2019 AAD Summer Meeting: The Hottest Topics in Dermatology

Dermatologists attending the 2019 American Academy of Dermatology Summer Meeting (New York, NY; July 25-28, 2019) were treated to breaking updates and informative reviews of the latest evidence on dermatologic conditions. On the third day of the conference, Mark Lebwohl, MD, led a panel to review the hottest topics in the field of dermatology that were discussed at the meeting.¹ The panel highlighted presentations covering a range of subjects, including psoriasis, atopic dermatitis (AD), skin cancer, dermatology surgery, pediatrics, and dermatology practice. 

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, according to Dr Strober. BMS-986165, a tyrosine kinase 2 (TYK2) inhibitor, is under investigation and showing similar efficacy to biologics without the effects on biomarkers associated with other Janus kinase inhibitors. Bimekizumab is an IL-17A 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. He reviewed other studies on guselkumab (Tremfya), risankizumab (Skyrizi), apremilast (Otezla), and the latest phase 3 results for another oral TYK2 inhibitor.

Dr Strober reviewed studies that showed guselkumab had long-term efficacy compared with secukinumab (Cosentyx), as well as  comparison of risankizumab with ustekizumab (Stelara). He discussed safety data of certolizumab (Cimzia) among women who are pregnant, which showed no presence of drug in umbilical cord blood and neonatal blood, as well as no presence of drug in breast milk.

In addition, Dr Strober recommended clinicians always consider psoriatic arthritis when selecting treatment, noting 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 AD 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 the IL-13 inhibitor lebrikizumab, which showed similar efficacy to dupilumab (Dupixent) 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 oncostatin-M-specific receptor subunit beta, showed promise for pruritis and improvement on Ezema Area Severity Index in a phase 1 study, as well as other therapies still being developed. A few topicals under investigation include ruxolitinib (Jakafi) cream and tapinarof, as well as delgocitinib 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 programed cell death protein 1 inhibitors, cytotoxic T-lymphocyte-associated protein 4 inhibitors, Mohs surgery, nivolumab (Opdivo), and cemiplimab (Libtayo), 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 also reviewed the FDA’s new sunscreen recommendations. 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.

Dermatology Surgery

Mehul D. Bhatt, MD, MBA, FAAD

Due to the risk for misuse, Dr Bhatt reviewed some nonpharmacologic and pharmacologic options for reducing opioid prescriptions, such as lowering patients’ anxiety and prescribing nonsteroidal anti-inflammatory drugs. A study showed a combination of nonopioids 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 added, 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 AD, 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, glycopyrronium tosylate (Qbrexza), 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. These guidelines 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. 

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 human papillomavirus vaccine in treating tumors and cancers. 

Reference

Strober BE, Guttman E, Rigel DS, Bhatt MD, Eichenfield LF, Lebwohl M. Hot topics in medical dermatology. Presented at the 2019 American Academy of Dermatology Summer Meeting; July 25-28, 2019; New York, NY.