Superheroes were the theme of the Dermatology Education Foundation’s DEF Essential Resource Meeting 2024 (DERM2024) NP/PA CME Conference in Las Vegas, Nevada, from July 24-28. “Dermatology heroes aren’t born … they’re trained,” a sign at the entryway to the conference proclaimed. 

Practical Dermatology® Editorial Board members Adam Friedman, MD, FAAD; Brad P. Glick, DO, MPH, FAAD; and Susan C. Taylor, MD, FAAD, were among the faculty for the meeting. For further coverage of DERM2024, visit PracticalDermatology.com. 

WHEN IT’S NOT ECZEMA 

Dr. Friedman, MD, FAAD, presented “When It’s Not Eczema,” noting that eczema is a clinical diagnosis, so therefore looking/ assessing for all essential, important and common features are central to making the right diagnosis. Under-appreciated clues include pityriasis alba, keratosis pilaris, ichthyosis vulgaris, hyperlinear palms, perifollicular changes such as follicular accentuation, ocular/periorbital changes, and perioral/periauricular lesions. 

“There is an incredible spectrum of clinical presentations,” Dr. Friedman said. “One common feature is that plaques are usually poorly defined/demarcated, whereas psoriasis or papulosquamous dermatoses are well demarcated.” 

Dr. Friedman said it was his view that it is not atopic dermatitis (AD) unless there is pruritus. “Things in the eczematous spectrum absolutely feel good to scratch, which I believe is unique and distinguishing about this category” he said. If the distribution of the rash is atypical and/or conventional therapy does not appear effective despite patient adherence, he added, an alternative diagnosis should be considered. 

Cutaneous T-cell lymphoma (CTCL), for example, is often missed and misdiagnosed as eczema. It can be pruritic (thank you, IL-31) but is often asymptomatic. The distribution is often sun-protected areas, not to mention it does not match that of textbook AD. For CTCL not one, but several biopsies of steroid-untreated sites are needed to find the rogue atypical lymphocyte. Dr. Friedman noted that CTCL, among other chronic inflammatory skin diseases, can be “great mimickers, and this may in turn warrant a biopsy,” but cautioned to “consider from where you sample to get the most out of it.” Dr. Friedman also cautioned not to biopsy elbows, hands, feet as these areas often yield the dreaded and somewhat useless “spongiotic psoriasiform dermatitis.” 

If a diagnosis of CTCL is made, Dr. Friedman said, options for early-stage MF include topical corticosteroids, nitrogen mustard, topical bexarotene, and nbUVB. Options for refractory early-stage CTCL include PUVA or NBUVB and/or oral bexarotene (low-dose). 

Other common mimickers include contact dermatitis, dermatophytosis (which can be identified through a bedside potassium hydroxide prep), seborrheic dermatitis, lichen planus, scabies, and many more.

UPDATES AND WHAT’S NEW IN PEDIATRIC DERMATOLOGY 

Lisa Swanson, MD, FAAD, presented, “Updates and What’s New in Pediatric Dermatology.” Dr. Swanson said a challenging trend has been many parents’ desire for natural options for treating AD. Among natural options, she noted that olive oil has been studied and worsens AD, so it should be avoided; black tea compresses are good for facial dermatitis; the jury is still out on CBD, but there are some reputable companies involved if families want to try it; coconut oil has good antibacterial properties but does not seem to help the AD itself; and sunflower seed oil does appear to help, but it is difficult to find a good preparation. 

Dr. Swanson noted that good therapeutic drugs exist for children with AD, and that more are likely on the way. Topical ruxolitinib is one option that should be available for young children soon. “We are eagerly awaiting the approval down to age 2,” she said. “We can hardly wait.” 

She noted that parents should be advised that the black-box warning for ruxolitinib is a result of higher-risk JAK inhibitors, but that this is a lower-risk therapy, jokingly comparing ruxolitinib to Kendall Jenner among the Kardashians. 

Among current options, Dr. Swanson praised dupilumab. One mother, she said, told her: “We had our first month of peace since our child was born” following treatment with dupilumab. Dr. Swanson noted that the frequency of injections can be decreased once the condition is under control. “These medicines really, really help people,” she added. 

Dr. Swanson also discussed oral JAK inhibitors being approved for ages 12 and older. “These can be amazing options to consider for our teenage patients,” she said. Dr. Swanson also talked about counseling patients and families about the safety profile of JAK inhibitors and the boxed warning, emphasizing that these medications can change lives. “We need to embrace the boxed warning, learn about it, understand it, and be able to explain it to patients because we cannot let the boxed warning stand in the way of utilizing these life-changing therapies,” she said. 

ATOPIC DERMATITIS – GUIDELINES OF CARE

David Cohen, MD, MPH, presented “Atopic Dermatitis – Guidelines of Care AAD 2023-2024.” Dr. Cohen was one of the authors of the American Academy of Dermatology’s recently updated guidelines, though he noted that he was not speaking on behalf of the AAD. 

Dr. Cohen began by discussing the ample evidence supporting associations between atopic dermatitis (AD) and atopic comorbidities, such as asthma, food allergies, allergic rhinitis, allergic conjunctivitis, eosinophilic esophagitis, alopecia areata, and urticaria. He cautioned that patients might mistakenly believe that their dermatitis medications are causing these conditions, especially if the comorbidities appear around the same time they start treatment. Therefore, he said, it’s important to inform patients that these diseases often coexist with dermatitis rather than being caused by the medication. 

Dr. Cohen also noted that AD is associated with mental health conditions, such as depression and anxiety, and that associations between AD and cardiovascular conditions are more controversial. 

The Hanifin criteria for diagnosis were covered as well. Dr. Cohen suggested “less words, less prose in the subjective and more bullets” in notes. Using these criteria, he said, “it’s not hard to funnel someone into AD, with the appropriate assessment.” 

Dr. Cohen noted that the AAD guidelines use the word “recommend” and the phrase “conditionally recommend,” saying, “The level of certainty is based on the weight of the data.” 

Dr. Cohen noted strong recommendations for moisturizers, topical calcineurin inhibitors, topical corticosteroids, and topical JAK inhibitors. However, he added that topicals should not be a relied upon too heavily for more widespread disease activity. “We should not be using topicals for moderate to severe disease other than bridging for a week or two, or for treating flares or stubborn spots in patients on systemic or photo therapy,” he noted. “It is for mild disease, and it is for the co-treatment with systemic therapies.” 

The guidelines conditionally recommend the use of narrow band UVB phototherapy, Dr. Cohen said, adding that any topical therapy can be used in combination with any systemic therapy. If an insurance company says otherwise, he said, there is no evidence to support that. “Push back and use what is appropriate for the patient,” he implored. 

Among systemic therapies, Dr. Cohen presented network meta-analysis suggesting upadacitinib and abrocitinib are more efficacious than baricitinib. The guidelines conditionally recommend against systemic corticosteroids for use in AD. Dr. Cohen pointed out that they can be used in limited circumstances or as a bridge to other therapies. 

He concluded the following: 

When AD is more severe or refractory to topical treatment, advanced treatment with phototherapy or systemic medications can be considered. 

In the clinical practice guideline, strong recommendations are made for the use of dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib. 

Conditional recommendations are made in favor of photo-therapy, cyclosporine, methotrexate, azathioprine, and mycophenolate, and against systemic corticosteroids. 

Disclaimer: This content was developed independently and is not endorsed by the DEF or DERM2024.