Seaver Soon, MD, FAAD
A Patient Centered and Evidence-Based Approach to Field Pre-Cancerization Therapy
  • We should think of field pre-cancerization is a chronic disease. We have to ask patients how much downtime they willing to deal with when treating pre-cancerous lesions. Office based treatments include medium depth chemical peels, PDT using daylight as activation (hint: look at UC Irvine’s published protocol), and chemowraps. Oral medications to reduce squamous cell carcinoma progression are niacinamide and acitretin, but patients generally need to stay on these medications to experience ongoing effects. Combined calcipotriene+ 5% 5-fluorouracil is promising given its ability to reduce the number of squamous cell carcinomas patients have, even years after treatment.  

High Risk Skin Cancer: Merkel Cell Carcinoma, Squamous Cell Carcinoma, Basal Cell Carcinoma
  • Nghiem et. al found that Merkel Cell Polyomavirus (-) patients are at increased risk for disease progression and disease-specific death and have an overall worse survival trend.
  • Nghiem et. al also demonstrated that viral oncoprotein antibodies may be monitored as a marker for recurrence in MCC, since half of MCPyV patients make antibodies to the ST antigen. Increasing titers should trigger imaging studies to evaluate for progression. 
  • Single fraction radiation is an effective and durable option in metastatic MCC and may induce abscopal effect with concurrent immune checkpoint therapy, even in patients with progression. 

Taraneh Paravar, MD, FAAD
Cases from a Rheum-Derm Clinic
  • In patients with chronic urticaria refractory to antihistamines, strongly consider a biopsy to rule out urticarial vasculitis (UV). Not all cases of UV present “classically” with lesions persisting >24 hours, symptoms of pain/burning, and leaving behind purpura or post inflammatory hyperpigmentation.
  • Caution using hydroxychloroquine in patients with dermatomyositis. It may not be sufficient to control disease as monotherapy and may actually be associated with increased risk of cutaneous adverse events.

Jashin J. Wu, MD, FAAD
Financial Tips for the Dermatology Practice
  • Dr. Wu felt one should have 3-6 months of cash for living expenses in case of emergencies, and not to have too much in cash which earns little interest and loses value due to inflation, which is usually 2-3% each year. 
  • Gold is a hedge against inflation, because its price tends to rise when the cost-of-living increases or the local currency is losing value.  As storage of gold bars is an issue, it may be simpler to buy gold miner stocks. 
  • It’s important to own your primary home, as the value of the property goes up over time, and there are tax benefits in owning a home and when selling a home.  Interest rates are at historic lows, so mortgages may be more manageable.  
  • However, in comparison to equities (stocks/mutual funds/ETFs), real estate won’t appreciate in value as much over time (can’t get 5-10x or more return in a few years).  Equities (stocks/mutual funds/ETFs) are an have more upside, but losses can be real, and stocks can go bankrupt.
  • Historically, equities have beaten real estate over time. 
  • Most people will have ~10 mutual funds offered in their 401k.  He recommends picking just 1 or 2 index funds.  For taxable accounts, for the investor who doesn’t have the time or inclination to pick stocks or bonds: he recommends Vanguard Total Stock Market Index Fund Institutional Shares (VITSX) (expense ratio 0.03%) and Vanguard Total Bond Market Index Fund Institutional Shares (VBTIX) (expense ratio 0.035%).
  • In order to determine how much equities vs bonds to have, use 100 and 120 minus your age to get the percent in equities, and the rest is in bonds. For example, for a 40 yo person, it would be 100-40= 60 to 120-40= 80, so 60-80% should be in equities, so then 20-40% would be in bonds.  One can then put more or less in equities based on their personality.

Hyperhidrosis
  • Topical antiperspirants and Rx aluminum chloride are best applied overnight or for at least 6-8 hours on dry skin.  Apply nightly until effect is noted, then decrease frequency.
  • Glycopyrrolate can be started 1mg BID, escalate 1mg/day each week until desired effect occurs or adverse effects limit patient tolerance.

Dirk Elston, MD, FAAD
Best of JAAD
  • We do not need to tell our patients to stop anticoagulants prior to dermatologic surgery, but a certain subset of patients may be safe to stop direct anticoagulants preoperatively (ie: really hash out the risk: benefit analysis of transiently stopping the anticoagulant).
  • Regarding psoriasis patients, biologic therapy is associated with reduced mortality regardless of treatment duration whereas methotrexate is associated with reduced risk only with exposure for 1 year or longer. 
  • If patients with psoriasis fail one IL-17 inhibitor, transitioning to an alternate IL-17 inhibitor can still be effective.
  • Patients exposed to isotretinoin do not appear to have an increased risk of inflammatory bowel disease at 1 year after exposure (there was an absolute difference of 2.6 more cases per 10,000 patients in those exposed vs unexposed)
  • In patients with chronic itch, don’t forget to screen for substance abuse (including opiates, CNS stimulants such as cocaine, ADHD medications). 
  • Some patients on dupilumab developed or worsened current cutaneous T cell lymphoma. Therefore, when we follow patients with atopic dermatitis on dupilumab, complete a full skin exam to evaluate for evolving mycosis fungoides.
  • Use spouses to perform skin exams on their significant others. Apparently single people present with melanoma at higher stages than those who have a partner.
  • Consider intralesional methotrexate for keratoacanthomas. This therapy has high treatment success and burns less than injecting with 5% 5-fluoruouracil. 
  • When considering desmoplastic melanomas, there are differing biologic behaviors based on subtype. Those with any epithelial component (vs pure desmoplastic) are more likely to metastasize with higher associated mortality.

Tissa Hata, MD, FAAD
Rosacea and the Microbiome of the Skin
  • In hidradenitis suppurativa, antibiotics tend to improve flares without altering baseline control of the disease. The good news is that clindamycin and metronidazole do not require renal dosing.

Pearl Grimes, MD, FAAD
Hyperpigmentation Update 
  • Visible light and infrared light may be damaging the skin in addition to ultraviolet light by causing erythema, free radicals/oxidative stress, mast cell-mediated inflammation, angiogenesis, and hyperpigmentation. 
  • Visible light activates the OPN3 receptor on melanocytes which then upregulates MITF and tyrosinase/tyrosinase-related enzymes. 
  • Iron-oxide containing formulations block more visible light in contrast to other mineral sunscreen ingredients.

Jashin J. Wu, MD, FAAD
IL-17 inhibitors and IL-23 inhibitors
  • In the EXCEED study of secukinumab versus adalimumab for psoriatic arthritis, secukinumab was numerically more effective than adalimumab based on ACR20, ACR50, and resolution of enthesitis, but this was not statistically significant. 
  • Brodalumab has a boxed warning about suicide, but it has yet to be shown to occur in the two-year US pharmacovigilance data report.  In this recent publication, 2677 patients in the United States took brodalumab from 8-15-2017 through 8-14-2019, and there were 0 cases of suicide.  
  • In the ECLIPSE trial, guselkumab was shown to have higher PASI 90 responses than secukinumab at week 48. In the IMMerge trial, risankizumab was shown to have higher PASI 100 responses than secukinumab at weeks 52.  In the BE RADIANT trial, bimekizumab was shown to have higher PASI 90 responses than secukinumab at weeks 16 and 48.

Ronald Moy, MD, FAAD
What Works and What Doesn’t
  • Regarding new cosmetic procedures and devices, remember to be skeptical about what “the industry” tells you and what is published in the medical literature. There tends to be a “wave of enthusiasm” for new medical devices that may eventually fade when/if we realize certain treatments don’t work as well as we hoped. According to expert Dr. Moy, we need to really utilize clinical photographs as endpoints for efficacy of devices/cosmetic treatments as histopathological improvement doesn’t always equate to great before and after photos. 

Victor Ross, MD, FAAD
Lasers and Radiofrequency, Lifting, and Tightening Devices
  • Future advances with laser technology include development of a 1726nm laser for uses such as acne and sebaceous hyperplasia, as there is slightly more absorption with fat than water.
  • Skin tightening devices do not work for everyone, however for some select patients are a good option. 
  • Issues with microrneedling with radiofrequency include unknown needle depth, increased resistance to needle penetration with depth, variability in user pressure, delivery angle, and needs for more precise control of needle depth/penetration, energy delivered, speed of treatment, and more