The 39th Annual 2019 Fall Clinical Dermatology Conference kicked off this year at the Wynn Hotel in Las Vegas, NV. From October 17 through October 20, dermatologists attended sessions on the latest advances in aesthetic, surgical, and medical dermatology. Presentations covered everything from updates in atopic dermatitis (AD) to off-label uses of botulinum toxins.
In addition to sessions, attendees voted for their favorite speaker and participate in diagnostic quizzes for prizes. Neal Bhatia, MD, editorial advisory board member of The Dermatologist, was awarded the 2019 Clinical Educator of the Year for having the highest speaker evaluation from attendees at last year’s meeting.Â
Other highlights from this year’s meeting include:
New Developments in Itch
The antihistamine era for chronic itch is ending, declared Gil Yosipovitch, MD, at the 2019 Fall Clinical Dermatology Conference.1 Dr Yosipovitch is a professor of dermatology at the University of Miami and director of the Miami Itch Clinic in Miami, FL.
He reviewed data on the efficacy of crisaborole (Eucrisa) and dupilumab (Dupixent) for improving pruritus symptoms among patients with AD. Real-world data also showed crisaborole improved itch for patients with hand eczema, dyshidrotic eczema, and psoriasiform atopic eczema as well as for the flexures of arms/thighs. Dupilumab was also effective for other itchy dermatoses, Dr Yosipovitch noted.Â
In addition, he reviewed the role of IL-17, IL-31, and Janus kinase inhibitors for treating itch. One study, added Dr Yosipovitch, found ligelizumab improved chronic urticaria. Other therapies in his presentation included ketamine 5% to 10%, which has a robust antipruritic effect that lasts from 30 minutes to 7 hours. However, this cannot be applied to the entire body, noted Dr Yosipovitch, due to the risk of toxicity.
According to Dr Yosipovitch, substance P and neurokinin (NK) 1 are involved in both pain and itch in the periphery, spinal cord, and brain. Serlopitant, an NK-1 receptor antagonist, was found to reduce itch among patients with no specific cause for pruritis, stated Dr Yosipovitch, and has been reported to reduce psoriatic itch and treat prurigo nodularis.
Options for neuropathic itch include mechanical barriers, topical therapies, and gabapentinoids. Another option Dr Yosipovitch reviewed was low-dose mirtazapine, a nonaddictive antidepressant that has been reported to improve AD-associated itch along with neuropathic, psychogenic, and idiopathic pruritis.
For systemic itch, there are not a lot of options, said Dr Yosipovitch. One option are k-receptor opioids, such as nalfurafine, butorphanol (Stadol), and CR845. Butorphanol, indicated for migraines, is a nonaddictive kappa opioid administered as an inhaler but it is still considered a controlled substance, noted Dr Yosipovitch. He said he prescribed it for patients with intractable chronic itch who failed other therapies.
This is a new era and there will be new drugs for patients with pruritus, concluded Dr Yosipovitch. Dermatologists should expect multiple therapies in the pipeline to address the complexity of chronic itch, he added.
Do’s and Don’ts of Post-procedural Care
Dermatologists perform over 25 million in-office procedures per year, said Zoe Draelos, MD, a board-certified dermatologist in private practice in High Point, NC, during her presentation on optimizing post dermatologic procedural care.2Â
In dermatology, many wounds heal by secondary intention, which is best accomplished by removing any impediments to healing (eg, infections) and maintaining an environment conducive to repair, which includes leaving wound edges open, keeping the wound surface moist, and insulating the wound. This is typically achieved using semiocclusive dressings, added Dr Draelos, which prevent scab formation and help accelerate reepithelization.
Dr Draelos also reviewed a study of 169 postoperative handouts that showed 84% recommended petrolatum and 43% recommended topical antibiotic use. According to the Centers for Disease Control and Prevention (CDC), wounds created in dermatology offices are categorized as class 1 wounds, meaning they are clean and created in aseptic conditions. Because of this, the CDC does not recommend antibiotics for dermatologic procedures, said Dr Draelos. Dermatologists prescribe approximately 4.9% of antibiotics, despite only representing 1% of health care.
Dr Draelos reviewed several studies that assessed the rates of infection from in-office dermatologic procedures. Overall, the infection rate ranged from 0.2% to 2.5%, she said, with none of the studies showing differences among patients treated with topical antibiotics compared with healing ointments.
In addition, Dr Draelos discussed a study that showed nonmedicated petrolatum ointment was associated with faster barrier repair and earlier wound healing compared with an antibiotic. Another study showed no difference between a healing ointment and polymyxin/bacitracin ointment; the ointments had similar outcomes for seborrheic keratosis, added Dr Draelos.
Topical antibiotics are not recommended for class 1 wounds, said Dr Draelos, adding that infection rates from dermatologic procedures were low and treatment with topical antibiotics did not differ from petrolatum ointments.
Antibiotics can induce allergic contact dermatitis (ACD), which is another reason to reconsider their use for post-procedural care in dermatology. Neosporin and bacitracin were ranked in the top 10 causes of ACD by the American Contact Dermatitis Society for over 20 years, said Dr Draelos. In a Cochrane review of three studies with 3042 patients, no patients treated with petrolatum ointment experienced ACD compared with five patients treated with antibiotics.
Semiocclusive dressings promote wound healing better than fully occlusive dressings, said Dr Draelos. The concentration for semiocclusive dressing of petrolatum is 41% to 54%. Lanolin alcohol, which is used in wound care, can cause ACD. However, the lanolin alcohol used in healing ointment had low rates of positive reactions, said Dr Draelos. Quality has a great deal to do with allergic potential, she added, noting that there has been no reporting of ACD caused by healing ointment in clinical and patch test studies.
Dr Draelos concluded her presentation with evidence-based recommendations for wound care, including cleaning the wound daily with mild cleanser; applying a semiocclusive, petrolatum-based ointment as needed to keep a moist wound bed; appropriately dressing the wound; and avoiding topical antibiotics.
Dermatology Urban Legends
Dawn Sammons, DO, with Oakview Dermatology in Athens, OH, presented on some of the pervasive beliefs patients and providers still have at the 2019 Fall Clinical Dermatology Conference.3
We need ways to talk to our patients, said Dr Sammons, noting that many come in after using Google and often feel like they understand what they have. In addition, patients could have seen other providers who have their own opinions about a condition not based on data.
One common belief is that antibiotics lower the efficacy of birth control. Dr Sammons said she receives many phone calls from patients after a pharmacist tells them the antibiotic might affect their birth control. According to her, the case reports that this belief is based on were from the early 20th century. Newer studies have shown that serum levels of over-the-counter contraceptives are not affected by antibiotics, with the exception of rifampin (Rifadin), which is mainly used for hidradenitis suppurativa. She recommended educating patients and pharmacists when prescribing antibiotics about whether the therapy will affect contraceptives.
Another common belief is that retinoids have to be applied at night because they are sensitive to sunlight. This was based on early retinoids, which were deactivated by UV exposure, said Dr Sammons. Most products that are prescribed today are photostable for about 8 hours. While there is an increase in photosensitivity, she added, patients can use retinoids in the morning if they are more likely to be adherent.
In hair loss, patients may say they do not want to use minoxidil because they will have to use the product forever. While this is true for female pattern hair loss, other types of hair loss may not need continuous use. Female pattern hair loss is a chronic condition, said Dr Sammons, stressing the importance of discussing expectations with patients’ expectations.
For dermatologists, a common belief is to not use epinephrine when injecting lidocaine into the toes and fingers. According to Dr Sammons, the cases where necrosis was seen following epinephrine use in these areas had many flaws, including inappropriate tourniquet use. The good news is new evidence does not support this avoidance; Dr Sammons recommended buffering because lidocaine is slightly acidic, but this therapy combination can be used in the toes and fingers.
Another common belief in dermatology is that cosmetic therapy should be delayed by 6 months following the use of isotretinoin. The American Society of Dermatologic Surgeonstask force consensus statement said treatment does not need to be delayed following isotretinoin therapy, so long as it is nonfractionated ablative therapies, said Dr Sammons.
Dr Sammons reviewed allergies to sulfa antibiotics and the risk of an allergic reaction to dapsone. She discussed a study that showed 10% of patients who were allergic to sulfa antibiotics also had a reaction to a nonantibiotic sulfa therapy. However, more patients who were allergic to sulfa drugs also had a reaction to penicillin. The take home, said Dr Sammons, is these patients are just more likely to have an allergic drug reaction in general.
Other urban legends Dr Sammons reviewed included testing with biologics, which was not found to be absolutely useful aside from baseline tuberculosis screening, and testing with isotretinoin, which did not require continuous testing for most patients after 2 months.Â
According to Dr Sammons, 80% of patients with psoriasis are not receiving treatment other than topicals regardless of psoriasis severity because practitioners are nervous about biologics. When discussing risks associated with tumor necrosis factor (TNF) inhibitors, which range from about 0.5% to 4.5%, Dr Sammons said the provider’s job is to have a conversation with a patient about the risk and how likely they are to experience it. For example, Dr Sammons noted that the risk of dying while driving home is higher than the risk of malignancy associated with TNF inhibitors. “Every single one of us are going to get in a car and not think twice about it,” she said, adding that it is important providers help patients understand these risks to make better treatment decisions.
There are a lot of misconceptions, which are based on some true information, concluded Dr Sammons. She stressed the importance of being able to answer questions regarding these and other urban dermatology legends.Â
References
1. Yosipovitch G. What you have been itching to know about pruritis therapies. Presented at: 2019 Fall Clinical Dermatology Conference; October 17, 2019; Las Vegas, NV.
2. Draelos Z. Optimizing post-dermatological procedural wound care. Presented at: 2019 Fall Clinical Dermatology Conference; October 17, 2019; Las Vegas, NV.
3. Sammons D. The urban legends of dermatology. Presented at: 2019 Fall Clinical Dermatology Conference; October 20, 2019; Las Vegas, NV.
