Learn more about what treatments are on the rise for plaque psoriasis, the latest management advice and what trends are shaping the future of the disease. 

The changing treatment landscape of plaque psoriasis

Poll

POLL: Would you like to see KOLs host the Cutaneous Connection podcast?

Coverage on vitiligo and other trending topics;

Articles

Click to see a preview of what to expect this week. 

What's New on Dermatology Times: December 6-10

and joined the MJH Life Sciences team in April 2021. She graduated from Kent State University in 2018 with a bachelor's degree in journalism and a minor in sociology. Linda used to work as a creative writer for 

 and was a technical writer/regulatory specialist/purchasing agent at GM Industrial before coming on to the team. She enjoys reading, traveling, and learning new perspectives. You can reach her at 

POLL: Are Pre- Pro- Post- biotics Effective for Skin Care?

What's Trending in Skin Care? November 2021

Each month, Dermatology Times® features a roundup of products trending in skin care. Click here to find out what products are trending for the month of November.

Vitiligo: Clinical Presentations and Classifications

A comprehensive breakdown of the different classifications of vitiligo and how these may present clinically.

Diagnosing Vitiligo and Improving Care Provider Awareness

Expert perspectives on the diagnosis of vitiligo and considerations for improving provider awareness in dermatologist and community settings.

In this video interview, James Del Rosso, DO, tackles the clinical impact of JAK Inhibitors and how to deal with patient concern.

Pointers with Dr Portela: Sugaring for Hair Removal

In this week’s Pointers with Dr Portela, the 208SkinDoc undergoes sugaring for hair removal.

Galderma announced it has signed a definitive agreement acquire ALASTIN Skincare.

Omicron COVID-19 variant: What we know and what we don’t

The Omicron variant of COVID-19 is spreading quickly, jumping continents with infected travelers. Here’s the latest on what global health officials know about it.

The Cutaneous Connection- Episode 35: QRPs and the Dermatology Practice

In this week's podcast, we sit down with from the OJM Group to discuss qualified retirement plans and how dermatology practices may be able to save money.

Meet the Aesthetic Expert with Dr. Will Kirby: José Raúl Montes, MD, FACS, FACCS

In this month’s “Meet the Aesthetic Expert” column, Will Kirby, DO, FAOCD, talks with José Raúl Montes, MD, FACS, FACCS, a board-certified Oculoplastic surgeon and established injector, researcher, speaker, and trainer. They speak about his aesthetics journey, the changing aesthetic patient, and the future of the field.

COVID-19 and malpractice lawsuits: What the future may hold

COVID-19 is prompting significant changes to malpractice laws and regulations at the state and federal levels.

Looking at the scalp and nails during a skin exam is key

A presentation from the 2021 virtual American Academy of Pediatrics Conference & Exhibition urges including examination of the scalp and nails during any skin exam.

ICYMI, some of this week’s featured content includes an exclusive interview about the clinical implications of JAK inhibitors, and articles on trending skincare, Galderma, and more.

Weekly Roundup: November 29- December 3

“Examination of the scalp and nails is an important part of any skin exam,” noted Sheilagh M. Maguiness, MD, associate professor of dermatology and pediatrics at the University of Minnesota in Minnesota at her session, “Common Hair and Nail Conditions in Children.”

Maguiness described a case of tinea capitis, a common fungal infection of the scalp in children. Swollen lymph nodes in the neck (cervical lymphadenopathy) often signal this condition. Confirm diagnosis with a fungal culture prior to treatment, she said, especially because of the “long duration of oral antifungal therapy…up to 4 to 8 weeks, depending on the agent.”

Maguiness also reviewed longitudinal melanonychia, which she described as “brown to black pigmented longitudinal bands in the nail plate [caused by] melanocyte hyperplasia or increased melanin production,” common in African American and Asian children but rare in Caucasians.

Maguiness also discussed congenital malalignment of the great toenails and psoriatic nails, which can cause pitting, onycholysis, and subungual hyperkeratosis. “When children have psoriasis, about 15% to 20% will also have nail findings,” she said.

When it comes to head lice, Maguiness advised practitioners to check the postauricular areas and nape of the neck. “That’s where the nits like to group,” Maguiness said. She outlined available treatments, OTC topicals such as permethrin and pyrethrins, prescription drugs such as topical and oral ivermectin, and topical spinosad.

Maguiness ended with this advice: review dose and duration of therapy for oral antifungal agents to treat tinea capitis; perform a fungal culture of the scalp to help diagnose tinea capitis; and know how to distinguish between several common nail disorders in children

This article was originally posted by our sister publication Contemporary Pediatrics. 

Since COVID-19 arrived in the United States, health care providers have been working tirelessly to address every aspect of the pandemic. The public saw how frontline workers were making sacrifices day in and day out to keep as many people healthy as possible. But even as the media focused on this heroic work, behind the scenes COVID-19 was prompting significant changes to malpractice laws and regulations at the state and federal levels.

Providers should be aware of what has happened and of the changes that may occur in coming months and years.

At medical malpractice insurer EmPRO, we have been keeping a close eye on the pandemic because global health events have the potential to expose both insured clients and insurers alike to staggering liabilities. Thankfully in New York state, where EmPRO is headquartered, the governor and the legislature moved swiftly to enact emergency measures that shielded health care professionals from the worst liabilities. Had they not done so, the pandemic had the potential to lead to the proposal of new, more stringent regulations and policies, which in turn could have resulted in increased premiums.

New York was hit incredibly hard with COVID-19 cases right from the start, with the first confirmed case on March 1, 2020. The legislature and the governor produced the Emergency Disaster Treatment Protection Act (EDTPA), which extended broad immunity to health care providers and facilities.

Around the state, hospitals filled with patients with COVID-19 had to bring in nurses from out of state, bring health care providers out of retirement, build temporary facilities to provide COVID-19 care and enlist doctors, nurses, physician assistants and others to provide services out of title — meaning outside their usual purview of care.

The EDTPA granted them immunity from liability in the diagnosis and treatment of patients with COVID-19, as well as other patients whose treatment was affected by a facility’s response to the pandemic. Before doctors knew precisely how to care for patients with COVID-19, many frontline health care providers had reasonable concerns that experimental treatments could not only expose them to the disease but also lawsuits. The EDTPA helped alleviate those fears.

Medical malpractice attorney Tom Benvenuto, J.D., of Benvenuto & Slattery says this was a critical decision that empowered health care providers to make every effort to save patients without fear of legal action. “The immunity the EDTPA provided to New York health care professionals was essential to the state’s response and handling of the pandemic because it enabled physicians to pursue necessary measures to care for patients that may have otherwise been construed as extraordinary under otherwise normal circumstances,” he said.

The federal government issued its own legislation on protections for frontline workers, facilities and even personal protective equipment (PPE). The Public Readiness and Emergency Preparedness (PREP) Act provides liability immunity related to the manufacture, testing, development and — importantly for medical providers — use of medical countermeasures against pandemics and other public health emergencies.

Essentially, the government extended liability protection to medical equipment and PPE manufacturers. With this protection in place, manufacturers such as General Motors, Ford, Fitbit and Procter & Gamble were able to quickly launch production lines or repurpose existing ones to make medical equipment such as respirators, ventilators, face shields and masks.

The PREP Act also covered health care facilities that were using these countermeasures. For example, in the event of a PPE shortage — as was seen across the country due to a global shortage — a facility may invoke the immunity from liability if a patient claimed that they contracted COVID-19 at that facility while the facility was reallocating what PPE they had available to them.

In the midst of the pandemic, medical malpractice insurers and the attorneys working with them began planning for a potential tidal wave of lawsuits related to COVID-19, given the potential for morbidity that the diagnosis carried for a significant portion of the population. This would have put a tremendous strain on insurers across the country.

However, the industry so far has seen relatively few cases. In fact, medical malpractice lawsuit filings were down during the pandemic. This was due, in part, to many states implementing a hiatus on filing lawsuits when lockdown restrictions began. Because there are statutes of limitations on filing cases, there may be more COVID-19-based lawsuit filings when those statutes approach their expiration dates. Plaintiffs may file cases in order to buy time hoping that there will be a change in how the courts interpret and apply the immunities. However, in many cases, this situation is still more than a year away.

In August 2020, when New York’s infection rate was less than 1%, the legislature reduced the scope of the EDTPA to cover only patients with COVID-19, eliminating those tangentially affected by a facility’s COVID-19 care for others. Furthermore, the statute was repealed, thereby ending the immunity for providers treating patients with COVID-19 after April 6, 2021. New York has returned to business as usual for malpractice regulations.

Although it has been amended a number of times, the federal PREP Act is still in place, and malpractice insurers, courts and health care professionals are paying close attention to any potential legal aftershocks.

According to Benvenuto, the industry must keep a close watch on how federal courts approach challenges to PREP Act immunities that may be filed. “Although the immunities appear to be ironclad, and cases would likely be dismissed by the court in light of same, any suit that survives an initial motion to dismiss could provide plaintiffs in each state a playbook to filing and maintaining a similar case,” he said.

In the end, the COVID-19 pandemic did not bring about a sea change in medical malpractice regulations or policies. States expanded immunities where and when they had to, and when conditions improved enough to remove those exemptions, it appears most states have gone back to what worked before. Fortunately, this means premiums have not seen a “COVID-19 spike,” but it remains to be seen if this will hold in the future, especially if the Delta variant or another variant proves lasting or if a new pandemic emerges.

Bruce C. Shulan is president and CEO of EmPRO. For more than 30 years, he has served as a senior executive, board member, consultant and attorney to the insurance industry.

This article was originally published by our sister publication Medical Economics.

 and joined the MJH Life Sciences team in September 2019. She graduated from Cleveland State University in 2018 with a bachelor's degree in journalism and promotional communications. She enjoys yoga, hand embroidery, and trying new restaurants. You can reach her at 

Mental health continues to impact pediatric vitiligo and alopecia areata (AA) patients and their caregivers because of the feeling of isolation and lack of community, among other reasons. A recent study in the 

Journal of the American Academy of Dermatology

 looked at the potential positives in using virtual pediatric group visits to reduce these negative feelings and a create community support for patients and caregivers.

The study included 22 pediatric patients—13 with AA, 9 with vitiligo, 13 female, and 9 males—plus 20 parents who were surveyed anonymously through Zoom polling during 6 virtual visits.

The study participants, before the visits, showed that 86% of patients and 80% of parents knew no one or very few others with the same conditions, and 68% of patients and 70% of parents had none or very few people to talk to about the condition.

Also before the visits, 27% of pediatric patients and 65% of caregivers felt the visits could be helpful, while 59% and 79% reported they were helpful after the visits, and only 45% of patients and 26% of parents reported feeling isolated. Additionally, 73% of patients and 68% of parents reported that they would attend future sessions, according to the study.

The study investigators wrote that the virtual visits provide families with an opportunity to connect with others, despite background and geographic location, to support one other. They plan to expand the virtual group to create an extensive vitiligo and AA community network for support and education.

1. Rosenblatt A, Khosla N. 28629 Virtual group visits for reducing psychosocial distress in pediatric vitiligo and alopecia areata patients and caregivers. 

A recent study examined the impact of virtual group visits to obtain community and education for pediatric vitiligo and alopecia areata patients and caregivers. 

Virtual Group Visits Create Pediatric Vitiligo, AA Patient Support

I’d like to ask you about how individual variability in presentation, whether it’s extent or location of vitiligo, impacts treatment and how you walk patients through that, and what your decision-making process is?

It’s not a one-size-fits-all disease. I think you would agree. One thing that I will say is that this is a multimodal therapeutic approach. It can be a challenge with patients because some don’t want to use sticky ointments. Some can’t come in 3 times a week to get light box therapy, or twice a week to get targeted excimer laser. Some don’t want to take oral antioxidants. Some don’t want to take the steroids; they’re worried about immunosuppression, especially during COVID-19. All those things I agree with. I don’t do PUV-A [psoralen and ultraviolet A] therapy anymore. I don’t do any psoralen plus UV-A. I do use narrowband [UV-B phototherapy] extensively, and I also use targeted excimer phototherapy. We have both of those units in our practice. Topical calcineurin inhibitors and topical steroids make up a large workhorse part of my practice, especially before the advent of the topical JAK inhibitors, which I use a lot, off label. I’m excited that hopefully soon, we’ll have those FDA approved, potentially.

With topical corticosteroids and calcineurin inhibitors, typically, let’s say someone has truncal involvement, I used to pulse those every 2 weeks. I’d use one twice a day for 2 weeks, then the other, and go back and forth. And that also limits the effects, potentially, of steroid-induced atrophy and telangiectasia from the topical steroid. If I have a patient who’s got aggressive new areas on the face, I don’t hesitate to use a stronger steroid on the face for a short period. You want to be aggressive. Yes, there could be adverse effects, but you counsel and you watch the patients. Using a stronger steroid on the face, which typically we’re all trained not to do, but if you need it, you use it. It works and it helps, and we want to make sure we’re doing that. Lastly, I would say oral antioxidants are a big part of my practice, particularly polypodium leucotomos, which has been shown in several studies to increase the rates of head and neck repigmentation when on narrowband UV-B. And alpha-lipoic acid and vitamin C-, vitamin E-based oral antioxidant therapy, I use very frequently as well for similar reasons.

: Thanks for that great overview. It’s so helpful. I think that this is a nice segue into the next part. What are the challenges and unmet needs in vitiligo, and where are things headed?

: I think you and I know exactly the answer to that, which is the unmet needs are that we need an FDA-approved therapy, first and foremost. I think the second unmet need is that we need more data and we need more research. I will mention 2 important scientific tidbits that I know you and I both are excited about. I’ve heard you speak on the JAK inhibitors before. There’s a lot going on. I was at the New England Dermatological Society [NEDS] meeting with you virtually recently where you spoke, and it was a really great meeting…put together along with the NEDS board. I know it came up that there’s more interleukin and molecular basis of understanding some of these diseases.

For example, IL-15 [interleukin-15] signaling is an exciting new area of research because IL-15 is thought to be the driving influence that keeps those resident T-memory cells hidden in the skin so that even when you repigment, the color can be lost again because you’ve got these annoying pesky cells that are clingy and lurking in the background. Or CXCL10,which has been shown to be a potential predictive biomarker for vitiligo. What if one day we have a blood test we could draw and tell our patients, “Hey, your titer’s really high. Your vitiligo is likely going to spread within the next 6 months to a year. I’m going to keep you on systemic steroids longer or at a higher dose.” I’m really excited about that.

Videos

A brief review of the treatment armamentarium for vitiligo, as well as the prevalent unmet needs in that setting.

Treatment for Vitiligo: Options and Unmet Needs

A recent randomized, double-blind phase 2 study of 157 patients with vitiligo in the 

Journal of the American Academy of Dermatology 

examined the correlation between facial and total Vitiligo Area Scoring Index (F-VASI and T-VASI, respectively).

 This was evaluated through patient- and physician-reported measures of clinical improvement, including Patient Global Impression of Change-Vitiligo (PaGIC-V) which uses a 7-point scale, and Physician’s Global Vitiligo Assessment (PhGVA).

Stable study patients—having no change from baseline in PaGIC-V, a score of 4—showed VASI scores with “excellent test-retest reliability (≥ .95) at weeks 12 and 24,” investigators wrote.

Additionally, significant differences in VASI were seen among PhGVA categories (mild, moderate, severe) at baseline and change in disease status was detected by the VASI during the treatment period. These differences were detected between patients showing improvement (PaGIC-V, 1-3) or those who had worsening (PaGIC-V, 5-6) vitiligo (Pearson’s r ~.45, 

Interpretability was assessed using an anchor-based PaGIC-V (score of 1 or 2) approach to define clinically meaningful change (CMC) on the VASI at 24 weeks, according to the study.

The mean CMC shown was 57% for F-VASI and 42% for T-VASI, indicating that a higher percentage of patients treated with 1.5% ruxolitinib cream (Opzelura; Incyte Dermatology) “met or exceeded CMC thresholds vs vehicle on F-VASI (39.4% vs 3.1%; 

The study concluded that the efficacy analysis using F-VASI and T-VASI showed meaningfully relevant changes in patients with vitiligo.

1. Hamzavi I, Rosmarin D, Butler K, Kuo F, Zhu Z, Sun K. 25486 Correlation of the vitiligo area scoring index with patient- and physician-reported measures of clinical improvement in a randomized, double-blind phase 2 study. 

A recent JAAD study evaluated the correlation between F-VASI and T-VASI using patient- and physician-reported measures of clinical improvement, PaGIC-V and PhGVA.

Study: Correlation of VASI with PaGIC-V, PhGVA

I want to pick your brain about how you explain expectations of treatment with the patient and what you go over with a patient with a new diagnosis of vitiligo who’s going to be pursuing treatment. How do you walk them through that?

: The first thing I try to do is turn it into a positive discussion. If someone has, let’s say, facial involvement, I have an adage in my practice where I enthusiastically say, “Oh, you’ve got facial involvement, that’s fabulous. The face is fabulous,” is what we say. Because facial disease is the one area of the body where we can really make strides to get 80%, 90%, even close to 100% repigmentation. If you use combination therapies of topical modalities with phototherapy, you can achieve that, and that’s been shown in studies. That’s one of the first talking points.

The other thing is, I try to alleviate a lot of the stress on family history and passing it on to children and other family members because that comes up a lot. What I tell my patients is there’s about a 6% chance that you’ll pass this on to your child, and that alone, from the early onset of the consult, leads to a lot of that tension dropping. Just because you have it does not mean at all that your child is going to get it, or if one child has it, that the other child is going to get it.

I start with as many positive talking points as I can. Another really positive one, by the way, as you know, is you’re 3 times less likely to have melanoma if you have vitiligo. There are some positive sound bites we can share with our patients. The other thing I share is that it’s not a quick process, and it’s going to take time. For example, in phototherapy, I tell my patients, “You need to do a minimum of 45 to 50 sessions before we even say if this is a great success or not. If you see results at treatment 15 and we’re starting to see little dots of pigment, then that’s great. But we’re not going to make a judgment call until we get to about 45 to 50.” Phototherapy needs to be continued long term.

Then the last thing, at least in this stage of our discussion, I tell my patients is if their vitiligo is spreading, and I ask the question, “How many new white or light spots have you noticed within the past month?” And they say, “I have one on my cheek and, oh, yeah, I’ve got a white spot on my shoulder and one on my thigh.” I look at the size of those areas, and I try to estimate if that’s 1% of their BSA [body surface area]. If it’s approximately 1% of their BSA, and this is a rough estimate, I would call that rapidly progressing, in a 4- to 6-week period, of hypopigmentation to depigmentation. Those are the patients who need the systemic steroid stabilization, which I prefer to do as a pulse dexamethasone, Saturday/Sunday therapy usually, for about 8 weeks. That’s sort of broad; I’d be happy for you to give your pearls and add on to that.

: Again, I think you summarized it beautifully. I think that it’s really important to set expectations and acknowledge that treatment is difficult and treatment will be chronic, and it may take time to see improvement. Phototherapy, which is a mainstay of treatment of vitiligo, may take time to work. It’s important to set the expectation that it’s going to take time, and don’t get discouraged and keep with it. We’re here for you. All that stuff is really important. I couldn’t agree more.

Seemal Desai, MD, FAAD, and William Damsky, MD, PhD, discuss methods for managing a patient’s motivation and expectations when on therapy for vitiligo.

Vitiligo: Managing Patient Motivation and Expectations for Treatment

 asks if there is a diet that can help psoriasis symptoms and 

 gives 6 reasons why to add face steaming to the skin care routine. 

 talks butt acne and 21 treatments for acne scarring. 

Is There a Psoriasis Diet That Helps Manage Symptoms?

6 Benefits of Face Steaming That Prove It's Worth Adding to Your Routine

5 Vitamin C Myths Experts Say You Need to Stop Believing

I Never Thought Arthritis Would Derail My Career. Here’s What I Wish I Had Known.

How to Diagnose, Treat, and Prevent Butt Acne

The 21 Best Acne Scar Treatments, According to Dermatologists

This week’s edition of The Mainstream Patient features stories about a diet to manage psoriasis symptoms, face steaming, and more.

Virtual Group Visits Create Pediatric Vitiligo, AA Patient Support

Treatment for Vitiligo: Options and Unmet Needs

Study: Correlation of VASI with PaGIC-V, PhGVA

Vitiligo: Managing Patient Motivation and Expectations for Treatment

The Mainstream Patient: December 6

The changing treatment landscape of plaque psoriasis