Clinical Insights from Day 1 of the Elevate-Derm PA-NP East Conference in Boston, Massachusetts

Central Centrifugal Cicatricial Alopecia (Susan Taylor, MD)

• ● Occult vertex breakage may be a presenting and early sign of central centrifugal cicatricial alopecia.
  
• ● Subtypes of central centrifugal cicatricial alopecia include: classic, occipital/posterior vertex,frontal, patchy, temporal, and decreased hair density.
  
• ● A peripilar gray/white halo is a specific and sensitive dermatoscopic sign for diagnosing central centrifugal cicatricial alopecia.
  
• ● Consider using the Olsen scale to track the progression of central centrifugal cicatricial alopecia.
  
• ● Hair care practices are not causative of central centrifugal cicatricial alopecia and treatment
  recommendations based solely on hairstyle modifications are insufficient.
  

Vitiligo in Skin of Color (Susan Taylor, MD)

• ● It is important to know the signs of clinical activity in vitiligo; confetti lesions, trichrome lesions and koeber phenomenon.
  
• ● In patients with vitiligo, it is important to perform a thorough review of autoimmune comorbidities.
  
• ● For patients with a high body surface area of vitiligo (vitiligo universalis), you can consider
  depigmentation with monobenzone. Depigmentation treatment is not reversible.
  
• ● Use a Wood's lamp as a diagnostic tool for vitiligo.
  
• ● Use side lighting to see if hair has depigmented.
  
• ● For rapidly progressing vitiligo, treat with dexamethasone 2.5 - 4 mg/day two days per week
  

Challenging Inflammatory Cases (Peter Lio, MD)

• ● An escalating flare pattern in an atopic dermatitis patient is a red flag.
  
• ● Improving the skin barrier in atopic dermatitis patients can help prevent other comorbidities.
  
• ● Atopic Dermatitis Control Tool is a six question survey that is easily scored from 1-7. It is a
  validated and useful patient self-assessment tool. Can do it on an app.

Putting Skincare Products Under the Microscope (Chris Bunick, MD)

• ● Exposure to Benzene is associated with an increased risk of leukemia.
  
• ● Benzene is used as a solvent in chemical and pharmacological production.
  
• ● Benzoyl peroxide breaks down into benzene. This process is expedited by heat exposure.
  
• ● A safe amount of exposure to benzene should be zero.

An Integrative Approach to AD: A New Toolbar (Peter Lio, MD)

• ● Daily massage in children with atopic dermatitis can decrease anxiety, redness, scaling, lichenification, excoriations and pruritus. Massage with sunflower seed oil or coconut oil.
  
• ● Findings suggest that mindfulness and self-compassion training is an effective treatment option for adults with atopic dermatitis.
  
• ● Coconut oil, applied twice daily for four weeks, can decrease staphylococcus colonization by 95% in patients with atopic dermatitis.
  
• ● L-histidine supplementation may increase filaggrin formation and improve skin barrier function.
  
• ● L-Histidine taken orally (powder) daily for 4 weeks can decrease atopic dermatitis disease severity.
  
• ● Accupressure on certain pressure points can be effective in decreasing itch and disease severity of atopic dermatitis. It also has no side effects and is free!

Review of the Molecular Differentiation of Dermatologic Therapeutics (Chris Bunick, MD)

• ● Sarecycline is a narrow-spectrum, third generation tetracycline antibiotic effective for facial and truncal acne and does not affect the intestinal flora. And does not carry same risk for bacterial resistance as other tetracycline antibiotics
  
• ● An important property of the tetracycline class of antibiotics are it's anti-inflammatory properties.
  
• ● Interleukin 13 drives barrier defects, inflammation, itch, and microbiome dysbiosis in skin.
  
• ● Topical roflumilast is stabilized in 3 key areas on the phosphodiesterase-4 molecule, increasing
  efficacy. It is now approved for atopic dermatitis in addition to psoriasis and seborrheic dermatitis.
  
• ● Weight gain can be seen with janus kinase 2 inhibitors because it can block postprandial
  signaling.

Atopic Dermatitis in 2024: Panel (Chris Bunick, MD, Peter Lio, MD)

• ● The shingles vaccine can be recommended in patients 18 years or older who are being considered for treatment with a janus kinase inhibitor in order to decrease the chance of zoster events.
  
• ● The mechanism of the memory component of atopic dermatitis is thought to be important in the development of future treatments focused on disease remission.
  
• ● If facial dermatitis develops while taking Dupilumab, consider seborrheic dermatitis, contact dermatitis, and topical steroid withdrawal.

Interesting Cases/Lessons Learned in Managing Immunobullous Disorders (Brittney Schultz, MD)

• ● Immune checkpoint inhibitors can cause cutaneous eruptions such as bullous pemphigoid which has a more delayed on set (approximately 14 weeks).
  
• ● Rituximab is FDA-approved first line therapy for pemphigus vulgaris.
  
• ● There are increased rates of psoriasis in patients with pemphigus.
  
• ● Screen all patients with pemphigoid for mucosal involvement as they require more aggressive
  treatment.
  
• ● A new blistering eruption should be evaluated in-office to rule out viral etiology prior to initiating
  therapy.
  
• ● Hepatitis B virus reactivation can occur in patients on rituximab so it is imperative to check triple
  serologies.

Immunofluorescence/Immunobullous work-up Tips & Tricks (Brittney Schultz, MD)

• ● Direct immunofluorescence detects in vivo bound immunoglobulin G using the patient's skin. Indirect immunofluorescence detects circulating immunoglobulin G using the patient's serum.
  
• ● Immunofluorescent dermal salt split Laminin 332 is associated with malignancy in mucous membrane pemphigoid, typically adenocarcinoma. This warrants further workup.
  
• ● Direct immunoflourescent biopsy should be done perilesionally for blistering diseases. The biopsy should be taken 0.5 cm away from the lesion unless ruling out dermatitis herpetiformis, which should be biopsied 1 cm away.