Elevate-Derm West Conference 2024 Clinical Insights Day 1

Day 1: Thursday, November 7, 2024

Pathology Pearls and Pitfalls for the Experienced APP: Whitney High, MD

Provide information about biopsies to the dermatopathologist in “3D”: Description (or what was Done), Diameter (size or extend), and Diagnosis.

Malignant status in pathology is derived from behavior and architecture.

Biopsies are getting smaller (thinner), which can affect diagnosis by the dermatopathologist, make sure when doing a biopsy that biopsy is deep enough for proper diagnosis.

Mycosis Fungoides diagnosis requires clinicopathologic correlation, no single test establishes a diagnosis of Mycosis Fungoides.

For a suspected diagnosis of bullous pemphigoid, perform a shave biopsy of the entire intact blister in order to make examination and diagnosis easier for the dermatopathologist.

Cutaneous Oncology: Nonmelanoma Skin Cancer: Maya Thosani, MD

Electrodesiccation and curettage (ED/C) should only be used to treat basal cell carcinomas with smaller, well-defined lesions on the trunk or extremities without much hair. Skin with a higher density of folliculosebaceous units (head and neck) has a higher risk of recurrence after ED/C.

Often squamous cell carcinoma on the penis or vulva will look like a seborrheic keratosis.

Eruptive Keratoacanthomas result in progressive Keratoacanthoma formation occurring suddenly or after trauma. Do not operate because of the risk of koebnerization. Consider treatment with oral retinoids, intralesional treatment (5-Fluorouracil, methotrexate, or bleomycin), photodynamic therapy or topical immunomodulator/chemotherapy creams.

There are two distinct causative paths of Merkel Cell Carcinoma: polyomavirus and UV-induced.

The only curative approach to Cutaneous T-cell lymphoma is stem cell transplantation.

Panel: Challenging Nonmelanoma Skin Cancer Management: Whitney High, MD and Maya Thosani, MD

Hedgehog inhibitors have the following side effects: dysgeusia, alopecia, muscle spasms, and fatigue.

The appearance of new cutaneous superficial basal cell carcinomas can be seen during successful Nivolumab treatment of refractory metastatic disease.

Always palpate for lymph nodes or in transit metastasis in patients with a history of aggressive squamous cell carcinomas (poorly and moderately differentiated).

When a minimally inflammatory rash such as Cutaneous T-Cell Lymphoma comes up-you must at least consider doing two shave biopsies and a punch biopsy.

Pigmented Lesion Pearls from the Experts: Mark Gimbel, MD, and Whitney High, MD

In dermatopathology, loss of P16 expression in a melanoma lesion is associated with a poorer prognosis.

According to the AJCC melanoma staging system, any satellites upstage a patient to stage III disease, regardless of sentinel lymph node status.

Genetic testing for melanomas is based on threshold values and is not definitive for determining patient outcomes.

Melanoma: Updates, Genomics, and Molecular Profiling: Mark Gimbel, MD

Adhesive pigmented lesion assay is used to assess the genomics of a lesion to determine the risk of dysplasia/malignancy.

The gold standard prognostic tool for melanoma is AJCC staging. It provides guidelines for treatment.

For melanoma, there are four molecular prognostic tests available or in production: 11-GEP test (MelaGenix & Immunoprint), 8-Gene CP-GEP (Merlin), 31-GEP (Decision-Dx Melanoma), and Circulating Tumor cells ctDNA (Signaterra).

Currently, there is insufficient evidence to support the incorporation of current GEP tests into melanoma care. The use of gene expression profiling tests according to specific AJCC-8 melanoma stages (before or after sentinel lymph node biopsy) requires further prospective investigation in large, contemporary datasets of unselected patients.

For results of the melanoma gene expression profiling test, if there is less than 5% risk of recurrence and less than a millimeter depth of the melanoma, it is okay to discharge back to dermatology.

Panel: Subungual Tumor Panel: Enter the Matrix of Possibilities: Mark Gimbel, MD and Whitney High, MD

The most common causes of melanonychia, in order of occurrence, are subungual hemorrhage, matrix nevus, trauma, lentigo, race, and melanoma.

The pigment of a subungual lentigo will not be present in the cuticle.

Use the “ABCDEF” rule when considering a subungual biopsy to rule out melanoma: A-Age, Afro-americans, native Americans, Asians, B-nail band, C-Change, D-pigment involved on digit, E-extension (Hutchinson’s sign), and F-family (personal or family history of dysplastic nevi or melanoma).

Subungual hematoma does not rule out melanoma. Make sure to follow up with these patients to see if the subungual hematoma is growing out.

The majority of nail melanomas are in the nail matrix, so it is necessary to biopsy the nail matrix when taking a subungual biopsy.

Diet in HS: Jennifer Hsiao, MD

Excess zinc supplementation may lead to copper deficiency. Persons using zinc for greater than 2 months should also take copper supplements in a 10:1 ratio of zinc to copper.

In Hidradenitis suppurativa, the following micronutrients are considered: zinc, vitamin D, and vitamin B12.

A study suggested that eliminating brewer’s yeast can improve the symptoms of hidradenitis suppurativa.

Hidradenitis suppurativa patients who strictly adhered to the Mediterranean diet showed lower severity of hidradenitis.

AI in Dermatology: Eileen Cheever, PA-C

Machine learning is when a machine is trained to make predictions or decisions based on data previously seen.

The delay between the discovery and implantation of technology is astonishing-with medical innovations taking an average of 17 years to become standard practice.

An artificial intelligence system uses wide-field images to assist clinicians in detecting suspicious pigmented lesions or “ugly ducklings."

Proofread and review all content produced by artificial intelligence.

Elevate Your Expertise: A Review of Poster Presentations from Elevate-Derm West Conference 2024: Eileen Cheever, PA-C

A phase 3 study of the efficacy and safety of Delgocitinib cream, applied twice daily 20mg/g for 16 weeks, showed improvements in the Dermatology Life Quality Index (DLQI) in patients with moderate to severe hand eczema.

In a real-world effectiveness study of Tralokinumab in adults who had atopic dermatitis with hand and foot involvement, treatment with the medication for 9 months cleared hand and foot dermatitis in more than 50% of patients.

PDCA-Derm scale is a tool used for detecting and assessing post-inflammatory skin discoloration and dyschromia.

HS: Unroofing the Possibilities: Jennifer Hsiao, MD

Recurrent abscesses in the axillae, groin, perineum, buttocks, and infra/inter mammary folds are hidradenitis suppurativa until proven otherwise.

Patients with hidradenitis suppurativa should have routine screenings of anemia, arthritis/joint pain, depression/anxiety, diabetes mellitus, hypertension, inflammatory bowel disease, polycystic ovarian syndrome, and tobacco/substance use by their primary care provider due to its association with these conditions.

The mean delay in diagnosis of hidradenitis suppurativa is 10.2 years. Most patients visited a physician at least 5 times prior to receiving a diagnosis.

A punch incision and drainage is a good treatment option for draining an abscess due to hidradenitis suppurativa. Use a 4-8mm punch, and do not pack the wound.

Biologic treatments with the most evidence for successful treatment of hidradenitis suppurativa are Adalimumab (FDA approved), Secukinumab (FDA-approved), Bimekizumab (FDA-approved for PsOI), and Infliximab.