Conference Highlights: Dermatology Week 2021
Taking place virtually, the inaugural Dermatology Week 2021 was a new experience for dermatologists and advanced practice clinicians. Across 4 days of live virtual education, attendees heard from various experts in the field, including conference senior advisors Steve Feldman, MD, PhD, and Joel Gelfand, MD, MSCE, as well as cochairs Richard Gallo, MD, PhD; Brian Kim, MD, MTR, FAAD; Mital Patel-Cohen, MD; Ruth Ann Vleugels, MD, MPH, MBA; and Elizabeth Brezinski Wallace, MD, FAAD. Society partners of the conference included the Dermatology Nurses' Association, the National Psoriasis Foundation, and the National Rosacea Society. With more than 40 sessions, lectures included important topics such as management of chronic prurigo, use of Janus kinase inhibitors in dermatology, caring for skin of color, advice on navigating the latest evaluation and management coding guideline revisions, identifying cutaneous COVID manifestations, and more.
Continue reading for session highlights from Dermatology Week, and visit the-dermatologist.com for more coverage, including more session highlights and exclusive interviews with conference speakers and leadership.
Identifying Hemangiomas vs Vascular Malformations With Dr James Treat1
At Dermatology Week 2021, James Treat, MD, professor of clinical pediatrics and dermatology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, discussed the ins and outs of differentiating hemangiomas vs vascular malformations.
To start the session, Dr Treat stressed the importance of accurately defining both hemangiomas and vascular malformations. He pointed to the International Society for the Study of Vascular Anomalies (ISSVA) classifications for vascular anomalies. This resource, most recently revised in 2018, splits vascular anomalies into vascular tumors and vascular malformations, and the resource is available online at the ISSVA website.
With lesional definitions out of the way, Dr Treat moved onto discussing infantile hemangiomas. Typically, these lesions are not present at birth but begin to develop as a faint red or bruise-like patch at age 1 to 4 weeks that rapidly grows over the
next 1 to 3 months until involution begins around 1 year. Treatments of choice are propranolol (FDA approved for as young as age 5 weeks) and timolol. Dr Treat said a few hemangiomas should be considered “risky” due to their location and should be referred to a specialist early, including:
- Beard distribution (risk of airway involvement)
- Periocular (vision risk)
- Lips (risk of obstruction of breathing or eating)
- Lumbosacral (risk of spinal cord anomalies)
Hemangiomas may also be risky due to ulceration and rapid growth, but dermatologists should be on the lookout for a segmental pattern, which is more commonly associated with underlying abnormalities.
A congenital hemangioma is present at birth, typically with an outer rim of vasoconstriction. Dr Treat indicated that it is important to feel these for a soft/squishy response, because sarcomas can appear similarly but are firm to touch.
After establishing what to look for in examining a hemangioma, Dr Treat shifted focus to capillary malformations. Nevus simplex is almost never a cause for concern (unless the patient also presents with macrocephaly, macroglossia, asymmetric growth, or limb anomalies) and will fade over time. Port wine stains (PWSs) can be associated with Sturge-Weber syndrome, particularly those with forehead involvement, whereas reticulated PWS is more associated with genetic syndromes and geometric PWS is more associated with underlying venous or venolympathic malformations.
Dr Treat also highlighted thumb-print oval capillary malformations, which can look like café au lait macules that are red-purple in color. It’s important to make sure patients who present with these lesions undergo genetic testing and early screening to monitor for arteriovenous malformations in the central nervous system.
PWS-like lesions that do not seem to be respecting the midline, explained Dr Treat, are tufted angiomas. These appear as red-purple patch or thin plaque, and it may be congenital. However, it is important to check laboratory results to rule out Kasabach-Merritt phenomenon (KMP), which may also be a concern for Kaposiform haemangioendotheliomas, and sirolimus is an effective therapy for KMP if necessary.
The last lesion to note, said Dr Treat, is not a hemangioma or vascular malformation at all. He explained infantile fibrosarcoma can be a mimic of hemangioma, but it is firm to touch and its growth does not respect tissue planes. If unsure about a presentation, Dr Treat recommended referral to an expert or performing a biopsy due to the sensitive nature of the lesion.
The 101 on Itch With Dr Brian Kim2
With research beginning to focus more on atopic dermatitis (AD) and its most prominent symptom of itch, Brian Kim, MD, MTR, FAAD, lectured on how to measure itch and understanding the data in practice at Dermatology Week 2021. Dr Kim is an associate professor of dermatology and the codirector of the Center for the Study of Itch and Sensory Disorders in the division of dermatology, department of medicine, at Washington University School of Medicine in St Louis, MO.
Itch is a central feature of AD, and Dr Kim explained that the paradigm of AD pathogenesis and the role of itch in this is evolving. Various allergen and inflammatory stimuli can cross the leaky skin barrier and can activate the adaptive antigen-specific T helper 2 cells, IL-4, and IL-13. Those cytokines induce the production of IgE, a hallmark feature of atopy, as well as directly cause more inflammation and damage to the barrier, thereby contributing to the itch-scratch cycle. More recent research has identified the upstream role of IL-33 and thymic stromal lymphopoietin as well as a downstream role of basophils and innate lymphoid cell 2.
“For everyone to be on the same page, it’s very important to understand how itch transmission occurs within the skin,” said Dr Kim. Classically, a neurotransmitter binds to a receptor to open a cation channel, causing depolarization when ions cross the channel. If enough passage occurs, then an action potential is triggered, opening a voltage-gated sodium ion channel, which then sends another action potential to the spinal cord. A similar process follows in the spinal cord, which eventually transmits the message to the brain, triggering the perception of itch.
Currently, itch is measured on a numerical rating scale (NRS), with a score of 0 representing no itch and 10 representing worst itch imaginable. The NRS has been useful in practice and in clinical trials, even for diseases such as prurigo nodularis and chronic pruritus of unknown origin, and can show the increasing links to other patient-reported outcomes.
However, the NRS does not capture the impact of acute flares. The pattern of acuity of itch in AD may influence the patient’s perception of their disease and alter the definition of severity. Dr Kim stressed that clinical trials may be evaluating efficacy based on a mean NRS instead of objectively evaluating the itch pattern distribution, and dermatologists should remember that acute itch flares are dynamic and much more prominent in the patient population than previously thought.
To build on this knowledge, Dr Kim connected acute itch flares with allergen-specific IgE. While the science is still novel, he highlighted a study by Wang et al published in Cell that provokes “the hypothesis that this [IgE] reactivity is biologically meaningful, and that reactivity to environmental allergens is likely, in part at least if not significantly, driving these acute itch flares.”
Dr Kim shared an exciting development for an objective measurement of itch, describing a touchless technology called Emerald. The radiofrequency technology can track factors such as sleeping, and scratching, both factors important in the quality of life of patients with AD. In a few prospective observational studies, Dr Kim’s research group demonstrated that scratching impacts the number of awakenings during sleep, negatively affecting sleep efficiency.
“So, the conclusion of this is that we can perhaps measuring scratching objectively, and scratching can actually reveal hidden morbidities that patient-reported outcomes cannot capture,” added Dr Kim. The next step will be understanding how objective measurement of itch may be influenced by different disease states.
Disclosure: Dermatology Week is an event by HMP Global, the publisher of The Dermatologist.
References
1. Treat J. Pediatric dermatology: hemangiomas and vascular malformations. Presented at: Dermatology Week 2021; September 16-19, 2021; virtual.
2. Kim BS. Measuring itch in atopic dermatitis. Presented at: Dermatology Week 2021; September 16-19, 2021; virtual.
