We were fortunate to enjoy a case-based discussion on dyspigmentation from Dr. Nada Elbuluk. She first led us through several cases of hyperpigmentation, which included several presentations of extrafacial melasma, a case of lichen planus pigmentosus, erythema dyschromicum perstans, idiopathic eruptive macular pigmentation, and exogenous ochronosis. Next, we discussed several cases of hypopigmentation, including a case of steroid-induced hypopigmentation, nevus depigmentosus (achromic nevus), nevus anemicus, and progressive macular hypomelanosis. In the third section, she covered cases of depigmentation, including HIV photolichenoid dermatitis and inflammatory vitiligo. Lastly, Dr. Elbuluk shared useful clinical pearls in the evaluation and treatment of pigmentary disorders. For all patients, a detailed clinical history, medication list, medical history, and prior records should be reviewed. Dermatologists should have a low threshold for biopsy, and in cases of dyspigmentation both lesional and normal skin should be biopsied. During the exam, a Wood’s lamp should be used and the patient’s entire body should be examined and photographs taken. Of note, we must remember that patients can have more than one pigmentary condition, and that patients with pigmentary diseases may still also develop other common skin conditions. Finally, patients should be advised on their prognosis when discussing their disease and treatment options.
Atopic Dermatitis: Topicals and Biologics Jennifer Soung, MD
Dr. Soung led us on an exciting discussion on the therapeutic revolution currently underway in atopic dermatitis treatments with both topicals and biologics. She provided helpful and practical key recommendations for clinical practice and emphasized the importance of emollients in these patients' skin care routine. Studies have demonstrated no difference in efficacy based on the order of application of topical corticosteroids and emollients. She discussed steroid-sparing agents including topical calcineurin inhibitors and the topical PDE4 inhibitor crisaborole, as well as the first topical JAK inhibitor ruxolitinib (Opzelura). Recent studies on topical ruxolitinib have shown low rates of application site reactions, no new safety signals or significant changes in hematologic tests during 52-week study periods, and no adverse events suggestive of systemic exposure. She also discussed dupilumab (Dupixent), now approved for >6 months age, and treatment algorithms for dupilumab-associated conjunctivitis and head and neck associated dermatitis. Tralokinumab (Adbry) is a monoclonal antibody to IL-13 that was FDA-approved in December 2021 with few adverse effects comparable to placebo, most commonly mild-to-moderate conjunctivitis. Lebrikizumab is another monoclonal antibody that also targets IL-13 currently undergoing phase III clinical trials. Tapinarof cream is a small-molecule topical aryl hydrocarbon receptor agonist under investigation for atopic dermatitis that has already been approved for psoriasis treatment. Finally, roflumilast cream is a highly potent PDE4 inhibitor that has shown success in treatment of atopic dermatitis in phase II studies.
Warts and Molluscum Marcia Hogeling, MD
We enjoyed a helpful talk on current and emerging treatments for warts and molluscum from expert pediatric dermatologist Dr. Marcia Hogeling. Her initial approach to pediatric warts includes observation, salicylic acid 17% therapy, and cryotherapy. Duct tape and WartPeel cream containing compounded 5-fluorouracil cream and salicylic acid are also effective options. Immunotherapy options can treat distant lesions and prevent recurrence with less risk of scarring. High cure rates have been reported in case studies using oral cimetidine and in 13 out of 16 trials using zinc supplementation. Studies of injectable treatments using Candida antigen, MMR, and PPD demonstrated comparable response rates, while injections of BCG appeared to be inferior. Topical immunotherapy options include squaric acid and imiquimod. Over the counter devices containing compressed gases are available, with one study showing superior cure rates using the nitrous oxide device. Laser treatments for warts include Pulsed Dye laser, Nd:YAG laser, and CO2 laser. Plerixafor and Mavorixafor are innovative treatments targeting the CXCR4 receptor in phase 3 trials for WHIM syndrome. There is also a phase 2 study for a device containing cantharidin 0.7% called VP-102.
For destructive treatment of molluscum contagiosum, cantharidin 0.7% solution is applied with the wooden tip of a cotton applicator. Cryotherapy is generally avoided in children due to pain; curettage can be an option for an older child. Topical retinoids may be helpful for facial molluscum, OTC options such as Zymaderm and Molluscum Rx are also available, and topical imiquimod is generally not effective. The data for oral cimetidine in molluscum are conflicting. One study showed that cantharidin may be safe to use for facial molluscum. FDA approval for the VP-102 drug device containing 0.7% cantharidin may also be expected soon for molluscum. A new topical nitric oxide releasing gel called berdazimer is currently in phase 3 study.
Poster of the Day Efficacy and Safety of Roflumilast Foam 0.3% in Patients With Seborrheic Dermatitis in a Phase 3 Trial Andrew Blauvelt, Javier Alonso-Llamazares, Neal Bhatia, Zoe D. Draelos, Janet DuBois, Seth B. Forman, Melinda Gooderham, Scott T. Guenthner, Adelaide A. Hebert, Edward Lain, Angela Y. Moore, Kim A. Papp, Linda Stein Gold, Matthew Zirwas, Saori Kato, Scott Snyder, David Krupa, Patrick Burnett, David R. Berk, David H. Chu
Roflumilast is a selective phosphodiesterase 4 (PDE4) inhibitor with greater affinity and potency than apremilast and crisaborole, currently under investigation as a once-daily, nonsteroidal long-term treatment for psoriasis, atopic dermatitis, and seborrheic dermatitis. Results from a phase 2a trial and subsequent open-label safety trial have showed efficacy, safety, and tolerability of topical roflumilast foam. In this phase 3 randomized, parallel-group, double-blind, vehicle-controlled trial, topical roflumilast was investigated in patients 9 years and older with at least moderate seborrheic dermatitis. 80% of patients achieved IGA success and greater than 50% of patients achieved complete clearance by week 8. More than 60%b of patients achieved an itch response at week 8, with significant improvements seen at the 2-week and 4-week assessments. Overall, local tolerability was excellent with assessments of irritation, burning, and stinging consistent with safety profiles in prior trials. In summary, once-daily roflumilast 0.3% foam provided improvement across multiple efficacy endpoints versus vehicle in patients with seborrheic dermatitis in a phase 3 clinical randomized controlled trial. Read full poster here.