SISD 2021 - Day 2 Highlights - Symposium for Inflammatory Skin Disease

DAY 2 - DAILY SUMMARY
April 10, 2021

Psoriatic Arthritis for the Dermatologist: Symposium for Inflammatory Skin Disease 2021® Highlights

Joseph Merola, MD, MMSc

In this useful overview of psoriatic arthritis (PsA), Dr. Joseph Merola reminds us that about a third of all psoriasis patients go on to develop PsA and that about three-quarters of patients have skin disease before they develop joint disease. Even a six-month delay in diagnosing PsA is associated with increased bone erosion, joint deformity, and functional disability. Therefore it is critical for dermatologists to be able to screen patients for signs/symptoms of PsA to prevent such a delay. The pattern of joint involvement in PsA may be asymmetric oligoarticular, symmetric polyarticular, distal interphalangeal disease, and, uncommonly, arthritis mutilans. Other common features of PsA include enthesitis (e.g. Achilles tendonitis, plantar fasciitis), dactylitis, and axial spondylitis. Dr. Merola reviewed the differential diagnosis of PsA, which includes osteoarthritis, rheumatoid arthritis, gout, fibromyalgia, and Lyme arthritis.

To screen for PsA in the dermatology clinic, he recommends the mnemonic “PSA” – Pain in joints, Stiffness after waking or inactivity that lasts >30 minutes, and Axial/spine involvement that improves with activity. Other validated screening tools include the Psoriasis Epidemiology Screening Tool (PEST) and Psoriatic Arthritis Impact of Disease (PSAID) questionnaires.

Update on Scalp, Nail, and Inverse Psoriasis: Symposium for Inflammatory Skin Disease 2021® Highlights

Wilson Liao, MD

In this overview of special site psoriasis, Dr. Wilson Liao and his team began with the scalp. Topical treatments for scalp psoriasis can be divided into two categories: clearing agents (topical steroids +/- calcipotriene) and maintenance/adjunct agents (calcipotriene, tar and salicylic acid shampoos). Refractory patients may be considered for phototherapy (home handheld devices or in-office excimer laser) or biologic agents (secukinumab, guselkumab, and apremilast have scalp data on their FDA labeling). Patients with nail psoriasis tend to have more severe skin disease and have a higher frequency of psoriatic arthritis. Options for treatment of nail psoriasis depend on how many nails are involved and whether involvement primarily affects the nail bed (e.g. oil drop discoloration, onycholysis, subungual hyperkeratosis) or the nail matrix (e.g. pitting, crumbling of nail plate, leukonychia). Therapeutic options include topical therapies, localized injections, and systemic/biologic therapies. The IL-17 inhibitors may have the fastest onset of action in nail psoriasis, though over time the IL-17, IL-23, and TNF-alpha inhibitors all appear to have similar efficacy.

For genital psoriasis, the literature suggests that mid-potency topical steroids may be used safely for up to a month with daily use or two months with intermittent use. Nonsteroidal topical agents including tacrolimus, calcitriol, and crisaborole also have good data supporting their use. Ixekizumab is the only biologic with genital psoriasis data as part of its FDA label. Finally, for erythrodermic psoriasis, treatment approach is dependent on the acuity of the presentation. For acutely ill patients, first considerations should include cyclosporine, infliximab, and the IL-17 inhibitors. For more subacute erythroderma, one may consider the anti-TNF agents, anti-IL23 agents, or anti-IL-12/23 agent, as well as nonbiologic agents including methotrexate and acitretin.

Personal Finance and Stock Investing, part 2: Symposium for Inflammatory Skin Disease 2021® Highlights

Jashin Wu, M.D.

Jashin Wu, M.D., opened by saying that it’s important to teach your children about money matters early, which is why he feels he is fairly knowledgeable and interested in this area.  He reviewed current events involving GameStop/Reddit/Robinhood.  He then discussed that he doesn’t recommend day trading for most people, but if they wish to try, he listed some tips:

•       Day trade with money you are willing to lose
•       Start small
•       See big down days as buying opportunities, not days to panic and sell all
•       Don’t trade on margin
•       Don’t day trade in retirement accounts
•       Don’t trade with money you will need soon (like to buy a house)

He explained what is a Special Purpose Acquisition Company (SPAC) and how it compares with a traditional IPO.  He described why one might want to invest in cryptocurrency.  He made the case that saving for retirement is important to reduce taxes and to help money grow with the power of compounding.  Dr. Wu described the various retirement accounts and recommended residents to max out contributions in Roth IRA and buy high tech growth stocks.  Once as an attending, every year max out all retirement accounts with whatever vehicle is available.

He compared 2 types of educational accounts- 529 and custodial accounts and came to the conclusion that 529 is better in most scenarios.  Estate planning is important to start when one has young children, and that starts with a living trust with pour-over will.