Innovations in Dermatology Newsletter
Hot Topics in Dermatology: Hair Loss, Collagen, & RFMN: What’s the Latest and Greatest?
Innovations in Dermatology is back in your inbox this month with a candid interview with Shilpi Khetarpal, MD, who is an associate professor in dermatology at the Cleveland Clinic Foundation and specializes in cosmetic and procedural dermatology. Dr. Khetarpal and I dove right into several hot topics, including the most current research regarding the role of collagen supplementation, the efficacy and safety of radiofrequency microneedling (RFMN) and how it compares with other energy-based devices, and the newest innovations and/or research findings in hair loss.
In last month’s issue we shared key insights from Dr. Omer Ibrahim, dermatologist and cosmetic and laser surgeon and co-director of research at Chicago Cosmetic Surgery and Dermatology. Dr. Ibrahim and I discussed the use of platelet-rich plasma (PRP) and stem cells for hair loss, photodamage and scarring, and the benefits and drawbacks of use of social media. 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 was an educational event not to miss. (If you did, 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. Khetarpal. Also, this month’s Derm Resource section will keep you updated with a Dermatology News article on price transparency, updated AADA guidelines on actinic keratosis (AK), an article in Cutis titled “Phytophotodermatitis Is an Occupational and Recreational Dermatosis in the Limelight,” an original investigation in JAMA Dermatology titled “Long-term Outcomes and Prognosis in New-Onset Psoriasis,” and a CME/CE Certified Supplement from the Hawaii Dermatology Seminar—Cardiovascular Disease and Psoriasis.
Thank you to Dr. Khetarpal for her critical contribution on what’s new for several dermatological conditions.
Don’t forget to check out the Innovations in Dermatology: Virtual Spring Conference 2021 here, and please contact me at [email protected] with comments or suggestions. Thanks for reading!
Hot Topics in Dermatology: Hair Loss, Collagen, & RFMN: What’s the Latest and Greatest?
Shilpi Khetarpal, MD is an ASDS fellowship-trained, board-certified dermatologist who is an associate professor in dermatology at the Cleveland Clinic Foundation and specializes in cosmetic and procedural dermatology.
Colleen: Please tell us about the most current research and understanding regarding the role of collagen supplementation in skin rejuvenation.
Dr: Khetarpal: There is limited data supporting the use of oral collagen supplementation for skin health and rejuvenation. Once an oral supplement is ingested, it is digested by the GI tract, so very little is absorbed. Additionally, supplements can have side effects like GI upset and food allergies because the supplement industry is not well regulated and has a history of inaccurate labeling, contamination, and other safety concerns.
Rather than taking oral collagen, I recommend protecting the collagen we have by using daily SPF and topical antioxidants. We lose collagen from environmental factors like sun, cigarette smoke, and pollution causing sun damage like wrinkling, dryness, and discoloration of the skin. It is better to protect skin from sun (SPF) and pollution (antioxidants), stay hydrated, and avoid cigarettes to care for the collagen you do have, rather than trying to replenish it with supplements.
Colleen: In a special issue of Dermatologic Surgery, you coauthored a critical review of radiofrequency microneedling (RFMN). Can you give us the main takeaways on your findings regarding the efficacy and safety of RFMN, and how it compares with other energy-based devices in a clinician's armamentarium?
Dr: Khetarpal: RFMN is a safe, effective treatment in patients of all skin types for various indications including acne, acne scarring, hyperhidrosis, cellulite, melasma, rosacea, skin rejuvenation and striae. There is an increasing amount of evidence in the literature supporting its use with the effects being slow and progressive. It can be used independently or in combination with other treatments to improve efficacy.
Compared to other therapies, RFMN is able to go deeper than lasers and, given that it only heats the dermis, it is safe in all skin types. There are numerous devices on the market that vary in terms of needle depth, insulation, number, and pulse duration. Not all devices are equal, so it is important to counsel patients accordingly.
Colleen: Can you give us some insights from your latest article in Dermatology Online Journal, Patient Safety in Dermatology: A Ten-year Update?
Dr: Khetarpal: This study looked at patient safety issues surrounding dermatology, including medication errors, diagnostic errors including telemedicine, office-based surgery, wrong-site procedures, COVID-19 and other infections, falls, laser safety, scope of practice and electronic health records. Despite the increasing number of dermatologic patient safety studies, our study suggests the need for more reports to reduce the number of preventable errors in order to provide optimal care.
Colleen: Can you share with us what you feel are the most useful and applicable innovations and/or research findings in hair loss treatment?
Dr: Khetarpal: Platelet rich plasma (PRP) is one of the newest and most popular treatments for hair loss in my practice due to its autologous nature and regenerative properties. PRP is an autologous concentration of platelets in plasma with numerous growth factors that contribute to hair regeneration. The growth factors contained within platelets act on stem cells in the hair follicles and stimulate development of new follicles along with growth of new blood vessels. It is a well-tolerated, in-office treatment that is used as adjunctive therapy in additional to medical therapies for androgenetic alopecia (AGA) and several other types of hair loss.
Stem cells are a hot topic but are currently not FDA approved and require additional studies regarding efficacy and safety before becoming mainstream. But they do have a lot of potential as a hair loss therapy.
Nutraceuticals are also very popular. These are supplements that are not prescription but are recommended by physicians and sold through their offices and can be used along with medical therapies and PRP. Newer therapies improve patient compliance by including a hair supplement, multivitamin and probiotic all in one.
Colleen: What would you consider to be the most useful and innovative new tools and/or devices in your dermatologist’s arsenal?
Dr: Khetarpal: As a medical and cosmetic dermatologist, there are several things that I use on a daily basis. A dermatoscope is essential, allowing one to see high power magnification of specific skin lesions, both pigmented and non-pigmented. Electrocautery is a cost-effective, simple device that can be used to treat a variety of medical and cosmetic conditions like hemostasis during surgery, but also sebaceous hyperplasia, dermatosis papulosa nigra, syringomas, and other benign lesions in cosmetically sensitive areas. Injectables such as neurotoxins and hyaluronic fillers are safe and popular treatments. The new injectable for cellulite dimples on the buttocks also shows promise. Laser therapy is progressing at a rapid pace but lasers like the pulsed dye laser (PDL) and nano and picosecond lasers are workhorse devices. For skin texture, my favorite treatments are non-ablative fractional resurfacing and RFMN. Non-invasive skin tightening is also popular with monopolar radiofrequency being a treatment that many of my patients are very happy with. PRP for hair and skin rejuvenation along with microneedling are also great options for those wanting a more ‘natural’ treatment relying on the body’s own growth factors and wound healing response.
Article: COVID-19/SARS-CoV-2 virus spike protein-related delayed inflammatory reaction to hyaluronic acid dermal fillers: a challenging clinical conundrum in diagnosis and treatment. Munavalli GG, Guthridge R, Knutsen-Larson S, et al. Arch Dermatol Res. 2021 Feb 9;1-15.
Dr: Khetarpal: There is an increasing concern of filler reactions with COVID 19 vaccine from patients and other non-core aesthetic physicians. This article summarizes the diagnosis and treatment for these patients and is helpful in discussing this topic with patients and other physicians.
Dermatology Resource Section
Innovations in Dermatology Virtual Spring Conference 2021: Available Online Here: https://na.eventscloud.com/website/20848/
Dermatology News Article: Price transparency comes to medicine
Cutis Article: Botanical Briefs: Phytophotodermatitis Is an Occupational and Recreational Dermatosis in the Limelight
NEJM Article: Bimekizumab versus Secukinumab in Plaque Psoriasis
NEJM Article: Bimekizumab versus Adalimumab in Plaque Psoriasis
Topical Therapies for Psoriasis: Cardiovascular Disease and Psoriasis—
A CME/CE Certified Supplement from the Hawaii Dermatology Seminar
JAMA Dermatology Editorial: Long-term Outcomes and Prognosis in New-Onset Psoriasis—Original Investigation
American Academy of Dermatology Association (AADA) new guideline on actinic keratosis, including evidence-based recommendations for treatment:
Innovations in Dermatology Daily – Session 3
The seventh dynamic virtual session of Innovations in Dermatology: Virtual Spring Conference 2021, “Body of Evidence: Updates on Body Contouring” was co-chaired by Michael S. Kaminer, MD, and Sabrina G. Fabi, MD. Faculty presented on several critical topics and updates in body contouring, and the session was rounded out by an Ask the Experts panel that focused on OTC, skin and aesthetic dermatology.
Regarding this last panel of the session, Dr. Kaminer commented, “In the session-closing Ask the Experts panel, Dr. Zoe Draelos and I have some quality case-based discussions on timely hot topics, including hyaluronic acid filler reactions in patients who receive the Covid vaccine. We also discuss other filler complications including vision loss. The cases presented by the audience provide for critical lively discourse and direction on various aspects of OTC, skin, and aesthetic dermatology treatments, and also provide pearls for patient selection and treatment optimization.”
Read on to learn about the most critical presentations from this session of the conference.
In her presentation, “Nonsurgical Skin Lifting: Boosting Collagen and Elastin,” Dr. Elizabeth Tanzi explored nonsurgical skin lifting, boosting collagen and elastin. Her presentation shared results from three devices, including radiofrequency micro-needling treatments for tightening, high intensity focused ultrasound, and a fractionated laser device to improve tone, texture and tightening. Dr. Tanzi stressed, “Realistic expectations are absolutely critical when talking about success. You have to talk to your patients, because even if they are good candidates, they can have mixed results.” She added, “Most patients need multiple treatments as well as maintenance treatments to obtain the best improvement because the aging process will continue to progress.” Going forward, Dr. Tanzi expects to see more combination treatments that use a device with potentially hyper-dilute injectables, calcium hydroxyapatite, or a very dilute polylactic acid to yield even more improvement than the devices alone can deliver. In closing, Dr. Tanzi shared that even if you have a perfect patient who is very appropriate for treatment, that patient can get an underwhelming response. She noted, “Advanced technology clearly yields more reliable results, but continued research is needed.”
Next, Dr. Michael Kaminer presented, “A Targeted Approach to Addressing Cellulite.” Dr. Kaminer said that treatment options for cellulite are evolving, with a strong focus on fiber septae. He shared that for a long time nothing really worked to improve cellulite. However, during his update on what treatments are available, Dr. Kaminer reported, “Nearly all of the efficacy that comes in the treatment of cellulite comes when fiber septae are first targeted.” He shared three types of treatments that all include a breaking down of the fiber septae, including mechanical, acoustic, and chemical subcision.
Dr. Kaminer advised attendees, “All cellulite is not equal, so try and match new technology to the patient’s cellulite and see if there are ways to either treat the fiber septae to make them better or perhaps use a filler as an adjunct.” He said that all of these things together may finally help treat patients with cellulite in a predictable and durable way.
Also in today’s session is a presentation by Dr. Sabrina Fabi on “Toning and Tightening: Appropriate Patient Selection to Optimize Effectiveness.”
Please make sure to visit our live Q&A panel here and check out our “Ask the Experts” interactive session with Dr. Zoe Draelos and Dr. Michael Kaminer, featuring case-based discussions submitted by conference attendees with a focus on OTC (over the counter), skin, and aesthetic dermatology.
Innovations in Dermatology Daily – Session 2
At the third dynamic virtual session of Innovations in Dermatology: Virtual Spring Conference 2021, “The Cutting Edge on Cutaneous Malignancies,” Co-Chairs Ashfaq A. Marghoob, MD, and Neal Bhatia, MD, oversaw faculty present on several topics essential to patient management and treatment of cutaneous malignancies. Read on to learn about the most critical presentations from this session of the conference.
"Unlike the stereotype of the pimple popper that Jerry Seinfeld created, dermatologists have a lot of options for treating skin cancer in addition to surgery,” stated Session Co-Chair Neal Bhatia. “Many of the advances in topical and systemic therapies—some of which evolve from treating actinic keratoses and some from other visceral tumors—are now safer and easier to incorporate. Too many patients have risks such as anticoagulants and other comorbidities, or having malignant tumors near the eyes, ears, and nose, as well as on the legs, where surgery might involve potential risks or high recurrence potential.” Looking to the future, Dr. Bhatia concluded, “Our opportunities to maximize combinations of medical and surgical interventions, similar to oncologists, will lead to better clearance and safer alternatives for patients."
In his presentation, “Basal Cell Carcinoma: How to Effectively Manage Your Patients,” Dr. Vishal Patel explored current topics in basal cell carcinoma and how to effectively manage your patients. He explained that while basal cell carcinoma is the most common malignancy in the United States, it is unknown exactly how many cases are seen each year since there is no centralized database. Noting that effectively managing treatment for basal cell carcinoma “requires a little bit more thought than we sometimes initially put into the basal cell,” Dr. Patel suggests that in order to treat tumors effectively, it is important to begin by stratifying them into low risk and high risk. Dr. Patel explained that there is not a staging system for basal cell carcinoma. “We utilize the staging system for squamous cell carcinoma for basal cells, which is woefully inadequate.” He revealed that a paper will be released soon that will propose a new staging system for basal cell carcinoma but said, “This just really doesn’t get at how we should be thinking about how to treat our patients.” Dr. Patel then shared three different cases to illustrate treatment and management of basal cell carcinoma.
Later in the session, Dr. Michael Marchetti presented, “The Road Ahead: Updates in the Management of Melanoma.” Dr. Marchetti discussed all updates to melanoma, the fifth most common cancer in the United States in 2021. According to Dr. Marchetti, there are over 100,000 cases of invasive melanoma diagnosed each year. However, when identified early, the five-year survival rate is very favorable. And, Dr. Marchetti reported, “The good news is that, since 2013, deaths from melanoma have been rapidly dropping.”
Dr. Marchetti introduced three emerging tools for diagnosis, including the pigmented lesion assay test, a noninvasive molecular test that is an adhesive patch placed on the skin lesion. It can be used at home or at the clinic. He said, “The accuracy of this particular study sensitivity appears to be quite high at 90%.” He added that an economic analysis suggested that if used in the right conditions, this test has the potential to save money and avoid unnecessary biopsies. The second new device used for diagnosis relies on electrical spectroscopy. This tool measures how current flows through individual cells in lesions. Dr. Marchetti said the device provides a numeric score and takes about 30 seconds to assay the lesion. He then revealed a third tool he called the “next-generation total body photography.” He stated, “This is not something clinically validated yet, but we are seeing a lot of progress on this front.” Sharing his optimism for the future, he further stated, “I think there is a lot of progress and things to come in the future. Over the last four years, we have also seen incredible progress in terms of the application of artificial intelligence to skin cancer.”
Also in today’s session were presentations by Dr. Neal Bhatia on “Actinic Keratosis: The Importance of Early Detection and Management,” and Dr. Kishwer Nehal’s presentation, “Expert Perspectives on Managing Patients with High-Risk Cutaneous Squamous Cell Carcinoma.” The session was rounded out by Dr. Ashfaq Marghoob presenting “Seeing Clearer: Dermoscopy Tips and Tricks.”
Before you go, make sure to visit our live Q&A panel here. Also make sure to check out our “Ask the Experts” interactive session with Dr. Ashfaq Marghoob and Dr. Linda Stein Gold, which features case-based discussions submitted by attendees with a focus on acne, rosacea, and cutaneous malignancies.
Don’t miss! The second session of Innovations in Dermatology: Virtual Spring Conference 2021 served as an update on psoriasis. Co-chair Linda Stein Gold shared her thoughts on the day: “Drs. Bruce Strober, Joel Gelfand, Amy Paller, and I discussed the latest therapeutic options for psoriasis and timely hot topics, including treating psoriasis patients in the environment of the COVID-19 pandemic. We had a lively discussion and also provided many pearls for optimizing treatment for our adult and pediatric psoriasis patients.”
Innovations in Dermatology Daily – Session 1
During the first dynamic virtual session of Innovations in Dermatology: Virtual Spring Conference 2021, “All You’re Itching to Know About Atopic Dermatitis,” Dr. Jonathan Silverberg explored current topics in oral and topical therapies for atopic dermatitis.
In his presentation, “Current Concepts in Targeted Oral and Topical Therapies for Atopic Dermatitis,” Dr. Silverberg reviewed guidelines for clinicians to use in the Step-up approach to atopic dermatitis (AD) management and introduced some of the newer topical therapies to be approved.
“Ruxolitinib is not just some emerging pipeline therapy in development,” Dr. Silverberg explained. This is already a drug that has completed phase 3 trials and is likely to be approved any day now.” He continued, “This is really important for us to see that ruxolitinib is more effective potentially than some of the things that we are commonly using.”
Regarding other therapies, Silverberg stated, “The oral JAK-inhibitors are the next wave of options to add to the toolbox. Baricitinib, abrocitinib, and upadacitinib all demonstrated efficacy for skin lesions, itch, pain, sleep disturbance, quality of life, anxiety, and depression.” Dr. Silverberg relayed that some patients showed positive responses within hours or days, and overall patients showed good long-term results. He also shared some common adverse events such as headaches, acne, nausea, and upper respiratory infections.
Additionally in this first session of Innovations in Dermatology: Virtual Spring Conference 2021, Dr. Eric Simpson’s presentation, “Biologics: New and Emerging Agents,” revealed new and emerging agents in this dermatological therapeutic area. “There is a lot of exciting science and innovation taking place right now in biologics,” Dr. Simpson commented. He explained that when considering a systemic treatment if a patient’s condition is not under control, there are several options. “The newest is dupilumab, the only FDA-approved biologic.” He stated, “90 to 95% of patients achieve some clinically relevant response in skin or symptoms, and it provides long-lasting benefits with no new adverse event risks.” Dr. Simpson also said that while tralokinumab has modest efficacy results, it continues to capture more successes beyond week 16 and the drug lebrikizumab also shows promise.
Also in today’s opening session were presentations from Dr. Emma Guttman on “Atopic Dermatitis Pathophysiology” and from Dr. Lawrence Eichenfield on “Atopic Dermatitis in Infants and Pediatric Patients.” You can access them here. Before you go, make sure to visit our live Q & A panel from this session as well here.
Hot Topics in Dermatology: Discussing PRP and Stem Cells for Hair Loss, Collagen Supplements, and Social Media with Omer Ibrahim, MD, PhD
Innovations in Dermatology is back in your inbox this month with a candid interview with Dr. Omer Ibrahim, who is a dermatologist and cosmetic and laser surgeon, as well as co-director of research, at Chicago Cosmetic Surgery and Dermatology. Dr. Ibrahim and I dove right into several hot topics, including use of platelet-rich plasma (PRP) and stem cells for hair loss, as well as photodamage and scarring, the real role of collagen supplementation in skin rejuvenation, and the benefits and drawbacks of use of social media.
In issue last month we shared key insights from Bruce Strober, MD, on 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. 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 this month and daily oral presentations on selected abstracts and interactive case-based discussion from 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. Ibrahim. 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. Ibrahim for his critical contribution on what’s new in hair loss and other treatments.
Don’t forget to check out the Innovations in Dermatology: Virtual Spring Conference 2021 here, and please contact me at [email protected] with comments or suggestions. Thanks for reading!
A Melting Pot: Platelet-Rich Plasma and Stem Cells for Hair Loss, Collagen Supplements, and Social Media
Omer Ibrahim, MD is a board-certified, fellowship-trained dermatologist and cosmetic and laser surgeon at Chicago Cosmetic Surgery and Dermatology, where he also serves as co-director of research.
Colleen: How are platelet-rich plasma (PRP) and stem cells used to treat hair loss?
Dr. Ibrahim: Platelet-rich plasma (PRP) is an autologous blood-derived product that contains an increased concentration of platelets suspended in plasma. PRP also contains cytokines, plasma proteins, and growth factors that can all contribute to the stimulation of hair growth. Although large randomized controlled trials are lacking, smaller studies and reports have shown that injectable PRP (when properly concentrated and administered) can stimulate terminal hair growth. In my practice, PRP is seldom offered as a monotherapy treatment; I offer PRP as an adjunct to tried and true medical therapy (minoxidil, spironolactone, finasteride, etc). In fact, when PRP is administered alone, the results can be very tenuous and fleeting without maintenance medical treatment at home. The typical PRP regimen includes 3-4 monthly treatments followed by a single “booster” treatment every 4-6 months. Recently, a few companies have begun to tout the use of injectable mesenchymal-derived “stem cells” as a treatment for hair loss. Given that the evidence for safety and efficacy are lacking, and the treatments are quite costly in comparison to PRP, I do not recommend the use of stem cell therapy yet for my hair loss patients.
Colleen: How is PRP used to treat photodamage and scarring?
Dr. Ibrahim: As discussed earlier, PRP contains a multitude of factors that can stimulate wound healing, tissue growth, neocollagenesis, and angiogenesis. As such, PRP has been microneedled into the skin, injected into the skin, and applied topically following ablative laser therapy. In terms of volumizing the face, PRP is not very effective; in comparison to commercially available soft tissue fillers, PRP has not been shown to provide appreciable lifting and volumizing of the face. For cutaneous rejuvenation (i.e., fine lines, wrinkles, pigmentation, and scarring), PRP may be effective. When injected subdermally, some patients have noted improvement in skin texture. When applied during and after microneedling, studies have demonstrated greater improvements in scarring and photodamage in comparison to microneedling alone. Finally, when applied topically following ablative laser, PRP has been shown in some studies to speed up healing and enhance results.
Colleen: What is the role of collagen supplementation in skin rejuvenation?
Dr. Ibrahim: The role of oral collagen supplementation in skin rejuvenation has long been debated among the dermatologic community. In fact, the results of studies examining oral collagen’s effects on the skin are often conflicting. Some studies have demonstrated increased cutaneous hydration, increased elasticity, and decreased rhytides with oral collagen peptide supplementation, while some studies showed no difference in these parameters in comparison to placebo. The issue is that there are no large, randomized controlled trials to study the effect of oral peptides on the skin, and the supplements available vary greatly in dosage, purity, and bioavailability. In addition, these supplements are not regulated by the FDA and their safety profile is unknown. As such, clinicians should approach with caution and consider the available evidence if they suggest collagen peptide supplementation for their patients.
Colleen: How would you characterize the benefits and drawbacks of use of social media as a clinician?
Dr. Ibrahim: Social media has placed the power of marketing and branding in the hands of the individual. Gone are the days of shelling out hundreds, if not thousands, of dollars in order to purchase a print-ad in a newspaper or magazine. A photo or video is captured and stored on a mobile device and, with a few finger taps, is uploaded onto a social media platform to be seen by hundreds of eyes and potential patients. The individual has become the driver of the narrative of their career online, at a relatively low financial cost.
There can be drawbacks to social media. One, especially true for the newer social media platforms, is that the clinician for the first time is much more accessible on a personal level. The debate between what is considered “professional” and “unprofessional” can become muddled. Another drawback to social media is that the clinician finds him or herself competing with other “skin experts” online that in fact have no training in dermatology, and just happen to have a wider fan base. The provider now not only needs to educate patients on what treatments are appropriate for them, but also finds themselves having to demystify myths propagated by the so-called “skin experts” online.
Article: Wang JV, Schoenberg E, Saedi N, Ibrahim O. Platelet-rich Plasma, Collagen Peptides, and Stem Cells for Cutaneous Rejuvenation. J Clin Aesthet Dermatol. 2020 Jan;13(1):44-9.
Dr. Ibrahim: The use of platelet-rich plasma, collagen supplementation, and stem cells is rapidly expanding and evolving. This article reviews the current evidence, or lack thereof, of these treatment modalities, and is a helpful resource for clinicians that use these therapies in their practice.
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!
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.
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.
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
Cutis Article: Reimbursement for Teledermatology During the COVID-19 Public Health Emergency: Change Has Come, But Will It Stay?
NEJM Article: Phase 3 Trials of Tirbanibulin Ointment for Actinic Keratosis
Topical Therapies for Psoriasis: The Revolution in Vehicles, Combinations, and Novel Agents—
A CME/CE Certified Supplement from the Hawaii Dermatology Seminar
JAMA Dermatology Editorial: Shared Decision-Making in Dermatologic Care—A Call for More Training and Resources
Dermatology News Conference Coverage: Face masks can aggravate rosacea
From the EADV Congress
American Academy of Dermatology Association: Office-Based Surgery Clinical Guidelines
NEJM Audio Interview: An International Look at Covid-19
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.
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.
Article: Insights into the Pathophysiology of Cellulite: A Review. Bass LS, Kaminer MS. Dermatol Surg. 2020 Oct;46 Suppl 1(1):S77-S85.
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.
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.
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)
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
Medical Intelligence Quiz—Challenge Yourself, Build Your Knowledge: Actinic keratosis—Are shorter ALA incubation periods effective?
JAMA Dermatology Article: Enanthem in Patients With COVID-19 and Skin Rash:
Innovations in Dermatology: Virtual Spring Conference 2021: March 16–20:
NEJM Perspective: Testing in a Pandemic — Improving Access, Coordination, and Prioritization: