Elevate-Derm West Conference 2024 Clinical Insights Day 3
- In:
Clinical Practice
Day 3: Saturday, November 9, 2024
Challenging Cases in Atopic Dermatitis and Pruritus: Jason Hawkes, MD, and James Song, MD
Patch testing should be considered for any atopic dermatitis patient who is not responding to dupilumab.
Excellent efficacy has been shown with dupilumab non-responders who were switched to an oral JAK inhibitor.
There is no compelling evidence to suggest a causal association between dupilumab and cutaneous T-cell lymphoma.
It is probably okay to patch-test patients on dupilumab, tralokinumab, and lebrikizumab. It is not okay to patch test patients on JAK-inhibitors.
JAK-inhibitors can be used as rescue therapy in dupilumab refractory severe atopic dermatitis.
Any patient with a chronic skin disease is at increased risk for cutaneous T-cell lymphoma.
Text Messages to a Pediatric Dermatologist: Lisa Swanson, MD
Aron regimen is a compounded product that is helpful for babies and toddlers with difficult to treat facial eczema. Aron regimen is compounded with 30 grams of betamethasone valerate 0.1, 24 grams of mupirocin cream, and 400 grams of vanicream or plastibase (makes a one pound tub). Prescribing the components separately and having the family mix it is not the same and not nearly as effective.
A good oral antibiotic to use in kids with perioral dermatitis is Amoxicillin 30mg/kg/day divided bid.
In pediatric patients with perioral dermatitis, pustules on the nose are likely due to demodicosis.
Patients with Gianotti Crosti present with monomorphic skin-colored-pink papules all over the cheeks, arms, and legs, which are often very remarkable on the ears.
Herpes simplex virus in a baby that is younger than three months old needs to be admitted into the hospital for IV acyclovir and be monitored for encephalitis, hepatitis, and pneumonitis.
In addition to topical and oral antibiotic treatment for impetigo, consider adding vinegar soaks for treatment as well. Mix one part vinegar with four parts water, moisten a paper towel in the mix and then drape over the affected area for 10-15 minutes 2-3 times a day.
Tinea capitis with kerion is essential to treat because it often leads to permanent alopecia.
An asymmetric facial rash on a child is fungus until proven otherwise.
Psoriasis Evolution: Where We’ve Been and What’s to Come: Jason Hawkes, MD
Fifty percent of plaque psoriasis patients have genital involvement.
Erythrodermic and pustular psoriasis flares are most commonly caused when patients are given oral steroids.
The JAK2 pathway has the broadest immune impact, plus hematopoiesis and hormone signaling. TYK2 mediates the narrowest range of cytokines.
You cannot provide expert care without the use of systemic or biologic medications for psoriasis.
Deucravacitinib is the first-in-class TYK2 inhibitor and has no black-box warning, lab requirements, or gastrointestinal issues associated. It does not require dose adjustments. After four years of safety data, adverse events were lower or the same compared to year one data.
An oral IL-23 receptor inhibitor is being studied for the treatment of psoriasis and is in phase three clinical trials with promising results.
Bimekizumab is an IL-17A/F inhibitor that has a nineteen percent incidence of candidiasis. The majority of these cases are mild and easily treated.
Generalized pustular psoriasis is driven by IL-36, treat these patients with spesolimab.
Dermatoscopy of Special Sites: Face: Ash Marghoob, MD
Always be cautious when receiving a pathology of a dysplastic nevus on the face; it is most likely an early melanoma.
When early melanoma forms on facial skin it will preferentially start in a hair follicle.
Dermatoscopic findings that are specific for malignant melanoma include annular granular patterns, isobars (circle within a circle), radial projections arising from follicular openings, angulated lines and polygons, blotches, and vessels.
When using dermoscopy, perifollicular linear projections have a specificity of 96 percent for the diagnosis of lentigo maligna on the face.
Suspicious palpable lesions on the face should always be biopsied rather than monitored.
Under polarized dermoscopy, actinic keratoses have prominent, large white follicles and rosettes.
If monitoring a flat, non-palpable lesion on the face, you must continually follow up for one year since lentigo malignas are slow to change.
Dermatoscopy of Special Sites: Palms and Soles: Ash Marghoob, MD
Wallace line is the boundary between the non-glabrous and glabrous skin of the hands and feet.
Eccrine glands on the hands and feet open up on the ridges of the skin, making them wider than the furrows.
When using dermoscopy, if you see pigment on the ridges in the skin on the palms or soles, be highly suspicious of melanoma. This may not be true for ethnic-pigmented macules.
The parallel ridge pattern is 99% predictive of melanoma.
Pigment in the furrows of the palms or soles is the hallmark sign of benign acral lesions.
The fibrillar pattern occurs in areas of chronic friction on the skin. The fibrillar pattern is atypical on the palms but more common on the feet.
If there is irregular diffuse pigmentation (blotches) over ridges and furrows, a biopsy is necessary because it is probably a melanoma.
Dermatoscopy of Special Sites: Nails: Ash Marghoob, MD
Blood isolated to the nail bed speaks against melanoma since there are no melanocytes in the nailbed with the exception of congenital nevus.
Features of onychopapilloma and early squamous cell carcinoma can look identical on dermoscopy.
Patients with multiple onychopapillomas may have a BAP1 gene mutation, so they need genetic testing.
If you see a pigmented band on the nail, measure the width of both the distal and proximal bands. If the measurements are not identical, you need to biopsy irrespective of dermoscopy.
If you see Hutchinson’s sign or micro Hutchinson’s sign, you need a biopsy of the matrix regardless of dermoscopy.
If a pigmented band has irregular spacing and thickness of the lines and/or disruption of parallelism, it must rule out melanoma.
Dermatoscopy of Special Sites: Mucous Membranes: Ash Marghoob, MD
Blue, gray, or white color on mucosal lesions are 100% sensitive and 64.3% specific for melanoma.
Melanoma on the mucosa will present as an asymmetric, disorganized lesion under dermoscopy and generally have 2 to 3 colors and two or more structures.
Baby Bumps: Understanding Dermatoses of Pregnancy: Jenny Murase, MD
There are five pregnancy dermatoses: atopic eruption of pregnancy, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, pemphigoid gestationis, and pustular psoriasis of pregnancy.
Elevated levels of estrogen in pregnancy cause a shift from TH1 to Th2, making Th2 more dominant, which can trigger atopic eruption of pregnancy.
“Soak and smear” method clears the vast majority of eczematous dermatitis if the patient is diligent. The patient should first take a 15-minute bath followed by applying a mix of 7.5 oz of sensitive skin cream with 2 oz of desoximetasone ointment.
Severe psoriasis in pregnant patients yields a 1.5 times higher risk of low birth weight.
Be cautious with the use of topical steroids in pregnant women in areas of rapidly expanding skin, such as the breasts.
Avoid antihistamines in the last month of pregnancy since it can have oxytocin-like effects, increased rates of retrolental fibroplasia in premature infants, and withdrawal symptoms in the infant.
Intrahepatic cholestasis of pregnancy causes itching in the third trimester with no primary lesions. The bile acids can cross the placenta and put the fetus at risk for prematurity, stillbirth and fetal distress. It is also a risk for bleeding complications.
Direct immunofluorescence is the gold standard for the diagnosis of pemphigoid gestationis.
Pediatric Lumps and Bumps: Lisa Swanson, MD
Consider topical Timolol 0.5% to treat a pyogenic granuloma in children. Make sure to follow up in one month to make sure it is getting better; if it has not improved, then biopsy.
Eclipse nevi on the scalp typically do not require biopsy.
When treating hemangiomas with propranolol, make sure to tell parents to give the medication with food since it can cause hypoglycemia.
In distinguishing a diagnosis of wart versus corn, apply pressure to the top of the lesion; if it hurts, then it is a corn/callus. If you squeeze the sides of the lesion and it hurts, then the lesion is a wart.
Eyelid hemangiomas are high-risk and need to be treated.
Nadolol has been shown to be more efficacious than propranolol in treating hemangiomas. If using Nadolol and the baby has not pooped in three days, stop the medication until the baby poops since the medication is excreted in poop.
Segmental hemangiomas can be associated with PHACES syndrome and need a workup (ophthalmology exam, MRI/MRA of head and neck, and echocardiogram) before starting propranolol.
A perineal hemangioma can be associated with PELVIS syndrome, and these patients need an MRI of the lumbar spine, abdomen, and pelvis.
A classic spitz nevus can be observed and followed with photos. Many spitz nevi in pediatric patients will eventually become involute and resolve themselves.