New Treatments in Dermatology Toby Maurer, MD University of - - PowerPoint PPT Presentation

8/4/2014 1

New Treatments in Dermatology

Toby Maurer, MD University of California, San Francisco Dept of Dermatology

Scabies: Classic treatment

• Permethrin 5% crème-2 applications 1 week

apart

• Must treat all intimates
• Clothing instructions essential
• But patients complain that this is a hassle

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Crusted scabies

• Scabies mite burden very high
• Have treated with malathion ( a pesticide)

and ivermectin (an oral medication)

• Easier to use and higher success rate-how

about using these agents in regular scabies

Scabies

• Oral ivermectin superior to malathion in

adults BUT this is second line drug

• While it is easier to give-it is expensive and
• veruse might lead to resistance
• We have seen resistance with Kwell (Lindaine)
• First line is still permethrin (elimite)

Martin Annals of DermatolVenerology 2010 Dec

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Scabies

• Big global burden-leads to infection and one
• f the major reasons for glomerulonephritis
• Vaccine?
• Stimulates specific protective antibodies as
• pposed to increasing general immunity
• XIAOSONG L. ,WALTON S., MOUNSEY K. Vaccine May 2014

New England Journal of Hepatitis C Treatment

• Telapravir
• Daclatasvir plus
• Sofosbuvir with or without Ribavirin
• Able to achieve cure rates up to 98% with

these drugs NEJM May 2014

• Telapravir-erythema multiforme, eczema
• Sofosbuvir with or without Ribavirin-dry skin

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Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

DRESS

• Drug hypersensitivity-monitor LFTs , Cr, Eos
• If elevated, start prednisone 60 qd x 10 days

then slow taper over as much time as it takes (eosinophil count may help guide taper)

Post DRESS

• Check TSH 3 months post DRESS
• Be aware of cardiac abnormalities

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Drug Reactions

• Thiazides known to give photodrug reaction
• Calcium Channel blockers-associated with non-

specific eczematous reactions/itch in the elderly- starts on arms and legs-if you can, switch pt’s to

• ther drugs

Summers et al JAMA Dermatol May 2013

• Allopurinol- rare drug reactions but 25%

mortality rate-don’t use for hyperuricemia-risk is too high Kim et al Arthritis Care Res April 2013

Guttate Psoriasis Psoriasis

• Mounting evidence that cardiovascular

disease and psoriasis are associated

• Now concern re: kidney disease-increased risk

independent of traditional risk factors

Risk of moderate to advanced kidney disease in patients with psoriasis: population based cohort study. Wan J1, Wang S, Haynes K, Denburg MR, Shin DB, Gelfand JM. BMJ Oct 2013

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Let’s go back in time

• The old moist wraps:

Used about 25 years ago Corticosteroid and ointment goes directly onto skin Moisten first layer-kerlex, gauze, socks that are cut

• pen-ring out for excess water

Dry layer on top-sleep in this overnight Can be done nightly for up to 2 weeks until gone OR Every 5 days-watch for maceration of skin

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Food

• Not enough evidence to suggest that any

foods or categories of food contribute to atopic dermatitis 9adults)

• Not enough evidence to suggest that breast

feeding reduces risk for developing atopic dermatitis

• Not enough evidence to suggest that holding

back on solids or milk after 4-6 months of age reduces risk for developing atopic dermatitis

Nursing Education

• Two nice studies: Great Britain and

Netherlands Atopic families who had the benefit of intense nursing education did much better re: quality of life and severity indices compared to families who just saw the doctor. des Bes et al Acta DermatolVenereol 2011 Jan

Eczema Guidelines AAD March 2014

• Emollients, emollients
• When fail-use topical steroids and maintain
• nly on problem areas
• Additives to bath-no benefit except with

bleach

• Wraps are good in flares
• Avoid systemic steroids

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• Clobetasol oint qd x 1 wk when severe then
• Fluocininide (lidex) x 2 wks then
• TAC 0.1% oint bid (maintenance)
• Aclovate oint or HC !% oint bid face
• If needed, cyclosporine, methotrexate,

azathioprine and mycophanelate mofetil and ultraviolet light-all useful!

• Antihistamines help with sleep but do not

help with itch

• No evidence to support or refute its use
• Watch in the elderly

Cellulitis

• Goal in study was to have dermatologists

diagnose cellulitis vs other diseases

• 635 pts seen-67% had cellulitis N=425
• 33% had other-eczema, lymphedema,

lipodermatosclerosis

• Of the 425 with cellulitis, 30% had predisposing

dermatologic disease

• Hospitalization was averted for 96% of those with

cellulitis (p.o antiotics) Levell et al Br J of Dermatol (BJD) 2011 Feb

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Red legs Take Home Points:

• Does the patient really have cellulitis?
• Is there an underlying dermatologic cause that

contributes to condition-if treated could prevent repeated episodes?

• Does this patient require hospitalization?

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Recurrent Cellulitis

• In study of 274 pts who had at least 2

episodes of cellulits in 3 yrs:

• Prophylactic penicillin 250 bid decreased rates
• f recurrence in treatment gp vs placebo

group ( tx=22% vs 37% in placebo gp)

• BUT off meds and followed-recurrence rate

was the same in both groups.

• NEJM Thomas etal. May 2013

Hidraadenitis supparativa

• Hidradentitis-go back to strong

antiinflammatories like rifampin and clindamycin-12 week course

• Moxifloxicin, metranidazole, rifampin-Lambert et
• al. Dermatology 2011
• Acitretin may have some activity-drug is

classically used for psoriasis (original use for TNF blockers Boer et al Br J Dermatol 2011 Jan

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Chronic wounds

• If not healing and developing thickened or

ulcerated skin-biopsy for cancer

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• Can it be used in pts with previous zoster-yes
• How about use in younger age groups?
• Needs to be give within ½ hour of

reconstitution

• $150.00 for injection
• Cost-effectiveness of vaccination against

herpes zoster and postherpetic neuralgia: a critical review-Kawai K et al, Vaccine March 2014

• uptake in most communities is only around 30%
• recommended now before giving patients

immunosuppressive drugs like MTX or TNF blockers JAMA 2011

• Sunscreens- Australian study randomized

residents to daily use vs discretionary us between 1992 and 1996

• Risk for developing any melanoma reduced by

50% and invasive melanoma risk reduced by 73%

• Same trial also showed reduction of risk of

developing squamous cell cancer Green et al. J Clin Oncol 2011 Jan 20; 29:257

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Tanning Beds

• International Agency for Research on Cancer
• Comprehensive metaanlaysis found that risk
• f melanoma (skin and eye) increases by 75%

when tanning begins before age 30.

• Cite this to your young patients

El Ghissassi et al. Lancet Oncol 2009 Aug 10:751

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Photodynamic therapy

• Place photosensitizer on skin and then use light

therapy-increases absorbency of light

• Evidence that it changes histologic features of

photodamage and changes expression of

• ncogenes

Uses in:

• Actinic keratoses
• Basal cell cancers
• Superiority studies being evaluated
• Bagazgoitia et al BJD 2011 July

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BCC

• New drugs for multiple BCC’s-vismodegib-?

SCC development-JAMA Derm May 2014 For superficial BCC’s:

• PDT vs imiquimod?-imiquimod better
• Imiquimod vs surgery?-surgery better

The Telederm Experiment

• California Health Care Foundation-can we

make it happen in San Francisco area

• Primary care provider has any derm question
• r wants to refer to derm
• ALL referrals go through telederm-even if it is

a pt followed by derm in past

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• Obtains verbal consent from pt
• Provider or assistant takes picture and uploads

picture

• Question can be typed in on web based

template at the time of pt visit or later that day, etc

• Derm group answers question and primary

will get notification that derm report is ready

• Provider will get first pass advice-what is it, how

to treat, when he/she should see pt back or when to refer OR

• Provider will be alerted that pt needs derm

appointment and pt will be LINKED into CARE within an appropriate time to be seen in LIVE CLINIC (manned by our dermatologists).

• Derm report is part of the electronic medical

record

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• Dermatologists from UCSF read the triage

consults and they also staff the live clinics at the primary care providers site

Results to date

• We have completed around 4000 consults
• 75% of consults have been successfully

treated by primary provider with derm guidance-the GPS system

• 25% seen in live derm clinic
• Wait time at San Mateo was 9 months to see
• DERM. Now we get consults back in 2 days

and live clinics booked within 1 month

• Primary providers have learned from one on
• ne consults
• Primary providers have had to DO some

dermatology

• Live dermatology clinic –difficult cases but

time has been properly apportioned to see them

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• Suspect Hypertrophic lichen planus
• Start pt on clobetasol oint bid
• Order CBC, LFT’s and G6PD
• Look in mouth and genitals-if lesions-set up

with GI for endoscopy

• Our scheduler will call pt to come in next 3

wks

PCP’s reply

• Labs obtained, linkage of care to specialists

within 1 month ( bonus for hospital), meds started, I learned what this is, what labs to get and that in some circumstances assoc with cancer-can I get CME?