Hottest topics in dermatology revealed

There is no question about the hottest topics in dermatology this year. Attendees submitted their top choices for hot topics when they registered for the Annual Meeting, and AAD featured the top seven during a standing-room only “Hot Topics” (S048) symposium on Monday.

New cosmeceuticals
Consumers see a steady parade of new cosmeceuticals, but dermatologists see very few new compounds. Micellar water, for example, is among the hottest and most useful new products, according to Zoe Diana Draelos, MD, consulting professor of dermatology at Duke University School of Medicine.

Micellar water contains micelles, tiny balls of hydrophobic molecules surrounded by a hydrophilic layer. The combination of hydrophobic and hydrophilic ingredients is a good cleanser for both waterproof and water-removable cosmetics, and is useful for patients with eyelid dermatitis, eczema, atopic dermatitis, and mature skin. The secret ingredient: mild detergent.

“It is a very useful cleanser, but remember that you are paying $5 to $10 for a small bottle of diluted baby shampoo,” Dr. Draelos cautioned.

A new class of moisturizers promises greater effects from peptides in the formulation. Three classes of peptides have been introduced: carrier peptides, signal peptides, and neurotransmitter peptides. The moisturizers do contain the peptides as claimed, Dr. Draelos said, but little, if any, of the active ingredient penetrates the stratum corneum. Whatever activity is seen is generally due to the moisturizer.

The resurgence of interest in false eyelashes and extensions has created new problems for dermatologists. The cyanoacrylate glues can cause dermatitis, and sleeping in false eyelashes can break or pull out the natural lashes.

Challenges of acne and rosacea treatment
“Acne and rosacea are medical issues, not cosmetic issues,” said Hilary E. Baldwin, MD, medical director at Acne Treatment & Research Center in Morristown, New Jersey. “The earlier we can get people into the appropriate treatment, the better.”

Just getting patients into treatment is the first step. The more difficult part is getting them into the appropriate treatment. For acne, that means dealing with dryness and discomfort that can cause patients to drop out of treatment.

There is growing evidence that the pathology of acne may include a barrier defect. Skin with acne tends to have lower levels of epidermal ceramides, which can vary by season. Acne medications also tend to dry the skin.

Patients typically turn to familiar drugstore products such as coconut oil, petrolatum, baby oil, and mineral oil, she continued. None are effective, and some can exacerbate acne. Moisturizers containing ceramides or hyaluronic acid are more appropriate. Patients should look for products that are non-acnegenic.

“The sooner and better you do the job of educating your patient on moisturizing and cleansing, the happier your patient will be,” Dr. Baldwin said. “Patients are happier with doctors who manage their dryness.”

New options for alopecia
“We have tremendous new options for alopecia and more are on the way,” said Wilma Bergfeld, MD, professor of dermatology and pathology at Cleveland Clinic. “The hair follicle has become a hot topic of pharmaceutical study.”

The follicle is easily accessible for study, has the fastest turn-over cells in the body, and contains stem cells for skin, hair, follicle, and fat that are easily available for analysis. Patients worldwide want help.

Clinical trials for male pattern baldness in both men and women have shown inhibiting prostaglandin D2 by blocking the prostaglandin receptor on human hair follicles, CRTH2, can reverse alopecia.

Low-light laser treatment of the scalp can activate the Wnt pathway, another pathway that improves hair growth. The FDA has approved laser devices using 655 nm and 635 nm.

Injection of platelet-rich plasma (PRP) has shown promise in clinical trials, as well as in everyday clinical use, and a topical anti-androgen is in preclinical trials, Dr. Bergfeld said.

JAK inhibitors, both topical and parenteral, show promise, including tofacitinib. At least eight clinical trials for alopecia are underway, Dr. Bergfeld said, with others in the preclinical phase.

Treatment advances for atopic dermatitis (AD)
From 2001 to 2016, there were no new drugs for AD.

“Now there is an explosion of new therapeutics and some exciting new work,” said Lawrence F. Eichenfeld, MD, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital.

Crisaborole is the first PDE-4 inhibitor for AD, he continued. Nearly half of patients in the two pivotal phase 3 trials were clear or nearly clear out to one year. Patients had dramatic improvement in quality of life and, unlike steroids, there is no apparent limit on the duration of use.

Clinicians are still waiting for comparative effectiveness data, but there have been no new safety signals in either adult or pediatric patients. The drug is currently being studied in children under the age of 2, and other PDE-4 inhibitors are in trials around the world.

JAK inhibitors are also on the way. A topical agent — JTE-052 — shows about 70% response, similar to tacrolimus, but with a much improved safety profile.

Multiple studies suggest that prophylactic emoluments can reduce the incidence of AD in high-risk infants by about 50%.

The most recent entrant to the systemic medications is dupilumab, which blocks IL-4 and IL-13. About half of patients achieve EASI 90. Pediatric studies are in progress.

Searching for ideal biologics for psoriasis
Biologics have transformed the treatment of psoriasis and psoriatic arthritis.

“PASI 75 is easy to reach,” said Mark Lebwohl, MD, Waldman professor and chair of dermatology at Icahn School of Medicine at Mount Sinai. “PASI 90, a huge proportion of patients get there. Clear to almost clear is a realistic goal.”

The ideal biologic would be fast, durable, safe (including pregnancy), effective in obese patients, work for PsA, come in oral form, and be cheap.

Oral formulation and cheap pricing are still dreams. About 80% of psoriasis patients who could benefit from biologics never get them because cost limits access. The other 20% can see their lives transformed.

IL-17 inhibitors have the fastest onset of action, with brodalumab showing good activity in two weeks. Secukinumab, ixekizumab, and brodalumab have the strongest five-year data. Other agents may have a similarly durable response but data are not yet available.

Many biologics carry black box warnings, but none carry as many warnings as methotrexate.

“People who use TNF blockers live longer,” Dr. Lebwohl said. “There is a dramatic reduction in heart attacks with TNF inhibition.”

Certolizumab pegol is the only biologic known to be safe in pregnancy.

Multiple agents are useful in obese patients, including secukinumab, ixekizumab, brodalumab, guselkumab, tildrakizumab, risankizumab, and mirikizumab.

Biologics that are useful for both psoriasis and PsA include etanercept, adalimumab, infliximab, certolizumab pegol, and golimumab.

New staging system in melanoma
The biggest news in melanoma is a new staging system from the American Joint Committee on Cancer. The new manual was published in 2017, and the new standards took effect in January 2018.

“You need a cheat sheet to make your way through the changes in melanoma staging,” said Allan C. Halpern, MD, chief of dermatology at Memorial Sloan Kettering Cancer Center. “The good news is that The Melanoma Letter is publishing a very handy guide in the next issue.”

The hottest topic in melanoma diagnostics is dermoscopy. U.S. adoption has been slower than in the rest of the world, where it is becoming standard-of-care. The latest development is the digital dermascope, which allows clinicians to not only diagnose, but to take and store high-resolution images to monitor the progression of suspicious lesions.

The International Dermoscopy Society maintains dermoscopedia, the most complete and authoritative dermoscopy resource.

The next step, already in use at Memorial Sloan Kettering, is 3D full-body imaging. Dr. Halpern described the system, which uses 96 cameras to capture high-resolution images that are combined for a full 3D view of the patient’s skin. Simply touching the screen increases resolution for a close-up view of any lesion — anywhere on the body.

Cosmetic surgery expands its armamentarium
The hottest news in cosmetic surgery is the use of topical silicone rather than petrolatum ointments to speed healing for superficial incisions. Patients, and most dermatologists, almost automatically reach for a petrolatum-based antibiotic ointment.

“That’s a habit without any evidence that carries a real risk,” said Anthony V. Benedetto, DO, clinical associate professor of dermatology at the University of Pennsylvania Perelman School of Medicine. “That kind of indiscriminate use of antibiotic ointments contributes to antibiotic resistance, and, in my experience, antibiotic ointment is not as good as silicone. Silicone gel is inert, bacteriostatic, and bactericidal; it promotes wound hydration, and may reduce scar formation.”

An investigator-initiated comparison was done using silicone gel versus antibiotic ointment following Mohs surgery showed no contact dermatitis for silicone against 22% dermatitis for the antibiotic cream, with no difference in infection rates. The silicone gel also showed faster healing time and better quality of healing.

“Consider using any silicone, antibiotic-free dressing over any petrolatum-based product,” he advised. “In the future, we may all go to silicone.”

The other hot topic is vaginal rejuvenation using C02 laser. The procedure works quickly and painlessly to temporarily reverse vaginal atrophy due to menopause, age, and other causes. Clinical experience suggests that many patients will need follow-up treatments once or twice yearly following an initial treatment.


Return to index