the chronicle of skin & allergy june 2015

C l i n i c a l p r a c t i c e

Should laserremoval of tattoosbe performed onlyby physicians?n Some techniquesmay be safer in thehands of physicians,observers report by JOHN EVANS,Assistant Editor, The Chronicle

In a recent news article publishedonline in the Canadian MedicalAssociation Journal (Apr. 13,

2015), Canadian DermatologyAssociation president Dr. David Zlotysaid that the CDA would prefer if alldirected-energy dermatology devices,including tattoo-removal laser sys-tems, were operated exclusively byphysicians or physician-designatedstaff. However, there are argumentsboth for and against making laser tat-too removal a restricted medical pro-cedure, according to two Canadiandermatologists who spoke with THe

CHRONICLe OF SKIN & ALLeRgy.

In favourStrongly agreeing with Dr. Zloty thatlaser tattoo removal should be arestricted proce-dure, dermatolo-gist Dr. LisaKellett of Torontosays that formalmedical trainingis needed to ade-quately assessand screen candi-dates before lasertattoo removal.

“There arepeople who would not be good can-didates for the procedure,” says Dr.Kellett. “If you have had an allergicreaction to the ink, there is a chancethat by lasering the ink you can actu-ally have an anaphylactic reaction,which is potentially life-threatening.”

As well, she says, if a patient has acancerous or pre-cancerous lesion inthe tattooed area that has not beenidentified, the tattoo-removal proce-

Please turn to Tattoo page 14à

100,” said Dr. Charles Lynde,medical director at the LyndeInstitute for Dermatology inMarkham, Ont., and associateprofessor in the Department ofMedicine at the university ofToronto. “One of the most excit-ing things [revealed at the AAD]is the introduction of the data onthe [anti] IL-17 agents.”

Different pathways assessedSecukinumab (which has beenapproved for chronic, plaquepsoriasis in Canada and the u.S.),

PRACTICAL THeRAPeuTICS and CLINICAL NeWS from the WORLD of DeRMATOLOgy n JUNE 2015

by LOUISE GAGNON,Correspondent, The Chronicle

At the most recent annualmeeting of the AmericanAcademy of Dermatology

in San Francisco, data on thenewest therapies to treat chronicplaque psoriasis revealed one cer-tainty—that the demonstrated effi-cacy of these treatments will raisepatient expectations to a level thathas never before been seen.

“We are now talking about[endpoints like] PASI 90 or PASI


PASI 90 or 100 new endpointsin management of psoriasisn Therapies raising patient expectations regarding treatment outcomes

o f & A L L E R G YSKINSKINThe Chronicle

All rights reserved. C

hronicle Information Resources Ltd.Canada Post C

anadian Publications Mail Sales Product Agreem

ent Number 40016917

brodalumab, and ixekizumab, will allbe “game changers” in the manage-

ment of the con-dition, says Dr.Lynde.

“This is a dif-ferent pathway,”said Dr. Lynde. “Itseems to be morespecific and hasvery high efficacyand higher effica-

cy than other biologics that we have.We can see from the data, that theyare all quite safe.”

Recently released results point to

Please turn to PASI 90 page 12àP i g m e n t d i s o r d e r s

New alternatives to long-termuse of hydroquinone in melasmanKojic acid, azelaic acid, adapalene usefulby LOUISE GAGNON, Correspondent, The Chronicle

Clinicians can consider using topical therapies such as kojicacid, azelaic acid and adapalene as alternatives to pro-longed use of hydroquinone for melasma, says a professor

in the Department of Dermatology at Maulana Azad MedicalCollege and Lok Nayak Hospital in New Delhi, India.

One of several dermatologists speaking in San Francisco at theannual meeting of the Please turn to Melasma page 32à

Dr. Charles Lynde

Dr. Lisa Kellett

See page 4See page 4

Image courtesy Vanessa Tevesti (cc) Creative Commons

Cosmetic Dermatology

New fillers offer advancements

n The Chronicle is committed tomaintaining leadership in envi-ronmentally sustainable poli-cies, and to encouraging theadoption of “green-aware” prac-tices in healthcare. We inviteyour comments via e-mail, at:[email protected]

Skin_June_2015,rar12_w cover art_9.1_Skin_March_2014,rar1.qxd 26/06/2015 6:07 PM

THERE IS A NEW TREATMENT FOR CHRONIC IDIOPATHIC URTICARIA (CIU)1*

XOLAIR ®

A new option to

treat CIU

PrXOLAIR® (omalizumab) is indicated for the treatment of adults and adolescents (12 years of age and above) with chronic idiopathic urticaria (CIU) who remain symptomatic despite H1-antihistamine treatment.1Please refer to the study parameters and reference list at http://www.eppendix.com/APS-Xolair-14XOL062EXOLAIR® 150 mg also showed a reduction in itch and hives: 56% reduction from baseline in weekly ISS seen at week 12 with XOLAIR® 150 mg vs. 36% for placebo. Mean change from baseline to week 12 in weekly ISS: -8.1 vs. -5.1 for placebo (p<0.0011). 57% reduction from baseline in weekly number of hives score seen at week 12 with XOLAIR® 150 mg vs. 31% with placebo (secondary endpoint). Mean change from baseline to week 12 in weekly hives score: -9.8 vs. -5.2 for placebo.1,2†

*CIU is sometimes referred to as chronic spontaneous urticaria (CSU).†ASTERIA II

Clinical use:

other conditions. There is limited experience with XOLAIR® in patients over 65 years of age. Most serious warnings and precautions:Anaphylaxis: Anaphylaxis, presenting as angioedema of the throat or tongue, bronchospasm, hypotension, syncope, and/or urticaria has been reported to occur after administration of XOLAIR®.

but also has occurred beyond 1 year after beginning regularly administered treatment. Because of the risk of anaphylaxis, patients should be closely observed for an appropriate period of time after XOLAIR® administration, and healthcare providers administering XOLAIR® should be prepared to manage anaphylaxis that can be life-threatening. Patients should also be informed of the signs and symptoms of anaphylaxis and instructed to seek immediate medical care should symptoms occur.Other relevant warnings and precautions:• Cardiovascular and cerebrovascular disorders

• Corticosteroid reductions• Immune system disorders: Churg-Strauss syndrome and

hypereosinophilic syndrome; serum sickness; immunogenicity• Information for patients on anaphylaxis; driving or using machines• Caution in other IgE-associated disorders• Patients at high risk of parasitic (helminth) infections• Patients with renal or hepatic impairment• Pregnant women• Nursing women• Fertility • Pediatrics (<12 years of age)• Monitoring and laboratory tests: elevated serum total IgEFor more information:Consult the Product Monograph at http://www.novartis.ca/XolairMonograph for important information relating to adverse drug reactions, drug interactions, and dosage and administration information which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-363-8883. Consult the references and study parameters at http://www.eppendix.com/APS-Xolair-14XOL062E

from baseline in weekly itch severity score (ISS)

seen at week 12 with XOLAIR® 300 mg vs. 36% for placebo2

Mean change from baseline to week 12 in weekly ISS: -9.8 vs. -5.1 for placebo (p<0.0001)1†

ITCH: 71%reduction

from baseline in weekly number of hives score

seen at week 12 with XOLAIR® 300 mg vs. 31% for placebo (secondary endpoint)2

Mean change from baseline to week 12 in weekly hives score: -12.0 vs. -5.2 for placebo1†

HIVES:

74%reduction

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THe CHRONICLe of SKIN & ALLERGY

Vol. 21, No. 4 June 2015 · 3

R e s e a r c h

Wounds may heal more quickly

TOP ofthe MONTH

Diabetic foot care: Primaryscreening would help prevent ulcersAs prevalence of diabetes increases,so will the incidence of diabetic footulcers, according to a presentation atthe annual meeting of the CanadianAssociation of Wound Care inToronto. early foot screening mayhelp prevent these ulcers . . . . . . . . .8

From stinging plants to fire antsDr. Julian J. Trevino offers clues toclinical presentations that may resultfrom problematic plants and bugsthat reside in the gardens of yourpatients . . . . . . . . . . . . . . . . . . . . 10

Delayed diagnosis of psoriaticarthritis can lead to increased jointdamage and disabilityStudy indicates that after just sixmonths of undiagnosed psoriaticarthritis and untreated symptoms,joint outcome measures showeddeterioration . . . . . . . . . . . . . . . . . . .16

Dermatologists call for regulationsgoverning nickel content in jewelryContact sensitivity to nickel is statisti-cally associated with body piercingand appears to be exposure depen-dent and stronger in males . . . . . . .26

Chronicle Postgraduate Educational SupplementIn this month’s Chronicle Post -graduate educational Supplement,researchers from Spain investigatethe association of metabolic syn-drome and its components inpatients with psoriasis . . . . . . . 35

“Keep in mind . . . spines and splinters from plantscan penetrate the skin and cause foreign body

granulomas. Some people can get a granulomoussynovitis or a monoarticular arthritis.”

Dr. Julian J. Trevino, Wright State University, Dayton, Ohio(see page 10)

A novel nanoparticle therapy for skinwounds halved the time it tookwounds to heal in a mouse model,according to findings publishedonline in the Journal of InvestigativeDermatology (Mar. 10, 2015).

The researchers, working at theAlbert einstein College of Medicine ofyeshiva university in New york, hadpreviously shown that the enzyme fid-getin-like 2 (FL2) slows the migrationof skin cells toward wounds in thehealing process. Hypothesizing thatreducing levels of FL2 would allowthese cells to migrate to the woundfaster, they developed a drug to inacti-vate the FL2 gene, and encapsulatedthe drug in nano-scale gel capsules.Wounds in the skin of mice treatedwith the nanoparticles healed muchfaster than untreated wounds.

When the treatment was appliedto human cells in vitro and those cells

were placed on a standard woundassay, the cells moved unusually fast.“This suggested that if we could finda way to target FL2 in humans, wemight have a new way to promotewound healing,” said study co-leaderDavid J. Sharp, PhD, professor ofphysiology and biophysics at einstein.

The therapy utilizes silencingRNAs (siRNAs) specific to FL2, whichbind to the gene’s messenger RNA(mRNA) and prevent the cell’s mech-anisms from translating the mRNAinto the FL2 enzyme proteins.However, siRNAs are not well takenup by cells, and degrade quickly ontheir own, said Dr. Sharp in therelease. This led to the use of thenanoparticles, which had been devel-oped by Dr. Joel Friedman, a profes-sor of physiology and biophysics andmedicine at einstein, and Dr. AdamFriedman, director of dermatologicresearch at einstein.

From the News Resources of The Chronicle

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Affiliated journals of the ChronicleCompanies include The Chronicle ofCosmetic Medicine+ Surgery, TheChronicle ofNeurology &Psychiatry, PediatricChronicle, The

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June 2015 • Vol. 21 No. 4

Medical EditorWayne Gulliver, MD, FRCPC

Editor, Cosmetic DermatologySheldon V. Pollack, MD, FRCPC

Publisher Mitchell ShannonEditorial Director R. Allan Ryan

Senior Associate Editor Lynn BradshawAssistant Editors John Evans, Emily Innes

Production and Circulation Cathy Dusome

Sales & Marketing Sandi Leckie, RN

Founding Editor Colin A. Ramsay, MD, FRCPC (1936-2003)

John P. Arlette, MD, FRCPC

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Marc Bourcier, MD, FRCPC

Eric Goldstein, MD, FRCPC

Peter Hull, MD, FRCPC

Rod Kunynetz, MD, FRCPC

Richard Langley, MD, FRCPC

Danielle Marcoux, MD, FRCPC

R.A.W. Miller, MD, FRCPC

H. Eileen Murray, MD, FRCPC

Kim Papp, MD, FRCPC

Yves Poulin, MD, FRCPC

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Contacting The Chroniclen READER SERVICE: To change your address, or

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Comptroller Rose Arciero

A Message from theMedical Editor

My wife Bev and I have just set-tled into our seats on one ofAir Canada’s finest, heading

home to St. John’s from the 23rdWorld Congress ofDermatology in Van-couver.

Two, well possiblythree, points come tomind as I try to resistthe temptation to tuneinto the latest reality

show displayed on the in-flight moni-tor. (Has anybody seen Alaskan BushPeople? I hope not, that’s a show tomiss).

Point one: This country has thesecond-largest land mass in theworld, and it’s a 13-hour airplane tripfrom our home base on the eastcoast to Vancouver on the westcoast. Considering that factoid, itstrikes me that although there are rel-atively few dermatologists spreadpretty thinly across much of the coun-try, our specialty has become aleader in determining policy and con-ducting medical research in Canada.

One result of this higher profilehas been, in my view, an improvedrecognition of the value we as der-matologists can bring to the lives ofour patients. It’s instructive to com-pare and contrast the situation todaywith the situation just a decade or soago, when it seemed as if dermatol-ogy was in danger of being perma-

Please turn to Message page 32à

THERE IS A NEW TREATMENT FOR CHRONIC IDIOPATHIC URTICARIA (CIU)1*

XOLAIR ®

A new option to

treat CIU

PrXOLAIR® (omalizumab) is indicated for the treatment of adults and adolescents (12 years of age and above) with chronic idiopathic urticaria (CIU) who remain symptomatic despite H1-antihistamine treatment.1Please refer to the study parameters and reference list at http://www.eppendix.com/APS-Xolair-14XOL062EXOLAIR® 150 mg also showed a reduction in itch and hives: 56% reduction from baseline in weekly ISS seen at week 12 with XOLAIR® 150 mg vs. 36% for placebo. Mean change from baseline to week 12 in weekly ISS: -8.1 vs. -5.1 for placebo (p<0.0011). 57% reduction from baseline in weekly number of hives score seen at week 12 with XOLAIR® 150 mg vs. 31% with placebo (secondary endpoint). Mean change from baseline to week 12 in weekly hives score: -9.8 vs. -5.2 for placebo.1,2†

*CIU is sometimes referred to as chronic spontaneous urticaria (CSU).†ASTERIA II

Clinical use:

other conditions. There is limited experience with XOLAIR® in patients over 65 years of age. Most serious warnings and precautions:Anaphylaxis: Anaphylaxis, presenting as angioedema of the throat or tongue, bronchospasm, hypotension, syncope, and/or urticaria has been reported to occur after administration of XOLAIR®.

but also has occurred beyond 1 year after beginning regularly administered treatment. Because of the risk of anaphylaxis, patients should be closely observed for an appropriate period of time after XOLAIR® administration, and healthcare providers administering XOLAIR® should be prepared to manage anaphylaxis that can be life-threatening. Patients should also be informed of the signs and symptoms of anaphylaxis and instructed to seek immediate medical care should symptoms occur.Other relevant warnings and precautions:• Cardiovascular and cerebrovascular disorders

• Corticosteroid reductions• Immune system disorders: Churg-Strauss syndrome and

hypereosinophilic syndrome; serum sickness; immunogenicity• Information for patients on anaphylaxis; driving or using machines• Caution in other IgE-associated disorders• Patients at high risk of parasitic (helminth) infections• Patients with renal or hepatic impairment• Pregnant women• Nursing women• Fertility • Pediatrics (<12 years of age)• Monitoring and laboratory tests: elevated serum total IgEFor more information:Consult the Product Monograph at http://www.novartis.ca/XolairMonograph for important information relating to adverse drug reactions, drug interactions, and dosage and administration information which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-363-8883. Consult the references and study parameters at http://www.eppendix.com/APS-Xolair-14XOL062E

from baseline in weekly itch severity score (ISS)

seen at week 12 with XOLAIR® 300 mg vs. 36% for placebo2

Mean change from baseline to week 12 in weekly ISS: -9.8 vs. -5.1 for placebo (p<0.0001)1†

ITCH: 71%reduction

from baseline in weekly number of hives score

seen at week 12 with XOLAIR® 300 mg vs. 31% for placebo (secondary endpoint)2

Mean change from baseline to week 12 in weekly hives score: -12.0 vs. -5.2 for placebo1†

HIVES:

74%reduction

:HTCI

noitucder

%71:HTCI

noitucder

:SIVEH

es ulacilinC

:

reoidretsoictro C•

-sniotcud re

Imaging of burns indicates that those treated with theFL2 inhibitor nanotechnology experienced collagendeposition and hair follicle formation. Image: VeraDesMarais/Albert Einstein College of Medicine


by LOUISE GAGNON,Correspondent, The Chronicle

4 · June 2015

Lead article THe CHRONICLe of SKIN & ALLERGY

AVAILABLENOWIN CANADA

COSENTYX is a trademark.Product Monograph available on request.Printed in Canada 15COS022E© Novartis Pharmaceuticals Canada Inc. 2015


n Topical growth factors a new area of research; other advances in cosmetic therapy examined

Emerging cosme-ceuticals that arei n c r e a s i n g l ysteeped in sci-ence, a new

treatment for cellulite, anda new application for cal-cium hydroxylapatite(CaHA) are some of thecosmetic innovationsCanadian dermatologistswill be able to incorporatein their practices in thefuture.

“Topical growth factors are a veryexciting area of development,” saysDr. Shannon Humphrey, a dermatolo-gist and clinical assistant professor,Department of Dermatology and SkinScience, university of BritishColumbia, Vancouver.

In the past, some manufacturersof cosmeceuticals made claimsabout the efficacy of their productswithout providing clinical evidence,but claims without supporting evi-dence are no longer cutting it for clin-icians, explained Dr. Humphrey. “Aspractitioners, cosmetic dermatolo-gists are demanding more robust evi-dence,” she said.

DNA egF Renewal, for example,was studied to determine its impacton under-eye bags, atrophic acnescars, and purpuric lesions, andresults presented at the annual meet-

ing of the American Academy ofD e r m a t o l o g y(AAD) showedhow patientswith these condi-tions reportedvisible improve-ment with thetopical therapy.The topical agentpromotes synthe-sis of collagenand proliferationof epidermalstem cells.

S u b m e n t a lfullness is a hard-to-treat conditionthat has beenaddressed largelywith surgicalinterventions, butthe approval of ATX-101 by the u.S.Food and Drug Administration, a drugformulated with naturally-occurringdeoxycholic acid, will offer a non-invasive option to get rid of submen-tal fat.

Minimizing downtime important“To have a treatment with minimaldowntime and good safety profileand good efficacy will expand whatwe do in our cosmetic practice,” saidDr. Humphrey, who was a principalinvestigator for the Phase III trial ofthe injectable drug.

In terms of the treatment sched-ule for ATX-101, Dr. Humphrey saidthe schedule will adjust according toseveral factors. The recommendation

is up to six treatments at monthlyintervals, butmost patientswill have two tofour treatmentsat monthly inter-vals.

“My projec-tion for whatwould happen isthat it willdepend on whatthey [patients]were looking for,how much fatwas present,and, as with allcosmetic treat-ments, there willbe variableresponse,” saidDr. Humphrey.

Dr. PeterVignjevic, a der-matologist inHamilton andassistant clinicalprofessor ofmedicine atM c M a s t e runiversity, notedcosmeceuticals

can be a nice adjunct to skin rejuve-nation treatments.

“People use them to comple-ment procedures [like IPL for skinrejuvenation], for skin cancer preven-tion, for anti-aging, or moisturiza-tion,” said Dr. Vignjevic.

Dr. ShannonHumphrey

Dr. Martie Gidon

Dr. Vince Bertucci

Dr. AndreiMetelitsa

Dr. PeterVignjevic

Please turn to Advances page 6à

Cosmetic Dermatology

New fillers offeradvancements


AVAILABLENOWIN CANADA

COSENTYX is a trademark.Product Monograph available on request.Printed in Canada 15COS022E© Novartis Pharmaceuticals Canada Inc. 2015


NEW ROSIVER™ (ivermectin) Cream, 1% for thetopical treatment of papulopustular rosacea in adults1

ROSIVER™ is a trademark of Galderma Canada Inc.

ROSIVER (ivermectin) Cream, 1% is for the topical treatment of infl ammatory lesions (papules and pustules) of rosacea in adults 18 years of age or older.

Refer to the page in the bottom right icon for additional safety information and for a web link to the Product Monograph discussing:

• Relevant warnings and precautions regarding skin reactions, allergic reactions, and skin irritation; concomitant use of potentially irritating topical products or procedures; use in pregnant women; and serious adverse reactions in nursing infants

• Conditions of clinical use, adverse reactions, drug interactions, and dosing/administration instructions

The additional safety information page contains the reference list and study parameters relating to this advertisement.

*Mean infl ammatory lesion counts at baseline: ROSIVER 31.0; vehicle 30.5.1 †Mean infl ammatory lesion counts at baseline: ROSIVER 32.9; metronidazole 0.75% cream 32.1.3

• Demonstrated a powerful and rapid reduction in infl ammatory lesions vs. vehicle° Median percent reduction from baseline in infl ammatory lesion counts at

Weeks 2 and 12 was 30.0% and 76.0% vs. 16.5% and 50.0% for once-daily ROSIVER vs. vehicle cream, respectively; both P<0.001 (secondary endpoint)*2

• Provided superior effi cacy vs. metronidazole 0.75% cream ° Percent reduction from baseline in infl ammatory lesion counts at Weeks 3

and 16 were 32.5% and 83.0% vs. 30.5% and 73.7% for once-daily ROSIVER vs. twice-daily metronidazole 0.75% cream, respectively; both P≤0.04 (primary endpoint)†1,3

• Demonstrated an excellent safety and tolerability profi le° Most common adverse reactions were: skin burning sensation, skin irritation, pruritus, and dry skin (1.0% vs. 2.2%, 0.9% vs. 2.4%, 0.8% vs. 1.1%, and 0.5% vs. 0.7% for ROSIVER vs. vehicle cream, respectively)1

° The safety profi le remained stable under conditions of long-term use as observed with treatment for up to one year1

6 · June 2015

Lead article THe CHRONICLe of SKIN & ALLERGY

Another topical agent, XAF5, aimsto diminish excess eyelid fat, orsteatoblepharon. The ointment pene-trates the skin and targets adipocytesto decrease subcutaneous fat. A ran-domized, double-masked, placebo-controlled trial of 90 patients found85% of patients were satisfied withthe topical agent’s impact on theirperiorbital skin, and no seriousadverse experiences were recorded.

“This is quite novel and very inter-esting,” said Dr. Humphrey, com-menting on XAF5. “Right now, thesolution for excess eyelid fat issurgery. Most people don’t want tohave surgery.”

Toronto dermatologist Dr. Martiegidon, agrees a non-surgical interven-tion to eliminate excess eye fatsounds very appealing. “It’s a veryinteresting concept,” she said. “Wedon’t have anything to remove[excess eyelid] fat besides surgery.”

Skin rejuvenationDr. gidon is impressed by the novelapproach of Montreal’s KloxTechnologies to skin rejuvenation.The company is using a biophotonicsplatform for various uses, one ofwhich is LeD light and a gel formula-

tion that responds to the light makingpositive changes to the skin. Lumibelemploys a non-thermal technique totighten skin, improve pore size,improve skin texture, and improveoverall appearance.

“The gel acts like a prism,enhancing LeD light penetration,”said Dr. gidon. “It does not give thesame result as a laser, but an advan-

tage is there is no downtime with theprocedure.”

Fillers continue to be anotheroption for cosmetic rejuvenation, andnewer filling agents are formulatedwith specific properties to target vari-ous areas of the face, observed Dr.Vince Bertucci, who is a dermatolo-gist and co-director of the

Dermatologic Laser Surgery andCosmetic Dermatology Fellowship atthe university of Toronto.

“Some hyaluronic acid (HA)fillers have fixed HA concentrationand cross-linking but variable particlesize while maintaining a fixed HAconcentration,” said Dr. Bertucci.“The goal is soft tissue filler cus-tomization so as to achieve

favourable product characteristicsand good soft tissue integration. It’sall about achieving a natural look andbeing able to uniquely target each ofthe different parts of the face. Theyprovide good soft tissue integration.”

Dr. Bertucci noted that the newline of emervel fillers, which includeemervel Lips, Classic, Deep and

Volume use Optimal BalanceTechnology to tailor particular fillersto various parts of the face. For exam-ple, emervel Lips is used for lip andperioral line enhancement, emervelDeep might be appropriate for thenasolabial folds and marionnetteregion, while emervel Volume isinjected deeply for cheek and chin liftand projection. emervel Classic is aworkhorse product that may be usedin multiple areas.

While aging of the skin is highlyvisible on the face, the hands are alsosubject to the effects of the agingprocess. For those individuals whohave undergone facial rejuvenationprocedures, the discrepancy in theappearance of their hands may giveaway their age, prompting manypatients to seek hand rejuvenationtreatments.

“With age, there is more promi-nent visibility of dorsal hand veinsand tendons due to loss of subcuta-neous fat. CaHA is a soft tissue fillerthat is approved for dorsal hand vol-ume restoration in patients who findthey have increased visibility of veinsand tendons as a result of lost vol-ume,” said Dr. Bertucci. “Correction

Advances in cosmetic dermatology include new fillersContinued from page 4

“The goal is soft tissue fillercustomization so as to achieve

favourable productcharacteristics and good soft

tissue integration. It’s all about achieving a natural lookand being able to uniquely target each of the

different parts of the face.”—Dr. Vince Bertucciq

Female pattern hair loss: Female androgenetic alopecia isthe most common cause of clinically significant hair loss.1–3 Otherdisorders include alopecia areata, telogen effluvium, cicatricialalopecia, and traumatic alopecias.1–3 In female pattern hair lossthere is progressive hair follicle miniaturization and conversion ofterminal follicles into vellus-like follicles.1–3 These have ashortened hair cycle as their anagen phase is reduced.3 Completeareas of baldness are not likely to occur as hair follicleminiaturization is not uniform.3

Hair loss is typically categorized as scarring or non-scarring.3

The diagnosis is usually based on a thorough history and aphysical examination.1–3 When evaluating hair loss the followingmay be taken into account: duration, pattern, thinning versusshedding, hair falling out from the roots or breaking, family history,hair care practices, systemic illness, childbirth, psychosocialstressors.1–3 The emotional impact of female pattern hair loss is notto be underestimated by dermatologists.1 Prompt diagnosis andtreatment are essential for obtaining optimal outcome.3

Topical minoxidil 5% foam for hair regrowth Minoxidil is a potassium channel opener, believed to enhanceangiogenesis around the hair follicle by increasing the expression ofvascular endothelial and hepatocytic growth factors.1–4,6 Whentopically applied, 5% minoxidil induces telogen hairs to enter theanagen phase, prolonging anagen duration, increasing hair count andweight.1–4,6 Although uncommon, a possible treatment side effect ishypertrichosis of the forehead, usually caused by improperapplication of the topical.5 (Patients should be advised to limit spreadbeyond the application site by taking such measures as washing theirhands thoroughly after application and letting the minoxidil dry beforegoing to bed to avoid transfer to the pillow case.)

Application of topical minoxidil 5% foam* has been shown topromote hair regrowth.1,5 In clinical studies of women aged 18 to 45years with mild to moderate degrees of hair loss, using topicalminoxidil for eight months was reported to result in more hairregrowth, compared to the result obtained using the placebo vehiclewithout the active ingredient.1,5 The foam did not drip and stayedlocalized.5 Topical minoxidil 5% foam may be applied asmonotherapy or may be combined following hair auto grafting.

Patient caseThe 45-year-old white woman presented with a one-year history ofscalp-hair loss.

Profile: On physical examination, she has diffuse, non-scarring hairthinning with a widened part over the central portion of the scalp thatmay indicate hereditary hair loss (Fig. 1). She divorced her husbandtwo years ago after a troubled marriage of 22 years. As a result shehad to sell their house and moved with her two teenage children. Shereported she was stressed and challenged by her situation.

The condition: Her female pattern hair loss was unmasked by atelogen effluvium which may have been triggered by psychologicalstress factors. Stress related telogen effluvium is a common cause ofhair loss and can easily unmask female pattern hair loss.1 She isconcerned about how she looks and is insecure about building newrelationships. After consulting a dermatologist, who is specialized infemale pattern hair loss, she agreed to start with the topical treatment.

Treatment: The dermatologist explained the condition to her anddiscussed patient expectations of treatment outcome as well asmonitoring and follow-up of treatment.

The patient was successfully treated with 5% minoxidilfoam used as monotherapy (Figs. 2a and 2b). The product waseasy to use, did not drip and stayed localized in the area where itwas applied.

Consider � Androgenetic alopecia is the most common cause of hair loss

in women and has a significant emotional impact. It can bemasked by a telogen effluvium.

� In clinical studies application of topical minoxidil 5% foampromoted hair regrowth, which was also the case in thispatient with female pattern hair loss.

*Rogaine 5% foam, Johnson & Johnson; for more information, seeProduct Monograph at http://www.jnjcanada.com/sites/www_jnj-canada_com/files/pdf/en/Rogaine.pdf.

References1 Shapiro J: Hair loss in women. N Engl J Med 2007; 357(16):1620–1630.2 Herskovitz I, Tosti A: Female pattern hair loss. Int J Endocrinol Metab Oct

2013; 11(4):e9860.3 Birch MP, Messenger JF, Messenger AG: Hair density, hair diameter and

the prevalence of female pattern hair loss. Br J Dermatol 2001;144(2):297–304.

4 Blumeyer A, Tosti A, Messenger A, Reygagne P, Del Marmol V, Spuls PI,et al: Evidence-based (S3) guideline for the treatment of androge-netic alopecia in women and in men. J Dtsch Dermatol Ges 2011; 9Suppl 6:S1–57.

5 Blume-Peytavi U, Hillmann K, Dietz E, Canfield D, Garcia Bartels N: Arandomized, single-blind trial of 5% minoxidil foam once daily ver-sus 2% minoxidil solution twice daily in the treatment of androge-netic alopecia in women. J Am Acad Dermatol 2011;65(6):1126–1134.

6 Tyagi V, Singh PK: A new approach to treating scarring alopecia by hairtransplantation and topical minoxidil. Indian J Dermatol VenereolLeprol 2010; 76:215.

TTooppiiccaall Minoxidil Foam 5% ffoorr HHaaiirr RReeggrroowwtthh iinn WWoommeenn wwiitthh NNoonn--ssccaarrrriinngg AAllooppeecciiaaJerry Shapiro, MD, FRCPC � Clinical Professor � Department of Dermatology and Skin Science � University of British Columbia � Vancouver

Editorial feature of The Chronicle of Skin & Allergy, June 2015, supported by a grant from Johnson & Johnson, which is not responsible for content

Fig. 1a and 1b: Before treatment with topical 5%minoxidil foam.

Fig. 2a and 2b: After treatment with topical 5%minoxidil foam, showing a marked improvement.

Please turn to Advances page 24à


NEW ROSIVER™ (ivermectin) Cream, 1% for thetopical treatment of papulopustular rosacea in adults1

ROSIVER™ is a trademark of Galderma Canada Inc.

ROSIVER (ivermectin) Cream, 1% is for the topical treatment of infl ammatory lesions (papules and pustules) of rosacea in adults 18 years of age or older.

Refer to the page in the bottom right icon for additional safety information and for a web link to the Product Monograph discussing:

• Relevant warnings and precautions regarding skin reactions, allergic reactions, and skin irritation; concomitant use of potentially irritating topical products or procedures; use in pregnant women; and serious adverse reactions in nursing infants

• Conditions of clinical use, adverse reactions, drug interactions, and dosing/administration instructions

The additional safety information page contains the reference list and study parameters relating to this advertisement.

*Mean infl ammatory lesion counts at baseline: ROSIVER 31.0; vehicle 30.5.1 †Mean infl ammatory lesion counts at baseline: ROSIVER 32.9; metronidazole 0.75% cream 32.1.3

See page XX for additional safety information.

• Demonstrated a powerful and rapid reduction in infl ammatory lesions vs. vehicle° Median percent reduction from baseline in infl ammatory lesion counts at

Weeks 2 and 12 was 30.0% and 76.0% vs. 16.5% and 50.0% for once-daily ROSIVER vs. vehicle cream, respectively; both P<0.001 (secondary endpoint)*2

• Provided superior effi cacy vs. metronidazole 0.75% cream ° Percent reduction from baseline in infl ammatory lesion counts at Weeks 3

and 16 were 32.5% and 83.0% vs. 30.5% and 73.7% for once-daily ROSIVER vs. twice-daily metronidazole 0.75% cream, respectively; both P≤0.04 (primary endpoint)†1,3

• Demonstrated an excellent safety and tolerability profi le° Most common adverse reactions were: skin burning sensation, skin irritation, pruritus, and dry skin (1.0% vs. 2.2%, 0.9% vs. 2.4%, 0.8% vs. 1.1%, and 0.5% vs. 0.7% for ROSIVER vs. vehicle cream, respectively)1

° The safety profi le remained stable under conditions of long-term use as observed with treatment for up to one year1


Contraindications:• Hypersensitivity to other corticosteroids• Viral (e.g. herpes or varicella) lesions of the skin, bacterial or fungal skin infections, parasitic infections, skin manifestations relating to tuberculosis or syphilis, eruptions following vaccinations

• Treatment of rosacea, acne vulgaris, pruritis without inflammation or perioral dermatitis

• Topical application to the eye

Most serious warnings and precautions:• Pediatric patients: safety and effectiveness have

not been established in patients <18 years of age

Other relevant warnings and precautions:• Patients should inform physicians of prior use

of corticosteroids• Should not be used under occlusion• Use under occlusive dressing or over extensive

areas of the scalp may result in sufficient absorption which may result in adrenal suppression and other systemic effects

• Caution in stasis dermatitis and other skin diseases with impaired circulation

• Systemic absorption may result in hypothalamic- pituitary-adrenal (HPA) axis suppression, glucocorticosteroid insufficiency, Cushing’s syndrome, hyperglycemia and glucosuria

• Monitor for HPA-axis suppression in conditions which augment systemic absorption

• Patients/caregivers should be instructed to use LUXIQ® Foam for the minimum amount of time necessary to achieve the desired results

• Increased risk of infections• Caution on lesions close to the eye, risk of

increased intraocular pressure, glaucoma or cataracts

• Hypersensitivity reactions• Caution in psoriasis• Risk of irritation, striae or atrophy of the skin or

subcutaneous tissue• Should not be administered during pregnancy

or lactation unless the expected benefits to the mother outweigh the potential risks to the fetus or the infant

• Cautious dose selection in elderly• Minimum quantity/duration in elderly patients

and patients with renal/hepatic impairment

Dosage and method of administration: • Apply a thin layer of LUXIQ® Foam to the

affected area(s) twice daily, morning and evening for a maximum of 4 weeks.

• Dispense the smallest amount of LUXIQ® Foam (typically a dollop the size of a golf ball, approximately 3 g) necessary to adequately cover the affected area(s) onto a saucer or other cool surface. Do not dispense directly onto hands as foam will begin to melt immediately upon contact with warm skin.

• LUXIQ® Foam is extremely flammable, avoid fire, open flame, spark or smoking during and immediately following application.

Adverse reactions:• In a controlled clinical trial, the most frequently

reported treatment-related adverse reactions were local skin reactions (burning, stinging, itching) and included mild to moderate: pruritus (2%), psoriasis (2%), acne (2%), and alopecia (2%)

For more information: Please consult the product monograph at http: //webprod5.hc-sc.gc.ca/dpd-bdpp/ for important information relating to contraindications, warnings and precautions, adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-387-7374.

To report an adverse event, please call 1-800-387-7374.

AD number LUX-15-01Client: SteifelSize: Full page 11” X 16”Agency: Anderson DDBPublication: The Chronicle of Skin & Allergy

LUX_46432_Chronical_11x16.indd 2 2015-03-11 11:15 AM

by LOUISE GAGNON,Corrrespondent, The Chronicle

One of the ways to improve diabetic footcare in Canada is to increase the rate ofannual foot screening in patients with

diabetes, a condition that affects 15% of adultCanadians, panelists agreed during the CanadianAssociation of Wound Care (CAWC) annualmeeting in Toronto.

“The issue is that we will see more [diabeticfoot] ulcers because the prevalence of diabetes isgoing up,” said James elliott, director of Advocacyand government Relations for the CAWC. “ulcershave to be seen earlier, and they have to be pre-vented in the first place through primary screen-ing [of the feet].”

Other complications such as retinopathy andnephropathy are typically more top of mind whenclinicians see patients with diabetes, said elliott.

A national Australian study concluded that50% of the population with diabetes were notexamined by a health care professional within aperiod of one year while eye screening was per-formed for 80% of that population (Diabetes Care2004; 27:688–693).

Panelists discussed bar-riers to improving diabeticfoot care, as well as oppor-tunities to improve diabeticfoot care, in Canada. elliottsaid that Canada shouldlook to the u.K. and itsNational Health System as amodel for preventing diabet-ic foot disease.

Depending on the healthcare system, patients withdiabetes may have to coverthe cost of annual footscreening, which elliottdescribed as an impediment to effective preven-tion of a diabetic foot ulcer. This cost may be inplace for patients despite the fact that annual footscreening can serve to prevent or delay the devel-opment of foot complications like ulcers andtheir potential progression to lower limb amputa-tions.

Prevention far cheaper than care In terms of dollars and cents, prevention pro-duces far more cost savings than providing carefor advanced state of disease. An analysis thatexamined 1,677 patients with diabetes regardedas at risk or at high risk for foot ulcers and ampu-tation concluded it would be cost effective oreven cost saving to provide prevention measuressuch as foot screening (Diabetologia 2001;44:2077–2087).

It is generally agreed that multi-disciplinaryand inter-disciplinary care involving health careprofessionals such as physicians, nurses, chi-ropodists, and dieticians are needed for optimalcare of patients with diabetes, but it may not beclear which member of the team is responsiblefor annual foot screening, said elliott.

If patients need to pay out-of-pocket for itemssuch as off-loading shoes that will help a diabeticfoot ulcer heal, they may opt to go without theseitems, said elliott.

geography can be a barrier to accessingadvanced foot care services, resulting in patientswho live further away from a city’s core may havedecreased access to services such as Dopplerassessments, wound debridement, and gaitassessments, a fact that was noted in a surveyconducted in Ottawa, noted elliott.

Carolyn gall Casey, director, education,Canadian Diabetes Association (CDA), said theCDA encourages annual foot screening as amajor preventive measure to avoid diabetic footdisease.

“Part of our guideline strategy is that peopleshould be having their feet screened at leastannually during their visit with primary careproviders,” said gall Casey.

Referral patterns continue to be issue Referral patterns of care vary across Canadianjurisdictions, but that doesn’t have to be a barrierto foot disease care. The fundamental point isthat patients who need advanced care receiveadvanced care, said gall Casey.

“If there are complications that go beyondprimary care, the primary care provider shouldknow where they need to send patients for care,”

she said.Patient education

and education of familiesis an important part ofoverall prevention of footdisease, she added.

“There should beteaching of people [withdiabetes] to check theirown feet or ensuring thata family member ischecking their feet forthem,” she said in aninterview with THe

CHRONICLe OF SKIN &ALLeRgy. “Patients with

diabetes need to be their own advocates [fortheir feet].”

Steps that patients can take include wearingsupportive shoes, trimming their toe nails straightacross, checking feet for cuts, cracks, bruises,blisters, sores, infections, and unusual markings.They should change their socks every day, wearshoes that have low heels, and consider wearingorthotics that have been professionally fitted.

They should also avoid walking barefoot bothinside and outside the home to avoid foot traumaand avoid cutting their own corns or calluses, shesaid.

A foot examination by a health professionalshould check for structural abnormalities, neu-ropathy, vascular disease, ulceration, and infec-tion, explained gall Casey.

gall Casey agreed that low-cost options forcare in the community will help to avoid the needfor major interventions such as the amputation oflower limbs at a future time.

Messages about the need for improvedglycemic control and the need for smoking ces-sation are being filtered to patients to help themunderstand the link between their overall healthstatus and how it impacts healing of an ulcerand recurrence of ulcers in the future, said gallCasey.

8 · June 2015


CAWC panel: Diabetic foot screening urgedn Primary screening would help prevent ulcers, improve care

If patients need to pay

out-of-pocket foritems such as

off-loading shoes thatwill help a diabetic foot ulcerheal, they may opt to gowithout these items.

—James Elliottq

with LUXIQ®

THE ONLYMEDIUM POTENCY*

CORTICOSTEROID INDICATED

DELIVERED IN A FOAM FORMAT1†

FOR MODERATE TO SEVERE

SCALP PSORIASIS

Reference: 1. LUXIQ® Foam Product Monograph. GlaxoSmithKline Inc., October 28, 2013.LUXIQ is a registered trademark of Stiefel Laboratories Inc., used under license by GlaxoSmithKline Inc. VERSAFOAM is a registered trademark of Stiefel Laboratories Inc., used under licence by GlaxoSmithKline Inc.Stiefel, a GSK company, Mississauga (Ontario) L5N 6L4

© 2015

* Clinical signifi cance has not been established.† Comparative clinical signifi cance has not been established.

LUXIQ® Foam (betamethasone valerate) is a medium potency topical corticosteroid indicated for the relief of the infl ammatory and pruritic manifestations of moderate to severe psoriasis of the scalp for up to 4 weeks in adult patients. Not recommended in patients less than 18 years of age.

0055603/15

Delivered in

Hydroethanolic

TM

IT’S IN A FOAM

®


Contraindications:• Hypersensitivity to other corticosteroids• Viral (e.g. herpes or varicella) lesions of the skin, bacterial or fungal skin infections, parasitic infections, skin manifestations relating to tuberculosis or syphilis, eruptions following vaccinations

• Treatment of rosacea, acne vulgaris, pruritis without inflammation or perioral dermatitis

• Topical application to the eye

Most serious warnings and precautions:• Pediatric patients: safety and effectiveness have

not been established in patients <18 years of age

Other relevant warnings and precautions:• Patients should inform physicians of prior use

of corticosteroids• Should not be used under occlusion• Use under occlusive dressing or over extensive

areas of the scalp may result in sufficient absorption which may result in adrenal suppression and other systemic effects

• Caution in stasis dermatitis and other skin diseases with impaired circulation

• Systemic absorption may result in hypothalamic- pituitary-adrenal (HPA) axis suppression, glucocorticosteroid insufficiency, Cushing’s syndrome, hyperglycemia and glucosuria

• Monitor for HPA-axis suppression in conditions which augment systemic absorption

• Patients/caregivers should be instructed to use LUXIQ® Foam for the minimum amount of time necessary to achieve the desired results

• Increased risk of infections• Caution on lesions close to the eye, risk of

increased intraocular pressure, glaucoma or cataracts

• Hypersensitivity reactions• Caution in psoriasis• Risk of irritation, striae or atrophy of the skin or

subcutaneous tissue• Should not be administered during pregnancy

or lactation unless the expected benefits to the mother outweigh the potential risks to the fetus or the infant

• Cautious dose selection in elderly• Minimum quantity/duration in elderly patients

and patients with renal/hepatic impairment

Dosage and method of administration: • Apply a thin layer of LUXIQ® Foam to the

affected area(s) twice daily, morning and evening for a maximum of 4 weeks.

• Dispense the smallest amount of LUXIQ® Foam (typically a dollop the size of a golf ball, approximately 3 g) necessary to adequately cover the affected area(s) onto a saucer or other cool surface. Do not dispense directly onto hands as foam will begin to melt immediately upon contact with warm skin.

• LUXIQ® Foam is extremely flammable, avoid fire, open flame, spark or smoking during and immediately following application.

Adverse reactions:• In a controlled clinical trial, the most frequently

reported treatment-related adverse reactions were local skin reactions (burning, stinging, itching) and included mild to moderate: pruritus (2%), psoriasis (2%), acne (2%), and alopecia (2%)

For more information: Please consult the product monograph at http: //webprod5.hc-sc.gc.ca/dpd-bdpp/ for important information relating to contraindications, warnings and precautions, adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-387-7374.

To report an adverse event, please call 1-800-387-7374.

AD number LUX-15-01Client: SteifelSize: Full page 11” X 16”Agency: Anderson DDBPublication: The Chronicle of Skin & Allergy

LUX_46432_Chronical_11x16.indd 2 2015-03-11 11:15 AM

with LUXIQ®

THE ONLYMEDIUM POTENCY*

CORTICOSTEROID INDICATED

DELIVERED IN A FOAM FORMAT1†

FOR MODERATE TO SEVERE

SCALP PSORIASIS

Reference: 1. LUXIQ® Foam Product Monograph. GlaxoSmithKline Inc., October 28, 2013.LUXIQ is a registered trademark of Stiefel Laboratories Inc., used under license by GlaxoSmithKline Inc. VERSAFOAM is a registered trademark of Stiefel Laboratories Inc., used under licence by GlaxoSmithKline Inc.Stiefel, a GSK company, Mississauga (Ontario) L5N 6L4

© 2015

* Clinical signifi cance has not been established.† Comparative clinical signifi cance has not been established.

LUXIQ® Foam (betamethasone valerate) is a medium potency topical corticosteroid indicated for the relief of the infl ammatory and pruritic manifestations of moderate to severe psoriasis of the scalp for up to 4 weeks in adult patients. Not recommended in patients less than 18 years of age.

0055603/15

Delivered in

Hydroethanolic

TM

IT’S IN A FOAM

®


10 · June 2015

V THe CHRONICLe of SKIN & ALLERGY

by IAN J.S. MOORE,Correspondent, The Chronicle

Agarden can be acomfortable home tohazardous plants and

annoying anthropods, as der-matologist Dr. Julian J.Trevino reminded those whoattended one of the scientificFocus sessions during the

annual meeting of theAmerican Academy ofDermatology sessions in SanFrancisco.

“exposures to certainplants can produce a numberof reactions,” the self-con-fessed avid gardener and pro-fessor of dermatology atWright State university inDayton, Ohio, said. “They

include both immunologicand non-immunologic [toxic]urticaria, mechanical andchemical irritant dermatitis,phytodermatitis and allergiccontact dermatitis.”

Most common forms Toxin-mediated contacturticaria is the most commonform of plant-induced

urticaria, he noted, and thestinging nettle is often thecause. Wheals will appearwithin five minutes of contactand the consequent releaseof histamine, acetylcholineand serotonin.

Contact with the spurgenettle (Cnidoscolus stimulo-sus) will produce similarsigns of urticaria, along with

an irritant contact dermatitis.“It’s a double-whammy[plant] you want to stay awayfrom.”

Immunologic contacturticaria often appears onthe skins of atopic patientsand long-time food handlersafter exposure to certainfruits and vegetables. Celeryis a common allergen, andwithin 30 minutes in allcases pruritus, erythema,urticaria will be evident. Inrare cases, systemic respira-tory, cardiovascular and gas-trointestinal symptoms mayalso emerge as medicalemergencies.

“Allergenicity can bereduced by cooking, crushingor deep freezing the plants,”Dr. Trevino said. “Preventionis the preferred treatment,and oral antihistamines andnorepinephrine will berequired for anaphylacticreactions.”

Patients can be tested fort o x i n -mediatedc o n t a c tur t icar iawith ano p e n -a p p l i c a -tion testand astandardprick test

or scratch chamber test forimmunologic contacturticaria, he added.

Mechanical irritant der-matitis accounts for mostcases of plant-related der-matoses. In most cases thereactions range from a milderythema to hemorrhagicbullae necrosis. Cactus,prickly pear, figs, mulberryand saw palmetto are theusual sources of pruriticpapular eruptions that looklike scabies or fiberglass der-matitis.

“Keep in mind,” Dr.Trevino said, “spines andsplinters from plants can pen-etrate the skin and cause for-eign body granulomas. Somepeople can get a granulo-mous synovitis or a monoar-ticular arthritis.”

Here come the arthropodsIn and out of the garden,arthropods can also be amajor cause of patient mor-

Canadian guidelines for the primary pre-vention and management of non-melanoma skin cancer (NMSC) have

been released in the May/June 2015 edition ofthe Journal of Cutaneous Medicine and Surgery.

“These NMSC guidelines were created tofulfill an unmet need,”said Dr. Kirk Barber,who along with the guide-lines committee of 10Canadian dermatologists(surgeons and spaeical-ists) collaborated to es-tablish these CanadianNMSC guidelines.

“We noticed that[Canadian clinicians] were able to consult treat-ment guidelines for psoriasis, for example, butwe were lacking guidelines for NMSC. We alsonoticed that we often tendto focus on melanoma, butnot on NMSC despite thefact that it is extremelycommon,” said Dr.Charles Lynde, founder ofthe Lynde Cen tre for Der-matology in MarkhamOnt., and an associate pro-fessor in the Departmentof Medicine at the University of Toronto.

“From a dermatologist’s point of view, wetake many of these [lesions] off [of patients]everyday,” said Dr. Lynde, who added that fig-ures collected in the United States suggest that11% of all dermatologic visits are for actinickeratoses (AK).

“I think when you add in office visits forbasal cell carcinoma and squamous cell carci-noma, then [these reasons] probably accountfor 20 to 30 per cent of our office visits versusappointments for nevi, psoriasis, eczema, acneand other skin conditions,” said Dr. Lynde.

According to Dr. Lynde, an article publishedrecently in the Archives of Dermatology encour-aged clinicians to start thinking more aboutNMSC because the term ‘non-melanoma skincancer’ somehow minimizes these NMSCs.

“It is almost like we are saying that theyare not melanoma, therefore, they are not asimportant, but we must remember that peopledie from squamous cell carcinoma also,” saidDr. Lynde.

Guidelines divided into five chaptersThe creation of this sophisticated report in-volved a team of dermatologists and medicalwriters who reviewed 5,000 articles in the clin-ical literature dating back at least 10 years to col-lect 700 established and relevant NMSC articles,added Dr. Barber, who operates a dermatologypractice in Calgary and is a clinical professor ofdermatology at the University of Calgary.

“We basically went through all of the lit-

erature, graded it and then provided recom-mendations based on what we called the levelof evidence in the guidelines,” Dr. Barber said.

With all of the data that was collected, theguidelines committee categorized and dividedthe literature into five chapters:

Introduction to the guidelinesPrimary prevention of non-

melanoma skin cancerManagement of actinic keratosesManagement of basal cell carcinomaManagement of squamous cell car-

cinoma

“These guidelines are evidence-basedguidelines established by the published litera-ture—they are not simply a consensus guide-line,” said Dr. Barber.

“Each chapter really consists of a treat-ment algorithm so that practitioners can easilyreview the algorithm and then return to the ac-tual chapters to focus on specific information,”Dr. Barber added.

Dr. Lynde explained that there are a num-ber of NMSC recommendations that em-manated from this report. He added that theuse of any particular treatment could dependon patient preference.

Atypical AKs should be biopsied“I think the most common NMSCs that derma-tologists deal with are AK lesions,” said Dr.Lynde. He stressed that any AK lesions that areatypical and that persist and are resistant totreatment should be biopsied.

A person who has about seven AK lesionshas an increased risk of 10% to 20% of devel-oping squamous cell carcinoma over a 10-yearperiod.

“In the NMSC guidelines, in Chapter 3 forthe treatment of AKs, we reported that if thepatient has isolated AK lesions then they can betreated by using cryotherapy or through surgi-cal excision,” said Dr. Lynde.

In cases where patients have a number ofAK lesions, Dr. Lynde added that “field therapyshould be used and that is where different top-ical therapies come into play.” Field therapy canbe a useful approach to treating sub-clinical AKlesions, he noted.

“The topical therapies for the treatment ofAK lesions summarized in chapter 3 of the reportinclude 5% 5-fluorouracil cream, 3.75% and 5%imiquimod cream and ingenol mebutate gel,” Dr.Lynde told THE CHRONICLE OF SKIN & ALLERGY.

He added that in some cases clinicians mightwant to also consider photodynamic therapy as aoption for field therapy of AK lesions.

“Ultimately, which treatment [a clinician]uses depends on patient preference. For exam-ple, some patients like the fact that ingenolmebutate gel causes a quick inflammatory re-action, so [they can get the treatment] over

with fairly quickly,” said Dr. Lynde.Ingenol mebutate gel is a novel field-di-

rected therapy derived from the sap of Euphor-bia peplus plant that has demonstrated efficacyin clearing AK lesions. Ingenol mebutate is con-sidered to be a topical AK therapy that can beused for a regimen as short as two or threedays. It is designed and approved for two dif-ferent treatment approaches—a 0.015% con-centration for treating a field of 25 cm2 on theface and scalp over three days, and a 0.05%concentration for a two-day treatment on thetrunk and extremities.

Continuous monitoring often importA statement included in the NMSC guide-lines—and an important one to remember, saidDr. Lynde—is that clinicians should closely fol-low patients with a history of NMSC or patientswith a history of long-term systemic immuno-suppression as a result of kidney or renal trans-plant, said Dr. Lynde.

“These patients should be monitored fornew lesions that could occur because there ispotentially a high level of transference into fullskin cancer,” said Dr. Lynde. “Again field ther-apy is thought to be useful to prevent theemergence of NMSC.”

Concise and clear NMSC guidelines“The NMSC guideline chapters are fairly clearand concise. We have already done the workof poring through the literature to extract rel-evant data that is included within each chapter,”said Dr. Lynde.

“For the most part what is included in theguidelines are motherhood statements. They arecommon sense statements and it is probablywhat people are doing already, but this reportputs evidence behind it,” Dr. Lynde concluded.

For more information visit: http://ow.ly/NJBiZ

Supplement to The Chronicle of Skin & Allergy,June 2015. Chronicle is an independent medicalnews service that provides educational updatesregarding medical developments around theworld. Views expressed are those of the partici-pants and do not necessarily reflect those of thepublisher or sponsor.

Support for distribution of this report wasprovided by LEO Pharma through an unre-stricted educational grant without conditions. In-formation provided in this report is not intendedto serve as the sole basis for individual care.

Printed in Canada for Chronicle Informa-tion Resources Ltd., 555 Burnhamthorpe Rd.,Suite 306, Toronto, Ont. M9C 2Y3.Telephone416.916.2476; facsimile 416.352.6199; e-mail:[email protected]. Copyright 2015 byChronicle Information Resources Ltd., exceptwhere noted. All rights reserved. Reproductionin any form is expressly prohibited without writ-ten permission of the publisher.

Spe c i a l Repo r t

Released: Canadian non-melanoma skin cancer guidelinesReport summarizes recommendations about prevention, management of AK, BCC and SCC

P a t i e n t c a r e

From stinging plants to fire antsnClues to clinical presentations that may result from problematic plants and bugs that reside in gardens

Please turn to Garden page 26à

Dr. Julian J.Trevino

Is there something missing from your considerations for rosacea treatment?

APPRILON® (doxycycline) – the fi rst and only oral anti-infl ammatory therapy indicated for adult patients with papulopustular rosacea1,2*†

• A unique formulation of 30 mg immediate-release and 10 mg delayed-release beads of doxycycline for once-daily dosing1

• Plasma concentration of doxycycline following administration of APPRILON is below the level required to treat bacterial diseases1‡

*No meaningful effect was demonstrated for generalized erythema (redness) of rosacea.

REFERENCES:

1. APPRILON Product Monograph, Galderma Canada Inc., August 30, 2012.

2. Health Canada Drug Product Database, http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp. Accessed January 17, 2012.†Comparative clinical signifi cance is unknown.

APPRILON (doxycycline) modifi ed-release capsule is indicated for the treatment of only infl ammatory lesions (papules and pustules) of rosacea in adult patients.

Consult the Product Monograph at www.galderma.ca/pm/apprilon.pdf for important information on:

• Contraindications in women in the second or third trimester of pregnancy, or nursing women, infants and children up to the age of 8 years and patients with myasthenia gravis

• The most serious warnings and precautions regarding the use of APPRILON as an antibiotic

• Other relevant warnings and precautions regarding risk of overgrowth of non-susceptible microorganisms, caution in patients with a history of or predisposition to candidiasis overgrowth, risk of drug-drug or drug-food interactions (avoid concurrent oral retinoids), not recommended in patients with gastric insuffi ciency, risk of Clostridium diffi cile-associated disease, risk of esophagitis and esophageal ulcerations, caution in patients with hepatic impairment or receiving potentially hepatoxic medicinal products, risk of hypersensitivity reactions, risk of autoimmune disorders, risk of pseudotumor cerebri in adults and bulging fontanels in infants, use in patients with ocular manifestations of rosacea, risk of bacterial resistance, risk of photosensitivity, risk of tissue hyperpigmentation, and periodic laboratory evaluations of organ systems

• Conditions of clinical use, adverse reactions, interactions and dosing/administration instructions

The Product Monograph is also available by calling us at 1-800-467-2081.

APPRILON (doxycycline) anti-infl ammatory therapy

‡ APPRILON should not be used for treating bacterial infections, providing antibacterial prophylaxis, or reducing the numbers or eliminating microorganisms associated with any bacterial disease.

APPRILON® is a registered trademark of Galderma Canada Inc.

MISSING

An oral anti-infl ammatory therapy indicated in rosacea


Is there something missing from your considerations for rosacea treatment?

APPRILON® (doxycycline) – the fi rst and only oral anti-infl ammatory therapy indicated for adult patients with papulopustular rosacea1,2*†

• A unique formulation of 30 mg immediate-release and 10 mg delayed-release beads of doxycycline for once-daily dosing1

• Plasma concentration of doxycycline following administration of APPRILON is below the level required to treat bacterial diseases1‡

*No meaningful effect was demonstrated for generalized erythema (redness) of rosacea.

REFERENCES:

1. APPRILON Product Monograph, Galderma Canada Inc., August 30, 2012.

2. Health Canada Drug Product Database, http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp. Accessed January 17, 2012.†Comparative clinical signifi cance is unknown.

APPRILON (doxycycline) modifi ed-release capsule is indicated for the treatment of only infl ammatory lesions (papules and pustules) of rosacea in adult patients.

Consult the Product Monograph at www.galderma.ca/pm/apprilon.pdf for important information on:

• Contraindications in women in the second or third trimester of pregnancy, or nursing women, infants and children up to the age of 8 years and patients with myasthenia gravis

• The most serious warnings and precautions regarding the use of APPRILON as an antibiotic

• Other relevant warnings and precautions regarding risk of overgrowth of non-susceptible microorganisms, caution in patients with a history of or predisposition to candidiasis overgrowth, risk of drug-drug or drug-food interactions (avoid concurrent oral retinoids), not recommended in patients with gastric insuffi ciency, risk of Clostridium diffi cile-associated disease, risk of esophagitis and esophageal ulcerations, caution in patients with hepatic impairment or receiving potentially hepatoxic medicinal products, risk of hypersensitivity reactions, risk of autoimmune disorders, risk of pseudotumor cerebri in adults and bulging fontanels in infants, use in patients with ocular manifestations of rosacea, risk of bacterial resistance, risk of photosensitivity, risk of tissue hyperpigmentation, and periodic laboratory evaluations of organ systems

• Conditions of clinical use, adverse reactions, interactions and dosing/administration instructions


APPRILON (doxycycline) anti-infl ammatory therapy

‡ APPRILON should not be used for treating bacterial infections, providing antibacterial prophylaxis, or reducing the numbers or eliminating microorganisms associated with any bacterial disease.

APPRILON® is a registered trademark of Galderma Canada Inc.

MISSING

An oral anti-infl ammatory therapy indicated in rosacea


Patient case: This 42-year-old female has suffered with

acne since her teens. During the teenage years she was

treated with oral antibiotics including tetracycline 1 gm per

day for several months. In her twenties she was treated

with oral isotretinoin and remained clear for just two years.

She received minocycline 200 mg per day for many

months in her late twenties with some improvement but

flared when the antibiotic was discontinued. She com-

plained that her acne worsened markedly the week before

her menses so her family doctor prescribed an oral contra-

ceptive pill (OCP) containing 2 mg cyproterone acetate and 0.035 mg ethinyl estradiol as well as a topical

retinoid and benzoyl peroxide.

She was fairly clear until two years ago when her family doctor thought it was safer for her at the age of

40 to be on a low estrogen OCP containing 0.10 mg of levonorgestrel and 0.02 mg of ethinyl estradiol.

Within three months of switching the OCP her acne flared and continued to worsen for another six months.

In despair, she stopped the OCP completely. She had also noted intolerance to the topical retinoid at around

age 35, manifesting as red dry scaly skin associated with a burning skin sensation. She subsequently devel-

oped an allergic reaction to the benzoyl peroxide leave-on product consisting of itching, redness and eyelid

swelling. She presented on no therapy whatsoever and was concerned about her frequent flares and ongo-

ing skin irritation, which had lowered her self-esteem markedly (Fig. 2). She is a single mother with two

teenage daughters and holds a demanding job as head of marketing in a publishing company and is despon-

dent after struggling with acne for over 25 years.

The condition: Her acne was mainly inflammatory in nature with papules and nodules along the lower third of

her cheeks, jawline and chin. Her facial skin was dry with erythema and scaling over the malar region. .

Treatment: She was educated on the cause of her acne and on treatment options. Serum androgens were

checked and found to be normal. She was started on spironolactone 100 mg per day. She was also given oral

isotretinoin 20 mg per day for six months to control her acne while waiting for the anti-androgen to achieve

control. She was prescribed an OCP while on oral isotretinoin. A well-tol-

erated adjunctive skin care regimen with a HMPs containing *cleanser and

a **moisturizer with SPF were initiated.

Consider:

� Female adult acne patients are often prone to skin dryness, peeling,

and irritation resulting from acne therapy or other skin conditions

(sensitive skin, rosacea)

� Treatment regimens should include a gentle skin care regimen reduc-

ing skin irritation and optimizing treatment outcomes

References

1. Herane MI, Ando I: Acne in infancy and acne genetics. Dermatology

2003; 206:24–28, doi:10.1159/000067819.

2. Bhambri S, Del Rosso JQ, Bhambri A: Pathogenesis of acne vulgaris: recent advances. J Drugs Dermatol

2009; 8:615–618.

3. Dao H Jr, Kazin RA: Gender differences in skin: a review of the literature. Gend Med 2007; 4(4):308–328.

4. Lynde C, Tan J, Andriessen A, Barankin B, Dutil M, Gilbert M, Hong CH, Humphrey S, Rochette L, Toole J,

Thomas R, Vender R, Wiseman M, Zip C: A consensus on acne management focused on specific patient

features. J Cutan Med Surg 2014 Jul-Aug; 18(4):243–255.

5. Walters RM, Fevola MJ, Gandolfi L, Librizzi JJ, Tamareselvy K, Tierney NK: Polymer-surfactant self-assembly

for the design of mild skin cleansers. Polymeric Materials: Science & Engineering 2011; 105(6):697–698.

6. Draelos Z, Hornby S, Walters RM, Appa Y: Hydrophobically modified polymers can minimize skin irritation

potential caused by surfactant based cleansers. J Cosmet Dermatol 2013 Dec; 12(4):314–321.

Minimizing skin irritation in adult femaleswith acne using a skin cleanser containinghydrophobically modified polymers

Acne in Adult Females: A skin disease primarily of adolescence,acne is typically triggered by initiation of androgen production bythe adrenal glands and gonads and may subside after this develop-mental phase.1,2 However, acne may persist beyond adolescence oroccur for the first time in adult years in a significant proportion ofindividuals, particularly women.1,2 Gender differences in skin func-tion and structure have been studied to understand more aboutacne pathogenesis and treatment response.3 It has been suggestedthat hormonal interactions contribute substantially to the genderdifferences in acne, notably on sebum production, which plays an

important role in acne development.3

Hereditary mechanisms may be causal insome and may be associated with moresevere or more persistent acne. Abnormalgene expression for cytochrome P-450–1A1 and steroid-21-hydrox-ylase has been reported.1 Several non-acne dermatoses such asrosacea, which typically has a later age of onset (30 to 50 years),may present with morphology similar to that of acne vulgaris. Itmay complicate adult acne as in the case study below and needsto be distinguished and treated appropriately.

Fig 1: Surfactant penetration5

Fig 2: Acne patient case: Adult female with inflammatoryacne along the lower one-third ofher face and chin

Editorial feature supported by an unrestricted grant from Johnson & Johnson Inc., who are not responsible for content.

*Neutrogena NEUTROGENA® Ultra Gentle Daily Cleanser, **Neutrogena NEUTROGENA® HEALTHY DEFENSE® Daily Moisturizer SPF 45,Johnson & Johnson Inc.

Acne skin cleansers con-taining hydrophobicallymodified polymers: Female

patients suffering from

adult acne are often prone

to skin inflammation, mani-

fested by dryness, peeling,

and irritation from topical

acne therapy.4 The focus of

treatment is to reduce the

production of the micro-

comedo and inflammatory

mediators.4 Acne treatment

should include not only

medical therapy as indi-

cated by the morphology of

the lesions, but also adju-

vant therapy in the forms of

cleansers, moisturizers, cos-

metic skin care regimens

and proper nutrition.4

When selecting a suit-

able cleanser for these pa-

tients, a gentle one is

indicated. Adding hy-

drophobically modified

polymers (HMPs) to surfac-

tant containing cleansers

can result in a less irritating

product.5,6 An in vitro study,

combined with patch test-

ing on human subjects, as-

sessed surfactant-based

cleansing systems contain-

ing HMPs.5 In vivo exposureto surfactant solutions fol-

lowed by analysis of tape

strips for surfactant con-

centration, provided a

depth profile of surfactant

penetration into the stra-

tum corneum (Fig 1).5 The

HMP cleansers are less

likely to penetrate the skin

and leave less residue,

thereby causing less irrita-

tion.5 These cleansers help

to maintain the integrity of

the skin barrier and offer

benefits when used in facial

acne in individuals that are

prone to skin irritation.5,6

Maha T. Dutil, MD, FRCPC

12 · June 2015

Atopic dermatitis research THe CHRONICLe of SKIN & ALLERGY

the efficacy and safety of the emerg-ing therapies that target the IL-17pathway. Data from a one-year followup of patients who had reached PASI75 with administration of secukinum-ab in two separate Phase III trials andwho had been randomized toassigned doses or to crossover or toplacebo in an extension trial found87% patients who continued withsecukinumab therapy maintainedtheir responses during an additional12 months of treatment.

Phase III data comparing the anti-IL-17 receptor A antibody brodalum-ab and ustekinumab in patients withmoderate-to-severe psoriasis foundthe higher dose of brodalumab wassuperior to ustekinumab in achievingPASI 100.

Ixekizumab, an IL-17 neutralizingantibody designed to treat psoriasis,produced outcomes of clear and almostclear in about 80% of patients withmoderate or severe disease in a 12-week trial. Subsequent randomizationdemonstrated the majority of patientswho continued therapy for another 48weeks maintained responses.

Evaluate treatment optionsDespite the compelling figures, somedermatologists express caution aboutthe hasty adoption of IL-17 inhibitors inclinical practice in the absence of long-term experience and real-world data.

“It may be too early to considerthese three new agents [secukinumab,brodalumab, ixekizumab] before con-sidering ustekinumab,” said Dr. RonVender, a Hamilton-based dermatolo-gist and director of DermatrialsResearch Inc. in that city. “They want tostand out compared to ustekinumab,

although recently published head-to-head trials show that there may be effi-cacy advantages with secukinumab.”

Still, the increasing number oftreatment options creates “a greatopportunity” for patients with psoria-sis, and with study endpoints such asPASI 90 and PASI 100, the perfor-mance bar is being continuouslyraised, says Dr. Anatoli Freiman, adermatologist and medical director atthe Toronto Dermatology Centre inToronto.

“We are getting close to having a‘cure’ for psoriasis,” said Dr. Freiman.“you stay in remission as long as youstay on the therapy. With more targetedtherapies, we hopefully will improvethe efficacy and safety profile.”

The emergence of biosimilars hascreated some unease among derma-tologists, who fear that in an era ofcost containment, cost concerns maydrive the prescription of biosimilars.

“There is some debate about howsimilar they are,” said Dr. Freiman inan interview with THe CHRONICLe OF

SKIN & ALLeRgy. “There is some con-cern among dermatologists that theywould not be giving the patients thesame quality of medications, and weneed to know more about these mol-ecules before prescribing them.”

Like Dr. Freiman, Dr. RodKunynetz, medical director ofultranova Skin Care Trials in Barrie,Ont., and assistant professor of medi-cine at the university of Toronto,agreed that there have never beenmore therapeutic options for patientswith plaque psoriasis.

“We have many drugs that can beused for patients, and the efficacy isgetting better and better as we godown the psoriasis pathogenesis

pathways,” said Dr. Kunynetz, addingthat the new biologics also addressscalp psoriasis and offer modestimprovement in nail psoriasis.

One of the appealing characteris-tics of the anti IL-17 agents is that allthree appear to have a faster onset ofaction than ustekinumab, noted Dr.Kunynetz.

Dose titration resolves side effectThe oral small molecules, which areparticularly suited to patients who areneedle-phobic, have demonstratedthat they are very safe, said Dr.Kunynetz.

“We have done a number of trialswith apremilast, an inhibitor of phos-phodiesterase 4, and it does notrequire any monitoring whatsoever,”he said.

One side effect witnessed hasbeen loose stools or diarrhea with theinitiation of therapy, which has led totitration of the dose, such thatpatients start at a lower dose andincrease the dose after the first weekof use, and this approach tends toresolve any issues with diarrhea,explained Dr. Kunynetz.

Data presented at this year’s AADmeeting suggested that patients withmoderate-to-severe psoriasis whohad been on etanercept maintainedefficacy when they were switched toapremilast.

Another small molecule that iscurrently under study for use in psori-asis is tofacitinib, and data presentedat the AAD sessions suggested thatwere no serious safety concerns withtofacitinib.

While it is not new informationthat patients with psoriasis typicallyhave a greater rate of some co-mor-bidities than individuals in the generalpopulation, the significance of theage of onset of the chronic diseasehas new weight in relationship to car-diovascular co-morbidities, accordingto recent data out of Newfoundland.

Dr. Wayne gulliver, a dermatolo-gist in St. John’s, Newfoundland andLabrador and professor of medicineat Memorial university and his co-investigators conducted a case-con-trol investigation and studied recordsof 178 patients with moderate-to-severe psoriasis, matching themagainst 440 control subjects. Theyfound patients who developed thechronic condition prior to their 25thbirthday had an 885% elevated risk ofhaving a heart attack.

“early age of [psoriasis] onsetseems to be important,” said Dr.gulliver. “There is increased cardio-vascular mortality with early age ofonset.”

Investigators also found that treat-ment with a biologic agent signifi-

cantly decreased the cardiovascularrisks associated with an early courseof psoriatic disease: patients on a bio-logic had a relative risk of having aheart attack of 0.017. “Treatment[with a biologic agent] decreases therisk of co-morbidities like cardiovas-cular events,” said Dr. gulliver.

Not only are major adverse car-diovascular events a concern withpatients who have psoriasis, but co-morbidities such as depression,smoking, and alcoholism are notuncommon in patients with chronicplaque psoriasis. These patients canalso face employment challengesbecause of their external appearance,said Dr. Kunynetz. effective therapycan be life-changing for patients,affecting their personal and profes-sional lives, he stressed.

Life-changing therapy“They have a challenge if they havejobs where they have to deal with thepublic,” said Dr. Kunynetz. “If theyhave psoriasis all over their faces,they may be socially inhibited. [Withtherapy], they no longer have to besocially inhibited. They are not reclus-es anymore. They can socialize, andthey can feel comfortable being on abeach, for example.”

Clinicians are especially vigilantabout the selection of a biologic agentto treat pediatric patients who havepsoriasis. To date, the most well-stud-ied biologic agent in the pediatricpopulation has been etanercept.

New data from Canadian andeuropean trial centres presented dur-ing a poster study at the AAD highlightsthat ustekinumab, particularly the fulldose, offers efficacy and a favourableside effect profile in the managementof children with psoriasis.

“I feel that the efficacy and safetydata are both very exciting as theysupport the use of ustekinumab in thepediatric psoriasis population,” saidDr. Ian Landells, an investigator onthe study and medical director atNexus Clinical Research in St. John’s,Newfoundland and Labrador, andclinical associate professor atMemorial university.

“Furthermore, [ustekinumab]offers a safe and effective treatmentthat is suited for these patients as itwill only require four subcutaneousinjections per year. We also saw thatno new safety concerns arose.”

Non-proprietary and brand names oftherapies: secukinumab (Cosentyx,Novartis); brodalumab (not approvedin Canada); ustekinumab (Stelara,Janssen); ixekizumab (not approvedin Canada); apremilast (Otezla,Celgene Corp.); etanercept (Enbrel,Amgen).

PASI 90 or 100 new endpoints in psoriasis management

Canadian DermatologyIndustry Association

Corporate. . . . . . . . . . . . . 16

CelgeneOtezla. . . . . . . . . . . . . 40

Dermtek PharmaDermburo. . . . . . . . . . . . . 27

Galderma Canada Inc.Apprilon. . . . . . . . . . . . . 11

Rosiver. . . . . . . . . . 7, 32

Johnson & JohnsonNeutrogena Sun Lotion. . . . . . . . 29

Women’s Rogaine Foam. . . . . 31

LEO PharmaPicato. . . . . . . . . . . . . 15

NovartisXolair. . . . . . . . . . . . . 2

Corporate. . . . . . . . . . . . . 5

Pierre FabreDermo Cosmetique

Avène Sun Care. . . . . . . . . . . . . 17

Procter & GambleGillette. . . . . . . . . . . . . 22-23

Olay Regeneris. . . . . . . . . . . . . 34Venus Swirl. . . . . . . . . . . . . 19

Stiefel,a GSK Company

Clindoxyl. . . . . . . . . . . . . 25Luxiq. . . . . . . . . . . . . 8, 9

Valeant CanadaCereVe . . . . . . . . . . . . . 39

THERAPEUTIC INDEX

Continued from page 1


Patient case: This 42-year-old female has suffered with

acne since her teens. During the teenage years she was

treated with oral antibiotics including tetracycline 1 gm per

day for several months. In her twenties she was treated

with oral isotretinoin and remained clear for just two years.

She received minocycline 200 mg per day for many

months in her late twenties with some improvement but

flared when the antibiotic was discontinued. She com-

plained that her acne worsened markedly the week before

her menses so her family doctor prescribed an oral contra-

ceptive pill (OCP) containing 2 mg cyproterone acetate and 0.035 mg ethinyl estradiol as well as a topical

retinoid and benzoyl peroxide.

She was fairly clear until two years ago when her family doctor thought it was safer for her at the age of

40 to be on a low estrogen OCP containing 0.10 mg of levonorgestrel and 0.02 mg of ethinyl estradiol.

Within three months of switching the OCP her acne flared and continued to worsen for another six months.

In despair, she stopped the OCP completely. She had also noted intolerance to the topical retinoid at around

age 35, manifesting as red dry scaly skin associated with a burning skin sensation. She subsequently devel-

oped an allergic reaction to the benzoyl peroxide leave-on product consisting of itching, redness and eyelid

swelling. She presented on no therapy whatsoever and was concerned about her frequent flares and ongo-

ing skin irritation, which had lowered her self-esteem markedly (Fig. 2). She is a single mother with two

teenage daughters and holds a demanding job as head of marketing in a publishing company and is despon-

dent after struggling with acne for over 25 years.

The condition: Her acne was mainly inflammatory in nature with papules and nodules along the lower third of

her cheeks, jawline and chin. Her facial skin was dry with erythema and scaling over the malar region. .

Treatment: She was educated on the cause of her acne and on treatment options. Serum androgens were

checked and found to be normal. She was started on spironolactone 100 mg per day. She was also given oral

isotretinoin 20 mg per day for six months to control her acne while waiting for the anti-androgen to achieve

control. She was prescribed an OCP while on oral isotretinoin. A well-tol-

erated adjunctive skin care regimen with a HMPs containing *cleanser and

a **moisturizer with SPF were initiated.

Consider:

� Female adult acne patients are often prone to skin dryness, peeling,

and irritation resulting from acne therapy or other skin conditions

(sensitive skin, rosacea)

� Treatment regimens should include a gentle skin care regimen reduc-

ing skin irritation and optimizing treatment outcomes

References

11.. Herane MI, Ando I: Acne in infancy and acne genetics. Dermatology

2003; 206:24–28, doi:10.1159/000067819.

2. Bhambri S, Del Rosso JQ, Bhambri A: Pathogenesis of acne vulgaris: recent advances. J Drugs Dermatol

2009; 8:615–618.

3. Dao H Jr, Kazin RA: Gender differences in skin: a review of the literature. Gend Med 2007; 4(4):308–328.

4. Lynde C, Tan J, Andriessen A, Barankin B, Dutil M, Gilbert M, Hong CH, Humphrey S, Rochette L, Toole J,

Thomas R, Vender R, Wiseman M, Zip C: A consensus on acne management focused on specific patient

features. J Cutan Med Surg 2014 Jul-Aug; 18(4):243–255.

5. Walters RM, Fevola MJ, Gandolfi L, Librizzi JJ, Tamareselvy K, Tierney NK: Polymer-surfactant self-assembly

for the design of mild skin cleansers. Polymeric Materials: Science & Engineering 2011; 105(6):697–698.

6. Draelos Z, Hornby S, Walters RM, Appa Y: Hydrophobically modified polymers can minimize skin irritation

potential caused by surfactant based cleansers. J Cosmet Dermatol 2013 Dec; 12(4):314–321.

Minimizing skin irritation in adult femaleswith acne using a skin cleanser containinghydrophobically modified polymers

Acne in Adult Females: A skin disease primarily of adolescence,acne is typically triggered by initiation of androgen production bythe adrenal glands and gonads and may subside after this develop-mental phase.1,2 However, acne may persist beyond adolescence oroccur for the first time in adult years in a significant proportion ofindividuals, particularly women.1,2 Gender differences in skin func-tion and structure have been studied to understand more aboutacne pathogenesis and treatment response.3 It has been suggestedthat hormonal interactions contribute substantially to the genderdifferences in acne, notably on sebum production, which plays an

important role in acne development.3

Hereditary mechanisms may be causal insome and may be associated with moresevere or more persistent acne. Abnormalgene expression for cytochrome P-450–1A1 and steroid-21-hydrox-ylase has been reported.1 Several non-acne dermatoses such asrosacea, which typically has a later age of onset (30 to 50 years),may present with morphology similar to that of acne vulgaris. Itmay complicate adult acne as in the case study below and needsto be distinguished and treated appropriately.

FFiigg 11:: SSuurrffaaccttaanntt ppeenneettrraattiioonn55

Fig 2: AAccnnee ppaattiieenntt ccaassee:: AAdduulltt ffeemmaallee wwiitthh iinnffllaammmmaattoorryyaaccnnee aalloonngg tthhee lloowweerr oonnee--tthhiirrdd ooffhheerr ffaaccee aanndd cchhiinn

Editorial feature supported by an unrestricted grant from Johnson & Johnson Inc., who are not responsible for content.

*Neutrogena NEUTROGENA® Ultra Gentle Daily Cleanser, **Neutrogena NEUTROGENA® HEALTHY DEFENSE® Daily Moisturizer SPF 45,Johnson & Johnson Inc.

Acne skin cleansers con-taining hydrophobicallymodified polymers: Female

patients suffering from

adult acne are often prone

to skin inflammation, mani-

fested by dryness, peeling,

and irritation from topical

acne therapy.4 The focus of

treatment is to reduce the

production of the micro-

comedo and inflammatory

mediators.4 Acne treatment

should include not only

medical therapy as indi-

cated by the morphology of

the lesions, but also adju-

vant therapy in the forms of

cleansers, moisturizers, cos-

metic skin care regimens

and proper nutrition.4

When selecting a suit-

able cleanser for these pa-

tients, a gentle one is

indicated. Adding hy-

drophobically modified

polymers (HMPs) to surfac-

tant containing cleansers

can result in a less irritating

product.5,6 An in vitro study,

combined with patch test-

ing on human subjects, as-

sessed surfactant-based

cleansing systems contain-

ing HMPs.5 In vivo exposureto surfactant solutions fol-

lowed by analysis of tape

strips for surfactant con-

centration, provided a

depth profile of surfactant

penetration into the stra-

tum corneum (Fig 1).5 The

HMP cleansers are less

likely to penetrate the skin

and leave less residue,

thereby causing less irrita-

tion.5 These cleansers help

to maintain the integrity of

the skin barrier and offer

benefits when used in facial

acne in individuals that are

prone to skin irritation.5,6

Maha T. Dutil, MD, FRCPC


14 · June 2015


dure can obscure it. Thiscould make it more challeng-ing for a dermatologist to diag-nose the lesion when thepatient does present with it or,perhaps more worryingly, toassume the lesion is ‘treated’and not seek out a dermatolo-gist until it has progressed intoa serious, potentially life-threatening melanoma.

She also noted that somenon-physician laser operatorsdo not restrict themselves totattoo removal. She has seen

non-medical operators inToronto advertise that theytreat moles and other pig-mentation issues. even if theoperator restricts their laseruse to removing tattoos, “it isstill a [medical] procedure,we still end up breaking thesurface of the skin,” she says.

Lack of knowledge of howto deal with complications,including scarring and pig-ment changes, should theyoccur, is also a concern whennon-physicians carry out lasertattoo removal, says Dr. Kellett.

Restrictions not warrantedWhile agreeing that there issome risk involved with lasertattoo removal procedures, Dr.Jaggi Rao, a dermatologist andcosmetic surgeon in edmon-ton and a member of theCanadian Standards Assoc-iation committee on laser safe-ty, says it is unreasonable torestrict tattoo removal to physi-cians while tattoo applica-tion—often a riskier proce-dure—is not so restricted.

Tattoo-removal lasers “arerelatively safe compared to

what they used to be,” says Dr.Rao. The original tattoo proce-dure is often more risky, andother directed-energy treat-ments such as laser hairremoval are not restricted inspite of not necessarily beingbenign. The question arises,when there is a call to restrictone procedure—laser tattooremoval—where is the linedrawn and using what criteria,he says. The CSA committeeDr. Rao sits on has drafted astandards document on lasersafety, and he says they deliber-

ately omitted a call for medicalrestriction of laser tattooremoval for this reason.

There are certainly advan-tages toperform-ing lasert a t t o or e m o v a lin a med-ical set-ting, saysDr. Rao,including

the availability of a wider arrayof anesthetic options andpotentially a faster response tocomplications, but those alsoapply to laser hair removal,photo-rejuvenation, and tattooapplication.

“I would say there shouldbe some kind of standard soanywhere that a laser is beingoperated, they maintain thatcertain safety standard,” saysDr. Rao. “I do agree [laser oper-ators] should have some type ofstandard of certification if theywant to use any type of lasers.”An unbiased, comprehensivethird-party course—rather thanone from a laser manufactur-er—along with laser registrationand an accreditation processwould be ideal.

“If you look at the tattooindustry, it is very well regulat-ed, more so than laser hairremoval. They are held to avery high standard that, unfor-tunately, we don’t see in thelaser world. But that’s what wewant to see [implemented forlaser treatments],” he says.

“That’s why the CSA hascome out with guidelines forsafe application of laser,”says Dr. Rao. “In those guide-lines we do recommend peo-ple take a course, and in thatcourse they’ll learn to recog-nize complications and acton them quickly—eitherdirectly or referred to some-body who can do it.”

Many provinces havetalked about creating a stan-dardized course to teach thefundamentals of laser therapy,and the Canadian Associationof Aesthetic Medicine (CAAM)developed a course on the fun-damentals of laser safety andlaser science that they plan tointroduce this year which willbe open to physicians as wellas to physician-delegates, saysDr. Rao. These courses couldserve as a template to developa program for training non-physician operators, he adds.

TThhee CChhrroonniicclleehhaass llaannddeedd oonnyyoouurr mmoobbiilleepphhoonnee

TTeexxtt ffoollllooww sskkiinncchhrroonniiccllee ttoo 2211221122iinn CCaannaaddaa ((oorr ttoo 4400440044 iinn tthhee UUSSAA))ffoorr uupp--ttoo--tthhee--sseeccoonndd uuppddaatteess ffrroommtthhee wwoorrlldd ooff cclliinniiccaall ddeerrmmaattoollooggyy,,aanndd ttoo pprreevviieeww aarrttiicclleess ffrroomm uupp--ccoommiinngg eeddiittiioonnss ooff TThhee CChhrroonniiccllee ooff SSkkiinn && AAlllleerrggyy..

FFoollllooww uuss oonn TTwwiitttteerr:: wwwwww..ttwwiitttteerr..ccoomm//sskkiinncchhrroonniiccllee

Laser tattoo removal regulations: Are they necessary?Continued from page 1

Picato® Gel (ingenol mebutate) is indicated for topical treatment of non-hyperkeratotic, non-hypertrophic actinic keratosis (AK) in adults.

Picato® Gel is about treatment time in actinic keratosis.

C O V E R E DO N M O S TP R I V A T EP L A N S

• Local Skin Responses (LSRs)* are transient and typically occur within 1 day of treatment and peak in intensity up to 1 week following completion of treatment. These e�ects typically resolve within 2 weeks on the face and scalp, and within 4 weeks on the trunk and extremities.

• Short duration dosing: once daily for 3 days on face/scalp or 2 days on trunk/extremities

*LSRs included erythema, flaking/scaling, crusting, swelling, vesiculation/pustulation, and erosion/ulceration

vePr•Use in pr•

t not be ingesMus•Use near the e•

ontact with skin outside the trC•Use on skin which is not healed•

ervSe•ervSe•veleR

ell carention of squamous cegnant and nursing wUse in pr

edtt not be ingeses, inside the nosyUse near the e

ontact with skin outside the trUse on skin which is not healed

derse disorye eeresponses (LSRsocal Skin Re Ler

ecautionsv

C) has not been scinoma (SCell caromenegnant and nursing w

trils or ears or on the lipses, inside the nosea should be atment areaontact with skin outside the tr

Use on skin which is not healed

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Picato® Gel (ingenol mebutate) is indicated for topical treatment of non-hyperkeratotic, non-hypertrophic actinic keratosis (AK) in adults.

Picato® Gel is about treatment time in actinic keratosis.

C O V E R E DO N M O S TP R I V A T EP L A N S

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16 · June 2015


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P a t i e n t c a r e

Delayed PsA Dx worsens damage, disabilitynAfter six months of undiagnosed, untreated symptoms, joint outcomes deteriorated in these patientsby FRIEDA WILEY,Special to The Chronicle

Patients with psoriatic arthritis(PsA) who delayed seeing arheumatologist by more than

six months were more likely to expe-rience joint destruction and to haveworse functional disability than if theywere seen promptly, a study conduct-ed in Ireland found.

In a multivariate analysis, patientswho had not seen a rheumatologistwithin sixmonths of theonset of pain,stiffness, or jointswelling weres i g n i f i c a n t l ymore likely todevelop jointerosions (OR4.25, 95% CI2 . 3 2 – 7 . 9 9 ,p<0.001), according to Dr. OliverFitzgerald and colleagues from St.Vincent’s university Hospital inDublin.

In addition, those “late consul-ters” were more likely to have worsedisability scores on the HealthAssessment Questionnaire (OR 2.2,95% CI 1.29–3.74, P=0.004), theresearchers reported in the Juneissue of Annals of the RheumaticDiseases (2015; 74:1045–1050).

Previous studies have shown thatjoint destruction can occur early inthe course of PsA, when treatment ismost likely to be beneficial.

“Anti-rheumatic treatmentshould ideally be started within afew months after the onset of symp-toms, and the delay in assessmentby rheumatologists of patients withPsA is potentially an important deter-minant of delay in treatment initia-tion,” Dr. Fitzgerald and colleagueswrote

Therefore, to examine factors thatwere associated with delay and tocompare outcomes in early and lateconsulters, the researchers analyzeddata from a large cohort of patientswho all had a confirmed diagnosis ofPsA

Their study included 283 patientswho had had PsA for an average of 19years (+/- 9 years).

Participants’ mean age was 54.6,and 52% were women. At baseline,one-quarter had sacroiliitis, 44.5%already had erosions, and almost

one in ten had arthritis mutilans.Fewer than one-third were earlyconsulters.

PASI assessedevaluators assessed the degree ofseverity of skin psoriasis utilizing thePsoriasis Area and Severity Index tooland analysed clinical variables,including body surface area. For therheumatologic analysis, cliniciansperformed a thorough physical exam-ination of patients using the 68 ten-der/66 swollen joint counts, in addi-tion to screening for dactylitis, enthe-sitis, and permanent joint deformity.

evaluators also documentedwhether patients had previously beentreated with disease-modifying anti-

rheumatic drugs (DMARDs) and tumornecrosis factor (TNF) inhibitors.

The study revealed that not onlydid patients who had delayed physi-cian follow-up present with morejoint abnormalities and joint dam-age—including sacroiliitis, joint defor-mities, and arthritis mutilans—butthey were more likely to fail treat-ment with DMARDs (OR 1.47,p=0.007) and less likely to experi-ence drug-free remission (OR 0.42,p=0.01).

Factors associated with delayed DxA univariate analysis indicated thatthe patients who were late consul-ters were more than four times aslikely to have erosions (OR 4.58,p=0.001), and more prone to havingthe following additional pathologiesassociated with PsA: osteolysis (OR3.6, p<0.001), sacroiliitis (OR 2.28,p=0.01), arthritis mutilans (OR 10.6,p= 0.02), and/or joint deformities(OR 1.06, p=0.006).

Factors associated with delayeddiagnosis included low body massindex and borderline association witheducational status. In fact, peoplewith less education were more likelyto delay seeing a rheumatologist bytwo years or more after initial symp-tom onset.

The health assessment question-naire revealed that, regardless of thelength of treatment delay (six months,one year, or more than two years),even the shortest delay could havedire consequences regarding func-tionality.

The results also indicated theessential need that patients with PsAsee a rheumatologist, not simply ageneral practitioner or a dermatolo-gist, in order to optimize treatmentspecificity, improve success, andminimize unfavourable outcomes,according to the authors.

Moreover, the findings in thisstudy bear particular significancebecause no other current studieshave analysed the potential long-termimpact delayed rheumatologic caremight play in joint pathology anddegradation.

“These data clearly suggest thatadverse clinical, radiographic, qualityof life, and physical function out-comes happen early in the diseasecourse and efforts to diagnosepatients soon after symptom onsetwill likely improve outcomes,” Dr.Fitzgerald and colleagues concluded.

A limitation of the study was itscross-sectional design.

Copyright MedPage Today, LLC. Allrights reserved. Reprinted with per-mission.

Dr. OliverFitzGerald

“These data clearly suggest thatadverse clinical, radiographic,quality of life, and physical

function outcomes happen earlyin the disease course and efforts to diagnose

patients soon after symptom onsetwill likely improve outcomes.”

—Dr. Oliver FitzGeraldq


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A triple exclusive association forhigh effectiveness and tolerance.

CreamLotion

Body

Face

TitaniumDioxide

Pre-Tocopheryl

Avène ThermalSpring Water

100% mineral photoprotector complexBroad spectrum UVB-UVAWater resistant (80 minutes)Long lasting photostability (4 hours)

www.clubpharmaweb.com

Potent antioxidantPhotostable precursor of Vitamin EPrevents cellular photoaging

Unique active ingredientSoothing and anti-inflammatory

Intolerant and allergic skin

AtopicDermatitis

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* vs. Embrace † vs. 3 blades on Venus Original

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EASY MANEUVERABILITY. EASY CONTROL.

Differences betweenTP, ETR quantified T

eLANgIeCTATIC PHOTOAgINg (TP) is a distinct and different clinical entity than erythematotelang-iectatic rosacea (eTR), with less transient and nontransient erythema, a more lateral distribu-tion of erythema and telangiectasia, less neurogenic mast cell activatoin, and less MMP-medi-

ated matrix remodelling, researchers report online in JAMA Dermatology (Mar. 23, 2015).Researchers at the Program for Clinical Research in Dermatology at the university of Michigan conducted a case-

control observational study of the clinical, histologic, and gene expression features of 56 participants—26 with eTR, 20with TP, and 11 age- and sex-matched controls. Transient erythema was more severe in the eTR group than in the TPand control groups (38% were moderate to severe, vs. 0% (p<0.001) and 0% (p<0.002), respectively). erythema andtelangiectasia were mostly seen in the central face in the eTR group (79%), while they were seen more laterally in theTP group (57%, p<0.001). eTR patients also had significantly less clinical evidence of photodamage than those with TP(0% graded 6 to 8 on a photonumeric scale, vs 40%, p=0.01). There was also less histological evidence of photodam-age in eTR—in TP wispy collagen and solar elastosis surrounded blood vessels. Mast cell tryptase staining revealed alarger geometric mean stained area in eTR samples (0.018%) than either TP (0.004%, p=0.01) or control samples(0.001, p<0.001), but not a larger number of mast cells, indicating more granulation. gene expression of matrix metal-loproteinase-3 was also four times higher in eTR than in TP (p=0.004), and five times higher in controls (p=0.004).

—For more information visit http://tinyurl.com/ov2ljp4

Study findingssupport geneticcomponent inrosacea

AgeNOMe-WIDe ASSOCIATION STuDy has identified gene variants that support a genetic componentin rosacea, providing candidate targets for future studies to improve treatment and furtherunderstand the condition, according to a paper published online in Journal of Investigational

Dermatology (Mar. 12, 2015).A population of 2,618 individuals with rosacea and 20,334 controls was analysed, which led to the identification of

two significant single-nucleotide polymorphisms (SNPs) that were associated with rosacea. One of the two SNPs wasthen confirmed in a second population of 3,205 rosacea patients and 26,262 controls. This confirmed SNP, rs763035(p=8.0x10-11 in the discovery group, p=0.00031 in the replication group) was located between the HLA-DRA andBTNL2 genes.

Immunohistochemical analysis of the expression of those two genes in six individuals, one with the rs763035 SNP,showed staining in the perifollicular inflammatory infiltrate of rosacea for both proteins. Three HLA alleles, all majorhistocompatibility class II proteins, had significant association with rosacea in the discovery group, which was con-firmed in the replication group (HLA-DRB1 ’03:01, p=1.0x10-8 in the discovery group, p=4.4x10-6 in the replicationgroup; HLA-DQB1 ’02:01, p=1.3x10-8 discovery, p=7.2x10-6 replication; HLA-DQA1 ’05:01, p=1.4x10-8 discovery,p=7.6x10-6 replication.)

—For more information visit http://tinyurl.com/mjrjl7r

Study comparestherapies foruncomplicated skininfections

THeRe IS NO SIgNIFICANT DIFFeReNCe in either efficacy or side-effect profile between trimethoprim-sulfamethoxazole (TMP-SMX) and clindamycin in the treatment of uncomplicated skin infec-tions including cellulitis and abscesses, according to research published in the New England

Journal of Medicine (Mar. 19, 2015; 372:1093-1103).Outpatients with uncomplicated skin infections—cellulitis or abscesses larger than 5 cm in adults or smaller in young

children, or both—were enrolled at four study sites, a total of 524 patients. Abscesses were incised and drained, andpatients were randomly assigned to treatment with either clindamycin (264) or TMP-SMX (260) for 10 days. Primary out-come was clinical cure seven to 10 days after the treatment period. Of the 524 patients enrolled, 155 (29.6%) were chil-dren, 150 (30.5%) had an abscess, 280 (53.4%) had cellulitis, and 82 (15.6%) had mixed infections (at least one lesion ofeach type). S. aureus was isolated from 217 (41.4%) patients’ lesions, and in 167 (77.0%) of those patients the isolate wasMRSA. Both groups had similar numbers of patients cured—80.3% in the clindamycin group and 77.7% in the TMP-SMXgroup in the intention-to-treat population, a difference of -2.6 percentage points; 95% confidence interval [CI], -10.2 to 4.9,p=0.52). In the populations of patients who could be evaluated (466 patients), it was 89.5% of the clindamycin group and88.2% of the TMP-SMX group, a difference of -1.2 percentage points, 95% CI, -7.6 to 5.1, p=0.77. The two treatment’s curerates were similar in the subgroups of children, adults, and patients with abscess vs. cellulitis. Proportions of patientswho experienced adverse events were similar between the two treatment groups, as well.

—For more information visit http://tinyurl.com/mr5ntjp

Surveying the current

Dermatologic literature

Recently come across something from the peer-review literature that you consider to be interesting orimpactful? Share it with your colleagues. E-mail your clippings, along with your comments, to:

[email protected]

18 June 2015

Vol. 20, No. 5 THe CHRONICLe of SKIN & ALLERGY


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EASY MANEUVERABILITY. EASY CONTROL.


CeraVe® Bébé Diaper Rash Cream wasranked as a more favourable optioncompared to six other diaper rashcreams by a blinded group of Canadiandermatologists during a roundtablemeeting in Toronto.

During the session chaired by Dr.Charles Lynde,dermatologistswere asked toblindly compare,analyse and ratesix diapercreams accord-ing to their prefer-ence byass ess ing theproducts in termsof odour, texture,greasiness, stickiness, and permeability.

“The results of the blinded diapercream comparison assessment sug-gested that CeraVe® Bébé Diaper RashCream was rated as more favourableamong the dermatologist attendees,”reported Dr. Lynde, associate profes-sor, department of medicine and assis-

tant clinical professor at the Universityof Toronto.

Unlike other diaper rash creams, Cer-aVe®BébéDiaper Rash Cream pleasantlyand smoothly glides on to the skin toleave a protective barrier on a baby’s pos-terior that helps seal out wetness withoutthe thick, sticky mess that many other di-aper rash creams leave behind.

One dermatologist who attendedthe meeting, Dr. Michele Ramien, assis-tant professor at the University of Ot-tawa and the Children’s Hospital ofEastern Ontario, commented during thesession that she found CeraVe® BébéDiaper Rash Cream to be cosmeticallyappealing and elegant, so much so thatshe applied CeraVe® Bébé Diaper RashCream onto her own hands.

“CeraVe® Bébé Diaper Rash Creamwill be cosmetically elegant for parentsto use on their infant’s bottom becauseit is smooth and not as goopy as otherdiaper creams,” added Dr. Ian Landells,clinical assistant professor, Disciplinesof Medicine and Paediatrics, Faculty ofMedicine, Memorial University of New-foundland and Labrador.

“There appears to be a bit of a par-adigm shift suggesting that diaper rashcream products do not necessarilyhave to be a thick cream that just pro-vides a film over top of an infant’s bot-tom,” said Dr. Lynde.

“Rather a diaper cream should besomething that actually has barrier re-pairing qualities,” he added.

Ceramides have barrierrepairing qualitiesInterestingly, ceramides have been foundto be beneficial and have barrier repair-ing qualities for the treatment of atopicdermatitis (AD), according to a cohortstudy that assessed ceramide-contain-ing cleansers and moisturizers used forAD (Cutis April 2014; 93(4):207–213).

In the paper, authored by Dr.Lynde, the investigators evaluated theeffectiveness of a twice-daily regimenof a ceramide-containing cleanser andmoisturizer in men, women, and chil-dren with AD (n=151) for a treatmentperiod of six weeks.

Over the course of the investigation,the participants were evaluated at base-line (day 0) and at the end of treatment(day 42) using clinical photographs, theSCORAD (SCORing of Atopic Dermatitis)index, and quality of life (QoL) assess-ment. According to the authors, the par-ticipants were divided into two groups: 12years and older (group one, n=118) andyounger than 12 years (group two, n=33).

At day 42, results suggested thatSCORAD scores for group 1 showedsignificant improvement (t115=18.33,p=0.0001). Findings of group 2 as eval-uated by the participants’ guardians at

day 42 also showed signifi cant improve-ment (t27=5.38, p=0.0001).

Overall, the authors concluded thestudy results indicate that the ceramide-containing cleanser and moisturizer reg-imen substantially improved skincondition and clinical outcomes relatedto AD severity as well as QoL aspects.

CeraVe® Bébé Diaper Rash Cream contains three ceramidesCeraVe® Bébé Diaper Rash Cream con-tains ceramides (ceramide 3, ceramide6-II, and ceramide 1), cholesterol andphytosphingosine that help repair theskin barrier. The product also includes In-visibleZinc™ that helps treat, prevent andsoothe diaper rash, and aluminum/mag-nesium stearate, a novel ingredientunique to CeraVe® that helps repel mois-ture and keep the affected areas pro-tected between diaper changes.

As added benefits, CeraVe® BébéDiaper Rash Cream is hypoallergenic,fragrance-free, and it does not containparabens, sulfates and phthalates. It isalso gluten-free.

The CeraVe® Bébé Diaper RashCream contains 1% zinc oxide, a lowerzinc oxide content compared to other di-aper creams available on the market.However, according to Health Canada,diaper creams must contain at least 1%zinc oxide while not exceeding 40% zincoxide. It also contains a blend of sili-cones (dimethicone, cyclopentasiloxane,cyclohexasiloxane) that aid in providinga protective barrier on the affected area.

During the first part of the discus-sion, the attendees were concernedabout the low level of zinc oxide in Cer-aVe® Bébé Diaper Rash Cream, butmost agreed that for healthy infants Cer-aVe® Bébé Diaper Rash Cream wouldbe beneficial. In cases where a higheramount of zinc was required, it was de-termined that parents could decide tostep up and use another product with ahigher amount of zinc on their infant.

“Many parents of infants use cloth di-apers and cloth diaper cleaning services,and the service may recommend againstusing certain diaper creams because ofstaining or an effect on absorptive ability. . . This diaper cream [CeraVe® Bébé Di-aper Rash Cream] may be an option dueto its ingredients (low zinc oxide content),but how well the product washes out ofcloth diapers would need to beassiessed,” said Dr. James Bergman, aVancouver pediatric dermatologist andclinical assistant professor, Departmentof Dermatology and Skin Science at theUniversity of British Columbia, Vancouver.

“In cases where I see parentscome in with infants who wear cloth di-apers, I instruct those patients to usedisposable diapers on their infants untiltheir child’s diaper rash clears up.”

Prevention and treatment of diaper dermatitisDiaper dermatitis prevention and treatment is important because infants have ap-proximately a one-in-four chance of developing the condi-tion and it can be quite distressing for infants and parents,said Dr. Danielle Marcoux, one of the keynote speakerswho attended the roundtable meeting in Toronto.

“The most frequent cause of diaper dermatitis is an irri-tant cause. Then there are infectious causes that can simplycomplicate the irritant contact dermatitis,” said Dr. Marcoux,clinical associate professor at the University of Montréal.

“Diaper dermatitis can also be related to primary infec-tious contact dermatitis or inflammatory diseases.”

Physical degradation of the epidermal barrier causedby exposure to excrement, moisture and friction can di-rectly contribute to diaper dermatitis, she indicated.

“When the skin barrier is already damaged due to diaper dermatitis there is oftenan increase in the likelihood of candida infection development,” said Dr. Marcoux.

Generally, diaper dermatitis clears up within two to three days. Dr. Marcouxcautioned, however, that lack of improvement when first-line diaper dermatitistherapies are used suggests that there might be a candida infection.

Incidence of diaper dermatitis peaks between eight and 12 monthsThe peak age of diaper dermatitis incidence varies but it generally peaks at abouteight to 12 months of age, she said.

“As a child’s mobility increases, so does the amount of friction, which couldbe one of the factors that contributes to diaper dermatitis,” noted Dr. Marcoux.

She added that changes in diet when a baby is between six and eightmonths of age tend to impact fecal pH and increase the odds of fecal skin expo-sure, which could lead to diaper dermatitis.

A study referenced by Dr. Marcoux during her presentation suggested that in-fants who are exclusively breast-fed had lower rates of diaper dermatitis com-pared to formula-fed infants (Curr Opin Pediatr Aug. 2012; 24(4):472-479).

Diaper dermatitis prevention strategiesOne of the first strategies for the prevention of diaper dermatitis involves parentsor caregivers changing soiled diapers as quickly as possible, said Dr. Marcoux.

She added that using disposable diapers can be helpful because new ver-sions have been engineered with absorbant gelling material and microbreathe-able materials that appear to be associated with a decrease in diaper dermatitis.

Use of ointments and pastes that are formulated with ingredients such aspetrolatum or zinc oxide are also useful to aid in epidermal barrier repair and main-tenance of skin health in general to prevent diaper dermatitis, said Dr. Marcoux.

A more favourable treatmentoption for diaper rash

Supplement to The Chronicle of Skin &Allergy, June 2015. Chronicle is an inde-pendent medical news service that pro-vides educational updates regardingmedical developments around the world.Views expressed are those of the partici-pants and do not necessarily reflect thoseof the publisher or sponsor.

Support for distribution of this reportwas provided by Valeant Canada throughan unrestricted educational grant withoutconditions. Information provided in this re-

port is not intended to serve as the solebasis for individual care.

Printed in Canada for Chronicle Infor-mation Resources Ltd., 555 Burn-hamthorpe Rd., Suite 306, Toronto, Ont.M9C 2Y3.Telephone 416.916.2476; facsim-ile 416.352.6199; e-mail: [email protected]. Copyright 2015 by ChronicleInformation Resources Ltd., except wherenoted. All rights reserved. Reproduction inany form is expressly prohibited withoutwritten permission of the publisher.

Special Report

Dermatologistsranked six diaperrash creams, CeraVe® Baby found preferred

AD treatment outcome

Day 1: Therapy begins Day 7: Steroid + CeraVe©

Cleanser and CeraVe© Cream

CereVe bebe_26_June_2015_Layout 1 26/06/2015 10:16 AM Page 1

20 · June 2015

Pediatric derm research THe CHRONICLe of SKIN & ALLERGY

R e s e a r c h

MRSA training for carersn Recurrence prevention falling short

Methicillin-resistant staph aureus (MRSA) eradication or preventioninstructions are not typically included in the discharge instructions tochildren undergoing abscess incision and drainage (I&D) at pediatricemergency departments, yet with the high number of these patientswho have had prior MRSA infections, the emergency department maybe the ideal place to educate patients who have recurrent infections andtheir families, researchers report in Pediatric Emergency Care (April2015; 31(4):266-268).

The authors conducted a retrospective cohort study of patients aged0 to 18 years of age undergoing I&D for cutaneous abscesses at theCincinnati Children’s Hospital Medical Center emergency department. Atotal of 575 patients were included in the study. Roughly 25% of thepatient population had a prior history of MRSA, skin and soft tissue infec-tions (SSTI), or boils or abscesses. Some 26% had a household familymember with a history of MRSA, SSTI, or boils or abscesses. Wound cul-tures were obtained in 339 of 575 abscesses (69%), and among those57% grew MRSA. Of all the patients, only 21 (3.7%) were documented ashaving received MRSA eradication and prevention instructions for theparents and family.


R e s e a r c h

Imiquimod for wartsn 5% cream as effective as cryotherapyFrom the News Resources of The Chronicle

Imiquimod 5% monotherapy is as effective as cryotherapy for the treat-ment of cutaneous warts in children, and when combined with salicylicacid (SA), imiquimod 5% is slightly more effective than cryotherapy forthe treatment of plantar warts, according to findings published online inthe Journal of Dermatological Treatment (Apr. 17, 2015).

Researchers included 86 children in the study; 35 females and 51males. Participants were divided into two groups, receiving either stan-dard cryotherapy for their cutaneous warts every two weeks for a maxi-mum of six months (49 patients) or imiquimod 5% combined with SA15% to assist in the penetration of the imiquimod through areas of thickkeratin such as the palms and soles of the feet (37 patients). Imiquimod5% was left on the warts for six to 10 hours per day, five consecutive daysa week, for up to three months. At the end of three months no statisticallysignificant difference was seen between the two treatment arms(p=0.154). There were 30 (81.1%) children in the imiquimod 5%/SA groupwho were free from warts by the end of the three months compared to 33(67.3%) of the cryotherapy patients. The authors note that with no place-bo control group, some of the clearance may have been by spontaneousremission.

Pediatric derm updateCAREGIVER FEARS OFCORTICOSTEROIDS FOR ECZEMACaregiver fear of corticosteroids (CS)for childhood eczema varies indepen-dently of CS acceptance but correlateswith Children’s Dermatology LifeQuality Index (CDLQI) , suggesting thatdesensitizing CS fear should be anintegral part of eczema education andtherapeutics, investigators reportonline in the Journal of DermatologicalTreatment (Apr. 20, 2015).

eczema patients being managedat a university hospital’s pediatric der-matology outpatient clinic were sur-veyed, using the Nottingham eczemaSeverity Score (NeSS) to evaluate dis-ease severity, the CDLQI for Qol, and aset of quantified questions to recordfear and acceptability of CS along withfrequency of CS use. While 58% of par-ents reported a CS acceptability levelof ‘good’ or ‘very good’ and manyapplied CS to their child every week,more than 40% noted CS fear ‘always’or ‘often’, and 41% only applied CSwhen eczema worsened. Some 57%would ‘always’ or ‘often’ discuss CSfear with their doctor, 30% wouldrequest CS-sparing medication, and14% ‘always’ or ‘often’ use herbal med-ications. Fears were primarily interper-sonal and not iatrogenic, with the mostfrequent CS side effect concern beingskin problems. CS fear, acceptability,and use of CS or herbal medicationswere all independent domains. CS fearcorrelated with CDLQI. Frequency ofCS use correlated with NeSS, and neg-atively correlated with parent educa-tion. CS acceptability correlated withparent education. greater CS fear cor-related with worse QoL.

LONG-PULSE ND:YAG LASER ASAFE, EFFECTIVE MODALITY FORINFANTILE HEMANGIOMASTreatment with long-pulse 1,064 nmneodymium-doped yttrium alu-minum garnet (Nd:yAg) laser is asafe, effective modality for infantilehemangiomas, researchers reportonline in Pediatric Dermatology(May 7, 2015).

Infants who had been treated forinfantile hemangiomas with thelong-pulse 1,064 nm Nd:yAg laser atthe First Hospital of Jilin university,Changchun, China within the lastfive years were recruited for thestudy. Patients’ demographic andclinical features were recorded, andthe outcomes of their laser treat-ment were assessed. The authorsthen performed a statistical analysison the data to determine what fac-tors impacted treatment efficacy.Overall, the efficacy of the long-pulse 1,064 nm Nd:yAg laser inthese patients was 87.57%, and thisefficacy was not impacted by patientsex or lesion location. greater effica-cy was observed in the treatment ofolder and more superficial lesions.The most commonly seen sideeffects were pigment changes, skinatrophy, and redundant wrinkledskin. Cases of redundant wrinkledskin usually resolved spontaneouslyin one to three years.

EPIDEMIOLOGICAL STUDIES OFALLERGY MAY BE OVERLOOKINGCELL-MEDIATED REACTIONSA survey of an unselected popula-tion of children has found that ratesof positive atopy patch tests weresimilar to those of positive atopyprick tests, with 8.8% of subjectsonly having positive results from thepatch test. These findings,researchers say, suggests patch test-ing should be added to future epi-demiological studies of allergy toavoid overlooking individuals with T-cell-mediated allergies, according toa paper published in Clinical andMolecular Allergy (May 7, 2015;13(1):2).

The authors note that epidemio-logical studies of allergic disorders inrecent decades are typically carriedout through questionnaires, skinprick tests, or in vitro Ige tests,which do not account for cell-medi-ated mechanisms of allergy. In thisstudy, the student populations of aprimary school and a junior sec-ondary school in Italy were included,a total of 456 individuals. Data wasgathered by questionnaire. Amongthe participants, 78 (17.1%) had apositive skin prick test and 57(12.5%) had a positive atopy patchtest. Looking at exclusive response,13.4% were only positive to skinprick, and 8.8% were positive only toatopy patch test. The most commonpositive allergen was house dustmite (41 skin prick positives, 55atopy patch positives).

Pollen-related allergy positiveswere almost exclusively from skinprick tests.

KOH 10% EFFECTIVE FORMOLLUSCUM CONTAGIOSUM Potassium hydroxide (KOH) 10% isan inexpensive and efficient treat-ment modality for molluscum conta-giosum (MC) in pediatric patients,with only minor adverse effects, andwhile imiquimod 5% is effective withminimal adverse events, the longertreatment time compared to KOH10% may deter usage, researchersreport in Indian Dermatology OnlineJournal (Mar.-Apr. 2015; 6(2):75-80).

The authors note that while MCis self-limiting, actively treating itcould reduce its spread and improvethe preservation of appearance.Many existing treatments requiretraumatic lesions, necessitating hos-pital care and stressing children. Asan alternative, investigators exam-ined two potential topical alterna-tives. From Oct. 2011 to Mar. 2013,40 patients aged one to 18 years withclinically diagnosed MC wereenrolled in the study and dividedinto two groups via a lottery method.Half the patients (group A) weretreated with 5% imiquimod cream,and the remaining 20 patients(group B) were treated with KOH10% solution. Follow-up visitsoccurred at weeks four, eight, and12 of the treatment period. At theend of 12 weeks of treatment, 17 of20 patients in the KOH 10% grouphad achieved complete clearance,compared to 10 in the imiquimod5% group. However, adverse eventswere more common in the KOH10% group, the most common ofwhich were pigmentary distur-bances.


CeraVe® Bébé Diaper Rash Cream wasranked as a more favourable optioncompared to six other diaper rashcreams by a blinded group of Canadiandermatologists during a roundtablemeeting in Toronto.

During the session chaired by Dr.Charles Lynde,dermatologistswere asked toblindly compare,analyse and ratesix diapercreams accord-ing to their prefer-ence byass ess ing theproducts in termsof odour, texture,greasiness, stickiness, and permeability.

“The results of the blinded diapercream comparison assessment sug-gested that CeraVe® Bébé Diaper RashCream was rated as more favourableamong the dermatologist attendees,”reported Dr. Lynde, associate profes-sor, department of medicine and assis-

tant clinical professor at the Universityof Toronto.

Unlike other diaper rash creams, Cer-aVe®BébéDiaper Rash Cream pleasantlyand smoothly glides on to the skin toleave a protective barrier on a baby’s pos-terior that helps seal out wetness withoutthe thick, sticky mess that many other di-aper rash creams leave behind.

One dermatologist who attendedthe meeting, Dr. Michele Ramien, assis-tant professor at the University of Ot-tawa and the Children’s Hospital ofEastern Ontario, commented during thesession that she found CeraVe® BébéDiaper Rash Cream to be cosmeticallyappealing and elegant, so much so thatshe applied CeraVe® Bébé Diaper RashCream onto her own hands.

“CeraVe® Bébé Diaper Rash Creamwill be cosmetically elegant for parentsto use on their infant’s bottom becauseit is smooth and not as goopy as otherdiaper creams,” added Dr. Ian Landells,clinical assistant professor, Disciplinesof Medicine and Paediatrics, Faculty ofMedicine, Memorial University of New-foundland and Labrador.

“There appears to be a bit of a par-adigm shift suggesting that diaper rashcream products do not necessarilyhave to be a thick cream that just pro-vides a film over top of an infant’s bot-tom,” said Dr. Lynde.

“Rather a diaper cream should besomething that actually has barrier re-pairing qualities,” he added.

Ceramides have barrierrepairing qualitiesInterestingly, ceramides have been foundto be beneficial and have barrier repair-ing qualities for the treatment of atopicdermatitis (AD), according to a cohortstudy that assessed ceramide-contain-ing cleansers and moisturizers used forAD (Cutis April 2014; 93(4):207–213).

In the paper, authored by Dr.Lynde, the investigators evaluated theeffectiveness of a twice-daily regimenof a ceramide-containing cleanser andmoisturizer in men, women, and chil-dren with AD (n=151) for a treatmentperiod of six weeks.

Over the course of the investigation,the participants were evaluated at base-line (day 0) and at the end of treatment(day 42) using clinical photographs, theSCORAD (SCORing of Atopic Dermatitis)index, and quality of life (QoL) assess-ment. According to the authors, the par-ticipants were divided into two groups: 12years and older (group one, n=118) andyounger than 12 years (group two, n=33).

At day 42, results suggested thatSCORAD scores for group 1 showedsignificant improvement (t115=18.33,p=0.0001). Findings of group 2 as eval-uated by the participants’ guardians at

day 42 also showed signifi cant improve-ment (t27=5.38, p=0.0001).

Overall, the authors concluded thestudy results indicate that the ceramide-containing cleanser and moisturizer reg-imen substantially improved skincondition and clinical outcomes relatedto AD severity as well as QoL aspects.

CeraVe® Bébé Diaper Rash Cream contains three ceramidesCeraVe® Bébé Diaper Rash Cream con-tains ceramides (ceramide 3, ceramide6-II, and ceramide 1), cholesterol andphytosphingosine that help repair theskin barrier. The product also includes In-visibleZinc™ that helps treat, prevent andsoothe diaper rash, and aluminum/mag-nesium stearate, a novel ingredientunique to CeraVe® that helps repel mois-ture and keep the affected areas pro-tected between diaper changes.

As added benefits, CeraVe® BébéDiaper Rash Cream is hypoallergenic,fragrance-free, and it does not containparabens, sulfates and phthalates. It isalso gluten-free.

The CeraVe® Bébé Diaper RashCream contains 1% zinc oxide, a lowerzinc oxide content compared to other di-aper creams available on the market.However, according to Health Canada,diaper creams must contain at least 1%zinc oxide while not exceeding 40% zincoxide. It also contains a blend of sili-cones (dimethicone, cyclopentasiloxane,cyclohexasiloxane) that aid in providinga protective barrier on the affected area.

During the first part of the discus-sion, the attendees were concernedabout the low level of zinc oxide in Cer-aVe® Bébé Diaper Rash Cream, butmost agreed that for healthy infants Cer-aVe® Bébé Diaper Rash Cream wouldbe beneficial. In cases where a higheramount of zinc was required, it was de-termined that parents could decide tostep up and use another product with ahigher amount of zinc on their infant.

“Many parents of infants use cloth di-apers and cloth diaper cleaning services,and the service may recommend againstusing certain diaper creams because ofstaining or an effect on absorptive ability. . . This diaper cream [CeraVe® Bébé Di-aper Rash Cream] may be an option dueto its ingredients (low zinc oxide content),but how well the product washes out ofcloth diapers would need to beassiessed,” said Dr. James Bergman, aVancouver pediatric dermatologist andclinical assistant professor, Departmentof Dermatology and Skin Science at theUniversity of British Columbia, Vancouver.

“In cases where I see parentscome in with infants who wear cloth di-apers, I instruct those patients to usedisposable diapers on their infants untiltheir child’s diaper rash clears up.”

Prevention and treatment of diaper dermatitisDiaper dermatitis prevention and treatment is important because infants have ap-proximately a one-in-four chance of developing the condi-tion and it can be quite distressing for infants and parents,said Dr. Danielle Marcoux, one of the keynote speakerswho attended the roundtable meeting in Toronto.

“The most frequent cause of diaper dermatitis is an irri-tant cause. Then there are infectious causes that can simplycomplicate the irritant contact dermatitis,” said Dr. Marcoux,clinical associate professor at the University of Montréal.

“Diaper dermatitis can also be related to primary infec-tious contact dermatitis or inflammatory diseases.”

Physical degradation of the epidermal barrier causedby exposure to excrement, moisture and friction can di-rectly contribute to diaper dermatitis, she indicated.

“When the skin barrier is already damaged due to diaper dermatitis there is oftenan increase in the likelihood of candida infection development,” said Dr. Marcoux.

Generally, diaper dermatitis clears up within two to three days. Dr. Marcouxcautioned, however, that lack of improvement when first-line diaper dermatitistherapies are used suggests that there might be a candida infection.

Incidence of diaper dermatitis peaks between eight and 12 monthsThe peak age of diaper dermatitis incidence varies but it generally peaks at abouteight to 12 months of age, she said.

“As a child’s mobility increases, so does the amount of friction, which couldbe one of the factors that contributes to diaper dermatitis,” noted Dr. Marcoux.

She added that changes in diet when a baby is between six and eightmonths of age tend to impact fecal pH and increase the odds of fecal skin expo-sure, which could lead to diaper dermatitis.

A study referenced by Dr. Marcoux during her presentation suggested that in-fants who are exclusively breast-fed had lower rates of diaper dermatitis com-pared to formula-fed infants (Curr Opin Pediatr Aug. 2012; 24(4):472-479).

Diaper dermatitis prevention strategiesOne of the first strategies for the prevention of diaper dermatitis involves parentsor caregivers changing soiled diapers as quickly as possible, said Dr. Marcoux.

She added that using disposable diapers can be helpful because new ver-sions have been engineered with absorbant gelling material and microbreathe-able materials that appear to be associated with a decrease in diaper dermatitis.

Use of ointments and pastes that are formulated with ingredients such aspetrolatum or zinc oxide are also useful to aid in epidermal barrier repair and main-tenance of skin health in general to prevent diaper dermatitis, said Dr. Marcoux.

A more favourable treatmentoption for diaper rash

Supplement to The Chronicle of Skin &Allergy, June 2015. Chronicle is an inde-pendent medical news service that pro-vides educational updates regardingmedical developments around the world.Views expressed are those of the partici-pants and do not necessarily reflect thoseof the publisher or sponsor.

Support for distribution of this reportwas provided by Valeant Canada throughan unrestricted educational grant withoutconditions. Information provided in this re-

port is not intended to serve as the solebasis for individual care.

Printed in Canada for Chronicle Infor-mation Resources Ltd., 555 Burn-hamthorpe Rd., Suite 306, Toronto, Ont.M9C 2Y3.Telephone 416.916.2476; facsim-ile 416.352.6199; e-mail: [email protected]. Copyright 2015 by ChronicleInformation Resources Ltd., except wherenoted. All rights reserved. Reproduction inany form is expressly prohibited withoutwritten permission of the publisher.

Special Report

Dermatologistsranked six diaperrash creams, CeraVe® Baby found preferred

AD treatment outcome

Day 1: Therapy begins Day 7: Steroid + CeraVe©

Cleanser and CeraVe© Cream

CereVe bebe_26_June_2015_Layout 1 26/06/2015 10:16 AM Page 1Skin_June_2015,rar12_w cover art_9.1_Skin_March_2014,rar1.qxd 26/06/2015 6:10 PM

* Among fusion razors.† Versus Gillette Fusion ProGlide.

© 2015 P&G www.gillette.ca

RECOMMEND GILLETTE FUSION PROGLIDE WITH FLEXBALL TECHNOLOGY FOR YOUR PATIENTS WITH SENSITIVE SKIN.

RESPONDS TO

CONTOURSFOR OUR BEST SHAVE

Sensitive skin: Increasingly common problemMen with sensitive skin encounter signifi cant dermatologic challenges when shaving. Their skin tolerance of a daily shave is compromised, making it diffi cult to maintain their daily grooming routine.

A growing body of clinical research has shown that the prevalence of the problem is rapidly becoming more widespread. A recent global study among 3,326 men in 11 countries* revealed that as many as 66% of men report having sensitive facial skin, rising to 82% in some countries.1

The same study reported that two-thirds of men believed themselves to have sensitive facial skin – with nearly half of men reporting that the problem had become worse over the last fi ve years. In fact, the rates of occurrence in men are rapidly approaching those in women.1

FlexBall Technology: Key features and benefi tsThe management and care of sensitive skin can be diffi cult, especially in view of the fact that for many men, daily removal of facial hair is desired or required. Gillette Fusion ProGlide with FlexBall Technology razor (manual and power) is Gillette’s #1 razor for sensitive skin. It is designed to respond to the contours of a man’s face for maximum contact, capturing virtually every hair.

This effectiveness is based on 4-way fl ex technology which allows maximum contact on the curves, translating to an upgraded shaving experience that is gentler to every man’s face. In addition, the razor’s comfort guard, comprised of soft, fl exible microfi ns, stretches the skin ahead of the fi rst blade, presenting a smoother surface to the blades.

The Gillette Fusion ProGlide with FlexBall Technology features Gillette’s thinnest, fi nest blades† requiring less force to cut the beard hair, leading to lower localized stresses on the skin. The razor’s blade technology features an advanced, low-resistant coating for effortless cutting through hair with less tug and pull. Furthermore, 5-blade technology – with blades placed closer together – reduces the height of the skin bulge under the razor cartridge, compared to 3-blade razors.

Gillette Fusion ProGlide: A positive response among menClinical trials have shown that the Gillette Fusion ProGlide blades are well tolerated by men with self-assessed sensitive skin. In a 28-day trial, 52 men with self-assessed sensitive skin shaved daily, 26 with a commercial 5-blade manual razor (Gillette Fusion ProGlide) and 26 with a commercial 5-blade powered razor (Gillette Fusion ProGlide Power). In self-grading for signs and symptoms including redness, dryness, burning, stinging and soreness, none of these increased during the course of the study – and several attributes showed improvements.1

Addressing the dermatologic shaving challenge for men with sensitive skin

* Gillette consumer survey: Online survey by independent market research agency (Research Now) in October 2012.

†First 4 blades

Reference: 1. Data on fi le, Procter & Gamble.

According to research, more than 90 percent of dermatologists agree that a man’s choice of shaving products matters.1 A growing number of men with sensitive skin are turning to the dermatologist community for guidance on the correct shaving regimen.

As always, Gillette continues its longstanding commitment to provide clinically proven solutions to men’s dermatologic concerns. Recommend Gillette Fusion ProGlide with FlexBall Technology for your patients with sensitive skin and for men who want to remain clean-shaven.

Visible dryness rated 0 for all panellists

Ave

rage

scor

e

Manual razor

3

2.5

2

1.5

1

0.5

0Redness Dryness

After 28 days of daily shaving

Stinging Burning Itching Soreness

Rated 0

Visible dryness and sensation of stinging, burning and itching rated 0 for all panellists

Powered razorAfter 28 days of daily shaving

Ave

rage

scor

e

3

2.5

2

1.5

1

0.5

0Redness Dryness Stinging Burning Itching Soreness

Rated 0

© 2015 P&G


* Among fusion razors.† Versus Gillette Fusion ProGlide.

© 2015 P&G www.gillette.ca

RECOMMEND GILLETTE FUSION PROGLIDE WITH FLEXBALL TECHNOLOGY FOR YOUR PATIENTS WITH SENSITIVE SKIN.

RESPONDS TO

CONTOURSFOR OUR BEST SHAVE

Sensitive skin: Increasingly common problemMen with sensitive skin encounter signifi cant dermatologic challenges when shaving. Their skin tolerance of a daily shave is compromised, making it diffi cult to maintain their daily grooming routine.

A growing body of clinical research has shown that the prevalence of the problem is rapidly becoming more widespread. A recent global study among 3,326 men in 11 countries* revealed that as many as 66% of men report having sensitive facial skin, rising to 82% in some countries.1

The same study reported that two-thirds of men believed themselves to have sensitive facial skin – with nearly half of men reporting that the problem had become worse over the last fi ve years. In fact, the rates of occurrence in men are rapidly approaching those in women.1

FlexBall Technology: Key features and benefi tsThe management and care of sensitive skin can be diffi cult, especially in view of the fact that for many men, daily removal of facial hair is desired or required. Gillette Fusion ProGlide with FlexBall Technology razor (manual and power) is Gillette’s #1 razor for sensitive skin. It is designed to respond to the contours of a man’s face for maximum contact, capturing virtually every hair.

This effectiveness is based on 4-way fl ex technology which allows maximum contact on the curves, translating to an upgraded shaving experience that is gentler to every man’s face. In addition, the razor’s comfort guard, comprised of soft, fl exible microfi ns, stretches the skin ahead of the fi rst blade, presenting a smoother surface to the blades.

The Gillette Fusion ProGlide with FlexBall Technology features Gillette’s thinnest, fi nest blades† requiring less force to cut the beard hair, leading to lower localized stresses on the skin. The razor’s blade technology features an advanced, low-resistant coating for effortless cutting through hair with less tug and pull. Furthermore, 5-blade technology – with blades placed closer together – reduces the height of the skin bulge under the razor cartridge, compared to 3-blade razors.

Gillette Fusion ProGlide: A positive response among menClinical trials have shown that the Gillette Fusion ProGlide blades are well tolerated by men with self-assessed sensitive skin. In a 28-day trial, 52 men with self-assessed sensitive skin shaved daily, 26 with a commercial 5-blade manual razor (Gillette Fusion ProGlide) and 26 with a commercial 5-blade powered razor (Gillette Fusion ProGlide Power). In self-grading for signs and symptoms including redness, dryness, burning, stinging and soreness, none of these increased during the course of the study – and several attributes showed improvements.1

Addressing the dermatologic shaving challenge for men with sensitive skin

* Gillette consumer survey: Online survey by independent market research agency (Research Now) in October 2012.

†First 4 blades

Reference: 1. Data on fi le, Procter & Gamble.

According to research, more than 90 percent of dermatologists agree that a man’s choice of shaving products matters.1 A growing number of men with sensitive skin are turning to the dermatologist community for guidance on the correct shaving regimen.

As always, Gillette continues its longstanding commitment to provide clinically proven solutions to men’s dermatologic concerns. Recommend Gillette Fusion ProGlide with FlexBall Technology for your patients with sensitive skin and for men who want to remain clean-shaven.

A D V E R T O R I A L

Visible dryness rated 0 for all panellists

Ave

rage

scor

e

Manual razor

3

2.5

2

1.5

1

0.5

0Redness Dryness

After 28 days of daily shaving

Stinging Burning Itching Soreness

Rated 0

Visible dryness and sensation of stinging, burning and itching rated 0 for all panellists

Powered razorAfter 28 days of daily shaving

Ave

rage

scor

e3

2.5

2

1.5

1

0.5

0Redness Dryness Stinging Burning Itching Soreness

Rated 0

© 2015 P&G


Indications and Clinical use:• CLINDOXYL® Gel (5% benzoyl peroxide, 1% clindamycin)

and CLINDOXYL® ADV Gel (3% benzoyl peroxide, 1% clindamycin) are indicated in the topical treatment of moderate acne vulgaris characterized by the presence of comedones, papules and pustules.

• Not indicated for the treatment of cystic acne• Not for use in children <12 years

Contraindications:

• Hypersensitivity to medications containing lincomycin• Patients with or with a history of regional enteritis,

ulcerative colitis or antibiotic-induced colitis (including pseudomembranous colitis)

Most serious warnings and precautions:• For external use only • Not for oral, ophthalmic or intravaginal use

Other relevant warnings and precautions:• Concomitant topical acne treatments: not recommended

because a possible cumulative irritancy effect may occur• May cause Clostridium diffi cile-associated disease • Avoid contact with hair, fabrics, carpeting or other materials

(may cause bleaching)

• May cause increased sensitivity to sunlight; sunlamps should not be used and deliberate or prolonged exposure to sunlight should be avoided or minimized

• Sunburns should be resolved prior to use• Avoid contact with the mouth, eyes, lips, other mucous

membranes or areas of irritated or broken skin• Could cause gram-negative folliculitis• May cause skin adverse events including irritation (peeling,

reddening, dryness, itching, stinging/burning)• Cross-resistance between clindamycin and lincomycin and

resistance to clindamycin is often associated with inducible resistance to erythromycin

• Safety and effi cacy not established in patients <12 years of age or those >65 years of age

• Caution in use with neuromuscular blocking agents, tretinoin, isotretinoin and tazarotene

• Should not be used with erythromycin or topical sulphonamides • Should not be administered during pregnancy or lactation

unless the expected benefi ts to the mother outweigh the potential risks to the fetus or the infant; if used during lactation, do not apply to the chest so as to avoid accidental ingestion by the infant

Dosage and method of administration: • Gently apply once daily to lightly cover the entire affected

areas of the face with a thin layer of gel.

• A pea-sized amount should be applied for each area of the face (e.g., forehead, chin, each cheek), then hands should be washed.

Adverse drug reactions:• CLINDOXYL® ADV Gel: application site dermatitis (1%) and

application site photosensitivity (1%)

• CLINDOXYL® Gel: peeling (16.3%), erythema (7.6%), dryness (7%), burning (2.3%), pruritus (1.7%), mild application-site paraesthesia (<1%) and acne worsening (<1%).

For more information: Please consult the product monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for important information relating to contraindications, warnings and precautions, adverse reactions, drug interactions, dosing information and post-market adverse drug reactions which have not been discussed in this piece. The product monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374.

Reference: 1. CLINDOXYL® GEL / CLINDOXYL® ADV Gel Product Monograph. GlaxoSmithKline Inc., November 7, 2013.

® CLINDOXYL is a registered trade-mark, used under license by GlaxoSmithKline Inc.

Stiefel, a GSK company, Mississauga (Ontario) L5N 6L4

0069904/15

Your decisions could show on

24 · June 2015


of dorsal hand soft tissue volume loss with CaHAhelps to restore that youthful, plump appearance ofthe hands.”

Another unmet need in cosmetic dermatologyis the elimination of unsightly cellulite that is typi-cally observed on the thighs, with women patientsparticularly bothered by this phenomenon.

“Cellulite describes the dimpled appearance ofthe skin that affects greater than 85 per cent ofadult women,” explained Dr. Andrei Metelitsa, co-director of the Institute for Skin Advancement inCalgary, clinical associate professor, Section ofDermatology, university of Calgary. “Althoughnumerous treatments have been developed toaddress this extremely common esthetic concern,they have all had a variety of limitations.”

Cellfina, developed by Cabochon Aesthetics,is a minimally-invasive approach where a precisemicro-blade acquires targeted dimples and releas-es them. The procedure takes about 45 minutes toperform and local anesthesia is used. A study of

55 patients showed all experienced at minimum aone-point improvement in severity of their cel-lulite.

“Significant and rapid improvement can be visi-ble as early as three days after treatment,” said Dr.Metelitsa, who conducted pilot studies on the tech-nology. “At one year, 94 per cent of patients weresatisfied with their results, surpassing patient ratesfor other cellulite treatments.”

Dr. Metelitsa noted common side effects asso-ciated with the treatment included bruising, fluidaccumulation, tingling, and soreness. “All of theside effects were of mild severity, of short dura-tion, and all resolved spontaneously,” he said.“Over 90 per cent of patients had no bruising atfour weeks.”

Outer thigh fat can be targetedAnother offering in esthetic devices is the CoolProApplicator, another modality in Zeltiq’sCoolSculpting technologies, which targets the “sad-dlebags” or fat that resides on the outer thighs.

One study of 40 patients who underwent a two-hour, single treatment where the applicator wasapplied to the lateral thigh, with the contralateralthigh serving as a control. Patients reported satis-faction with the results after one treatment, andultrasound imaging revealed a 2.6 mm-mean nor-malized decrease in fat thickness, a reduction thatwas statistically significant, in the treated thighcompared to the untreated thigh (Aesthetic Surg J2015 Jan; 35(1):66–71).

“This treats more fibrous fat, like fat on theouter thigh,” said Dr. Humphrey. “It can cover larg-er areas and is more shallow in how it works.”

Also new is the u-Sculpt transducer fromultraShape, which received FDA clearance late lastyear. The transducer is smaller and lighter inweight than the VDF transducer by ultraShape,both of which target subcutaneous fat using pulsedfocused ultrasound energy.

“It is a nice addition that can treat smallerareas like the arms or inner thighs,” noted Dr.gidon.

Advances in cosmetic dermatology include new fillersContinued from page 6

than in other studies carried out in our local environ-ment due to the higher BMI of our subjects.

In summary, the present study also confirms ahigh percentage of MetS among subjects with psoriasisand considers it an independent risk factor for MetS,showing significantly higher levels than amongst thesubjects from our control population and far higherthan those found by other local studies. Consequently,it is important to detect it early for this group ofpatients, to be able to start treatment early and thusreduce the risk of cardiovascular disease. The presentstudy is unable to confirm any relationship betweenthe characteristics of psoriasis and MetS which couldindicate that subjects with psoriasis present a greaterrisk of MetS.

COMPETING INTERESTS The authors declare they have no competing interests.

AUTHORS’ CONTRIBUTIONSMA carried out the project, recruited control subjects,did the analysis of the results and drafted the manu-script. AR assisted in drafting the manuscript andrecruited patients with psoriasis. MC reviewed the med-ical history of the subjects with and without psoriasisand assisted in drafting the manuscript. SS performedthe physical examination and laboratory studies. LPassisted in the search of subjects with psoriasis. LVassisted in data analysis and drafting the manuscript.All authors read and approved the final manuscript.

ACKNOWLEDGMENTS We would like to express our gratitude to MontserratMartín for its comments which enabled us to improvethe result interpretations of this article.

The present study has been partly financed by agrant from Assaig Private Foundation for HealthResearch (ref.: 2008/3).

REFERENCES1. Alberti KGMM, Eckel RH, Grundy SM, et al:

Harmonizing the metabolic syndrome. A joint interimstatement of the International diabetes FederationTask Force on Epidemiology and Prevention: NationalHeart, Lung, and Blood Institute; American Heart

Association; World Heart Federation; InternationalAtherosclerosis Society; and International Associationfor the Study of Obesity. Circulation 2009; 120:1640-1645.

2. Armstrong AW, Harskamp CT, Armstrong EJ: Psoriasisand metabolic syndrome: a systematic review andmeta-analysis of observational studies. J Am AcadDermatol 2013; 68:654-662.

3. Channual J, Wu JJ, Dann FJ: Effects of tumor necrosisfactor-a blockade on metabolic syndrome compo-nents in psoriasis and psoriatic arthritis and addi-tional lessons learned from rheumatoid arthritis.Dermatol Ther 2009; 22:61-73.

4. Christophers E: Comorbidities in psoriasis. JEADV2006; 20(suppl 2):52-55.

5. Fernández-Bergés D, Cabrera de León A, Sanz H, etal: Metabolic syndrome in Spain: prevalence andcoronary risc associated with harmonized definitionand WHO proposal. DARIOS study. Rev Esp Cardiol2012; 65:241-248.

6. Ferraz-Amaro I, Arce-Franco M, Muñiz J, et al:Systemic blockade of TNF-a does not improveinsulin resistance in humans. Horm Metab Res 2011;43:801-808.

7. Fredriksson T, Pettersson U: Severe psoriasis oral—therapy with a new retinoid. Dermatologica 1978;157:238-244.

8. Gabriel R, Alonso M, Parra J, et al, en nombre delgrupo cooperativo del estudio VIVA: Patrón deagregación y análisis factorial de los factores de ries-go cardiovascular integrantes del síndromemetabólico en población española no diabética:estudio VIVA. Av Diabetol 2009; 25:131-138.

9. Gisondi P, Tessari G, Conti A, Piaserico S, Schianchi S,Peserico A, Giannetti A, Girolomoni G (2007)Prevalence of metabolic syndrome in patients withpsoriasis: a hospital-based case–control study. Br JDermatol 157:68-73.

10. Gisondi P, Del Giglio M, Di Francesco V, Zamboni M,Girolomoni G: Weight loss improves the responseof obese patients with moderate-to-severe chronicplaque psoriasis to low-dose cyclosporine therapy: arandomized, controlled, investigator-blinded clinicaltrial. Am J Clin Nutr 2008; 88:1242-1247.

11. Hamminga EA, Van der Lely AJ, Neumann HA, ThioHB: Chronic inflammation in psoriasis and obesity:implications for therapy. Med Hypotheses 2006;67:768-773.

12. Kiortsis D, Mavridis A, Vasakos S, Nikas S, Drosos A:Effects of infliximab treatment on insulin resistancein patients with rheumatoid anthritis and ankylos-ing spondylitis. Ann Rheum Dis 2005; 64:765-766.

13. Kutlu S, Ekmekci TR, Ucak S, Koslu A, Altuntas Y:Prevalence of metabolic syndrome in pacients with

psoriasis. Indian J Dermatol Venereol Leprol 2011;77:193-194.

14. Langan SM, Seminara NM, Shin DB, Troxel AB,Kimmel SE, Mehta NN, Margolis DJ, Gelfand JM:Prevalence of metabolic syndrome in patients withpsoriasis: a population-based study in the UnitedKingdom. J Invest Dermatol 2012; 132:556-562.

15. Love TJ, Qureshi AA, Karlson EW, Gelfand JM, ChoiHK: Prevalence of the metabolic syndrome in psori-asis. Arch Dermatol 2011; 147:419-424.

16. Ludwig RJ, Herzog C, Rostock A, et al: Psoriasis: apossible risk factor for development of coronaryartery calcification. Br J Dermatol 2007; 156:271-276.

17. Micha R, Imamura F, Wyler von Ballmoos M,Solomon DH, Hernán MA, Ridker PM, MozaffarianD: Systematic review and meta-analysis ofmethotrexate use and risk of cardiovascular disease.Am J Cardiol 2011; 108:1362-1370.

18. Neimann AL, Shin DB, Wang X, Margolis DJ, TroxelAB, Gelfand JM: Prevalence of cardiovascular riskfactors in patients with psoriasis. J Am Acad Dermatol2006; 55:829-835.

19. Nisa N, Qazi MA: Prevalence of metabolic syndromein patients with psoriasis. Indian J Dematol VenereolLeprol 2010; 76:662-665.

20. Prey S, Paul C, Bronsard V, et al: Cardiovascular riskfactors in patients with plaque psoriasis: a systematicreview of epidemiological studies. J Eur AcadDermatol Venereol 2010; 24(suppl 2):23-30.

21. Setty AR, Curhan G, Choi HK: Obesity, waist circum-ference, weight change, and the risk of psoriasis inwomen: Nurses’ health study II. Arch Intern Med2007; 167:1670-1675.

22. Shafiq N, Malhotra S, Pandhi P, Gupta M, Kumar B,Sandhu K: Pilot trial: pioglitazone versus placebo inpatients with plaque psoriasis (the P6). Int JDermatol 2005; 44:328-333.

23. Shapiro J, Cohen AD, Weitzman D, Tal R, David M:Psoriasis and cardiovascular risk factors: a case–con-trol study on inpatients comparing psoriasis to der-matitis. J Am Acad Dermatol 2007; 66:252-258.

24. Sommer DM, Jenisch S, Suchan M, Christophers E,Weichenthal M: Increased prevalence of the meta-bolic syndrome in patients with moderate to severepsoriasis. Arch Dermatol Res 2006; 298:321-328.

25. Sterry W, Strober BE, Menter A, on the behalf of theInternational Psoriasis Council: Obesity in psoriasis:the metabolic, clinical and therapeutic implications.Report of an interdisciplinary conference andreview. Br J Dermatol 2007; 157:649-655.

26. Ucak S, Ekmekci TR, Basat O, Koslu A, Altuntas Y:Comparison of various insulin sensitivity indices inpsoriatic patients and their relationship with type ofpsoriasis. JEADV 2006; 20:517-522.



Indications and Clinical use:• CLINDOXYL® Gel (5% benzoyl peroxide, 1% clindamycin)

and CLINDOXYL® ADV Gel (3% benzoyl peroxide, 1% clindamycin) are indicated in the topical treatment of moderate acne vulgaris characterized by the presence of comedones, papules and pustules.

• Not indicated for the treatment of cystic acne• Not for use in children <12 years

Contraindications:

• Hypersensitivity to medications containing lincomycin• Patients with or with a history of regional enteritis,

ulcerative colitis or antibiotic-induced colitis (including pseudomembranous colitis)

Most serious warnings and precautions:• For external use only • Not for oral, ophthalmic or intravaginal use

Other relevant warnings and precautions:• Concomitant topical acne treatments: not recommended

because a possible cumulative irritancy effect may occur• May cause Clostridium diffi cile-associated disease • Avoid contact with hair, fabrics, carpeting or other materials

(may cause bleaching)

• May cause increased sensitivity to sunlight; sunlamps should not be used and deliberate or prolonged exposure to sunlight should be avoided or minimized

• Sunburns should be resolved prior to use• Avoid contact with the mouth, eyes, lips, other mucous

membranes or areas of irritated or broken skin• Could cause gram-negative folliculitis• May cause skin adverse events including irritation (peeling,

reddening, dryness, itching, stinging/burning)• Cross-resistance between clindamycin and lincomycin and

resistance to clindamycin is often associated with inducible resistance to erythromycin

• Safety and effi cacy not established in patients <12 years of age or those >65 years of age

• Caution in use with neuromuscular blocking agents, tretinoin, isotretinoin and tazarotene

• Should not be used with erythromycin or topical sulphonamides • Should not be administered during pregnancy or lactation

unless the expected benefi ts to the mother outweigh the potential risks to the fetus or the infant; if used during lactation, do not apply to the chest so as to avoid accidental ingestion by the infant

Dosage and method of administration: • Gently apply once daily to lightly cover the entire affected

areas of the face with a thin layer of gel.

• A pea-sized amount should be applied for each area of the face (e.g., forehead, chin, each cheek), then hands should be washed.

Adverse drug reactions:• CLINDOXYL® ADV Gel: application site dermatitis (1%) and

application site photosensitivity (1%)

• CLINDOXYL® Gel: peeling (16.3%), erythema (7.6%), dryness (7%), burning (2.3%), pruritus (1.7%), mild application-site paraesthesia (<1%) and acne worsening (<1%).

For more information: Please consult the product monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for important information relating to contraindications, warnings and precautions, adverse reactions, drug interactions, dosing information and post-market adverse drug reactions which have not been discussed in this piece. The product monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374.

Reference: 1. CLINDOXYL® GEL / CLINDOXYL® ADV Gel Product Monograph. GlaxoSmithKline Inc., November 7, 2013.

® CLINDOXYL is a registered trade-mark, used under license by GlaxoSmithKline Inc.

Stiefel, a GSK company, Mississauga (Ontario) L5N 6L4

0069904/15

Your decisions could show on


by LYNN BRADSHAW,Senior Associate Editor, The Chronicle

Allergic contact sensitivity tonickel is statistically associat-ed with body piercing and

this relationship appears to be expo-sure dependent and stronger inmales, according to a NorthAmerican study published inDermatitis (Oct. 2014; 25(5):255–264).

“The goal of this study was tolook at the association between bodypiercing and pos-itive reactions tonickel, cobalt,and chromium inpatients with der-matitis who havebeen patch-test-ed in the unitedStates andCanada,” saidlead author Dr.erin Warshaw,d e r m a t o l o g i s tand professor at the university ofMinnesota, Minneapolis.

This retrospective analysisinvolved 9,334 dermatitis patients

who were tested by the NorthAmerican Contact Dermatitis group(NACDg) between Jan. 1, 2007 andDec. 31, 2010, Dr. Warshaw told THe

CHRONICLe OF SKIN & ALLeRgy.each of the participants were

patch tested using the NACDg stan-dard series of 65 to 70 allergens,which included three metals: nickel(nickel sulfate, 2.5% petrolatum),cobalt (cobalt chloride, 1.0% petrola-tum), and chromium (potassiumdichromate, 0.25% petrolatum).

Findings revealed that nickel sen-sitivity was statistically associatedwith at least one piercing (risk ratio[RR], 2.52; 95% confidence interval[CI], 2.26–2.81; p<0.0001) and nickelsensitivity rates increased with thenumber of piercings (16% for onepiercing to 32% for ≥5 piercings).

In addition, the authors reportedthat the prevalence of nickel sensitivi-ty was higher in females (23.2%) thanin males (7.1%), but the associationwith piercing was stronger in males(RR, 2.38; 95% CI, 1.72–3.30;p<0.0001) than in females (RR, 1.30;CI, 1.13–1.49; p=0.0002).

Crude analysis indicated that

cobalt sensitivity was statistically asso-ciated with piercing (RR, 1.63; 95% CI,1.40–1.91; p<0.0001); however, strati-fied analysis showed that this relation-ship was confounded by nickel.

Subsequently, the authors alsoindicated that after adjusting for nick-el sensitivity, the adjusted risk ratiofor piercing and cobalt was 0.78,which the investigators considerednot significant. On the other hand,chromium sensitivity was negatively

associated with piercing (RR, 0.60;95% CI, 0.48–0.75; p<0.0001).

Nickel sensitivity increased withnumber of piercings, study found“I think one of the most importantfindings from our investigators wasthat nickel sensitivity is associatedwith at least one piercing,” Dr.Warshaw said.

“Interestingly, data also suggestedthat nickel sensitivity rates were high-er in participants who had a greaternumber of piercings; therefore, adose response relationship was dis-covered.”

Dr. Warshaw added that theresearchers found that the associa-tion between nickel allergy and pierc-ing was stronger in males than infemales.

“We hypothesize that there was astronger association with piercingand nickel sensitivity in men becausetheir frequency of jewelry use is likelymuch less than women, therefore,males’ risk for being sensitized tonickel from a source other than pierc-ing is lower,” she suggested.

“In places of the world such asNigeria, where men tend to wear cos-tume jewelry at similar rates towomen, there appears to be no dif-ference in nickel allergy prevalencebetween both genders.”

Call for regs limiting nickel content “Our findings suggest a nickel allergy-piercing association and in responseto that I hope the u.S. governmentwill step in and consider regulationson the allowable amount of nickelrelease from consumer products,similar to the regulations that are nowin place in europe,” she said. TheAmerican Contact Dermatitis Societyhas been working on a NickelDirective Initiative with this goal.

“european studies have clearlydocumented that limiting nickelexposure is successful in decreasingnickel allergy in young females.”

Dr. Erin Warshaw

Burow’s solution is back!

C o n t a c t d e r m a t i t i s

Regulations needed for nickel in jewelryn Allergic contact sensitivity to nickel can be associated with body piercings, dermatologist reports

bidity, he said, because any encounter—accidental ordeliberate—with these creatures can produce systemictoxic, infectious or inflammatory reactions.

Some arthropods, Dr. Trevino said, are also vectors ofpotentially serious illnesses such as the West Nile virus.His list of potential pathologic agents includes spiders,mites, mosquitoes, flies, bees, wasps, caterpillars, mothsand butterflies.

Mechanical trauma, secondary infection, sensitizationphenomenon and venomous toxic effects are some of theskin reactions a dermatologist may observe after a patientmeets up with any one of these creatures.

Other factors may influence effects of toxins Age, the presence of other skin disease and immune sta-tus will influence reactions after exposure and contact.Children, the elderly and atopic individuals are more like-ly to endure severe reactions if they have not taken theprecaution of wearing protective clothing and using insectrepellent, or have dared to use scents and perfumes orwear clothes with colours attractive to any one of Dr.Trevino’s list of arthropods.

Among the arachnids, the female Black Widow spiderof the Latrodectus species is not aggressive, but inadver-tent contact will provoke a bite that will produce alpha-latrotoxin and the consequent pre-synaptic release ofneurotransmitters such as acetylcholine and norepineph-rine.

Pain, severe muscle cramps, anxiety and, occasional-ly, difficulty breathing are the most common symptoms ofa bite and they can be successfully treated by thoroughwound cleaning, ice packs, analgesics and tetanus pro-phylaxis.

“Symptomatic pregnant women, children and the

elderly with co-morbidities should be hospitalized forobservation,” Dr. Trevino advised.

“Some people also need lab evaluation andLatrodectus anti-venom therapy is indicated in severeregional or systemic latrodectism, uncontrolled hyper-tension seizures or respiratory arrest,” Dr. Trevinonoted.

The brown recluse spider is also a non-aggressivearachnid, but a stinging bite will produce a necroticlesion, red blood cell hemolysis and, sometimes, dissemi-nated intravascular coagulation (DIC).

Thorough wound cleansing, cold compresses, eleva-tion of the extremities, mobilization and analgesia are thebasics of treatment. Dapsone, cholchicine and hyperbaricoxygen have failed to show much efficacy as therapeuticoptions.

Young children may be more at risk “This can be a life-threatening condition in some folks,”Dr. Trevino said, noting that some patients, most com-monly children, will develop systemic loxoscelism withfever, arthralgias, leukocytosis, and, in some cases, a non-descript maculopapular rash.

To defend or attack the tarantula throws off urticatinghairs, which penetrate skin or eyes to produce a dermati-tis or ophthalmia nodosa. Management includes removalof the hairs, antihistamines and steroids and referral to anophthalmologist.

The neurotoxins in a scorpion’s bite will produce sig-nificant local wounds, Dr. Trevino said, and potentiallyeven cardiovascular complications or death. Pain, numb-ness beyond the sting site, regional adenopathy, musclespasticity and excessive salivation.

“Particularly in young children, these bites can be amajor issue,” he said.

Garden pests can lead to clinic visitsContinued from page 10

26 · June 2015



Burow’s solution is back!


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28 · June 2015

Laser research THe CHRONICLe of SKIN & ALLERGY

R e s e a r c h

Fraxl CO2 for PCAn Superficial application better tolerated

Both superficial and deep modes of fractional CO2 laser treatment for pri-mary cutaneous amyloidosis (PCA) appear equally effective, but thesuperficial mode is better tolerated and so is recommended as a thera-peutic option, researchers report online in Lasers in Surgery and Medicine(May 6, 2015).

A group of 25 patients with PCA were included in the study, 16 withmacular amyloidosis and nine with lichen amyloidosis. Patients weretreated with each modality in different skin areas—superficial ablation inarea A, and deep rejuvenation in area B. Treatment was done in four ses-sions at four week intervals, with skin biopsies taken at baseline and onemonth after the last treatment session. Histological assessment was donewith Congo red staining and polarized light, along with clinical assess-ment, and there was three months of post-treatment follow-up. Significantreduction in pigmentation, thickness, itching, and amyloid deposits wereseen with both laser modalities (p<0.001). Percentage of reduction of pig-mentation was significantly higher in area A (p=0.003), while pain wassignificantly higher in area B. The authors note that significant reduction indermal deposits of amyloid indicates their trans-epidermal eliminationspurred by the fractional photothermolysis.


R e s e a r c h

Lasers in Latin skin typesn Staggering treatments reduces complicationsFrom the News Resources of The Chronicle

Treating Latin skin types (Fitzpatrick phototypes III, IV, and V) with CO2

ablative and microfractionated laser systems produces good results withan acceptable rate of complications either alone or in combination. Aswell, staggering treatments along with adequate post-procedure care canfurther reduce the rate of complications, researchers report online inAesthetic Plastic Surgery (Apr. 24, 2015).

Investigators carried out a standardized review of medical recordsfrom a database of private practice patients who had been treatedbetween Jan. 1998 and July 2012 using the Slime30 MiXto SX CO2 laser.Outcomes, complications, and satisfaction from ablative treatment,microfractionated treatment, or a combination of the two were evaluat-ed. In total, 665 patients were included in the study, of whom 80.3%received ablative laser treatment, 15.1% received microfractionated treat-ment, and 4.5% received mixed treatment. Hyperpigmentation was seenin 30.4% of the ablative group, 16.3% of the combination group, and 11%of the microfractionated group, with a steady increase in these rates asphototype became higher. All groups had high satisfaction rates—86.7%in the mixed group, 82.2% in the microfractionated group, and 79.6% inthe ablative group.

Laser dermatology updateALA-PDT/CO2 LASER FOR SCCIN SITU CALLED SAFE, EFFECTIVEFor treating squamous cell carcinoma(SCC) in situ, a combination ofaminolevulinic acid (ALA) photosensi-tized photodynamic therapy (PDT)with CO2 laser is safe, effective, andassociated with low recurrence andreduced side effects, according toresearch published online in Lasers inMedical Science (April 22, 2015).

Some 22 lesions from 18 patientswere included: 11 treated with topicalALA-PDT (180 J/cm2 at 100 mW/cm2,

plus CO2 laser, one to three sessions);11 were treated with CO2 laser alone..Patients were reviewed at least once aweek. Biopsies were taken beforetreatment and one month after treat-ment for histological evaluation. Non-responders were referred to surgicalintervention. The combination grouphad 72.73% (n=8) lesions achievecomplete remission (overall clearanceof 90.91%) with one lesion (9%) recur-ring. Local side effects included milderythema, edema, erosion, and burn-ing or stinging sensations. No systemicside effects were seen. In the controlgroup, 63.63% (n=7) of lesionsachieved complete remission (overallclearance of 54.55%), with five(45.45%) lesions recurring. Local sideeffects among included mild to mod-erate edema, erosion, ulceration,delayed healing, prolonged pain, andscarring. The difference in recurrencebetween groups was significant(p<0.05).complete necrosis wasobserved in responsive lesions, withatypical cells replaced with normalkeratinocytes within three months.

FRACTIONAL CO2 LASER SPEEDSHEALING OF POST-TRAUMATICWOUNDS IN THE ELDERLYA small case series suggests thatfractional CO2 laser treatment canaccelerate healing in posttraumat-ic, lower-extremity ulcers in elder-ly patients, according to a paperpubl ished onl ine in JAMADermatology (May 6, 2015).

Noting that it can be challeng-ing to treat posttraumatic lowerextremity wounds in the elderly,and that fractional CO2 laser treat-ment has been shown to improvewound heal ing in scar-relatedwounds, the authors tested thetreatment modality in three elderlypatients' slow-healing posttraumat-ic wounds. each wound was treat-ed once, with the wound base irra-diated at 30 mJ at 5% density, andthe wound edge and one to twocm of the normal surrounding skinwas treated with 50 mJ at 5% den-sity. Treatment was done with asingle pass at 150 Hz. The proce-dure was well tolerated with milddiscomfort , and the woundshealed by 60% or more withinthree weeks of treatment.

The only reported adverseevents were mild and transienterythema at the treatment site.

ER:YAG LASER VS. CRYOTHERAPYFOR SEBORRHEIC KERATOSESFor the treatment of seborrheickeratoses (SKs), erbium:yAg(er:yAg) lasers represent a simple,economical, one-step alternative tocryotherapy which produces bettercosmetic results, researchersreport online in the Journal ofDermatological Treatment (Mar. 23,2015).

Some 42 patients were includ-ed in the study, each with SKsbetween 0.5 cm and 3 cm in sizeon their back, chest, face, or neck.The investigators matched lesionsof similar size and location, andthen in the same treatment sessiontreated half the lesions withcryotherapy and half using er:yAglasers. All patients were then clini-cally evaluated in two recall visits,with one month between visits.efficiency of the treatments wasalso evaluated.

Complete healing wasobserved in al l (100%) of thelesions treated with the er:yAglaser after the first treatment ses-sion, while the healing rate in thecryotherapy group was 68%(p<0.01). The er:yAg-treated groupalso experienced signif icantlylower hyperpigmentation and lesserythema than the cryotherapygroup.

.

FLASH LAMP PULSED DYE LASERIS SAFE, EFFECTIVE FORKELOIDS, HYPERTROPHIC SCARSA small study testing the use offlash lamp pulsed dye laser (FPDL)as a treatment for hypertrophicscars and keloids found the treat-ment to be effective, according to apaper published in Photomedicineand Laser Surgery (May 2015;33(5):274-277).

Having previously used FPDL ina group of patients with hyper-trophic scars and keloids, theauthors set out to evaluate its effica-cy in a large number of cases. Thestudy included 59 patients, of which33 were male and 26 were female,with a mean age of 37.5 years.Patients had hypertrophic postsurgi-cal scars and keloids. each partici-pant was treated with four to sixFPDL treatment sessions, and therewas a clinical follow-up visit sixmonths after the last treatment.Among the 59 patients, 29 (49.1%)achieved excellent clearance, 15(25.4%) achieved good to moderateclearance, and another 12 (20.4%)obtained slight improvement. Littleto no lesion improvement was seenin three (5%) patients. In all patientsthe treatment was well tolerated,with minor and transient sideeffects.

The authors note that morestudies, involving larger patient pop-ulations, will be needed to developa standardize and reproduciblemethod of treating hypertrophicscars and keloids using FPDL.


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by JOHN EVANS,Assistant Editor, The Chronicle

In his role as Chief of the Sectionof Pediatric Dermatology at theChildren’s Hospital of

Philadelphia, Dr. Albert C. yan and histeam have seen a wide array ofunusual dermatologic cases that havetaught him important lessons. Heshared 10 (plus one extra) of thesecases and pearls with his Canadiancolleagues at Paediatric Dermatologyupdate in Toronto. The first fivepearls were published in theApril/May issue of THe CHRONICLe OF

SKIN & ALLeRgy; following are addition-al insights of Dr. yan on some of thedermatologic conditions unique to, orwhich present differently in, the veryyoung.

Congenital midline lesionsWhen a child has a lesion on the mid-

line of the head that hasbeen present from birth,the child should be investi-

gated and evaluated forunderlying neurological

abnormalities, said Dr. yan. He provided the example of a

case of a severevariant of aplasiacutis congenitafound on the mid-line of an infant’shead. There was amembrane overthe lesion, sur-rounded by hair.“This is a moresubtle variant [ofaplasia cutis] that has been calledhair collar sign. It has that thick, luxu-rious hair around a kind of thinner,circular membrane. And often timesyou’ll see this kind of faint erythemaaround it.”

“These midline lesions are impor-tant to recognize because, when theyare present right from birth and yousee them on the midline, they repre-sent a region of embryological mal-formation.” Imaging revealed that thislesion was actually heterotrophicbrain tissue exposed through a gap inthe skull.

Blame it on a virusThere are several signs that couldsuggest to a dermatologist that a mys-

tery rash may be viral in ori-gin, said Dr. yan. “They’reoften clustered in commu-

nities, they often occur onlyonce and the patient doesn’t get itagain, we can’t find any other causesfor them, and they spontaneouslyresolve.”

Some mysteries may not be

solved, he added, citing a case wherea five-month-old, otherwise healthychild was developing a widespreadrash when—and only when—he fellasleep. The child’s mother even

brought Dr. yan a cell phone cameravideo of the rash developing in realtime. “As soon as you wake him up, itdisappears,” said Dr. yan. “It hadbeen going on for about three weeks,every time he went to bed, whether itwas a nap or his regular bedtime.”

unable to determine the causefor three weeks, Dr. yan referred thepatient to a neurologist to rule out adysautonomic condition. While wait-ing for that appointment, the rashresolved and never reccured.

If it is decided a virus is the causeof a rash, it may not be worth theeffort to identify the specificpathogen, he added. “If we don’tknow what causes [the rash], or wedo but there are a number of different[potential causes] but we’re not surewhich one it is at this time, is it worthfinding out which virus it is, if thereare five or six different ones associat-ed with [the exanthem pattern]?”

Signs of an ‘outside job’Artificial-looking lesions are often just

that: signs of an outside, non-biological cause, said Dr.yan. “unusual patterns orgeometric, or linear, non-

anatomic lines indicate anoutside job.” This is particularly com-mon in teens and pre-teens whodeliberately challenge each other invarious ways.

He showed a series of images oflesions—partial-thickness burns,many of which were perfect rectan-gles on the forearm. Most of theimages had been taken from socialmedia, and showed “an atypical frost-bite reaction,” said Dr. yan. “This isthe salt-ice challenge. The kids do itas a kind of test of willpower. Theylayer salt on their skin, either on theirhands or their forearms or their back.Then they have somebody put ice ontop. It allows for the ice to stay frozen,

longer, instead of melting away andwarming up so they get a frostbitereaction.”

This salt-ice challenge is just oneexample of deliberately inflicted skin

injuries, said Dr. yan, so it is impor-tant to be aware of the sort of artifi-cial, unnatural shaped lesions thatpoint to an outside cause.

Old diseases returningIt is worthwhile to be familiar withhistorical diseases, because while

they have become thankful-ly rare in the modernworld, they can still appear

and dermatologists need tobe able to recognize them, said Dr.yan.

Several patients have presentedat the Children’s Hospital ofPhiladelphia with a lacy, peeling-paint rash and failure to thrive, withthe parents suspecting a reaction tosomething in their diet. Diet was theproblem, Dr. yan related, but not howthe parents thought. “I think we’veseen, now, half a dozen cases ofKwashiorkor in the last five years,” hesays.

Health-conscious parents, think-ing they are doing the right thing, aresubstituting low-protein alternativeslike rice beverages instead of milk intheir infants’ diets and causing pro-tein-energy malnutrition. “They thinkthat because this is advertised foradults as a healthy alternative to milk,they can use it in their children,” Dr.yan said.

“It’s important. We may think ofthis as one of the historical diseases,something you read out of books, butyou may still come across it,” he said.The hospital has seen two cases ofscurvy as well, again due to restrictivediets parents are giving to their chil-dren.

Know when to call other specialistsWhen a 13-year-old boy presented atthe hospital having had fevers forthree weeks, chills and shortness ofbreath—which scans revealed to be

adenopathy calcifying pul-monary nodules—thediagnostic team also

noticed a single skin lesionand decided to consult with

the dermatology department, Dr. yansaid. “So of the different services [atthe hospital], they thought ‘let’s con-sult derm also. Because there is oneskin lesion we should ask them whatis going on.’”

As part of the work-up the dermteam took a more detailed history,which revealed a history of tick expo-sure, he said. A biopsy of the lesionshowed some granulomas but noobvious organisms, but the history oftick exposure led the team to requesta chocolate agar culture.

“It grew Francisella tularensis,which is the cause of tularemia. Sotick exposure, it turns out, is possiblymore common than handling rawrabbit for tularemia,” said Dr. yan.

The takeaway is that for challeng-ing cases in search of a diagnosis, it isimportant to call on your colleagues,he says.

Don’t forget the InternetIn addition to a physician’s ownexpertise and consulting with col-leagues, a dermatologist should not

overlook the potentialpower of a google orPubmed search to find lit-

erature that helps clear up amystery diagnosis, said Dr. yan.

When a three-year old presentedat the eR with a history of tick bitesand a painful lesion on the back of hishead, characterized by a darkereschar, a spreading ring of erythema,and some underlying lymphadenopathy, initial cultures turned upno organisms which seemed to ruleout many of the initial hypothesessuch as tularemia or some form ofLyme disease. Consultations with col-leagues also did not shed much lightonto the situation. “So I went togoogle,” Dr. yan said. “I typed ‘scalp,’‘eschar’ and then ‘adenopathy’ to seewhat I find.”

One of the results listed ‘after tickbite, and he followed it.

“What did I see? ‘Tick-bornelymph adenopathy: an emerging syn-drome,’ ‘update on SeNLAP,’ which isscalp eschar and neck lymphadenopathy. This was the diagnosis,essentially,” reported Dr. yan.

“Some of the patients who havebeen tested for this, when [doctors]got the test data back they identifiedRikettsia organisms as the cause,”said Dr. yan. “If you want to knowmore about it, you can google it orsearch Pubmed.”


Pearls for pediatric dermatology: Part IIn Part two of a special report outlining Dr. Albert C. yan’s top 10 pediatric pearls (plus one)

30 · June 2015


Dr. Albert C. Yan

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American Academy of Dermatologyduring a forum on disorders of pig-mentation, Dr. Rashmi Sarkar,Secretary general of the IndianAssociation of Dermatologists,Venereologists and Leprologists,reported that while hydroquinone isthe gold standard for treating melas-ma, there is someconcern aboutside effects withits extended use,particularly athigh concentra-tions.

“We can usetopical kojic acid,azelaic acid anda d a p a l e n e[instead of hydroquinone],” said Dr.Sarkar. “They can be used as mainte-nance agents.”

The condition is more prominentin individuals with Fitzpatrick skintypes IV to VI, said Dr. Sarkar.

It’s critical that patients withmelasma use effective photo-protection, particularly physicalblockers. “Protection from thesun is very important,” said Dr.Sarkar, explaining ongoing uVexposure will not allow melas-ma to fade even when it’sbeing treated.

The majority of patientswho develop melasma arewomen, and it’s typically asso-ciated with hormonal changes,particularly pregnancy, but birthcontrol pills and hormonal replace-ment can also result in melasma.Men can also develop the condition,noted Dr. Sarkar.

Disorders of hypopigmentationSeveral disorders of hypopigmenta-tion can develop, and cliniciansneed to differentiate those condi-tions from vitiligo, according to Dr.Seemal R. Desai, founder and med-ical director, Innovative Dermatol-ogy, Plano, Tex.

“It’s a common misperceptionthat light skin patches mean vitiligo,”said Dr. Desai. Pityriasis alba, forexample, is a form of eczema thatcan be confused for vitiligo, said Dr.Desai, noting dermatologists can usea Wood’s lamp to examine the skin

and assist them in differentiatingbetween vitiligo and pityriasis alba. Askin biopsy can also be performed toconfirm the diagnosis of pityriasisalba, but clinicians would generallytry to avoid that step in childrenaffected by the condition, said Dr.Desai.

“We treat pityriasis [alba] like wewould AD [atopicdermatitis],” hesaid, suggestinglow-to-mediumstrength topicalsteroids be usedas well as emol-lients to maintainskin moisture. “Itimproves, getsbetter, and gener-

ally resolves on its own.”Fungal infections, such as tinea

versicolor, can also cause hypopig-mentation which to the untrained eyecould lead to a diagnosis of mimicvitiligo being considered due to theskin lightening, with light patches

appearing on the chest and the back,said Dr. Desai.

“The way the infection looks onthe skin [resembles vitiligo],” said Dr.Desai. “I suggest patients use antifun-gal shampoo and apply it to the skinlike they would a body wash whilethey are in the shower.

If patients do not respond to anti-fungal shampoo, oral antifungalagents can be considered as therapy,he said.

Still another condition that can bemistaken for vitiligo is progressivemacular hypomelanosis. The exactetiology of the condition is notknown, but some have put forth thecondition is linked to acne bacteriaand decreased production ofmelanin.

“It is thought to be due to P.acnes,” said Dr. Desai. “Some of thetreatments include benzoyl peroxideor oral antibiotics.”

Sarcoidosis is another conditionthat can manifest as hypopigmenta-tion, and it can be mistaken for otherpigmentary disorders, potentiallyeven vitiligo, said Dr. Desai.

Patients with skin phototypes IVthrough VI can be left with hypopig-mentation after experiencing acne oran inflammatory condition like psori-asis. “Once psoriasis is treated, it canleave a hypopigmented area, andpatients are left with dyschromia,” hesaid.

Dr. Desai suggests patients lookfor healthcare providers who have aninterest in pigmentary disorders ifthey experience such disordersbecause many of the conditions arechronic.

Post-inflammatory hypopigmentationPost-inflammatory hyperpigmentationis the skin’s response to inflammation,can develop after “an inciting event”

such as acne, and is more visiblein individuals with darker skintypes, explained Dr. MarshaHenderson, clinical instructor,Department of Dermatology,Henry Ford Medical Center,Detroit.

“PIH is more severe in dark-er skin types and more notice-able, but it can happen in lighterskin as well,” said Dr.Henderson.

If the PIH develops becauseof a condition like acne, that the acneremains poorly controlled, the PIHwill recur, explained Dr. Henderson.exposure to some lasers can lead toPIH, so clinicians should be carefulabout which lasers they select whenusing them in darker-skinned individ-uals, said Dr. Henderson.

Similar to melasma, a course ofhydroquinone can appropriately treatPIH, said Dr. Henderson, but lowerdoses of hydroquinone are generallyrecommended.

uV exposure exacerbates PIH inthe same way that uV exposure wors-ens melasma, reported Dr.Henderson.

“It takes longer to clear the PIH ifyou are not protecting yourself fromsunlight and uV radiation.”

Melasma Tx options include kojic acidContinued from page 1

32 · June 2015

Indication and clinical use: ROSIVER (ivermectin) Cream, 1% is for the topical treatment of infl ammatory lesions (papules and pustules) of rosacea in adults 18 years of age or older.

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References:1. ROSIVER™ Product Monograph. Galderma

Canada Inc. April 22, 2015.2. Stein Gold L et al; Effi cacy and safety of

ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies. J Drugs Dermatol. 2014;13(3):316–323. A phase 3, multicentre, randomized, double-blind, 12-week, vehicle-controlled, parallel-group study assessing the effi cacy and safety of ROSIVER once daily in 683 patients with moderate to severe papulopustular rosacea (IGA score of 3 or 4). The co-primary effi cacy endpoints were the success rate based on the IGA outcome (percentage of patients “clear” and “almost clear” at Week 12 of the study) and absolute change from baseline in infl ammatory lesion counts.

3. Taieb A et al; Ivermectin Phase III Study Group. Superiority of ivermectin 1% cream over metronidazole 0.75% cream in treating infl ammatory lesions of rosacea: a randomized, investigator-blinded trial. Br J Dermatol. 2015;172(4):1103–10.An investigator-blinded, multicentre, randomized, parallel-group study comparing the effi cacy and safety of ROSIVER once daily with metronidazole 0.75% cream twice daily in 962 patients with moderate to severe papulopustular rosacea (IGA score of 3 or 4) over a 16-week treatment period. The primary effi cacy endpoint was percent change in infl ammatory lesion counts from baseline to week 16.

IGA: Investigator Global Assessment.

Message from the Medical Editor

nently undervalued and marginalized by governments andpolicy makers alike.

Point two: I expect that the impact of the WCD willcontinue to reverberate in our specialty for years to come.Organizers Drs. Harvey Lui and Jerry Shapiro and BerniceChu and Annette McCunn and the crew at Simply eventfulmust be congratulated for an amazing Congress that willno doubt continue to further elevate the profile of derma-

tology in Canada. Our specialty is grateful. Harvey now goes on to head the International League

of Dermatological Societies, in addition to his medical,research, and teaching responsibilities in Vancouver.

We look forward to Harvey’s leadership of the ILDS.His election as ILDS president is indeed an honour notonly for Harvey, but for all Canadian dermatologists.

—Wayne P. Gulliver, MD, FRCPCMedical Editor


Dr. RashmiSarkar

Dr. Seemal R.Desai

“We treat pityriasis[alba] like wewould AD[atopic

dermatitis] . . . It improves, getsbetter, and generally resolves

on its own.” —Dr. Seemal R. Desaiq


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INTRODUCTION

Psoriasis is a genetic multifac-torial disease of the skin,which affects approximately2% of the population. Thecause of the disease remainsunknown. It has been sug-

gested that it is probably caused bysome kind of autoimmune mechanism,though the triggering antigen has yetto be identified.

Over recent years, a series of publi-cations has appeared showing anincreased frequency of metabolic syn-drome (MetS) and its componentsamongst subjects with psoria-sis,2,9,18,20,24 leading in turn to anincreased risk of cardiovascular diseaseand death.16,24 Said association wouldnot appear to be related to age, sex orthe kind of psoriasis,9,24 but there issome dispute with regard to its relation-ship to the severity and duration of thedisease.9,20

Among these patients, a higherlevel of prevalence of a series of factorshas also been described, which couldaccount for the more extensive pres-ence of MetS and heightened cardio-vascular risk. Such factors include

tobacco addiction, obesity, physicalinactivity, depression, poor food habitsand psychological stress.4,11,24,25

The etiopathogenetic relationshipbetween the two processes is notentirely known. However, the presenceof certain pro-inflammatory cytokinesand immunological mediators has beenidentified in both diseases.25

Some authors suggest that theheightened incidence of MetS in psoria-sis patients could partly be explained bythe chronic presence of systemic inflam-mation with psoriasis.20,23 However, inMetS a proinflammatory state is also tobe found and certain studies indicatethat it is obesity which predisposes thebody to developing psoriasis.21

The aim of our study is to assessthe association of MetS and its compo-nents in a sample of subjects with pso-riasis and to compare it to that of acontrol group of the same age, sex andbody mass index (BMI). The secondaryobject is to study the relationshipbetween the duration and severity ofthe psoriasis and the MetS.

METHODS Study protocol

The present is a case–control study. Itwas approved by the research commit-tee of Consorci Sanitari Integral and it

was performed during the course ofdermatology consultations at theBarcelona Hospital Dos de Maig (level 2hospital). Included in the study arepatients with psoriasis who attendedthe hospital regularly and signed theinformed consent form. The controlgroup was recruited from among hos-pital workers or family members withno history if psoriasis. Control subjectswere individually paired with psoriasissubjects according to sex, age and BMI.

The size of the sample was calcu-lated with a view to the main object ofthe study, that is, to assess the preva-lence of MetS among a sample of sub-jects with psoriasis and compare it tothat of a control group. To do so, webased our calculations on the Love, etal study,15 which described a percent-age of MetS among the populationwith psoriasis of 39.9%, as compared tothe 23.5% of the control population (adifference of 16.4%). To determinesample size for the present study, weassumed an expected level of preva-lence among subjects with psoriasis of30%. Given a risk of 0.05 and a ß risk of20% in bilateral contrast, we required97 subjects for each group to enable usto detect a difference of 16.4% in theprevalence of MetS as a statistically sig-nificant difference between the twogroups.

All psoriasis patients attending thedermatology department were asked ifthey would like to participate in thestudy. If the subjects accepted, the fol-lowing protocol would then be fol-lowed: 1) Anamnesis: family and per-sonal history of any of the componentsof MetS or cardiovascular disease aswell as any other pathological, pharma-cological, diet related, tobacco and/oralcohol addiction (<3 vs. =/>3 alco-holic drinks per day), exercise (light,moderate or high) history, collected byway of the IPAQ (short version) ques-tionnaire and the history of the psoria-sis (onset, evolution, type, previous andcurrent treatment, presence of psoriaticarthritis). 2) Physical examination:weight, height (calculation of BMI),waist circumference, systolic and dias-tolic blood pressure (BP) (two readingsin a seated position, taken five minutesapart with an automatic electronicOMRON device). Calculation of thePsoriasis Area and Severity Index(PASI).7 3) Analytical study:Hemogram, basal glycemia, creatinine,urea, GOT, GPT, lipid profile total cho-lesterol (TC), HDL-cholesterol (HDLc),LDL-cholesterol (LDLc), triglycerides(TG), TSH, free T4 and basal insuline-mia. 4) Oral Glucose Tolerance Testwith 75 g (glycemia 120 minutes). 5)Estimation of insulin sensitivity by theHOMA method. The control subjects,after signing the informed consentform, followed the same protocol, withthe exception of any assessment of theextent of psoriasis.

The presence of MetS was assessedin line with the 2009 consensus crite-

ria:1 MetS is considered present whensubjects present three or more of thefollowing: Waist circumference =/>80cm for women and =/>94 cm for men(all subjects European); triglycerides=/>150 mg/dL (1.7 mmol/L) orhypolipemiant treatment; HDL <50mg/dL (1.3 mmol/L) for women and<40 mg/dL (1.0 mmol/L) for men; BP=/>130/85 or hypertension (HT) treat-ment; basal glycemia =/>100 mg/dL(or hypoglycemia treatment, or glucoseintolerance or OGTT or diagnosed dia-betes mellitus (DM)).

Analytical studies

Analytical samples were taken after 12hours of night fasting, and 120 minutesafter the administration of 75 g of oralglucose. The methods used to determinethe different parameters were as follows:Glucose: Hexokinase, Dimension; CT:molecular absorption spectroscopy, cho-lesterol esterase and oxidase enzymemethod, Dimension; direct LDLc: spec-tro-enzymatic assay with cholesterolesterase and oxidase. Dimension; HDLc:spectro-enzymatic assay with cholesterolesterase and oxidase. Dimension; TG:molecular absorption spectroscopy,enzyme assay with lipoprotein lipase,Dimension; Insulinemia: chemilumines-cent microparticle immunoassay (CMIA),Architect.

Statistical analysis

We started with a descriptive analysisof the data. For qualitative variables,percentages and the corresponding95% confidence interval were applied,while for quantitative variables, aver-age and standard or mean deviationand minimum and maximum valueswere all employed.

The comparison of the groupswith/without psoriasis was performedby way of a bivariate analysis, taking theX2 test for qualitative variables andStudent’s t-test for quantitative variables.If the latter were found not to complywith the normality assumptions, theMann–Whitney U test was used.

Last, we performed a logisticregression analysis, taking MetS andthe components thereof as our depen-dent variables, and the diagnosis ofpsoriasis, sex, age, diet, exercise andtobacco addiction as independent vari-ables. A further logistic regressionanalysis was performed on the subjectswith psoriasis, taking MS as our depen-dent variable while our independentvariables were both those found signif-icant in the bivariate study and othersfound clinically relevant. A secondanalysis was then carried out, differen-tiating between mild and moderate-severe psoriasis (mild PASI </=10 withno systemic treatment; moderate: PASI>10 and/or systemic treatment: oralcorticosteroids, methotrexate, biologicaltreatment, retinoids).

For all the above tests, statisticalsignificance was set at a level of 5%.

All statistical analysis was per-

POSTGRADUATEEDUCATIONAL SUPPLEMENTMetabolic syndrome and

its components inpatients with psoriasisMercè Albareda,1,* Anna Ravella,2 Marta Castelló,1Sandra Saborit,4 Laura Peramiquel,3 and Luís Vila1from 1Endocrinology Department Hospital de Sant Joan Despí Moisés Broggi. CSI, Jacint

Verdaguer st, 90, 08970 Sant Joan Despí, Spain, 2Dermatology Department Hospital Dos de

Maig. CSI, Dos de Maig st, 301, 08025 Barcelona, Spain, 3Dermatology Department, Hospital

de Sant Joan Despí Moisés Broggi. CSI, Jacint Verdaguer st, 90, 08970 Sant Joan Despí,

Spain. *Corresponding author.

ABSTRACTPsoriasis is a chronic inflammatory disease of the skin which affects 1 to 3% of thepopulation. A higher association of metabolic syndrome (MetS) has been describedamong patients with psoriasis. The objective of this study was to assess the associa-tion of MetS and its components among subjects with psoriasis and compare it withthat found for the control group. The secondary objective was to study the relation-ship between the duration and severity of the psoriasis and the MetS. This was acase–control study: 102 subjects with psoriasis and 102 control subjects paired bysex, age and body mass index. Anamnesis: history of diabetes mellitus, arterialhypertension, dyslipidaemia and psoriasis. Lifestyle. Physical examination: weight,height, blood pressure, waist circumference. Tests: lipid profile, oral glucose toler-ance test and insulinemia (HOMA calculation). MetS classified according to the2009 consensus. The prevalence of MetS among psoriasis patients was 52.9%, ascompared to 34.31% in the control group. MetS independent factors: age (OR1.085), body mass index (OR 1.346), sex (OR 2.69 for men) and psoriasis (OR 3.634).A comparative study of patients with psoriasis with or without MetS, revealed norelationship to the severity, age at time of diagnosis or time of evolution of the pso-riasis. In conclusion, the association of MetS among psoriasis patients is very highand the disease is considered as an independent risk factor for MetS. Our resultsshow no relationship between the different characteristics of psoriasis and the pres-ence of MetS. The main limitation of this study is that it does not enable us to con-clude whether psoriasis is a risk factor for MetS or the opposite.

Chro

nicle

Reprinted with permission from: Albareda, et al; SpringerPlus 2014, 3:612 ©2014 Albareda, et al; licensee Springer.http://www.springerplus.com/content/3/1/612


formed on an IBM SPSS v-19 statisticalsoftware package.

RESULTS A total of 204 patients participated inthe study, 102 affected by psoriasisand 102 with no history of psoriasis(55 men and 47 women in eachgroup). Average age was 49.32±13.47years and average BMI index 27.7kg/m2 (18.9-41.79) for the group withpsoriasis, while 48.71±13.84 years and27.36 kg/m2 (18.24-40.5) were the aver-ages found for the control group.Table 1 shows a description of thestudy population.

Fifty-three subjects (52.9% CI95%: 42.4-61.4) with psoriasis present-ed with MS and 35 (34.31% CI 95%25.8-43.9) from the control group(p=0.016). With respect to the diversecomponents of MS, no significant dif-ference was observed, even thoughthere was a tendency toward a higherfrequency of dyslipidaemia (DLP)among psoriasis patients (Table 2).

A univariate analytical study,comparing the two populations, with

and without psoriasis, showed highersystolic BP and greater insulin resis-tance among subjects with psoriasis.Moreover, the same subjects present-ed known DM with greater frequency(13.7 vs. 3.7%) and had a greater ten-dency to active tobacco addiction.

The multivariate study, comparingthe psoriasis and control populations,underscores an independent relation-ship between age (OR 1.085 CI 95%1.049-1.123), BMI (OR 1.346 CI 95%1.228-1.499), sex (OR 2.690 CI 95%1.195-6.057 men) and psoriasis (OR3.634, CI 95% 1.645-8.025), with respectto the development of MetS (p<0.001).An analysis of each of the differentcomponents is shown in Table 3.

With respect to the characteristicsof the patients’ psoriasis, 90 presentedwith plaque psoriasis, six guttate, fourpalmoplantar, one localized pustularand one inverse psoriasis. The averageage at the time of diagnosis of the dis-ease was 29.46±15.67 years whileduration was 19 years (0.5-55). ThePASI score was 6.4 (0–36.6). Withrespect to treatment, four followed no

course of treatment, 35 one singleform of treatment and the remainderreceived combined treatment. Thetreatment employed was as follows:16 on PUVA, 34 on UVB B-E, six onimmunosuppressors (four onmethotrexate, one on leflunamide andone on methotrexate+deflazacort),two on biological treatment with adal-imumab, six on retinoids, 66 on topicalcorticosteroids, 39 on calcipotriol, 10on topical keratolytics, three ontazarotene, one on coal tar and one ontopical tacrolimus. Twenty-one sub-jects (20.58%) mentioned they alsopresented with psoriasic arthritis. Aunivariate study, comparing subjectswith psoriasis alone with those withMetS is shown as Table 4. The patientswith psoriasis and MetS were older,with a higher BMI, greater insulinresistance and were older at the timeof the initial diagnosis of psoriasis. Norelationship was observed with eitherthe PASI score or when the subjectswere classified as having mild or mod-erate-severe psoriasis.

The multivariate study comparingsubjects with psoriasis, groupedaccording to whether or not they alsopresented MS, showed an age (OR1.083 CI 95% 1.035-1.134) and BMI(OR 1.346 CI 95% 1.168-1.550) inde-pendent relationship. Neither the ageat the time of diagnosis, the time ofdevelopment of the disease or thePASI score served as independentmarkers for MetS.

DISCUSSIONSeveral studies have been publishedrecently showing a higher prevalenceof MetS and the components thereofamong subjects with psoriasis, withMetS figures varying between 4.3 and40%, clearly higher than those found inthe control populations2,9,13,15,19,24 andlower than the prevalence found inour sample. A recent systematic andmeta-analytical review of the moreobservational studies describes an ORof 2.26 for MetS in subjects with psoria-

sis.2 Certain variables, that could derivein differences between the studies,should be examined. First, the criteriaby which MetS was assessed, whichvaried from study to study (WHO,NCEP, ATP III). Secondly, the popula-tion studied, with observations of theSpanish population (VIVA Study)revealing lower levels of MetS whencompared to the other European andAmerican populations.8 Among theSpanish population, looking at non-diabetic subjects aged between 30 and65 years and following NCEP ATP IIIcriteria, a MetS prevalence of 15% hasbeen described (19.5% for men and14.7% for women).8 A more recentSpanish study (DARIOS Study), per-formed in 24,670 subjects aged 35 to 74years, the level of prevalence observedwas 31%.5 Third, the severity of thepsoriasis has only been observed to berelated to the presence of MetS in cer-tain studies.14,20 Finally, the prevalenceof obesity: obese subjects face a greaterrisk of presenting different compo-nents of MetS, according to most stud-ies. Subjects with psoriasis presentedobesity with greater frequency thanthe control group9,15,24 and a systemat-ic revision describes an OR of 1.18-5.49for obesity in subjects with psoriasis.20

In our study, we applied the MScriteria of the 2009 consensus,1 whichare stricter, and thus selected a greaternumber of subjects affected from bothgroups in comparison with VIVAstudy,8 but the prevalence of controlgroup was similar to DARIOS Study.5

On the other hand, the prevalence ofobesity was found to be 32.35%, some-what higher than in the VIVA study,which placed it at 27%.8 This is account-ed for by the fact that cases and controlswere paired by BMI, meaning the casesubjects were at greater risk of beingoverweight and obese.

With respect to the other MetSrisk factors, the relationship betweenMetS and age and BMI is known andthe higher risk of MetS among menwas also described for the Spanishpopulation by the VIVA study.8

POSTGRADUATE EDUCATIONAL SUPPLEMENT

Table 1: Description of subjects with/without psoriasis studied

Table 2: Prevalence of MetS and the components thereof in the subjects studiedwith/without psoriasis


As opposed to previous stud-ies,18,24 we did not find MetS compo-nents to be present more frequentlyamongst subjects with psoriasis,though we did observe a higher per-centage of known DM, a tendency tomore frequently encounter lipid alter-ations and higher average systolicblood pressure. These results concurwith those of the Prey, et al review,20

in which no conclusive figures wereseen with respect to HT, DM and DLP.The differences encountered withrespect to other studies could beaccounted for by the prevalence ofobesity in the control group which, inour study, was similar to that of thepsoriasis group, while in other studiesit was lower, possibly thus creatingmore differences between the casesand controls. On assessing the compo-nents of MetS, psoriasis continues tostand as an independent risk factorwith respect to altering levels of glu-cose tolerance and dyslipidemia.Subjects with psoriasis have a higherpercentage of known DM, but no dif-ference in the percentage of patientswith impaired glucose tolerancebetween groups was observed. Patients

with psoriasis also have an increasedinsulin resistance and probably worseimpaired glucose tolerance, therefore ahigher risk of diabetes.

On the other hand, we mustpoint out that the subjects with psori-asis also presented greater insulinresistance, supporting the findings ofthe earlier study by Ucak, et al.26

Additionally, an improvement to pso-riasis has been described when undertreatment with pioglitazone, a drugthat enhances insulin sensitivity22 andwhen there weight-loss improves theresponse to treatment withcyclosporine for subjects with moder-ate-severe psoriasis.9

Despite this relationship betweeninsulin resistance and the way thepsoriasis responds to treatment, thereare controversial results concerningthe severity and duration of the dis-ease and the MetS.9,14,15,19,20,24,26

Neimann, et al18 describe a greaterfrequency of cardiovascular risk fac-tors, both with mild and severe psori-asis, and associate severe psoriasiswith a higher percentage of DM.Other studies find no relationshipwith severity, but do find a relation-

ship to a greater duration of the psori-asis or younger age at diagnosis.9,19

Sommer, et al24 describe a greater riskof MetS in subjects hospitalized withsevere psoriasis while other studiesperformed with ambulatory subjectswith less severe disease rule out anysuch relationship,9,13,26 as does ourstudy. This could point to it beingrelated to severity, given that it wasfound in more severely affectedpatients and not those with milderforms of the disease or to, as suggest-ed by Gisondi, et al,9 the fact that awant of any kind of relationshipwould tend to indicate that it was theobesity itself that was favoured by thepsoriasis. Finally, a more recent studydescribed a clear relationship betweenMetS and the severity of psoriasis,with 14% of MetS found in subjectswith mild psoriasis, 34% with moder-ate and 66% with severe disease. Theresults offered by the Setty, et al21

study support this hypothesis, andrelate BMI and weight increase withthe diagnosis of new cases of psoria-sis.21 On the other hand, it should benoted that several different ways ofassessing the severity of psoriasis wereemployed by the different studies: thePASI Index,13,24 the form of treatmentthe patient was on18 and the percent-age of body surface affected.14 Ourstudy used the PASI Index and treat-ment, but quite probably the fact thatthe patients were not freshly diag-nosed but were mostly already on acourse of treatment could mean thePASI Index would indicate the severi-ty of the disease at the moment of thestudy, but not its earlier severity dur-ing the course of the subject’s historywith the disease.

Our study presents certain limita-tions. First, since it is a cross-sectionalstudy, it does not enable one toobserve the onset and evolution of therelationship between psoriasis andMetS. Secondly, and as already men-tioned, the fact that the patients werealready on treatment could affect

assessment of the severity of the psori-asis with the PASI Index and couldalso modify the components of MetS,as would be the case for treatmentwith oral corticosteroids, cyclosporine,methotrexate or biological agents. Inour study, there were two subjectsunder treatment with adalimumab(TNFa antagonist). There are studieswhich suggest that TNFa antagonistscould have a beneficial effect on car-diovascular risk factors.3 A review ofthe effects of adalimumab treatmentof MetS for subjects with psoriasis,shows one case of hyperglycemia in asubject with type 2 DM, while anotherstudy showed weight increase and anabsence of lipid profile changesamongst 30 subjects.3 However, otherstudies performed with TNFa antago-nists on subjects with rheumatoidarthritis and ankylosing spondylitisreveal different results (improvementand no change), but not an increase ininsulin resistance.6,12 With our currentresults we are unable to either ruleout or confirm any effect adalimumabmay have on the MetS of the twopatients assessed, given that theywere both found free of MetS. Withregard to methotrexate, diverse stud-ies refer to it affording a reduction ofcardiovascular risk17 and in our studyits possible effect on MetS would be toreduce risk and thus lessen the differ-ences between the two groups.Finally, we wish to underscore thepossible skew there could have beenin the choice of the control sample(health care deliverers and their fami-lies), chosen given difficulty of findingcontrol subjects that could be pairedwith the subjects with psoriasis fromamong the psoriasis-free patients visit-ing the dermatology department. Itcould be considered that health caredeliverers have a healthier lifestyle,but any such factor will be eliminatedwhen the subjects are compared bydiet and also because of the level ofprevalence of MetS, clearly higher

Table 3: Results of the multivariate study performed, taking each of the compo-nents of MetS as dependent variables and age, sex, diet, exercise, tobacco addic-tion, consumption of alcohol and history of psoriasis as independent variables

Table 4: Differences between subjects with psoriasis with or without MetS

Continued on page 24

MetS No MetS


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ADVANCE IN SCAR PREVENTION?A drug approved for treating type 2diabetes may have a use in the pre-vention of scarring, reports Time(Apr. 16, 2015).

The research was led by Dr.Michael Longaker, co-director of theInstitute for Stem Cell Biology andRegenerative Medicine at Stanforduniversity, and published in the jour-nal Science. Dr. Longaker becameinterested in scar formation whilecarrying out plastic surgery on fetus-es in the womb and noting how thewounds healed virtually withoutscars, the news outlet reports.

To investigate this process usinga mouse model, the researchersfocused on one particular type offibroblast which is primarily involvedin wound healing. After treating thetest mice with a diptheria toxin thatdestroyed the fibroblasts being stud-ied, the mice’s skin scarred less.According to the Time report, thesefibroblasts have a marker on theirsurface which the diabetes druginhibits. In the animal model, scarformation was reduced withoutcompromising skin integrity. Dr.Longaker says it is not yet clear whatimpact this treatment would haveon existing scars, but such a treat-ment might make physicians lesshesitant to carry out scar revisionsurgery, the news outlet reports.

MANY PSORIASIS PATIENTSUNAWARE OF EFFECTIVENESS OFNEW BIOLOGIC THERAPIESNew biologic drugs entering themarket and coming through thedevelopment pipeline hold promiseof improved treatment for severepsoriasis, reports The VancouverSun (Apr. 2, 2015).

However, it seems manypatients with the condition havegiven up hope, Surrey B.C. dermatol-ogist Dr. Lorne Albrecht told thenews outlet. “People aren’t reallyaware. Most patients who come intomy clinic, even if they have signifi-cant disease, don’t know anythingabout these medications,” Dr.Albrecht was quoted as saying. “Itell them that they target the path-ways in psoriasis much more effi-ciently and safely than our oldermedications.”

The new therapies are expen-sive, and it will take some time forprovincial health plans to coverthem, the Sun reports.

REPORTS ON RESULTS OF IMMUNECHECKPOINT INHIBITOR STUDIESTwo trials in the New EnglandJournal of Medicine announcedimpressive results from newimmune checkpoint inhibitor drugsused to treat advanced melanoma,reports Forbes (Apr. 20, 2015).

One trial showed that theimmune checkpoint inhibitor pem-brolizumab resulted in better out-comes than ipilimumab, which iscommonly used for advancedmelanoma, the news outlet reports.The second trial showed improvedresponse in patients’ tumours to acombination of ipilimumab and thenew drug nivolumab compared toimilimumab alone, with 22% (16)experiencing complete response.However, half the patients in that trialon the combination treatment expe-rienced severe, even life-threatening,side effects. One patient in the com-bination trial was a 49-year-oldwoman who had had threemelanoma growths removed fromher skin, but the disease was spread-ing, with a growth several centime-ters across under her left breast,growing deep into her chest wall.Three weeks after the woman’s ini-tial treatment, she returned for hersecond dose. The tumour was gone,and fluid taken from the cavity didnot contain melanoma cells.

RESEARCH INTO THE METHODSCELLS USE TO COMMUNICATEResearchers from the university ofSouthern California have found thathuman skin cells appear to use amethod of intra-cellular communi-cation similar to the ‘quorum sens-ing’ that bacteria use to co-ordinatecollective activity, reports ScientificAmerican (Apr. 9, 2015).

The team plucked 200 hairsfrom a confined area on the back ofanesthetized mice. Where the hairshad been removed, 1,000 new hairstook their place. It appears, thenews outlet reports, that the trauma-tized follicle cells released chemicaldistress signals. When enough of theneighbouring cells relayed the sig-nal, releasing their own distresschemicals, the nearby skin reactedby regrowing five times the originalnumber of hairs. If this does indeedrepresent a case of quorum sensingit would be some of the first evi-dence to date that such communi-cation occurs in animal cells, thepublication reports. However, thephenomena only occurred wherethe plucked hairs were confined to asmall area. If the 200 hairs wereplucked from an area more than 6mm in diameter, no regrowthoccurred at all.

Research of NoteINVESTIGATING PATIENTS WITH BOTH AIBDS AND PSORIASIS

Prior case reports have described coexisting autoimmune bullous diseases (AIBDs) andpsoriasis, of which the most well-known AIBD was anti-laminin g1 (p200) pemphigoid.To characterize patients with both AIBDs and psoriasis, and to investigate which AIBDs

were common in this group, researchers enrolled 145 patients (male:female ratio 5.7:1) whohad coexisting AIBD and psoriasis who were diagnosed between Jan. 1, 1996 and July 31, 2013at an academic dermatology department. Some 134 of the cases were consultation casesregarding AIBD diagnosis. In most patients, the onset of psoriasis was before the onset of theAIBD—mean age of onset of AIBD was 65.4 years, with a mean duration between the onsets ofthe psoriasis and the AIBD was 14.6 years. While most cases had a single AIBD, 16 cases hadmultiple AIBDs. The most common AIBD was bullous pemphigoid (63.4%), with anti-laminin g1pemphigoid second (37.2%). The authors conclude there is indeed an association betweenpsoriasis and anti-laminin g1 pemphigoid, but because bullous pemphigoid is common, psoria-sis is more often seen with the latter.Ohata C, Ishii N, Koga H, et al: Coexistence of autoimmune bullous diseases (AIBDs) and psoriasis:

a series of 145 cases, in J Am Acad Dermatol (in the Apr. 18, 2015 online edition).

PIMECROLIMUS 1% COMPARED TO TOPICAL CORTICOSTEROIDS IN AD IN INFANTS

Researchers enrolled 2,418 infants in a five-year, open-label study to compare the safetyand long-term efficacy of pimecrolimus 1% cream (PIM) to topical corticosteroids(TCSs) for treatment of mild to moderate atopic dermatitis (AD). The infants were ran-

domly assigned to either the PIM group (n=1,205, with short-term TCSs for flares of disease) orthe TCSs group (n=1,213). Treatment success was evaluated as scores of 0 (clear) or 1 (almostclear) an an Investigator’s global Assessment. Both treatment groups experienced a rapid onsetof action, with more than 50% of patients achieving treatment success by week three. After fiveyears, more than 85% of patients in both groups had overall success, and 95% had facial success.Significantly fewer steroid days were needed by the PIM group (seven) than the TCS group (178).

The authors conclude that long-term management of mild to moderate AD in infants usingeither PIM or TCSs is safe, without any effect on the immune system, and PIM is steroid-sparing.They say the data also suggests that PIM was similarly efficacious to TCS, and supports usingPIM as a first line treatment for this type of AD in this population..

Sigurgeirsson B, Boznanski A, Todd G, et al: Safety and efficacy of pimecrolimus inatopic dermatitis: a five-year randomized trial, in Pediatrics (Apr. 2015; 135(4):597-606).

What THE LAY PRESS is saying about . . .

Department Editor: John Evans

Diagnostic Quiz

A. Molluscum contagiosumB. Epidermal cystsC. Nevocellular nevi

D. Sebaceous hyperplasias

THE EDITORS invite your participation in thisregular feature of the journal.Please send all images and

correspondence to:Medical Editor,

The Chronicle of Skin & Allergy555 Burnhamthorpe Road, Suite 306,

Toronto, Ont. M9C 2Y3.Telephone: (416) 916-2476E-mail: [email protected]

Correct answer: Molluscum contagiosum

38 · June 2015

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NEWa new, oral tablet for the treatment of moderate to severe plaque psoriasis1

References: 1. OTEZLA Product Monograph, Celgene Corporation, November 2014.2. Papp K et al. Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with moderate to severe plaque psoriasis: results of a phase III, randomized,

controlled trial (ESTEEM 1). J Am Acad Dermatol 2015 (in press).

Clinical use: OTEZLA has not been studied and is therefore not indicated in combination with other systemic (conventional or biologic) therapies or phototherapy for psoriasis.Should be used with caution in very elderly patients (≥75 years of age).

Contraindications: • Pregnancy• Women who are breastfeeding

Relevant warnings and precautions:• History of tachyarrhythmia or conditions worsened by

increases in heart rate• Weight loss (monitor as necessary)• Diarrhea and nausea

• Severe immunological diseases, severe acute infectious diseases or patients treated with immunosuppressive medicinal products; experience in patients with latent infections is limited

• Headache and migraine• History of depression and/or suicidal thoughts or behaviour• Renal impairment

For more information:Please consult the Product Monograph at http://www.celgenecanada.net/pdfs/Otezla_Product_Monograph_English_Version.pdf for important information relating to adverse reactions, drug interactions, dosing instructions and dosage adjustments in patients with severe renal impairment which have not been discussed in this piece.


Demonstrated efficacy in clinical trials1,2

• PASI-75 response at Week 16 with OTEZLA 30 mgBID: 33.1% vs. placebo: 5.3%, p<0.0001*

Proven safety profile1 • Most common adverse reactions (≥5%) were

diarrhea (17.8%), nausea (16.6%), upper respiratory tract infection (8.4%), tension headache (7.3%), and headache (5.8%), which were mostly mild in intensity.1† Incidences of these adverse events were higher in females than males‡

Simplicity of oral dosing1§

OTEZLA® (apremilast) is indicated for the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.1

Fictitious case. Individual results may vary.

* Adapted from OTEZLA Product Monograph, 2014 and Papp K et al, 2015.1,2 A multicentre, randomized, double-blind, placebo-controlled study (ESTEEM 1) designed to evaluate the efficacy, safety, and tolerability of OTEZLA for the treatment of psoriasis. In ESTEEM 1, patients (N=844) with moderate to severe plaque psoriasis (PASI ≥12, BSA ≥10%, sPGA ≥3) were randomized 2:1 to OTEZLA 30 mg BID or placebo. At week 16, all placebo patients were switched to OTEZLA (placebo/OTEZLA) through week 32. At week 32, all patients who were randomized to OTEZLA at baseline and who achieved at least 75% reduction from baseline PASI score (PASI-75) were re-randomized (1:1, blinded) to continue OTEZLA or receive placebo. Upon loss of PASI-75 or at week 52, patients re-randomized to placebo resumed OTEZLA. The primary endpoint was the proportion of patients who achieved PASI-75 at week 16. Mean baseline PASI scores: OTEZLA 18.7; placebo 19.4.

†Nearly half of the adverse reactions of diarrhea, nausea, tension headache, and headache resolved within 2 weeks of onset.‡ The particular incidence rates for females experiencing nausea was 29.7% (vs. 9.9% for males), 24.0% for diarrhea (vs. 14.6% for males), 7.9% for vomiting (vs. 1.6% for males), and 11.5% for tension headache (vs. 5.2% for males).

§ OTEZLA is administered 30 mg BID after initial titration. Please consult the Product Monograph for complete dosage and administration instructions, including dose adjustments in patients with severe (CrCl <30 mL/min) renal impairment.

OTEZLA® is a registered trademark of Celgene Corporation.© 2015 Celgene Corporation.


the chronicle of skin & allergy june 2015

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