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Derm Update
February, 2017
Matthew J. Deeths, M.D., Ph.D.
Mountain West Dermatology
Grand Junction, CO
Contents
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4.
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6.
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8.
9.
Management of keratinocyte carcinoma- SCC, AK
Mohs AUC
New and old drugs for psoriasis
Melanoma update
Surgical pearls
Simplifying acne treatment
Atopic dermatitis news
Review of UV and Vitamin D data
The long and short of onychomycosis
9. Onychomycosis
• Differential diagnosis?
• Not all funky nails are fungal
Differential diagnosis
• Trauma and secondary infection
• Hiking
• Running
• Old age, nail growth slows
• Psoriasis
• Other things
What we DID and why
• What
• Scrapings for KOH prep, if negative… culture
• Treat positive with PO terbinafine 250mg PO 3-6 months
• Check LFT’s every 4-8 weeks on drug
• Why
• Drug was expensive and thought to cause hepatitis about 1:10,000 patients
• What we didn’t do
• Treat with latest new-fangled topical
What we DO and why
• What
• Decide on clinical grounds if its fungal and if so, treat with PO terbinafine 250mg PO
3-6 months
• Why
• Studies have shown derms can diagnosis onychomycosis clinically 90% specificity,
and cultures and KOH are less sensitive then that
• Drug is cheap now
• Approximately zero cases of liver failure requiring transplant in last 10 years due to
terbinafine
• What we don’t do
• Check labs
• Treat with latest new-fangled topical
• Treat with laser- Podiatrists doing this
8. UV and Vitamin D
• Western Colorado
• Ground zero for UV radiation
• UVA
• 10X more
• Goes through glass
• Photoaging>mutagenic
• UVB
• Blocked by glass and most sunscreens
How to answer the sunscreen question
• K.I.S.S.
• Sun screen SHOULD BE LAST line of defense, or at most 1/5 of the solution
• Clothing- collared shirt, no tank tops, tight woven long sleeves, hats (not cap)
• Plan ahead- Find a shady place to work or play mid day, or stay indoors
• Use a sunscreen on lips, dorsal hands (and forearms) and lower ½ of face
• SPF 30 or better
• Contains Zinc (tinted with iron oxide) or avobenzone
Vitamin D
• We put this one to rest about 2 years ago?
• Data supporting Vit D preventing cancer- debunked
• Same old story- Vitamin D + Calcium = Strong Bones
• You guys know more about this then me
• AAD and Endocrinologists recommend if deficient take supplement
7. The Latest on Atopic Dermatitis
• One really cheap treatment
• One, OK maybe 2, soon to come really expensive treatments
Prevention: Cheap
• Risk factors:
• Race: Asian, Hispanic, African American
• Parents have it
• Parents have seasonal allergies, asthma
• Breast feeding- Nope
• No soy- Nope
• No peanuts- Nope
• No cats- Nope
• Extra cats- Nope (but happier kiddo?)
Prevention: Cheap
• Answer: Less bathing- Empirical based on atopic derm following the
installation of plumbing
• Answer: Daily emollient use in 1st 6 mos., several studies 2014, J. Clin.
Immunol. 2014, 134: 824-830; J. Allergy Clin. Immunol. 2014; JAMA
Pediatrics 2016, Dec. 5, doi: 10.1001
• Prospective: 50% reduction in incidence of atopic derm at follow-up
• Don’t need fancy cream
• Petrolatum cheapest
• Cetaphil cream, available generic, easy to use
Treatment: Less cheap, mostly safe
• Topical steroids for flares 1-2 weeks
• Emollients
Treatment: Expensive- yes; Safe- maybe
• Old expensive topicals… Not much better then vehicle (i.e. emollient)
• Topical Tacrolimus or pimecrolimus
• New expensive topicals… Don’t use it…”Eucrisa” crisaborole… PDE4
inhibitor… 30% better then vehicle…60% improved (vs. 30% with emollient
alone)
• New systemic agent
• Injectable “biologic drug”
• Dupilumab- Due out this March…Blocks TH2 cytokines IL-4 and IL-13…$30,000 per
year…Self injected every 2 weeks… 74% vs. 18% improvement vs. placebo (Lancet
387:40-52), “without significant safety concerns”
• “Use new drugs quickly, while they are still safe!”
• I still use UV rx, methotrexate and azathioprine
• “The devil you know”
6. Acne Treatment Has Gotten Much Easier 
• Should be much easier?
• Mild- Topical
• Moderate- Males topical or isotretinoin
-Females topical plus spironolactone
• Severe- isotretinoin
Mild
• Topical- Best options now OTC
• No rx topical antibiotic… 1% clindamycin- OUT
• Use OTC 10% Benzoyl peroxide once daily
• Generic $4
• No tretinoin cream
• Use OTC Differin Gel, about $11 at Walmart, once daily
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Can use both together at the same time
Watch irritation, no scrubbing, gentle cleanser, moisturize with SPF
Try every other day for sensitive skin
Not spot treatment
Set expectations: Use it 10 weeks, you’ll have 50% less pimples
Moderate
• This is the female who is not satisfactorily improved with topical rx,
cannot tolerate or has pretty severe disease and expected 50%
improvement is not going to be enough
• PO antibiotics, short term only, doxycycline>minocycline may cause
inflammatory bowel disease (Am. J. Gastroenterol. 2010; 105:2610-2616,
retrospective study)
• OCP’s thromboembolism risk
• Spironolactone 25-100mg BID… No serious side effects.. Breast tenderness,
menstrual irregularities, decrement in libido, mood changes
• Don’t need labs
Severe
• Isotretinoin- Not as bad as everyone thought… Finally the truth
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Does not cause pregnancy… but requires iPledge STILL
Does not cause inflammatory bowel disease
Does not cause suicide (but does improve self esteem)
Does not usually cause liver damage
• Check labs once at 6 weeks
• Does cause elevated TG and cholesterol temporarily
• Rule of 1/3’s
• 1/3 relapse
• 1/3 cured
• 1/3 need topical rx
5. Save Packaging, Money and Time in
Outpatient Surgery
• Use exam gloves for minor surgery
• Rates of infection after minor outpatient surgical procedures, e.g. skin cancer
excision, similar with clean bulk exam gloves vs. sterile surgical gloves
• 493 pts randomized nonsterile clean boxed gloves or sterile gloves, “minor skin
excisions”, about 9% rate of wound infection both groups. Med. J. Aust. 2015; (1):2731
• Several smaller studies before this
• Meta-analysis 14 articles, 11,071 pts, JAMA Derm. 2016, Sep 1; 152(9):1008-1014
• 1.9% infections non-sterile gloves vs. 2.0% sterile gloves
• I’ve been doing this for about 1.5 years… Have not seen more infections
• If you haven’t already started, its not necessary to prep skin prior to
infusion of anesthesia for biopsies
4a. Melanoma Treatment
• Several new drugs, last 2 years or so
• Combination of ipilimumab (CTLA4 inhibitor) and nivolumab (PD-1 inhibitor),
FDA approved combination rx gives about 30% long term remission in stage IV
melanoma
• Vemurafenib and dabrafenib- Selective kinase inhibitors- more along the lines
of traditional chemotherapy- several months added survival in stage IV
disease
4b. Melanoma work-up
• Melanoma in situ stage T0
• excise 5 mm margin
• Stage T1a- thin melanomas, < 1mm and no dermal mitoses or ulceration… Low risk, 95%
survival at 5 years
• Excise 1 cm margin
• Skin exams q-6-12 mos
• That’s it
• Stage T1b (<1 mm with mitoses or ulceration) intermediate risk… ~85% survival at 5
years
• These are much more common then higher stage melanomas and thus more cumulative mortality
in population, even though risk of progression per incident is smaller
• Excise as above +/-sentinel lymph node biopsy
• GENE EXPRESSION PROFILING???
• Stage T2 (1-2 mm thick) and above, send to oncology for consideration of imaging, for
staging work-up; and to surgery for excision with sentinal lymph node bx (SNLNBx)
4b. Melanoma- What is gene expression
profiling?
• Not some sort of immigration policy
• Probably will replace SLNBx… much cheaper and non-invasive
• RT-PCR on biopsy material
• No additional tissue required
• Done if biopsy shows T1b melanoma… Maybe someday on T1a also?
• Looks at expression of 31 genes in melanoma- compares these against
profiles of previously studied melanoma with known outcomes to predict
biologic behavior of the melanoma in question
4b. Melanoma- What is gene expression
profiling?
• Castle Biosciences patented test, called DecisionDx-Melanoma
• Validated in large studies- DOI 10.1158/1078-0432.CCR-13-3316, January
2015 and, and others
• Able to identify subset of SLNBx negative pts who go on to develop mets.
• Will be seeing more of this, call me if you have questions or send pts
over for discussion
4. Melanoma
• Oncologists don’t want to see stage T1a, T1b patients…
• These patients need skin exams and directed ROS and regional lymph node
exam for new primary melanomas, their risk of a new primary is much higher
then their risk of systemic recurrence
• They don’t need scans
• As time goes by Gene Expression Profiling (GEP) may replace sentinel lymph
node biopsy (SLNBx)
• T1a: Do the excision yourself or send to me, and schedule skin exams for ever
• T1b: Same as above except consider SLNBx, for that they go to ENT or general
surgery, then back to you or derm for skin exams
3. Old-New and New-New Drugs for Psoriasis
• Biologics- check for occult Hep B and C infection anf TB, also cocci,
histo and blasto serologies if from endemic areas
• Old-New
• TNF inhibitors- Etanercept, weakling of the group, will be generic in months…
biosimilar approval, should help costs
• I use adalimumab first.. Biosimilar in about a year… easy to use- one shot every other
week
• Really good long term safety record- I see patients every 1-2 years to see how
there doing and give them refills, recheck above tests and get LFT’s and CBC
and review signs of systemic infection
3. Old-New and New-New Drugs for Psoriasis
• New-New drugs
• Biologics- Many or most will not be approved by insurance without trial of
adalimumab first
• Ustekinumab next oldest, about 7 years old… I use this first line as dosing is easier
• Same baseline testing
• Others ixekinumab, secukinumab and others… very effective good safety profile so far
• Using these second or third line… because their newer and insurance won’t usually cover first
• May become first line in a few years
• FYI: Apremilast- PO QD dosing, gives about 60% improvement, that may be
enough
• No known side effects except weight loss, about 5% at one year
2. Mohs AUC
• Skip it… just know there are appropriate use criteria (AUC) and you
can google them… most BCC can be treated with ED&C or excision
1. Management of spectrum of cutaneous
squamous cell carcinoma (SCC)
• Actinic keratosis (AK)- Lag time of 30-40 years to develop
• Damage first 40 years never goes away
• Educate on sun precautions
• First 40 years of damage comes out worse at age 80 vs. age 60
• Age 90, watch out!
• If they have a few AK at age 60, untreated by age 80, many and some SCC
• By age 90 w/o treatment high risk of metastatic SCC
• Pt specific risk for metastatic SCC of skin: Age >80, male, CLL, immune
deficiency, more then 8 previous SCC
• Tumor specific risk: Pseudo-adenoid histology, invasion to fat or muscle,
greater then 1 cm diameter
AK
• No good treatment
• Cryo- treat a lot, best for thicker
• Fluorouracil- Poor response of scalp, non-compliance, recurrence after few
years, resistance after a few treatments, danger of self treatment and false
sense of security (with all pt administered rx)
• 2 weeks BID face and ears and neck
• 4 weeks BID scalp and upper limbs
• Immiquimod- Very good rx for facial AK, requires 5 weeks rx
• Ingenol mebutate- 2-3 days, price prohibitive o/w good
• Photodynamic therapy- administered in office- field rx using aminolevulonic
acid and “blue light”
• They always seem to have AK, see previous slide
AK Grading
• Diffuse vs. Focal
• Indication for field rx or cryo
• Diffuse- concept of field cancerization
• Grade 1,2 or 3, has to do with thickness and size