Innovations in Dermatology Newsletter

February 2021

Hot Topics in Dermatology: Discussing Psoriasis Advances with Bruce Strober, MD, PhD

Innovations in Dermatology is back in your inbox this month with a candid interview with Dr. Bruce Strober, who is Clinical Professor of Dermatology at Yale University School of Medicine and Medscape’s upcoming Innovations in Dermatology: Virtual Spring Conference 2021 faculty. Dr. Strober and I dove right into several hot topics, including the new targeted oral therapies for psoriasis, biologics for psoriasis, the readiness of frontline practitioners having to address psoriasis, and whether COVID has changed his practice.
In our inaugural issue last month we shared key insights from Michael S. Kaminer, MD, Linda Stein Gold, MD, and Lawrence Eichenfeld, MD—co-chairs of Innovations in Dermatology: Virtual Spring Conference 2021, on the microbiome and dermatology, racial disparities in dermatology, how ready and informed our frontline practitioners are in addressing the dermatological cases and conditions that they regularly face, and COVID. If you missed it, you can find that interview here.
Innovations in Dermatology: Virtual Spring Conference 2021 is a MedscapeLIVE! event from the producers of the Hawaii Dermatology Seminar and Caribbean Dermatology Symposium. With 8 live-streamed sessions over a 5-day period in March and daily oral presentations on selected abstracts and interactive case-based discussion based on attendee case submissions, this will be an educational event not to miss. (If you do, however, each session will also be available for immediate on-demand access following the conference.)
In this e-news, don’t miss the Suggested Reading from Dr. Strober. Also, this month’s Derm Resource section will keep you updated with a NEJM article on phase 3 trials of tirbanibulin ointment for actinic keratosis plus a NEJM audio interview, updated AAD guidelines, a CME supplement on topical therapies for psoriasis, a perspective in Cutis on if reimbursement for teledermatology during COVID is here to stay, and an editorial in JAMA Dermatology on shared decision-making in dermatology and the need for more training and resources.
Thank you to Dr. Strober for his critical contribution on wha’s new in psoriasis treatments. 
Don’t forget to check out details for the Innovations in Dermatology: Virtual Spring Conference 2021 here, and please contact me at [email protected] with comments or suggestions. Thanks for reading!
–Colleen Hutchinson

 

Interview

Hot Topics in Dermatology: Psoriasis Advances
Bruce Strober MD, PhD, Clinical Professor of Dermatology at Yale University School of Medicine and Central Connecticut Dermatology. He is currently the Editor in Chief of the Journal of Psoriasis and Psoriatic Arthritis and Co-Scientific Director of the Corrona Psoriasis Registry.

Colleen: We hear a lot now about targeted oral therapies for psoriasis. What’s new in this arena, and is any of it ready for prime time or designation as standard of care?

Dr. Strober: There is much that we don’t know about the relationship of the gut microbiome to skin conditions, and there is fascinating research going on that may give us insights into many of our inflammatory skin disorders and others. But a question of more immediate interest to dermatologists is for whom the skin microbiome mediates disease, and how it may be a target for intervention for disease management (or potentially, avoidance). Atopic dermatitis (AD), for instance, is well known to be associated with colonization with Staph aureus, and that flaring AD has more staph on the skin and less microbial diversity then when AD is calm and controlled. We are learning that some of our new systemic biologic agents affect the microbiome as they minimize inflammation, and several groups of AD researchers are testing whether microbial interventions with strains of non-staph bacteria applied topically may be anti-inflammatory.

Colleen: There is a lot of discussion about biologics for psoriasis as well. What’s new in this arena and is any of it ready for prime time or designation as standard of care?

Dr. Strober: Also approved for systemic-treatment appropriate psoriasis in adults within the next year will be bimekizumab, a biologic that blocks both IL-17A and IL-17F. This is a novel mechanism of action that appears to give this biologic higher efficacy than all previous medications for psoriasis, with 85 to 90% of patients achieving PASI 90 after 16 weeks of therapy. It also looks to be very effective for psoriatic arthritis and hidradenitis suppurativa in early trials. For psoriasis, this drug will likely be self-administered every 4 weeks for the first 3 to 4 doses, and then every 8 weeks thereafter. The safety data look comforting, but there will be a tolerability issue related to candidiasis, mostly oral, which occurs in 10 to 18% of patients in clinical trials. 

Colleen: How would you characterize the general care and readiness of frontline practitioners having to address psoriasis in their patients?
Dr. Strober
: Increasingly over the past decade, dermatologists have become much better at managing more severe skin disease, including psoriasis. The advent of biologic therapy has made us all better medical dermatologists, as the drugs have become increasingly safe and much more effective. The newer drugs about to be approved will only hasten that process.

Colleen: Many have said that COVID has changed the way medicine is practiced. How has COVID changed your practice and what has the biggest challenge been?

Dr. Strober: Our practice has continued forward somewhat like old. While we have instituted common sense, well-known protections for staff and patients, most of us have sidelined teledermatology only for the most appropriate situations, e.g., isotretinoin follow-up visits and patients with very stable skin disease controlled with biologic therapy.

 

Suggested Reading

Article: Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council. Strober B, Ryan C, van de Kerkhof P, van der Walt J, Kimball AB, Barker J, Blauvelt A. J Am Acad Dermatol. 2020 Jan;82(1):117-122. 
https://pubmed.ncbi.nlm.nih.gov/31425723/
Dr. Strober: This article is a good update on how we should abandon terms “mild,” “moderate,” and “severe” for how we classify psoriasis.

 

Dermatology Resource Section

Innovations in Dermatology Virtual Spring Conference 2021: March 16–20 
https://na.eventscloud.com/website/20848/

Cutis Article: Reimbursement for Teledermatology During the COVID-19 Public Health Emergency: Change Has Come, But Will It Stay?
https://www.mdedge.com/dermatology/article/235459

NEJM Article: Phase 3 Trials of Tirbanibulin Ointment for Actinic Keratosis
https://www.nejm.org/doi/full/10.1056/NEJMoa2024040

Topical Therapies for Psoriasis: The Revolution in Vehicles, Combinations, and Novel Agents—
A CME/CE Certified Supplement from the Hawaii Dermatology Seminar
https://www.globalacademycme.com

JAMA Dermatology Editorial: Shared Decision-Making in Dermatologic Care—A Call for More Training and Resources
https://jamanetwork.com/journals/jamadermatology/article-abstract/2775500

Dermatology News Conference Coverage: Face masks can aggravate rosacea
From the EADV Congress
https://www.mdedge.com/dermatology/article/234827/rosacea/face-masks-can-aggravate-rosacea

American Academy of Dermatology Association: Office-Based Surgery Clinical Guidelines
https://www.aad.org/member/clinical-quality/guidelines/obs

NEJM Audio Interview: An International Look at Covid-19
https://www.nejm.org/contact-nejm?query=footer

 

 

 

January 2021

Inaugural Issue

Hot Topics in Dermatology: Our Thought Leaders Weigh In

MISS E-News Inaugural Issue

Welcome Innovations In Dermatology E-News. I am excited to take on the management of this new Medscape publication with this inaugural issue! As you will see in this issue and those to come, we have some e-news features in store for you that we think you will find beneficial. 
First, every issue will feature a candid interview with either one or multiple thought leaders in dermatology. In this inaugural issue, I interview Michael S. Kaminer, MD, Linda Stein Gold, MD, and Lawrence Eichenfeld, MD—the three co-chairs of Medscape’s upcoming virtual conference, Innovations in Dermatology: Virtual Spring Conference 2021, and get their thoughts on the microbiome and dermatology, racial disparities in dermatology, how ready and informed our frontline practitioners are in addressing the dermatological cases and conditions that they regularly face, the biggest current challenges in training, and COVID in your practice. These thought leaders bring a critical knowledge of current issues and challenges in dermatology, as well as pulse on current best practices, to both this interview and to the conference that they co-chair. Innovations in Dermatology: Virtual Spring Conference 2021 is a MedscapeLIVE! event from the producers of the Hawaii Dermatology Seminar and Caribbean Dermatology Symposium. With 8 live-streamed sessions over a 5-day period in March—each session including 4-5 faculty presentations plus discussion and live Q&A—and daily oral presentations on selected abstracts and interactive case-based discussion based on attendee case submissions, this will be an educational event not to miss. (If you do, however, each session will also be available for immediate on-demand access following the conference.)
In this e-news, we will also sometimes feature Suggested Readings from the thought leaders interviewed. Experts will provide timely articles with not only their own recommendations of articles to read, but often the critical article takeaways as well. It’s one thing to read a list of what we should be reading, but it’s totally another to get picks from the experts. 
Given the ever-changing nature of dermatology and the current healthcare environment, we are also including a Derm Resource section to keep you updated on critical research, resources, and new developments. Please look to us as a collective resource of all things dermatology. This includes association updates, COVID and other general topic publications, and other helpful dermatology best practices information so you have all you need in one place at your fingertips to stay informed.
Get ready to be engaged and entertained, as well as educated, in the coming months. We have great things in store for you!
Thank you to this month’s interview participants and upcoming meeting faculty, Michael S. Kaminer, MD, Linda Stein Gold, MD, and Lawrence Eichenfeld, MD. Don’t forget to check out details for the Innovations in Dermatology: Virtual Spring Conference 2021 here.
Here’s to a new Medscape tool designed to keep you plugged in and informed, to the new names and faces you will see in these issues, and to developing a lasting rapport with you, the readership! We want to be your go-to source of information in all things dermatology. Please contact me at [email protected] with any comments and/or suggestions.
Colleen Hutchinson

 
Interview

Hot Topics in Dermatology: Our Thought Leaders Weigh In
Dr. Kaminer is currently Associate Clinical Professor of Dermatology, Yale Medical School, and Adjunct Assistant Professor of Medicine (Dermatology) at Brown Medical School and is team dermatologist for the Boston Celtics.
Dr. Stein Gold is Director of Dermatology Clinical Research for the Henry Ford Health System in Detroit, Michigan. She is also Division Head of Dermatology for the Henry Ford Health System in West Bloomfield, Michigan.
Dr. Eichenfield is Distinguished Professor of Dermatology and Pediatrics, Chief of Pediatric Dermatology and Vice-Chair of the Department of Dermatology at the University of California, San Diego and Rady Children’s Hospital. 

Colleen: We hear a lot now about the microbiome and its effects in all aspects of medicine. How would you characterize the connection between gut and skin as it pertains to your patient base, and is there new current research and/or treatments on the horizon that will target this connection?

Dr. Eichenfield: There is much that we don’t know about the relationship of the gut microbiome to skin conditions, and there is fascinating research going on that may give us insights into many of our inflammatory skin disorders and others. But a question of more immediate interest to dermatologists is for whom the skin microbiome mediates disease, and how it may be a target for intervention for disease management (or potentially, avoidance). Atopic dermatitis (AD), for instance, is well known to be associated with colonization with Staph aureus, and that flaring AD has more staph on the skin and less microbial diversity then when AD is calm and controlled. We are learning that some of our new systemic biologic agents affect the microbiome as they minimize inflammation, and several groups of AD researchers are testing whether microbial interventions with strains of non-staph bacteria applied topically may be anti-inflammatory.

Dr. Stein Gold: We are starting to understand the role of the microbiome in acne and the impact that our treatment has on it. Cutibacterium acnes (formerly Propionibacterium acnes) is a gram-positive, anaerobic bacteria that normally occupies the hair follicles and sebaceous glands. C. acnes has a role in the pathogenesis of acne. We now understand that it may be the particular strain of bacteria and not the amount of bacteria that influences acne. We know that our treatments, including the use of oral and topical antibiotics, also influence both the microbiome on the skin and in the gut. In order to minimize the impact on the gut, we try to use narrow spectrum antibiotics when treating acne. Also, by treating topically, we can avoid systemic antibiotic influence. 

Colleen: Many have said that COVID has changed the way medicine is practiced. Do you see this in dermatology, and if so, how? Will these be short-term or lasting changes?

Dr. Stein Gold: Teledermatology has enabled us to stay connected to our patients even in times of crisis. Many dermatologists adopted this for the first time during the pandemic but will likely continue to offer this service in the future. Although nothing takes the place of a face-to-face visit, telemedicine can be extremely useful in select cases.

Dr. Eichenfield: The most acute change, and the one that I think will have transformative impact, is the speeding up of adoption of telemedicine in dermatology by years. At our center, we have a strong interest in teledermatology, and had set up consultative dermatology for our emergency department, for instance, but hadn’t set up ‘direct to patient’ services. Within several days of recognition on the pandemic and the rapid shutting down of most clinic-based services, we transformed most of the practice into teledermatology. It was interesting to be “thrown into the deep end of the pool,” and we learned quite a lot within weeks about the pleasures and limitations of virtual visits. We have now learned for what kinds of visits it works well, for what kinds of conditions it doesn't, and the differences in visit preparation and execution between successful in-person “live” vs. teledermatology visits. Many patients so appreciate the convenience of virtual visits, though I would much rather mix and match over time between in clinic and teledermatology services for each patient, as the establishment of the doctor/patient (or family, in pediatrics) relationship is much easier in person.

Dr. Kaminer: COVID has obviously had a profound impact on the practice of medicine, including dermatology. Fortunately, dermatologists were at the forefront of developing strategies to keep our patients and staff safe during the pandemic, enabling in-person visits to resume safely. Telemedicine initially became a mainstay of care, but with the resumption of in-person visits, telemedicine has taken on a lesser role. We envision telemedicine to remain an adjunct to care, particularly with follow-up or maintenance of care visits including acne, eczema, etc. There may be a role for telemedicine as we move forward in dermatology, which will be refined based on efficiency and efficacy of care, as well as policies relating to HIPAA and insurance coverage. 

Colleen: How would you characterize the current racial disparities in dermatology? Is there disparity in diagnosis and treatment based on factors such as lack of use of dark skin in medical training, inadequate training regarding differences in skin conditions based on ethnicity and skin color, and general gaps in research?

Dr. Stein Gold: We have a lack of diversity in both physicians and in education. Although racial and ethnic minority physicians are underrepresented in medicine overall, this is especially pronounced in dermatology, with Black and Hispanic doctors each accounting for under 5% of the workforce. In addition, dermatology textbooks generally show skin conditions on Caucasian skin. In clinical trials with new medications, we have minority patients underrepresented. This is a problem in that we do not obtain enough data to ensure that a particular medication works in a similar way in all patient groups. As a specialty, we are working to improve this in all areas.

Colleen: What do you think will help solve the conundrum of frontline practitioners regularly having to address (common and uncommon) skin conditions and disorders that they do not know how to treat or, even in many cases, properly diagnose? 

Dr. Eichenfield: I think that educating primary care practitioners is crucial to improve care across the spectrum of healthcare delivery. I have been fortunate to have been involved in several projects where we have partnered with our affiliate pediatricians to improve their knowledge and care of certain common dermatology conditions, with great success. They still refer patients regularly with the diseases we have worked on, but the patient selection is better, and the therapies initiated before referral have helped them figure out who would benefit from specialist input. There is much work to do to improve education at the medical school and residency levels for non-dermatologists. 

Colleen: What is/are the biggest current challenges in training in your area of dermatology?

Dr. Kaminer: Cosmetic dermatology continues to experience robust growth, with the development of improved products and techniques. However, it is essential that hype doesn’t outpace science. Cosmetic dermatology was built on the foundation of scientific integrity, and the public has come to expect and trust that our profession will maintain that standard. Failure to adhere to scientific principles, allowing anecdotal evidence or social media to sway opinion, is a recipe for long term problems. Furthermore, it is essential that proper training remain the bedrock of cosmetic dermatology. Dermatology residency programs have improved and expanded cosmetic training, which will help propel the field forward with thought leaders. Non-dermatology cosmetic providers must adhere to and demonstrate similar training and competence if we are to maintain the high level of skill and trust that is central to our mission. The profession must monitor itself to ensure that we hold each of our colleagues to the high standards that are essential to the safe and effective practice of cosmetic dermatology. 

Colleen: Do you find noncompliance to be an issue, and if so, do the implications of that go beyond aesthetic repercussions to affect practices in terms of revenue and also reputation?

Dr. Kaminer: It is the ethical responsibility of healthcare providers to be appropriately trained and skilled when performing any procedure. This also applies to cosmetic dermatology and is one of the most important issues facing the profession today. Complications and sub-optimal results can be the byproduct of inadequate training, and it is incumbent on all providers, whether they are dermatologists or not, to ensure that they meet the standards set by the industry. Compliance with this basic tenet of medical practice is simply essential. Dermatology has been a leader in training, innovation, and the practice of cosmetic procedures, and the field has benefitted tremendously. If we wish to continue to lead the way, then dermatology as a specialty must ensure that we hold our profession to the same high standards that have been our foundation. Failure to do so will likely lead to an erosion of public trust, and a collective decrease in the standard of care. All of this is avoidable with proper education and training, and dermatology must insist that our non-dermatology colleagues follow these same principles.

 
Suggested Readings

Article: Insights into the Pathophysiology of Cellulite: A Review. Bass LS, Kaminer MS. Dermatol Surg. 2020 Oct;46 Suppl 1(1):S77-S85.
https://pubmed.ncbi.nlm.nih.gov/32976174/
Dr. Kaminer: This is a thorough review of cellulite, with novel insights as to pathogenesis and treatment.

Article: The role of the skin microbiome in atopic dermatitis. Nakatsuji T, Gallo RL.
Ann Allergy Asthma Immunol. 2019;122(3):263-269. 
https://pubmed.ncbi.nlm.nih.gov/30550810/
Dr. Eichenfield: This is an interesting article discussing the interrelationship of the microbiome with our most common inflammatory skin disease.

Article: Update on pediatric atopic dermatitis. Tracy A, Bhatti S, Eichenfield LF. Cutis. 2020 Sep;106(3):143-146.
https://pubmed.ncbi.nlm.nih.gov/33104117/
Dr. Eichenfield: There is a rapid evolution of therapy in atopic dermatitis. This article discusses new aspects of epidemiology and new therapies for pediatric eczema. 

 
Dermatology Resource Section

Highlights of the 43rd Annual Hawaii Dermatology Seminar (CME/CE Certified Supplement)
https://www.globalacademycme.com

Journal of the American Academy of Dermatology: Joint AAD–NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures
https://www.jaad.org/article/S0190-9622(20)32288-X/fulltext

Medical Intelligence Quiz—Challenge Yourself, Build Your Knowledge: Actinic keratosis—Are shorter ALA incubation periods effective?
https://www.mdedge.com/dermatology/actinic-keratosis

JAMA Dermatology Article: Enanthem in Patients With COVID-19 and Skin Rash:
https://jamanetwork.com/journals/jamadermatology/fullarticle/2768252

Innovations in Dermatology: Virtual Spring Conference 2021: March 16–20:
https://na.eventscloud.com/website/20848/

NEJM Perspective: Testing in a Pandemic — Improving Access, Coordination, and Prioritization:
https://www.nejm.org/doi/full/10.1056/NEJMp2025173?query=featured_home