dermatology is essentially esoteric and something that only a small group of people have. Why wouldn’t I want to share that?” Providing hands-on experiences to students is not the only way that Today, Dr. Schreiber’s student program has grown to become an Dr. Schreiber is giving back to the medical community. He recently essential part of his practice, with anywhere from five to ten students in went on a medical mission with the WE Charity to Maasai Mara, the office on a given day. High school students often assist with front- Kenya. While there, he and 17 other practitioners treated over 400 and back-office responsibilities, while pre-med students often help set patients at a clinic and screened over 700 children from two schools. up for surgeries. Medical students are given a high level of responsibility as they assist with surgeries, provide on-the-spot medical research “I think I’ve had an amazing career in medicine,” says Dr. Schreiber. during appointments, and gain extensive documentation training. “It gives you a really good feeling to do good with the knowledge Additionally, Dr. Schreiber has didactic sessions and delivers lectures to and skills that you have. And when you’re at a point in your life medical students whenever there is a spare moment in the busy day. when you have more yesterdays than tomorrows, what’s the point in keeping that knowledge to yourself?” “I feel honored and privileged if a student wants to be in my office,” says Dr. Schreiber. “I definitely notice the days when there Innovation Spotlight is a new DermLine column focusing on projects are fewer students.” AOCD members are developing. If you have a new and innovative idea or project, such as an app, device or research that you would like Dr. Schreiber and his staff are not the only ones who appreciate to feature in the column, please contact [email protected]. This having students in the office. His patients do, too. Because Las column is for informational purposes only. AOCD does not endorse Vegas has a very large Hispanic population, Dr. Schreiber often sees any products featured by Innovation Spotlight and receives no payment patients who speak little English. And typically, students who come in exchange for inclusion. All projects submitted for consideration are to Dr. Schreiber from the Vegas area are bilingual. subject to review and approval by the AOCD editorial committee.

“We speak Spanish in the office a good portion of the day so that we This story originally appeared in the Summer 2017 issue of can provide a quality experience to all patients,” says Dr. Schreiber. PCOM Digest Magazine. Republished with permission, courtesy “I really need to have bilingual employees and students in the office Philadelphia College of Osteopathic Medicine and PCOM to make sure that happens.” Digest Magazine. HELP WANTED Opportunity in Delaware Busy dermatology office with four great locations. Seeking full time Dermatologist to join our practice for any of our locations. For more information on the opportunity and to learn how to apply please contact Burke Dermatology by phone at (302) 230-3376 or by email at [email protected].

Page 16 2017 AOCD Fall Meeting Highlights By Cassandra Beard, DO; Rachel Giesey, OMS-IV Shane Swink, OMS-IV; & Laura Jordan, DO

Practical Pearls in Dermatologic Surgery • Works on intact mucous membranes Edward H. Yob, DO, FAOCD • Syringe with protective barrel • Can reuse if not clicked into place • Lidocaine shortage • Factory in Puerto Rico hit by hurricane • Does not appear to be a shortage of dental cartridges; can buy dental administrators from Amazon for about $6 • Magnification • Can be useful for surgeries • Can also be used by medical assistants to help remove sutures • Eye shields • Do not use metal shields during surgeries requiring cautery • Yellow plastic shields protect patients’ eyes yet allows them to see; come with knob on outside to easily remove them • Use lubricant, do not use if contacts in place • “I use these in the case that if you may jump during surgery, I won’t poke you in the eye” • Laundry • Q-Tips • Easier than doing inventory and dealing with outside business • Can point in pictures • Bosch condensation dryer • Can dab in surgeries • Hypafix tape • When saturated, squeeze with gauze and reuse to reduce time • Stays in place very well • Suction • Can be cut into desired shape • Complicated cases where a need may be anticipated • Co-flex • Helps visualization • Coban • Stationary thermal cautery unit • Almost always latex free anymore • Safe for defibrillators or implants • Remember to pad both ears if wrapping head • Delasco skin marking ink • Glass-cocked ear dressing • Poured into medicine cup on table and used to mark specimens • Used by plenty of ENTs • Sewing magnet or other magnet • Held on with Velcro • Helps find needles when lost in a field, on the floor, on a • Put over bandage to protect ear while sleeping tray, etc. • Sling • Grip-it pen holder • After hand and arm procedures • Placed on the side of microscope to always keep pen nearby • Prevents people from bumping into patient post-op • Distraction technique • Prevents patient from swinging arms and hitting it on something • Some sort of vibrating device to negate the pain of • Telfa dressings with adhesive tape anesthesia injection • Doesn’t require tape • Shaking hands at end of meeting • Good for simple dressings • If hand is wet and clammy, to know if they are about to • Dental Rolls pass out • Shield sharp instruments • Keep ammonia inhalants nearby! Tape them to the paper • Prevents sharp instruments from poking holes in peel packs towel dispenser • Pressure points within dressings • Ice packs • Reinforce pressure on flaps as opposed to periosteal suture • Wet towel, place in plastic bag, and freeze for quick ice packs • Nasal packing • Topical anesthesia following cryo • When sending a through-and-through nasal case to plastic • Dabbed on immediately after freezing takes away pain in surgeon for repair about 75% of cases • Nasal probe • Lidocaine cream or 2% lidocaine in a bottle applied with Q-Tip • When taking stages from nasal area in hard-to-reach • Useful for kids with warts concave lesion • Lollicaine • Bolsters • When injecting fillers • When using bolster for graft with two sutures to hold it • When doing intraoral blocks to reduce pain into place • 20% benzocaine • Xeroform bolster

Page 17 • Rolled xeroform held in place with Updates in the Medical & Surgical Treatment • Skin changes include facial horizontal mattress suture of Hair Loss papules, cobblestone-appearance • Silastic drains Nicole Rogers, MD of forehead, chin • Pediatric IV tubing, 8 French drain • Destruction of the • Cut into pieces for use in surgical pilosebaceous unit, loss of sites if drain is required function of PPAR-g receptors • Sewn into place so drain doesn’t • Upregulation of aryl-hydrocarbon migrate up into the wound receptorCentral centrifugal • Stabilize helical sulcus cicatricial alopecia • Sewn into place, kept in place for • Loss of hair in vertex 4-5 days • Genetic etiology > • Maintains divot of helical sulcus, grooming techniques also prevents hematoma formation • Complaints of itching, burning • Button bolsters early on • Distribute tension on a wound • Later follicles are replaced by • Hold graft in place scar tissue • Reduces bulk, can get wet, very • Seen frequently with comfortable for patient traction alopecia • Hold flap in place • FDA approved medications • Minimized hematoma formation • Finasteride (propecia) • When using buttons on ear, make • 1mg/daily sure to use button on other side • Hair naturally grows in groupings of 1-4 • Available as a generic of ear to prevent tissue necrosis or hairs, not individual follicles • Monthly cost $22-60 tissue tear from suture • Nonscarring • Proscar= 5mg • Leave in place 4-5 days • Androgenic alopecia • Take ¼ pill daily • Duoderm in post-op wound care • Shrinking and shortening of the • $9 for 4-month supply • Used in double skin graft at hair growth cycle • No effect on sperm morphology, suture removal • Occurs in both MPHL and FPHL possible temporary reduction in • Used on most patients at • FPHL sperm count suture removal • Runs in families • Cannot donate blood due to • Do not use ointments underneath or • Can be progressive risk of birth defects in female it will slide out of place • Frontal hairline remains intact blood recipient • Keeps moist environment for healing • Loss of fullness or density in frontal • Not FDA approved for FPHL • Protects patients from scratching and 1/3-2/3 scalp or thinning on the • Risk of birth defects disturbing surgical site sides only • Post-finasteride syndrome • Duoderm gel in secondary • MPHL • Rare condition reported in intention healing • Runs in families a small number of men after • Gel prevents air pocket under • Can be progressive discontinuing finasteride duoderm patch • Variety of patterns • Loss of libido, brain fog, • Bilateral fenestrated advancement flap • Anterior thinning/recession depression, suicidal ideation • Pull with skin hooks to determine • Vertex (crown) thinning • Data remains limited and where skin stretch is desired • FDA approved medications controversial (recall bias, selection • “Poke holes” with scalpel to allow • Finasteride (propecia); Rogaine bias, no control for other causes for stretch 2% BID for females, 5% BID for of ED) • Close and remove dog ears men; Low-level light therapy; PRP; • Rogaine 2% BID for females, 5% • Fully ambulatory without casting Spirinolactone; OCPs; Dutasteride daily, 5% BID for men for splinting • Primary scarring • Low-level light therapy • No need for grafting • Lymphocytic • PRP • Friable skin • Lichen planopilaris • First described for hair growth in 2006 • Steri-strip parallel to wound edge, • Women >> men, usually 40 years • Safe (autologous treatment) suture through steri-strip to reinforce old, ethnicity • No side effects wound edges • ROS: itching, burning • No drug interactions or • XRT • Band-like lichenoid inflammation lab monitoring • Radiation tattoo ink to help identify at infundibulum or hair follicle • PDGF, TGF, VEGF, IGF, EGF lesion for easy follow up and attached sebaceous gland • Increased proliferation of dermal • Drop tattoo ink, puncture skin with • May burn out over 2-6 years papilla cells tattoo ink for a small mark • Frontal fibrosing alopecia • Increased ERK and Akt • Used in select cases where excision • Similar path to LPP signaling pathways will remove the tattoo spot in hard- • Women >> Men • Upregulation of FGF-7 and to-identify lesion • Hairline recedes 1-5mm beta-catenin

Page 18 • Centrifuged based system with • Hair transplantation • We are the major influencers of subsequent injection of plasma into • FPHL, MPHL, traction alopecia, patients in making a decision areas of hair thinning radiation induced hair loss, scars about treatments • Limitations • Timeline for regrowth • Participate • No multicenter placebo- • Graft sheds 2-6 weeks later • Patients want to know your controlled trials • 2-3 months looks like it did experience–You can relate • Wide variety of protocols at baseline • Office staff are best advertisement and techniques • Significant growth at 7-9 months and support • One time treatment vs. • Full result in 12-18 months • Treating patients not friends ongoing treatment • Can be enhanced with • Photos • Role of additives in medical therapy • Expand social circle activation (calcium chloride, • 2nd procedure earliest 10 months • Products matrisem micromatrix) • Two techniques for harvesting • Too many choices for patients • Spirinolactone • Donor ellipse (strip) • They are coming to us for guidance • Off label for hair loss, • Follicular unit transplant (FUT) • Control of outcomes acne, hirsutism • Least amount of trauma • Purge • Diuretic and anti-estrogen effects to follicles • Comparison of tiered pricing • Pregnancy category C • Shorter harvest timeline • Products that don’t move • Should be on alternative • Follicular unit extraction (FUE) • Poor support birth control • Removal of individual • Single company OK • 50-200mg daily follicular units • Partner • Monitor increased K and • Hair regrows quickly to recover • Local versus national companies decreased Na, menstrual • Caution to avoid overharvesting • Events irregularities, breast tenderness the donor area • Samples • OCPs • Robotic hair restoration • Help selling • Dutasteride • Computerized system for • Speaking/Ad boards • Only FDA approved for hair loss in FUE harvest • Promote South Korea • Branding • Longer half-life than finasteride How to Turn Your Acne, Rosacea, and Skin • Social media • Can be added to long term Checks into a Robust Aesthetic Business • Advertising by area finasteride if at plateau Kate Holcomb, MD • Teaching and lecturing • Oral minoxidil • How to convert medical patients into • Used for recalcitrant HTN in cosmetic patients the 1970s • Identify patients who are candidates • ADE: hypertrichosis, fluid for cosmetic procedures retention, lower extremity edema, • Take pictures light headedness • Recommend and pair procedures and • Contraindication in a-fib proper skincare • 2.5 mg pill cut in ¼ • Give patients written information • JAK-STAT pathway inhibitors • This will: • Oral tofacitinib for scalp psoriasis • Differentiate you; Lead to better • Complete regrowth in one patient outcomes; Establish patient in 5-8 months trust; Lead to referrals and • Open label clinical trial cosmetic procedures • 5mg BID for AAm AT, AU • Identify patients interested in • 2/3 say some regrowth by cosmetic procedures three months • Statistics on acne • Very high rate of relapse • 40-50 million Americans • Baseline lab monitoring required • 1 out of 3 women in 30’s • Avoid in history of malignancy, TB • EOB United Health • 1 out of 4 women in 40’s • Cost $2000-5000 per month • Cash pay alternatives for • #1 complaint in skin of color, #2 • Topical JAK inhibitors for medical dermatology in Caucasians pediatric AA • Finding happiness and pleasure in • 13 products tried before coming • Promising results our work to dermatologist • LPP & FFA Treatment • Steps to developing 6 P’s • Statistics on rosacea • Topical/IL steroids • Perfect • 16 million Americans • Tetracycline Abx • Aesthetics is an art • 5% in 30’s and 40’s • Hydroxychloroquine • Delegation removes EXPERT! • >50% over 50 • Finasteride, dutasteride • We have years of training on • Use photography • Eyebrow tattooing anatomy and subtle skin changes • Builds trust- “being objective”

Page 19 • Improved outcomes for acne, pigmentation, rosacea • Great for long-term positive outcomes • Easy conversation to additional procedures when looking • ASDS Consumer Survey 2017 at face • The percent of consumers considering a cosmetic medical • Patients want to know our experience procedures has doubled in the last five years • You can relate • Patients want to know what we recommend • You have patients who look like them • Average acne patient tries 13 products before coming • Office staff are best advertisement and support to dermatologist • Photographic release • 7/10 respondents said they are considering a cosmetic • Expand social circle treatment • Treat patients, not friends • Dermatologists ranked as the #1 influencer on the decision to • May tend to be unreliable with follow up, not ideal have a cosmetic procedure each year results, but will recommend you • Dermatologist 50% • Acne Patient • Friends 49% • Follow up acne • Primary Care Physician 34% • Not sure if better • ASPS Plastic Surgery Statistics Report 2016 • Concerned about scarring • Injectables and laser treatments continue to increase 2-4% • Atopic since 2015 • Retinoid intolerant • Exceptions • Fragrance intolerant • Laser hair removal • Multiple medications • Non-dissolvable fillers (PLLA, CaHA, etc.) • Not remembering to take birth control • Yeast infections with antibiotics The 5th Dimension: All Inclusive Aspects of Osteopathic Medicine • Before and after pictures proved improved appearance of in Dermatology acne and scarring Suzanne Sirota Rozenberg, DO, FAOCD • Led to patient and patient’s mother purchasing laser Amy Spizuoco, DO, FAOCD treatments because they were impressed with results proven in photographs • Rosacea patient • Follow up 2 weeks • Patient in a Mardis Gras ball mid-December • Presented mid-October • Hormonal vs isotretinoin • Not on OCP • Periods irregular • Scarring • Started laser therapy and topical medical management • Photographs proved clinical response • Always take multiple pictures before and after cosmetic treatments without makeup • Especially with various angles and facial expression • Photos of various age groups for demonstration • Also show what to expect immediately after injection • Burning mouth syndrome • Recommend and pair procedures and proper skin care • Chronic pain syndrome characterized by burning or stinging • If you don’t talk to patients about products, patients will go to feeling affecting the oral mucosa in the absence of clinically the wrong places for information detectable signs • Gives better control of outcomes • Triad: chronic, unremitting pain, dysgeusia and xerostomia • Too many options for patients • Trigeminal nerve dysfunction or hypo-functioning of the PNS • Cash pay revenue streams may be possible areas of treatment • Be able to give specific products to avoid confusion within • Current treatments include antidepressants, antipsychotics, large brands anti-epileptics and analgesics • Selling products in the office helps to control outcomes • Tricyclic antidepressants, benzodiazepines, • 16 Baumann Skin types based on the 4 “barriers to skin care” anticonvulsants, capsaicin • Gives product recommendations based on results • DDX • Saves physician time • Pemphigus vulgaris • Can choose which to carry in the office • 80% of pemphigus cases • Can also offer online webstore for other products • Autoantibodies to DSG3 • Average patients pick 2-3 skin concerns they want to discuss • Suprabasal bullae with acantholysis as a result of filling out questionnaire • Tombstone appearance of basal layer • Clear written instructions are the key to patient compliance • Clefting down adnexal structures • Also provide instructions to MAs to discuss with patients • DIF- IgG intercellular pattern

Page 20

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PREPARED BY FCB Releasing as: PDFX1a Production: Steve Curry Job #: 10770703 Colors: 4C AD: Maureen Client: Pfizer Flat Size: 7.5”w x 9.875”h AE: Kaitlin Product: Eucrisa Bleed: n/a Producer: Sadiki Francis Client Code: PP-CRI-USA-0553-02 Trim: 7.5”w x 9.875”h QC: L. Powell x8654 Date: July 27, 2017 3:03 PM Safety: 7”w x 9.375”h Digital Artist: gh, VA, tp Add’l Info: Proof: M3 M1 Spellcheck: Mark Ameen FR Spellcheck: Path: PrePress:Pfizer:Eucrisa:10770703:10770703_Con_Ad_NoBleed_M3 4C Convention Ad Template - No Bleed • Mucocele • Cervical spine • Results in direct inhibition of • Ruptures salivary gland duct • Peripheral neuropathy of the arm agonist muscles • Common on lower lip, buccal • Diaphragmatic weakness • Rib raising to normalize the mucosa tongue • Thoracic spine sympathetic nerves • Cystic space • Abdominal wall weakness • Brachioradial Pruritus • Poorly defined cystic lining • Abdominal wall pseudoherniation • Neurogenic pruritic condition • Granulation tissue, mucin, • Lumbar spine between the wrist and elbows macrophages, salivary glands • Ramsay Hunt Syndrome • Unknown etiology • Cheilitis • Geniculate ganglion to the • Unilateral or bilateral excoriations • Hyperkeratosis of SC facial nerve • Common in fair skinned, affluent, and • Acanthosis of epidermis • May affect eternal auditory canal middle-aged people in sunny climates • Spongiosis • May have tinnitus • Scratching makes the symptoms worse • No cellular atypia • Herpes Zoster • Exacerbated by sun exposure • Verruciform xanthoma Folliculitis histopathology • Ice packs usually helps the itch • Tongue, genitals • Superficial and deep infiltrate • May increase in incidence with • Hyperkeratosis of SC • Bottom heavy increased popularity of spin classes • Focal “triangular” parakeratosis • Necrotic follicle • Brachioradial pruritus treatment • Foam cells in papillary dermis • Outer root sheath • Cervical nerve block • OMT ballooning degeneration • Acupuncture • Sphenopalatine ganglion release – • Current pharmacologic therapy • Injections with botulinum toxin A using Myofascial release • Antiviral agents • Topical mixture of amitriptyline • Relaxing of contracted • Acyclovir, valcyclovir, hydrochloride 1.0%, ketamine muscles stimulates stretch famcyclovir hydrochloride 0.5% and reflex and increases salivary • Oral corticosteroids vanicream applied 2-3 times gland secretions • Anti inflammatory agents per day • Herpes Zoster Infection • Oral and topical options • Aprepitant, a • Viral infection due to Varicella Zoster • Opioids neurokinin-1 inhibitor Virus (HHV3) • Botulism Toxin injections • OMT • Airborne droplets are the usual route • Complementary treatment • Patients have altered sensation in of transmission; the incubation ranges including honey, capsaicin, the distribution of the posterior from 11-20 days and lidocaine cutaneous nerve of the arm • The virus replicates in the affected • Anti-depressants that supplies the skin over the dorsal root ganglion and produces • Tricyclic, anticonvulsants brachioradialis muscle painful ganglionitis; neuronal • Alternative treatment options • Corresponds to C5-C8 inflammation and necrosis can result • IV vitamin C for herpetic neuralgia • Remember to palpate the cervical in a severe neuralgia that intensifies • Acupuncture in acute herpes zoster spine on PE as the virus spreads down the as adjuvant treatment • Presence of a cervical rib or sensory nerve • In vitro antiviral activity of honey cervical nerve root impingement • Typically resolves without sequelae; against varicella zoster virus may contribute to altered however, the most common • Topical capsaicin: a review of cutaneous sensation complication is post-herpetic pharmacologic properties and • Treatment of cervical arthritis neuralgia that persist after the skin therapeutic potential in post- and cervical spine manipulation lesions have healed herpetic neuralgia, diabetic provides relief • Herpes Zoster histopathology neuropathy and OA • Muscle energy of cervical spine • Vesicular • Not used in vesicular phase • Flex neck +/- rotation • Ballooning degeneration of outbreak • Counterstrain • Acantholysis • Not used long-term • Tender point arises when • Slate grey nuclei • Review of lidocaine patch abnormal muscle tone is • Homogenous/Eosinophilic cytoplasm 5% studies in treatment of maintained through an • 3 M’s postherpetic neuralgia inappropriate strain reflex • Molding, Multinucleation, • OMT in VZV • Passively placing the patient Marginaton • Can be use as adjuvant therapy after into a position of ease, allows • Intranuclear inclusion bodies acute phase to help prevent post for resetting of the neural • Clinical findings related to herpetic neuralgia components involved in the dermatome involved • Suboccipital decompression to strain reflex • Hutchinson’s sign normalize the PNS • Normal resting tone is achieved, • Include ophthalmology when • Muscle energy to upper thoracic resulting in balance in the ocular involvement occurs and cervical regions muscular system, skeletal system, • May result in ocular scarring and • Direct treatment requiring neural and vascular systems loss of vision patient involvement • Notalgia Paresthetica

Page 23 • Uncommon pruritic condition seen • Papillomatosis the fibrosis most commonly in middle aged women • Hyperkeratosis of SC • DDX • Unknown etiology • Vacuolated koilocytes • Morphea profunda • Affecting mainly the interscapular region • Verruciform xanthoma • Scleroderma (especially the T2-T6 dermatomes) • Bowenoid papulosis • Acrodermatitis chronica atrophicans • Usually unilateral • Resembles Bowen’s disease • Medical Management • OMT may decrease the sensation of • HPV 16, 18, 31, 33, 35, 41-45 • Compression therapy neuropathic pain/itch • Full-thickness epidermal atypia • Stanozolol • Macular amyloid • Dyskeratostis cells, mitoses • 5mg BID with compression • Acanthosis of epidermis • Stasis Dermatitis shown to reduce induration, • Small globular deposits of amyloid • Common condition seen in older pain, hyperpigmentation • Hyperkeratosis patients with cardiac insufficiency and • Pentoxifylline • Complementary Treatments venous incompetence • Superficial venous surgery • Botulinum toxin type A • Due to gravity and increased • Antibiotics • Topical capsaicin hydrostatic pressure leading to leaky • ILK • OMM techniques vessels • Foam sclerotherapy • Muscle energy • Hemosiderin deposits in the • Danazol • HVLA skin of lower extremities causing • Histopath • Chapman’s points hyperpigmentation • Infarction of fat lobules • Counterstrain • Lymphatic pump/effleurage may • Fibrosis replaces subcutis • Vulvodynia decrease edema and thus improve • Lipomembranous change • Burning vulvar discomfort, with condition and decrease the incidence • Complementary therapies increased pelvic floor muscle tonicity of venous stasis ulcers • Intralesional platelet-rich • Irritation, itching, pain, • Medical management plasma can be considered for rawness, allodynia, hyperalgesia • Support stockings (knee high, 20- refractory LDS and dysparenuria 30 mmHg pressure) • OMT • Possible due to nerve compression • Leg elevation • Effleurage and/or myofascial hypertonicity • Topical steroids • Pedal pump • DNA polymorphisms, peripheral • Compresses if weeping • Be sure to get a good stretch to and central neuropathic processes, • Unna boot the calf muscles nerve compression, increased • Surgery • Hyperhidrosis density of C-afferent nociceptive • Histopath • Affects 0.6 to 1% of western population fibers in the vestibular mucosa as • Impaired venous drainage • Excessive function of the sweat control possible pathogenesis. • Spongiosis of epidermis system typically affecting palms, axilla • Treatment options • Proliferation of superficial vessels in and soles • Topical medications such as papillary dermis • Primary lidocaine ointment • Nodular vascularization • Inherited, AD with variable • Drug therapy: pain relievers, • Osteopathic manipulation in penetrance antidepressants, or anticonvulsants elephantiasis nostras verrucosa • Secondary • Biofeedback therapy • Marked edema of affected extremity • Cancer, endocrine dysfunction, • Physical therapy to strengthen the secondary to severe lymphadema or infections and medications pelvic floor musculature venous insufficiency • OMM Findings: • Kegal excercises • Results in cutaneous changes: • T2-T3 dysfunction • Injections of steroids or anesthetics hyperkeratotic verrucous plaques • Pathogenesis • Surgery to remove the affected skin • Treatment is challenging • May be aggravated by and tissue in localized areas • Patients benefit from lymphatic autonomic dysfunction • Relaxation techniques, massage pumping and effleurage • Spinal sympathetic nerve action on therapy, homeopathy, acupuncture • Lipodermatosclerosis peripheral sympathetic nerve that • OMT • Also known as sclerosing panniculitis innervates sweat gland • Trigger points of the levator ani • Acute phase – painful, symmetric, • Current treatment options muscles red to purple, poorly demarcated, • Topical aluminum • Pelvic diaphragm release indurated plaques in a stocking chloride hexahydrate • Make sure to have chaperone or like distribution • Topical anticholinergics to thoroughly explain procedure • Exact pathogenesis remains • Oral anticholinergics • Counterstrain unknown, possible static blood in • Iontophoresis • DDX lobular capillaries ultimately leading • Botulinum A neurotoxin • Condyloma accuminata to pannicular ischemia, fat necrosis • Liposuction and surgical • STD, HPV 6, 11, 16, 18, 31, 33, and fibrosis excision (axilla) 35, 39, 41-45, 51, 56, 59 • Treatment similar to stasis dermatitis, • Sympathectomy • Acanthosis of epidermis can add manual stretching to help • OMT

Page 24 • Rib raising • Diffuse lepromatous leprosy • Occipital release • Frequent in Mexico • Cranial manipulation • Susceptible to same drugs as M. leprae • Conclusions • May be associated with infection in other animals • Multifactorial approach to medical dermatology previously unrecognized • Think “outside the box” • Advent of Genomic Sequencing can greatly benefit our • Osteopathic manipulation has definite benefits to our understanding of non-Cultivable pathogens dermatology patients Clinical Hansen’s Hansen’s Disease in the United States Today Barbara M. Stryjewska, MD Epidemiology & Microbiology of Leprosy Richard W. Truman, Ph.D • Today primarily in tropics and subtropics • Largest incidence currently in Brazil • Approximately 200 new cases in U.S. per year • In U.S. most prevalent in California and surrounding Gulf of Mexico • Typical U.S. case: 35-52 y/o, male:female 60:40, symptomatic >1 year before diagnosis • 1 in 3 still suffer nerve damage even after cured “bacteriologically” • Transmission • Mostly direct long-term close contact; conjugal (5%), missionaries (1.3%) • Probably transmitted by respiratory routes • CAN use normal hospital sanitation measures and do not have to take extreme caution • Large occult reservoir • 80% report no known contact • Chronic, infectious disease that primarily affects peripheral • Cooler areas of body nerves, skin, eyes, mucous membranes • Nine-banded armadillo (very cool internal body temp) • Discovered in 1873 in Norway by Gerhard A. Hansen main reservoir • Stigma huge problem • Potential but very low risk from contact with armadillos • Wide variety of clinical presentations • Strong genetic susceptibility- >95% of population • Uncomplicated- insidious onset, indolent infection, little or naturally immune no malaise, no fever, no complaints except ‘rash’ • Specific risk factors unknown • Paucibacillary (tuberculoid)- larger, solitary, asymmetrical, • HLA I & II, MICa/MICb, TLR, Killer-Cell Ig receptors, hypopigmented, may spontaneously resolve, loss of TNFa, IL-10, NRAMP1 sensation may occur at some lesions • 2-8% of normal population are nasal carriers • Borderline- moderate sensory loss • Long incubation period (3-5 years) • Multibacillary (lepromatous)- small, symmetrical, diffuse, • Spontaneous self-healing possible early sensory loss • No early diagnostic tests, inability to culture M. leprae à • Other sequelae- diffuse thickening of skin, ocular lesions, clinical diagnosis digits get absorbed, motor weakness, paralysis and disability, • Uniformity of armadillo strains- suggests recent introduction hypogonadism, gynecomastia and inefficient interspecies transfer • Diagnosis- punch biopsy, 3-4mm deep to reach • M. lepromatosis- new organism causing leprosy • Treatment- early treatment very effective! • Paucibacillary: 12 months of both- • Dapsone 100 mg/day • Rifampin 600 mg/day • Multibacillary: 24 months of all 3- • Dapsonse 100 mg/day • Rifampin 600 mg/day • Clofazamine 50 mg/day • Other- minocycline, macrolides, fluroquinolones • Type 1 (reversal) reaction- usually paucibacillary • Gradual, vague malaise, neuritis • Treatment = corticosteroids drug of choice, immunosuppressives, symptomatic (gabapentin, NSAIDs, amitriptyline)

Page 25 • Type 2 (erythema nodosum leprosum) • Pressure = force/area (as area • Patient selection reaction- usually multibacillary increases, pressure decreases) • High medical/anesthesia or • Sudden, +/- pain, fever, • Risk categories surgical risk malaise, new red/tender lesions, • 0 - No loss of protective sensation • Manage expectations neuritis, neutrophils • 1 - Loss of protective sensation, 6 • Will patient be happy with no- • Treatment = corticosteroids 1mg/ month follow-up surgical management? kg symptomatically or thalidomide • 2 - Loss of protective sensation with • Perineural/vascular invasion post op (drug of choice but teratogen, deformity, 3 month follow-up • SCC >6mm deep hypercoagulable, neutropenia, • 3 - History of plantar ulcer/Charcot • Large lesion bradycardia, constipation) or high Foot, 1 month follow-up • Positive or close or uncertain margins dose clofazimine 200 mg/day (post- • Integrated care model: occupational • Recurrent disease inflammatory hyperpigmentation but therapist, physical therapist, podiatrist, • LN mets reversible with time) pedorthist, social worker, orthopedist • “Insurance” if surgeon uncomfortable • CTCL Consequences of Hansen’s Disease The Art of Radiotherapy in Skin • Merkel cell tumors Capt. John Figarola, MA, LOTR, CHT Cancer Management • Very sensitive to radiation • 30-40% of patients have some disability David Herold, MD • Keloids in the hand and foot • After surgical removal • Consequences: Psychological, sensory • Should initiate radiation within 24- loss, muscle paralysis, self-care, economic 48 hours of surgical removal and physical dependence • Contraindications • Stigma…disbelief, fear, confusion • Pregnancy • Key: physician’s initial reaction sets tone • Scleroderma of recovery • Lupus • Educate patients that the disease is • Gorlin’s syndrome (BCC Nevus) curable and not easily transmitted • Prior XRT to exact site • Inquire about patient’s concerns, • Young patients (<60 years old) empower patient and provide hope • Concern for late effects, • Can palpate nerves to check for second cancers tenderness/enlargement • Non-compliant patient • Peripheral neuropathy: calluses, ulcers, • Unwilling or unable to make loss of protective sensation (e.g. corneal repeated visits ulcers), deformities • Overview • Prevention of Disability: • Full radiation dose divided • Annual hand & foot screen into fractions • Baseline on diagnosis • Small doses delivered over • Annually x 5 years or more • Radiation therapy is an evidence-based several weeks frequently if necessary curative cancer treatment • Larger doses delivered 2-3 • Patient education • Indicated for functional, cosmetic, and times weekly • Protection of insensate areas (e.g. patient preference as a primary treatment • Treatment 1-3 minutes insulated mugs when microwaving) • Advantages • Painless • Assistive devices (e.g. for • Tissue preservation • Fractionation buttons, utensils) • Not removing tissue • Need to allow normal cells to recover • Daily self-inspection hands & feet: • Better cosmetic and between treatments • Open wounds, blisters, callus, functional outcomes • Normal cells can repair DNA damage ingrown nails, redness, increased • Disadvantages more effectively than cancer cells temperature, signs of infection • Requires series of treatments • Repeated “hits” on cancer cells • Management of hand & foot • Long term subtle skin changes damages these cells problems and routine follow-up • Salvage surgery could be more difficult • Need to choose a field size that gives • Callus and nail care, offloading, • High cost margin for subclinical extension splinting and casting (rest, • Rare significant side of lesion prevent contractures and shear), effects/complications • Technology wound management • Indications • Orthovoltage units penetrate • Offloading with total contact cast • Definitive management of malignancies 1-2 cm deep 4-6 weeks (don’t use if infected)- • Post-op management of malignancies • Papillon units used for anal and reduces pressure by 84-92% and • Treatment of benign proliferative vaginal cancer cuts cost in half diseases (keloids, postop) • Sensus (topex) unit for simple, • Footwear selection & assistive devices • BCC, SCC, SCCIS, lentigo maligna/ superficial cancers • Should be worn at ALL times MMIS, post op for invasive MM • Xstrahl photoelectric machine useful for faster therapies

Page 26 • Many others as well • Lepromatous leprosy • Diagnosis is done by culture of CSF, • Superficial units • Associated with decreased pain in the sputum, urine, and blood • Pros lower extremities • Fixed tissue sampling with • Relatively inexpensive • Tuberculoid type mucicarmine and Fontana-Masson • Small footprint/mobile • Asymmetric, hypo/ can aid diagnosis • Minimal (if any) shielding needed hyperpigmented macules, swelling • Primary varicella • Simple operation of peripheral nerves • Polymorphous skin lesions in • Can hypofractionate • Lepromatous (multibacillary) various stages • Can treat cancers and keloids • Symmetric, multiple skin • Tzanck smear has high sensitivity • Cons lesions present and specificity • Thick lesions need debulking • Anesthesia in stocking- • Staphylococcal scalded skin syndrome • Limited to small lesions glove distribution • Important to go to the primary site of • High surface field sizes/shapes • Diagnosis is by skin/nerve biopsy the infection to get a positive culture • High surface gradient dose • Cutaneous mycobacterium (throat, conjunctiva, rectum) • High bone dose (with orthovoltage) • M. fortuitum is associated with • Skin culture is negative! • Challenge for pinna/irregular nail salons • Due to exfoliative toxin cleaving at contours • Skin microtrauma from shaving desmoglein 1 • Relatively meek reimbursement increases risk, as does tattooing • Represents 5% of staph aureus isolates • Megavoltage electrons • Molluscum contagiosum • Prodrome of fever/malaise, but • Pros • Caused by parapox virus neonates may only have mild fussiness • Long-term data available • In HIV patients, the presence of • Positive Nikolsky sign and heals • Can treat deep lesions multiple lesions can be an indicator of without scarring • Can limit surface dose to 100% advanced immunosuppression • Cutaneous mucormycosis • High dose brachytherapy • Herpes simplex • Necrotic skin lesions caused by • Placement of radioactive seeds in the • Unique presentation of a large rhizops, mucor, or absidia tumor erythematous, crusted plaque with • Broad non septate hyphae with • Follow with brachytherapy machine ulcerating and scalloped border 90* branching • Pros • In patients with CD4 counts, vesicles • Can be primary (by inoculation) or • Can be mobile can be very transient, leaving crusted secondary (by hematogenous spread) • Can treat large and small lesions necrotic lesions • Dermatomyositis • Cons • Multinucleated keratinocytes on • Affects the muscle as well as the skin • High cost HDR unit $400K pathology are key for the diagnosis • Photodistributed, mottled, • Source contacts ($40-75K/year) • Disseminated Cryptococcus neoformans heliotrope, and gottron’s are all things • Need vault/shielding/safety • Occurs in patients with very low to look for • Summary CD4 counts • Drug induced dermatomyositis • Many ways to skin a cat • Typically a primary • Hydroxyurea, phenytoin, tegafur, • RT can provide preservation of pulmonary infection and TNFa-inhibitors are all function, cosmesis, and excellent • Cutaneous manifestations are known causes tumor control areas widely variable • SLE • For certain anatomic sites, functional and cosmetic outcomes of radiation may exceed those of surgery

Cases from the Crescent City: Dermatology Self-Assessment Tulane University Panel • Disseminated gonorrhea • Arthritis dermatitis syndrome and localized septic purulent arthritis • You should culture from urethra, cervix, throat, or rectum • Treat with IM or IV antibiotics • Epidermodysplasia Verruciformis • Predisposes to HPV • Genetic defect in EVER1 and EVER2 • Acquired phenomenon in immunodeficient patients • “Blue gray cytoplasm” on histopathology is present, not seen in more common warts

Page 27 • Hypocomplementemic urticarial • Corticosteroid therapy is the • HV-6 and 7 have been reported to vasculitis (HUV) is associated standard treatment and usually be associated with SLE provides rapid relief • Can also be a drug eruption • Associated with MSK, pulmonary, • Zinc deficiency • Eczema herpeticum ocular, and renal manifestations • Diarrhea, depression, dermatitis • Best treatment is valacyclovir • Chronic cutaneous lupus • Seen in alcoholics, malabsorption • AD patients are especially susceptible • Acute CLE: butterfly rash conditions, GI surgery, and AIDS to infections and can be fatal • Subacute CLE: polycyclic plaques/ • Can also have alopecia, paronychia, • Graft versus host disease papulosquamous, psoriasiform and onychodystrophy • Best initial treatment is corticosteroids • Chronic CLE: discoid, chilblain, • Zinc competes with copper • 3 features are skin eruptions, GI tumid, panniculitis for absorption involvement, and hepatic involvement • Work up • Roux en Y procedure is the greatest • <50% of patients will have sustained • ROS, PE, chart review bariatric surgery risk for zinc deficiency response to steroids, so secondary • CBC with diff, CMP, ANA, UA • Dermatitis can resolve within 4 weeks therapy is often required and consider ENA, C3/C4, at 220mg of zinc sulfate • Acute: morbilliform eruption more ESR/CRP • Phytophotodermatitis common with GI/liver involvement • At follow up: ROS, PE, CBC, UA, • Caused by figs (Moraceae family) • Chronic: polymorphous appearance ANA (if not positive) • Furocoumarins are the inciting agent and affecting multiple sites • Urticaria multiforme • Most commonly is the citrus reactions • Grover’s disease • Presents in otherwise healthy children • More common with increased UVA • Transient or persistent with recent viral illness and plant exposure monomorphous papulovesicular • Annular or polycyclic lesions with • Blister and persistent eruption classified as non-familial transient ecchymosis hyperpigmentation acantholytic disorder • Favorable response to • Cow parsnip can also cause a reaction • More common in older males oral antihistamines known as “pushkie burns” • Unknown etiology but UB, heat, and • Key to differentiate from EM and • Potassium dichromate allergy sweating are all indicated serum sickness like reactions • Found in leather shoes, cement, and • Acute general exanthematous wood finishes Physician Burnout pustulosis (AGEP) • Cutaneous sarcoidosis Lisa Swanson, MD • Acute, febrile, drug eruption with • Lupus pernio: indurated, lumpy, sterile pustules violaceous papules/plaques on nose/ • >90% of cases are due to beta-lactam cheeks/lips/ears antibiotics, typically within 48 hours • More predictive of • Elevated neutrophil counts are pulmonary sarcoid present, mild eosinophilia possible • ⅓ of sarcoid patients will develop (but less than DRESS) cutaneous lesions • Treatment includes discontinuing • CTCL offending medications and • Pleomorphic T-cell lymphoma is a rare monitor for systemic involvement type of CTCL affecting the head and and superinfection neck area • Calciphylaxis • Presence of prominent granulomatous • Skin biopsy for H&E and infiltrates can make the diagnosis of cultures are first step, preferably a CTCL more difficult, but does not telescoping biopsy affect the prognosis nor treatment • Exquisitely painful lesions, livedo • Kaposi’s Sarcoma reticularis, and possible eschar • Most common tumor in HIV • Predominantly affects CKD patients patients, and is an AIDS • What is burnout? on dialysis defining illness • Physical or mental collapse caused by • Can be uremic (up to 80% mortality) • CD4 count is considered to be overwork or stress or nonuremic the most important factor in • Burnout is not just stress - • Tends to affect areas of high tumor development differentiated because it is difficult to fat content • Lymphedema is classically associated recharge in a short period of time • Treatment is wound care, debridement with non-AIDS related variant, but • Leads to decreased productivity, (controversial), hyperbaric can also be seen in AIDS-related KS quality of care, depression, anxiety, oxygen, infection prevention, pain • Pityriasis Rosea substance abuse, relationship issues, management, sodium thiosulfate (best • Herald patch which is pink to salmon and suicide treatment available) colored patch/plaque with slightly • The physician wellbeing index is a good • Sweet’s syndrome raised margin indicator for your level of burnout • Secondary to strep pyogenes, IBD, • Symmetrical lesions appear along the • Burnout rates in dermatologists has risen malignancy, and medications Langer lines of the trunk from 32% to 57% from 2011 to 2014

Page 28 • Women have higher rates of burnout than men, predominantly • Admit the patient to the hospital in women with children working in academia • Treat with topical triamcinolone • Common causes are increasing clinical requirements, EMR, • They clear up in 3 days lack of efficiency in office, and generalized decreased respect for • When hospitalized and medications were applied for him, physicians, malpractice concerns he improved rapidly because someone was making him use • Decision fatigue his topicals • Working in blocks of 90 minutes is ideal • Adherence definitions • We are allotted a certain number of decisions in a day, and the • Prescriptions given initiates acceptance end of the day we get tired of making decisions • Initiation of treatment marks the end of acceptance and • What can be done to treat burnout? beginning of period of persistence/quality of execution • Fine tune your practice • Discontinuation marks the end of execution • Think about the ideal properties for your practice and find • Three big reasons for poor treatment outcome the steps to reach those goals • 1. Poor compliance • Initiate a 5 minute huddle at the beginning of the day, that • 2. Poor compliance will save 30-60 minutes during the day • 3. Poor compliance • Adjust your mindset • In an anonymous survey of psoriasis patients, 40% • What are you metrics for success? report noncompliance!!! • Realize you’re only human • The rest are probably lying • Physicians are perfectionists, and this is a challenge • Psoriasis resistant to topical treatment • Celebrate your success • 35 year old male • Have your moments when things go right • Psoriasis of the elbows and knees • Celebrate with your whole team • Prescribed combination of betamethasone and calcipotriol • Recharge your batteries • Returns in 2 weeks with no improvement • Get comfortable saying “no” • Is the patient genetically deficient in steroid and vitamin D • Listen to music, take vacation, get a “walk out” song receptors? • Manage your stress • Primary nonadherence • Exercise, sleep, eat well, smile, monotask, breathe, • Many patients don’t even fill the prescription mindfulness, be grateful • Psoriasis patients are among the worst • To do lists are good and have been shown to release the • Topicals stopped working same levels of dopamine as shopping • 45 year old woman with psoriasis of the legs • Start a gratitude journal • Initial good response to topical betamethasone • Over time, the medication has gradually become less effective Adherence to Treatment and no longer controls the psoriasis Steven R. Feldman, MD, PhD • Why is the disease now resistant? • Has she developed mutant T cell steroid receptors? • Were the T cells in the lymph nodes exposed to the steroid? • Secondary nonadherence • Medication bottles that record when they are opened • Noted discrepancy between when the bottle was recorded as opened and when the patients report they used their medication • Biologic failure • 52 year old woman had extensive psoriasis • 20% body surface area affected • Treated with adalimumab • Initial very good response • Gradual loss of efficacy • Why are patients non-adherent? • Poor motivation: The patient may not be particularly bothered • Secondary gain: Seeking disability or other gain • Lack of trust in doctor: Physician-patient relationship is • Low hanging fruit the foundation • We have treatments that are remarkably effective • Fear of medication: Founded or unfounded fear of treatment • Patients don’t always get better • Don’t know what to do: Patients may not remember • Consider resistant atopic dermatitis oral instructions • 12 year old patient • Burden of treatment: Sometimes the treatment is worse than • Total body, lichenified atopic dermatitis the disease! • Failed outpatient treatment with high strength topical • Perceived burden: Sometimes treatment seems worse than steroids, sauna suit, methotrexate, cyclosporine the disease • Resistant atopic dermatitis • Passing the responsibility buck: With multiple caregivers, no • Solution one may take responsibility

Page 29 • Forgetfulness: “Pavlov’s dog” problem • Treated with: • Anchoring • Laziness: No energy to follow treatment • Scalp: fluocinonide and • How willing would you be to take a • Resignation: Some patients have just calcipotriol solutions shot once a month? given up • Face: desonide ointment and • How willing would you be to take a • We can encourage better compliance topical tacrolimus shot once a day? Once a month? • Establish a relationship with patients • Palms: Clobetasol ointment and • Loss aversion • Involve patients in tazarotene gel • Losses make bigger impact than treatment planning • Body: betamethasone/ equivalent gains • Make it easy! calcipotriene ointment • Taking a statin • Don’t scare patients with side effects • Returns in 8 weeks with • If you take this statin regularly, on • Choose fast acting agents minimal improvement average, you would live a • See patients back for a return visit • Simplify treatment year longer • Give clear, written instructions • Resistant atopic dermatitis • If you don’t take your statin • Good medical practice • 12 year old patient regularly, on average, you would die • Make the right diagnosis • Total body, lichenified a year sooner • Prescribe the right treatment atopic dermatitis • Sunscreen • Get patients to use the treatment • Failed outpatient treatment with high • Will keep you looking young • Communicate & follow up strength topical steroids, sauna suit, • If you don’t use it, you will lose the • Project the appearance of empathy methotrexate, cyclosporine youthful look of your skin • Appear caring • This time, you don’t want to admit • Address cost issues • People want caring doctors him to the hospital • Prescribe low cost medicines • Friendliness and caring attitude • Add a one week return visit • Give patients a range of options coincide with patient • Kids with atopic dermatitis • Lower cost generics satisfaction rating • 0.1% tacrolimus ointment BID • Higher cost drugs that have • Interventions to appear caring • Return in 4 weeks or 1 week/4 weeks greater benefit • Open the door slowly to appear as • Curse of knowledge • Patient assistance programs though not in a hurry • Better informed people find it • Company-sponsored copay or other • While washing hands tell the difficult to think from the perspective assistance programs patients “I’m doing this to protect of less well-informed people • Local indigent pharmacy resources you from (insert favorite infectious • Makes it hard to meet patients’ • Change the priority/urgency disease here)” education needs • Real and perceived cost/benefit • Sit down • Give instructions in writing • Encourage patient to share cell phone • Examine patients carefully • Motivating kids with the pharmacist • Palpate the rash • Positive reinforcement • Inertia/default option/anecdote • Waive a lighted magnifier • Sticker calendar • Powerful force over lesions • Use sticker charts to motivate your • Thaler & Sunstein’s book: Nudge: • Asking a few questions about residents, too ;-) Improving Decisions About Health, the disease • Side effects are a mixed bag Wealth, and Happiness • “Your previous treatments have • Side effects & fear of them can • Opt out versus opt in probably been very frustrating…” reduce compliance • Dramatically increases retirement • Address psychosocial issues • Side effects may also be an opportunity plan participation • Use support groups • For acne patients on spironolactone • Keeps people from • Put a clock on the wall behind • “This drug is a diuretic. In switching medications the patient addition to its effect on your • Also, too much choice isn’t helpful • Looking at a watch can be the kiss acne, you may also notice some • People choose the middle of death weight loss.” • Assessing adherence • Put clocks behind where patients sit • For scalp psoriasis, tell patients: This • The honest truth about dishonesty • I’m doing it now because I care, not may sting… • “Try to recall the Ten because I am in a hurry • That’s because it is so strong Commandments” • What matters is how it is perceived • The stinging is a sign that it • Putting patients in a religious state • Choose a vehicle that the patient will use is working of mind makes them less likely to lie • Less messy products seem to be • Most guys don’t have what it takes • Also, ask indirect questions preferred over: to use this stuff • “Are you keeping the extra syringes • Ointment • Framing you’ve accumulated refrigerated like • Cream • A set point, even an arbitrary one, you are supposed to?” • Emollient affects perceptions • They shouldn’t have extra syringes • Gel • A risk that is more likely than being • “What do you do with leftover • Scalp, palm, face and body psoriasis killed by lightning doesn’t sound medication? Is it in a locked cabinet • 38-year-old male presents with nearly as bad as a risk that is less likely or in the medicine cabinet or do scattered lesions of psoriasis than a coin flip you throw it away?”

Page 30 • Adherence to biologics • Internet survey & contest • Referenced the textbook quotes • Adherence to biologics is limited • Half the subjects received a weekly from Bolognia and Fitzpatrick • Ask, “Are you keeping the extra email link to the survey chapters and a Canadian FP article syringes you’ve accumulated • For each completed survey, as seen in Wikipedia refrigerated like you are subjects were entered to win an • Survey says…patients don’t care unless supposed to?” iPod Nano we make them care • Some practices have better • For 5 of 6 completed surveys, subjects • 571 pts surveyed at PSU-Hershey: adherence rates than others received a $5 gift card 3 questions about AKs between • Provide structure • Conclusions June 1-July 31 2016, mean age 42, • Have patients pick the one or two • Difficulty clearing psoriasis is often gender equal days of the week that they take the due to poor adherence • The question that presented AK medicine and stick to it • Improving adherence is low as a “precancer” had the highest • Anchoring hanging fruit proportion (92.2%) responding they • You only need to take the injection • Adherence is a major issue in the preferred treatment. once a day. Wait, did I say once a treatment of chronic skin diseases • Two questions presenting the risk day? It’s only every month.” • We can promote better adherence of AK as not progressing to cancer • Resistant scalp psoriasis • Timing of follow up yielded the lowest proportion of • 36-year-old woman with resistant but • Easy to use treatments individuals who chose treatment limited scalp psoriasis • We need to look to new ways to [57.7%] and [60.9%]. • Has seen many dermatologists enhance patients’ adherence and • Conclusions: pts’ decisions on • Has tried numerous topicals with treatment outcomes whether to receive treatment for AK no benefit is significantly affected by physician • She brings a bag full of them, Skin Cancer Hour wording, especially if made aware of including clobetasol solution Neal Bhatia, MD risk of CA • Is wondering about using a biologic • Are actinic keratoses the cutaneous • Cell phone number version of “cavities”? • Return visits make people get the • Treatment medicine and use it • Dermatologists examine for AKs • Focus on initial adherence also the same way dentists search for promotes habit dental caries • A cell phone call can do the • One cavity today à ten same thing cavities later • Giving patients your cell phone • Filling cavities is like freezing AKs: number is a powerful statement it is a bandage not a remedy of how much you care about the • Prevention patient (whether you answer the • When you brushed your teeth, phone or not) did you brush only one tooth or • Do Not Preprint Your Cell Phone all of them? Number on Your Business Card! • Do we take that same approach • Patient wants natural treatment for AKs? • 8-year-old with atopic dermatitis • Is sunscreen the same as toothpaste • Mom would like the child treated for the skin? with all natural treatment • What is a “subclinical AK?” • 25-year-old woman with very • What is the disease? • Evolving AKs are still AKs, severe psoriasis • Actinic Keratosis can either regress, whether we see them with our eyes, • She says she wants all persists, or progress to SCC? dermatoscope, confocal microscopy, natural treatment • AK as a symptom of photodamage, a or fluorescence • Prescribe only “all natural” treatments disease that cannot be cured? • To reduce the risk of skin cancer, we • The words we use with patients • SCC in situ that should be treated to treat what is coming and not just what are important avoid recurrence or invasion? we see today • Never label patients • “AK is the initial clinical manifestation • “Squamous cell carcinoma is the major “non-compliant” of a disease continuum that progresses to cause of nonmelanoma skin cancer • Never, ever use the word “steroid” frank SCC…” related death” with a mom • Ackerman, BA, “Respect at last for • Weinstock, M. Arch Dermatol • Use reassuring words solar keratosis,” Dermatopathology, 129:1286-90,1993. • “All natural” 1997, 3:101-3 • “cSCC is the 4th most common • “Complements natural healing pathways” • “Actinic keratosis is a premalignant cause of death in renal • “Holistic” condition of thick, scaly, or crusted transplant patients” • “The sun makes vitamin D in your patches of skin.” • Marcen, R, Transplant Proceedings skin naturally”

Page 31 • “Almost 50% of Caucasian • Results: Highest risk factors correlated • Results: Australians will develop a BCC before with the Bsml polymorphism in the • All in 4% arm achieved 75% the age of 70…it is likely that the Vitamin D receptor almost 2:1 clearance (vs. 95%) same person will develop another • Hot off the Press: New label • 80% were 100% clear (vs. 75% for within three years.” for sonidegib 5% 5-FU) • Do AKs grow up to become SCC? • Label reflects long-term sustained • 30% irritation in 4% cream arm • Anywhere between 0.025 and 16% of response of BCC compared to 60% in 5% arm AKs can progress to invasive SCC • BOLT Trial: n=194 locally advanced • Same comparison of stinging, • Extrapolation studies suggesting BCC, 36 metastatic crusting, and itching the risk of progression at • 200 mg/d vs 800 mg/d • Peanut Oil added moisturizing approximately 8% • Objective response rate for 200 mg effects and was safe to use in • Risks vary with age, gender, chronic dose: 56% patients with peanut sensitivity UV exposure, and location of AKs • Sustained median duration of • Combining calcipotriol and 5-FU • Spontaneous regression of AK response: 26 months • Combination cream of both superior • Estimated 15–25% in 1-year period • 30% experienced side effects that lead to 5-FU alone • Occurrence rate of invasive SCC to discontinuation • Induction of TSLP results in • 5–20% over follow-up periods of • Can AK treatment be simple recruitment of anti-tumor T cells 10–25 years yet complete… • 131 pts applied combo or 5-FU alone • 0.1% and 0.24% transformation rate • Veterans Affairs Keratinocyte bid for 4 days from AK to SCC in 1 year Carcinoma Chemoprevention • 8 weeks after: combo 87% mean AK • 82.4–100% pts with invasive SCC (VAKCC) trial reduction vs. 26% 5-FU arising on sun-exposed areas have a • 12 VA medical centers recruited • Face, scalp, and upper arms also tested history of AK from 2009 to 2011 and followed up • Higher incidence burning and • Hot off the Press: Seborrheic keratosis until 2013 erythema in combo group (SK) may mimic cancer • 932 veterans with 2 or more AKs • 39% combo group vs. 13% • Dermatopathology samples • Mean follow-up duration was 5-FU alone from 2015: 2.6 years • Concerns: stability of combo, • “SK” or “ISK” “SK rule out others,” • “A single course of 5% fluorouracil treatment time, AEs changing, growing, and so on— cream effectively reduces AK counts • What’s coming for AKs were excluded. A total of 4,361 and the need for spot treatments for • KX2-391 Ointment eligible cases were identified and longer than 2 years.” • Inhibit T cell migration and used for analysis • Is “spot treating” better than endothelial tubule, lymphocyte • Of total cases identified as only “not treating?” infiltration, angiogenesis “SK” or “ISK” in the clinical data, • 5% FU cream, (n = 468), or vehicle • VDA-1102 Ointment 3,759 (86.2%) were, in fact, SK cream (n = 464) to the face and ears • Placebo vs 5% vs 10% for 28 d or ISK bid for 4 weeks • Anti-neoplastic agent • A total of 466 (10.7%) were an • At 6 months 5-FU • Selective modulation of VDAC/ assortment of non-malignancy group demonstrated: HK2, unique to glycolysis and diagnoses, such as dermatofibroma • Fewer AKs compared with the mitochondrial • There were 136 (3.1%) cases control group • Selectively triggers apoptosis in histologically diagnosed • (3.0 vs 8.1, P cancer cells as malignancies • Ingenol disoxate (LEO 43204) 0.018% • SR-T100 gel--antiproliferative • The majority (9/136 cases; 67%) and 0.037%: ester of ingenol for • Solanum lycocarpum alkaloidic extract were in situ or invasive squamous treatment of AKs and their constituents, solamargine cell carcinoma; 24.3% (33/136) • Currently in trials for full face, scalp, and solasonine were basal cell carcinoma and and chest—3 day prescription with 12 • 16 week treatment study, 8 wk F/U 8.8% (12/136) were melanoma month follow up for recurrence for recurrence evaluation • Hot off the Press: Vitamin D receptor • More potent activation of protein • Actikerall (LAS41005) polymorphism increasing NMSC risks? kinase C • 0.5% 5-fluorouracil (5-FU) and 10% • Protection from cumulative UV that • Significantly more exuberant salicylic acid in film-forming base induces NMSC is exerted via signaling neutrophil bursts • Comparison trial against placebo and mechanisms involving the vitamin D • Superior antitumor effect in B16 mice LAS106521 similar compound receptor (VDR) with melanoma • Management strategies • Single-nucleotide polymorphisms in • Improved stability at • Start slowly VDR can potentially increase NMSC ambient temperatures • Wait at least a week after cryotherapy risk: 3 mutations types ApaI, BsmI, • New 4% 5-FU cream in Peanut Oil • Consider regions instead of full face and TaqI • Aqueous vehicle cream w/ peanut oil, • Forehead MWF • Study evaluating 200 patients, matched apply once daily • Rest of face TuThSat for high risk factors—skin type, • 4 week comparison study against 5% • Make sure there is no history of sunburn history, lighter eyes and hair 5-FU bid, n=841 HSV labialis

Page 32 • Bacteriostatic healing ointment • Anticipated ALA PDT Response: • Overall lack of experience and • Barrier restoration erythema and edema regimens in the dermatology world • Pramoxine lotion • Edema generated by mast • Pharma will not support it • Mix equal parts with moisturizer to cell degranulation • Recurrence and relapse data not maximize surface areas • Erythema response is unaffected by completely published • Spray sunscreens H1 blockade • What actually works for treating • Turn the radio up or down but not off • More mast cell related over 72 hours NMSC? • Tips for success than lymphocytic, so steroids not as • Most every agent for treating AKs has • Have patients fill prescriptions between potentially helpful been investigated for treating BCC, only Monday to Thursday—less likely to be • New trial underway to measure LSRs imiquimod is FDA approved for sBCC switched than Fridays or weekends • Randomized, double-blind, placebo- • Topical treatments for SCC still do • Have patients start treatments on controlled, 5-20 AKs not relieve or mitigate the risk of Sundays so that reactions occur mid • 20 patients, given Cetirizine 10 mg invasion or metastasis week rather than on weekends or placebo prior to and • Is the concept of a non-surgical option • Take at least 4-7 days off before and after treatment even possible anymore? Aside from after destructions or surgery • Measure LSRs: erythema, edema, efficacy, what about liability? • Use every adjunct possible crusting, exudation, vesiculation/ • If you were a skin cancer, and want to be except steroids pustulation and erosion/ulceration successful, you would… • Chemoprevention with PDT is not old • Return of red: 10% ALA in • Try to evade the host’s inflammatory news but should be routine nanoemulsion BF-200 (Ameluz®) mechanisms and take advantage • Does blue light PDT using 20% ALA • 7.8% ALA free acid equivalent to of immunosuppression reduce occurrence of AK in high risk 10% ALA • Recruit your own blood supply from patients: 52 week study. • Spectrum around 630 nm the host to sustain growth • Submitted as abstract 5194 • No PpIX induction below the • Maintain and accelerate unregulated • Multi-center evaluator-blinded, basal membrane cell division to outgrow host defenses placebo-controlled study • European studies: emitting light • Become as immortal as possible • Measures occurrence of AKs and between 580–1400 nm to counter host apoptosis and development of NMSC subsequent to • Nanotechnology optimizes the death enzymes cryotherapy then multiple treatments transport of 5-ALA through the • Checkpoint inhibitors for NMSC with ALA-PDT Stratum Corneum • Programmed cell death proteins on • N=166, facial AKs, a history of • Nanoemulsion delivery of BF-200 allows T-cellsà PD-1 NMSC, and histologic evidence of penetration of ALA without permeation • PD-1 binds ligand PD-L1 on tumor dysplasia within clinically normal- into dermis cells blunts immune response appearing perilesional skin • Return of Red: 10% ALA in • Monoclonal Abs (Pembrolizumab) • Clinically evident facial AKs were nanoemulsion gel Phase III pivotal trials target and block this interaction treated with cryotherapy prior to • 779 patients skin type I-II • Cemiplimab (REGN2810)-- FDA initial PDT randomly assigned to • 4 to 8 AKs Breakthrough Designation for ALA-2X: (Baseline, Week 4); ALA- • BF-200 10% gel vs. MAL 21.3% Advanced Cutaneous SCC 3X (Baseline, Week 4, Week 24) or vs. Placebo • EMPOWER-CSCC 1,Phase 2, VEH-PDT • Narrow emission LED lamps 630 nm potentially pivotal, single-arm, open • Placebo treatments matched 1:1 to the • BF-200 10% nano-ALA: Phase III Field label clinical trial of Cemiplimab two active groups treatment efficacy • Enrolling for metastatic or locally • Treatment day • Pros and cons of medical options advanced unresectable CSCC • Remind patients to bring a wide- for NMSC • Various targets for therapy brimmed hat to shield the treated • Pros • Mitogen-Activated Protein Kinases lesions from ambient light • Plenty of non-surgical patients: (MAPKs) Raf/ERK • Bring books, music, or something to • Anticoagulants • Most critical mediator of Ras- pass the time • Oxygen dependent carcinogenesis • Put together a package: • Nursing home/non-ambulatory • Activated Akt promotes cell survival • Topical anesthetics: lidocaine • Issues with anesthesia by inhibiting apoptosis and regulates gel, pramoxine • Surgical fatigue (no más por favor) activation of NF-κB and AP-1 • Moisturizers, sunscreens • Bad locations • Adding MEK inhibitors • There is no reason to stop meds that are • Eyelids (cobimetinib, trametinib) helps sensitizing in the UV spectrum since • Ears combat tumor resistance PDT works in 410-417nm Antibiotics, • Genitals • Demonstrated in melanoma, still Diuretics, Anti-hypertensives • Multiple investigated in SCC • If you are worried, then have them • Cons • Resistance to topical 5% 5-FU - No hold the drugs on the day before and • Expensive controlled studies for 0.5%, 1%, or 4% the day of treatment • Off-label or not covered…or both • 31 patients with sBCC--5% 5-FU bid • Rationale for antihistamines • Margins not defined for 11 weeks:

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• 90% histologic clearance, as early as • Currently in trials for full face, scalp, • Photolyases 3 weeks and chest—3-day prescription with 12 • Naturally occurring enzymes • 10% “tumor resistance” reported month follow up for recurrence • Repair UV-induced thymidine dimers within 3 months • More potent activation of protein • Absent in placential mammals • 29 pts with SCC in situ--5% 5-FU kinase C • Active in organisms with high bid for 4 weeks • Significantly more exuberant cumulative UV exposure. • Complete response rates fall: 83% at 3 neutrophil bursts • Exogenous forms isolated from a months, 60% at 12 months • Superior antitumor effect in B16 mice cyanobacterium Anacystis nidulans in • 17% recurrence after one year with melanoma marine plants • Theories behind resistance: • Improved stability at ambient temps • Long-term use improves: • Dihydropyrimidine dehydrogenase • What works for SCC in situ? • Expression of MMP-1, Ki67, PCNA • Protein deficiencies: Bag-1, Hsp-70 • Topical 5% 5-FU • Mutations of p53, p21 • Stem Cell proliferation • 26 pts, applied bid for about 9 weeks • Photolyases provide protection during tumorigenesis • Complete clearance up to 55 months post-PDT • Imiquimod 5% cream vs excisional • 5% 5-FU vs. ALA-PDT • Sunscreens contain Photolyases surgery (4 mm margin) of nodular or • Daily for 4 weeks vs. one or two cycles encapsulated in liposomes superficial BCC • 12 months after treatment: • 36 pts, scalp AKs, treated with PDT; • 401 (80%) patients intention-to-treat • 5-FU 48% clearance biopsies performed pre-PDT, after one group year 3 • PDT 82% clearance month and one year use • At 3 years, 178 (84%) of 213 pts • Imiquimod 5% cream • Overall reduction of p53 expression cleared with imiquimod group vs • 31 patients, treated qd for 16 weeks (indicative of apoptosis cell) and 185 (98%) of 188 participants in • All resolved with clearance up to Ki67 expression in comparison with a the surgery group (RR 0.84, 98% CI 9 months sunscreen with SPF 50 + 0.78-0.91; p • Erythroplasia of Queyrat: • Preventative effects of photolyases • PDT vs imiquimod vs 5-FU for • Imiquimod doses ranged from 3 compared to conventional sunscreens treatment of sBCC times per week to once daily for • 9 month long study involving 30 • 7 centers in Netherlands, n=601: anywhere from 4 to 24 weeks resulted patients after treatment with PDT on • MAL-PDT; two sessions with interval in clearance the face or scalp of 1 week • Extramammary Paget’s disease • Sustained remission of previously • Imiquimod cream daily, 5 times per • Imiquimod: Adjuvant to surgery treated AKs and in patients treated week for 6 weeks • Topical 5-FU: few case reports once with PDT • 5-FU cream bid for 4 weeks as monotherapy • All patients in the group treated • Follow-up was at 3 and 12 months • Pipeline for NMSC Micali G et al, with photolyases avoided a second post-treatment “Topical Pharmacology for NMSC,” PDT treatment vs. 10 of 15 • MAL-PDT: 144/196 patients 72.8% JAAD, June 2014 subjects in the sunscreen only (95% CI 66.8-79.4) • Dobesilate 2.5% and 5% gel group needing a second treatment • Imiquimod: 158/189 pts 83.4% • Inhibition of Fibroblast Growth to stay clear (78.2-88.9) Factors (FGF) upregulated in • Long-term prevention strategy with • 5-FU: 159/198 80.1% (74.7-85.9) cutaneous tumors exogenous photolyases in sunscreens • PDT vs. 5-FU-vs. Imiquimod for BCC • Impairs proliferation and angiogenesis • Study with Xeroderma Pigmentosum • 3 year follow-up: MAL-PDT, • Stinging and burning on n=8 Imiquimod 5%, and 5% 5-FU first applications • Inherited defects in nucleotide repair • 590 patients treated, 66 treatment • Efficacy data down the road mechanisms and ongoing formation failures within three years • Betulinic Acid of CPDs • Ingenol Mebutate gel and BCC • Purified from bark of Birch Trees • Treated for at least 12 • PEP005 0.0025%, 0.01% and 0.05% • Pentacyclic Triterpenes—direct consecutive months Gel With Two Treatment Schedules, anti-mitochondrial effects lead to • 65% reduction in appearance of Day 1 & 2 or Day 1 & 8 cytotoxicity and promotion new AKs • sBCC 4-15 mm, nBCC of apoptosis • 56% BCC and no new SCC • Ingenol Mebutate 0.05% gel and SCC • Ointment based Triterpenes tolerated • Polypodium leucotomos extract: Yes it is in situ in AKs awaiting trials for BCC and natural but what is the dose? • 24 patients, two applications SCC in situ • Marketed OTC as a food supplement: of 0.05% PEP005 gel on the • Stay away skin cancer… 240 mg capsule extremities, trunk or face • Photolyases—sunscreen based • Antioxidant effects through • Return for check-up visits the day • Polypodium leucotomos extract polyphenolic acids after the first application and routine • Nicotinamide • Use for daily photoprotection is milestones x 2-3 months • Photodynamic Therapy different than incorporation into a • Ingenol Disoxate (LEO 43204) 0.018% • Retinoids treatment regimen and 0.037%: Ester of Ingenol for • NSAIDs • One capsule daily, add one before Treatment of AKs • Caffeine sun exposure

Page 35 • Higher doses~480-960 mg for treating • Just something natural please… • Merkel cell carcinoma vitiligo, melasma, and PMLE • Caffeine • Avelumab • New data: patients with lighter • Oral ingestion: strong inhibitory effect • CDK 4/6 inhibitor of PD skin types could benefit from more on UVB-induced carcinogenesis (programmed cell death pathway) photoprotection from an extra dose • Topical caffeine to the dorsal skin • 88 pts studied—33% complete or than darker patients of mice pretreated with UVB for 20 partial shrinkage • “Measurable suppressive effects on weeks resulted in enhanced apoptosis • 6 months—86% sustained clear, 12 UVB-induced erythema” • Green Tea Extract (Polyphenols) months—45% sustained • Polypodium leucotomos extract for Derivatives for Chemoprevention • Similar studies with chemoprevention? So far only data in mice • DNA repair mediated through IL- Pembrolizumab Cordes LM, • PLE in UV-irradiated mice 12 induction Gulley JL,”Avelumab for the delays tumorigenesis • Anti-photocarcinogenic activity treatment of metastatic Merkel • Increases epidermal p53 expression when green tea added through cell carcinoma, Drugs Today and the anti-oxidant status of UV- drinking water in mice models (Barc), 2017 Jul; 53(7):377-383 irradiated hairless mice • Targets for polyphenols: Ras • New approaches to cutaneous oncology • In non-tumoral skin, this increase oncogene, activator protein-1 • Revival of topical Nitrogen Mustard was significantly higher in PL-treated (AP-1) • Topical hypericin plus UVB— animals than in non-treated mice • Potential additives to sunscreens or localized photodynamic tx • Can contribute in delaying tumor other topical agents • Systemic options revisited: Bexarotene, development, either by repairing the • Epigallocatechin gallate (EGCG) JAK Inhibitors damaged DNA or by • Perillyl alcohol from limonene • PD-1 Inhibitors for CTCL increasing apoptosis • DFMO ornithine • BRAF inhibitors for Langerhans Cell • Studies coming for chemoprevention decarboxylase inhibitor Histiocytosis in humans? • Selenium, retinoids and salicylates • Topical rapalogues for angiofibromas, • Nicotinamide 1000 mg daily ($10 • Switch from liquor to coffee to reduce Kaposi’s Sarcoma per month) NMSC • JAK Inhibitors for GVHD • Phase 3 ONTRAC skin cancer • Meta-analyses: 241 NMSC cases prevention study (942 BCC and 3299 cSCC) cases Holy MACRA! Avoiding MIPS Penalties • N=386 pts, aged 30-91 years, hx ≥2 • 307 articles, 13 case-control Mark Kaufmann, MD NMSC over past 5 years and cohort • Reduced incidence of new skin CA by • For every 10-gram increase in 23% vs. placebo after 1 year among ethanol intake per day, a positive high risk patients association was found for both BCC • Reduced new AKs by 11% at 3 and SCC months, 15% after 12 months • Sparse data at higher alcohol • Prevents UV-induced ATP depletion, intake levels glycolytic blockade • Meant to serve as public • Enhanced DNA repair health message • Reduces UV-induced • Relative risks for NMSC: immunosuppression • 0.96 for one cup of coffee • No vasodilatory side effects: HA, • 0.92 for one to two cups flushing, itching, hypotension • 0.89 for two to three cups • Good news and bad news on using • 0.81 for more than three cups of retinoids for chemoprevention coffee per day, respectively • Good News: • Caffeinated coffee may have dose • Retinoids stabilize differentiation dependent chemopreventive effects and atypical keratinocyte replication against basal cell carcinoma • Inhibit of ornithine decarboxylase • Not to be forgotten… • 2018 changes in reimbursement: • Promote of dendritic cell activity • Sebaceous carcinoma • 10040 +6.87% and restoration of apoptosis • 3 cases/1 million people • 96910 +55.6% • Bad News: Good luck finding a way • Increasing frequency in males skin • 17000: -2.37% to get them for your patients types I-II • 17003: -18.52% • But if you can: Start slow 10 mg • Increasing mortality in males skin • 17004: -12.67% acitretin daily and increase as type VI, extraocular tumor • Two new codes for photodynamic tolerated, 25 mg qod then qd • Dermatofibrosarcoma protuberans therapy- code determined by who does • Titrate up and down to manage side • 0.41/100,000 people the painting effects…but don’t stop • Higher incidences in black skin and • If non-qualified healthcare • Every systemic retinoid is females than in past provider (e.g. medical assistant) does considered off-label • Increasing cases of males over 80 illumination and painting for chemoprevention with tumors on head with chemical

Page 36 • 96567 as you try to see the patient less often, Clinical and Dermoscopic Characteristics of • 2018 payment amount will be do fewer procedures, and shift to less Desmoplastic and Amelanotic Melanomas decreased by 46.66% expensive interventions Ali Banki, DO, FAOCD • MD/DO/MPPA (not RN/LPN) • Consolidate into larger group practices • 96X73: if only paint + illuminate • Increase use of extenders • 96X74: if also debride (targeted & teledermatology curettage, abrasion) at least 1 actinic • One thing government agrees on: keratosis before painting data-driven healthcare • Don’t forget to use J code* • MACRA Bureaucracy and Burnout Panel • Prevented Centers for Medicare Neal Bhatia, MD and Medicaid Services (CMS) from Mark Kaufmann, MD pulling the global periods from Andrea Murina, MD our codes! Lisa Swanson, MD • Repealed the SGR (Sustainable • AADA actively working on: Growth Rate) avoiding a 21% pay cut • FDA’s compounding proposals • Mandates The Merit based • Access to pharmaceutical Incentive Payment System begin in cost transparency 2019 (MIPS) • Medical spa standards • Those in Alternative Payment Models • Easing burden of prior authorization (APMs) will be excluded from the • Fighting scope expansion • Desmoplastic melanoma (DM) MIPS program efforts nationwide • Accounts for less than 4% of primary • 99024 - Use if you see someone in • Truth in advertising (e.g. board cutaneous melanomas global period (not payable visit but certified credentials) • Elderly individuals tracking visit) • Successes in 2017 • Found on chronically sun-damaged skin • Any group of 10 or more • Sunscreen allowed in schools in • The male to female ratio is physicians/qhp needs to start 7 states approximately 2:1 reporting code 99024 on ALL visits • Step therapy in 3 states • DM most often affects the head and that take place in the global period: • Indoor tanning restrictions 2 states neck region (51%) • Florida, Kentucky, Louisiana, • Modifier 25 update: • Extremities (30%) Nevada, New Jersey, North Dakota, • Only 3 E/M codes cover cost of • Trunk (17%) Ohio, Oregon, Rhode Island PE and malpractice RVUs (99204, • Clinical presentation • MIPS: 2017 is a transition year. How to 99205, 99215) • It can arise de novo: tan, avoid penalties- • Anthem: 14 states. Some of which as erythematous, firm papule, nodule, • Test pace: just have to submit of January 2018 will only pay 50% of or plaque, usually lacking any something for MIPS. Cheat Sheet… evaluation and management modifier epidermal component or as an ill- • https://qpp.cms.gov/mips/ • What YOU can do: spread the defined scar like lesion quality-measures word- state insurance commissioner, • It can be associated with other • Data submission methods drop patients, small business associations melanoma subtypes, mainly down menu à claims à in your state, insurance companies, lentigo maligna type: It is • Documentation of current Centers for Medicare and Medicaid recommended to palpate the skin medications in the medical record Services, state/federal legislators overlying a lentigo maligna to • Be sure to include all of following: • Otherwise…People will end up not detect for any dermal tumors medication name, dosage, frequency having procedures done same day • Differential diagnosis and route of administration they are seen • Benign: • Use code G8427 (current • www.surveymonkey.com/r/mod25 • Dermatofibroma, Scar, medications documented) for more information Cyst, Neurofibroma • EOB: look for comment code N620 • Burnout • Malignant: (“this procedure code is for quality • Compared to 2011, burnout among • Sarcoma, Basal cell carcinoma, reporting/information purposes dermatologists has increased from Squamous cell carcinoma, only”) = you have submitted a 31.8% to 59.6% Amelanotic melanoma quality measure. • Tips: Off-load nonessential tasks, • Histopathological subtypes • **Only has to happen one time on one reasonable pace and productivity • Two subtypes, based on the degree patient to be exempt from targets, allow “protected time” of desmoplasia: 4% penalty! to complete administrative tasks, • 1. Pure DM: More than 90% of the • Partial participation commit time to customizing EMR, tumor shows desmoplastic features • Full participation be involved in making rules, reward • Pure DM is less likely to affect • Healthcare Reform: successes, collect positive patient the lymph nodes and has a less • Challenges to being paid for value not comments, lunch with peers, mentor, aggressive course compared to volume: financial incentive reversed teach, advocate the mixed DM

Page 37 • 2. Mixed DM: Desmoplastic features in less than 90% • Key points but more than 10% of the lesion • DM head and neck, elderly individuals • Perineural invasion • Non-pigmented, tan or erythematous, nodule or plaque • DM frequently show perineural invasion and such tumors • Associated with lentigo maligna, palpate the underlying skin are termed desmoplastic neurotropic melanoma • Two forms histologically: Pure and Mixed • Aggressive, higher tendency for local recurrence • Mixed DM more aggressive form, more likely to invade the • Dermoscopy review regional lymph nodes • Vascular morphologies melanocytic lesion • Dermoscopy summary for DM • Linear comma-type (dermal nevi) • Atypical vascular structures (high prevalence) • Dotted (melanomas, melanocytic lesions, spitz nevi) • Dotted blood vessels, linear irregular blood vessels, • Linear irregular (melanoma) Polymorphous blood vessels, Milky-red areas • Vascular morphologies nonmelanocytic • Melanoma specific structures (100% of cases) • Linear loop/hairspin (SK) • Peppering more frequent in pure DM • Glomerulus (bowens, itraepidermal carcinoma, SCCIS) • Crystalline structures, polymorphous vessels, and milky read • Branched (nodular bcc) area more common in mixed DM • Vessels never crossing through center of lesion • Amelanocytic melanoma (sebaceous hyperplasia) • Accounts for 2-8% of all melanomas • Melanoma specific structures • Sun exposed skin, elderly individuals • Helical vessels • Nodular or superficial spreading • Milky globules • Males: found on the trunk • Linear irregular vessels • Females: found on the limbs • Dotted vessels • Clinical presentation • Irregular dots/globules • Can be classified into three groups according to the extent • Irregular pigment network or absence of pigment: • Irregular streaks • 1. Amelanotic - complete lack of melanin even • Regression (peppering scar-like depigmentation) under dermoscopy • Crystalline structures) • 2. Partially pigmented-pigmentation is found in less than • Blue/whitish veil 25% of the lesion • Irregular pigmentation • 3. Lightly colored melanoma-faint brown pigmentation • Dermoscopic features study that covers more than 25% of the lesion but without dark • The most common dermoscopic features in DM include brown, blue or black pigmentation • Atypical vascular structures, peppering, and occasionally • Truly amelanotic melanoma: other melanoma specific structures • Superficial: asymmetrical or symmetrical erythematous • Largest series describing dermoscopic features of DM macules or patches with/or without scale (n=37) • Nodular: flesh colored, pink, red. EFG (Elevated, firm, • All DM featured at least one melanomaspecific structures growing), lacking ABCDs of melanoma • Most common being atypical vascular structures (81%) • Hypomelanotic melanoma: • The most common melanoma-specific structures after • Look for signs of pigmentation (especially pigmentation atypical vascular structures were as followed: pattern with dermoscopy) • Regression structures (peppering and scarlike areas) • Differential diagnosis • Blue-white veil • Benign: • Atypical globules • Eczema, Contact dermatitis, Pyogenic granuloma, Nevi, • Atypical network Hypergranulation tissue, Hemangioma • Peppering was more frequent in pure DM than • Malignant: mixed DM • Basal cell carcinoma, Bowen’s disease • Crystalline structures, polymorphous vessels, and milky • Study: Clinical and dermoscopic characteristics of red area were more commonly seen in mixed DM than in amelanocytic melanomas not nodular types pure DM • Retrospective review of 20 amelanotic melanomas • It can be hypothesized that since mixed DM has more • Amelanotic melanomas often present as symmetrical of a melanoma specific structures (crystalline structures, erythematous lesions polymorphous vessels, milky red area) therefore it can be • Superficial spreading type: more easily be diagnosed than pure DM • Scaly, erythematous macules and patches, with a relatively • At least one of the 14 melanoma-specific features evaluated circular to oval symmetric shape, and regular border on dermoscopy was found in 100% of DM • Dermoscopic criteria of melanomas lacking pigment, • Dermoscopy may be a useful tool for identification of DM depends on the analysis of its vascular structures: • Study of dermoscopy and confocal microcopy in DM • Most common vascular structures: • Both this study and Jaimes et. al found a high prevalence of • Dotted vessels atypical vascular structures in DM • Milky-red areas • Both studies found melanoma-specific structures in 100% • Linear irregular vessels (serpentine) of cases • Polymorphous vessels

Page 38 • AM should be strongly considered if one of the following • Key dermoscopic vascular features: three vascular structures is present: • Dotted vessels • More than one shade of pink, • Milky-red areas • Dotted and linear irregular (serpentine vessels) • Linear irregular vessels • Predominant central vessels • Polymorphous vessels • This study showed that 90% of the lesions has at least one • Other features to look for when lesion has some of the vascular criteria: pigmentation: • More than one shade of pink most common (80%) • Blue-white veil • Dotted and linear irregular (serpentine vessels) (60%) • Scarlike depigmentation • Predominant central vessels (20%) • Multiple blue-gray dots (peppering) • Study: Dermoscopic evaluation of amelanotic and • Irregularly shaped depigmentation hypomelanotic melanoma • Irregular brown dots/globules • 105 melanomas • Nodular Amelanotic melanoma: • 170 Benign melanocytic lesions • EFG (Elevated, Firm, Growing), despite lacking ABCDs • 222 non-melanocytic lesions of melanoma • Lacking significant pigment (amelanotic, partially • Biopsy these lesions pigmented or lightly colored) • Imaged using glass-plated dermoscopy and scored for 99 Desmoplastic Melanoma: Surgical Management and Adjuvant Therapy dermoscopic features Dale Han, MD • Main outcome measures: • Sensitivity, specificity, and odds ratio for individual features and models for the diagnosis of melanoma and malignancy • The most common predictor of melanoma lacking significant pigment: • Blue-white veil • Scarlike depigmentation • Multiple blue-gray dots (peppering) • Irregularly shaped depigmentation • Irregular brown dots/globules • 5 to 6 colors • Predominant central vessels • The most significant negative predictors of melanoma: • Multiple >3 milia like cysts • Comma vessels with a regular distribution • Background • Comma vessels as the predominant vessel type • Desmoplastic melanoma (DM) represents <4% • Symmetrical pigmentation pattern of melanomas • Multiple blue-gray globules • Older patients (median age: about 65 years) • Thickness of amelanocytic melanoma • More common in males and on head and neck • Thin AM < 0.75mm: • Often thicker tumor compared with non-DM • Atypical network • Median thickness for DM: 2.5 – 3.7 mm • More than 1 shade of tan or brown • In contrast, for all newly diagnosed melanomas • Dotted/pinpoint vessels (as the predominant type) • 70% are thin melanomas (≤1 mm) • Thick AM, > 1 mm • Median tumor thickness approximately 1 mm • Greater frequency of hairpin vessels • Distinct biology with clinical behavior that is unique • Central vessels compared with non-DM • Ulceration • Histologically divided into pure and mixed subtypes based on • Large diameter vessels and irregular vessels the extent of desmoplasia • Pink color • MSKCC classification system • Key points • Pure DM: spindle cell melanoma with ≥90% desmoplasia • Sun exposed skin, elderly individuals Yale University School of Medicine • Accounts for 2-8% of all melanomas • Mixed DM: desmoplasia involving 10% of the spindle • Can be classified into three groups according to the extent cell melanoma or absence of pigment: Amelanotic, partially pigmented, • DM histologic subtype correlated with outcome lightly colored melanoma • In 2004, Busam et al. classified DM as pure or • Spotting amelanotic melanoma can be challenging, due to a mixed/combined broad differential diagnosis and lack of significant pigment • Histologic subtype significant predictor of disease-free • Dermoscopy can be an effective tool in diagnosing these survival (DFS) on multivariable analysis lesions at an earlier stages • Mixed DM: 3.5 times greater risk for death or metastases • Vascular features can be useful for amelanotic melanomas (95% CI 1.3 – 9.5) compared with pure DM (no Pigment) • Hawkins et al. compared DM histologic subtypes

Page 39 • Classified as pure or mixed DM • Conley et al.: 3 of 7 (42.9%) patients • 5-year melanoma-specific mortality (MSM) varied by • Devaraj et al.: 4 of 13 (30.8%) patients histologic subtype • Larger and more recent studies on DM (2001 onward) show • 31% for mixed DM much lower overall nodal metastasis rates • 11% for pure DM (P <0.01) • SEER-based studies: 2.8 – 4.3% • Melanoma variant with unique biology • Single institution studies: 9 – 18% • Treatment of primary melanoma • Lower nodal disease rate for DM compared with non-DM • Wide local excision (WLE) • Nodal metastasis rates for non-DM of comparable thickness • Margins: (>3 mm) is >25% • 0.5 - 1 cm for in situ • Livestro et al.: • 1 cm for ≤1 mm • Case-matched DM and non-DM patients by age, gender, • 1 or 2 cm for >1-2 mm tumor thickness • 2 cm for >2 mm • SLN metastasis rates lower for DM (8%) compared with • Resect to fascia non-DM (33.8%, P=0.013) • Closure of defect • Melanoma variant with unique biology • Local control + remove microscopic satellites • Sentinel node biopsy for desmoplastic melanoma • Wide local excision margin for desmoplastic melanoma • Given the lower nodal metastasis rate for DM, use of SLNB • P=0.014 5-year overall survival: for DM is debated • 79.5% for pure vs. 61.3% for mixed DM (P=0.001) • SLN disease rates for DM • Patients with mixed DM had higher death rate than those • Contemporary series: 0 to 18.2% with pure DM • Several studies report a zero rate of SLN metastases for DM • Different biology between pure and mixed DM • Small series assessing <25 patients who • Locally, pure DM is more aggressive underwent SLNB • Mixed DM behaves like non-DM for local disease • Of these, one study specific for head and neck but was • No data presented for pure DM ≤1 mm thickness treated also the only one to assess histologic subtype with 1 cm margin • Studies evaluating SLNB in DM • Nodal status for melanoma • +SLN rate: – If exclude zero rate of +SLN: 6.2-18.2% – If • Nodal status predicts survival for melanoma exclude studies with <50 patients: 6.3-13.7% • Majority with no clinical evidence of nodal spread • Although lower rate of nodal disease for DM compared • Microscopic nodal spread? with non-DM, nodal status appears to predict survival in • Morton et al. reported on sentinel lymph node biopsy DM patients (SLNB) for melanoma as a less invasive technique to evaluate • SLN disease rate in the range of 6 – 14% nodal status • If a 5% risk threshold for nodal disease is utilized to justify a • Within SLNB group, melanoma-specific survival (MSS) procedure, SLNB would in general be indicated for DM differs significantly based on SLN status in intermediate • Prognostic value of SLN status in desmoplastic melanoma thickness (1.2-3.5 mm) and thick groups (>3.5 mm) • Most studies on DM are unable to assess prognostic • Crucial staging tool providing significant prognostic significance of SLN status due to low numbers information in intermediate thickness group • Two studies showed that SLN status significantly • Is nodal status also prognostic for DM? predicted DFS • Nodal status predicts survival for melanoma but is this also • Additional study demonstrated that a positive SLN status was true for DM variant? significantly correlated with a higher MSM • Feng et al. studied DM patients in the SEER database • Which DM patients are at higher risk for a positive SLN (1992 – 2007) • Rates vary with histologic subtype • Nodal metastasis correlated with higher risk for DM- • Significantly higher positive SLN rate in mixed versus specific death pure DM • Not consistently seen in other SEER-based studies on DM • SLN disease rate for mixed DM: 8.5 – 24.6% • Most studies on DM unable to assess prognostic significance • Potentially mirrors what is seen for non-DM of nodal status due to low numbers • Pawlik et al. compared non-DM with mixed DM and • Recent large study evaluated predictors of survival in DM pure DM patients • Non-DM positive SLN rate 17.5% • 316 patients presented with local disease • Mixed DM positive SLN rate 15.8% • Median follow-up: 5.3 years – Positive nodal • SLN disease rate for pure DM: 2.2 – 9% status included: • Which patients with DM should be offered SLNB? • Positive SLN patients • Older population: consider age and comorbidities • Negative SLN patient who developed nodal recurrence • Based on a 5% risk threshold for nodal disease, SLNB should • No SLNB and developed nodal recurrence be offered for mixed DM • Patients with positive nodal status significantly predicted • Controversy over use of SLNB for pure DM MSS for DM patients on multivariable analysis • Often thicker but lower positive SLN rate • Nodal metastasis rate for desmoplastic melanoma • If follow lower range for a positive SLN (2-4%): SLNB • Initial and early reports showed relatively high nodal disease rates probably should not be done

Page 40 • If follow upper range for a positive SLN (5-9%): SLNB Dermoscopy Simplified: the TADA Algorithm probably should be offered Ashfaq A. Marghoob, MD • Remains debated and further studies are needed • Completion lymph node dissection for melanoma • Completion lymph node dissection (CLND) recommended for positive SLN • SSO/ASCO and NCCN guidelines • Based on data showing unknown survival benefit* • Recommended for regional disease control • Rate of additional nodal disease in CLND after positive SLNB: • Range: 15-32% • MSLT-I: 16%, Sunbelt Melanoma Trial: 16% • Meta-analysis: 20.1% • For DM, what is the rate of finding additional nodes with metastatic disease after a positive SLNB? • Limited data due to low numbers of positive SLN patients • 2 larger studies (>200 patients) reported on positive CLND rates • Melanoma specific structures • Moffitt Cancer Center: 4 of 24 (16.7%) positive SLN • The more structures present, the higher likelihood a lesion is patients with additional positive CLND nodes a melanoma • Melanoma Institute Australia: 4 of 17 (23.5%) positive • Intraclass correlation for any given melanoma specific SLN patients with additional positive CLND nodes structure is poor, ranging from 0.05 to 0.34 • Positive CLND rate for DM also appears consistent with • Ground truth is that if a structure is present, rates of reported literature melanoma are still higher • Does performing CLND improve survival? • The distribution of colors and structures is more important • DeCOD-SLT Trial than any single color or structure that is present • MSLT-11 Trial • i.e. organized versus disorganized on dermoscopy images • No survival benefit for having CLND • Are there simpler methods for melanoma detection? • Adjuvant radiation therapy for DM • Triage algorithm • Studies show radiation therapy improves local • Other published algorithms: 3-point checklist, AC rule, BB control significantly rule, Chaos & Clues, and prediction without pigment • Radiation therapy, margin status, and subtype were • TADA algorithm (triage amalgamated dermoscopy algorithm) good predictors • SKs, hemangiomas, and DFs do not enter the algorithm • Adjuvant systemic therapy options for nodal disease (unequivocal lesions) • Interferon • Then look at organized versus disorganized on dermoscopy • High dose ipilimumab (10 mg/kg) • If disorganized, biopsy it! • Clinical trials • Then examine specific structures • Neoadjuvant (for macroscopic nodal disease) vs. adjuvant • Some cancers are organized and are difficult to diagnose • Targeted therapy • Difficult due to morphology • Various immunotherapy regimens • Nodular • Summary • Pigmented: lack features of BCC, nevi, and SK. They • DM is histologically categorized into pure and mixed subtypes also lack network, streaks, and regression • WLE margins for DM are similar to what is used for • Amelanotic: lack features of BCC, nevi, and SK. They non-DM, but thinner cases of pure DM may need also lack arborizing vessels and comma vessels. 2 cm margins • Desmoplastic • As for non-DM, nodal status is also prognostic for this • Pure (no epidermal changes) and mixed types melanoma variant associated with LM • Nodal metastasis rate in DM is lower than for non-DM but • Nevoid varies by histologic subtype • Histologic definition: the cells have a nevoid appearance • SLNB for DM provides key prognostic data • Nevoid with conventional features • Significantly higher positive SLN rate for mixed DM • Nevoid with nevus like structures compared with pure DM (similar to non-DM) • Amelanotic • For medically fit cases, SLNB should be offered for patients • Nodular and non-nodular variants with mixed DM • Non-nodular are often pink and symmetric • Controversial if SLNB should be used for pure DM cases • If you see only dotted and linear vessels in a and further studies needed lesion, the only thing you should suspect • Adjuvant radiation may be used to improve local control, is melanoma particularly in cases with positive margins or other high • Spitzoid risk features • Lack ABCD features

Page 41 • Starburst, negative network, • Drugs approved for melanoma: • Standard dose (metastatic disease) and shiny white lines are • Anti CTLA4 = ipilimumab versus the high dose which is 3 times known features • 20% of patients are alive at the standard (used as an adjuvant) • Difficult to diagnose melanomas that 10 years, which is a huge • The future of adjuvant therapy SHOULD be biopsied have varying change in previous data • Anti PD-1 antibodies are features including: (previously 0%) better than CTLA-4 in • Starburst pattern • Became standard of care metastatic melanoma • Blue or black color in 2011 • Makes sense to try it as • Gray color • Anti PD-1 = pembrolizumab, adjuvant therapy • Shiny white structures or nivolumab (more nontoxic) • Adjuvant targeted therapy white circles • Pembro versis ipi was shown to • BRAF/MEK combo for BRAF+ • Negative network improve survival from 20% to patients is on the horizon • Vessels (dotted AND linear) 40% at 10 years • Ulceration • Anti PD-1 is better than Anti Surgical Approach to Melanoma • Overall, the sensitivity of TADA is CTLA4 à making it the new Merrick I. Ross, MD about 95%, and specificity of 72% standard of care • Irrespective of lesion, the sensitivity • Combining Anti CTLA4 is about 95% and PD-1 • Previous training in dermoscopy • Response rates with combo does not affect the sensitivity therapy are higher than (comparing dermatologists to family ipi alone medicine physicians) • However, survival rates are no different; Only progression Updated Medical Treatment for Melanoma was diminished with the Sanjiv Agarwala, MD combo therapy • Combo therapy also has higher rates of adverse events, coming on sooner and take longer to resolve • Higher levels of the biomarker PDL-1 is shown to improve tumor response to a single drug versus combo therapy • Stage I and II patients (up to 85% of • BRAF+ therapies (remember we can use new melanoma patients) targeted or immunotherapy) • Margins of excision • BRAF mutation is present in 50% • <1 mm : 1 cm margins of melanomas • 1-2 mm: 1-2 cm margins (adjusted • You can target both BRAF and MEK in anatomically restricted areas) (another enzyme in the same pathway) • >2mm : 3 cm is better than 1cm, to improve outcomes with oral 4 cm is not better than 2 cm, 3 cm medications can’t be better than 2 cm, most 2 • Previous therapies were largely poisoning • Targeted therapies have a high cm excisions can be closed primarily the patient, and we have moved toward response rate that is very rapid • Regional nodes are most common site of much more targeted therapies • Immunotherapy takes a longer time first recurrence after WLE of melanoma • Current therapeutic agents for to work • Goals for SLN Biopsy is to improve metastatic melanoma • When comparing targeted versus disease outcome and provide minimally • BRAF-WT patients (~50%) à immunotherapy in these patients, the invasive approach to nodal staging immunotherapy (mono or combo) outcomes are similar • Risk factors for regional recurrence • BRAF+ patients (~50%) à • Front line and second line therapy of after surgery alone has a weighted immunotherapy or targeted therapy BRAF Inhibitors is almost no different average of 21% • Immunotherapy in terms of response rates • Nodal dissection significantly • Checkpoint inhibitors • Current status of adjuvant therapy improves the outcomes of durable • T-cell activity is regulated by • The burden of high risk disease dwarfs local regional disease control immune checkpoints to limit that of advanced melanoma. Adjuvant • Multidisciplinary components auto-immunity therapies are mostly used for stages • Preoperative lymphoscintigraphy, • Immune checkpoints function at IIB to III surgical approach, and the different steps in the • Adjuvant IFN-a treatments (the old) pathologic evaluation of the immune response to regulate at • It’s non-targeted immunotherapy node all require high level of care multiple phases • Ipilimumab (the new) and detail

Page 42 • Stage III patients • Case 1 • There is huge prognostic heterogeneity in this patient • Local recurrence (or possibility of new primary?) after initial population ranging from 30% to 90% wide excision of primary melanoma • CLND was recommended for stage III patients in the 2015 • Next steps: further excision and new split thickness skin graft NCCN guidelines and SLN biopsy • Rationale: probability of +NSLN for staging, improved • Case 2: History of 10+ melanomas regional control, improved survival, and less morbidity for • Two rounds of isolated limb perfusion with Melphalan and the patient TNF performed • A selective approach to completion dissection • Topical Aldara tried with little benefit is rational • Placed on Dendritic Cell Vaccine Protocol and resulted in • The strong independent prognostic significance of positive complete response to therapy and remission since 2008 NSLN has been confirmed by 4 separate studies • Case 3: 3 primary melanomas + history of lymphoma • Reasons for CLND after positive SLNBx • Added risk of her diagnosis of lymphoma to her melanoma risk? • Improved regional disease control and less post-dissection • If prior radiation treatment for lymphoma definitely need morbidity for patients with non-sentinel node involvement increased screening for basal and squamous cell carcinomas, (may be the only benefits of CLND) but melanoma(?) • However, there is no direct evidence that CLND provides a • Anecdotally seems to be a link but no known survival benefit associated syndrome • New NCCN 2016 guidelines recommend that you discuss • Role for genetic testing? and offer CLND with patients • Probably no but opinions differ • Stage IV patients • Role for new DermTech adhesive skin biopsy skits due to the • Oligometastatic disease (resectable) numerous scars from excisions and biopsies? • Standard of care is upfront surgery, selective use of • More false positives with DermTech adjuvant irradiation, and the use of systemic adjuvant • Case 4: Incompletely excised melanoma on scalp, lesion in right therapy (nivolumab) lower lobe of lung questionable on CT à PET +, negative SLN, • Potential benefit of treating patients before surgery has FNA biopsy of lung lesion positive for desmoplastic melanoma potential advantages including • BRAF WT: excise and give adjuvant therapy according to • Decrease surgical burden and morbidity recent trial, or expectant management with immunotherapy • Avoid unnecessary irradiation • Patient was placed on nivolumab and disease is stable • No delay in treating micro-mets, preventing distant • Case 5: Pigmented lesion on thumb with irregular bands x 8 disease spread years. Proximal nail biopsy (because lunula involved) revealed • Systemic therapy may be more effective with the tumor severely atypical melanocytic proliferation approaching the in tact (more tumor to target, more antigen, more T-cells diagnosis of melanoma in situ to activate) • Treatment? Remove entire nail matrix, save dorsal tendon, • Possible role for intralesional therapy cross finger flap • Case 6: Superficial spreading melanoma treated with 8 wide Case Studies in Melanoma: An Interactive Panel local excisions on scalp + imiquimod. Single focal invasion of Sanjiv Agarwala, MD 1.18mm along a hair follicle, final margins appeared clear Ashfaq A. Marghoob, MD • No regional nodal disease by ultrasound of head and neck Merrick I. Ross, MD area, chest x-ray negative for metastasis Edward H. Yob, DO, FAOCD – Moderator • Next step? No further therapy recommended

Page 43 Select Dermatopathology Topics for the Melanoma. N Engl J Med. 2017 Jun • The skin can be wet or dry Practicing Dermatologist 8;376(23):2211-2222) • Topical steroid burst for severe flares Sean Stephenson, DO, FAOCD • Melanomaprognosis.org (as effective as oral prednisone without • Cutaneous Squamous Cell Carcinoma • Criteria based on the withdrawal flare) staging update: AJCC7 vs. AJCC8 • Primary or metastatic • Clobetasol BID for 4-5 days • T category changes with T1-2 based • Age of patient • Fluocinonide BID for 10 days on purely on size, and T3 based on • Location • TAC BID until clear or follow size and high risk features • Breslow depth up appointment • High risk feature: depth of invasion • Ulcerated vs. non-ulcerated • Pimecrolimus study from Pediatrics changed to beyond the SC fat or • Estimates 1, 2, 5, and 10-year • No evidence of lymphoma, >6mm melanoma survival malignancy, or immune system • Differentiation, immunosuppression • Gene expression profiles impairment in a study of 2418 and anatomic location no longer are • Offers additional information to patients. Concluded that it was safe high risk features TNM and SLNB even in the younger age group (age • Comparison of BWH alternative staging • Serum studies 3-12 months) system vs. AJCC8 • Higher S100-Beta Protein in • New treatments • BWH based on number of risk factors melanoma stage III and IV • Crisaborole: Boron based treatment. including but not limited to size poorer prognosis Inhibits PDE4 and decreases • Important Changes in Melanoma • Spitz tumor markers with proinflammatory cytokines Staging AJCC8 vs AJCC7 poorer prognosis • 50% patients clear/almost clear at • Measurement to the nearest 0.1mm • Gain of 6p25 and 11q13 4 weeks (from .01mm) • Deletions of 9p21 • Stinging/burning is the only • Mitoses are no longer part of the T1 • TERT-p mutations major side effect category for thin Melanoma <1mm • Positive SLNB not poor prognostic • Dupilumab: blocks IL-4 and IL- • T1 category uses 0.8 mm as a factor for atypical spitz tumor 13, decreasing TH2 threshold with T1b category • Immunohistochemisty and molecular inflammatory response defined as 0.8 – 1 mm with or studies (e.g. FISH and gene • SubQ every other week without ulceration expression profile) can aid in a • Good side effect profile • “Microscopic” and “macroscopic” more definitive diagnosis with • Injection site reaction, detection of tumor in lymph nodes is melanocytic lesions conjunctivitis, and HSV now referred to as “clinically occult” • Re-excision of dysplastic nevi (questionable, because there’s a and “clinically detected” • Low grade- none decrease in eczema herpeticum) • New N1c, N2c, and N3c categories • Moderate grade • Studies in kids are happening that take into consideration the • If out in the planes of section right now. Early reports show presence of microsatellites, satellite examined (shave or punch), and positive results metastases, and in-transit metastases clinically completely removed: likely • Nemolizumab: IL-31 blocker, the • New M1d for distant metastasis ok to observe for recurrence “itch cytokine” to CNS • If extends to biopsy margin and • IL-13 blockers including • How could it affect your practice? clinically completely removed: lebrikuzumab and tralokinumab • Melanomas 0.76-1.0 mm thick: SLNB observation for recurrence is • Ustekinumab may be beneficial in may be considered in the appropriate likely ok some AD patients clinical context (e.g. age ≤45, Breslow • If extends to biopsy margin and • Natural treatments depth ≥0.85 mm, mitotic rate >1mm, clinically is visible: likely should • Coconut oil has good and/or with ulceration) completely remove antibacterial properties • ≤1.0 mm: little consensus as to what • High grade • Sunflower seed oil does appear should be considered “high-risk • Full thickness elliptical excision to help. Aroma workshop in features” for a positive SLN recommended (with up to 5mm Chicago has the best formulation. • Conventional risk factors margin of normal skin) • Olive oil makes AD worse! for a positive SLN, such as • If diagnosis is confirmed by FISH, • Chilled noxzema can help ulceration, high mitotic rate, and CGH, or GEP should still do a full decrease the itch lymphovascular invasion (LVI), thickness elliptical excision • Hard water can worsen AD are very uncommon in melanomas (recommend a water softener) ≤0.75 mm thick. When present, Pediatric Dermatology • Prevention of AD SLNB may be considered on an Lisa Swanson, MD • Don’t smoke, avoid exposure individual basis • What’s new in atopic dermatitis? • Probiotics taken by a pregnant • If the SLNB is positive does complete • Patients have increased risk of anxiety woman 2 weeks prior to delivery and dissection improve survival? and ADHD, injuries, and infections for the first 3 months after delivery • No (Faries MB, et al. Completion • Always do topical steroid ointments in • TEWL management early on in Dissection or Observation for little kids a baby’s life can reduce AD risk Sentinel-Node Metastasis in • There is no need to “soak and smear” by 50%

Page 44 • Most studies now show that ⅔ of • Alternative treatments • Epipens are unnecessary children outgrow AD by age 5, and • 1 cup baking soda to a bath • What’s new with moles? more by adulthood once weekly • Giant congenital nevi • Early peanut exposure reduces the rate • Fish oil has been shown to be • >20 satellite nevi increases risk for of allergies helpful in small studies neurocutaneous melanosis • What’s new in pediatric allergic • What’s new in pediatric rashes • New classification of 6 patterns, contact dermatitis? • Perioral dermatitis hopeful to determine which are at • Wet wipe contact dermatitis • Standard treatment is elidel BID, greatest risk • Also think about wet wipes as a amoxicillin 30 mg/kg/day divided • Eclipse nevi cause of persistent facial dermatitis BID for a month • Typically on the scalp with 2 tones • Nickel contact dermatitis • Always ask about steroids (inhalers, • Path is often “overread” because this • Most common contact allergen topicals, nasal sprays) because they is a special site • www.nonickel.com can aggravate this rash • What’s new with acne • Can trigger an id reaction • Diaper rashes • Happening younger and younger • Can be confused with Gianotti- • Irritant contact (concave • Epiduo is now approved for 9 Crosti (but GC involves the ears) surfaces affected) and yeast and older which lasts up to 8 weeks (satellite pustules!) • Skim milk appears to be associated • Shin guard dermatitis • Use zinc oxide barrier cream with with increased acne, but not • Try drysol, guard liners, and some each diaper change other dairy. even use duct tape • Pick one cause and go with your • High glycemic index diets increase • Use fluocinonide or clobetasol to treat gut and treat. If not significant acne • Toilet seat dermatitis improvement, use the other • Changes in isotretinoin monitoring • Either a reaction to a cleanser or to treatment option • At baseline, and after 2 months of the components of the seat itself • Hydrocortisone 2.5% therapy • Plastic training seats are for irritant • No need to check CBC common triggers • Econazole 1% for yeast • Isotretinoin and depression • Classic on the lateral buttock and • HFMD • Did NOT show any posterior thighs • Commonly produces association, actually showed an • What’s new in pediatric psoriasis? onychomadesis 1-2 months later improved mood • Plaque psoriasis is a little less common • Tinea capitis • However, doctors still report in kids • Cochrane review considered anecdotal evidence few and far • Guttate - can be triggered by strep griseo (20-25 mg/kg/day) and between • Inverse - nearly always mistaken for terbinafine are both 1st • OCPs year/tinea in kids/teens line treatments • Become comfortable prescribing • Anti TNF alpha psoriasis - most • Never use oral ketoconazole! these as dermatologists! common on the scalp • Onychomycosis • Start the Sunday after the patient’s • Caused by infliximab and humira • Treat with terbinafine for 3 months period starts most commonly • <20 kg- 62.5 mg daily (1/4 pill) • Migraine with aura are at increased • Check the nails, tongue, and • 20-40 kg- 125 mg daily (1/2 pill) risk of stroke while taking OCPs, so belly button • >40 kg- 250 mg daily determine this during history taking • #1 association in children is obesity • Griseo does not work • All OCPs help with acne • Screen for diabetes and NASH every 3 • Lichen sclerosus • Best: Yaz, Yasmin years starting at age 10 • Maintenance treatment is better • Contraindications: age >35, heavy • Topical treatment than as needed treatment smoker, migraines with focal • Clobetasol • Shingles neurologic symptom • Elidel/protopic for face/folds • Unclear why this is occurring • Progesterone only birth control • Steroids are the mainstay treatment • Treat with acyclovir 30-50 mg/kg/ increase acne • Biologic therapy day, valtrex if they’re old enough • What’s new with hemangiomas? • Etanercept is now approved for • Crohn’s disease • Propranolol is still great! children as young as 4 • “Persistent funky rash” in • Dose for a baby is around • Adalimumab is currently pursuing a the genital area or persistent 1 ml TID pediatric indication penile/scrotal swelling showing • 2 mg/kg/day divided TID • Ustekinumab is now approved for granulomatous inflammation • ALWAYS give with food to kids 12 and older • Urticaria pigmentosa prevent hypoglycemia • Live vaccines need to be avoided! • Most kids outgrow it (mean • Topical timolol 0.5% gel • MMR, varicella, Herpes zoster, duration 9-10 years) forming solution is best for intranasal flu • No reason to check serum tryptase superficial hemangiomas • Others: typhoid, yellow fever, • No risk of mast cell leukemia • Can also use for oral polio, vaccinia/smallpox, • Manage with topical steroids prn, pyogenic granulomas BCG, rotavirus antihistamines +/- • What’s new in genodermatoses?

Page 45 • Ichthyoses can be associated with vitamin D deficiency • Onset less than 15 years of age may indicate more severe, • What’s new with cooties? resistant disease • Scabies • Family history • “Dirty” appearing rash in babies with pustules on • Up to 33% patients report family history palms/soles • HLA-B13, B17, Bw57, Cw6 (most significant) • Treat the whole family!! • Genetics of psoriasis • Post scabietic dermatitis: schedule follow up 1 week after • 2000: susceptibility loci completing scabies treatment • PSORS1: 6q21.3 most common genetic abnormality • What’s new in warts? • Clinical features • WartPeel is a great treatment • Chronic relapsing immune dysregulatory • New studies show giving HPV vaccine can clear large numbers inflammatory disease of warts • Don’t forget to screen for psoriatic arthritis • What’s new in molluscum? • Psoriatic plaques • Candida injections treating 1 every 3 weeks • Erythema (redness) • Pseudofurunculoid • Induration (thickness) • BOTE - beginning of the end sign • Desquamation (scaling) • Can cause an ID reaction • Affected areas of the body • What’s new in JAK inhibitors? • Bony prominences • Increasing use in alopecia showing good outcomes • Symmetric • Also used in vitiligo (and ensure patients get sunlight) • Extensors (elbows, knees) • Other tips and tricks • Scalp • MAM air pacifier • Trunk • Buzzy (for injections/biopsies) • No permanent cure • Invest in a “prize box” to help kids feel comfortable • Prevalence • Global disease, South Africa, parts of Europe, etc. Psoriasis • Co-morbid conditions Bradley Glick, DO, FAOCD • Obesity • Insulin resistance • Endothelial dysfunction à atherosclerosis à MI • Classical and emerging co-morbidities • Classic • Psoriatic arthritis • Inflammatory bowel disease • Psychological and psychiatric disorders, psychosocial issues • Metabolic syndrome and its components • Cardiovascular diseases • Atherosclerosis • Emerging comorbidities • Nonalcoholic fatty liver disease • Lymphomas • Sleep apnea • Chronic obstructive pulmonary disease • Osteoporosis • What is psoriasis? • Parkinson´s disease • Inflammatory and hyperplastic disease of skin • Celiac disease • Characterized by erythema and elevated scaly plaques • Connective Tissue Disease (SLE, Sjogrens Syndrome) • Auspitz sign with removal of scale • Erectile dysfunction • Chronic, relapsing condition • Uveitis • Course of disease often unpredictable • Related to lifestyle • Common, genetic, systemic inflammatory disease with • Smoking habit prominent skin and joint manifestations • Alcoholism • Skin inflammation correlates with systemic inflammation • Anxiety • Comorbidities are common • Dyslipidemia (acitretin and cyclosporine) • Has significant impact of quality of life • Related to treatment • Caused by a complex interplay of genes, environment, and • Nephrotoxicity (cyclosporine) immune system • Hypertension (cyclosporine) • Epidemiology – occurrence • Hepatotoxicity (methotrexate, leflunomide and • Age of onset acitretin, methotrexate) • Bimodal –2nd to 3rd decade of life and second peak • Skin cancer (PUVA) incidence after 50 years of age • Immunopathogenesis of psoriasis

Page 46 • Whole host of inflammatory • At least check every 2 years, more • Lowered self confidence cytokines responsible often if elevated (>120/80) • Chronic depression • Multifactorial • Fasting glucose, HbA1c, glucose • Avoid sports (especially swimming) • Keratinocyte growth: Normal skin tolerance test every 3 years • Affects employment vs. psoriasis • Cholesterol every 5 years after age 21 • Some report loss of job because • Normal • More aggressive lipid control? of condition • 28-30 days • Annual skin cancer exam • Social relationships • Newly generated keratinocytes • Risk Factors • Reports of poor or very poor produced at normal rate • Psoriasis independent risk factor for relationships because of condition à normal movement of MI from traditional risk factors • General public less likely to become keratinocytes from basal layer to • Risk for DM higher in patients romantically involved with patients surface à normal shedding of with psoriatic arthritis than with psoriasis non-nucleated keratinocytes at rheumatoid arthritis • Screen patients before starting systemic/ skin surface • Increasing disease severity increases biologic therapy • Psoriasis risk for developing comorbidities • Social history • 3-4 days • Increasing BSA increases risk of • Labs • Keratinocyte production and metabolic syndrome • Viral hepatitis movement is speeded up • Significance • TB • Keratinocyte production outpaces • Increased risk for MI, stroke, CKD, • HIV if high risk shedding at skin’s surface loss of life, DM, cardiovascular death • Routine blood tests • Keratinocytes pile up on skin • 10 year risk for major CV event • Vaccinations surface and form lesions attributable to psoriasis = 6% • Influenza • Role of T cells in psoriasis • Talk to patients • Pneumonia • T cell directed therapy • Ask how their disease affects their • Zoster (>60 years old) immensely helps with clinical and QOL • Live vaccine not recommended if immunohistochemical appearance • Lifestyle recommendations for thing on biologic • Abnormal response to inflammation within control (weight, smoking, • Age appropriate cancer screenings • Proinflammatory cytokines outweigh alcohol consumption) • Colon cancer the anti-inflammatory cytokines • Psoriasis may be risk factor for • Various methods, starting about • Study: Circulating levels of Th17 and development of coronary 50 years old Th1 cells decreased in subset of 5 artery calcification • Breast cancer patients following induction of therapy • Particularly in patients with • Mammography with infliximab severe disease • Cervical cancer • Drove focus into Th17 pathway as a • Study: Psoriasis is a systemic • Pap smear cause of psoriasis inflammatory disease • Prostate cancer • Various causes of psoriasis • Increased signals on imaging • Controversial • Trigger activates dendritic cells, indicative of systemic inflammation • Lung cancer activates T cells (Il17A, IL22, TNFa, • Knees and ankles • Annual low does CT if >30 py IFNg, IL17F) • Liver smoking history • Vasculogenic activation recruits • Aorta and femoral arteries • Confirm the diagnosis more inflammatory cytokines • Psoriatic plaques • Biopsy patients with atypical • Not just a skin disease • Psoriasis associated with reduction in features of psoriasis and/or those not • Comorbidity: medical condition HDL efflux capacity independent of CV responding to treatment existing simultaneously but risk factors • Arthritis independently within anther • Associated with increase in LDL • Peripheral and axial joints affected condition in a patient particle concentration and decrease • Spondylitis, sacroilitis, • Obesity 2x increases risk of psoriasis in LDL particle size based on NM syndesmophytes development (BMI >30) resonance analysis • Extra articular • More common incidence of DM • Comorbid malignancy associations • Uveitis, scleritis, skin, nail, • Role of TNFa on insulin resistance • Lymphoma urethritis, bowel disease • Cardiovascular conditions • Especially when considering a TNF • 30-40% have arthritis • Psoriasis patients should have inhibitor for therapy • TNF inhibitor, ustekinumab, regular if not increased screenings • Rates of lymphoma dramatically apremilast, concomitant MTX, for cardiovascular comorbidities high in psoriasis, especially if severe rheumatology consult • Many times patients taking • 3-fold risk compared to • Consider agents that halt multiple medications for various general population progression or radiologic damage serious health conditions à • Psychosocial matters: QOL • Clinical evaluation alone may not be potential drug-drug interactions • ½ of patients would prefer a different enough to identify psoriatic arthritis • Standard screening recommendations chronic condition over their psoriasis • Laboratory test results may be • Check BP at every PCP visit? • Feel need to hide psoriasis helpful in some patients

Page 47 • Impact on comorbid conditions when selecting therapy • Multiple Wiesner’s nevi: consider BAP-1 germline • Newest agents mutation especially with a family history of mesothelioma • Guselkumab, Brodalimumab or uveal melanoma • Obese patients with psoriasis • BAP-1 gene - chromosome 3p21 (short arm) • Weight-based dosing typically has better efficacy • Cell cycle regulation, differentiation, cell death, DNA • Ustekinumab, Infliximab, Adalimumab, Secukinumab, damage response Apremilast • Many different types of mutations • Concurrent cardiovascular disease • PCR not feasible in detection • Treatments that reduce CV risk • Immunohistochemistry is procedure of choice for detection • MTX, TNF inhibitors, Ustekinumab BAP-1 mutations • Lifestyle changes • Cancer syndrome involving predisposition to • Psoriasis and heart failure mesothelioma, multiple melanocytic nevi, uveal melanoma, • Package inserts for TNF inhibitors and cutaneous melanoma • No warnings for • Concomitant BRAF mutation is frequent • Ustekinumab, Secukinumab, Apremilast • 85% of metastatic uveal melanomas have BAP-1 mutation • Consult cardiology • Histone deacetylase inhibiters used for uveal melanoma with • Psoriasis and MS BAP-1 mutation • TNF inhibitors contraindicated, Ustekinumab, Anti IL17s, • Valproic acid helps with differentiation MTX, Apremilast • Lack of BAP-1 expression associated with worse survival in • Consult neurology cutaneous melanoma • History of cancer • Clinical Appearance • Type and timing is important • Solitary or multiple • Acitretin, Phototherapy, NBUVB • Well circumscribed pink papule or nodule • Risk vs benefit of treatment • Often polypoid • Crohn disease • Frequently present since childhood • Adalimumab, Infliximab, Ustekinumab • Lesions are often Spitzoid or Epithelioid • Secukinumab warning • Spitzoid cytology without epidermal hyperplasia, Kamino • Treatment-emergent psoriasis bodies, or clefts • Woman of childbearing potential • Various populations with different degrees of atypia • Need to know plan (HETEROGENEITY) • Etanercept (short half-life) • Different populations of cells • More experience with TNF inhibitors • Contain highly cellular areas with pleomorphic melanocytes • Avoid acitretin and MTX that are BAP-1 negative • Antibodies can cross placenta • What would be seen on a report? • Atypical Spitzoid tumor with BAP-1 loss BAP-oma & Beyond • Wiesner’s nevus is associated with BRAF EXPRESSION and Michael Nowak, MD typically lacks epidermal hyperplasia and Kamino bodies • P16 - cyclin-dependant kinase inhibitor 2 (CDKN2A gene) tumor suppressor is EXPRESSED • Therefore, “melanocytic tumor of uncertain biological potential” is the best description • “Combined melanocytic nevus, including a component of desmoplastic BAP-1 inactivated spitzoid necvus ‘BAP-oma’” • What do you do next? • Complete excision with generous clear margins (margin of error) and look for additional lesions • Inquire about eye tumors and mesothelioma • Long term surveillance similar to a melanoma patient • Referrals for multiple lesions with suspected germline mutation • Multiple lesions followed for change in clinical appearance, radiologic studies, and genetic counseling • Summary • Solitary or multiple • BAP-oma • Risk of melanoma is surprisingly low • Wiesner 2011: Families with multiple tan dome-shaped • Melanocytic tumor of uncertain biological potential (different papules of head, neck, trunk, and extremities from Spitz nevus) • Lesions with BAP-1 loss are termed BAP-oma or Wiesner’s nevus • Wiesner’s nevus • Loss of expression of BAP-1 • Nevi, uveal melanoma, cutaneous melanoma, Familial • Most Wiesner’s nevi are solitary (sporadic somatic mutation) mesothelioma (non-asbestos related) and behave in an indolent fashion • Extramammary Paget’s Disease

Page 48 • Overview • Zoon’s • Mammary • Granular Parakeratosis • Extramammary • Malignancy (high index of suspicion) • Bone • Microscopic DDX • Prototype (microscopic pattern) • Paget’s/Extramammary Paget’s disease • 1874 Sir James Paget • Melanoma/Melanoma in-situ • Mammary skin involvement (nipple) associated with an • Squamous cell carcinoma in-situ underlying breast cancer in virtually 100% of cases • Sebaceous carcinoma (and other adnexal) • Poor prognostic sign • Pagetoid reticulosis • 1889 Radcliffe Crocker • Merkel cell carcinoma (Golgi CK20 +) - Polyomavirus? • Occurs in anatomic sites rich in apocrine glands • Morphologic Clues • Frequently NOT associated with an underlying glandular • Eyeliner sign (thin vs. thick) carcinoma (confined to the skin) • Pigmentation • Presentation • Parakeratosis • Vulva most common • Sebacous cells • Male genital area second most common • String of pearls • Axilla • Nuclear molding • Perianal area • Dermal involvement (differentiation) • Sharply demarcated erythematous patch • Special Stains • Pruritus and burning pain are common • EMPD vs. SCCIS vs. MIS • Primary vs. secondary • Primary vs. Secondary • Similar to mammary Paget’s since it is frequently • Invasion (CKNBD-56 expressed, MUC-2 lost) associated with underlying visceral malignancy • Lymphatic involvement (D2-40) • Frequently NOT limited to the perianal skin • PAS + • More referrals and worse prognosis • Mucicarmine + • Microscopic Findings • Alcian Blue + • Limited to epidermis • CK7 + • Invasive - Depth of Invasion (>4mm) • GCDFP-15 +/- (primary/secondary EMDP) • Associated with worse prognosis • CK20 -/+ (primary/secondary EMDP) • Cell of origin - likely adnexal stem cell origin (primary) • S100 = MIS • Arch Pathol Lab Med. 1998 Dec;122(12):1077-81. Perianal • CK5/6 (LMW) = SCC Paget’s disease: distinguishing primary and secondary lesions • EMA/Oil-red-O = sebaceous carcinoma using immunohistochemical studies including gross cystic • CK7 = EMPD disease fluid protein-15 and cytokeratin 20 expression • GCDFP-15 = primary • Nowak MA, Guerriere-Kovach P, Pathan A, Campbell TE, • CK20 diffuse = secondary Deppisch LM • CK20 perinuclear = Merkel • Primary lesions (limited to skin): CK20 negative/ • Work up GCDFP-15 positive, good prognosis, high 5 year • Clinical trial with topical therapy survival, intraepidermal apocrine carcinoma • Medium potency steroid and antifungal • Secondary lesions (skin and rectal involvement): CK20 • NR in compliant patient at 3-4 weeks positive/GCDFP-15 negative, poor prognosis, low 5 • Biopsy (4 mm punch in formalin) year survival, rectal carcinoma involving skin vs. invasive • History and Physical (pelvic, rectal, breast, lymph nodes) Paget’s involving rectum • Referrals and Staging (Internist, GYN, GE, surgical and • Am J Dermatopathol. 2011 Aug;33(6):616-20. Signet medical oncology) ring cell perianal Paget disease: loss of MUC2 expression • Procedures (culposcopy, sigmoidoscopy, cystoscopy) and loss of signet ring cell morphology associated with • Treatment invasive disease • Topical chemotherapy • Grelck KW, Nowak MA, Doval M • Wide local excision (Stage 1 and 2A) • Morphology (loss of signet ring cell features) • AP resection (Stage 2B and Stage 3) • Immunohistochemical (loss of Muc2 expression) • Medical oncology (Stage 4) • Depth of invasion (> 4 mm): Depth of invasion • Radiation (Stage 4) associated with a worse prognosis (shift in phenotype • Other referrals and differentiation) • Long term monitoring • DDX: Erythematous plaque of groin • Summary • Eczematous dermatitis including irritant and allergic • Mammary vs. extramammary contact dermatitis • Primary vs. secondary • Tinea Cruris • Clinical differential diagnosis • Candidiasis • Microscopic differential diagnosis • Intertrigo • Referrals and treatment • Psoriasis/Seborrhea • Long term monitoring

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