Hottest Topics in Dermatology: Experts Weigh In

NEW YORK—Saturday morning’s hot topics session at the American Academy of Dermatology Summer Meeting featured the latest evidence on conditions like psoriasis, as well advances in the fields of infectious, pediatric, and general dermatology. Mark Lebwohl, MD, led the panel on hot topics. Highlights included:

Psoriasis—Bruce Elliot Strober, MD, PhD, FAAD

The number of treatments for psoriasis will continue to grow, with the possibility of 13 biologics approved for psoriasis within the next year. BMS-986165, an TYK2 inhibitor, is under investigation and showing similar efficacy to biologics without the effects on biomarkers associated with Janus kinase inhibitors. Bimekizumab is an IL-17 A and IL-17F inhibitor that completed phase 2 trials and showed higher percentage of patients achieving clearance with fast response. A small study demonstrated the potential for targeting IL-16 in pustular psoriasis.

In addition, Dr Strober reviewed the results of studies that showed guselkumab had long-term efficacy compared with secukinumab, comparison of risankizumab with ustekizumab, safety data of certolizumab among women who are pregnant, showing no presence of drug in umbilical cord blood and neonatal blood, as well as no presence of drug in breast milk. The effects of apremilast on hemoglobin A_1c and weight loss, as well as the potential safety and efficacy of this oral molecule in children, were also discussed, along with phase 3 results of an oral TYK2 inhibitor.

Dr Strober recommended clinicians always consider psoriatic arthritis when selecting treatment, noted that a stepwise approach is not always necessary, and added that combination therapy is sometimes needed.

Atopic Dermatitis—Emma Guttman, MD, PhD, FAAD

According to Dr Guttman, the therapeutic drought in atopic dermatitis is ending. One important contribution to this is the increased understanding of the pathogenic molecules involved in the disease. Personalized medicine will play an important role in the coming years, she said.

Several new therapies she discussed include IL-13 inhibitors lebrikizumab, which showed similar efficacy to dupilumab and suggests IL-13 maybe an important cytokine; nemolizumab, which targets the itch cytokine, IL-31, and showed improvement of pruritis; KPL716, which targets the OSM receptor beta, showed promise for pruritis and improvement on EASI in a phase 1 study, as well as OX40 mAB, KHK4083, MOR-106, and ANB020.

There is a lot of excitement in the field of AD, particularly with JAK inhibitors, said Dr Guttman, Upabicitinib showed 50% of participants achieved EASI 90 after 16 weeks in phase 2b study, but more studies are needed to determine safety and blood monitoring, she said. A few topicals under investigation include ruxolitinib cream and tapinarof, as well as delocitinib for hand eczema.

Skin Cancer—Darrell S. Rigel, MD, FAAD

Advances in the detection and treatment of skin cancer have impacted disease rates and mortality. Dr Rigel reviewed options for treating advanced nonmelanoma skin cancer (NMSC), such as PD-1 inhibitors, CTLA-4, Mohs surgery, nivolumab, and cemiplimab, which have demonstrated efficacy.

Early detection and treatments with gene targeted therapy have had some impact on mortality rates. Reporting melanoma to state cancer registries is required, Dr Rigel said. Patients with secondary melanomas have an increased risk for NMSC, lentigos, and elevated risk for other cancers, as well as for more melanoma. Dr Rigel emphasized that this latest data suggests patients with a history of melanoma should be followed regularly.

Dr Rigel reviewed the FDA’s new sunscreen recommendations and noted that more data regarding the environmental impact of sunscreens is needed to determine the impact of these ingredients in a real-world setting.

He concluded his presentation on the potential for computer-aided diagnoses, electrical impendence spectroscopy, as well as findings that showed volume was better than thickness for determining prognosis.

Dangerous Dermatoses—Jonathan Ungar, MD, FAAD

Nonpharmacological interventions involve ceasing the offending medication and supportive care, which includes wound care, fluid electrolyte balance, and transfer to appropriate center, preferably a burn center, said Dr Ungar. Glucocorticosteroids and IVIg, although used for SJS and TEN, have not been found to benefit patients, while cyclosporine showed some benefits. TNF inhibitors may also benefit patients and also reduced time to skin healing. Thalidomide has been found to increase mortality, said Dr Ungar. He recommended IVIg as an option for patients in whom cyclosporine and etanercept are contraindicated.

Therapies for bullous pemphigoid include high-potency steroids and systemic steroids, said Dr Ungar. Studies showed doxycycline does not perform as well as steroids. However, data suggests rituximab should be first-line therapy, as 93% of patients achieved complete remission, he added. Other possible therapies under investigation include bertilimumab and BIVV009. Certain medications such as DPP-4 inhibitors, anti-PD-1, and PD-L1 therapies cause BP.

For pemphigus, rituximab was approved last year and is more effective than steroids. According to Dr Ungar, the time to treatment matters as failure to achieve remission is associated with longer time of disease activity prior to initiating treatment. He recommended treating early with rituximab. Rituximab followed by azathioprine showed longer remission, he added.

Next Page: Topicals, Surgery, Infectious Dermatology, and More

Topicals— Linda F. Stein Gold, MD, FAAD,

Dr Stein Gold reviewed several topicals currently under investigation, such as tapinarof for atopic dermatitis, topical ruxolitinib, and crisaborole, which she said may be effective for intertriginous psoriasis.

According to Dr Stein Gold, ointments are better than foam, which is better than cream. The order of application is important, she said. Ointment should be applied first followed by moisturizer to avoid decreased penetration of the drug.

Dermatology Surgery— Mehul D Bhatt, MD, MBA, FAAD,

Due to the risk for misuse, Dr Bhatt reviewed some nonpharmacological and pharmacological options for reducing opioid prescriptions, such as lowering patients’ anxiety and prescribing NSAIDs. A study showed a combination of non-opioids is as effective, if not better, than opioids, he said.

If a patient requires an opioid, Dr Bhatt recommended screening them for opioid abuse risk factors first. A short course (3 days or less) should be prescribed, and dermatologists should be careful of the number of pills prescribed and use low-potency opioids, such as codeine. About 10% of the population lacks the enzyme to metabolize codeine, he said, and will not benefit from this particular therapy.

In addition, Dr Bhatt discussed removing melanomas from specialty sites, such as the head, neck, hands, feet, genitals, and pretibial leg. He recommended physicians follow the rule of 10 for wide local incisions. There is a 10% risk of upstaging, 10% risk of positive margins following excisions, 10% risk of local recurrence, and 10 times increased chance of complex reconstruction. To address these risks, have a definitive stage first with clear microscopic margins before closure and do not reconstruct until after obtaining margins, said Dr Bhatt. He suggests working closely with a dermatopathologist to obtain margins. This is more time-consuming, but yields better results, he said.

Pediatrics—Lawrence F. Eichenfield, MD, FAAD

Dr Eichenfield highlighted some of the breakthroughs in pediatric dermatology, such as the approval of dupilumab. One of the bigger findings was that emollients did not appear to prevent atopic dermatitis, he noted. Slime-dermatitis, according to Dr Eichenfield, is on the rise and something to consider when counseling children with AD.

Cantharidin 0.7% solution for molluscum contagiosum showed 46% and 54% clearance in studies and is moving on for FDA approval, he said. The latest FDA-approved therapy for hyperhidrosis, glycoprronium tosylate, showed robust results but has a higher risk for dilated pupils in children, which is mitigated by washing hands after applying therapy, he said.

Dermatologists should be aware of the new guidelines for the management of hemangiomas, said Dr Eichenfield, which recommend early consultation by age 1 month for lesions, particularly disfiguring ones. He recommended implementing an appointment process to ensure patients referred to dermatologists can be seen early, when interventions have the most profound effects.

Infectious Dermatology—Kenneth J. Tomecki, MD, FAAD

In his presentation, Kenneth J. Tomecki, MD, FAAD, reviewed infectious diseases dermatologists should be aware of in their practice. Despite declines, HIV continues to affect 76 million individuals globally. There are multiple treatment options available, which should be started as soon as patients test positive for HIV. Although pre-exposure prophylaxis therapies have been approved to decrease HIV risk, patients on these therapies have a higher risk for other sexually- transmitted infections.

Measles continues to be a global health problem, as well as syphilis and lymphogranuloma venereum. Rocky Mountain spotted fever has reemerged, with 6500 cases reported last year. It is associated with a 5% mortality rate and occurs primarily in the Carolinas, although other states are affected, said Dr Tomecki. He also discussed ebola, leprosy, and shingles.

Dermatology Practice—Mark Lebwohl, MD, FAAD

Dr Lebwohl reviewed the latest advances in general dermatology, including new diagnostic tests for mycosis fungoid, fungus, and evaluating melanoma risk. He also suggested dermatologists discuss the risks of biotin consumption with patients, which is associated with chest pain, Grave disease, and interference with amino acids and laboratory testing.

In addition, he reviewed the use of sildenafil and Botox for treating Raynaud disease, Lyme disease, and the potential role of the HPV vaccine in treating tumors and cancers.

—Melissa Weiss

Reference

Lebwohl, Strober, Guttman, et al. Hot topics in medical dermatology. Present at: the 2019 American Academy of Dermatology Summer Meeting; July 25-28, 2019; New York, NY.