Clinical Insights from Day 2 of the Elevate-Derm PA-NP Conference in Boston, Massachusetts

Updates in Immunobullous Disorders (Brittney Schultz, MD)

• ● Pemphigus can be induced by drugs, vaccines, infections, nutrition, pregnancy, stress, and trauma.
  
• ● Pemphigus vulgaris is associated with autoimmune diseases; thyroid disease and myasthenia gravis.
  
• ● Patients with bullous pemphigoid are at two times increased risk of venous thromboembolism.
  
• ● Mucous membrane pemphigoid is challenging to diagnose so multiple biopsies are helpful. Consider direct immunofluorescence of normal buccal mucosa or skin even if there is no evidence of oral or cutaneous involvement.

Melanoma Updates 2024 (Rebecca Hartman, MD)

• ● The American Academy of Pediatrics recommends avoiding sunscreens with Oxybenzone in children since it may be an endocrine disruptor.
  
• ● Depth is the most important staging feature of melanoma, so try to obtain complete staging information when doing a biopsy.
  
• ● Genetic testing should be recommended to any patients with three or more primary invasive melanomas and/or pancreatic cancer among first- or second-degree relatives on the same side of the family.
  
• ● Total body photography is helpful for monitoring patients who are at high risk for melanoma or have a melanoma history.
  

When to Put Down the Scalpel: Non-Surgical Therapies for Skin Cancer (Rebecca Hartman, MD)

• ● 5-fluorouracil and Imiquimod are both topical treatments that are FDA approved for treatment of superficial basal cell carcinomas.
  
• ● It is reasonable to consider active surveillance in patients with limited life expectancy who
  can follow-up clinically and have small, asymptomatic, non-aggressive basal cell carcinomas in low risk locations.
  
• ● Think twice about using low-risk therapeutic approaches in the treatment of keratinocyte carcinomas in patients with large or aggressive tumors, patients who are organ transplant recipients, patients with chronic lymphocytic leukemia or small lymphocytic lymphoma, patients with HIV or patients on long term immunosuppressive therapy.
  
• ● 5-Flurouracil is toxic to dogs.
  
• ● For eruptive squamous atypia on legs, treatment with intralesional 5-fluoruracil resolved the majority of lesions with monotherapy. 33% of lesions required additional treatment.
  

Acne, Rosacea, Cosmeceuticals #1 (Josh Zeichner, MD)

• ● Cutibacterium acnes is part of the normal skin flora. Patients with acne may have an overactive host immune response to this bacteria.
  
• ● A diet rich in high glycemic index foods, skim cow's milk, vitamin B12 and whey protein may contribute to the development of acne.
  
• ● Simple acne treatment regimens have been shown to yield better results and patient adherence. Consider prescribing fixed dose combination creams when possible.
  
• ● Trifarotene is a fourth-generation retinoid that not only helps with acne clearance but also helps treat acne scarring.
  
• ● Applying a ceramide moisturizer prior to a prescription acne topical can help maximize acne treatment outcome.
  
• ● Isotretinoin should be prescribed twice daily. Isotretinoin drug exposure is more efficacious if taken twice a day than once a day dosing.
  

Cases from the Clinic! (Josh Zeichner, MD, Vaneeta Sheth, MD)

• ● Isotretinoin should be taken with a high-fat, high-calorie meal for optimal absorption. Per FDA guidelines, the meal should total 800-1000 calories with 50% of the calories being derived from fat.
  
• ● Routine potassium monitoring is typically unnecessary for healthy women on Spironolactone. However, you should check for hyperkalemia in older patients, patients with renal, cardiacor liver disease, and patients on a higher dosage of spironolactone (200mg/day).
  
• ● If a patient on isotretinoin is not improving as expected, consider compliance, absorption, and hormonal irregularities.
  
• ● Take a biopsy to rule out deep fungal infections or malignancy prior to initiating immunosuppressants for treatment of pyoderma gangrenosum.
  
• ● Congenital adrenal hyperplasia is a rare cause of abrupt,recalcitrant acne.
  
• ● Patients on testosterone supplements may benefit from low-dose, long-term isotretinoin.
  

Acne, Rosacea, Cosmeceuticals #2 (Josh Zeichner MD)

• ● Cosmeceuticals are not subject to pre-market FDA approval.
  
• ● Cosmetics are products that beautify or cleanse the skin while topical drugs affect the structure or function of the skin.
  
• ● Daily sunscreen use alone improves clinical parameters of skin aging.
  
• ● Petrolatum is different from petroleum (crude oil). Crude oil contains impurities and can be carcinogenic. Pure white petrolatum is safe for use on the skin.
  
• ● Cleansing with water alone removes sixty five percent of dirt and oils from the skin.
  

Cosmeceutical Updates in Skin of Color (Vaneeta Sheth, MD)

• ● There is no difference in the number melanocytes in varying skin tones. Melanosomes are more numerous and larger in skin tones with higher melanin content.
  
• ● Azelaic acid has anti-tyrosinase activity and antioxidant activity and can be effective in the treatment of melasma and post inflammatory hyperpigmentation.
  
• ● Bakuchiol is a plant-derived retinol analog that may help pigmentary disorders through inhibition of melanogenesis.
  
• ● Skin of color patients, being seen for acne, may be more concerned about the post inflammatory hyperpigmentation of their skin rather than the active acne lesions.
  
• ● Visible light induces pigment darkening in Fitzpatrick skin types IV-VI that is more long-lasting and intense than that induced by UVA1. Tinted sunscreens containing iron oxide protect against visible light and ultraviolet light.
  
• ● Silymarin, derived from milk thistle, is an antioxidant and comedolytic available over-the-counter. It has been shown to decrease acne lesion counts, sebum secretion and pigmentation.