2019 Scientific Poster Abstracts from Skin of Color Update

Impact of High Coverage Make-up Coverage against Visible Light Exposure

Authors: Hawasatu Dumbuya, PhD & Janet Wangari-Talbot, PhD

Historically, photo-protection studies have focused on UVB (280-320 nm) and UVA (320-400 nm) protection. However, it is now evident that visible light (400-700 nm) causes skin darkening and contribute to worsening of dyschromia, particularly in individuals with Fitzpatrick phototype III and higher.

Currently, few sunscreens provide protection against visible light. Due to their capabilities in absorbing and reflecting visible light, topical products containing pigments and/or metal oxides (i.e. iron oxide, zinc oxide, and titanium dioxide), can provide additional protection against harmful effects of that spectrum.

Here, we demonstrate that lightly or darkly tinted high coverage pigmented foundation containing iron oxides or a combination of iron oxide and titanium dioxide significantly protected against visible light-induced pigmentation when compared to a mineral SPF50+ sunscreen in Fitzpatrick IV individuals when assessed by visual grading and by chromameter.

Our results show the benefits of high coverage pigmented foundation, containing different concentrations of iron oxide and titanium dioxide, in offering visible light photoprotection. Depending on the metal oxides concentrations, these formulations have the potential to extend protection beyond UV for multiple skin phototypes.

Twenty Nail Dystrophy; a case report from DISHARC, Nepal

Author: PRARTHANA ADHIKARI, MD

Background: Twenty-nail dystrophy (TND) is rare and less reported chronic inflammatory disorder affecting nail matrix of all twenty nails. Literature reports mainly as idiopathic but are also associated with cutaneous or systemic disorders among childhood. It clinically presents as rough, thin, brittle lustureless nails with multiple pits. The diagnosis was made clinically but pathological study shows spongiosis and exocytosis of inflammatory cells in epithelium.

Case Report: We present a case of 9-year-old boy with complaints of rough, thin and pitted nails. He was asymptomatic but was under antithyroid medication for hypothyroidism. His only concern was bad appearance. He was given mild topical steroids and emollients. After 6 months of follow-up, patient has shown sign of improvement. Therefore, TND can also be inferenced as self-limiting disease with minimum treatment can have positive reference.

Treatment of Central Centrifugal Cicatricial Alopecia: A Retrospective Chart Review

Author: Edward Hochman, Bachelor of Science

Central Centrifugal Cicatricial Alopecia (CCCA) is a highly debilitating form of scarring hair loss which primarily affects African American women. There is a lack of data regarding treatment options for patients with CCCA, and therefore, investigation of therapies and responses to these therapies is warranted. In this single-center retrospective chart review, 24 patients with biopsy-proven CCCA were analyzed in terms of their responses to various treatment modalities. The majority of patients showed improvement of their condition in response to either topical clobetasol or intralesional triamcinolone. Patients who did not respond to either of these treatments progressed to therapy with Doxycycline, Hydroxychloroquine, or Methotrexate, with inconsistent responses to therapy amongst patients. There was a significant association between frontal hair loss in CCCA patients and response to intralesional triamcinolone. There was also a statistically significant association between history of chemical relaxer use and response to topical clobetasol. Overall, this study provides insight into potential treatment options for patients struggling with CCCA, and provides direction for future clinical research that will be required to make greater strides in improving the quality of life in patients who have this condition.

A Rare Case of Lipedematous Scalp in an African American Female

Authors: Tiffany Mayo, MD & Amena Alkeswani, BS

This case presents a 55-year old African American female referred to dermatology for an evaluation of hair loss predominantly at the vertex of a 2-year duration. She reported tenderness of the scalp but denied pruritus. Her exam showed a boggy, tender, non-scaly scalp with minimal perifollicular erythema at the vertex. A punch biopsy of the scalp showed no scarring or inflammation. An ultrasound of the scalp demonstrated a gradual increase in tissue thickness at the area of palpable transition without evidence of a focal mass or fluid collection, a finding consistent with lipedematous scalp. The patient was started on mycophenolate 500mg for 1 week, followed by a dosage increase to 500mg BID.

Lipedematous scalp is a rare disorder characterized by thickening of the adipose subcutaneous layer. About 50 cases have been reported in the literature. When associated with hair loss, it is known as lipedematous alopecia. The etiology for this disorder is unknown and no treatment guidelines exist for this rare condition. Literature review showed that intralesional and topical steroid use neither improve symptoms nor slow the progression. A few case reports of surgical debulking and mycophenolate use were demonstrated to be successful treatment options. This case report will discuss the clinical presentation, differential diagnosis, and treatment options for this rare condition.

Cysteamine- Towards A Novel First Line Treatment for Melasma?

Authors: Jennifer David, DO & Maryam Karrabi, MD

Introduction: Kligman’s formula, consisting of hydroquinone, retinoic acid and a corticosteroid remains to date the dermatologist’s treatment of choice for melasma. However, side effects and draw-backs such as  ochronosis, skin atrophy, irritation, photosensitivity and post inflammatory hyperpigmentation are significant.

Cysteamine is a natural molecule synthesized in human cells, and has a long history of safe systemic use in humans. Topical cysteamine was shown to have a significant depigmenting activity in 1960’s and to be significantly more potent than hydroquinone in animal studies. Only recently, cysteamine was managed to be stabilized for use in topical products. In vivo studies have confirmed the higher depigmenting effect of cysteamine compared to hydroquinone.

Methods & Results: The efficacy of Kligman’s formula was compared with cysteamine in a group of 50 patients with epidermal melasma using MASI score and patients questionnaires: 4 months of treatment with cysteamine or the Kligmans formula showed that the MASI scores were reduced equally in both groups; showing the same efficacy for the treatments. Cysteamine, however, was significantly better tolerated than the Kligman’s formula by patients and did not induce any skin irritation.

Sporadic cases are now being reported indicating that melasma patients who are resistant to Kligman’s formula can show a significant therapeutic response to cysteamine.

Discussion: Cysteamine is at least as effective as the Kligman’s formula. Cysteamine is a safe molecule with anti-mutagenic, anti-carcinogenic and anti-melanoma activities. The high efficacy of cysteamine as well as its high safety profile in contrast to Kligman’s formula makes it a very promising alternative for the treatment of melasma.

Influences of therapeutic choices and treatment outcome in acne vulgaris among patients in South Nigeria

Authors: Belema Abbey, MD & Erere Otrofanowei, MD

Acne Vulgaris (AV), a chronic inflammatory disease of the skin and hair follicles is one of the most common reasons to present to the dermatologist. In Nigeria, as with most parts of the world, patients will typically present when they have persistent or worsening lesions and following treatment trial with over the counter (OTC) medications and suggestions from concerned individuals. The awareness that AV can be treated and that there are a few options for treatment is quite new in my environment. Treatment of AV will usually take at least 3 to 6 months for patients to achieve a good treatment outcome. This will involve out of pocket financing, adherence to therapeutic regimens and changing treatment options when treatment outcome is not optimal.

Materials and Methods: This is a retrospective study conducted in a relatively new private dermatology clinic in Southern Nigeria, West Africa from August 2017 to July 2019. Records of patients that were diagnosed for AV were obtained from case notes. Variables such as age, gender, duration, predisposing factors for adult onset acne, knowledge of chemical peel as treatment option for acne, lesion type, type and duration of treatment, including perception of resolution of symptoms were collated and analyzed.

Results: A total of 22 (17.7%) out of 124 patients seen were diagnosed with AV. 81.8% are females and 18.2% are males. The highest age prevalence (54.5%) were in the age range of 31-40 years, 18.2% were 21-30 years old, 13.6% were 41-50 years old, 9.1% were < 18 years and 4.6% were 51-60 years old. The duration of AV was 13.6% for <1 year, 31.8% for 1-5 years, 9.1% for 6-10 years, 22.73% for 10-20 years and >20 years respectively.

About 40.9% had inflamed papules and pustules,27.3% with non-inflamed papules, 18.2% with comedonal acne with 13.6% having nodulocystic acne. The predominant primary or secondary lesion seen in descending order were post inflammatory hyperpigmentation (36.4%), non-inflamed papules (27.3%), ice pic/box scars (13.6%), nodulocystic 9.1%, comedonal 9.1% and inflamed papulopustules 4.6%.

Treatment choices were either standard treatment +/- chemical peels or chemical peels alone. Patients choice were influenced by their finances, need to treat secondary lesions, treat acne and have an even smooth skin. Most patients had an aggressive multi therapy combination of topical retinoid, 5% benzoyl peroxide, oral doxycycline and sunscreen (27.3%), 22.7% opted to combine a chemical peel plus standard treatment, 18.2% had chemical peel plus topical retinoid, benzoyl peroxide minus antibiotics,  13.6% had chemical peel plus oral doxycycline, topical clindamycin, benzoyl peroxide, sunscreen, 9.1% had topical retinoids, benzoyl peroxide with sunscreen while 4.6% was treated with retinoid and sunscreen only. Duration of standard treatment to onset of chemical peel was found to range between 1- 18 months. Reason for delay in peel onset were mostly because of finances in 13.6%, being unsure of a “new” treatment  in 13.6%, while response was not applicable for 40.9% of patients who did not choose to do chemical peels and there was no delay in 31.8% of patients with AV. Whilst 40.9% of patients did not opt for chemical peels,22.7% had glycolic acid peels, 13.6% had glycolic acid and modified Jessner peels, 9.1% had salicylic acid peels, 4.6% had modified Jessner, 4.6% had glycolic acid plus azelaic acid, phytic acid and resorcinol. Only 13.64% of patients treated for AV had done 3 sessions of peels. Patients lost to follow up made up 40.9% of total patients and 27.3% reported that lesions are seventy percent resolved.

Conclusion: Decision on treatment type in patients presenting with acne vulgaris at the clinic were influenced by the predominant lesion type seen. Patients in our environment as with other people with skin of color, have low self-esteem and feel depressed with presence of secondary lesions like post inflammatory hyper pigmentation, scarring and of course the presence of primary acne lesions.

Therefore, the frequently used option of glycolic acid alone or in combination with other peels plus, minus aggressive treatment of acne vulgaris in these patients to improve outcome.

Refractory Cutaneous Crohn’s Disease of the Vulva Treated with Infliximab in an African American Female

Authors: Evelina Pierce, MD & Amena Alkeswani, BS

Crohn’s disease is a chronic inflammatory bowel disorder that has a variety of extra-intestinal manifestations. Cutaneous Crohn’s disease of the vulva is one of these rare manifestations with less than 200 cases reported in the literature. It’s often difficult to diagnose due to extensive differential diagnoses and delays in dermatology referral. Treatment of refractory cases is challenging due to the lack of data and well-established treatment guidelines. However, a few case reports have been published that showed successful use of infliximab in treating refractory cutaneous Crohn’s.

We present a case of a 49-year-old African American female with a long history of Crohn’s disease who presented to dermatology with painful knife-cut ulcerations and swelling of the vulva that first appeared 2 years ago. She was diagnosed with cutaneous Crohn’s disease of the vulva and was started on oral immunosuppression due to the severity of her symptoms.  She eventually failed prednisone, methotrexate, and metronidazole. Recently, she was started on infliximab and has shown good initial response. This case will highlight the challenges of diagnosing cutaneous Crohn’s disease of the vulva and will discuss therapeutic options for this condition.

Unique Patterns: The Koebner Phenomenon in Disseminated Cutaneous Herpes Simplex Virus Infection

Authors: Alexis Carrington, MD; Daniel Mazori, MD; Edward Heilman, MD

A 70-year-old African American woman with metastatic lung adenocarcinoma presented for a one-week history of a blistering eruption. Physical examination of the left anterior thigh revealed a ring of tense bullae with scalloped borders on an erythematous base. This ring corresponded to the shape of an adhesive that the patient had been applying to the area. Additionally, there were grouped tense vesicles on an erythematous base on the right hand and lower legs, as well as papules with hemorrhagic crust on the lower legs, dorsal feet, and soles. Punch biopsies of a left thigh bulla and right leg hemorrhagic papule were consistent with herpesvirus infection. Viral culture of a left thigh bulla identified herpes simplex virus-2. The patient was treated with valacyclovir for 10 days with resolution of the eruption and without recurrence at 1-month follow-up.

This case is notable for the ring-like configuration of the lesions on the patient’s thigh, demonstrating the Koebner phenomenon. The Koebner phenomenon refers the appearance of skin lesions on areas of skin trauma or irritation, in this case from an adhesive. This case is also noteworthy for the disseminated nature of the eruption, for which the patient was at risk because of her immunocompromised state.

Trends in the outpatient management of lower extremity stasis dermatitis in the United States: Use of topical therapy may vary by race and physician specialty

Authors: Jeave Reserva, MD & William Adams

Background:  Chronic venous insufficiency (CVI) of the lower extremities is a common condition encountered in the ambulatory setting that may present as asymptomatic varicosities or as stasis dermatitis with ulceration and/or secondary infection.  Prior studies assessing national practice data on stasis dermatitis management have not investigated treatment utilization of topical steroids and topical antibiotics.  Research has shown racial disparities in CVI, with African-Americans often presenting with more advanced disease. Practice variations likely exist in the use of topical therapy in the treatment of stasis dermatitis.

Objectives: (1) Compare the proportion of stasis dermatitis visits managed by dermatology versus non-dermatology specialties; (2) Evaluate demographic and health-care related factors associated with the use of topical steroid and topical antibiotic in the treatment of stasis dermatitis

Methods:  Fourteen years (2003 – 2016) of data from the National Ambulatory Medical Care Surveys (NAMCS) and National Hospital Ambulatory Medical Care Survey – Emergency Department (NHAMCS-ED) as well as nine years (2003 – 2011) of data from the NHAMCS-Outpatient Department (OPD) survey were aggregated for analysis.  Visits were stratified and weighted to reflect their clustered sampling probability as described by National Center for Health Statistics (NHCS).  After identifying visits with a diagnosis of stasis dermatitis (i.e., CVI with inflammation/ulcer), logistic regression for complex surveys was used to estimate the odds of stasis dermatitis as a function of multivariable patient characteristics, including race, age, sex, and insurance status, as well as physician specialty.  The odds of prescribing topical steroid or topical antibiotic during a stasis dermatitis visit was estimated using the same multivariable patient and physician characteristics.

Results:  Among the 15.9 billion ambulatory visits between 2003 and 2016, approximately 1.6 million stasis dermatitis visits were managed by dermatologists, accounting for 0.33% of their total ambulatory visits.  Similarly, general surgeons managed 1.7 million stasis dermatitis visits (0.64%) among their 257 million total ambulatory encounters. Approximately 20.8 million stasis dermatitis visits were to non-dermatologists, accounting for 0.13% of non-dermatologists’ total ambulatory visits.

Controlling for sex, age, insurance status, race, and survey year, visits to dermatologists were 1.79 (95% CI: 1.04 – 3.07) times more likely to mention a diagnosis of stasis dermatitis than visits to other specialties (p = .03).  Similarly, controlling for all other variables in the model, increasing age was associated with a diagnosis of stasis dermatitis.  That is, for every 5-year increase in age the odds of a diagnosis of stasis dermatitis increased by approximately 18% (OR = 1.18, 95% CI: 1.13 – 1.24; p < .001).   Controlling for sex, age, insurance status, race, and survey year, dermatologists were 3.14 (95% CI: 1.33 – 7.43) times more likely to prescribe a topical steroid during a stasis dermatitis visit than other specialties (p = .01).  Further, controlling for all other variables in the model, increasing survey year was associated with receiving a topical steroid during a visit mentioning a diagnosis of stasis dermatitis.  That is, for each year increase in the survey period the odds of receiving a topical steroid during a visit mentioning a diagnosis of stasis dermatitis increased by approximately 20% (OR = 1.20, 95% CI: 1.10 – 1.31; p < .001).  Controlling for sex, age, race, physician specialty, and survey year, patients without private insurance were 3.41 (95% CI: 1.11 – 10.51) times more likely to receive a topical antibiotic during a visit for stasis dermatitis than those with private insurance (p = .03).  Further, controlling for all other variables in the model, non-White patients were 3.79 (95% CI: 1.18 – 12.18) times more likely to receive a topical antibiotic during a visit for stasis dermatitis than those identifying as White (p = .03).

Limitations:   Although prevalence estimates may be calculated using census data, the number of visits does not reflect the true disease prevalence.

Conclusion:  Dermatologists and general surgeons manage the highest of proportions of patients with stasis dermatitis in the ambulatory setting.  Dermatologists appear to be more attuned to the value of topical steroid therapy in the management of stasis dermatitis than non-dermatologists, probably as consequence of specialty training.  Non-white patients and those without private insurance are three times more likely to receive topical antibiotics during a stasis dermatitis visit.  This finding may suggest disparities in these groups who may be presenting more often with secondarily infected stasis dermatitis.

Dupilumab for Adolescents With Moderate-to-Severe Atopic Dermatitis: Results From a Phase 3, Randomized, Double-Blinded Trial

Author: Andrew Blauvelt, MD, MBA

Background: Atopic dermatitis (AD) is the most common chronic inflammatory skin disease in children and has a profound impact on quality of life (QoL). Dupilumab (DPL) is approved for patients aged 12 years and older in the USA with moderate-to-severe AD inadequately controlled by topical prescription treatments or when those therapies are not advisable, adult AD patients in Japan not adequately controlled with existing therapies, and moderate to severe AD patients aged 18 years and older in Europe who are candidates for systemic therapy.

Objective: To report the efficacy and safety of DPL monotherapy in a phase 3, double-blinded, placebo (PBO)-controlled trial in adolescent patients (pts) with moderate-to-severe AD inadequately controlled with topical therapies (NCT03054428).

Methods: Pts (≥12 to <18 years) received subcutaneous DPL every 2 weeks (q2w; 200 mg if baseline [BL] weight <60 kg, 300 mg if BL weight ≥60 kg) or every 4 weeks (q4w; 300 mg) or PBO q2w, for 16 weeks (Wks).

Results: Of 251 pts randomized, 85 received PBO, 84 DPL 300 mg q4w, and 82 DPL 200/300 mg q2w. At Wk 16, DPL treatment (q2w/q4w vs PBO) resulted in greater proportions of pts achieving Investigator’s Global Assessment scores of 0 or 1 (24.4%/17.9% vs 2.4%; P<0.0001/P=0.0007) and ≥75% improvement in Eczema Area and Severity Index score (EASI-75; 41.5%/38.1% vs 8.2%; P<0.0001 both regimens). DPL improved least squares mean % changes from BL to Wk 16 in EASI (−65.9%/−64.8% vs −23.6%), peak pruritus Numerical Rating Scale (NRS) (−47.9%/−45.5% vs −19.0%), body surface area affected by AD (−30.11%/−33.41% vs −11.66%), and SCORing AD (P<0.0001, all comparisons). At Wk 16, more DPL- than PBO-treated pts achieved ≥3- or ≥4-point improvement in pruritus NRS score, EASI-50, or EASI-90 (P<0.0005 for all). DPL also improved (BL to Wk 16) scores on the Children’s Dermatology Life Quality Index and Patient-Oriented Eczema Measure (P<0.0001 for all). A numerically higher proportion of pts used rescue medications in the PBO vs DPL and DPL q4w vs q2w groups. Rates of non-herpetic skin infections (11.0%/13.3% vs 20.0%) were numerically higher with PBO; conjunctivitis (9.8%/10.8% vs 4.7%) and injection-site reactions (8.5%/6.0% vs 3.5%) were more frequent with DPL. There was 1 serious adverse event (AE) and 1 AE leading to treatment discontinuation with PBO and none with DPL.

Conclusions: DPL treatment resulted in clinically relevant and statistically significant improvements in AD signs and symptoms and QoL in adolescents with moderate-to-severe AD, with an acceptable safety profile. DPL q2w was numerically superior to DPL q4w in most clinical endpoints. Both PBO-corrected efficacy and safety of DPL in adolescent pts were similar to those in adults.

Clinically Meaningful Responses in Moderate-to-Severe Atopic Dermatitis Patients Treated With Dupilumab

Author: Marjolein de Bruin-Weller, MD, PhD

Introduction: Dupilumab (DPL), a fully human anti-IL-4Rα mAb, is approved for patients aged 12 years and older in the USA with moderate-to-severe AD inadequately controlled by topical prescription treatments or when those therapies are not advisable, adult AD patients in Japan not adequately controlled with existing therapies, and moderate to severe AD patients aged 18 years and older in Europe who are candidates for systemic therapy. Here we determine the proportion of moderate-to-severe AD patients (pts) treated with DPL who achieved a clinically meaningful response in at least 1 of the 3 major AD domains (signs, symptoms, and quality of life [QoL]), across four phase 3 trials: LIBERTY AD SOLO 1 & 2 (NCT02277743, NCT02277769), CHRONOS (NCT02260986), CAFÉ (NCT02755649).

Methods: Pts received subcutaneous DPL 300mg weekly (qw)/every 2 weeks (q2w) or placebo (PBO) qw for 16 weeks (SOLO 1&2), or DPL qw/q2w plus concomitant topical corticosteroids (TCS) or PBO+TCS for 16 weeks (CAFÉ) or 52 weeks (CHRONOS). Clinically meaningful response was measured by the proportion of pts achieving improvement of ≥50% on the Eczema Area and Severity Index (EASI-50), or reduction in peak pruritus Numerical Rating Scale (NRS) score ≥3 points from baseline (BL), or improvement in Dermatology Life Quality Index (DLQI) score ≥4 points from BL. Pts were considered “nonresponder” after rescue treatment use.

Results: BL characteristics were similar in all treatment groups across trials. DPL resulted in a significantly higher proportion of pts achieving at least 1 clinically meaningful response after 16 weeks of treatment compared to PBO (SOLO 1&2 [qw/q2w vs PBO]: 70.1%/76.6% vs 35.0%) or PBO+TCS (CHRONOS [qw/q2w+TCS vs PBO+TCS]: 83.4%/84.0% vs 52.7%; CAFÈ [qw/q2w+TCS vs PBO+TCS]: 91.8%/95.3% vs 61.1%), and after 52 weeks (CHRONOS [qw/q2w+TCS vs PBO+TCS]: 72.1%/79.2% vs 36.2%), as measured by EASI-50, or NRS score ≥3, or DLQI ≥4. P<0.0001 for all results.

Conclusions: Across multiple phase 3 trials, the majority of AD pts treated with DPL experienced clinically meaningful improvement in at least one of the 3 key domains (signs, symptoms, and QoL), as measured by the proportion of pts achieving EASI-50, NRS≥3, or DLQI≥4 at Weeks 16 and 52.

Combined Doxycycline 40 MG Modified Release Capsules Plus Ivermectin 1% Cream Therapy for Severe Papulopustular Rosacea

Authors: James Q. Del Rosso, DO & Sandra M. Johnson, MD

Introduction: Rosacea is a chronic inflammatory skin disease that is often best managed with combination therapy. There have been a limited number of rigorous controlled studies of combination therapies, despite high interest in such approaches. Doxycycline 40 mg modified release (DMR) and ivermectin 1% cream (IVM) are two well-established treatments for rosacea with proven efficacy, tolerability and safety. DMR and IVM have different and complementary targets in the inflammatory cascade of rosacea, suggesting that this would be a good combination for study. The objective of our study was to evaluate whether DMR + IVM was more efficacious than IVM alone in treating severe papulopustular rosacea (PPR; Investigator Global Assessment [IGA] 4), and whether there was a better improvement in quality of life with combination versus monotherapy. Additionally, we studied whether combination therapy could increase the percentage of subjects reaching “Clear” (IGA 0; 100% reduction of inflammatory lesions plus no erythema) as well as relief of other rosacea-associated symptoms.

Methods: 12-week, multicenter, randomized, investigator-blinded, parallel-group comparative study. Subjects aged 18 years or older with severe PPR (IGA 4) including >20 to 70 inflammatory lesions on the face were eligible and were randomized to either DMR + IVM (combination arm) or IVM + placebo. All subjects used Cetaphil Redness Relieving facial wash and Cetaphil Redness Relieving Moisturizer, SPF 30. The primary efficacy assessment was percent change in inflammatory lesion count from baseline to week 12; secondary variables included Clinician’s Erythema Assessment (CEA) and change in stinging/burning and flushing. Adverse events and cutaneous tolerability were recorded.

Results: A total of 273 IGA 4 rosacea subjects participated; 60% had severe erythema (CEA 4), 50% had moderate to severe stinging/burning, and 40% had ocular symptoms. Compared with IVM alone, the combination of DMR + IVM:

• Displayed superior efficacy in reduction of inflammatory lesions (-80.29% vs -72.56%, P=.032) and IGA score (P=.032).
• Combination therapy had a faster onset of action, with a significant differences over topical alone, as early as week 4.
• Significantly increased the number of subjects achieving IGA 0 (11.9% vs. 5.1%, P=.043%) and 100% lesion reduction (17.8% vs 7.2%, P=.006) at week 12.

Both combination and monotherapy treatment arms substantially reduced CEA score, burning/stinging, flushing frequency, Dermatology Life Quality Index (DLQI) and ocular symptoms. The combination of DMR + IVM was well tolerated, there were no increases in GI related symptoms, and there were no discontinuations of treatment due to related side effects.

Conclusion: Combination therapy with DMR + IVM was shown to be a safe and more efficacious option compared to monotherapy in the treatment of PPR.

Maintenance Regimens with Triple Combination Cream (0.01% fluocinolone acetonide + 4% hydroquinone + 0.05% tretinoin) in Moderate to Severe Melasma

Authors: Tania F. Cestari, MD & Nabil Kerrouche, MSc

Background and Objectives: The relapsing nature of the disease is a problem for melasma treatment: there is a real need to address how to maintain efficacy achieved after acute treatment. Previous long-term data on a triple combination (TC) cream showed that 50% of the patients needed a second treatment course within 58 days after their melasma had satisfactorily resolved. As there is no robust guidance for a maintenance dosage regimen with TC, we compared two maintenance regimens with TC in patients with moderate to severe melasma.

Materials and Methods: Patients aged 18 years or older, with moderate to severe melasma [Global Severity Score (GSS) of 2 or 3], entered an initial phase where they applied TC once daily for 8 weeks. Patients showing a GSS≤1 (mild severity) then entered an Investigator-blinded maintenance phase in which they were randomized to either TC twice weekly for 6 months (twice weekly regimen) or TC 3/week (1 month), 2/week (1 month), 1/week (4 months) (tapering regimen). A SPF 60 sunscreen was also provided. If relapse occurred (GSS≥2), patients were withdrawn from the study. The primary efficacy measure was the time to first relapse. A dichotomized variable (no relapse=0 and relapse=1) was also analyzed based on GSS.

Results and Conclusion: 320 patients were enrolled in the initial phase (52.2% moderate melasma, 47.8% severe melasma). Mean age was 41.5 years. 78.8% had no or mild melasma at the end of this phase. 242 patients entered the maintenance phase. After 4 weeks, 78% of the patients in the twice weekly group and 83.5% in the tapering regimen group remained free of relapse. This 5% difference between the two groups persisted at week 8. Starting at week 12, the two maintenance regimens display the same percentage of patients free of relapse until the end of the study. After 6 months, 53.8% patients (twice weekly) and 53% patients (tapering regimen) were free of relapse. The median time to relapse was around 190 days, regardless of the treatment regimen. Results of this study show that for physicians who do not want to treat their melasma patients daily for several months with TC, alternative maintenance regimens are possible and effective for long-term maintenance treatment of moderate to severe melasma. Such maintenance regimens could help to postpone the relapse of melasma.

High patient satisfaction with adapalene 0.3%/ benzoyl peroxide 2.5% in the treatment of moderate or severe acne in subjects with skin of color

Authors: Janet DuBois, MD & Gavin Chun Wei Ong, MD

Introduction: In skin of color subjects (Fitzpatrick skin phototypes [FST] IV to VI), the objective was to evaluate subject reported outcomes with a fixed combination treatment containing adapalene 0.3%/ benzoyl peroxide 2.5% (A0.3/BPO2.5) gel in the treatment of moderate to severe acne vulgaris of the face.

Methods: This was an open label, single arm, interventional study conducted in 3 countries (Mauritius, Singapore, USA) in subjects of Asian, Latin American, or Black/African-American ethnicity (planned enrollment 1:1:1), with an Investigator’s Global Assessment (IGA) of moderate or severe acne (planned enrollment 2:1), and FST IV to VI. For 16 weeks, subjects applied: A0.3/BPO2.5 gel (once daily, evening) and a skin care regimen (oil control foam wash and oil control moisturizer SPF30). Assessments included the Dermatology Life Quality Index questionnaire (DLQI), the Children’s Dermatology Life Quality Index (cDLQI) questionnaire (if ≤16 years old), subject questionnaires, IGA, investigator Global Assessment of Improvement (GAI), Post-Inflammatory Hyper-pigmentation (PIH; if present at baseline), tolerability, and safety.

Results: Subjects (N = 50) enrolled included 20 Asians, 17 African-Americans, and 13 Latin Americans. Most had FST IV (74%) or V (22%), with moderate (70%; IGA 3) or severe (30%; IGA 4) acne at baseline. A DLQI/cDLQI score indicating a moderate to extremely large effect on QoL was observed for approximately 50% of subjects at baseline compared to 15% at W16. At W16, 76.6% of subjects were overall satisfied or very satisfied with the study treatment.

At W16, 56% of subjects had an IGA score of 0 or 1 (clear/almost clear), and 87% had a good to excellent improvement in GAI score.

Of those subjects with PIH at baseline (60%), all were rated very mild to moderate. By W16, the majority (75%) had none or very mild PIH, and the mean percentage decrease in PIH was 27%. Seven subjects (14%) reported related adverse events but all were mild. Overall, 49% of subjects (W16) were not bothered at all by treatment side effects.

Conclusions: Subjects of Asian, African American, and Latin American ethnicities, with dark skin phototypes (FST IV VI), and moderate or severe facial acne reported high patient satisfaction with A0.3/BPO2.5 gel treatment. Subjects experienced good tolerability, improved QoL, acne treatment efficacy, and improvement in PIH.

Identifying high burden patients with rosacea by demographic and disease related factors

Authors: Jerry Tan, MD & Martin Steinhoff, MD

Introduction: Rosacea is a chronic inflammatory skin disease with potential to adversely impact quality of life (QoL). Those with high disease burden have greater medical needs; identifying high burden (HB) rosacea patients facilitates targeting of medical resources.

Methods: Online survey of 710 patients (mean age: 44.5 years; 243 male, 467 female) from the US, Canada, Italy, UK, Germany and France. HB was defined as the presence of at least 3 of 4: 1) overall impact on QoL score >5 on scale 0-10, 2) level of behavioral adaptation score >6 on scale 0-10, 3) willingness to pay >20% monthly income to obtain complete cure, and 4) willingness to trade >6 months of life for complete cure. Characteristics of HB patients were analyzed using the Wald Chi2 Test and the factors most associated with the HB state were estimated by multivariate logistic models with variable selection performed using Lasso’s procedure.

Results: HB patients (n=158) were younger and more likely to be working and urban dwellers vs non-HB patients (n=552; P<.01). Compared with non-HB patients, HB patients were more likely to have skin sensations over the past 12 months as follows: itching (P=.02); burning and pain (P<.01); swelling (P=.01); nose permanently red and swollen (P<.01). HB patients spent more time on their daily skin care routine vs non-HB patients (31.1 vs 20.6 min; P<.01), with 50.0% spending ≥30 min (vs 27.2%; P<.01), respectively. HB patients were more likely to adapt their behavior vs non-HB patients (P<.01) and to miss ≥5 hours from work in the past 7 days due to health problems (P<.01). Also, HB patients were more likely to have at least one rosacea-related emergency room visit in past 12 months (P<.01), and 17.7% had ≥3 visits (vs 2.5%; P<.01); rosacea-related office visits were also significantly greater for HB patients (P<.01), with 71.5% visiting a dermatologist ≥3 or more times (P<.01).

Although symptom severity contributed to disease burden, we found the HB state could be associated with any severity. HB patient rosacea self-ratings on the survey day were severe 12.7%, moderate 44.3%, mild 28.5%, almost clear 8.2% and clear 6.3%.

‘Moderate’ or ‘severe’ rosacea increased the risk of HB vs ‘clear’ (OR 2.7 and OR 2.6). Other factors affecting HB risk included impact on daily activities and age; patients <30 years at first symptoms showed the highest burden risk of all age groups (OR 2.83).

Conclusions: Demographic/disease factors can characterize the HB rosacea population.

Identification of HB patients in clinical practice would optimize use of therapeutic resources for early and effective interventions.

Support: This study was supported by Galderma. All authors served as consultants to Galderma, except Mr. Rives who was employed by Galderma.

Cutaneous Manifestations of EGFR-Inhibitors in African Americans and Treatment Considerations – A Case Report and Review of the Literature

Authors: Sarah Jawed Noor, MD; Amaris Geisler; Mario E Lacouture, MD

Introduction: Targeted therapies in particular epidermal growth factor (EGFR)-inhibitors have emerged as the primary therapy in advanced solid tumor malignancies including colorectal, pancreas, head and neck cancers, and non-small cell lung carcinoma because of improvement in survival with overall favorable side effect profile. EGFR-inhibitors include small molecule Tyrosine Kinase Inhibitors (TKIs) such as gefitinib, erlotinib, and lapatinib, as well as Monoclonal Antibodies such as cetuximab and panitumumab. However, 50-90% of patients treated with EGFR-inhibitors develop a follicular or acneiform rash, which can be symptomatic and source of psychosocial distress, negatively impacting quality of life. The pathogenesis of this rash is thought to be due to EGFR inhibition preventing keratinocyte migration, inducing keratinocyte apoptosis, and modulating cytokine release, which leads to the influx of inflammatory cells in the epidermis and dermis. The epidermis becomes thin leading to skin atrophy and xerosis, and extensive follicular involvement can lead to scarring alopecia. Areas with the highest follicle and sebaceous gland density, including the head and neck, chest, and back, are most frequently involved.

As this acneiform rash is a well-recognized cutaneous toxicity of EGFR-inhibitors, a treatment algorithm has been proposed for management based on severity. However, this algorithm does not account for biologic differences in skin in patients of different races and ethnicities. Herein, we provide a case of an African American patient who developed this acneiform rash while on cetuxima.

Case: A 52-year-old African American male with a history of recurrent, metastatic oropharynx squamous cell carcinoma involving the lymph nodes, lungs, liver, and bone, on cetuximab weekly and a VEGFR inhibitor daily for the past four months, presented to dermatology with pruritic acneiform papules and pustules diffusely over the face, neck, upper chest, and back. He had not previously tried any topical or oral medications to treat the rash. He was otherwise afebrile, well-appearing, with normal labs. Diagnosis of EGFR-inhibitor acneiform rash grade 2 was made and patient was started on oral antibiotics, doxycycline 100 mg twice a day in addition to topical clindamycin and alclometasone. The acneiform rash improved while on this regimen, but he had areas that resolved with hyperpigmentation.

Discussion: The typical algorithm for EGFR-inhibitor induced rash includes use of an emollient, a non-alcohol based sunscreen with titanium dioxide and zinc oxide, topical steroids/topical antibiotics, and oral tetracyclines.  Topical steroids are recommended to be used with caution, given concern for skin atrophy and dyspigmentation with long-term use, and exacerbating acne. Using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE), studies have suggested better efficacy with prophylactic use of tetracyclines. Treatment of acneiform eruption, rather than EGFR-inhibitor dose reduction or discontinuation, is preferred as there has been a positive correlation described between rash severity and cancer survival. However, treatment options for EGFR-inhibitor induced rash may not be generalizable to African Americans, who not only differ in their skin biology but are also underrepresented in therapeutic clinical trials, preventing complete understanding of side effects. Furthermore, EGFR-inhibitor induced rash has been reported to occur later in African American patients, often after 4-6 cycles of treatment.

EGFR-inhibitor rash in African American patients has only been reported a few times previously. One case was of a 61-year-old male with oropharyngeal cancer also treated with cetuximab who developed a mild facial acneiform rash after the second cycle of treatment, that progressed in severity with continued treatment. He was similarly treated with doxycycline with significant improvement. The second case was of a 41-year-old African American female who developed a milder presentation after six cycles of lapatinib and was treated only with low potency topical steroids. In both cases, treatment was continued, although in the first case, dose was held for one week. Although one case mentioned the need to investigate the challenges in treating this rash in patients of skin of color, both cases were treated similarly according to known rash algorithm.

One of the main challenges in treating this rash in different patient populations is inherent biologic differences in skin of African Americans and Caucasians. In both cases, acne begins with the retention of desquamated keratinocytes and sebum within the pilosebaceous unit leading to follicular plugging. Propionibacterium acnes, which also resides in the pilosebaceous unit, incites an inflammatory response by acting on toll like receptor-2 (TLR-2), stimulating the secretion of cytokines. African Americans have a higher density of P. acnes, and larger sebaceous glands with increased sebum secretion. Consequently, skin of color displays substantial histological inflammation even around comedones that are not clinically inflamed. This heightened inflammatory response may be why African Americans with even mild to moderate acne develop post-inflammatory hyperpigmentation (PIH), hypertrophic scarring, and keloid formation. African Americans also have an increased number of fibroblasts, as well as larger fibroblasts, resulting in an increased prevalence of keloids.

These inflammatory mediators can also stimulate tyrosinase activity and subsequent melanin synthesis. It is known that the differences in skin color are not due to the number of melanocytes, but rather the activity of tyrosinase in melanosomes, the number, size, and aggregation of melanosomes within melanocytes, and the efficiency of melanosome transfer from melanocyte to keratinocyte. In African Americans, the number of melanosomes transferred to keratinocytes is significantly higher, melanosomes are more active in producing melanin, and they are larger and present in all layers of the epidermis. PIH is more prevalent in African Americans due to these increased melanosomes which exhibit labile responses to irritation and injury. Other factors that may contribute to worsening PIH include increased skin sensitivity in African Americans thought to be due to impaired barrier function/increased transepidermal water loss, which may increase irritation after topical acne products such as retinoids. Skin care practices including use of hair emollients and heavy oils leading to “pomade acne” and the increased incidence of other follicular skin and hair disorders in the African American population such as acne keloidalis may also contribute to worsening acneiform rash in patients receiving EGFR inhibitors.

Conclusion: Treatment of EGFR-inhibitor induced rash in patients with skin of color can present both cultural challenges, due to skin care product use, and pathophysiologic challenges, due to differences in skin biology and sensitivity. Delays in treatment and misdiagnoses may lead to sequelae such as PIH and keloids which is more prevalent in this population. Reducing skin irritation and xerosis, which may adversely affect darker skin, is a key goal in treating rash in skin of color. Further studies are needed to evaluate EGFR-inhibitor rash presentation and treatment outcomes with standard algorithm in African Americans to determine if the typical management approach needs to be modified in this patient population.

Willingness-to-pay of patients with chronic skin diseases in Korea: A skin or color’s perspective

Authors: Jung Min Bae, MD & Miri Kim, MD

Chronic skin diseases have significant impacts on the quality of life (QoL) of the patients, although not life threatening. However, current QoL measurements often do not adequately reflect the actual disease burden of the affected person. Willingness-to-pay (WTP) questionnaire was developed to assess disease burden economically. In the present study, we evaluated QoL and WTP in patients with five chronic skin diseases; alopecia areata (AA), atopic dermatitis (AD), chronic urticaria (CU), psoriasis, and vitiligo. QoL was evaluated using the Dermatology Life Quality Index (DLQI) questionnaire, and WTP was assessed from two aspects: monthly WTP for disease control and one-time WTP for disease cure. The body surface area (BSA) of involvement and monthly income of each patient were also collected.

A total of 269 patients (118 males and 149 females; mean age: 41.6 years) were enrolled: 58 for AA, 58 for AD, 47 for CU, 45 for psoriasis, and 61 for vitiligo. The median DLQI score was highest in AD patients (13 for AD, 10 for psoriasis, 9 for CU, 8 for vitiligo, and 7.5 for AA). The median monthly WTP control was highest in vitiligo ($168 for vitiligo, $92.4 for psoriasis, PSO, AD and AA, and $84 for CU), and the median one-time WTP cure was also highest in vitiligo ($1891 for vitiligo, $941 for PSO, AD and AA, $891 for CU). DLQI scores showed a positive correlation with BSA in AD, psoriasis, and vitiligo, however, WTP did not show a positive correlation with BSA in vitiligo, unlike AD and psoriasis.

In conclusion, we demonstrate that WTP was the highest in vitiligo, although it had a lower DLQI score than others. It may imply that DLQI is not a critical indicator of patient’s treatment decision. Furthermore, vitiligo patients with small BSA (<1%) also have high WTP comparable to those with large BSA, unlike AD and psoriasis.

Sunscreen stick SPF70 improves global skin conditions and hyperpigmentation on skin of color subjects

Authors: Katleen Conceição, MD & Mirela Seixas, Other

Skin discoloration is a common concern with limited treatment options for multi-ethnic patients due to the increased risk of Post Inflammatory Hyperpigmentation (PIH). Combination therapy with sunscreen has been shown to be more effective in addressing hyperpigmentation. However, the most effective galenic form sunscreen have been minimally investigated. Sunscreen stick could be suggested to be used in patients with hyperpigmentation due to ease of application, resistant and cohesive protective film forming and high-water resistance. The aim of this study was to evaluate the efficacy of sunscreen stick SPF70 formulation (containing iron oxides and tinted) for the improvement of skin conditions in patients with moderate to severe facial hyperpigmentation. Subjects with moderate to severe hyperpigmentation were included in the study and applied the sunscreen stick SPF70 twice a day for 30 days. Clinical assessments were made at the beginning and after 30 days of daily treatment, including global improvement in hyperpigmentation scale by dermatologist, subject’s self-questionnaire for quality of life, standardizes digital photographs (Visia- CR) and reflectance confocal microscopy (RCM). Clinical evaluations showed that all skin parameters improved significantly after 30 days of sunscreen stick application. The combination of high sun protection factor, long wavelength UVA protection, visible light and infrared radiation protection with high coverage and high-water resistance seem to be associated with the effectiveness of the sunscreen stick. The self-assessment questionnaire showed a positive impact on subjects’ quality of life since the first application due to the high coverage provided by the iron oxide pigments and the film provided by the stick formula. Results demonstrate the benefits of daily use sunscreen stick FPS70 to improve skin hyperpigmentation. This type of sunscreen may be suggested as the most appropriate form of sun protection for patients with mild to severe hyperpigmentation.

Novel Tretinoin 0.05% lotion for the once-daily treatment of moderate-to-severe acne vulgaris in a Hispanic population

Authors: Fran E Cook-Bolden, MD & Susan H Weinkle, MD

To determine the efficacy and safety of tretinoin 0.05% lotion in treating moderate-to-severe acne in a Hispanic population. Post hoc analysis of two multicenter, randomized, double-blind, vehicle-controlled Phase 3 studies in moderate or severe acne. Hispanic subjects (aged 11 to 50 years, N=766) were randomized (1:1) to receive tretinoin 0.05% lotion or vehicle, once-daily for 12 weeks. Tretinoin 0.05% lotion was significantly more effective than its vehicle in achieving treatment success and reducing inflammatory and noninflammatory acne lesions in a Hispanic population. The new lotion formulation was well-tolerated, and all treatment-related AEs were both mild and transient in nature.

Efficacy, Safety and Tolerability of a Halobetasol 0.01%/Tazarotene 0.045% Fixed Combination in the Treatment of Moderate-to-Severe Plaque Psoriasis in a Hispanic Population: Post Hoc Analysis of 2 Phase III Randomized Controlled Trials

Authors: Andrew F Alexis, MD & Paul S Yamauchi, MD

This poster presented a post hoc analysis of two multicenter, randomized, double-blind, vehicle-controlled Phase 3 studies. 115 Hispanic patients randomized (2:1) to receive HP/TAZ or vehicle, once-daily for 8 weeks, with a 4-week posttreatment follow-up. HP/TAZ lotion was associated with significant, rapid and sustained reductions in disease severity in a Hispanic population with moderate-to-severe psoriasis with good tolerability and safety over 8 weeks once-daily use.

Implementing Best Practices for Screening People of Color for Melanoma

Author: Yasmin Mathlin, NP

Introduction/Statement of Problem: Melanoma has a low incidence in skin of color. However, the mortality rate is higher in this population because it is often diagnosed in advanced stages (Guy, Thomas, Thompson, Watson, Massetti, & Richardson, 2015). The key reason for this is that people with skin of color have a perception that their skin color protects them from skin cancer. There is a knowledge deficit in skin cancer and how it presents in people with skin of color (Chao, Patterson, Rademaker, Liu, & Kundo, 2016). This quality improvement project was developed to improve the knowledge and awareness of melanoma in people with skin of color through education.

Materials and Methods Used: The Health Belief Model (HBM) will be used to guide this quality improvement education project. One of the concepts of the HBM is that people need to believe they are susceptible to a condition/disease to be willing to implement a change (LaMorte, 2018). Therefore, education is needed in this patient population to bring awareness of melanoma in people with skin of color. A teach back method will be used to educate people with skin of color about their susceptibility to melanoma. As a result, this population will gain awareness and will be able to change their health behavior about melanoma.

• 50 patients with skin of color at Tory Sullivan MD General and Cosmetic Dermatology will be sampled at convenience on Mondays for a period of 1 month.
• Patients with skin of color will be educated about melanoma, specifically acral lentiginous melanoma using the ABCDEs of melanoma and pictures showing acral lentiginous melanoma at various stages
• After patients with skin of color are educated about melanoma they will be asked what they learned that they didn’t know. Patients will be scored 1 point if:

a) they verbalize understanding of the ABCDEs of melanoma (0.2 points will be given for each letter of the ABCDEs of melanoma)

b) could patient identify a possible pigmented lesion that would need to be examined

c) did patient verbalize the need to have hands and feet examined

• A response of 2.8-3/3 will be deemed as a successful learning outcome. 2.4-2.79/3 will be considered moderately successful. 1.8-2.39/3 will be considered mildly successful and 0-1.79/3 will be deemed as an unsuccessful learning outcome.
• Data from the quality improvement project will be collected and analyzed using basic statistical analysisResultsThe mean age of the participants was 43.8 years old. Forty-four percent of the project participants had a high school education, while 56% had a post secondary education. The mean score was 2.69. Forty-eight percent of the participants were African American, while 44% were of Caribbean decent. Eight percent of the participants were Hispanic.

Conclusions: The overall results showed a moderately successful learning outcome; however, when individual results were examined, it was determined that participants with a high school education had lower scores after the teach back. These participants had trouble remembering words that were not part of their normal vernacular, such as asymmetry and evolving. The results support the need for focusing education about melanoma to people with skin of color that have less education. Different learning tools, such a pictures and pamphlets with vocabulary written at a 6th grade education need to be explored to foster understanding and comprehension.

Not so red in the face: a challenging case of Morbihan disease in skin of color

Authors: Kimberly Huerth, MD & Olivia Ware, Other

 Morbihan disease (MD), also referred to as solid facial edema, rosacea lymphedema, and morbus Morbihan, is characterized by slowly progressive, persistent, non-pitting edema of the upper 2/3 of the face (forehead, glabella, eyelids, and cheeks). It is a rare disorder that is regarded to be more common among Caucasian women in their 3rd-4th decade of life, though a majority of published cases describe male patients. MD is thought to be even rarer in skin of color, with only 2 cases reported in the literature. We describe a case of MD in a 52-year-old African American male who presented with slowly progressive, non-tender facial swelling of 16 years duration. Prior to the onset of his facial swelling, the patient reported a several years history of facial warmth, flushing, photosensitivity, and a grit-like sensation in his right eye. His diagnosis of MD was based on a combination of relevant histopathologic findings, namely perivascular and periadnexal lymphohistiocytic inflammation with dermal edema, and an extensive laboratory workup that ruled out various alternative causes of facial swelling. The patient has been treated with low dose isotretinoin for several months, with gradual improvement of his facial edema.

MD is a diagnosis of exclusion, requiring a number of potential causes of facial edema to be ruled out with a thorough history, relevant laboratory tests, and often histopathologic study. The differential diagnosis includes infectious causes (erysipelas), myxedema, drug-induced dermatoses, inflammatory granulomatous conditions (sarcoidosis, orofacial granulomatosis, Melkersson-Rosenthal syndrome), inflammatory depositional conditions (amyloidosis), allergic contact dermatitis, and contact urticaria. Patch testing is often part of the workup when considering allergic triggers. Autoimmune connective tissue diseases such as systemic lupus erythematosus and dermatomyositis can also present with periorbital swelling. Our patient’s serologic work up did not reveal any evidence of autoimmune connective tissue disease or paraproteinemia, and laboratory tests for thyroid disease and angioedema were negative.

The etiology and pathogenesis of MD is not completely understood, but it has been suggested that vasodilation and chronic inflammation in the setting of rosacea and/or acne results in increased vascular permeability and fluid transudation, and ultimately dermal remodeling and fibrosis, which obstructs facial lymphatic drainage.  MD may go unrecognized in skin of color, as it may be difficult to appreciate erythema, which can be an early clinical clue. Likewise, rosacea in skin of color may be underreported and underdiagnosed for the very same reason. Clinical characteristics common among skin of color patients with rosacea include prior misdiagnoses, and symptoms that have persisted beyond a year, both of which may contribute to more uncontrolled and progressive disease. Our patient, with his history of facial flushing and photosensitivity, as well as the 16-year delay in diagnosis that he experienced, personifies these challenges and considerations.

Effects of Brodalumab on Quality of Life Measured by the EuroQol 5-Domain Questionnaire in Patients With Psoriasis and Skin of Color

Authors: Amy McMichael, MD & Neal Bhatia, MD

Psoriasis is a chronic, systemic disease of the skin characterized by thick, scaly patches and has been shown to have a negative effect on health-related quality of life. Brodalumab, a fully human anti–interleukin-17 receptor A monoclonal antibody, has demonstrated efficacy in three large phase 3 trials in patients with moderate-to-severe plaque psoriasis (AMAGINE-1/-2/-3). The objective of this post hoc analysis was to evaluate the association of brodalumab on health-related quality of life, as measured by the EuroQol 5-domain (EQ-5D) questionnaire, in nonwhite and white patients in clinical studies of brodalumab. The EQ-5D classifies the health of a patient on 5 dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), and the EQ-5D index score ranges from 0 (death) to 1 (perfect health). Data were pooled from the 12-week placebo-controlled induction periods of AMAGINE-1/-2/-3. The EQ-5D index scores at week 12 were analyzed in nonwhite and white racial/ethnic groups receiving either brodalumab 210 mg every 2 weeks (Q2W) or placebo. At week 12, mean observed EQ-5D index scores were significantly higher in the brodalumab 210 mg Q2W group compared with the placebo group in nonwhite (0.9 [n=18] vs 0.6 [n=17]; P=0.0016) and white patients (0.9 [n=191] vs 0.6 [n=188]; P<0.0001). Patients with moderate-to-severe plaque psoriasis treated with brodalumab experienced improvement in health-related quality of life.

Hydroquinone-Induced Hyperpigmentation: A Case of Exogenous Ochronosis

Authors: Natasha Baah, BS & George Skandamis, MD

Introduction: Exogenous Ochronosis (EO), a rare but serious complication of long-term, high concentration hydroquinone (HQ) use, is a localized and paradoxical cutaneous disorder characterized by diffuse, symmetrical, asymptomatic hyperpigmentation over sun-exposed skin.

Case Description: 61-year-old female of Venezuelan decent, with olive skin tone, Fitzpatrick skin type IV, diagnosed with EO. Included in her 10+ year skin care regimen was HQ 4% which a plastic surgeon suggested to help achieve a more even complexion.

Discussion: EO is more common in the darker Fitzpatrick skin types IV, V, VI. Once thought to be a rarity in the United States, dermatologists are finding that EO more frequently presents on a spectrum than with the extremes described in many dermatological texts and can easily be misdiagnosed—resulting in more HQ use. Exact mechanism of EO is unclear. EO is histologically defined by yellow-brown, curvilinear, “banana-shaped” ochre or yellow dermal deposits. An open dialogue and patient-physician partnership and patient education reduces the risk of excessive, un-supervised HQ use which is the primary risk factor for developing EO, and not the compound HQ itself

Conclusion: HQ’s paradoxical side effect of EO is an important adverse reaction and is the result of an unintended but vicious cycle that should not be neglected by clinicians and consumers. As the demographic in the United States continues to shift to towards being a multi-ethnic nation, while the laxity and accessibility of HQ-containing products, both prescription and over-the-counter, continues to rise, is it imperative that adequate patient education on HQ and EO be addressed both early on with a board-certified dermatologist and with more awareness as a society.

Examining the Race-Specific Prevalence of Hidradenitis Suppurativa at a Large Academic Center; Results From a Retrospective Chart Review

Author: Toral Vaidya

Hidradenitis suppurativa (HS) is a chronic, inflammatory, debilitating disease of unknown etiology [1]. During acute exacerbations of HS, patients may suffer from malodorous discharge that leads to embarrassment, social stigma, and contributes to low self-worth. Pain associated with HS lesions can be intense and chronic, and is the most significant factor contributing to impaired quality of life among patients [2]. HS can occur in people of all ethnicities and ages, and affects approximately .3-4% of the United States [3]. Literature suggests HS may be more common among women, African-Americans, and young adults, though definitive epidemiological information is limited [1].

To date, few studies have specifically examined the race prevalence of hidradenitis suppurativa. Studies conducted at Henry Ford Medical Center and University of Pittsburgh have found the highest frequency of HS among African-Americans patients, with 54.4% and 65% majorities, respectively [4,5]. However, a similar study examined race prevalence of HS patients of Olmsted County, Minnesota, and reported a Caucasian-majority (90.3%) [6]. This discrepancy may reflect the demographics of these regions; further epidemiological research is needed to identify specific trends among HS and its racial predilections [4].

We conducted a retrospective review of HS patients seen at the University of Cincinnati Department of Dermatology between July 1, 2012 to December 31, 2015. During this period of time, there were a total 88,120 patients for all diagnoses (both HS and non-HS) at our center. In total, HS patients comprised .32%  (n=284) of our dermatology clinic patient population. Our findings correlate closely to current literature reporting the prevalence of HS as .3-4% in industrialized countries [3]. The US Census Bureau data for 2015 for Hamilton County, Ohio, indicates that the population of Hamilton County is 26.1% African-American, 69.0% Caucasian, and 4.9% “other” [7].

Patients seen at our clinic for all diagnoses were 12.8% African-American, 76.8% Caucasian, and 3.6% “other” (Table I). For the HS patients, 52.5% were African-American, 43.7% were Caucasian, and 3.9% ‘‘other” (Table I). We compared the prevalence of African-American patients with HS and Caucasian patients with HS via chi square test. At our center, 1.3% of African-American patients were seen for HS, compared to .18% of Caucasian patients; this difference was significant (p<.05). At our center, the ratio of % of African-American patients with HS vs. % of Caucasian patients with HS is 7.22:1. Single center studies performed at Henry Ford Medical Center and University of Pittsburgh report ratios of 1.70:1 and 3.26:1 respectively [4,5]. 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 [4,5]. These data support study trends suggesting HS is more common among patients of African-American descent [8]. However, these findings may underestimate the percentage of black patients with HS, as current literature suggests this specific population experiences decreased access to health care compared to the general population [9].

The overall prevalence of HS at our clinic may also be underestimated, as HS often goes unrecognized or misdiagnosed [5]. In addition, our study findings may not be generalizable to the general population, as our study data is limited to a single academic center.  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 patients with this disease.

Effects of Brodalumab on Quality of Life as Measured by the Short Form 36 Health Survey Version 2 in Patients With Psoriasis and Skin of Color

Authors: Andrew Alexis, MD, MPH & Seemal Desai, MD

Psoriasis is a chronic, systemic disease of the skin characterized by thick, scaly patches and has been shown to have a negative effect on health-related quality of life. Further, the severity of psoriasis can vary between different racial and ethnic populations. Brodalumab, a fully human anti–interleukin-17 receptor A monoclonal antibody, has demonstrated efficacy in three large phase 3 trials in patients with moderate-to-severe plaque psoriasis (AMAGINE-1/-2/-3). The objective of this post hoc analysis was to evaluate the association of brodalumab on health-related quality of life, as measured by the Medical Outcomes Study Short Form 36 health survey version 2 (SF-36v2), in nonwhite and white patients in clinical studies of brodalumab. The

SF-36v2 comprises 8 physical and mental scales (physical functioning, role functioning [emotional and physical], social functioning, bodily pain, mental health, vitality, general health perception, and change in health), with higher scores indicating better health. Data were pooled from the 12-week placebo-controlled induction periods of AMAGINE-1/-2/-3. The SF-36v2 physical and mental component summary scores at week 12 were analyzed in nonwhite and white racial/ethnic groups receiving brodalumab 210 every 2 weeks (Q2W) or placebo. At week 12, mean SF-36v2 physical component summary scores were significantly higher in the brodalumab 210 mg Q2W group compared with placebo in nonwhite (52.8 [n=18] vs 42.8 [n=17]; P=0.0075) and white patients (50.9 [n=190] vs 46.8 [n=188]; P<0.0001). In nonwhite patients at week 12, numerically higher mean SF-36v2 mental component summary scores were observed in the brodalumab 210 mg Q2W group (50.0) versus the placebo group (45.9). Significantly higher mean SF-36v2 mental component summary scores at week 12 were observed in white patients receiving brodalumab 210 mg Q2W (52.0) compared with those receiving placebo (46.5; P<0.0001). Patients with moderate-to-severe plaque psoriasis treated with brodalumab experienced improvement in health-related quality of life. Small sample sizes in the nonwhite population was a limitation of this study.