SCALE Notes

SCALE INSIGHTS: CLINICAL DERMATOLOGY

Over four major presentations, James Q. Del Rosso, DO reviewed many currently relevant subjects in dermatology, including management of atopic dermatitis, psoriasis, acne, rosacea, hyperhidrosis, cutaneous infections, and adjunctive photoprotection. Dr. Del Rosso is Research Director of JDR Dermatology Research and practices clinical dermatology and dermatologic surgery at Thomas Dermatology in Las Vegas. He recapped key points from his presentations.

What are some of the latest therapeutic developments you addressed? Why should dermatologists be aware of these?

Dr. Del Rosso: At this SCALE meeting, my goal was to select information that is currently relevant to clinicians who are practicing dermatology in the trenches, seeing patients day after day, and who may not be as involved as I am in new research or academic initiatives. I also maintain a very active general and surgical dermatology practice, so my perspectives are not only derived from research and publications. Translation of information that can impact on better patient care and improved therapeutic outcomes is my focus when presenting. Most importantly, at a meeting like SCALE, I see it as an obligation to help attendees receive information that they can apply clinically. Here are three examples:

1.) In atopic dermatitis (AD), incorporating good skincare is vital, including the selection of a good moisturizer for barrier repair, as atopic skin is unable to sustain adequate moisture even when not flared, is prone to colonization with staphylococci (i.e., S aureus), is more susceptible to certain viral infections (i.e., molluscum contagiosum), and is often very pruritic. Daily proper moisturization can mitigate the “smoldering embers” of atopic skin that can lead to an AD flare, and can also reduce frequency of flares and the total amount of topical corticosteroid (TC) use required over time. Appropriate use of TCs is vital, with intermittent (proactive) therapy a viable approach to reduce flares at frequently recurrent sites (i.e., antecubital, popliteal, etc). Non-steroidal topical agents (i.e., crisaborole ointment, pimecrolimus cream) assist in both the initial and long-term management of AD due to its chronicity.

We are fortunate to have the anti-IL4/IL-13 biologic agent, dupilumab, which exhibits very favorable efficacy and safety in patients with AD that are beyond just topical therapy, and where short-course systemic corticosteroid use (oral or IM) has become too frequent (i.e., more than twice per year, maybe less). Dupilumab reduces both the eczematous dermatitis and even more rapidly reduces pruritus, appears to be devoid of immunosuppression, and does not require laboratory testing at baseline or for monitoring, based on the FDA-approved label. In fact, cutaneous infections have been shown to decrease with dupilumab use, as its mechanism contributes to restoring skin barrier structure and function in addition to decreasing Th2-driven inflammation and other immunologic pathways operative in AD. A subset of patients may develop or experience worsening of conjunctivitis (usually blepharitis) during dupilumab treatment, which appears to be inflammatory in origin. Keep in mind that many AD patients have ocular problems, including blepharitis, before they start therapy, so an external ocular examination is important to assess pre-therapy. Most cases associated with or exacerbated by dupilumab use are easily managed and resolve, despite continued use of dupilumab, however, some may be more troublesome. I work closely with an ophthalmologist when necessary on such cases as the majority are manageable without discontinuation of therapy.

2.) In rosacea, it is important to assess the visible manifestations present in the patient at the time of presentation (phenotypic approach). Persistent facial erythema (PFE) of rosacea, which is diffuse macular redness on the central cheeks, forehead, and chin, is caused by chronically dilated superficial facial vasculature and is often responsive to topical alpha-agonist therapy (brimonidine gel, oxymetazoline cream). Physical devices such as intense pulsed light or lasers (i.e., pulsed dye) can assist in PFE reduction and may also reduce telangiectasias, the latter not responsive to any medical therapies. When papulopustular lesions are present, the patient also has the background of PFE, but they also have perilesional erythema around the papules and pustules that compounds the intensity of their facial redness. Agents that reduce papules and pustules (i.e., topical ivermectin, topical azelaic acid, topical metronidazole; sub-antibiotic dose doxycycline) reduce papulopustular lesions and their associated erythema, but do not appreciably affect the PFE caused by persistently dilated superficial vessels. Combination therapy is very important in the management of rosacea, as it is in acne, and compliance is vital as rosacea is a chronic inflammatory disorder.

Dr. Biesman demonstrates Restylane Lyft injection at SCALE 2019

3.) Primary hyperhidrosis (unknown underlying cause) affects more than 90 percent of individuals affected by hyperhidrosis, with bilateral axillary involvement the most common presentation. Onset is usually between ages 14 to 25 years, with many patients adversely affected psychosocially. Unfortunately, 50 to 75 percent of cases remain undetected, as many patients do not bring it up to their clinician. It is important that methods be incorporated to increase awareness to patients that dermatology practices can help them. Although OTC and prescription antiperspirants are most commonly prescribed for primary axillary hyperhidrosis, skin tolerability is a common limiting factor, with 50 percent of patients reporting moderate or severe skin irritation. Data are limited with oral anticholinergic agents, which may help some patients, but may be limited by side effects (i.e., dry mouth, urinary retention, mydriasis). Glycopyrronium 2.4% cloths (wipes) have been shown to reduce axillary sweating and result in high levels of patient satisfaction in those with primary axillary hyperhidrosis. It is very important that patients utilize this therapy as recommended.

Glycopyrronium is a topical anticholinergic, which reduces sweating by inhibiting acetylcholine activation of sweat receptors locally where applied, and is not an antiperspirant. The patient is instructed to use only one wipe across each axilla (one swipe of each axilla only one time on each side) once a day, that is all, then discard the wipe and wash the residue off of their hands to avoid accidental transfer to eyes and/or mouth. When used properly, anticholinergic side effects are uncommon. The patients should separate use of this therapy from deodorant application by at least four hours, so it is likely best to apply the glycopyrronium cloth at bedtime and deodorant in the morning.

Is any of this “controversial”? If so, why?

Dr. Del Rosso: One area of confusion-related “controversy” is with use of Polypodium leucotomos extract (PLE) formulations for adjunctive photoprotection. There are many peer-reviewed and indexed publications, including in reputable dermatology journals, supporting the adjunctive photoprotection benefit of PLE, including sunburn reduction, decreased sunburn cells and abnormal epidermal changes histologically, reduced parameters of DNA damage, and improvements in some photodermatoses. However, these studies incorporate one specific brand of PLE (Heliocare in the USA, Ferndale Laboratories), which is available OTC. Although many other PLE and PL products can be obtained OTC, these products have not been shown in studies to exhibit the full properties and appropriate collection of antioxidant polyphenols in necessary concentrations that are consistently present in the above mentioned brand of PLE, due to a tightly controlled manufacturing process. In fact, a recent study has compared the designated brand of PLE versus five other PLE formulations. This study confirmed that none of the other PLE formulations that were tested proved to be as complete with the necessary polyphenol constituents or the ability to exhibit the same photoprotective properties that decrease the parameters of UV-induced DNA damage as the designated brand formulation. It is prudent to recommend products that are substantiated by data whenever possible to the best of our knowledge. We now have this knowledge with PLE.

Another area that is not controversial per se, but is often asked, is whether or not oral apremilast can be used in combination with a biologic agent or light therapy in patients with psoriasis. Although randomized controlled studies have not yet been completed, there is published peer-reviewed and indexed literature addressing this question that supports beneficial use of oral apremilast with biologic agents in patients with psoriasis and with psoriatic arthritis, and also with narrow-band UVB. More data are needed in this area.

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