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

explains why itchy skin is so common during winter and details everything there is to know about tretinoin. Meanwhile, 

writes about the benefits of lactic acid as a chemical exfoliant and 

predicts the seven ingredients that will trend in skincare this year. Finally, 

dives into how long it takes for skincare ingredients to work and reveals why “skinimalism” will be 2021’s biggest beauty trend.

So This Is Why Your Skin Gets So Itchy During the Winter

Here's What Dermatologists Want You to Know About Tretinoin

Yes, There's an Acid That Doesn't Sting or Burn Sensitive Skin

Exactly How Long It Takes for Skincare Ingredients to Work, According to Dermatologists

2021's Biggest Beauty Trend Is All About "Skinimalism"

The 7 Skincare Ingredients You’ll See Everywhere in 2021, According to Experts

Articles

This week’s edition of The Mainstream Patient features stories on the benefits of lactic acid, itchy skin during the winter, tretinoin, 2021’s biggest beauty trend, plus more.

The Mainstream Patient: January 18, 2021

Poll

POLL: Do you think social media trends influence your patients' skin-related concerns?

The latest content from our January issue;

A brand new edition of the Mainstream Patient;

Breaking coverage from the Orlando Dermatology, Aesthetic & Surgical Conference (ODAC);

Check back with our website frequently so you don’t miss any of the latest dermatology news.

A glimpse at what to expect from Dermatology Times this week.

What’s new on Dermatology Times: January 18-22

In case you missed it, some of this week’s featured content includes a new podcast episode about building a COVID-19 dermatology registry, as well as stories on finasteride risks for younger males, how COVID-19 telehealth helps broaden patient population, updates in acne research, plans for Allergan Aesthetics to acquire a medical device company, plus more.

POLL: When do you expect in-person conferences to resume?

This week’s edition of The Mainstream Patient features stories on acne treatment alternatives, dermal fillers, skincare regimens for psoriasis, wet hair care, laser treatments, plus more.

Study Examines Finasteride Risks for Younger Males

A recent study shows an association between finasteride use and psychological adverse events (AEs) including suicidality. Dermatologists should weigh benefits and risks carefully when considering finasteride for certain patients with hair loss, according to one expert

COVID-19-related Telehealth Broadens Patient Population

A retrospective study shows significant differences in the characteristics of patients seen by telehealth during the COVID-19 pandemic versus those seen during in-office visits 1 year earlier.

Next-Generation Therapies and Approaches Will Advance Acne Treatment

Topicals and oral antibiotics, as well as research on the skin microbiome, are paving the way for the future of acne treatment, according to a recent presentation at the 2020 ODAC Pre-Conference Inflammatory Diseases Symposium.

Allergan Aesthetics to Acquire Cypris Medical in Warrant Agreement

Allergan Aesthetics has entered into a warrant agreement that will give the company an option to acquire Cypris Medical following the completion of a clinical trial evaluating Cypris’ Xact device.

The Cutaneous Connection- Episode 15: Building a COVID-19 Dermatology Database

Esther Freeman, MD, PhD, details how her and her fellow colleagues banded together to create a COVID-19 dermatology registry in just eight days. The registry has since seen over 1,000 submissions from frontline clinicians located in 40 countries, helping to identify and diagnose active COVID-19 through submitted skin findings.

Immunity Induction Therapy with Antibodies, Wound-Healing Therapies Show Potential

Acne research delineating molecular and cellular pathogenic pathways gives insight into new therapeutic targets. According to a recent review, biologics and other therapies that modulate scar formation and wound healing will have value for treating severe acne.

ICYMI, some of the content featured this week includes a new podcast episode and stories on finasteride, telehealth, medical device company acquisitions, updates in acne research, plus more. 

Weekly Roundup: January 11-15, 2021

Continuing research on the pathogenesis of acne has yielded a new understanding of underlying molecular and cellular pathways, suggesting new targets for therapeutic intervention, says Ichiro Kurokawa, MD, director, Department of Dermatology, Meiwa Hospital, and clinical educational professor, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan, in collaboration with Keisuke Nakase, PhD, assistant professor, Department of Microbiology, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan.

The information on these advances is summarized in a recent article1 written by Kurokawa and Nakase. The authors review recent findings on the pathogenesis of acne, discuss novel treatments, and propose future therapeutic strategies. With the need for additional treatments for severe acne, Kurokawa tells 

that findings from immunological studies are of interest as they suggest the potential to use immunity induction therapy with antibodies.

“The future treatment for severe acne will involve biologic therapies targeting interleukin (IL)-1α, IL-1β, IL-6, tumor necrosis factor (TNF)-α, and transforming growth factor (TGF)-β,” he says. In particular, these pro-inflammatory cytokines are involved in the development of scar formation, which is the most refractory complication of severe acne. In addition, TNF-α promotes lipogenesis in human sebocytes,” says Kurokawa.

“Treatments that enable wound healing are also of interest as a therapeutic intervention to prevent permanent scarring in patients who suffer from severe acne,” he adds.

The discussion of recent findings on acne pathogenesis is divided into sections reviewing research pertaining to sebaceous gland biology, sebum, genetics, keratinization, hair cycles, immunology, bacteriology, and wound healing. Findings from these studies suggest numerous novel potential treatments.

Kurokawa explains that insulin growth factor (IGF)-1 is involved in acne pathogenesis through stimulation of lipid formation. In addition, research investigating genetic associations with acne development implicates the involvement of genes in the IGF family as well as in the melanocortin receptor and peroxisome proliferator-activated receptor (PPAR) families among others.

Kurokawa and Nakase note that while existing antimicrobial agents used for treating acne are believed to have benefits for both their effects on 

(C acnes) and anti-inflammatory activity, the search for alternatives continues due to concern over the emergence of bacterial resistance with antibiotic overuse. Vaccination strategies for eradicating 

and preventing its overgrowth show promise.

induces production of pro-inflammatory cytokines. Complete suppression of acne inflammation would likely mean combining these vaccinations with monoclonal antibody agents able to block the pro-inflammatory cytokines,” Kurokawa says.

Although there has been limited study of hair cycles in acne and a lack of research into keratin expression in the hair cycle in acne lesions, available evidence shows a shift in the hair cycle from anagen to telogen or catagen phases, according to the authors.

Kurokawa and Nakase speculate that progenitor cells in the junctional zone might differentiate towards the infundibulum and sebaceous duct cells rather than towards the lower portion of the hair follicles.

“The sebaceous gland with hypercornification in the sebaceous duct is usually atrophic without the outer root sheath below the opening of orifice of sebaceous gland,” Kurokawa says.

The authors also review novel acne therapies being used in Japan that show encouraging results for the treating both nodulocystic acne and perifolliculitis capitis abscedens et suffodiens, a related treatment-refractory disorder.

Kampo is a traditional Japanese herbal medicine using Saireito. While it is used in combination with topical benzoyl peroxide, oral antimicrobial agents, and local steroid injections, there is biological plausibility for benefit of Saireito, according to the article’s authors.

“Basic research studies are needed to determine the mechanisms by which Saireito modulates acne pathogenesis, but there is evidence that its activities include effects on endogenous corticosteroids, inflammation, reactive oxygen species, coagulation, macrophages, neutrophils, and endothelial cells,” Kurokawa says.

Other treatments used for severe acne in Japan include Jyumihaidokuto and Keigairengyoto. Jyumihaidokuto contains Bokusoku, an extract from 

that has been shown to inhibit testosterone-induced sebum synthesis. Keigairengyoto has both an antibacterial effect on 

Kurokawa, MD and Nakase, PhD report no relevant disclosures.

1. Kurokawa I, Nakase K. Recent advances in understanding and managing acne. 

Immunity Induction Therapy with Antibodies, Wound-Healing Therapies Show Potential 

Podcasts

Allergan Aesthetics, an AbbVie company, announces the company has entered into a warrant agreement to acquire Cypris Medical, a private medical device company, according to a press release from Allergan.

After the completion of a clinical trial that will begin in 2021, Allergan will have the option to acquire Cypris Medical and its Xact device. The clinical trial will investigate the safety and efficacy of Xact in neck lifts and treating midface descent.

"As the market leader in facial aesthetics, Allergan Aesthetics is the ideal partner to lead the advancement and continued development of Xact," said Dan Holton, president and CEO of Cypris Medical. "We share the same vision with respect to product safety, efficacy and data-driven innovation which allow us to offer plastic surgeons and patients new options for aesthetic medicine."

The Xact is a minimally invasive facelift device that works by allowing lifting and suturing of the superficial muscular aponeurotic system (SMAS), the same tissue mobilized in a surgical facelift procedure. This technology provides patients with surgery-like results in the office with minimal to no downtime, according to the press release.

"As a global leader in aesthetics, we are proud to support the research of an innovative device that complements our iconic portfolio of non-invasive treatment options like Botox Cosmetic and our Juvéderm collection of fillers," said Carrie Strom, senior vice president of AbbVie and president of Global Allergan Aesthetics. "We know there is continued unmet need for minimally-invasive procedures for midface descent, and Xact affords us the ability to create a new alternative for our customers so they can continue to offer leading-edge treatments to patients."

1. Allergan Aesthetics Enters Into Option to Acquire Cypris Medical. (2021, January 12). Retrieved January 13, 2021, from https://news.abbvie.com/news/press-releases/allergan-aesthetics-enters-into-option-to-acquire-cypris-medical.htm?view_id=5591

Allergan Aesthetics has entered into a warrant agreement that will give the company an option to acquire Cypris Medical following the completion of a clinical trial evaluating Cypris’ Xact device. 

New topicals, narrow-spectrum antibiotics, and research on the skin microbiome are paving the way for the future of acne treatment, according to Jenna Lester, MD.

In a presentation at the Orlando Dermatology, Aesthetic & Surgical Conference (ODAC) Preconference Sneak Peek Inflammatory Diseases Symposium held virtually in December 2020, Lester provided an overview of promising treatments and therapies for patients with acne vulgaris. She is an assistant professor in the Department of Dermatology at University of California, San Francisco (UCSF), Health and founder and director of UCSF Skin of Color Clinic.

The US Food and Drug Administration (FDA) approved trifarotene (Aklief, Galderma), a topical retinoid for treatment of facial and truncal acne, in May 2020.

 Retinoids such as trifarotene, which bind to the retinoic acid receptor (RAR), have 3 isoforms: RARα, RARβ, and RARγ. Trifarotene is unique; it is the only topical retinoid that selectively targets RARγ, the most common RAR found in the skin. The drug is also the first topical treatment studied and proven to treat both facial (forehead, cheeks, nose, and chin) and truncal (chest, shoulders, and back) acne, according a press release from Galderma.

In a 52-week open-label comparative study, 455 patients were given trifarotene. Data showed that the agent was well tolerated among participants. The most common adverse effects included pruritus, irritation, and sunburn, all of which occurred most frequently within the first 3 months of treatment. Results showed that at 52 weeks, more than half (57.9%) of patients achieved treatment success at 52 weeks. Quality of life also improved over that time frame, according to the data.

“When I’m counseling about acne topical treatments, I’m usually telling people how things will improve in 3-month cycles. By 6 months, if things aren’t better, I might decide to increase strengths of tretinoin or move some things around,” Lester said. “But for trifarotene, it seems that the efficacy is experienced at the highest percentages at about a year. So, for patients who may not tolerate waiting that long, this may not be the best medication.…However, the trickle effects of it really can’t be ignored.”

In August 2020, clascoterone cream (Winlevi; Cassiopea), received FDA approval for the treatment of acne in patients 12 years and older.

 Clascoterone is an androgen receptor antagonist that specifically competes against androgens such as dihydrotestosterone by binding to the androgen receptors located in hair follicles and sebaceous glands. This mechanism of action helps decrease production of sebum and inhibits activation of inflammatory pathways and proinflammatory cytokine synthesis. 

In 2 randomized, vehicle-controlled, double-blind studies investigating clascoterone cream in 1440 males and nonpregnant females (all White), results showed a reduction in inflammatory and noninflammatory lesions. Overall, this topical was well tolerated, according to Lester.

Minocycline (Amzeeq; Vyne Therapeutics) was approved by the FDA in October 2019 for the treatment of nonnodular inflammatory moderate-to-severe acne in patients 9 years and older.

 A 4% minocycline foam falls under the tetracycline class of antibiotics, Lester said.

Results of a randomized, double-blind, vehicle-controlled study investigating 4% minocycline foam in 1488 patients showed an improvement in inflammatory lesions and revealed that 30.8% of patients achieved treatment success (Investigator Global Assessment of 0 or 1 and an improvement of 2 grades by week 12).

Lester adds that, compared with trifarotene, topical minocycline demonstrates a faster efficacy profile. “One of the reasons that this was an ideal medication to convert into a topical treatment is [that] because of the tetracyclines, minocycline has the least resistance and the most favorable [adverse] effects profile when comparing [with] doxycycline or tetracycline,” she said. “However, we know that there is potential for significant [adverse] effects, particularly discoloration and acne scarring, when taken systemically. With the increase in resistance to topical clindamycin and erythromycin, our setting is really prime for incorporating another topical antibiotic medication into our acne regimen.”

Lester also recommends the use of oral antibiotics such as sarecycline (Seysara; Almirall), a novel narrow-spectrum tetracycline class antibiotic approved by the FDA in 2018 to treat acne in patients 9 years and older.

The drug possesses a stable C-7 moiety and works by targeting 

)while having little activity against gram-negative organisms and intestinal microflora, Lester said. Protecting the microflora decreases short-chain fatty acids, which can be anti-inflammatory. It also prevents gastrointestinal distress, which, when disrupted, could make patients less likely to stay on the medication, she added.

In a clinical study, results showed that sarecycline performed well for facial, back, and chest acne, according to Lester. “We all are trying in dermatology to be better antibiotic stewards. If you’re not already recommending [sarecycline] for your patients, this is an excellent option,” she said. “It is a very narrow-spectrum tetracycline, and narrow-spectrum medications are what we’re aiming for in terms of being good antibiotic stewards in guarding against resistant bacteria.”

Lester reemphasizes the importance of protecting the skin and gut microbiome, which is made up of more than 1000 commensal species that occupy spaces that pathogenic bacteria otherwise would occupy.

 are associated with acne, whereas others are associated with healthy skin. Some phylotypes also attack unhealthy types of the acne. In addition, gut organisms can influence glycemic control, tissue lipid content, and inflammation, which can have a direct impact on skin disease.

Few clinical trials look at topical probiotics for prevention and treatment of skin conditions except in atopic dermatitis, according to Lester. The results of one study found that consuming 

 was just as effective as taking minocycline, whereas other study findings showed a decrease in inflammatory lesions.

Despite the promise of these findings, Lester said, more research must be done on the skin and gut microbiome and how they influence inflammatory skin diseases such as acne.

1. Lester J. Acne: changing practices in a changing clinical landscape. Presented at: Orlando Dermatology Aesthetic and Clinical 2021 Preconference Sneak Peek Inflammatory Diseases Symposium; December 3, 2020; virtual. 

The shift to telehealth visits during the height of the first wave of the COVID-19 pandemic effected noteworthy changes in the sociodemographic and clinical characteristics of patients presenting for care at a tertiary referral center, according to a recently published study.

The findings provide insights for understanding the impact of the pandemic on dermatology and, moving forward, for determining which patient populations may benefit most from access to teledermatology and how to optimize its delivery, says Avery LaChance, MD, MPH, director of Health Policy and Advocacy, Brigham and Women’s Hospital Department of Dermatology, and instructor in Dermatology, Harvard Medical School, Boston, Mass.

“It is essential that we study how the rapid expansion of telehealth throughout the pandemic impacted our patients and the practice of medicine,” says LaChance. “As a medical community, we should seek to learn as much as possible about how we can optimize telemedicine to improve patient access to dermatologic care.”

To evaluate the impact of the transition to telehealth on the practice of dermatology, LaChance and colleagues at the University of Massachusetts Department of Dermatology conducted a retrospective chart review comparing the characteristics of patients seen for in-person visits in April 2019 versus by telehealth in April 2020. The in-person cohort included 1565 patients while 767 patients were seen via telehealth during the pandemic period.

“In April, Massachusetts was recommending that all non-emergent health care be provided by telehealth. [Increased access to in-person care opened up in late May/early June.] Focusing on the month of April gave us an opportunity to investigate which patient populations were seeking out and accessing telehealth during this unique time period,” says LaChance.

She adds, “We felt that only patients who believed they would truly derive benefit from telehealth, such as those who felt their care could not wait, their condition could be adequately managed by telehealth, or who found this mode of care to be an acceptable alternative to an in-person visit, would have transitioned to virtual care during this period of time.”

Statistically significant differences identified in the two patient populations show that patients seen by telehealth were significantly younger, more likely to live out-of-state, and more diverse racially, ethnically, and linguistically. Online visits included a higher proportion of Medicaid recipients but a lower proportion of Medicare patients than the in-office cohort.

Virtual visits for inflammatory dermatoses and hair disorders accounted for higher percentages of the primary diagnoses in the teledermatology cohort. However, skin cancer and other neoplastic disorders were most common among study group patients seen in-office.

Commenting on the findings, LaChance says that the proportional increase in patients presenting for hair disorders is interesting considering a study reporting that dermatologists believe examinations for alopecia are less amenable to teledermatology.

“Hair loss is a very emotionally charged disease. Affected patients may have felt very strongly about keeping their appointment during the pandemic,” she says. “Another factor may be that certain hair loss disorders, such as telogen effluvium, which is a type of stress-induced hair loss, have increased throughout the pandemic, possibly contributing to this finding.”

LaChance says she and her colleagues “were happy to see” the uptake of telehealth by Medicaid patients. The investigators credit the broad insurance coverage of telehealth during the pandemic across multiple modalities and different types of technologies in facilitating telehealth access for patients across all backgrounds. Additionally, she notes that patients with Medicaid or in a low income bracket often face social pressures that may limit their access to in-person visits.

“The flexibility and convenience afforded by telehealth may offset the influence of a potential ‘digital divide’ and help explain the increased percentage of Medicaid patients seen by telehealth,” she says. “This is echoed by our findings in another study showing decreased no-show rates for teledermatology versus in-person visits with the most dramatic difference seen among minority patients.”

“We need to do the heavy lifting and conduct more research to understand how patients in all demographic and socioeconomic groups interface with technology and what can be done to ensure equitable access to telehealth now and moving forward,” says LaChance.

As in-person care has opened up, LaChance says that the characteristics of the patient she is seeing virtually match those of the study’s teledermatology cohort. The telehealth clinic patients are generally younger, face numerous social stressors, and have inflammatory diseases (versus concerning lesions).

“Patients and doctors together are considering multiple factors to select the mode of care that is best for each patient individually. We are improving access to care and the patient experience,” she says.

Ongoing research is focusing on defining the current digital divide in the dermatology patient population, evaluating patient satisfaction between telehealth and in-person visits for different conditions, and understanding how telehealth has improved access to care for different patient populations. Recognizing that patient populations differ depending on practice characteristics, LaChance is hopeful that others practicing in different settings and geographic locations will conduct similar research to gain a more comprehensive picture of which patient populations and disease states would benefit from continued access to teledermatology.

She and her colleagues are using their findings to advocate for legislation to ensure broad telehealth coverage in Massachusetts.

“To date, a lot of expanded coverage for telehealth is afforded by emergency legislation and executive orders at the state and federal levels,” she adds. “Legislation is needed to ensure patients continue to have broad access to telehealth coverage now and in the future.

Physicians must advocate for our patients to influence the next wave of telehealth legislation so we can maintain equitable access to this mode of care for all patients.”

1. Krueger S, Leonard N, Modest N, et al. Identifying Trends in Patient Characteristics and Visit Details During the Transition to Teledermatology: Experience at a Single Tertiary Referral Center. 

. 2020 Nov 27:S0190- 9622(20)33084-X. Epub ahead of print.

2. Franciosi EB, Tan AJ, Kassamali B, et al. Understanding the Impact of Teledermatology on No-Show Rates and Healthcare Accessibility: A Retrospective Chart Review. 

. 2020 Sep 11:S0190-9622(20)32604-9. Epub ahead of print

COVID-19-related telehealth broadens patient population 

John Jesitus is a medical writer based in Westminster, CO.

 showing an association between finasteride use and psychological adverse events (AEs) including suicidality suggests that dermatologists should weigh benefits and risks carefully when considering finasteride for certain patients with hair loss, according to one expert.

Based on the study, the characteristics of finasteride may precipitate or potentiate psychological morbidities including suicidality specifically in patients with alopecia who are less than 45 years of age, says Roger S. Ho, MD, MS, MPH. He is director of resident education and associate professor in the Ronald O. Perelman Department of Dermatology at New York University Grossman School of Medicine, New York, N.Y. Ho was not involved with the study but wrote an accompanying editorial on the topic.

“While a definitive causal association has not yet been established, dermatologists should take into consideration this potential signal and conduct a detailed, personalized risk-benefit assessment with the patient before each prescription of finasteride for our younger alopecia population,” says Ho.

Study1 authors Nguyen et al. used disproportionality analysis (specifically, case-noncase design) to detect signals of adverse finasteride

reactions of interest reported in the World Health Organization’s global VigiBase database as of June 2019. Researchers identified 3282 adverse events (AEs) of interest, including 2926 reports of psychological AEs and 356 reports of suicidality. Nearly all cases involved male patients, and 70.9% of involved patients with age data available were 18 to 44 years old.

Researchers identified significant disproportionality signals for both psychological AEs (reporting odds ratio (ROR) 4.33; 95% confidence interval (CI) 4.17-4.49, and suicidality (ROR, 1.63; 95% CI 1.47-1.81) in finasteride users. Investigators found no signals for attempted or completed suicide.

In sensitivity analyses stratified by indication and age, patients younger than 45 years (ROR 3.47; 95% CI 2.90-4.15) and those with alopecia (ROR 2.06; 95% CI 1.81-2.34) had significant disproportionality signals for suicide compared to patients in the database using other alopecia drugs such as minoxidil. No suicidality signals appeared among older men who presumably took finasteride for benign prostatic hyperplasia.

According to Nguyen et al., the findings raise concern that younger men with alopecia may be especially at risk for suicidality compared with the general population. “Taken together,” they

wrote, “our findings suggest that the disproportional reporting of suicidality and psychological AEs in association with finasteride use could potentially be attributed to unique characteristics of the drug in young patients with alopecia.”

For example, psychological AEs could stem from the possibility that the persistent sexual dysfunction (after discontinuation of treatment) that has been associated with finasteride takes a greater toll on younger patients who had used the drug to treat a non-urological condition.

The disproportionality signals for psychological AEs and suicide among finasteride users also may stem partly from reporting bias. Sensitivity analyses showed disproportional reporting of finasteride-associated suicidality after 2012, a year that drew significant attention to a possible link between finasteride and these AEs.

Ho points out the signals for suicidality and psychological AEs identified by Nguyen et al. for finasteride only serve to stimulate further large-scale prospective pharmacoepidemiologic studies designed specifically to further evaluate these potential AEs in young patients using the drug for androgenetic alopecia. “They should not be mistaken as proof that there is a causal association between the two, as the study had some inherent biases, in particular a reporting bias due to stimulated reporting in the database,” he says.

Dr. Ho reports no relevant financial interests.

Nguyen DD, Marchese M, Cone EB, et al. Investigation of suicidality and psychological adverse events in patients treated with finasteride [published online before print, November 11, 2020]. 

. 2020 Nov 11:e203385. doi: 10.1001/jamadermatol.2020.3385.

HoRS. Ongoing concerns regarding finasteride for the treatment of male-pattern androgenetic alopecia [published online before print, November 11, 2020]. J

2020;10.1001/jamadermatol.2020.3384. doi:10.1001/ jamadermatol.2020.3384.

A recent study shows an association between finasteride use and psychological adverse events (AEs) including suicidality. Dermatologists should weigh benefits and risks carefully when considering finasteride for certain patients with hair loss, according to one expert.