Highlights from Day 3 at DERM2019: Hyperhidrosis, Bug Bites, Sunscreen, and More
As the nation observed the 50th anniversary of the Apollo 11 lunar landing, the day the famous quote from astronaut Neil Armstrong was spoken “That’s one small step for a man, one giant leap for mankind," DERM2019 organziers say the shot for the stars with their faculty were not disappointed by the presentations. Here’s a brief recap from some of those talks!
Device Treatment in Hyperhidrosis Presentation from Gilly Munavalli
Recap by Leigh Ann Pansch, NP
In this field of medicine, we often hear patient stories regarding how excessive, uncontrollable sweating affects their lives. An estimated five percent of the global population suffers from hyperhidrosis. Primary hyperhidrosis (HH) typically begins in childhood (<25 years old) and can persist into adulthood. Evidence suggests this condition can affect nearly every activity of daily living. Clues that lead us to diagnosis include positive family history, at least one episode per week, and symptoms that don’t typically occur while sleeping. One of the challenges to this disorder is the subjective nature of a patient’s perception of increased sweat which is difficult to quantify. A better understanding of the burden on each individual patient can speak volumes. Asking questions (and documenting) effect on quality of life may be helpful with insurance coverage.
Treatment options for hyperhidrosis include OTC and clinical strength antiperspirants, oral anticholinergics, medical botulinum toxin, microwave destruction of eccrine glands, iontophoresis, and thoracic sympathomymectomy. Each of these treatment options must be carefully weighed with the risks and benefits. Topical anticholinergics show great promise in terms of overall tolerability, symptom improvement, and improved quality of life. But wait, other topical agents in the pipeline include sofpironium bromide, glycopyrronium bromide, and oxybutynin gel. Dr. Munavalli considers the 2.4% glycopyrronium bromide cloths a First-Line treatment for primary axillary hyperhidrosis. A more permanent treatment for this condition is iontophoresis (controlled thermolysis) which results in a permanent and significant reduction in sweat glands and hair growth. Thank you Dr. Munavalli for sharing your experiences with this exciting treatment option.
Beware of secondary hyperhidrosis! This condition typically affects more body surface area, may occur while asleep, and may be secondary to other conditions included mood disorders, infection, alcoholism, diabetes, gout, heart failure, hyperthyroidism, menopause, obesity, pregnancy, and cancer among others.
This Lecture Bites Presented by George Keough
Recap by Jayme M. Heim MSN, FNP-BC, West Michigan Dermatology
When was the last time you saw a patient in your office with a spider bite? Truth be told, it may not be as often as you think. While spider bites are rare, arachnophobia, or fear of spiders, is quite common.
Spider bites in clinical practice are a presumptive diagnosis unless a spider was observed delivering the bite, the spider was recovered after the assault, and the bite was confirmed by an expert or physical findings are consistent with a spider bite. If these criteria are not present, other differential diagnoses need to be considered. Are you aware that eighty percent of patients diagnosed with a spider bite actually have a soft tissue infection unrelated to a spider bite? In general, spider bites are not seen as multiple lesions, they will not be seen repeatedly in one area of the body or on various body locations, and you will never see multiple household members with similar lesions due to spider bites.
Two spiders that do pose a risk are the brown recluse spider and the black widow spider. The brown recluse spider prefers dark, isolated areas such as basements, attics, closets, shelves, and dressers. They bite when threatened; such as when a person reaches into a space or putting on clothing where the spider is present. Bites are uncommon to the face and hands; they are more commonly seen on the trunk, upper arms, or thighs. The brown recluse spider bite is usually painless at first, but the pain in the affected area will continue to increase over the next two to eight hours. The area may have a livedoid or vasculitic appearance that resolves in about a week. Necrotic reactions can occur in approximately ten percent of patients. The necrosis will spread in a gravity dependent manner. Healing for those patients can take months and monitoring for secondary infection is warranted. A systemic reaction is uncommon, but if it does occur hospitalization is necessary. It is important to note that anti-venom to counteract necrosis is not available in the United States.
The black widow spider is found in the southeastern United States as far north as Ohio and as far west as Texas. Black widow spiders are typically found outside the home in places such as lawn furniture, wood piles, and debris. Black widow spiders are rarely found indoors. The most common areas for black widow spider bites are arms and legs with the highest rates of incidence in the summer and fall. The black widow bite is painless to mildly painful and the venom can cause muscle spasms. The cutaneous reaction can present as a targeted lesion or possible a wheal while secondary infection is common and diaphoresis can occur in twenty percent of patients. A key characteristic is lymph node swelling and tenderness within thirty minutes of the bite. Mild to moderate reactions to the black widow venom are treated with wound care, oral pain medications, tetanus prophylaxis, muscle relaxers, and an antiemetic. For moderate to severe reactions, anti-venom can decrease the duration of the pain, but black widow anti-venom is in short supply in the United States.
So, the next time you think about treating a patient for a spider bite, you may want to reconsider your initial diagnosis first.
Atypical Nevi Clinical Management Issues Presented by Jennifer Stein
Recap by Leigh Ann Pansch, NP
Dr. Jennifer Stein shared management pearls for atypical nevi. For all of us who scratch our heads when considering just how and when to biopsy, how to treat the patient with too many atypical nevi to count, how to educate our patients on risk and improve outcomes, and when to re-excise; this was a practical and concise update.
Dr. Stein began with the recommendation to understand a patient’s signature in a nevus. This may start with your door post view. What colors, shapes, and sizes do you see? Focus in on the “ugly duckling” lesion. Consider dermoscopy, sequential dermatoscopic images and total body photography in your management arsenal. Be on the lookout for new tools in the melanocytic lesion management toolbox such as total body photography and tape stripping!
A 2017 Journal of the American Academy of Dermatology (Terushkin et al, JAAD 2017) study indicated we should consider a 2-mm margin for all biopsies of atypical nevi. Most of us are comfortable monitoring mildly dysplastic nevi. In moderately dysplastic atypical nevi with clear margins, we may be able to safely follow the patient without the need to re-excise. Severely atypical nevi should be treated like MMIS (5 mm margins).
Sunscreens and Cosmeceuticals Presented by Julie Harper
Recap by Leigh Ann Pansch, NP
I’ve heard it said that the best sunscreen is the one you use; but is this true? Dr. Julie Harper was breaking some myths today (looking ever-so-professional all the while)! It may not be enough to simply ask our patients if they use sunscreen. We should consider educating them on the AAD recommendations for application of sunscreen minimum SPF 30 anytime they’re outside longer than 15 minutes, approximately a shot glass full of sunscreen should be used for the average adult, and reapplication should happen every two hours or every hour if you’re swimming or sweating profusely. In complete skin exams, we have a captive audience to hear the facts about sunscreen and sun-protective clothing and other barriers. Who will educate on this important topic if we don’t?
Consider the ingredients (chemical vs physical) when we recommend specific sunscreen applications. Oxybenzone, octinoxate, and hemosalate (common ingredients in chemical sunscreens) may disrupt the endocrine system. Who knew our oceanic life was being significantly disrupted by these chemicals (likely from the urine of patients wearing chemical sunscreens). GROSS! Retinyl palmotate is likely a safe ingredient found in many cosmetic sunscreen applications. But what about the nanoparticles you say? Numerous studies indicate these tiny particles do not penetrate the skin and should be considered safe overall. While it is true we get a large amount of our vitamin D from the sun, there are safer ways (like diet and supplements) to meet our USDA daily dose of this important vitamin. I’m gonna wash that sunscreen right into my clothing! For those who will not be convinced, sunscreen formulations which can be washed into personal items may be a viable option. Further, polypodium leucotomos is a potent antioxidant which offers promise for those “who just want to take a pill” and nicotinamide may be considered for our immunosuppressed patients to reduce risks for nMsc.