Monthly Archives

April 2020

On-Demand Recording: COVID-19: Special Considerations for the Skin of Color Patient – A Conversation with the Experts

By | COVID-19 Resources | No Comments
SOC COVID 19 Webinar

This webinar was previously recorded on April 27th, 2020 and is now available on demand. Almirall has graciously supported the on-demand broadcast of this webinar.

Skin of Color Update (SOCU) and JDD invite you to attend “COVID-19: Special Considerations for the Skin of Color Patient – A Conversation with the Experts”. During this 90-minute webinar, Dr. Andrew Alexis will be joined by skin of color key opinion leaders to discuss special considerations and practical approaches to managing dermatologic disorders in skin of color during the COVID-19 pandemic.

 

Topics to be addressed include the following:

  • Hair Disorders
  • Pigmentary Disorders
  • Aesthetic Concerns
  • Inflammatory Disorders (including acne, atopic dermatitis, psoriasis, and others)
  • How to stay connected with your skin of color patients on social media
  • Vitamin D deficiency among people of color and its potential relevance to COVID-19 in patients of color
  • COVID-19 related shifts in common dermatologic concerns in skin of color
  • Impact on the practice of aesthetic dermatology for skin of color

MODERATOR:

Andrew Alexis, MD, MPH (Chair, Department of Dermatology, Mount Sinai West and Mount Sinai Morningside and Professor, Icahn School of Medicine at Mount Sinai)

 

PANELISTS:

Eliot F. Battle, Jr., MD (CEO and Co-Founder of Cultura Dermatology & Plastic Surgery)

Amy McMichael, MD (Professor and Chair of Dermatology, Wake Forest Baptist Medical Center)

Heather Woolery-Lloyd, MD (Director, Skin of Color Division, University of Miami School of Medicine)

Pearl Grimes, MD (Founder and Director, Vitiligo and Pigmentation Institute of Southern California)

Supported by:

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COVID-19: Special Considerations for the Skin of Color Patient – A Conversation with the Experts

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SOC COVID 19 Webinar
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Skin of Color Update and JDD invite you to attend “COVID-19: Special Considerations for the Skin of Color Patient – A Conversation with the Experts”. During this 90-minute webinar, Dr. Andrew Alexis will be joined by skin of color key opinion leaders to discuss special considerations and practical approaches to managing dermatologic disorders in skin of color during the COVID-19 pandemic.

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Long-Term Benefits of Daily Photo-Protection With a Broad-Spectrum Sunscreen in United States Hispanic Female Population

By | Aesthetic Dermatology, Medical Dermatology | No Comments
Image of photo aging

Source: JDD Online

The following is an excerpt from the Journal of Drugs in Dermatology article, Long-Term Benefits of Daily Photo-Protection With a Broad-Spectrum Sunscreen in United States Hispanic Female Population.

Introduction
The demographics of the United states are evolving with a large increase in racial and ethnic diversity driven by international migration of Hispanic, African, and Asian populations leading to a minority-majority shift in ~2050 towards persons of color (Fitzpatrick III, IV, V, and VI).1 Specifically, the Hispanic population is projected to be among the fastest growing population in the US, projected to increase from 55 million in 2014 to 119 million in 2060, a change of +115%.1

Subjects with skin of color are heterogeneous with multiple shades and tones and different reactions to intrinsic and extrinsic aging factors due to structural and physiologic differences.2,3 Skin of color individuals have fewer visible signs of aging (deep wrinkles, fine lines, rough surface texture, and sun spots). However, darker skin tones are more susceptible to certain skin conditions including post-inflammatory hyperpigmentation (may occur after acne, eczema, injury, laceration, melasma, post-inflammatory hypopigmentation, pityriasis alba (round, light patches covered with fine scales), dry or “ashy” skin, dermatosis papulosa nigra, and/or greater risk of keloid development.2,3 The incidence of skin cancer among US Hispanics has also increased 1.3% annually from 1992 to 2008.4

Photodamage is characterized histologically by degeneration of the connective tissue and abnormalities in keratinocytes and melanocytes. Clinically, it manifests primarily with wrinkles, dyschromia, texture changes, and, in more severe cases skin cancer.5 Formulations containing broad spectrum sunscreens against both UVA and UVB play an essential role in the prevention of photodamage and UV-induced skin cancers.6,7,8 However, the majority of clinical research on photoprotection has been conducted on subjects with Fitzpatrick types I to III skin and have reported improvements in signs associated with skin aging and texture.9,10 Verschoore et al was the first to conduct a short-term clinical study in India with Phototype IV and VI subjects, and provided first evidence on the effectiveness of daily sunscreen use on skin tone and radiance.11 Similar benefits were observed in an 8-week study in US.12

Although sun protection is highly recommended by dermatologists for skin cancer risk-reduction and the prevention of premature aging or pigmentary disorders, adherence to the recommendations is not commonly observed among US Hispanics.13 Moreover, a large number of US Hispanics reside in areas with high UV index with a high degree of sun seeking behavior. Among Hispanic adults who report engaging in sun protection, they do so mostly by staying in the shade (53.7%) rather than use of sunscreen (32.3%) or wearing sun protective clothes (18.1%); while 36.7% of the subjects surveyed indicated that they never use sunscreen.14,15 There are sociodemographic factors that contribute to the adherence to safe sun behaviour such as education, age, and gender, etc, therefore there is a need to raise awareness of skin cancer risks, advocate for preventive measures and educate on benefits of sunscreen and sun protection among US Hispanics.16

The benefits of topical agents for reversal of sun damage has been well established. Use of retinoic acid and its derivatives or other drugs to reverse and improve sun damaged skin has been demonstrated in many studies.17,18 Long-term sunscreenuse along with other topical agents have also been shown to prevent photodamage and hyperpigmentation in fair-skinned subjects.19 For effective photoprotection, sunscreen products containing both SPF and PPD are essential to battle the harmful UVB (skin cancer risks) and UVA (photo-aging risks).20 Daily use of a broad-spectrum sunscreen (SPF 30) over a one-year period has also been demonstrated to improve clinical parameters of photodamage in phototype I-III subjects.10 However, a comprehensive long-term sunscreen use study in skin of color is lacking. Therefore, this study was designed to assess the benefits of sunscreen of SPF30/PPD 20 in Hispanic women of Fitzpatrick skin types IV and V over 12 months in comparison to a real-life observational group with subjects who did not use sunscreen regularly.

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Discussions and Conclusions
Effective photoprotection is critical for healthy skin, in preventing skin cancers, reducing photodamage, and improving aesthetic appearance. A broad spectrum sunscreen protecting against both UVA and UVB irradiation is essential. Protecting against the UVA spectrum needs special attention, especially under daily diffused exposure, as UVA is more penetrating and less affected by seasonality and impacts photoaging and skin oxidative stress.22 It has been reported that in order to receive effective photoprotection on skin, a PPD value of 18 is desired.20 In this study, the investigational product with SPF 30/PPD 20 is considered sufficient for daily activity without prolonged direct sun exposure when applied properly. Concerning skin of color population, the use of sunscreen is lower than in Caucasians despite high prevalence of sun-related pigmentary disorders and rising rates of cutaneous cancers.4 This study provides strong evidence to educate and advocate for daily use of a proper sunscreen product for populations with high phototype skin.

The clinical evaluation demonstrated significant visible improvement in sunscreen group starting from 3 months and progressive increased over time. Benefits on multiple facial areas and body sites were visible (upper, mid- and lower face, neck, and hands), not only on pigmentary-related concerns (skin tone evenness, overall hyperpigmentation, dark spots, and blotchiness), but also on aging parameters such as fine lines, skin texture, and overall skin quality. This suggests that beyond the preventative benefits, long-term persistent use of a proper sunscreen may also allow the photodamaged skin to self-heal and repair over time.

Histological observations further supported the clinical findings. The observation that the real-life group had higher tendency for pigmentation incontinence is of strong research interest. It has been reported that UV irradiation can destabilize and damage the dermal-epidermal junction (DEJ), which facilitates the entrapment of melanin in the dermis.23 The dermal melanin is extremely difficult to remove, often resulting in stubborn hyperpigmentation.24 This is especially important for skin of color population in whom dermal hyperpigmentation lesions are common and can be worsened with excessive sun exposure. This study provides the first evidence that effective daily photoprotection can be a strategy to prevent dermal melanin formation by protecting the DEJ. A larger sample size study with DEJ biomarkers will help to further elucidate this hypothesis. Infiltration of CD68-positive Macrophages is a hallmark of the inflammatory response after UV irradiation. In the dermis, 2 out of 3 of the real-life biopsy samples showed significant increase in CD68 positive macrophage cells at 12 months compared to baseline, while such change was not observed in the sunscreen group. This suggests the potential preventative benefits of sunscreen in subclinical skin inflammation induced by chronic exposure to UV. In all of the histological evaluations, thegeographical location in which the study was conducted (Los Angeles versus Washington, DC) was not a strong contributing factor to any of the observed differences. However, the histological findings in this study are limited by the small number of biopsies obtained.

In summary, this 12-month study on long-term persistent use of an SPF30/PPD20 sunscreen on phototype IV and V subjects demonstrated significant improvement in skin quality and improvement in skin color and photoaging parameters. To our knowledge, this is the first study of this kind in skin of color and Hispanic population. This study confirms that effective sunscreen use is not only protective and beneficial for light skin population but is also critical in improving skin condition for skin of color patients. Overall, the study demonstrates that daily use of sunscreen can protect skin from photo related damage and even reverse some of the photo-damage that has already occurred in skin. In addition to previous studies that demonstrated the photo-protective properties of sunscreen use in normal and diseased skin states7,8,9,10 and in view of the fact that good photoprotection behaviors are not common among Hispanics,14,15,16 studies of this type can help educate and stress the importance of daily use of sunscreen and other sun protection behaviors in Hispanic and other skin of color populations.

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Intralesional Triamcinolone Acetonide in the Treatment of Traction Alopecia

By | Aesthetic Dermatology, Medical Dermatology, Sessions | No Comments
Patient with Alopecia

Source: Next Steps in Derm

In this case series, JDD authors evaluate the efficacy and safety of intralesional triamcinolone acetonide injections (ILK) when used with topical minoxidil in the management of traction alopecia in 6 African American women.

Background

Traction alopecia (TA) is a form of hair loss secondary to repetitive and/or prolonged tension to a hair follicle over an extended period of time. This typically results from wearing tight hairstyles, or an acute traumatic event.1,2 As the etiology is mechanical trauma of the hair follicle, it can occur in any ethnic/racial demographic or gender. It has been observed in ballerinas, as well as Sikh Indian males, all of whom wear hairstyles that exert tension on the frontotemporal hairline. However, most cases of TA occur in women of African descent.1,3

The diagnosis of TA can be made clinically, as well as through the histological examination of a scalp biopsy. The earliest signs of TA are perifollicular erythema and pruritus with or without surrounding papules and pustules.4 The fringe sign of TA is a clinical finding characterized by the presence of retained hair along the frontal and/or temporal hairline, and it has been shown to have high sensitivity for detecting early and late disease of TA.5 On dermoscopy, one may observe reduced hair density with an absence of follicular openings in late stages, and in earlier stages an absence of hairs with preserved follicular openings outlined in brown, particularly at the periphery of the patch of affected scalp, corresponding to the pigmented basal cell layer of the follicular infundibulum that can be seen on histology.6,7 The histological findings can also vary depending on the stage of the disease. Early findings on histology include trichomalacia, normal number of terminal hairs, preserved sebaceous glands, and increased number of telogen and catagen hairs.8 Late disease findings include a decreased number of terminal hair follicles which have been replaced by fibrous tracts, vellus hairs, and retained sebaceous glands.8

Recommended treatment for traction alopecia includes the use of minoxidil and intralesional steroid injections. However, evidence-based proof of the efficacy of ILK in the improvement of TA has not been reported in the literature. In this case series, we evaluate the efficacy and safety of intralesional triamcinolone acetonide injections (ILK) when used with topical minoxidil in the management of TA in 6 African American women.

Methods

A retrospective chart review was performed in patients carrying a diagnosis of TA, who were seen at an active hair disorder clinic between January 2016 and December 2017. All patients who were treated with ILK, and whose treatment progress were recorded with photographs were included. Those who used minoxidil as an adjunct treatment were also noted. The management of TA was assessed by comparing the changes in hair density along the frontotemporal hairline. All patients had been instructed to avoid tension-related hair care practices.

Discussion

This study shows that ILK, when used in conjunction with topical minoxidil, is effective in halting TA progression, and in improving frontotemporal hair density in patients with TA. Our patients reported no adverse systemic effects from the injections that are commonly associated with corticosteroids, and only one patient reported itch in the frontotemporal hairline, a symptom which is more likely a side effect of the topical minoxidil or a manifestation of the TA pathology itself.

Results

Of the TA patients seen, 6 met the criteria for our observational study. All 6 were African American females presenting for evaluation of frontotemporal hair loss, with ages ranging from 32 to 61 years. All subjects reported a history of hairstyling that exerted tension to the frontotemporal hairline at some point in their lives, whether it was recent, during childhood, or both. The clinical diagnosis of TA was established through the presence of the fringe sign. Five subjects had 3 to 4 ILK injections done at 6 to 8-week intervals, performed at a concentration of 5 mg/mL, while one subject (Subject #2) received only one treatment with ILK (Table 1) also at a concentration of 5 mg/mL. Injections were done both at the border of the hair loss in the frontotemporal hairline and extending backwards to include the normal density hair. Subjects concurrently used topical minoxidil 5% daily, and one subject (Subject #2) also took oral doxycycline. All subjects reported the cessation of all hair care practices that exert tension to the frontotemporal hairline, including tight ponytails, tight hair braiding/weaving, twisting of locks, use of scarves to tie hair down, and the use of hair gel on the frontotemporal hairline. All subjects demonstrated a visible increase in hair density along the frontotemporal hairline following their third treatment (Figure 1). None of the subjects reported any serious adverse effects from the injections. The subject that received only one ILK treatment and continued dual therapy on minoxidil and doxycycline reported itch initially, which was improved with the use of a topical steroid.

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Webinar Series Held to Assist Dermatology Practitioners During COVID-19

By | COVID-19 Resources | No Comments
3,644 registrants and 1,644 participants in COVID19 webinar

On April, 1, 2020, the Journal of Drugs in Dermatology (JDD) and SanovaWorks brands, including Skin of Color Update, launched Part I of the webinar series: COVID-19: Urgent Dermatology and Aesthetic Issues for Dermatology.

Over the course of the 2 hours, Joel L. Cohen, MD and 6 different thought leaders joined the COVID-19 conversation, discussing the pressing questions that are on the minds of many dermatologists and providers in the country. The initial broadcast attracted 1,900 registrants and nearly 800 attendees comprised of physicians, residents, fellows, nurse practitioners and physician assistants.  Attendees were interested and engaged throughout the entire 2 hours with a 76% average attentiveness and 72% average interest rating.

The on-demand broadcast has attracted over 500 registrants as of April 9th and is available on JDDonline.com.

On April 7, 2020, Part II of the webinar series was broadcasted: COVID-19: Your Questions Answered. Dermatology experts and thought leaders examined the legal and financial concerns of dermatology providers during the global coronavirus pandemic. Experts discussed furlough vs. layoffs; mortgage and rent relief programs; the CARES Act; the pros and cons of leveraging NPs or PAs for teledermatology and more. Then, hear questions answered by our panel of experts; discussed practical tips you can use in your practice right now; and how to move forward with patient care. Part II attracted 1,300 registrants with nearly 700 attendees. Attendees were engaged and interested throughout with an 82% attentiveness average and 75+% interest rating.

The on-demand broadcast of Part II will be available on April 11, 2020 on JDDonline.com.

Challenging Cases in Skin of Color Dermatology Patients

By | Media Coverage, Medical Dermatology, Sessions | No Comments
Skin of Color patient dermatology cases

Source: Next Steps in Derm

This year at the 17th Annual ODAC Dermatology, Aesthetic & Surgical Conference (ODAC), Dr Amy McMichael presented the audience with new pearls of advice on how to approach and diagnose complex medical dermatology cases in patients with skin of color. During her session, she addressed the important need for providers to be able to recognize disease in patients of all races. The majority of the global population consists of people with skin of color and the US population is changing to include a higher percentage of patients with diverse backgrounds. She covered a wide range of diagnoses from psoriasis to melasma and how these may present differently is darker skin types. As she walked the audience through each case it became apparent that being able to recognize and treat certain conditions in patients with skin of color is not only essential but also complex in nature.

First, Dr McMichael summarized the top conditions that African American patients were evaluated for during a dermatologist visit. The top 6 conditions included:

This helped to set the scene for the first case involving a 40-year-old African American female with hidradenitis suppurativa presenting with draining gluteal plaques. Even though the biopsy showed granulomatous dermatitis, the patient was not improving with multiple treatments and developed worsening pain and drainage from gluteal plaques. On a second biopsy the pathology showed psoriasis with granulomatous changes. The patient eventually improved with the systemic treatment Humira, a TNF-a inhibitor. Her major takeaways from this case included:

  • Do a second biopsy if the patient’s skin is not responding as expected to the treatment you have prescribed
  • Psoriasis can have a unique presentation similar to existing hidradenitis
  • Use systemic treatments early to help control symptoms

Second, she tackled the challenge of treating melasma with combination therapies. In melasma, there is too much melanin being created by melanocytes and it is then carried by keratinocytes. These cells then release melanin into the dermis, causing blotchy pigmentation often on the face. Topical therapies are usually directed towards preventing increased creation of melanin by melanocytes. People often use hydroquinone 2% or 4% along with encouragement of consistent daily sunscreen use. If used at too high of a concentration, then hydroquinone may cause ochronosis (skin becomes bluish – grey).

Dr McMichael suggested adding a novel treatment called cysteamine to the regimen for melasma treatment for more effective results. Cysteamine is an aminothiol that is made in our cells from the amino acid cysteine. Although more interest is arising now for its use in treating melasma, cysteamine was actually researched in 1966 when scientist Dr Chavin injected it into black goldfish skin and observed partial depigmentation. Cysteamine 5% cream may be a more effect treatment for melasma with less side effects.

Another novel treatment Dr McMichael discussed was the use of tranexamic acid for resistant melasma. This is another derivative of an amino acid, lysine, and it works as an anti-fibrinolytic. It has the ability to block UV-induced plasmin activity within keratinocytes. Patients would need to be screened out by their providers for a past medical history of DVT, pulmonary embolism, heart disease, and stroke before starting the oral medication. She emphasized the importance of getting a good medical history related to these conditions since tranexamic acid could increase the risk of these conditions. For patients who are able to take the medication they are expected to experience a few side effects such as mild GI upset and palpitations. This medication could provide improvement for many patients with chronic melasma who have had to struggle with this condition.

Third, in the next case we were reminded by Dr McMichael that keloids can be very disfiguring and distressful to patients. She talked about using intralesional Kenalog with contact cryotherapy as effective treatments of keloids. Other options for treatment included combining cryosurgery, intralesional Kenalog, and doxycycline. It was eye opening for the audience to hear her say we should be thinking about keloids not just as scars but tumors representing overgrowth of tissue. This paradigm shift of how we think about keloids can further shape how we think about treatment modalities for keloids as well.

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