Exciting therapies dominate Hot Topics in Medical Dermatology

No stone was left unturned during “Hot Topics in Medical Dermatology” (S010). Eight dermatologists covered a wide range of developments in the diagnosis and treatment of numerous conditions. The expert panel explored everything from skin cancer and traveler dermatoses to psoriasis, atopic dermatitis, topical therapies, and pediatric dermatology.

Mark Lebwohl, MD, a professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York, directed the panel discussion. Among the discussions of “what’s new,” Lawrence Eichenfield, MD, professor of dermatology and pediatrics at the University of California, San Diego, addressed new developments in medical and pediatric dermatology. It included a look at dupilumab, which was recently approved for the treatment of atopic dermatitis in young adults, ages 12 to 17. It’s the first systemic therapy approved for atopic dermatitis in adolescents.

Welcome to the future and its gooey dilemmas

“The future is happening!” Dr. Eichenfield declared. “There has been the promise that our genetic insights into diseases will translate into therapies and potentially cures. And this seems to be happening, with research in some of our most challenging birthmarks (e.g. vascular malformations) and genetic skin disorders (epidermolysis bullosa),” he said. “Finding mutations is becoming standard in pediatric dermatology, with translation into specific therapy starting to happen now, with the future of it expanding into more disease states just in front of us. In addition, with expanded drug development for children and adolescents with inflammatory skin diseases (atopic dermatitis, psoriasis, alopecia areata) and common skin infections (molluscum, warts), it is a very exciting time in pediatric dermatology.”

Lawrence Eichenfield, MD.

Dr. Eichenfield also discussed promising advances in treating vascular malformations in children with genetically directed therapy as well as a broad set of therapeutic agents in development.

One of the most intriguing parts of his presentation focused on a pediatric skin abnormality gaining increased attention. It’s the growing phenomenon of slime-associated dermatitis. The condition is caused by playing with homemade slime or “goo.” The substance is commonly made from boric acid and other common household ingredients, such as contact lens solution, liquid laundry detergent, shaving cream, and school glue. According to Dr. Eichenfield, children who play with slime can develop hand dermatitis. The condition displays exzematous rashes with erythema, scaling, vesicles, and lichenification.

The dawn of new atopic dermatitis treatments

The session also provided a look at new therapies for atopic dermatitis beyond the existing phototherapy, cyclosporine, and other immune-suppressant treatments. That’s good news for 7% of adults and up to 25% of children worldwide who have been diagnosed with atopic dermatitis. Promising new therapeutics will be welcome relief for the 20% to 30% of those individuals who have moderate to severe disease, according to Emma Guttman-Yassky, MD, PhD, a professor of dermatology at Icahn School of Medicine at Mount Sinai in New York.

Emma Guttman-Yassky, MD, PhD.

“This is the field with greatest excitement in terms of treatment developments for topicals and systemics,” she said.

Telling attendees that therapeutic drugs for atopic dermatitis are “finally imminent,” Dr. Guttman-Yassky said atopic dermatitis is a heterogenous disease and that current treatments target IL-17 and IL-23 pathways. Atopic dermatitis has more clinical phenotypes affecting pediatric, African American, Asian, and European American populations. These clinical differences are also translated into differences in molecular phenotypes, she said. For example, children have higher T helper 17 (Th17) activation compared to adults, and similarly, Asians have higher Th17 activation compared to European Americans. African Americans and children have no Th1 activation, an axis that is highly increased in chronic disease in European Americans. However, the common denominator to all the phenotypes is marked Th2 activation, an axis targeted by many of the drugs being considered to treat atopic dermatitis. Nevertheless, for quite a sizable number of patients, targeting only Th2 is not enough.

This may call for targeting other axes in the future, she said, leading to a personalized medicine approach.

 There is a translational revolution that will continue and a personalized medicine that will be developed, I hope,” Dr. Guttman-Yassky said.

Keeping pace with psoriasis

”Psoriasis therapy is a rapidly changing topic and dermatologists constantly need to stay abreast of the new therapies in the pipeline and those that are recently approved,” said Bruce Strober, MD, PhD, assistant clinical professor of dermatology at Yale University.

As one of the presenters during the Hot Topics session, Dr. Strober discussed a pipeline medication that inhibits the IL-36 receptor for the treatment of generalized pustular psoriasis, a rare yet disabling and potentially dangerous aggressive form of psoriasis.

Bruce Strober, MD, PhD.

Upon sharing the results of an anti-IL-36 antagonist in seven patients with generalized pustular psoriasis, Dr. Strober said the therapy proved robust and fast-acting. Future phase 2 studies will further clarify the efficacy and safety of this medication.

Dr. Strober also reviewed a study of IL-23 inhibitors, which he said showed great efficacy and at longer intervals between doses. Similar promise is evident with IL-17 pathway inhibitors and the novel pipeline drug, bimekizumab. According to Dr. Strober, this drug promises great efficacy for the skin and joints by blocking both IL-17A and IL-17F, an innovative mechanism of action.

As for the future implications for these therapies, Dr. Strober said there’s no shortage of new options for patients. He reminded dermatologists to choose therapy based on individual patient characteristics, and noted that combination therapy may be best for some patients. He also reminded dermatologists to consider the presence of psoriatic arthritis when making treatment decisions.

“Drugs for the treatment of moderate to severe psoriasis continue to be developed, despite the fact that many of the currently approved biologics demonstrate extremely robust efficacy,” Dr. Strober said. “The frontiers involve drugs that hold their efficacy long-term, as many biologics can lose efficacy over time, and the introduction of non-steroidal topical medications for psoriasis of any severity.”

Melanoma treatments shine bright

Darrell S. Rigel, MD, shared an encouraging update on treating malignant melanoma. Dr. Rigel is a clinical professor of dermatology at New York University’s Langone Medical Center.

“Five years ago, there was almost nothing for treating advanced malignant melanoma,” Dr. Rigel said. “Now, we don’t have a full cure yet, but there are some long-term survivors, particularly those treated with new PD-1 inhibitors (immune checkpoint blockade therapies).”

Darrell S. Rigel, MD.

Dr. Rigel asserted that genomics are making the biggest impact on management of malignant melanoma, he said. Dermatologists have relied on a treatment paradigm based upon clinical and pathologic factors. This new approach might improve patient care by providing a better assessment of diagnosis and prognosis, which may lead to more effective patient management, Dr. Rigel said.

Moving forward, Dr. Rigel reminded dermatologists that treatment is most effective when coupled with early detection and removal of the malignancy. New technologies are now available that can provide dermatologists with objective information that can be integrated into more optimal management, he said.

They’re out there

Infectious diseases continue to challenge dermatologists. Cleveland Clinic dermatologist Kenneth J. Tomecki, MD, discussed recent trends and developments during his Hot Topics presentation. Among the infectious diseases that continue to be problematic at home and abroad are HIV/AIDS, measles, syphilis, and Rocky Mountain spotted fever.

Globally, there are approximately 2 million new cases of HIV each year and approximately 2 million deaths annually. In the U.S., there are approximately 40,000 new cases per year and 13,000 to 15,000 deaths.

Kenneth J. Tomecki, MD.

Measles, once a somewhat forgotten disease, is back in the headlines, with more than 1,000 newly reported cases in 2019. Many individuals are not vaccinated despite a highly effective vaccine available for decades.

“It’s the leading cause of vaccine-preventable death in children younger than 5 years,” Dr. Tomecki said. “The goal is to achieve a 90% vaccination rate worldwide. At present, only 60% of countries achieve that level.”

During the session, Dr. Tomecki provided a brief summary of trends and developments for other infectious diseases, including the rise of syphilis in the U.S. (mainly among men having sex with women), the rise of congenital syphilis (more than 900 cases reported in 2017, a 150% jump), the steady increase in cases of Rocky Mountain spotted fever (more than 6,500 annually), and the success of the new shingles vaccine, Shingrix.

“Infectious diseases remain an important aspect of clinical and surgical dermatology,” Dr. Tomecki said. “Awareness of trends and developments is essential for good patient care. It’s a topic that is often ‘in the news.’”

The Hot Topics session also provided attendees with guidance in identifying cutaneous manifestations of various travelers dermatoses as well as lessons in diagnosing and treating life-threatening dermatoses such as toxic epidermal necrolysis, Stevens-Johnson syndrome, and immunobullous diseases.