‘Hot Topics’ attendees hear latest information on subjects of interest

0320-Hot TopicsNo one knows the key issues in dermatology better than dermatologists, so the “Hot Topics” agenda Friday afternoon was set by dermatologists. Speakers addressed 10 topics that meeting registrants chose in the weeks before the AAD Annual Meeting

“Dermatology has pivoted in the way we are achieving information on the pathophysiology of diseases and the advancement of treatment,” said session director David Eric Cohen, MD, Charles C. and Dorothea E. Harris professor of dermatology and Director of Occupational Environmental and Allergic Dermatology at New York University Langone Medical Center in New York. “It is happening at such a breakneck speed that ‘Hot Topics’ is a useful tool to catch up.”

Photoprotection

Photoprotection is an enduring question. Some authorities suggest that a little sun is acceptable, said Henry Lim, MD, chairman and C.S. Livingood Chair of Dermatology at Henry Ford Hospital in Detroit. Not so. Even suberythemogenic doses of UV can induce photoaging.

“There is no safe dose of ultraviolet exposure,” Dr. Lim said. “The regular use of photoprotection prevents photoaging and skin cancers.”

The rigorous use of sunscreens and other photoprotection strategies can also lead to vitamin D deficiency. Because most people do not use sunscreens adequately or properly, vitamin D deficiency is rarely an issue. Vitamin D supplementation can ensure adequate serum levels no matter how rigorous sunscreen use.

Immunomodulation

Immunomodulation is advancing into new therapeutic areas. Downmodulation is being used to treat inflammatory skin diseases. Upmodulation shows promise in enhancing immune activity against infections and cancer.

“New understanding of the workings of the immune system have led to remarkable changes in how we can improve immune-mediated disease,” said Kenneth Gordon, MD, professor of dermatology, Northwestern University Feinberg School of Medicine, Chicago. “In psoriasis, newer agents have allowed for unprecedented responses and promise to provide a better quality of life for our patients.”

Immunomodulation models developed for psoriasis are being applied to other immune-mediated diseases, including atopic dermatitis and hidradenitis, Dr. Gordon said. Deeper understanding of atopic dermatitis is leading to the identification of new targets and novel therapeutics. Dupilumab, an anti IL-4 receptor; lebrikizumab, an anti-IL13 receptor; CIM331, an anti-IL31 receptor; and AMG-157, an anti-TSLP, all show promise.

Cosmeceuticals

Cosmeceuticals are a conundrum. They are highly promoted, and ingredient concentrations are not disclosed.

“Two-thirds of the ingredients are moisturizers,” said Zoe Diana Draelos, MD, private practitioner and consulting professor of dermatology at Duke University, Durham, North Carolina. “These products may not actually contain the advertised ingredients.”

What cosmeceuticals do contain is a variety of preservatives, including parabens and stabilizers, such as phthalates, which are recognized as toxic but are probably not dangerous in low concentrations.

Topical probiotics need more study to determine whether they have anti-inflammatory or other useful health effects. Hair dyes contain aromatic amines that are both carcinogenic and mutagenic. Multiple meta-analyses of associations with lymphoma, leukemia, myeloma, and solid tumors are inconclusive, but these products should not be used immediately before or during pregnancy, or while breastfeeding, Dr. Draelos said.

Drug Reactions

New research suggests that drug reactions are more common and more readily identified than clinicians may realize.

“Overlapping clinical features of severe cutaneous adverse reactions (SCARs) are common,” said Kanade Shinkai, MD, PhD, associate professor of clinical dermatology at the University of California, San Francisco. “These overlaps can be confusing for dermatologists, making a high-stakes diagnosis of a potentially fatal drug rash. Key features of incidence, timing, and histopathology are critical to make a unifying diagnosis, which is possible in most cases.”

Multiple-drug hypersensitivity, hypersensitivity to two or more chemically different drugs, is emerging as a common problem. Up to 10 percent of allergy clinic patients with SCARs may be hypersensitive to multiple drugs, Dr. Shinkai said. Immune dysregulation from an initial hypersensitivity may increase the risk of subsequent sensitivity to drugs not typically associated with hypersensitivity.

“Viral involvement may explain many unusual features of DRESS, including the long time of onset, recurrent flares in the absence of drug, and late-onset autoimmunity,” Dr. Shinkai said. “We need to take a second look at the role of immunosuppression and anti-viral agents.”

Biologics

Do biologic agents cause cancer? Cardiovascular disease? Infections? Probably not.

“Biologics of any class used as monotherapy do not cause solid tumor or lymphoreticular malignancy,” said Bruce Strober, MD, PhD, associate professor and vice chairman of dermatology at the University of Connecticut, Farmington. “Cancers are rarely observed in patients on biologic therapies, but no rigorous clinical study conclusively links these occurrences to the therapy.”

Current data also suggest that biologics can be used safely in patients with a prior history of malignancy. Concerns over infection risks with IL-17 are overblown, he said. While infections have been reported, the most likely problem is minor candidal infections in about 5 percent of patients.

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