Transition de Otros a Dupi

Journal Scan / Commentary · October 29, 2020

Transitioning From Systemic Immunosuppressants to Dupilumab

Journal of the European Academy of Dermatology and Venereology: JEADV

TAKE-HOME MESSAGE

• The authors propose a practical treatment approach for transitioning patients with severe AD from immunosuppressants to dupilumab based on their experience with such patients (n = 88).

• In summary, patients are started on dupilumab and continued on their current regimen of immunosuppressant for 8 weeks. If disease is controlled, after 8 weeks, immunosuppressants other than cyclosporine (ie, azathioprine, mycophenolate, methotrexate, etc.) can be tapered by 50% every 4 weeks, with the earliest discontinuation after 12 weeks of dupilumab therapy. Cyclosporine may be reduced by 25% every 2 weeks with earliest discontinuation at 14 weeks of dupilumab therapy in order to prevent a rebound phenomenon. Topical treatments should also be optimized.

– Margaret Hammond, MD

Abstract

Atopic dermatitis (AD) is a complex and heterogeneous chronic inflammatory skin disease. A subset of patients requires systemic immunosuppressants including cyclosporine A (CsA), azathioprine (AZA), mycophenolate mofetil (MMF)/ mycophenolic acid (MPA) and methotrexate (MTX). Dupilumab is the first biologic for treatment of AD, mostly started in patients with insufficient effectiveness or side effects of systemic immunosuppressants. In daily practice, approximately 65% of patients are still using systemic immunosuppressants when starting dupilumab. Although a significant reduction in itch can be present by week 2, clinically relevant AD improvement continues until at least 8–12 weeks of dupilumab treatment. Additionally, abrupt discontinuation of systemic immunosuppressants is unpreferable due to a possible rebound phenomenon. We found that tapering the immunosuppressants after the start of dupilumab results in a seamless transition between therapies. In our patients (n = 88), we did not find side effects resulting from this combination treatment.

Journal of the European Academy of Dermatology and Venereology: JEADV

An Approach for the Transition From Systemic Immunosuppressants to Dupilumab

J Eur Acad Dermatol Venereol 2020 Sep 13;[EPub Ahead of Print], LEM de Wijs, JP Thyssen, C Vestergaard, HB Thio, ACM Kunkeler, T Biedermann, DJ Hijnen 

Vendajes de todos colores...

Journal Scan / Commentary · October 29, 2020

Bandages for Children With Skin of Color

Pediatric Dermatology

TAKE-HOME MESSAGE

• Many factors contribute to health care disparities among patients with skin of color. One such disparity that the author draws attention to is the fact that most bandages, including those available in most dermatology offices, are specifically designed for patients with lighter skin types. This may cause feelings of isolation and exclusion among patients, particularly children, with skin of color visiting dermatology offices.

• This article provides examples of several suppliers of bandages with various skin tones. Although a simple change, this consideration may strengthen inclusion and acceptance of all patients visiting dermatology offices.

– Margaret Hammond, MD

Written by

 

 

Ashish C. Bhatia MD, FAAD 

Written by

 

 

Eliot N. Mostow MD, MPH 

Written by

 

 

RobertT. Brodell MD, FAAD

Systemic racism medicine takes many forms. This is a beautifully written editorial that relates to a simple measure that all physicians can take, especially dermatologists who are regularly creating wounds from biopsies or skin cancer treatment. We applaud the author, along with the pediatric dermatology editorial board, for publishing this piece. Making our patients more comfortable "in their skin" is a core component of what we do, and we ought to adopt this simple suggestion to consider dressings that match skin tone.

Thanks to Dr. Maggie Hammond for suggesting this article for inclusion, recognizing this as a topic for an editorial rather than research per se.

Abstract

The act of healing is a uniquely humanizing experience ubiquitously symbolized by the application of a bandage, an action that occurs daily in dermatology and pediatric clinics. The beige bandages we use in clinics are merely a visible symbol and reinforcement of what is considered standard and what is a deviation from the norm. One hundred years ago, Johnson & Johnson was a pioneer in the field when they invented the adhesive bandage. One hundred years ago, they set an industry standard by creating, exporting, and upholding a normative standard for practically all adhesive bandages in medicine, including birth control and nicotine patches to nasal strips. It took one hundred years after its inception and with over 100 billion Band-Aids produced with cartoons and superheroes, and in countless forms, for the inventors of bandages to offer a multitude of skin tones. Can we as healers stick with them? Or, can we implore ourselves to decolonize our clinics with a seemingly insignificant yet powerful symbolic gesture that lets our patients know that they are seen and not deviations from the norm? The conversation of diversity and inclusion in health and healing and institutional racism is obviously much deeper and profound than adhesive bandages. However, we can choose to acknowledge and celebrate diversity and inclusion in our practices as much as we can because it is significant to all of our patients, children, and adults alike.

Pediatric Dermatology

A Plea for Making Brown Bandages Stick

Pediatr Dermatol 2020 Oct 17;[EPub Ahead of Print], LO Oyesiku 

Contactantes más frecuentes en Productos cosméticos

Journal Scan / Research · October 28, 2020

Contact Dermatitis to Personal Care Products in Men and Women

Journal of the American Academy of Dermatology

TAKE-HOME MESSAGE

• This retrospective cross-sectional analysis of the North American Contact Dermatitis Group database demonstrates an increased proportion of personal care product (PCP)-related dermatitis from 16.9% and 21.9% of patch tests in men and women, respectively, in 1996–1998 to 35.1% and 49.4% of patch tests in men and women, respectively, in 2015–2016 . Over the two decades of study, rates of PCP-related dermatitis increased by over 2.7 fold. The distribution of dermatitis in men was more likely to include the extremities and trunk versus women, in whom scalp, face, and neck dermatitis was more likely. Men were approximately twice as likely to have allergens related to soaps than women, who were more likely to have a hair care product-associated allergen.

• With increasing marketing of PCPs "for men", rates of dermatitis secondary to PCPs have increased. Men and women differ in the types of products in which allergens are encountered and the distribution of dermatitis.

– Margaret Hammond, MD

Written by

 

 

Christen Maria Mowad MD

Personal care products (PCP) are well-known causes of both allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD). Historically, women have had PCP-related dermatitis at a higher prevalence than men, but this study demonstrates that not only is PCP-related dermatitis on the rise, it is also increasingly being seen in men as well. In this study, the NACDG evaluated men and women and assessed variations between them. They found that in comparison with women who had PCP-related dermatitis, men were older and more commonly had trunk and extremity involvement. They were also more likely to have soaps as a source of the dermatitis. This vehicle for the allergen correlates with the more common distribution found in men on the trunk and extremities. Women, on the other hand, were twice as likely to have hair care products as allergens, and this correlates with the more common exposure pattern seen in women on the head and neck. The most common PCP-related allergens were the same for both sexes. These included primarily preservatives, fragrances, and hair dye. Methylisothiazolinone was the most common allergen identified. This is a well-known allergen in PCP and is not found in the FDA-approved screening series. Fragrance mix and balsam of Peru were also on the list as were quaternium-15 and paraphenylenediamine. The authors cite that there is an increase in PCPs that are specifically being marketed "for men." They also comment on past studies that demonstrate that men use half as many PCPs daily with almost half as many ingredient exposures when compared with women; however, this seems to be changing. Overall, PCP-related dermatitis was found in 28.8% of men and 39.5% of women, and this was an increase from past studies. Though the exact cause for the increase in frequency of PCP-related dermatitis is unknown, it may be attributed to several factors, including increased product usage, the use of more ingredients that result in allergy, or increases in patch testing. The study demonstrates that PCP allergy is increasingly being seen in both men and women. This reminds us to keep patch testing on our list of tools to utilize when assessing both women and men with dermatitis. Inquiring about PCPs is an important first step to making the diagnosis, and testing to these products is necessary in order to identify and avoid allergens so as to eliminate the resultant dermatitis.

Abstract:

BACKGROUND

Personal care products(PCPs) are commonly responsible for allergic(ACD) and irritant contact dermatitis(ICD). PCP use was historically associated with women but increasingly, male-targeted PCPs are being marketed.

OBJECTIVE

To characterize and compare males and females with PCP-related contact dermatitis(MPCP, FPCP).

METHODS

Retrospective cross-sectional analysis of North American Contact Dermatitis Group(NACDG) data (1996-2016).

RESULTS

4680/16,233 males (28.8%) and 12,730/32,222 (39.5%) females had a PCP identified as a source of ICD or a positive patch test reaction. The proportion of PCP-related dermatitis in both sexes significantly increased (>2.7 fold) over the decade of study. As compared to FPCP, a larger proportion of MPCP were older and/or had trunk/extremity dermatitis(p<0.0001). MPCP were twice as likely to have soaps as a source while FPCP were twice as likely to have hair care products(p values<0.001). The most common PCP-related NACDG allergens for both sexes were methylisothiazolinone(MI) (MPCP:28.8%, FPCP:21.5%), fragrance mix I (22.3%, 20.1%), balsam of Peru (18.5%, 14.1%), quaternium-15 (16.1%, 12.3%), and paraphenylenediamine (11.5%, 11.1%).

LIMITATIONS

Patient population referred for suspected contact dermatitis.

CONCLUSIONS

PCP-related dermatitis is increasing. Sites of involvement and relevant PCP sources are distinct between sexes. Male and female variation in exposure history may explain differences in reactivity to some allergen groups.

Journal of the American Academy of Dermatology

Contact Dermatitis to Personal Care Products is Increasing (but Different!) in Males and Females: North American Contact Dermatitis Group (NACDG) Data, 1996–2016

J Am Acad Dermatol 2020 Oct 08;[EPub Ahead of Print], EM Warshaw, JP Schlarbaum, JI Silverberg, JG DeKoven, AF Fransway, JS Taylor, HI Maibach, JF Fowler, AR Atwater, MJ Reeder, KA Zug, DV Belsito, D Sasseville, VA DeLeo, MD Pratt 

Peroxido de hidrogeno... agua oxigenada para verrugas

Published in Dermatology

Journal Scan / Research · October 20, 2020

Hydrogen Peroxide Topical Solution for Common Warts

TAKE-HOME MESSAGE

• In this clinical trial, 157 patients (age >8 years) with 1 to 6 warts measuring 3 to 8 mm were treated with twice-weekly application of hydrogen peroxide 45% (HP45, n=79) or vehicle (n=78) for 8 weeks. Nearly one-quarter of patients experienced clearance of target wart by 8 weeks (vs 2.6% with vehicle), and at week 20 follow-up, clearance was seen in 37.3% with HP45 (vs 11.8% with placebo), indicating that there may be a continued response after stopping treatment at 8 weeks. There were 76 treatment-emergent adverse events in the HP45 group, all of which were mild or moderate, and none led to treatment discontinuation.

• These data support the efficacy and safety of an 8-week biweekly application of hydrogen peroxide 45% solution for treatment of common warts.

– Caroline K. Crabtree, MD

Abstract

BACKGROUND

No FDA-approved prescription therapies are available for common warts.

OBJECTIVE

We evaluated a proprietary hydrogen peroxide topical solution, 45% (w/w) (HP45) for treatment of common warts.

METHODS

In the phase 2 randomized, double-blind, vehicle-controlled WART-203 trial (NCT03278028), eligible patients aged ≥8 years had 1–6 warts (1 target wart) on the trunk or extremities with a Physician's Wart Assessment™ (PWA) grade ≥2 (range, 0 [clear] to 3 [wart 3–8 mm in diameter or length]). Patients self-administered HP45 or vehicle twice weekly for 8 weeks and were evaluated through 12 weeks posttreatment (week 20). Efficacy assessments included mean change in target wart PWA grade from baseline at week 8 (primary endpoint) and proportions of patients with target wart clearance. Safety assessments included treatment-emergent adverse events (TEAEs) and local skin reactions (LSRs).

RESULTS

A total of 157 patients completed 8 weeks of treatment (HP45, n=79; vehicle, n=78); 151 patients completed the 20-week posttreatment evaluation (HP45, n=75; vehicle, n=76). A significantly greater reduction in mean target wart PWA grade from baseline at week 8 was achieved with HP45 (−0.87) vs vehicle (−0.17; P<0.0001) and maintained at week 20 (−1.00 vs −0.39; P=0.0004). The proportion of patients with target wart clearance at week 8 was significantly greater with HP45 (25.3%) vs vehicle (2.6%; P<0.0001) and remained significantly greater at week 20 (37.3% vs 11.8%; P=0.0002). Forty-seven patients reported 76 TEAEs; most were mild or moderate in severity. Most LSRs were mild and resolved by week 20. In pediatric patients (HP45, n=13; vehicle, n=6), greater reductions in mean target wart PWA grade from baseline were observed with HP45 vs vehicle at weeks 8 (−1.0 vs 0) and 20 (−1.2 vs −0.5).

CONCLUSION

These findings support the efficacy and safety of HP45 for the treatment of common warts in patients ≥8 years of age. J Drugs Dermatol. 2020;19(10):969-976. doi:10.36849/JDD.2020.5054.

Journal of Drugs in Dermatology

Hydrogen Peroxide Topical Solution, 45% for Common Warts: Phase 2 Efficacy and Safety Trial Results

J Drugs Dermatol 2020 Oct 01;19(10)969-976, SR Smith, SK Trying, KK Grande, J Schlessinger, MH Gold, SD Shanier 

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Dermatofibromas

Title:	Molecular basis of inherited dermatofibromas
Author:	Supsrisunjai, Chavalit
Awarding Body:	King's College London
Current Institution:	King's College London (University of London)
Date of Award:	2020
Availability of Full Text:	Access from EThOS: Immediate download. Please login to continue. Access from Institution: Link to institutional repository
Abstract:
Dermatofibromas are considered to be common benign fibrotic lumps in the skin, the aetiology of which is poorly understood. I identified two unrelated pedigrees in which there was autosomal dominant transmission of multiple dermatofibromas. Whole exome sequencing revealed a rare shared heterozygous missense variant in F13A1 gene encoding coagulation factor XIII subunit A, a transglutaminase involved in haemostasis, wound healing, tumour growth, and apoptosis. Coincidentally, FXIII-A is one of the key immunohistochemical markers for dermatofibromas. The variant (Lys679Met) has an allele frequency of 0.0002 and is predicted to be a damaging mutation (Polyphen-2 = 1; Mutation taster = 1; CADD = 25.5; DANN = 0.993). Recombinant human Lys679Met FXIII-A demonstrated reduced crosslinking activity in vitro. Of note, treatment of fibroblasts with Lys679Met FXIII-A led to enhanced adhesion, proliferation and type I collagen synthesis. Immunostaining revealed a close association between FXIII-A and α4β1 integrins, and treatment of fibroblasts with α4β1 inhibitors or mutation of the FXIII-A Isoleucine-Leucine-Aspartate-Threonine (ILDT) motif prevented Lys679Met FXIII-A-dependent proliferation and collagen synthesis. These data suggest that the Lys679Met mutation leads to a conformational change in the FXIII-A protein that enhances α4-integrin binding and provide insight into an unexpected role for FXIII-A in the pathobiology of familial dermatofibromas.

Recognition of Atopic Keratoconjunctivitis During Treatment With Dupilumab for Atopic Dermatitis

TAKE-HOME MESSAGE

• Dupilumab use may result in ophthalmic complications—commonly, simple reactive conjunctivitis and, rarely, atopic keratoconjunctivitis (AKC). In this papaer, 3 cases of AKC, a severe form of allergic ocular disease that can cause blindness, are reported, along with an ophthalmology-developed algorithm for screening patients before and after beginning dupilumab (Figure 2 in the article). Prior to starting dupilumab, screen patients by asking about a prior diagnosis of allergic conjunctivitis or whether prior use of steroid eye drops was required. Severe symptoms after starting dupilumab, such as new photophobia or decreased vision, should prompt urgent referral to ophthalmology and discontinuation of dupilumab until evaluation.

• Although most ocular side effects of dupilumab may be managed conservatively with lubricating eye drops, AKC is a severe inflammation of the entire ocular surface, which can lead to blindness, and it may be caused by dupilumab. Screening prior to starting dupilumab and recognizing danger signs afterward are critical for dermatologists.

– Margaret Hammond, MD

Written by

 

 

Jane Grant-Kels MD

Atopic dermatitis (AD) is extremely common as it is seen in approximately 7% of adults and 25% of children. Prior to the new targeted therapies, recalcitrant AD was extremely challenging to treat. Dupilumab has been found to not only be efficacious (as it is a monoclonal antibody that specifically targets IL-4 receptor alpha, resulting in the blocking of IL-4 and IL-13, the two key mediators of the TH2 pathway) but also shown to be relatively safe.1 Unfortunately, conjunctivitis, which is commonly seen in patients with AD, is a commonly reported adverse event in patients treated with dupilumab as well. Patients treated with this medication have a higher incidence of developing conjunctivitis (9%–22%) than those receiving placebo (2%–11%). What are the risk factors for patients developing this side effect?—severe atopic dermatitis and a self-reported history of conjunctivitis.2

This excellent collaborative research letter from the departments of dermatology and ophthalmology at the University of Iowa discusses the risk of developing severe atopic keratoconjunctivitis (AKC) with dupilumab versus "simple conjunctivitis." Severe AKC can result in significant inflammation of the cornea and conjunctiva, which can lead to blindness via "corneal neovascularization, infection, perforation, destruction of epithelial stem cells, and cicatricial malposition of the eyelids." Although their recommendations are based upon their experience with only a few patients, the authors' advice is entirely appropriate and should be followed so that we do not inadvertently improve a patient's AD but cause him severe ocular morbidity!

These authors recommend:

• Screening patients for a history of preexisting severe allergic conjunctivitis. Those with such a history should be evaluated by an ophthalmologist. If the patient has only a history of milder conjunctivitis, we should educate her to use preventive antihistamine and mast cell–stabilizer eye drop combinations, which are available over the counter.
• Once the patient is on dupilumab, she should be screened for ocular symptoms. Mild symptoms can be managed with artificial tears and antihistamine and mast cell–stabilizer eye drops. Patients with severe symptoms (including photophobia or decreased vision) should be immediately referred to ophthalmology, and their dupilumab should be held until this consultation.

References

1. Brunner PM, Guttman-Yassky E, Leung DYM. The immunology of atopic dermatitis and its reversibility with broad-spectrum and targeted therapies. J Allergy Clin Immunol. 2017;139(4):S65-S76. https://linkinghub.elsevier.com/retrieve/pii/S0091-6749(17)30205-1
2. Agnihotri G, Shi K, Lio PA. A clinician's guide to the recognition and management of dupilumab-associated conjunctivitis. Drug RD. 2019;19(4):311-318. https://link.springer.com/article/10.1007/s40268-019-00288-x

Abstract

Dupilumab, a monoclonal antibody that blocks Th2 cytokines,[1-4] is approved for the 3 treatment of cutaneous manifestations of atopic dermatitis (AD). Unfortunately, dupilumab use 4 can result in ophthalmic complications. In the inaugural phase III clinical trials, 14-19% of 5 patients reported dupilumab associated conjunctivitis but were not examined by an 6 ophthalmologist.[1, 4] Thus, it is possible that some of these patients could have experienced a 7 more severe form of ocular surface disease than simple reactive conjunctivitis. In this report, we 8 describe 3 patients who developed atopic keratoconjunctivitis (AKC), a severe inflammatory 9 condition affecting the cornea and conjunctiva, that results in more ocular morbidity than simple 10 conjunctivitis.[5] We also propose an algorithm that dermatologists may use to screen patients 11 for concerning ocular symptoms.

Journal of the American Academy of Dermatology

Recognition of Atopic Keratoconjunctivitis During Treatment With Dupilumab for Atopic Dermatitis

J Am Acad Dermatol 2020 Sep 18;[EPub Ahead of Print], J Cheng, L Jiang, NC Morrow, A Avdic, JA Fairley, JJ Ling, MA Greiner 

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Ketoconazole en acne

CAN TOPICAL KETOCONAZOLE TIP THE SCALES FOR ACNE VULGARIS?

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By Warren R. Heymann, MD
Oct. 21, 2020
Vol. 2, No. 42

"Now trending." How often have you seen that phrase when you go online? When it comes to trends in treating acne vulgaris (AV), despite the new addition of oral sarecycline and the release of topical minocycline foam, there is an impetus to move away from prolonged antibiotic therapy for managing acne. It has recently been suggested that spironolactone might have superior drug usage survival compared to oral antibiotics for the treatment of female patients with acne. (1)

AV is a cutaneous chronic inflammatory disorder with complex pathogenesis. Four key factors have roles in acne pathogenesis: hyperseborrhea and dysseborrhea, altered keratinization of the pilosebaceous duct, Cutibacterium acnes (C. acnes, formerly Proprionibacterium acnes, P. acnes) and inflammation. The main hormones responsible for the development of acne vulgaris include androgens, insulin, and insulin-like growth factor-1. (2) Available AV treatment modalities include: 

1. Topical medications: antibacterial (benzoyl peroxide, clindamycin, erythromycin), retinoids (tretinoin, adapalene, tazarotene), others (dapsone, azelaic acid); 

2. Oral agents: antibiotics (tetracyclines, macrolides, sulfamethoxazole trimethoprim), hormonal therapy (oral contraceptives, spironolactone); 

3. Isotretinoin; 

4. Procedural therapies (comedone extraction, chemical peels) (3); and 

5. Novel treatments (laser, photodynamic therapy). 

Focusing on hormonal therapy, Zaenglein asserts: "Combined oral contraceptive therapy and spironolactone are effective hormonal therapies for inflammatory acne in female patients and may be considered in patients who do not have a response to topical therapies alone." (4)

Spironolactone is well-tolerated, especially at lower doses. The most common adverse effects include menstrual irregularities (which is diminished with concomitant oral contraceptives), breast tenderness, breast enlargement, fatigue, dizziness, and headache. In young, healthy women, it is no longer necessary to monitor potassium levels. (3)

J Am Acad Dermatol 1998; 39 (2) Supplement 2; S34-37. 

Could a topical anti-androgen be effective in treating AV? Dermatologists have been using topical ketoconazole for years treating seborrheic dermatitis, psoriasis, and dermatophytosis. Ketoconazole inhibits the biosynthesis of fungal ergosterol and is capable of selectively inhibiting 17,20-desmolase and 17-alpha-hydroxylase at a dose of 400-600 mg/day. Ketoconazole can also inhibit the growth of P. acnes and decrease P. acnes lipase activity in a dose-dependent manner. Although oral ketoconazole has been reported to improve AV (5), because of hepatotoxicity and potential QT prolongation, the drug should not be utilized for this purpose.

Chaottawornsak et al evaluated the efficacy and safety of ketoconazole cream in mild adult female acne (AFA) by conducting a randomized, double-blind, placebo-controlled trial using ketoconazole 2% and placebo cream twice daily for 10 weeks. They assessed the improvement of clinical severity, measured by AFA score graded by investigators and participants, and the change of acne count. Forty-one participants enrolled in the study. The proportion of participants with acne improvement from baseline (42.9% vs 9.5%, P = 0.015) and the success rate (45.0% vs 14.3%, P = 0.043) in the ketoconazole group were significantly higher than that of the placebo group. The most common adverse events were dryness and itching. The percentage change of acne count decreased significantly compared with baseline but did not differ statistically between the two groups. Limitations of this study were its short duration in subjects with only mild AV. The authors concluded that ketoconazole monotherapy showed a plausible effect in improving AFA with an excellent safety profile. They suggested that ketoconazole be considered a viable therapeutic option for patients with AFA treatment. (6) 

Oral spironolactone is only prescribed for women with acne and the topical ketoconazole study was only performed in women. Currently, no prescription topical antiandrogen is available for AV. Clascoterone cream (CB-03-01, Cortexolone 17α propionate), a novel topical androgen receptor inhibitor is currently under investigation for AV. (7) I have never hesitated prescribing topical ketoconazole for men with seborrheic dermatitis; I see no need to withhold this treatment if it proves to be efficacious for acne in men or women. More studies are warranted for determining if topical ketoconazole is beneficial in men or women with moderate to severe AV. How ironic it would be if a good option for treating acne has been in front of our noses for years (while using it on the sides of the nose)!

Point to Remember: While data are preliminary, topical ketoconazole cream may prove to be a valuable topical agent for acne vulgaris based on its inhibition of C. acnes lipase and anti-androgenic activity. 

Our Experts' Viewpoints

Joshua Zeichner, MD
Assistant Professor, Department of Dermatology
Mount Sinai Hospital, New York City

Despite being the number one reason that patients visit dermatologists, effective and tolerable acne treatments remain an unmet need. The currently available armamentarium of drugs is effective in the majority of patients, yet tolerability of topical agents like benzoyl peroxide limits their use in those with sensitive skin. Topical ketoconazole has been used for decades to treat both superficial tinea infections as well as seborrheic dermatitis. Besides its antifungal properties, recent data demonstrating antimicrobial effects against P. acnes suggests that ketoconazole is a potential therapeutic option to treat acne. Given its excellent tolerability profile, ketoconazole may be considered an alternative therapy to patients intolerant of traditional topical acne treatments. We are lacking head-to-head studies comparing ketoconazole to the currently available options, but initial studies yielded promising results. Studies are currently underway evaluating the effect of ketoconazole on the microbiome, and more research is needed to assess any impact on the sebaceous gland itself. However, given its historic widespread use in treating seborrhea without the emergence of negative health effects, the use of topical ketoconazole in the treatment of acne is likely safe as well.

Dr. Zeichner had disclosed financial relationships with the following to the AAD at the time of publication:, AbbVie, Galderma Laboratories, L.P., Johnson & Johnson Consumer Products Company, La Roche-Posay Laboratorie Pharmaceutique, L'Oreal USA Inc., Pfizer Inc., Sanofi/Regeneron, Sun Pharmaceutical Industries Ltd., Unilever, and Valeant Pharmaceuticals International. Full disclosure information is available at coi.aad.org.

1. Barbieri JS, Choi J, James WD, Margolis DJ. Real world drug usage survival of spironolactone versus oral antibiotics for the management of female patients with acne. J Am Acad Dermatol 2019; 81: 848-851. 

2. Cong TX, Hao D, Wen X, Li XH, et al. From pathogenesis of acne vulgaris to anti-acne agents. Arch Dermatol Res 2019; 311: 337-349. 

3. Marson JW, Baldwin HE. An overview of acne therapy, part 2; Hormonal therapy and istotretinoin. Dermatol Clin 2019; 37: 195-203.

4. Zaenglein AL. Acne vulgaris. N Engl J Med 2018; 379:1343-1352 .

5. Unno M, Cho O, Sugita T. Inhibition of Propionibacterium acnes lipase activity by the antifungal agent ketoconazole. Microbiol Immunol 2017; 61: 42-44.

6. Chottawornsak N, Chongpison Y, Asawanonda P, Kumtornut C. Topical 2% ketoconazole cream monotherapy significantly improves adult female acne: A double-blind, randomized placebo-controlled trial. J Dermatol 2019; 46: 1184-1189.

7. Rosette C, Agan FJ, Mazetti A, Moro L, Geroloni M. Cortexolone 17α-propionate (Clascoteron) Is a Novel Androgen Receptor Antagonist That Inhibits Production of Lipids and Inflammatory Cytokines From Sebocytes In Vitro Drugs Dermatol 2019; 18: 412-418.

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All content found on Dermatology World Insights and Inquiries, including: text, images, video, audio, or other formats, were created for informational purposes only. The content represents the opinions of the authors and should not be interpreted as the official AAD position on any topic addressed. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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Secukinumab reduce ACE 2

Journal Scan / Research · October 19, 2020

Secukinumab and Expression of ACE2 in Affected Skin of Patients With Psoriasis

Journal of Allergy and Clinical Immunology

TAKE-HOME MESSAGE

• Angiotensin-converting enzyme 2 (ACE2) is the receptor used for entry by the SARS-CoV-2 virus. The authors analyzed mRNA expression of ACE2 in the serum and skin biopsies of psoriasis patients versus controls from the ObePso-S trial, which studied the effects of secukinumab on systemic inflammatory markers. At baseline, ACE2 levels were upregulated in affected psoriatic skin with IL-17 driven inflammation. With secukinumab inhibiting IL-17 inflammation, keratinocyte ACE2 levels decreased.

• It is not clear whether the response of keratinocytes to secukinumab is indicative of the response of other epithelial linings and whether these changes decrease SARS-CoV-2 entry. The study demonstrates the continually evolving body of knowledge on treating patients with psoriasis with biologics in the era of COVID-19.

– Margaret Hammond, MD

Abstract 

Secukinumab reduced the inflammation and the expression of ACE2, which encodes the SARS-CoV-2 receptor, in plaques of patients with psoriasis. Reductions in ACE2 expression with secukinumab significantly correlated with reductions in disease activity.

Journal of Allergy and Clinical Immunology

Secukinumab Lowers Expression of ACE2 in Affected Skin of Patients With Psoriasis

J. Allergy Clin. Immunol 2020 Sep 28;[EPub Ahead of Print], JG Krueger, DF Murrell, S Garcet, K Navrazhina, PC Lee, E Muscianisi, A Blauvelt

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Laser sin anestesia para PWS

Journal Scan / Research · October 13, 2020

Treatment Tolerance and Parental Perspective of Outpatient Pulsed-Dye Laser Treatment for Port-Wine Birthmark Without General Anesthesia in Infants and Toddlers

TAKE-HOME MESSAGE

• Infants undergoing treatment of port-wine birthmarks with in-office pulsed-dye laser (PDL) were given pain scores by their parents using the validated EVENDOL measure. Immediately after treatment, pain scores were nearly 9.1 but then resolved to preprocedure levels upon leaving the office (~0.9; P = .0001). Almost 95% of parents preferred their child being treated in an outpatient setting rather than an operating room, and nearly 76% preferred to be in the room with their child during treatment. Parents reported that their children could remember the laser treatment at a mean age of 12 months. Approximately 43% and 38% of parents said they were extremely satisfied or very satisfied with treatment, respectively.

• Although unable to assess the long-term psychological impact of painful laser treatments on infants, if any, this study suggests that in-office port-wine birthmark treatment by PDL without analgesia is well-tolerated, with rapid resolution of pain. Early and frequent treatment is optimal, however, as children start recalling the treatment at a mean age of 12 months.

– Margaret Hammond, MD

Written by

 

 

Sarah L. Chamlin MD

This group enrolled 47 infants with port-wine stains undergoing office pulsed-dye laser therapy. The investigators measured pain using validated infant pain scales. Of note, the pain was high immediately after treatment and normal by the time the infants left the office. The use of a metal corneal shield, age, and laser fluence did not impact pain scores.

Because of the possible neurodevelopmental effects of repeated general anesthesia, more practitioners are performing office laser treatments in young infants, and this study mirrors current experience. Infants seems to tolerate this procedure well and recover quickly with little pain immediately after procedure completion. Office laser can be repeated until the infants are older and are too difficult to restrain easily and safely, often by 12 to 18 months. Swaddling, oral sucrose, and immediate feeding after the procedure completion are excellent strategies to help control discomfort. In addition, nurses and staff who are adept at holding an infant still is of utmost importance.

Abstract

While there are robust data regarding the safety and efficacy of port-wine birthmark (PWB) treatment with pulsed dye laser (PDL) in early childhood,1,2 empiric data regarding pain, tolerability, and the parental perspective of in-office PDL treatment without general anesthesia are lacking. Understanding and quantifying these patient-centered outcomes and perspectives are critical to facilitate patient-clinician discussions and promote shared decision-making, especially given concerns of repeated general anesthesia's neurocognitive effects in young children.3

Journal of the American Academy of Dermatology

Assessment of Treatment Tolerance and Parental Perspective of Outpatient Pulsed-Dye Laser Treatment for Port-Wine Birthmark Without General Anesthesia in Infants and Toddlers

J Am Acad Dermatol 2020 Sep 30;[EPub Ahead of Print], H Feng, G Materne, S Ghalili, M Lederhandler, H Pomerantz, M Christman, LJ Bernstein, RG Geronemus 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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