By Caroline Tan, MD, UCLA Dermatology Resident, PGY3

Held for the first time in-person at the Hilton San Diego Bayfront, the Third Annual San Diego Dermatology Symposium (SDDS, March 11-13, 2022) offered networking, learning, and winning giveaways. Many attendees shared that this was their first live in-person meeting in a couple of years. Among highlights from the presentations:  

Scarring Alopecia. Carolyn Goh, MD, provided an overview and case-based discussion of scarring alopecia. She discussed the challenges of scarring alopecia including diagnosis, treatment, and time management, and that it is considered a “trichologic emergency” due to permanent loss of hair that can progress unexpectedly and rapidly. Primary scarring alopecia is divided into those due to a neutrophilic, lymphocytic, or mixed infiltrate. Secondary scarring alopecia may occur due to trauma or tumors, morphea, late tinea capitis, and late traction or trichotillomania.
In terms of diagnosis, Dr. Goh recommended a focused history and physical to include timing/duration, presence of increased shedding, pattern of loss, associated symptoms, dermoscopy to determine scarring vs. non-scarring, and a hair pull test. She recommends two 4mm punch biopsies (one for horizontal sectioning, one for vertical sectioning) at an active edge, suggesting a more subacute location rather than a very active location.
Dr. Goh then reveiwed a series of clinical cases, which included diagnoses of frontal fibrosing alopecia, lichen planopilaris, central centrifugal cicatricial alopecia, chronic cutaneous lupus, folliculitis decalvans, and dissecting cellulitis of the scalp.
The goals of treatment are to reduce symptoms, slow the progression of hair loss, and maintain the hair that is present. Treatment options for lymphocytic scarring alopecias include topical and/or intralesional corticosteroids, topical calcineurin inhibitors, doxycycline or minocycline, hydroxychloroquine, pioglitazone, mycophenolate mofetil, methotrexate, cyclosporine, possibly JAK inhibitors, finasteride or dutasteride, topical metformin, cetirizine, omalizumab, apremilast, low-dose naltrexone, and treatment of underlying non-scarring alopecia. Treatment options for neutrophilic scarring alopecias include doxycycline or minocycline, clindamycin and rifampin, other antibiotics, topical clindamycin, topical and/or intralesional corticosteroids, surgical excision at times, isotretinoin or topical retinoids, TNF inhibitors for dissecting cellulitis, and dapsone. A helpful resource to provide patients is the website for the Cicatricial Alopecia Research Foundation (www.carfintl.org). 

Medical Treatment of Actinic Keratosis and NMSC. Current and upcoming treatment options for actinic keratoses (AK) and non-melanoma skin cancers (NMSC) were presented by Neal Bhatia, MD, FAAD. The combination of topical calcipotriol with 5-fluorouracil or the use of short-contact topical calcipotriene foam with 5-fluorouracil after cryotherapy may result in improved long-term outcomes for actinic keratoses. Tirbanibulin is a new anti-proliferative and pro-apoptotic topical therapy that seems to be effective for actinic keratoses and induces less inflammation and tissue necrosis. Polypodium leucotomos extract (240mg) and nicotinamide (500mg) may help prevent UV-induced damage. In terms of PDT, treatment of actinic keratoses may be improved by combining PDT with microneedle pretreatment at a 20-minute ALA incubation time. Additionally, we may consider a simultaneous PDT regimen in which blue light is started immediately upon application of ALA, which is essentially painless with similar efficacy to conventional PDT. A promising new treatment for lesion-directed treatment of actinic keratoses is microwave therapy for non-ablative immune modulation.
Medical treatments for advanced NMSC include hedgehog pathway inhibitors and PD-1 inhibitors. Cemiplimab is a PD-1 inhibitor FDA approved for treatment of advanced cutaneous SCC, and more recently approved for locally advanced BCC or metastatic BCC previously treated with a hedgehog inhibitor or for whom a hedgehog inhibitor is not appropriate. In terms of hedgehog inhibitors, dermatologists should consider treating patients with these agents themselves instead of sending them to someone else. Vismodegib 150mg daily provided benefit to over 90% of patients. L-carnitine can be used prior to starting a hedgehog inhibitor to help with muscle cramps. Vismodegib may also be used to reduce tumor size prior to surgical treatment. To prevent late recurrences, patients may be offered a hedgehog inhibitor 10-15 days per month for 6-12 months. Other treatments for BCC and Gorlin’s syndrome that work via this pathway include itraconazole, and the newer Smoothened inhibitors taladegib (oral) and patidegib (topical).  

IL-17 Inhibitors, IL-23 Inhibitors, and Precision Medicine in Psoriasis. Jashin Wu, MD provided updates in IL-17 inhibitors and IL-23 inhibitors. On June 1, 2021, secukinumab was approved for psoriasis patients six years and older with dosage based on body weight (less than 50 kg: 75mg; greater than or equal to 50 kg: 150mg) administered weeks 0, 1, 2, 3, and 4 and every 4 weeks thereafter.
Bimekizumab is a IL-17A/F inhibitor that should be approved by the FDA shortly.  It is likely to be the most effective biologic for psoriasis when approved.  There are head-to-head trials of bimekizumab vs secukinumab, bimekizumab vs ustekinumab, and bimekizumab vs adalimumab, with bimekizumab showing higher efficacy in these 3 clinical trials.
Guselkumab and tildrakizumab had recent publications showing 5-year data for efficacy and safety.  Risankizumab was approved on January 21, 2022 for psoriatic arthritis.
Precision medicine in psoriasis is becoming a reality.  Up until last year, there was no simple predictive tool to select appropriate initial treatment, and patients may not respond optimally.  Mind.px is a painless, minimally invasive test to predict drug response to each biologic class.  It has a 91% positive predictive value with a turnaround time of 14 days.  Mind.Px from Mindera Health is currently available.