November Issue is Now Live 

Stay Informed on Latest News and Updates From Fall Clinical 

Around the Practice: Getting Into the Roots of Childhood Atopic Dermatitis 

DermView: Best Practices in Managing Atopic Dermatitis in Skin of Color 

Recognize and Refer: New Directions in the Treatment of Basal Cell Carcinoma

Patients with this rare and severe skin disorder may soon have a new therapeutic option.

Perspectives on Generalized Pustular Psoriasis

The first thing I do when I see a patient is assess whether the vitiligo is progressive or stable. If it’s progressive, I’m often opting for oral steroids or phototherapy. How about yourself?

 I look at it similarly. Are they stable or unstable? Does it look like it’s segmental or nonsegmental? If they’ve had it for a while, you can call it segmental for sure. If it’s my first time meeting them, I’ll say, “This is new onset. We’ll have to watch and see if this is localized or segmental, or if it’s going to become generalized.” Once I can categorize them, I also try to look at percentage of body surface area. Then I ask them about what’s bothering them.

Back to that question of treatment goals and what they want to do. I get into the conversation about the different categories of treatments for patients and break down for them that combination therapy is usually the best. I have a lot of patients who come in, who’ve previously tried 1 thing for 4 to 6 weeks. And trying a topical cream for a short time alone is not often enough. That doesn’t mean that they’ve failed the therapy. Because they’ll often come in and say, “I already did this.” But they didn’t do it long enough. Same with phototherapy. You can’t do phototherapy for just a month to know if it’s working. I prep them for the time frame of commitment. As you said, it takes at least 30 sessions or more to even know if it’s working. That’s just the beginning.

I love phototherapy if I can get the patients to do it and fit it into their lifestyle. Even if they can just do twice a week. I’ve even had a few patients who could do it only once a week. I tell them, “It’s going to take a lot longer.” But I love phototherapy if we can include it. Because we know it’s effective. We know it’s safe. Then I talk to them about the different categories of topical creams and using those with phototherapy. I agree with you about using steroids to stabilize the disease. I tell patients that there are basically 2 goals if they want to pursue treatment. One is disease stabilization, which is getting the disease to stop spreading. The second goal is repigmentation, which gets the color back in the areas where they’ve lost it. That’s helpful for people to understand. Sometimes, at the first follow-up, you might be seeing more stabilization than repigmentation. You have to explain that that goal is being reached in the process. They usually feel encouraged by that.

In addition, I’ll talk to them about the role of antioxidants and diet. People often have a lot of questions about that. Some of them have already gone on gluten-free diets or tried different types of measures—cutting out sugar, dairy, or random things that they feel are implicated in their vitiligo. We talk about how there are some data, but it’s limited when it comes to that area. Many times people have questions about procedural things they can do. I explain that there’s a surgical option for vitiligo, but it’s reserved for a unique subset of people. It works best with segmental. But if it’s done in a nonsegmental vitiligo patient, it has to be someone who has stable disease that’s not spreading. It’s meant for smaller surface areas. It’s a detailed conversation in that first visit, when you’re giving them the gamut of treatment options and what’s involved should they choose that.

 You well-summarized that into buckets of treatment, whether it’s some of our orals, phototherapy, procedures, and topicals, which we often consider our first-line agents, or even depigmentary options or supplements. I find it interesting that you mentioned that some of the patients do phototherapy once a week. The data do show the final results, and the degree of repigmentation is more reflective of the cumulative number of sessions rather than the frequency of sessions for phototherapy that people do.

Videos

Nada Elbuluk, MD, and David Rosmarin, MD, review treatments in vitiligo, including corticosteroids and phototherapy.

Current Treatment Options in Vitiligo

Cannabidiol (CBD) and other cannabis derived therapies may reduce both inflammation and the expression of inflammatory cytokines when used to treat acne and other acne-like conditions, according to a review published in the 

Acne is the most common skin condition in the United States, impacting an estimated 85% of individuals between the ages of 12 and 24. Current conventional acne therapies include topical retinoids, such as tretinoin and erythromycin; OTC bactericidal agents containing salicylic acid and benzoyl peroxide; and systemic treatments such as oral antibiotics or isotretinoin. Although these treatments can be effective, there is a potential for significant side effects and antibiotic resistance.

Researchers therefore have turned towards natural plant-derived treatments or phytotherapeutics and are investigating these agents as alternative or adjuvant treatments for current therapeutic acne regimens.

Previous research has evaluated—and “extensively supported”—the therapeutic potential of CBD for numerous immunological, neurodegenerative, cancer, cardiovascular, and dermatological diseases—all conditions with (like acne) an inflammatory component.

One study evaluating the impacts of CBD on human sebaceous glands found that CBD can dose-dependently inhibit excessive lipid synthesis in sebocyte cultures pre-treated with “pro-acne” inducing inflammatory compounds including arachidonic acid, linoleic acid, and testosterone; CBD also had anti-inflammatory effects that reduced inflammatory cytokine tumor necrosis factor-a. Results from this study, the review authors noted, “strongly demonstrate the clinical potential of CBD in the treatment of acne.”

Another study demonstrated the potential anti-acne effects of hem seed hexane extracts (HSHE), another derivative of the cannabis plant; these effects were observed in an 

 model. Results of a human study evaluating the safety and efficacy of cannabis seed extracts in treating acne showed that these extracts reduced erythema. Over a 12-week period—with erythema changes measured every 2 weeks—3% cannabis seed extract creams “significantly reduced erythema after each 2-week observation,” and a “notable, gradual reduction in erythema was observed” during the course of the study. The cream was also safe, well-tolerated, nonallergenic, and nonirritating.

Limitations to the studies in this review include a lack of reliable animal models mimicking acne conditions.

“There is an evident need for large-scale human studies to understand the impact of CBD on acne at the clinical level,” the authors concluded. “Future studies may also optimize the concentration and delivery of CBD for the treatment of acne.”

Peyravian N, Deo S, Daunert S, Jimenez JJ. 

The anti-inflammatory effects of cannabidiol (CBD) on acne.

 2022;15:2795—2801. Doi:10.2147/JIR.S355489

This article was originally published by 

Articles

CBD therapy has had positive outcomes in other inflammatory conditions.

Does CBD Play a Role in Acne Treatment?

Arthritis mutilans (AM), often called resorptive arthritis, is the most severe and rare form of psoriatic arthritis, affecting only about 5-16% of patients.

 The condition is often called opera glass or chronic absorptive arthritis.

AM is characterized by severe osteolysis of peripheral joints, often resulting in the shortening of digits and opera glass hand deformity. It primarily affects the joints of the hands and feet, causing severe functional impairment.

 It was previously believed that AM only affects hands, feet, toes or fingers. However, data shows that AM can affect any joint generally damaged by arthropathy.

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) in 2012 described the disease's specific features. The features included digital telescoping and shortening, pencil-in-cup deformities, osteolysis, and involvement of distal interphalangeal joints and other small joints of the hands.

Patients with AM have telescopic fingers with bone edema and erosion severe enough that the hands appear like paws. The condition initially appears at the metacarpophalangeal and interphalangeal joints. The excess skin of the fingers folds tangentially, giving an opera-glass appearance. As the condition progress, it may lead to dislocation and resorption of the phalanges.

On radiographic examination, patients with AM frequently exhibit deformities, including the pencil-in-cup deformity, where one end of the bone is worn down into the shape of a pencil tip, joint subluxation, and ankyloses. Evidence of comorbid conditions, including hypertension, dyslipidemia, metabolic syndromes, osteoporosis, and fragility fractures, have also been found among patients with AM.

AM mainly occurs in patients with pre-existing psoriatic arthritis or advanced rheumatoid arthritis. However, it can also occur independently.

 The exact cause of the condition is still unknown.

Joints with a high inflammatory burden are more likely to suffer further injury from mechanical stress.

 Studies have reported a link between HLA genes and an increased risk of AM. Moreover, Genetic markers like HLA-B27 and DQB1*02 have also been associated with AM.

As soon as the disease is diagnosed, immediate treatment is required to prevent further erosion of the joints and subsequent loss of function. Osteoedema, in the short term, can show dramatic improvement when treated with TNF inhibitors.

 Immunosuppressive medications like methotrexate and leflunomide help reduce inflammation; a once-weekly dose of methotrexate at 10-25 mg has been found to be effective.

 Biologics including IL-17 and IL-23 inhibitors target inflammatory proteins, whereas JAK inhibitors are another class of drugs approved for treating the condition.

 found significant improvements in the joints and skin of patients with AM after treating them with etanercept (Enbrel), a biologic TNF inhibitor. However, the treatment could not undo any pre-treatment damage or deformities experienced by the patients.

AM can be successfully treated with iliac bone grafts and arthrodesis of the interphalangeal and metacarpophalangeal joints.

Physical therapy is another option that may help reduce joint pain and inflammation with several different modalities, including ultraviolet (UV) treatment, ultrasound, cryotherapy, heat, electrical stimulation, and massage. Joints that are impaired by the disease can be supported using splinting.

Ishak AA, Al-Shamahy HA. Traveling Through Life with Arthritis Mutilans: Humanity Joins All Medical Practitioners in Treating and Supporting the Condition of Chronic Arthritis Mutilans Case. 

 2022;7:729. doi: 10.29011/2574-7754.100729

Cordeiro RA, de Oliveira JL, Sampaio-Barros PD, Goldenstein-Schainberg C. Psoriatic arthritis mutilans: a descriptive study from a Brazilian tertiary center. 

. 2022;62(1). doi:10.1186/s42358-022-00245-4

Chandran V, Gladman DD, Helliwell PS, Gudbjörnsson B. Arthritis mutilans: a report from the GRAPPA 2012 annual meeting. 

Rida MA, Chandran V. Challenges in the clinical diagnosis of psoriatic arthritis. 

. 2020;214:108390. doi:10.1016/j.clim.2020.108390

Perrotta FM, Scriffignano S, De Socio A, Lubrano E. Occult axial involvement in patients with psoriatic arthritis mutilans: a case report. 

. 2019;71(2):88-91. doi:10.4081/reumatismo.2019.1146

Sigurjonsdottir K, Jonsson H. A New Form of Arthritis Mutilans Related to Successful Gout Treatment. 

. 2018;07(03). doi:10.4172/2167-7921.1000i107

Samanta J, Chattopadhyay A, Sharma A. Psoriatic arthritis mutilans. 

QJM: An International Journal of Medicine

. 2020;113(10):765-766. doi:10.1093/qjmed/hcaa029

Afraz S. Consequences of Neglecting Rheumatoid Arthritis Treatment: A Case of Arthritis Mutilans in an Older Woman. 

Annals of Long-Term Care: Clinical Care and Aging

. 2017;25(6):39-43. doi:10.25270/altc.2017.10.00012

Arthritis mutilans, often called resorptive arthritis, is the most severe and rare form of psoriatic arthritis, affecting only about 5-16% of patients. 

Psoriatic Arthritis Mutilans

 recaps the 13th International Facial Plastic Surgery Symposium and 

 reviews the ideal shower temperature for soft skin. 

 lists 7 tattoo cover-up makeup products and 

 takes an in-depth look at the skin barrier. 

 explains how to use rosemary oil to strengthen hair and 

 gives recommendations for the best moisturizers for dry skin. 

10 Things We Learned at This Year’s International Facial Plastic Surgery Symposium

Last weekend, hundreds of the world’s most brilliant facial plastic surgeons gathered in Washington, D.C. to discuss new techniques, trends and more at the 13th International Facial Plastic Surgery Symposium. We were front-and-center to get the scoop directly from the experts, and these are 10 noteworthy things we learned.

This Is the Ideal Shower Temperature to Keep Your Skin Soft, Smooth, and Glowing

Like many people, over the past year and half I’ve found a long, hot shower to be a 

soothing and grounding escape from reality

: Slip in. Lather up. While away the minutes (or, erm, 

). Step out feeling new. In fact, the post-hot shower feeling has been so euphoric, I've ignored the clear-as-day signs of my subsequently unhappy skin—redness, tightness, and itchiness from head to toe. But as the cold months set in, my dry, sensitive skin becomes more vulnerable (and the temptation to turn the dial all the way up looms), I'm determined to find a better balance between a comforting shower and maintaining the health of my skin. Ask any dermatologist and they’ll tell you: that mission begins with the right shower temperature—especially this time of year. Here, New York dermatologist Robert Anolik talks through the best bathing and skin-care habits to keep your skin soft, smooth, and glowing through winter.

7 Best Tattoo Cover-Up Makeup Products That'll Hide Your Ink

Listen, if you've invested time and money into a tattoo, you should absolutely be showin' it off—I mean, it's a work of art! But one day, you may find yourself in a sitch where you want to cover it up temporarily—and my guess is that the day is today, and that's why you've landed upon this page. No biggie! I've gathered together the best tips and tattoo cover-up makeup products to hide your ink until you're ready to show it off again.

What Exactly Is Your Skin Barrier and Do You Actually Have to ‘Repair’ It?

Here’s a little riddle for ya: What has 

 (yes, with a “b”) views on TikTok, plays a role in conditions ranging from 

, and is currently all the rage when it comes to skin care products? If you guessed the skin barrier—congratulations, you are correct. Unlike some other trending skin care topics, the skin barrier is a very real thing, and one that plays an integral role in healthy skin function, according to the experts SELF spoke with. We’ll get to the specifics in a moment, but the skin barrier is well, exactly what it sounds like—a protective layer that’s responsible for keeping the good stuff in and the bad stuff out.

How to Use Rosemary Oil to Strengthen and Grow Hair

Although likely best known as a savory seasoning for your favorite dishes, rosemary is believed to have plenty of wellness and beauty benefits, too. In addition to its purported aromatherapy perks, it’s also thought to help moisturize skin and bring hair back to life—specifically repair damage, combat pesky dandruff, and even 

. TikTok and Instagram have certainly hyped up its greatness (particularly since there’s little evidence to support the efficacy of hair growth vitamins), but what’s actually the truth and what’s fiction? We turned to the experts for the facts on using rosemary oil for hair.

The 17 Best Moisturizers for Dry Skin All Year Round

As much as we love cozying up with a warm beverage and donning our cutest sweaters, the arrival of colder temps can do a number on skin, especially if you experience dryness or redness year-round. However, incorporating the right 

 can help minimize flaking and irritation, creating a healthy glow with or without makeup. And, thankfully, we had expert help finding out what to look for when it comes to the best moisturizer for all skin types, but specifically for those with dry skin.

This week's edition of the Mainstream Patient features stories about the 13th International Facial Plastic Surgery Symposium, skin barrier advice, rosemary oil for hair growth, and more. 

The Mainstream Patient: December 5 

Let’s talk about the background of this study. Why is it so important to even investigate these rates? Why do you think we are doing this type of study to begin with?

: I think we mentioned to some extent already that it’s a rare disease. What we have maybe are case series that have been published, etc, but we really don’t understand exactly how the population of patients with GPP [generalized pustular psoriasis] is presenting, how often they’re having flares, what’s associated with the flare. This study does give us some information about that. It tells us what kind of symptoms they’re having with flares. It tells us how often they’re having a flare after they have a single flare, and then it tells us the miserable state of affairs of treating the flares, which I think is all very helpful information.

Absolutely. Life is all about data. If you want anything done or if you want to convince anybody, you need data. You better believe when my kids try to convince me that they need to stay up later, I tell them to show me the data as to why they need to stay up. It’s important, particularly in these rare diseases, to have those numbers. Otherwise, you’re just going off of hearsay. It’s one thing for you and me to say that our patients with GPP, their disease is having a huge impact on their life and their quality of life, but now we actually have the data to go along with it. Another question; in this study patients with documented GPP flares were noted to have a higher comorbidity burden—we know—and higher all-cause inpatient admissions, which was greater than 3 times, and emergency department admissions, which is 2 times greater, compared to those without documented flares. They’re utilizing the health care system significantly. How about, in your opinion, what is the relative significance of this finding? Are there any conclusions you can draw from this?

: Yes, I think even though this is a relatively small number of patients, they’re having high utilization of the health care system. These are patients who are trying to get better, and they’re doing that by interacting with the health care system. Unfortunately, we haven’t had the best approaches to addressing this. I hope that by having drugs that target the flares, we’ll be able to decrease their health care utilization, and maybe we’ll be able to see that in the future.

That would be the goal. Another question we touched on but I’d love to hear more about is, the most commonly utilized treatment in these patients with GPP flares was unfortunately corticosteroids, and we talked about that. The use of biologics and other advanced treatments was surprisingly low. Most patients, as you noted, have all these various comorbidities, and you’re thinking about where’s the risk-benefit? What are the safest treatments we could provide? We know biologics are very safe. What advice do you have to increase the utilization of these, perhaps advanced but more appropriate therapies, for patients who are experiencing GPP flares?

: I think one of the issues here is that in a hospital setting, some of these patients are presenting to the ED [emergency department] and going into the hospital. It’s difficult to get biologic drugs. First of all, the diagnosis has to be made, and then it has to go through the formulary, etc. While at our office, it’s often very easy to get access to these drugs. I think one of the problems is just a part of the way these patients are presenting and getting access. That’s probably why we don’t see such great utilization of those in this database. That’s one reason. I think getting the patient to the right person to make the diagnosis is the most important thing, and that’s not easy to do. Dermatologists need to make themselves available to emergency departments and hospitals to help folks like this.

Absolutely. I plan on emailing these videos and these notes to all my colleagues within the hospital, every referral, ED, and urgent care I speak to, so they can understand this. It’s true, we as dermatologists have to be the experts and educate the public as well as our colleagues on these diseases. They may not know all the details that we are familiar with, but that is not their job. Their job is to recognize it, and then get the patient referred to a dermatologist. Now, there were some interesting data I pulled out here. It was noted that 24% of patients did not receive additional GPP treatment before, during, or immediately after the medical care for their GPP flare—24% didn’t receive any additional treatment. It was kind of shocking to me. Can you comment as to any of the potential rationale or ramifications? What impact does this have?

: Certainly some of that could be due to data collection, to errors within the system and collecting those data. They may be getting some treatment that’s not part of the process, but some of that is probably due to the ball being dropped. The patients are treated acutely. They’re told to follow up with the dermatologist, and that just doesn’t happen until they have the next flare. Again, it’s these systemic problems in terms of being able to address these patients when we don’t have dermatologists in most hospitals in the country that are seeing patients regularly.

Aaron S. Farberg, MD, and Jeffrey Crowley, MD, discuss the importance of investigating the data on generalized pustular psoriasis, comorbidities of the disease, and commonly used treatments.

Importance of Understanding Data of Generalized Pustular Psoriasis Data

Dustin Portela, DO, a board-certified dermatologist and dermatologic surgeon at Treasure Valley Dermatology in Boise, Idaho.

Dustin Portela, DO, a board-certified dermatologist and dermatologic surgeon at Treasure Valley Dermatology in Boise, Idaho, reviews a case of severe sunburn caused by increased sun sensitivity from medications. 

Opinions expressed are that of Portela and do not express the views or opinions of Dermatology Times®.

In this week’s Pointers with Dr Portela, the 208SkinDoc, reviews how some medications increase sun sensitivity. 


Pointers with Portela: Sunburn From Medications 

Endo Aesthetics has announced the discontinuation of the production and sale of its collagenase clostridium histolyticum-aaes (Qwo) injection for the treatment of moderate to severe cellulite in the buttocks after industry concerns about the extent and variability of bruising after initial treatment and the potential for prolonged skin discoloration.

“Healthy skepticism should be welcomed and encouraged whenever we witness unsubstantiated claims within the aesthetic dermatology industry. To wit, as physician scientists, we have an obligation to only provide patients with scientifically valid information. For successful practices and trustworthy clinicians, rectitude, integrity, and ethics will continue to reign supreme,” said Will Kirby, DO, FAOCD, chief medical officer of LaserAway, and Editorial Advisory Board member of 

Endo Aesthetics has been working to address these concerns for the past year. In June 2022, Endo launched an open-label study, APHRODITE (NCT05419505), to test various interventions to see if they could help mitigate bruising. Some APHRODITE cohort’s results showed a moderate reduction of bruising area and severity, but none achieved a consistent level of reduced bruising after initiation treatment.

According to Endo Aesthetics, the decision to stop the production and sale of Qwo is expected to result in annualized pre-tax cash savings of approximately $50 million to $60 million and a reduction to Endo's global workforce of approximately 90 full-time positions. Regarding ceasing QWO production and sales, the Company expects to incur pre-tax cash restructuring charges of approximately $15 million to $20 million and record a total pre-tax restructuring charge of approximately $235 million to $250 million in the fourth quarter of 2022.

Endo’s collagenase clostridium histolyticum-aaes injection remains approved by the US Food and Drug Administration with clinically proven results and an established safety profile, so practitioners may continue to use unexpired collagenase clostridium histolyticum-aaes injections that they have in stock, as well as order additional supply. Alternatively, practitioners can return unused collagenase clostridium histolyticum-aaes injections purchased before this announcement for a refund. Practices will be notified about these options.

Endo to cease production and sale of Qwo (collagenase clostridium histolyticum-aaes). Endo International. Published December 6, 2022. Accessed December 7, 2022. 

https://investor.endo.com/news-releases/news-release-details/endo-cease-production-and-sale-qwor-collagenase-clostridium

Cancellation is due to concerns about the extent of bruising following initial treatment and prolonged skin discoloration. 

Endo Aesthetics Cancels Production and Sale of Collagenase Clostridium Histolyticum-Aaes Injection 

Eliminating dairy products from pediatric patients with atopic dermatitis (AD) may not provide substantial improvement and could put the patient at risk for developing IgE-mediated food allergies.

Investigators at the Division of Clinical Immunology and Allergy in the Department of Medicine at McMaster University in Ontario, Canada conducted a systematic review and meta-analysis of 10 randomized trials involving 599 patients with AD, undergoing blind, placebo-controlled food challenges. The baseline median of the study mean age was 1.5 years old, and the median of the study mean SCOring Atopic Dermatitis index was 20.7. Compared with no dairy elimination, investigators found low-certainty evidence that it may slightly improve eczema severity (50% vs 41% without dietary elimination improved the SCOring Atopic Dermatitis index by a minimally significant difference of 8.7 points (95% CI, 0 - 17). Furthermore, insufficient data addressed the harm of elimination diets that include randomized controlled trials(RCTS), although indirect evidence suggests that elimination diets may increase the risk of developing Ige-mediated food allergies.

AD is a chronic inflammatory skin disease characterized by relapsing or persistent pruritus, skin pain, lichenification, excoriation, xerosis, and dyspigmentation and is commonly associated with skin infections and atopic comorbidities. It is one of the most common childhood diseases, affecting approximately 6% to 20% of children around the world, as well as being common in adults. The disease burden is high with significant impacts on mental health, sleep, function, and quality of life, and considerable financial costs for patients and caregivers.

One of the study’s lead investigators, Derek Chu, MD, observed that the influence of diet on AD is complex and the use of dietary elimination has historically conflicting views. He said the study’s findings reflect the view from many practitioners that the impact of dietary restriction (benefits, harms, and practical implications) needs to be carefully weighed and reviewed in every case. Chu concluded that the study data reveals the important need for new and robust randomized controlled trials to further improve the evidence regarding all benefits and harms of diets for AD.

Oykhman P, Dookie J, Al-Rammahy H, et al. Dietary Elimination for the Treatment of Atopic Dermatitis: A Systematic Review and Meta-Analysis. J Allergy Clin Immunol Pract. 2022 ;10(10):2657-2666.e8. doi:10.1016/j.jaip.2022.06.044. Epub 2022 Jul 19. PMID: 35987995.

New Clinical Trial Evidence Does Not Support Dairy Avoidance as a Beneficial Treatment for Pediatric AD. 

Eliminating dairy for atopic dermatitis may not make significant difference 

Ilya Petrou, MD, is a contributing writer for 

Vinegar or acetic acid, may not be as alluring as honey or controversial as stem cell therapy, however, the age-old remedy has long been employed in wound care and wound healing protocols due to the therapeutic success achieved from its antimicrobial and antioxidant properties. A recent study

 highlighted the therapeutic benefit of acetic acid in a mosaic of dermatologic diseases and conditions, underscoring the need for clinicians to perhaps rethink their topical treatment strategies and protocols, particularly in those patients who are seeking more natural alternative medicine treatment options.

Vinegar has been used to treat wounds by Hippocrates since the year 420 BC when its medicinal effects were already well-known. Many patients today are gravitating towards natural medicine and are actively looking for alternative treatment options for their condition and, according to Dr. Steve Daveluy, co-author of the study, acetic acid is one traditional treatment that could be better utilized as a monotherapy and/or an adjuvant to other topical therapies currently used in dermatology.

“As dermatologists, there are certain things that we are used to working with and that includes acetic acid for wounds and wound care. I think that patients are really hungry for alternative medicine but when it comes to the doctor’s side, I think it’s kind of mixed,” said Steve Daveluy MD, associate professor and program director of Wayne State Dermatology, president of WSUSOM Alumni Board of Governors, president of Michigan Dermatological Society, and past president of Wayne County Medical Society of Southeast Michigan, Dearborn, MI.

Dermatologists will often recommend acetic acid for subungual pseudomonas infections or for interdigital fungal infections. From the wound care aspect, pseudomonas infections often impact wounds in the skin and can be therapeutic challenging and here, Daveluy recommends the use of vinegar oaks as a great therapeutic option.

“If we already recommend it for subungual pseudomonal infections, we can pivot and also recommend it for cutaneous wounds in general as its efficacy has been proven in wound care and wound healing,” Daveluy said.

Daveluy and fellow colleagues recently conducted a literature review of clinical trials and epidemiologic studies looking at the evidence for the use of vinegar in the treatment of several skin diseases including bacterial and fungal infections, warts, dermatitis, wound healing, and marine animal injuries, among other indications. In summary, they found that acetic acid has proven antimicrobial, antifungal, and antioxidant properties and effects, and is useful in the treatment of several skin conditions including epidermolysis bullosa, uremic pruritus, and striae gravidarum. Data also showed variations in antimicrobial and antifungal activity depending on the type of vinegar applied and the type of microorganism involved.

Most research studies use commercially available apple cider or plain white vinegar between 2% and 5% acetic acid, which work similarly and are safe to use. Some of the studies on wound healing have shown therapeutic benefits with combined therapies consisting of acetic acid soaks followed by antibacterial ointments/creams or other wound dressings for optimal outcomes.

“For wound care, I usually tell my patients to either apply acetic acid directly in approximately 20-minute soaks or mix it with 50% water resulting in a 2.5% acetic acid soak, the latter being less irritating for more sensitive skin. It is critical to remind patients to make sure the soak is removed and not left on the wound for long periods of time, as this could result in severe irritation and burns to the skin, particularly with undiluted acetic acid,” Daveluy said.

While some physicians have acetic acid in their armamentarium and regularly recommend the treatment for various indications in their patients, Daveluy nevertheless admitted that it may be easier for others to simply write a prescription. However, incorporating acetic acid into topical treatment protocols and regimens could also help stem the alarming rise in antibiotic resistance of late.

Acne treatment will usually consist of a combination therapy starting with an antiseptic wash like benzoyl peroxide, followed by a topical antibiotic. According to Daveluy, this treatment dynamic could be utilized more often for the same therapeutic goal in wound care where acetic acid is first used to clean the wound, followed by an antibiotic cream.

“There is a lot of data out there showing that vinegar is safe to use and can play a role in achieving optimal therapeutic outcomes when used appropriately. As such, those patients seeking alternative therapies that have a proven efficacy can be encouraged to apply this therapy for a number of dermatologic indications including wound care and wound healing,” Daveluy said.

1. Elhage K, St Claire K, Daveluy S. Acetic acid and the skin: a review of vinegar in dermatology. 

 2022 Jul;61(7):804-811. doi: 10.1111/ijd.15804. Epub 2021 Aug 5.

Vinegar has an antibiotic and antioxidant effect that has been used in dermatology and medicine for ages. 

Acetic Acid and Wound Healing 

When I think of first-line options—topical corticosteroids [TCSs], topical calcineurin inhibitors [TCIs], and now ruxolitinib cream—it’s always interesting to ask other physicians, “What is the first regimen you give patients?” With topical corticosteroids, I’ll often start with that, especially if it’s on the body, but I try to avoid sensitive areas—the face, neck, axillae, groin. In areas where people have vitiligo, and even in those that may be a thicker like the trunk or extremities, I’ll still try to do intermittent treatment. Maybe once a day of the steroids, 1 week of the TCI, and then alternate.

There are a lot of regimens people use, whether they’re intermittent treatment or continuous. There’s no standard way that experts treat vitiligo. More recently, with the approval of ruxolitinib cream, particularly with strong data for monotherapy, I’ll offer that as well. Some patients may get corticosteroids and calcineurin inhibitors first, and some may get ruxolitinib cream first. If patients fail that, I’ll offer them ruxolitinib cream. How are you going about those first-line topical treatments?

 That’s a great question. Similar to you, I take into account the body location. I prefer TCIs for the face, intertriginous areas, and more sensitive areas and topical steroids for the body and the nonintertriginous sites. It’s all been a combination: use this on the face and something else on the body. I’ve started to move toward giving them a break on weekends. A lot of times I’ll have them do a Monday-to-Friday regimen because the toll of treatment is exhausting for patients. Every day they’re remembering to put on a cream once or twice a day in different locations plus phototherapy. Treatment burnout is a real thing too. Sometimes I say, “If you can be consistent Monday to Friday, you can take a break from the cream Saturday and Sunday.” That can help some people mentally.

I’m very excited about the JAK inhibitors and having another option that we could consider first line for patients and 1 that’s nonsteroidal and that we can use on those sensitive areas as well. I mention it to my patients as a first-line option. I still use a lot of our traditional things. But for a lot of patients who’ve been on those and who haven’t fully repigmented, I’ve switched a lot of them to ruxolitinib. Sometimes I have patients who come in and have already heard about ruxolitinib. They’re excited and want to try that specifically. I’m open to that if they feel strongly that they want to go right to that. That’s how I’ve been incorporating that. I’ve been pleased with it so far. I have a lot of patients still doing phototherapy also, although it can be done as a monotherapy. Some early data show that some people have additive or improved response by doing a JAK inhibitor with the phototherapy. I’m doing that as well.

 I have a lot of patients who come in asking for ruxolitinib cream specifically. I feel comfortable using all 3 topical options as initial treatment. That’s consistent with the package insert, which describes ruxolitinib cream for those who are 12 years of age and older with nonsegmental vitiligo. There’s no precondition for failing other treatment first, which is helpful. It’s a favorable label in that regard.

Usually, when I tell patients what to expect with the use of the cream, I tell them that it’s better to use it twice a day. We have data that even once a day can help repigment patients, but twice a day certainly works better. I tell them to be patient with it. I usually see patients back in 6 months. I don’t do any lab work beforehand with the ruxolitinib cream because with the phase 3 data, we weren’t seeing significant changes in lab abnormalities. Those were checked during the studies. I tell patients that half of those who use the cream will get 75% or more of pigment back on their face, and half will get 50% or more of their pigment back on the body.

Commonly, people ask, “I’ve tried some other things before. Does that mean I have less of a chance of this working?” In the subgroup analysis, that’s not the case. Patients who were naïve or who used phototherapy, TCI, or TCS had similar responses for repigmentation. Also, race and age are factors. What’s shocking to me is the duration of the vitiligo. Patients who’ve had it for over 50 years responded similarly well to patients who had it for a few months. It’s important to realize that despite that clinical characteristic and baseline demographics, patients respond similarly well.

However, anatomic location, as with all our treatments, affects prognosis. When patients have the head and neck affected, we have a better and an earlier response. With trunk and extremities, we can still get good responses as well. But when it comes to acral sites like hands and feet, you can see some response, but it’s more challenging and takes longer. I try to rest expectations around those sites. That’s important. Do you change your counseling base on the anatomic location where patients have their disease?

 Yes, it’s important to tell patients from the get-go about that. I tell them the face is 1 of the best places to repigment. It tends to have a nice response, even in areas like the eyelids. I warn them that hands and feet, particularly more distally, are a challenge and can be harder to treat. If acrofacial lip tip vitiligo is their predominant presentation, I go even deeper into that conversation. It’s important to set expectations. It doesn’t mean that we can’t try treatment options and see how they do. I prepare them for that. Similarly, with certain special sites, like nipples and genitals, it can be a challenge. In some of those areas, we’re not doing phototherapy. I let them know that the treatment response rate may not be as high. As I mentioned, we can try treatments.

 Another question that I commonly get is, how do you address a patient in terms of the black-box warning for the topical ruxolitinib cream? It has that JAK inhibitor black-box warning. How do you describe that to your patients?

 I let them know that that warning is there based on what was found with the oral JAK inhibitor data, and that topically, the clinical trial data have been supportive in terms of its safety and efficacy. You have to know their background history. Are they at higher risk for anything we still need to monitor? The absorption from the topical is much less than what people are getting orally. Even though that warning had to be on there, it’s not something they need to be significantly concerned about.

 I certainly describe the black-box warning to patients. It’s important to disclose it. But I put it in the context that this was seen for the systemic agents, and the reason why we’re giving you a topical is to try to mitigate those risks.

 The vast majority of patients understand that the risk isn’t the same with a topical as it is with a systemic.

 It’s important to go over it with all patients.

Experts in dermatology discuss ruxolitinib, an exciting new therapy approved for repigmentation of the skin for patients with vitiligo. 

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