Transcript Hot Topics & Recent Advances in Dermatology – What You Need to

What’s New in
Dermatology
Benjamin Barankin, MD FRCPC
Toronto Dermatology Centre
Faculty/Presenter Disclosure
Faculty: Dr. Benjamin Barankin
Relationships with commercial interests:
Speaker Honoraria:
Abbott Labs
Actelion
Amgen
Astellas
Galderma
Janssen
Johnson & Johnson
Leo Pharma
Valeant
Valeo Pharma
Disclosure of Commercial
Support
This program has received financial support from No Pharma Company. in the
form of nothing.
Potential for conflict(s) of interest:
Dr. Barankin has received no honoraria in the development or delivery of this
presentation.
Mitigating Potential Bias
Bias in this program has been mitigated using independent content
validation as follows:
All data has been sourced from evidence that is clinically accepted
All support used in justification of patient care recommendations
conform to generally accepted standards
Introductions
Dr. Benjamin Barankin, MD FRCPC
Dermatologist & Medical Director of
Toronto Dermatology Centre
4256 Bathurst St. #400 (Bathurst & Sheppard)
Ph: 416-633-0001 Fax: 416-633-0002
www.torontodermatologycentre.com
[email protected]
Toronto Dermatology Centre
2 Dermatologists
90% medical; also laser, surgical, & cosmetic
2 Plastic Surgeons
OHIP & Non-OHIP
Wait times: 1-3 weeks; Urgent referral squeeze ins
UVB-Phototherapy (OHIP-covered): psoriasis, eczema, itchy skin,
vitiligo, various rashes
Clinical research trials: psoriasis, acne, rosacea, cosmetic
Many languages spoken:
English, French, Russian, Hebrew, Italian, Cantonese/Mandarin
Disclosures:
** No support/sponsorship for this talk
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Abbott Laboratories
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Actelion
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Astellas Pharma Inc.
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Galderma
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Janssen
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Leo Pharma Inc.
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Pfizer-Amgen-Wyeth
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Valeant/Sanofi-Aventis/Dermik/Canderm/Medicis
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Previously: Graceway, 3M, Stiefel
Ceramide-Based Moisturizers
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Appears that disturbances in epidermal lipid compartment structures
(esp. ceramides) account for the defects in barrier function of atopic dry
skin.
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Ceramides are reduced in all atopics, particularly during a flare.
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Use of topical ceramides on a regular basis reduces need for topical
steroids.
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In Canada, only a few OTC ceramide-containing products:
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Cerave (cream, lotion, cleanser)
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Cetaphil Restoraderm™ (lotion)
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Impruv® (cream)
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Curel Advanced Ceramide Therapy
By prescription: EpiCeram (approved Sept. 2009)
– great safety profile & no restrictions of use.
Maintenance Therapy in
Atopic Dermatitis & Eczema
Topical tacrolimus (Protopic 0.03% & 0.1%
ointments) and pimecrolimus (Elidel cream) are used
to treat patients ≥2 years of age with eczema.
Topical calcineurin inhibitors are especially helpful
when sensitive areas like face/neck/groin/axillae are
involved.
Used twice per week, topical tacrolimus has been
shown to be an effective way to prevent, delay and
reduce occurrence of atopic dermatitis exacerbations.
References:
1. Proactive disease management with 0.03% tacrolimus ointment for children with atopic dermatitis: results of a randomized, multicentre,
comparative study. Thaçi D, Reitamo S, Gonzalez Ensenat MA et al; European Tacrolimus Ointment Study Group. Br J Dermatol. 2008
Dec;159(6):1348-56.
2. Proactive treatment of atopic dermatitis in adults with 0.1% tacrolimus ointment. Wollenberg A, Reitamo S, Girolomoni G et al;
European Tacrolimus Ointment Study Group. Allergy. 2008 Jul;63(7):742-50.
Chronic Hand Eczema
Actelion has launched Toctino® (alitretinoin), an oral retinoid for
chronic hand eczema.
10 & 30mg capsules; start at 30mg/day with meal.
Similar contraindications as isotretinoin, but much better
tolerated. Main SE: headache, LFTs, lipids
For patients with severe chronic hand eczema refractory to potent
topical steroids, ~ 50% will respond with good success to
Toctino® 30mg/day.
Appears to work for a variety of chronic hand conditions (offlabel) including dyshidrotic eczema and psoriasis.
Expensive, but now ODB covered
What’s New in Psoriasis Topicals
New topical vehicles & formulations:
Clobex® spray/lotion/shampoo – effective, and with
elegant vehicles likely increase compliance
Dovobet® gel – A gel rather than ointment (more
elegant) ; treatment for scalp and body
Silkis® ointment (calcitriol) – non-steroid option
(biologically active metabolite of vitamin D3), similar to
Dovonex® (calcipotriol), but less irritating for sensitive
areas
Foams & Solutions
What’s New in Psoriasis Biologics
Lots of Biologics !!
Remicade (Infliximab) - 5mg/kg IV infusion q 2months
Enbrel (Etanercept) – 50mg SC twice weekly
Humira (Adalimumab) – 40mg SC q 2 weeks
Stelara (Ustekinumab) – 45mg SC q 3 months
Many biologics in clinical trials!
What’s New in Psoriasis Biologics
Reduced dosing frequency.
TNF-inhibitors help psoriasis & psoriatic arthritis.
Stelara (Ustekinumab) is the newest biologic, and is a
first in class human monoclonal antibody selectively
targetting the cytokines IL-12 & IL-23.
More coming ; oral biologics!; biosimilars
ODB Coverage: Enbrel, Humira, Stelara.
Pricy: approximately $20-25,000 per year.
Biosimilars coming!
Allergic Contact Dermatitis:
Allergens of the Year
2013: Methylisothiazolinone
2012: Acrylates
artificial nails, dental prostheses, hearing aids
2011: Dimethyl Fumarate
2010: Neomycin
2009: Mixed dialkyl thioureas (neoprene rubber)
2008: Nickel
2007: Fragrance
2006: P-Phenylenediamine (PPD)
2005: Corticosteroids
What’s New in Acne
Acne: New Treatment Combination – Tactuo gel
2.5% Benzoyl peroxide & Differin 0.1%.
Biacna gel
1% Clindamycin + 0.025% tretinoin
Aczone
5% Dapsone ; anti-neutrophilic ; well-tolerated, for papulopustular
acne, especially adult female acne
Benzaclin gel vs. Clindoxyl gel - 90 vs. 60 day longevity ; pump preferred
Isolaz acne laser
Suction + Laser
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Diet may affect acne:
Acne worse in those consuming dairy and high glycemic diets.
What’s New in Acne - 2
Epuris – new oral form of Isotretinoin
10, 20, 30, 40mg tablets
Better absorption in absence of food (60% vs. 40%) &
more precise weight-based dosing
Minimal extra cost
What’s New in Rosacea
Azelaic acid 15% (Finacea®) came to market in summer of 2010
for rosacea by Bayer.
Ideal for papulopustular rosacea, but also reduces erythema
Main effect due to anti-inflammatory properties
Bid ; 50gm tube
Subantimicrobial dose antibiotics for Rosacea and Others
Apprilon 40mg po od (30/10)
Prescription topical anti-redness (alpha agonist brimonidine –
Mirvaso®, FDA Approved) product coming in 2013 – daily, fast
acting
Topical ivermectin coming soon
Lasers & Light devices for vascular rosacea
Newest info: bacteria inside the gut of the demodex mite may be
eliciting immunologic reaction.
What’s New in Hair Loss
Rogaine 5% foam (Minoxidil)
Better tolerated, no propylene glycol
3 month supply, ~$140
No compounding issues
Anacaps
Neoptide lotion
What’s New in Melasma
Lytera
Obagi Nu-Derm
Fractionated lasers – e.g. ProFractional
Triluma - ?2014
Skin Cancers & Pre-Cancers
FDA has approved Erivedge (Vismodegib) for
treatment of metastatic basal cell carcinoma (BCC) or
locally advanced BCC
150mg po od
Picato (Ingenol mebutate) for actinic keratoses
Comes from sap of the plant Euphorbia peplus
Home therapy, like Zyclara/Aldara/Efudex (& likely
similar efficacy)
2 (body; 0.05%) -3 (face; 0.015%) days of application =
higher compliance
Metvix - Actinic Keratoses
Photodynamic therapy for: Actinic keratoses, BCCs, Bowen’s disease.
Traditionally using Blu-U or other laser/light device to activate.
Topical application of Metvix® cream (registered in 30 countries) results
in the selective accumulation of photoactive molecules in the neoplastic
tissue; exposure to red light in the presence of oxygen generates reactive
oxygen species which kill neoplastic cells. Healthy surrounding tissue is
spared.
Active ingredient in Metvix® cream is methyl aminolevulinate (MAL), a
topical photosensitizer molecule that permits effective topical
photodynamic therapy.
Aktilite® is an LED light source specifically designed for Metvix because
of its 634nm wavelength. **Can also do daylight PDT!
Main issue: cost/coverage.
Metastatic Disease
New drugs approved for:
metastatic melanoma (Ipilimumab)
1st time ever showing prolonged survival
aggressive or metastatic basal cell carcinoma
(Vismodegib).
Vyloma for Genital Warts –
3.75% Imiquimod
Aldara (imiquimod 5%) has been used since 1997.
Approved and used for treating actinic keratoses, superficial BCCs, and
external genital warts; many off-label uses (e.g. SCC in-situ, other warts,
molluscum).
Zyclara 3.75% for AKs. Vyloma 3.75% for Genital Warts.
Lower concentration has meant better tolerability and thus compliance;
apparently similar efficacy.
Zyclara: easier dosing schedule with 2 weeks on, 2 weeks off, then 2 weeks on
again. “2, 2, 2” regimen for Aks.
Vyloma: od for up to 8 weeks.
Both now come in pumps.
Genital Warts
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Veregen (Sinecatechins ungt) approved for sale in sept.
2013 for external genital or perianal warts; available Q1
2014.
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A concentrate of catechins extracted from green tea leaves
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10% & 15% ointment – already part of U.S. & European
guidelines for treating genital warts.
HPV: cause of AK & SCC
A leading dermatologist-researcher Dr. Eggert
Stockfleth and his lab in Berlin has demonstrated that
HPV 21 can be found in 95% of actinic keratoses (AK)
and 100% of squamous cell carcinomas (SCC); less
commonly, HPV 5 & 8 have also been associated.
The need for immunomodulation using agents such as
topical imiquimod (approved for treating HPV & AKs)
makes even more sense now.
Herpes Simplex Virus (HSV) /
Cold Sores
Xerese – Acyclovir 5% & Hydrocortisone 1% cream
5/day ; >12 yo ; approved for lip cold sores
Reduces ulceration and duration
Onychomycosis
Tribute Pharma will be launching a topical terbinafine
solution for nails.
Valeant will be launching efinaconazole 10% solution
likely early 2014
No need to remove weekly (unlike Penlac)
Covers candida species
Safe, effective, high efficacy, with no monitoring
Unwanted Facial Hair
Vaniqa® (Eflornithine 13.9%) back on market
Irreversible inhibitor of ornithine decarboxylase which
is a rate-limiting enzyme. Inhibition results in slowed
hair growth.
Apply bid to unwanted facial hair; 30gm tube.
Works well in combination with laser hair removal
techniques.
20% of women at least once weekly will
tweeze/shave/wax/bleach hair.
New laser hair removal systems like lightsheer duet are
faster and much less painful.
Injectable Dermal Fillers
Hyaluronic acids – Restylane & Perlane, Juvederm, Teosyal, Ovita, Revanesse
Last 4-12 months depending on location injected
Belotero launched in U.S., likely will come to Canada
Calcium Hydroxyapatite (naturally found in bone) – Radiesse
Stimulates body’s natural collagen production
Deeper injection; lasts 12-18 months
Evolence & Artesense – taken off market
New: not widely used
Beautical (polyacrylamide) – 2-4 years
Bio-Alcamid (polyacrilimid) - permanent
New Botulinum Toxins
Botox® – 20 years of approved use in Canada
Originally approved March 14, 1990 for Strabismus & Blepharospasm
New toxins to market:
Xeomin® (incobotulinumtoxinA) – Merz Pharma Canada
Launched April 2012 ; same reconstitution as Botox
Dysport™ (abobotulinumtoxinA) - Medicis/ Valeant
Launched April 2013 ; different reconstitution to Botox
Vast array of uses:
Wrinkles
Hyperhidrosis
Blepharospasm
Cervical dystonia
Migraines, tension headaches
Cerebral palsy
Post-stroke spasticity
Club foot
Urinary incontinence
Raynaud syndrome
Lasers
Fractionated lasers (e.g. Profractional, Fraxel) provide
excellent option for laser resurfacing for:
Aging face, acne scarring, melasma.
Safer than traditional CO2 laser resurfacing by using
microthermal zones, leaving areas of normal skin for
better healing.
Lasers
Many non-invasive treatments now developed to treat unwanted fat – show modest
results, & unlikely to replace tumescent liposuction.
Ultrashape is an ultra-sound based device using selective focused ultrasound to
produce mechanical, nonthermal, acoustic effects which target & selectively
disrupt fat cells.
Zeltiq has developed “cryolipolysis” which employs cold for fat reduction. The
device is pressed against the area to be treated; the body reacts to the cold with
inflammation and the body disposes of the damaged fat cells.
No anesthesia, no recovery time ; good for stubborn areas of fat
Fat Removal
Sodium deoxycholate by Kythera injected into
submental fat (“mesotherapy”) is quite helpful; coming
to market in near future.
Thank you!