I have recently returned from the American Academy of Dermatology annual meeting in San Diego. Based on the quality of the presentations, the exciting new innovations discussed and the frank, yet upbeat assessments about the future of our specialty, I am once again fired up about being a dermatologist.
I would like to share a number of new ideas and therapeutic pearls that were presented at the meeting. This will be a small fraction of the information presented, but represents the portion of dermatology that is of most interest to me.
- Drs. Gregor Jamec and Haley Naik discussed the difficulties in managing hidradenitis suppurativa (HS). One potentially useful agent in severe and recalcitrant disease is adalimumab (Humira, Abbvie), which is approved for this indication. It is only of modest benefit and must be given weekly. The main problem is the fixed dose, which makes it less likely that obese patients (as many are with HS) get an amount that is probably too low to be of benefit. A good alternative could be infliximab (Remicade, Janssen) where dosage can be modified by weight to achieve the maximum benefit.
- Dr. Eric Simpson discussed the controversies surrounding the treatment of atopic dermatitis.It appears that bleach baths are no better than regular baths in improving skin. Bathing or showering maximizes the efficacy of topical corticosteroids when applied immediately after. Emollients remain the keystone of eczema control by helping to repair a chronically inadequate anatomic skin barrier.
- Dr. April Armstong gave a primer on evaluating clinical studies, specifically those with data based on long-term follow-ups. If the data are presented as “as observed,” test subjects that drop out before the end of the study period are not counted. Many of these subjects may have quit prematurely because of a treatment failure. Thus the “observed” data would be overly optimistic. At the other end of the spectrum, if all dropouts are considered failures, the conclusions might be too pessimistic. We need to be vigilant about how data are presented.
Dr. Armstrong also discussed the subject of inflammatory bowel disease (IBD) and biologic drug use. In patients with psoriasis and associated IBD, TNF inhibitors or IL-23 inhibitors are the best choices.
- Dr. Carolyn Bangert reviewed azathioprine and its value in the treatment of skin disease. The drug should be used only after a Thiopurine S-methyltransferase (TPMT) level is determined. In the rare (1 in 300) patient who lacks any enzyme activity, azathioprine should not be used at all. The drug should be started at a dose of 2.5 mg/kg/day and titrated as per the response and side effect profile. One should allow 6-8 weeks before making a definative determination about its effectiveness. There is a running controversy about whether azathioprine causes hepatosplenic lymphoma. This is probably not an important issue in dermatologic patients since it occurs almost exclusively in those treated for Crohn disease for greater than three years. Skin cancer after long-term use is a potential concern, however.
- One of my favorite bits of advice came from Dr. Jeanette Jakus who described two products used as “counter-stimulants” during injections. These are most useful in children but can also be valuable in needle-phobic adults.
They are “Buzzy Mini Personal Striped” and “Shot Blocker,” both of which can be purchased through a major online retailer. The contact points from these devices saturate the local sensory nerves, thus distracting the patient from injection pain signals.
- Dr. John Koo discussed one of our most vexing management problems: The patient with delusions of parasitosis. Although several anti-psychotic drugs have been used in this condition, pimozide (Orap, Teva Pharmaceuticals) remains the treatment of choice for one important reason: The only indication in the packet insert for this medication is Tourette’s syndrome, a purely neurologic condition. Thus, the patient is not stigmatized with the fact that he is taking a medication used in psychotic individuals. A dose of 3-5 mg per kg body weight is usually sufficient to achieve a complete remission. By starting at 1-2 mg per day and titrating upward over several weeks, the side ef ects can be largely mitigated. Checking for possible arrhythmias is almost certainly not necessary at the low doses used for this condition.
- Dr. Mark Lebwohl revisited the biologic agents and highlighted the advantages of the various products. Adalimumab and the other TNF inhibitors may actually help to prevent myocardial infarctions by reducing systemic inflammation. Secukinumab (Cosentyx, Novartis) may induce a remission which could last 1-2 years after the drug is discontinued.
Brodalumab (Siliq, Ortho Dermatologics) is perhaps the fastest acting biologic agent available today. Ixekinumab (Taltz, Eli Lily) is now indicated for both psoriasis and psoriatic arthritis. Ustekinumab (Stelara, Janssen) is now approved for use in adolescents and may be a good agent in this group because fewer injections per year are needed. Guselkumab (Tremfya, Janssen) may be the most ef ective drug for psoriasis, although it is a little slower acting than others. Apremilast (Otezla, Celgene) is a good alternative for those with more moderate disease.
Perhaps the most inspiring talk given at the meeting was by Dr. Abraham Verghese who is an internist and the author of the best-selling book, “Cutting For Stone.” He discussed the erosion of physician and patient satisfaction over the past 10-15 years and traced it, in part, to the situation where patients are no longer actually being examined, but rather their medical records are combed exhaustively in search of correct diagnoses. This inevitably leads to a deterioration in the doctor-patient relationship. However, he sees our specialty as one where the so-called old fashioned virtue of direct examination, including a detailed history and complete cutaneous examination, which includes actually touching the person, still prevails. I left that lecture and the meeting itself feeling very good about dermatology.