A selection of scientific poster abstracts from Skin of Color Seminar Series 2018 (now known as Skin of Color Update.) Thank you to our poster presentations and faculty.
Cutaneous Crohn’s Disease of the Vulva in an Elderly African American Patient
Authors: Leah Wells, MS & David Kent, MD
We present a case of a 79-year-old African American female with painful vulvar ulcers of several years duration. She presented to an OB-GYN and was tested for syphilis, lymphoproliferative granulomatosis, herpes, TB, and fungal infection. Once these etiologies were ruled out, she was referred to dermatology where the knife-like lesions prompted suspicion for cutaneous Crohn’s disease. However, the patient had not been previously diagnosed with Crohn’s and had no gastrointestinal symptoms of the disease. Biopsy revealed non-caseating granulomas, confirming a probable diagnosis of vulvar Crohn’s. The patient was initially treated with oral steroids, and her lesions showed improvement after one month of therapy. Due to the severity of her case, infliximab was recently added to her regimen to further promote healing.
Less than 200 cases of vulvar Crohn’s disease have been reported in the literature. The mean age of onset is 35, making our patient’s advanced age uncommon. Vulvar Crohn’s is often difficult to diagnose, due to the multitude of differential diagnoses for genital ulcers. Further, a significant amount of patients with vulvar Crohn’s disease will not exhibit any gastrointestinal symptoms and vulvar Crohn’s will be the initial manifestation of underlying disease. As a result, many patients suffer from the disease for many years before it is recognized as cutaneous Crohn’s. A biopsy is necessary to achieve definite diagnosis.
Treatment recommendations for vulvar Crohn’s have not been well-established. However, initial treatment often includes metronidazole, steroids, and/or immunosuppressants. Recent case-reports have shown success in treating severe, or refractory, vulvar Crohn’s with infliximab.
Increased Severity of Coccidioidomycosis in Persons with Skin of Color
Authors: Leah Swanson, MD & David DiCaudo, MD
Coccidioidomycosis is an infectious disease endemic to the desert southwest. Most infections are asymptomatic however can be complicated by severe pulmonary disease and dissemination to the central nervous system, bone, skin, and elsewhere. Persons with skin of color, mainly African Americans, are at a disproportionate risk for severe and disseminated disease. Skin manifestations are common and can be reactive or secondary to primary skin infection. Dermatologists therefore are crucial in early identification of this disease, especially in persons with skin of color.
Differential Facial Aesthetic Treatment Considerations for Skin of Color Populations: African American, Asian American and Hispanic
Authors: Charles Boyd, MD; Annie Chiu, MD; Jose Raul Montes, MD; Vic Narurkar, MD; Garrett T. Shumate, BS; Conor J. Gallagher, PhD
Introduction: By 2050, more than half of the total population in the United States will be of African American, Asian or Hispanic descent. The unique anatomical needs, aesthetic goals and cultural considerations for these growing patient populations should be evaluated to optimize treatment expectations and outcomes. A research study was performed to gain insights into the areas of aesthetic concern, relative prioritization of treatment areas, and any barriers to receiving injectables amongst these populations.
Methods: 401 African American, 403 Asian and 401 Hispanic females living in the United States, aged 30-65, completed an online evaluation in which questions focused on identifying bothersome facial areas, consideration levels for facial aesthetic treatments, and any barriers to receiving injectables. A Maximum Difference scaling method was used to identify which of the 15 facial areas would be prioritized for treatment. Respondents were naïve to facial aesthetic treatments but were aesthetically oriented and considering physician administered aesthetic treatment within the next two years.
Results: The Hispanic population reported the highest consideration rate for injectables (85%), followed by Asian American (75%) and African Americans (64%). African American and Hispanics were most bothered by their submental region whereas Asian American respondents were most bothered by the area underneath the eyes (infraorbital area). All skin of color populations prioritized first the periorbital region (infraorbital and crow’s feet areas) followed by the submental area and forehead lines. Relative to the other populations, African American respondents expressed the highest prioritization of the submental region. All respondents then prioritized treatment of glabellar lines, nasolabial folds, and oral commissures. Analysis by increasing Fitzpatrick Type (I to VI) showed an increasing prioritization of the periorbital region and decreasing prioritization of the chin and perioral lines. Most frequently cited barriers to considering injectable treatment included safety and side effects, concern about injecting a foreign substance into the body, and cost.
Conclusions: Understanding the unique aesthetic considerations of a diversifying patient population is imperative. Differences in injectable consideration rates and bothersome areas were apparent across the patient populations evaluated, but there was consensus regarding the facial areas most likely to be prioritized for treatment. An understanding of the differential aging patterns, cultural considerations and aesthetic goals for each patient population may help optimize treatment expectations and outcomes.
Understanding the Asian American Facial Aesthetic Patient
Authors: Annie Chiu, MD; Andrea Hui, MD; Kavita Mariwalla, MD; Vic Narurkar, MD; Garrett T Shumate, BS; Conor J Gallagher, PhD
Introduction: Aesthetic injectors may perceive challenges with addressing the aesthetic needs of Asian patients. Understanding the anatomy, facial aging patterns, aesthetic concerns, and treatment preferences may increase the comfort level for injectors and improve outcomes for these patients. Clinical case studies can provide practical examples for implementing this knowledge during patient consultation, assessment, and treatment.
Methods: Two research studies were performed to gain insights into self-reported facial aging patterns and treatment preferences for a total of 1,113 female respondents of Asian ethnicity. 710 participants in the first study assessed their static facial features against photonumeric scales depicting degrees of severity for 10 areas across the upper, mid, and lower face. 403 US-based participants in the second study reported current facial conditions, areas of aesthetic concern, relative prioritization of treatment areas, and attitudes toward injectable treatments. Respondents for both studies were naïve to facial aesthetic treatments. A subsequent meeting of experts with significant experience in treating the Asian patient population produced case studies to illustrate the translation of these data to the clinical setting.
Results: The majority of respondents reported having uneven skin tone/color (64%), facial wrinkles (50%), and sun damage (48%). Moderate-to-severe nasolabial folds and puffiness under the eyes were present in ≥30% of respondents in their 40s followed by the appearance of forehead lines (FHL) in their 50s. More broad signs of facial aging across the upper, mid and lower face were reported by their 60s. The moderate-to-severe threshold was reached ≥10 years later for many facial areas when compared to similar data for 1317 Caucasian females. Areas of greatest aesthetic concern were under eye/tear trough, FHL and crow’s feet lines (CFL). Areas most likely to be prioritized for treatment were under eye/tear trough and CFL, followed by FHL and the submental region. All respondents were considering a facial aesthetic treatment administered in a physician’s office within two years; 74% of them would consider injectables. Safety/side effects and cost were the most reported barriers to receiving injectables.
Conclusions: There was general alignment between the self-reported facial aging patterns, areas of greatest aesthetic concern, and those that were prioritized for treatment. Accordingly, treatment of the periorbital (under eye/tear trough and CFL), FHL and submental regions may be seen as entry points for injectables in this population. Consideration should also be given to their focus on addressing specific concerns including hypo/hyperpigmentation. Understanding these objective research findings and practical case studies may increase the comfort level for injectors and improve outcomes for Asian American patients.
Understanding the Hispanic/Latino Facial Aesthetic Patient
Authors: José Raúl Montes, MD, FACS, FACCS; Shino Bay Aguilera, DO; Vivian Bucay, MD, FAAD; Sabrina Fabi, MD; Garrett T. Shumate, BS; Conor J Gallagher, PhD
Introduction: Aesthetic injectors may perceive challenges with addressing the aesthetic needs of the diverse population of Hispanic patients. Understanding the anatomy, facial aging patterns, aesthetic concerns, and treatment preferences may increase the comfort level for injectors and improve outcomes for these patients. Clinical case studies can provide practical examples for implementing this knowledge during patient consultation, assessment, and treatment.
Methods: Two research studies were performed to gain insights into self-reported facial aging patterns and treatment preferences for a total of 927 female respondents of Hispanic ethnicity. 526 participants in the first study assessed their static facial features against photonumeric scales depicting degrees of severity for 10 areas across the upper, mid, and lower face. 401 US-based participants in the second study reported current facial conditions, areas of aesthetic concern, relative prioritization of treatment areas, and attitudes toward injectable treatments. Respondents for both studies were naïve to facial aesthetic treatments. A subsequent meeting of experts with significant experience in treating the Hispanic patient population produced case studies to illustrate the translation of these data to the clinical setting.
Results: The majority of Hispanic respondents reported having facial wrinkles (56%), dark circles (55%) and bags (45%) under the eyes. Moderate-to-severe nasolabial folds were present in ≥30% of respondents by their 40s, while more broad signs of facial aging were reported by their 50s. Upper facial lines (crow’s feet lines [CFL], forehead lines [FHL], and glabellar lines) reached the moderate-to-severe threshold for Hispanic respondents 10 years later compared to data obtained for 1317 Caucasian females. The areas of greatest aesthetic concern for Hispanic respondents were the submental region, periorbital area (under eye/tear trough and CFL) and FHL. Correspondingly, areas most likely to be prioritized for treatment were under eye/tear trough and CFL, followed by the submental area and FHL. All respondents were considering a facial aesthetic treatment administered in a physician’s office within two years; 84% of them would consider injectables. Cost and safety/side effects were the most reported barriers to receiving injectables.
Conclusions: There was general alignment between the self-reported facial aging patterns, areas of greatest aesthetic concern, and those that were prioritized for treatment. Accordingly, treatment of the periorbital (CFL and under eye/tear trough), FHL and submental regions may be seen as entry points for injectables in this population. Understanding these objective research findings and practical case studies may increase the comfort level for injectors and improve outcomes for Hispanic patients.
Understanding the African American Facial Aesthetic Patient
Authors: Andrew Alexis, MD, MPH; Charles Boyd, MD; Valerie Callender, MD; Jeanine Downie, MD, FAAD;
Garrett T. Shumate, BS; Conor J Gallagher, PhD
Introduction: Aesthetic injectors may perceive challenges with addressing the aesthetic needs of African American patients. Understanding the anatomical considerations, facial aging patterns, aesthetic concerns, and treatment preferences may increase the comfort level for the injector and improve outcomes for this patient population. Injectors should also consider any patient-based misperceptions (eg, keloid scarring) associated with injectable procedures. Accordingly, clinical case studies can provide practical examples of how to implement this knowledge during patient consultation, assessment, and treatment.
Methods: Two studies were performed to gain insights into self-reported facial aging characteristics and treatment considerations. 859 African American males (145) and females (714) completed an online evaluation in which they assessed their facial features against photonumeric scales depicting degrees of severity for 10 facial characteristics. 401 African American females completed a separate online evaluation to identify areas of aesthetic concern, relative prioritization of treatment areas, and attitudes toward injectable treatments. Respondents for both evaluations were naïve to facial aesthetic treatments. A subsequent meeting of experts with significant experience in treating this patient population produced case studies to illustrate the translation of these data to the clinical setting.
Results: In the African American population, moderate to severe signs of facial aging were not generally reported until 50-79 years of age. At ages 70-79, over 70% were still without moderate to severe perioral lines, loss of lip fullness, or midface volume loss. The majority reported having uneven skin tone/color (57%) and dark circles under the eyes (48%). African Americans were most bothered by their tear trough and submental regions. Areas most likely to be prioritized for treatment included tear trough, submental region, and horizontal forehead lines. In contrast, African Americans were less likely to prioritize treatment of perioral lines, lips, temples, and cheeks. African American women reported the lowest consideration rate for injectables (64%), as compared to Asian or Hispanic individuals. “Looking good for their age” was the top reason for considering aesthetic treatment, but the cost and safety/side effects were the largest barriers. Clinical case studies demonstrated practical treatment strategies utilizing commercially available facial aesthetic products.
Conclusions: Across the two research studies, self-reported facial aging characteristics correlated with bothersome areas. Correspondingly, both tear trough treatment and submental fat reduction may be seen as entry points to facial aesthetic injectables for this population. An understanding of these objective research findings and practical case studies may increase the comfort level for an injector and improve outcomes for the African American patient population.
Multiple, Late-Onset Facial Angiofibromas in Skin of Color (SOC)—Which Genodermatosis Fits Best?
Authors; Valerie Callender & Abrahem Kazemi, MD
A 74-year-old African American man was referred to our clinic after inadequate treatment of his facial bumps of two years’ duration. The patient’s facial lesions grew rapidly over 1-2 months, then stabilized. He reports associated lesion irritation by facial hairs worsened without shaving, and relieved after shaving. On examination, the patient has multiple, clustered, 3-9mm, flesh-colored, superficial telangiectatic papules distributed bilaterally and symmetrically on the cheeks, posterior neck, and helices of the ears with sparing of the nose, lips, and eyelids. One 4 mm punch biopsy was taken from the right lower face. Histopathologic evaluation of one clustered facial papule demonstrated features that were diagnostic of a fibrous papule, or angiofibroma, without changes of sarcoid or verrucae. Since our patient illustrates unique, incomplete, or rare features of a combination of tuberous sclerosis, multiple endocrine neoplasia type 1, or Birt-Hogg-Dube Syndrome, this patient represents an unusual case of isolated, late-onset facial angiofibromas in skin of color (SOC) without other symptoms of these genodermatoses. Electrodesiccation and curettage (ED&C) was utilized on a test-spot to surgically manage the facial angiofibromas with the Hyfrecator on a setting of 2 to avoid post-inflammatory pigmentary changes as a feared side effect in SOC patients. At 8 week follow-up, the patient healed well from ED&C without the development of keloid or hypertrophic scarring, or significant pigmentary changes. The best next step in management is to offer the patient a referral to a geneticist for counseling and testing.
Examining the Race-Specific Prevalence of Hidradenitis Suppurativa at a Large Academic Center; Results From a Retrospective Chart Review
Authors: Toral Vaidya, MPH
Hidradenitis suppurativa (HS) is a chronic, inflammatory, debilitating disease of unknown etiology. HS can occur in people of all ethnicities and ages, and affects approximately .3-4% of the United States. To date, few studies have specifically examined the race prevalence of hidradenitis suppurativa; further epidemiological research is needed to identify specific trends among HS and its racial predilections. At our center, 1.3% of African-American patients were seen for HS, compared to .18% of Caucasian patients; (p<.05), and the ratio of % of African-American patients with HS vs. % of Caucasian patients with HS is 7.22:1. Our ratio of number of African-American patients with HS vs. number of Caucasian patients with HS is 1.19:1. Studies performed at Henry Ford Medical Center and University of Pittsburgh report ratios of 1.64:1 and 1.98:1 respectively. These data support study trends suggesting HS is more common among patients of African-American descent. A large, population-based study across the United States is needed to better assess the associations between ethnicity and HS. Examining this patient population has the potential to improve our understanding of HS pathophysiology, and will enable clinicians to better manage
No Skin Atrophy Observed in Histopathologic Examination of Skin Biopsies After 6 Months of Treatment with Fluocinolone Acetonide 0.01%, Hydroquinone 4%, and Tretinoin 0.05%
Authors: Maria-Jose Rueda, MD
Concern regarding the safety of TC cream has centered on the fluocinolone acetonide component. Although fluocinolone acetonide 0.01% is a low-potency corticosteroid, it is often wrongly associated with more potent steroids. This has resulted in hesitancy regarding TC cream for long-term use on the face. In this study, subjects were given a treatment regimen involving once-daily treatment with TC cream for up to 24 weeks, and 2 mm punch biopsies were obtained from involved and adjacent uninvolved areas of the face. No histologic signs of atrophy of the epidermis or dermis were reported for any patient at any time point throughout the study. These results indicate that the risk of skin atrophy with 24 week use of TC cream for treatment of melasma is very low.
Long-Term Safety of Crisaborole Ointment, 2%, Across Racial and Ethnic Groups
Authors: Valerie D. Callender,1 Andrew F. Alexis,2,3 Linda F. Stein Gold,4 Mark Lebwohl,3 Seemal R. Desai,5,6 Amy S. Paller,7 Huaming Tan,8 Ivana Vranic,9 William C. Ports,8 Michael A. Zielinski,10 Anna M. Tallman9
Introduction: Atopic dermatitis (AD), a chronic inflammatory skin disease, is more prevalent in patients who are black, Asian, of multiple races, or of Hispanic ethnicity. AD often requires long-term topical treatment, so it is important to understand the long-term safety profile of topical AD treatments. Crisaborole ointment is a nonsteroidal phosphodiesterase 4 inhibitor for the treatment of mild to moderate AD. The long-term safety of crisaborole according to race and ethnicity was assessed in a post hoc analysis.
Methods: Patients ≥2 years of age who completed a 28-day Phase 3 pivotal study (NCT02118766, NCT02118792), without safety issues that precluded
further treatment with crisaborole, 2%, were enrolled in a long-term, open-label, 48-week safety study. Patients were assessed for AD severity every 4 weeks and treated with a 4-week cycle of crisaborole if AD severity was mild or greater (Investigator’s Static Global Assessment ≥2). Treatment-emergent adverse events (TEAEs) reported here included all events with an onset on or after treatment initiation in the Phase 3 pivotal studies. Post hoc analysis was by race and ethnicity. Race groups were defined as Asian (A; Asian/native Hawaiian/other Pacific Islanders), Black/African American (B), white (W), and other (O; other/American Indian/Alaskan Native). Ethnicity groups were defined as Hispanic/Latino (HL) or Not Hispanic/Latino (nHL).
Results: The long-term safety study enrolled 517 patients (n [%], A: 29 [5.6]; B: 152 [29.4]; W: 315 [60.9]; O: 21 [4.1]; HL: 82 [15.9]; nHL: 435 [84.1]). The proportions of patients reporting ≥1 TEAE were n (%), A: 15 (51.7); B: 76 (50.0); W: 227 (72.1); O: 18 (85.7); HL: 57 (69.5); nHL: 279 (64.1). Percentage of patients reporting treatment-related TEAEs ranged from 7.9% to 23.8% (n [%], A: 3 [10.3]; B: 12 [7.9]; W: 33 [10.5]; O: 5 [23.8]; HL: 12 [14.6]; nHL: 41 [9.4]). TEAEs resulting in discontinuation of crisaborole treatment were application site dermatitis (n, B: 1; nHL: 1), application site pain (n, W: 1; O: 1; nHL: 2), dermatitis atopic (n, B: 2; W: 3; HL: 3; nHL: 2), and eczema (n, W: 1; nHL: 1). No patients in the Asian/native Hawaiian/other Pacific Islander group discontinued crisaborole treatment due to a TEAE.
Conclusions: In this post hoc analysis, the rates of treatment-related TEAEs and discontinuations due to TEAEs were similar in all groups except the other group, which should be interpreted with caution given the small sample size of the other group.
Efficacy and Safety of Crisaborole Ointment, 2%, for Treatment of Mild to Moderate Atopic Dermatitis Across Racial and Ethnic Groups
Authors: Valerie D. Callender,1 Andrew F. Alexis,2 Linda F. Stein Gold,3 Mark Lebwohl,4 Huaming Tan,5 William C. Ports,5 Anna M. Tallman5
Introduction: Atopic dermatitis (AD), a chronic inflammatory skin disease, is more prevalent in patients who are black, Asian, multiple races, or of Hispanic descen. Black and Asian people are more likely to seek treatment for AD, making these patient populations important to assess in clinical trials of patients with AD. In 2 identically designed Phase 3 trials in patients with mild to moderate AD, crisaborole, a nonsteroidal phosphodiesterase 4 inhibitor for the treatment of mild to moderate AD, was superior to vehicle for the primary endpoint, success in global disease severity (pooled, crisaborole vs vehicle [%]: 32.1 vs 21.8, P<0.001), and the secondary endpoint, global disease severity of clear or almost clear (pooled, crisaborole vs vehicle [%]: 50.1 vs 35.2, P<0.001); incidence of treatment-related adverse events (AEs) was low. The efficacy and safety of crisaborole according to race and ethnicity were assessed in a pooled, post hoc analysis.
Methods: Patients were randomly assigned 2:1 to receive crisaborole or vehicle, respectively, twice daily for 28 days. The primary endpoint—success in Investigator’s Static Global Assessment (ISGA), a 5-point scale (clear [0] to severe [4])—was defined as a score of clear (0) or almost clear (1), with a ≥2-grade improvement from baseline (BL) at day 29. Safety was assessed by treatment-emergent AEs (TEAEs). Race included Asian (A), black/African American (B), white (W), and other (American Indian, Alaskan Native, native Hawaiian, other Pacific Islander, other [O]). Ethnicity included Hispanic/Latino (HL) or not Hispanic/Latino (nHL).
Results: A greater proportion of crisaborole-treated patients than vehicle-treated patients had success in ISGA at day 29 for all race and ethnic groups analyzed (Table). At day 29, more crisaborole-treated patients than vehicle-treated patients for all analyzed groups had an ISGA of clear or almost clear (secondary endpoint) (Table). Overall incidence of treatment-related TEAEs across groups was (crisaborole vs vehicle [%]) A: 5.1 vs 5.7; B: 6.7 vs 2.2; W: 7.2 vs 6.3; O: 16.4 vs 4.0; HL: 8.5 vs 8.1; nHL: 7.1 vs 4.3. Most treatment-related TEAEs were mild or moderate, and the most frequent for all race and ethnic groups was application site pain (stinging or burning) (crisaborole vs vehicle [%]; A: 3.4 vs 2.9; B: 2.8 vs 0.0; W: 4.9 vs 1.3; O: 9.1 vs 4.0; HL: 6.0 vs 2.0; nHL: 4.1 vs 1.0).
Acanthosis Nigricans Mimicking Melasma: Case Report and Pearls for Accurate Diagnosis
Authors: Monica Huynh, DO | Ezra Hoover | Tanasha Simela, DO
Facial dyspigmentation is one of the most common dermatological complaints from patients with skin of color. Although facial dyspigmentation is typically benign, it can cause cosmetic disfigurement that results in significant psychological impact. The challenge often lies in establishing the correct diagnosis. Accurate diagnosis is paramount to appropriate management which can both improve cutaneous disease and quality of life. We present a case of an African-American female with facial dyspigmentation that was treated for several years as melasma with hydroquinone cream with little relief. After special consideration of the patient’s medical history of diabetes mellitus combined with the physical presentation of dyspigmentation involving the hollow of the cheeks, the facial dyspigmentation was diagnosed as acanthosis nigricans. The patient was placed on a regimen of an alpha-hydroxy acid (salicylic acid) or beta-hydroxy acid (mandelic acid) cleanser twice daily, and triple-combination cream (hydroquinone 6%, retinoic acid 0.025%, dexamethasone 0.1%) nightly. The patient tolerated the regimen very well and had remarkable improvement by week twelve. We will discuss the significance of accurate diagnosis in patient outcomes as well as highlight the clinical pearls of a variety of pigmentary diseases.
Expert Perspectives on the Management of Moderate-to-Severe Atopic Dermatitis: Addressing Current and Emerging Therapies
Authors: Mark Boguniewicz, Andrew F. Alexis, Lisa A. Beck, Julie Block, Lawrence F. Eichenfield, Luz Fonacier, Emma Guttman-Yassky, Amy S. Paller, David Pariser, Jonathan I. Silverberg, and Mark Lebwohl
Objective: Atopic dermatitis (AD) is a chronic inflammatory skin disease commonly associated with other atopic diseases such as asthma, rhinoconjunctivitis and food allergies. A number of non-atopic co-morbidities have been associated with AD; these are indicative of the systemic nature of the disease, particularly in moderate-to-severe AD. Current treatment guidelines do not reflect new developments in systemic therapies available for patients with AD. We present recommendations from a steering committee (SC) of AD experts regarding the diagnosis and management of moderate-to-severe disease, with an evaluation of new treatment options and how they fit into the current treatment paradigm.
Methods:The SC consisted of 8 dermatologists, 2 allergists, and an AD patient advocacy group representative. The SC developed questions concerning the definition, diagnosis, and treatment of moderate-to-severe AD in a new era of biologic therapies. Statements to address each question were drafted using evidence obtained from a comprehensive literature review that included Medline, Cochrane Library, Global Resource for Eczema Trials, Excerpta Medica, and Web of Science databases, alongside abstracts presented at the American Academy of Dermatology and the European Academy of Dermatology and Venereology and perspectives from SC members. The SC consensus on recommendations for each statement was achieved via modified Delphi methodology voting on a 9-point scale.
Results:The strength of the SC recommendations ranged from 7-9, with a consensus level that ranged from 80-100%. The SC recognized moderate-to-severe AD as a systemic disease, supporting the use of systemic therapiesDiagnosis of moderate-to-severe disease was recommended based on a minimum involvement of 10% body surface area, and individual lesions with moderate-to-severe features, involvement of highly visible or functional areas, or significant impairment of quality of life. Treatment failure was defined as inadequate clinical improvement, failure to achieve stable long-term disease control, presence of ongoing impairment while on treatment, or unacceptable adverse events from these treatments. The SC recommended dupilumab as a first-line systemic treatment option for adults with moderate-to-severe AD whose disease is not controlled by topical treatment. The SC also highlighted the importance of treatment selection being a shared decision-making process between the patient and physician.
Conclusion:These expert recommendations provide up-to-date guidance on the diagnosis and treatment of moderate-to-severe AD.
The 3AD Steering Committee Meeting was funded by Sanofi-Genzyme and Regeneron; however, they had no influence in the discussions or development of recommendations. Lighthouse Medical Communications provided editorial support for the development of the abstract and poster; Sanofi-Genzyme and Regeneron funded this support.
A novel approach to contouring the submental area and jawline; First reported case combining ultrasound technology and unipolar radiofrequency for noninvasive submental contouring.
Author: Kavita Beri
Submental subcutaneous fat deposition and eventual laxity of the facial compartments of the lower portions of the face have an important impact on overall appearance as one ages. Various noninvasive modalities have been applied in an attempt to reduce submental fat and tighten the jaw line. Injection procedures using deoxycholic acid and other minimally invasive techniques such as liposuction or mesotherapy have recently become popular procedures that minimize patient downtime, surgical risk, and cost. This case study reports the first use of a combination therapy using a novel ultrasound-based technology combined with unipolar radiofrequency for reducing submental fat and tightening of the jaw line.
EPIDEMIOLOGY OF ANOGENITAL WARTS IN THE DERMATOLOGY CLINIC OF A HAITIAN TERTIARY HOSPITAL FROM 2013 TO 2015
Author: Sacha Henry, MD
INTRODUCTION: Anogenital warts are sexually transmitted lesions due to the infection with genotypes 6 and 11 of Human Papillomavirus (HPV). Their increasing incidence worldwide makes of them a public health issue. This study aims to determine the epidemiological profile of anogenital warts in the dermatology clinic of a Haitian tertiary hospital. MATERIALS AND METHODS: This is a retrospective study conducted in the dermatology department of the State University Hospital of Haiti (HUEH) in Port-au-Prince, Haiti, from January 2013 to December 2015. Variables such as age, gender, topography and comorbidities (HIV infection or syphilis) were collected from the medical records of the department to establish the epidemiological profile. RESULTS: Of the 41.489 patients who consulted during the study period, 151 had the clinical diagnosis of anogenital warts, which gives a prevalence of 0.36% [95 CI,]. Anogenital warts are in third position among the STIs after herpes and HIV-AIDS. 123 patients were selected for this study according to the selection criteria. The sex ratio is 1.3 for 56% males [95 CI,] and 44% females [95 CI,]. The median age is 26.04 years [0-68] with 47.2% [95 CI,] of the study population in the group age of 20-29 years. 28 of the 57 patients (49,1%) with known HIV status were positive and 6 of 51 tested patients (10,55%) had syphilis. 6 HIV-positive patients (21,4%) had a Buschke-Loewenstein tumor. DISCUSSION: Anogenital warts are among the most common STIs in the dermatology department of HUEH. HPV vaccination needs to be implemented to reduce its incidence, and testing for HIV and syphilis must be systematic for a better management. National and prospective data including genotyping are needed to better characterize the burden of anogenital warts in Haiti.
Dupilumab and Concomitant Topical Corticosteroids in the Long-term Management of Moderate-to-Severe Atopic Dermatitis: Analysis of Clinical Outcomes by Race (LIBERTY AD CHRONOS)
Authors: Manuela Pigors, PhD | David M Pariser, MD | Benjamin N Lockshin, MD
Introduction: Dupilumab, a fully human anti-IL-4Rα monoclonal antibody, inhibits signaling of both IL-4 and IL-13, which are key drivers of type 2/Th2-mediated inflammation. Dupilumab is approved in the EU, USA, Japan, and other countries for the treatment of adults with inadequately controlled moderate-to-severe atopic dermatitis (AD). The LIBERTY AD CHRONOS trial (ClinicalTrials.gov Identifier: NCT02260986) demonstrated long-term efficacy and safety of dupilumab plus concomitant topical corticosteroids (TCS) in patients with moderate-to-severe AD. In this study, we assess the consistency of the dupilumab treatment effect among different racial subgroups from CHRONOS.
Methods: CHRONOS was a 52-week, double-blind, randomized, placebo-controlled, parallel-group, phase 3 study in adults with moderate-to-severe AD and an inadequate response to TCS. Patients were randomized 3:1:3 to placebo, dupilumab 300 mg every 2 weeks (q2w), or dupilumab 300 mg every week (qw). Patients received a standardized regimen of concomitant low-/medium-potency TCS that could be tapered or stopped based on response or topical calcineurin inhibitors in areas inadvisable for TCS.
Results: Baseline characteristics were balanced among the placebo + TCS (n=315), the dupilumab q2w + TCS (n=106) and dupilumab qw + TCS (n=319) groups. Race was recorded by the clinic staff during the screening visit. White, Asian, and Black/ African American patients represented 66.2 % (n=490), 27.2% (n=201), and 4.6% (n=34) of the total study population, respectively. At Week 16 and Week 52, dupilumab + TCS treatment increased both the proportion of patients with an Investigator’s Global Assessment (IGA) 0/1 and ≥ 2-point improvement and the proportion of patients achieving ≥ 75% improvement in Eczema Area and Severity Index (EASI-75) compared with placebo + TCS in all subgroups (Figures 1 and 2). Similarly, in all racial groups analyzed, more dupilumab + TCS-treated patients vs placebo + TCS-treated patients achieved a ≥ 3-point and ≥ 4-point improvement in peak pruritus Numerical Rating Scale (NRS) at Week 16 and Week 52 (Figures 3 and 4). The broad 95% confidence interval (CI) for Black/ African American patients reflects the small sample size among all treatment groups. Treatment groups had similar rates of treatment-emergent adverse events. Higher rates of non-herpetic skin infections were reported in the placebo + TCS group. Conjunctivitis and injection-site injections were more frequent in the dupilumab + TCS groups.
Conclusions: Long-term treatment with dupilumab and concomitant TCS significantly improved signs and symptoms of AD. The efficacy of dupilumab treatment was comparable across the different racial groups in CHRONOS.
Socioeconomic and geographic barriers to dermatology care in urban and rural U.S. populations
Authors: Toral Vaidya, MD
Background: Access to dermatology care is affected by socioeconomic status, rurality, and distribution of providers. Patients of lower socioeconomic status and rural areas may experience longer wait times, treatment delays, and disease progression.
Objective: This study identifies barriers to dermatologic treatment pertaining to socioeconomic status, poverty and income levels, rurality, and race.
Methods: County-specific sociodemographic information was obtained from the AAD Members Services Team and U.S. Census Bureau.Variables were compared via T-test between counties with and without dermatologists, and with dermatologist: population ratios >3.5/100,000 and <3.5/100,000.
Results: The U.S. mean dermatologist: population ratio is 1.10/100,000; 12% of counties have a dermatologist: population ratio >3.5/100,000. Counties with a ratio >3.5 have significantly greater populations, median incomes, and Caucasian-American majorities. The majority of counties with underrepresented minorities, and those in rural areas do not have a dermatologist.
Limitations: Though 90% of allopathic dermatologists AAD members, those of osteopathic programs are not members. Our ideal dermatologist: population ratio has never been validated.
Conclusions: Patients in rural areas, in lower socioeconomic strata, and of racial minorities do not have acceptable access to dermatologists. Interventions must be developed to minimize sociodemographic barriers to care.
Griseofulvin vs. Terbinafine in the Treatment of Tinea Capitis
Authors: Humoud Mansour AlKhalaf 1, Adnan Meteb Mohamed Almezani 2, Youssef Mohammad Almodhaibri 3, Mustafa Mohamed Ali Almusallami 4, Jumanh Khalid Attiah 5, Abdulaziz Mohammed Alsahli 6, Maha Fahad Alluqmani 5, Fatimah Mohammed Saeedi 5, Ali Hassan Jaber Alzahrani 7, Ibrahim Abdullah Al Taha 8, Somaya Khalid Alsharif 9, Fatema Hassan A. ALAjwad 10, Nawal Hatem Herzallah 1
Background: Two oral antifungal agents, griseofulvin and terbinafine, have regulatory approval but it is unknown whether one has superior overall efficacy. Genus-specific differences in efficacy are believed to exist for the two agents. It is not clear at what doses and durations of treatment these differences apply.
Purpose: The purposes of this meta-analysis were to determine whether a statistically significant difference in efficacy exists between these agents at a given dose and duration of each in tinea capitis infections overall and to determine whether a genus-specific difference in efficacy exists for these two treatments at a given dose and duration of each. We performed a literature search for clinically and methodologically similar randomized controlled trials comparing 8 weeks of griseofulvin (6.25–12.5 mg⁄kg⁄day) to 4 weeks of terbinafine (3.125–6.25 mg⁄kg⁄day) in the treatment of tinea capitis. A meta-analysis was performed using the Mantel–Haenszel method and random effects model; results were expressed as odds ratios with 95%.
Results: Meta-analysis of randomized controlled trials did not show a significant difference in the overall efficacy of the two drugs at the doses specified, but specific efficacy differences were observed based on the infectious species. For tinea capitis caused by Microsporumspp., griseofulvin is superior (p = 0.04), whereas terbinafine is superior for Trichophyton spp. infection (p = 0.04).
Conclusion:Our results support species-specific differences in treatment efficacy between griseofulvin and terbinafine and provide a clinical context in which this knowledge may be applied.
Keywords: Griseofulvin, Terbinafine, Tinea Capitis.
Acquired epidermodysplasia verruciformis following hemorrhagic stroke and multiple craniotomies
Authors: Alexandra Lackey, MS3 & Mark Kaiser, MD
Introduction: Epidermodysplasia verruciformis (EV), known in popular culture as “tree man” syndrome, is a rare skin condition with just over 500 cases reported worldwide. Inherited and acquired forms exist, both occurring due to abnormal susceptibility to HPV. Inherited forms are linked to specific loss-of-function mutations in cell-mediated immunity, while reported acquired forms have been observed primarily in organ transplant recipients and HIV-infected patients. EV is characterized by pityriasis versicolor-like lesions with flat-topped papular verruca-like lesions. Of particular concern is the high susceptibility in these patients to actinic keratoses and squamous cell carcinoma of the skin.
Presentation of case: A 34-year-old disabled Hispanic male with past history significant for several left temporoparietal craniotomies secondary to hemorrhagic stroke at age 25 was evaluated for a skin rash. Both he and his family expressed concern, stating that the rash evolved within the months following his stroke and craniotomies. The lesions began as flat-topped hypopigmented lesions which slowly became more widespread and have continued to grow for the past 9 years over all extremities. The lesions do not bother the patient in any way besides their unsightly appearance. He previously attempted use of steroid and retinoid creams without success. No family members have ever experienced a similar rash. Prior to the stroke, he did not notice any similar lesions. There was clinical suspicion for epidermodysplasia verruciformis which was confirmed by biopsy and dermatopathology. The patient was advised to undergo lifelong follow-up with dermatology for regular skin exams. He was also instructed to avoid sun exposure due to his enhanced risk for squamous-type skin cancer.
Discussion: Acquired EV occurring status post hemorrhagic stroke or craniotomy, without other relevant offenses to the immune system, has not been previously reported. This particular case suggests that a mechanism of cell-mediated immunity was interrupted during the course of the patient’s neurologic insult, rendering him susceptible to certain strains of HPV. Although mildly invasive, biopsy was necessary for proper diagnosis so that the patient could be directed to appropriate lifelong follow-up.