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New Treatments in Dermatology

Toby Maurer, MDUniversity 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

overuse 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

of the major reasons for glomerulonephritis• Vaccine?• Stimulates specific protective antibodies as

opposed 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 drugsNEJM 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 other 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 factorsRisk 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 agoCorticosteroid and ointment goes directly onto skinMoisten first layer-kerlex, gauze, socks that are cut open-ring out for excess waterDry layer on top-sleep in this overnightCan be done nightly for up to 2 weeks until goneOREvery 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

NetherlandsAtopic 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

only 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

of 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

of melanoma (skin and eye) increases by 75% when tanning begins before age 30.

• Cite this to your young patientsEl 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 oncogenes

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 2014For 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

or 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 dermguidance-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 one 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?