Dermatology Weekly

In this special takeover episode, guest host Dr. Candrice Heath talks to Dr. Vincent DeLeo about the new sunscreen regulations issued by the US Food and Drug Administration (FDA), beginning at 7:54. Despite heightened concerns about the safety of sunscreen ingredients brought on by these new regulations, the FDA still recommends sunscreen use as an important component of sun protection. “They’re not saying that any of these [ingredients] are necessarily dangerous by any means,” Dr. DeLeo explains, “simply that they need more data.” Dr. DeLeo breaks down the complicated sunscreen regulatory process and provides tips for alleviating patient fears about sunscreen use. He also addresses recent concerns in the media about systemic absorption of sunscreen ingredients.

We also bring you the latest in dermatology news and research:

1. AAD issues position statement addressing sexual, gender minority health, featuring an interview with Klint Peebles, MD, co-author of the position statement and co-chair of the AAD's LGBTQ/SGM Expert Resource Group. Dr. Peebles is on twitter @DrKlintPeebles.

2. Tick-borne disease has become a national issue.

Things you will learn in this episode: 

• Sunscreens are regulated by the FDA as over-the-counter drugs.

• The first proposed rule for sunscreens was issued by the FDA in 1978 with 21 approved chemical agents that were generally recognized as safe and effective (GRASE).

• A number of preliminary rules have been issued over the last few decades, but a final monograph has never been provided.

• The 2011 sunscreen final rule included 16 ingredients that were considered GRASE and outlined labeling and testing methods for sunscreens.

• In the 1970s, consumers typically only used sunscreens 3 to 4 days per year during beach vacations. Today, health care professionals recommend more frequent use of sunscreens with higher sun protection factors, which has led the industry to use sunscreen ingredients at higher concentrations.

• An important component of the new sunscreen regulations is the requirement of maximal usage trials (MUsTs) to evaluate absorption of sunscreen ingredients into the skin and systemic circulation.

• Of the 16 approved sunscreen ingredients, only zinc oxide and titanium dioxide are recognized as GRASE per the FDA’s new guidelines. The remaining ingredients are not necessarily considered dangerous but will have to undergo industry testing so the FDA can determine their safety and efficacy.

• “My guess is that [the final monograph] is going to take years,” Dr. DeLeo speculates. “It will without question cost the industry money to do these tests, so my guess is that when this all shakes out, we will have fewer sunscreens on the market, and those sunscreens almost surely will be more expensive.”

• In 2014, Congress passed the Sunscreen Innovation Act to encourage the FDA to create a process to fast track the approval process for sunscreen ingredients used in Europe and other countries.

• Due to media coverage of the new sunscreen regulations and the complicated nature of the approval process, many patients may limit their use of sunscreens. Dermatologists should be prepared to dispel patient fears and give advice on which products are safe to use.

• The FDA’s recent findings on systemic absorption of sunscreen ingredients were intended to provide risk assessment guidelines for future industry testing, but more data are needed before any true risk can be established.

Hosts: Elizabeth Mechcatie; Terry Rudd; Candrice R. Heath, MD (Lewis Katz School of Medicine, Temple University Hospital, Philadelphia) 

Guest: Vincent A. DeLeo, MD (Keck School of Medicine of the University of Southern California, Los Angeles) 

Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie. 

You can find more of our podcasts at http://www.mdedge.com/podcasts     

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

In this episode, Dr. Vincent DeLeo talks to Dr. Eden Lake about outpatient management and follow-up recommendations for adverse drug reactions (ADRs), beginning at 11:28. There’s a lot of literature on what to do for an inpatient who has an ADR, but what do you do once they’re discharged? Dr. Lake reviews the clinical features of three serious ADRs — AGEP (acute generalized exanthematous pustulosis), DRESS syndrome (drug rash with eosinophilia and systemic symptoms), and SJS/TEN (Stevens-Johnson syndrome/toxic epidermal necrolysis) — and provides preliminary guidelines for outpatient dermatology care.

We also bring you the latest in dermatology news and research:

1. Systematic review indicates cutaneous laser therapy may be safe during pregnancy.

2. Dr. Raymond Cho discusses the promise molecular profiling shows for treating unusual skin rashes. Dr. Cho, a dermatologist and geneticist at the University of California, San Francisco, based his comments on his presentation at the annual meeting of the Society for Investigative Dermatology.

3. Some "slime"-related contact dermatitis is allergic.

Things you will learn in this episode: 

• Adverse drug reactions are very common in dermatology, particularly in the inpatient setting. There are approximately 2 million serious ADRs per year in the United States with more than 100,000 deaths.

• Acute generalized exanthematous pustulosis (AGEP) develops very quickly after exposure to an insulting medication but generally is considered self-limiting and benign. Internal involvement has been seen in up to 20% of patients.

• DRESS syndrome (drug rash with eosinophilia and systemic symptoms) is a severe morbilliform drug eruption that can persist for months after discharge from the hospital. It presents with systemic symptoms such as eosinophilia, but any visceral organ can be involved.

• SJS/TEN are overlapping conditions with mucosal involvement and cutaneous exfoliation of a necrotic epidermis. Mortality rates are high, and treatment in a burn unit is recommended.

• Visceral involvement in AGEP patients may be similar to DRESS syndrome and requires more long-term follow-up.

• Adverse drug reactions are trauma to the skin and therefore can be associated with an isomorphic phenomenon.

• DRESS syndrome requires laboratory testing, particularly for glucose and thyroid-stimulating hormone levels, as well as a thorough review of systems in the outpatient setting.

• Taper high-dose steroids in DRESS syndrome patients in the outpatient setting very slowly.

• Ocular and pulmonary function should be monitored for 1 year after diagnosis of SJS/TEN. Patients also should undergo psychologic evaluation due to high rates of posttraumatic stress disorder.

Hosts: Elizabeth Mechcatie; Terry Rudd; Vincent A. DeLeo, MD (Keck School of Medicine of the University of Southern California, Los Angeles) 

Guest: Eden Lake, MD (Loyola University Medical Center, Maywood, Ill.)

Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie. 

You can find more of our podcasts at http://www.mdedge.com/podcasts     

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Rate us on iTunes!

In this episode, three dermatology residents -- Dr. Daniel Mazori,  Dr. Julie Croley, and Dr. Elisabeth Tracey -- discuss items they keep in their on-call bags in this special resident takeover of the podcast. Beginning at 14:50, they talk about premade biopsy kits, tricks for achieving hemostasis in the hospital, portable electronic gadgets, and creative alternatives for basic items. They also discuss bedside diagnostics and unique cases while being on-call. “After rotating through the consult service, you really do grow as a dermatologist,” reports Dr. Croley. “You see rare things; you see severe disease processes. You learn to be efficient and self-sufficient.” 

We also bring you the latest in dermatology news and research:

1. Study finds inconsistent links with aspirin, nonaspirin NSAIDs, and reduced skin cancer risk.

2. Justin M. Ko, MD, MBA, of Stanford (Calif.) University discusses the American Academy of Dermatology's position statement on augmented intelligence. Dr. Ko is director and chief of medical dermatology for Stanford Health Care at Stanford Medicine, Redwood City, Calif. He is the chair of the AAD's Ad Hoc Taskforce on Augmented Intelligence, which wrote the position statement.

3. Prior authorizations for dermatology care nearly doubled in the last 2 years at one center.

Things you will learn in this episode:

• Recommendations on what type of bag to use for your on-call bag.

• Premade biopsy kits are key for your on-call bag so that you can perform shave or punch biopsies.

• Tricks for obtaining hemostasis in the hospital.

• The utility of dermatoscopes has been expanding in recent years, and it can be a helpful bedside electronic device.

• Purple surgical markers can be used as a topical antimicrobial.

• Normal saline or honey can be used if you run out of Michel solution.

• Nonmedical items to keep in your on-call bag may include a handheld guide for drug eruptions and consult templates.

• Examples of unique cases of misdiagnosed Stevens-Johnson syndrome, highlighting the expertise of dermatologists: “In our field, especially as a consultant, our expertise can be so crucial in the care of complex patients.”

• Be comfortable with bedside diagnostics such as Tzanck smear to diagnose viral infections and a positive Nikolsky sign for staphylococcal scalded skin syndrome.

Hosts: Elizabeth Mechcatie, Terry Rudd

Guests: Daniel R. Mazori, MD (State University of New York, Brooklyn); Julie Ann Amthor Croley, MD (the University of Texas Medical Branch at Galveston); and Elisabeth (Libby) Tracey, MD (Cleveland Clinic Foundation).

Show notes by Melissa Sears, Alicia Sonners, and Elizabeth Mechcatie.

Contact us: [email protected]

Twitter: @MDedgeDerm

Rate us on iTunes!

To subscribe to this podcast and more, go to mdedge.com/podcasts.

In this episode,

Dr. Vincent DeLeo talks to Dr. Robert G. Micheletti about managing patients with calciphylaxis, a rare but potentially fatal condition classically seen in patients with end-stage renal disease (ESRD). Early recognition and diagnosis of calciphylaxis are essential to reducing morbidity and mortality. Dr. Micheletti describes the clinical features of calciphylaxis that dermatologists may encounter bedside, noting that biopsy often is nondefinitive. “It’s a tough disease to have," Dr. Micheletti explains, "which is why you do need multidisciplinary care and the help of a good dermatologist to be able to make the diagnosis and address the wound situation.” 

We also bring you the latest in dermatology news and research:

1. Atopic dermatitis in adults is associated with increased risk of dementia.
2. U.S. measles total sees smallest increase in 2 months.
3. Dr. Dee Anna Glaser, professor in the department of dermatology, Saint Louis University, discusses diagnosis and treatment advice for hyperhidrosis.

Things you will learn in this episode: 

• Although calciphylaxis commonly is associated with ESRD, nonuremic calciphylaxis can be triggered by other clinical factors in a subset of patients without ESRD.

• Risk factors for calciphylaxis include various medications, clotting disorders, and autoimmune diseases, whether the patient also has ESRD.

• The clinical presentation of calciphylaxis depends on the point at which the area is examined. Early stages of calciphylaxis may present as a tender subcutaneous nodule, while late stages may present with more severe pain and ulceration. Maintain a high index of suspicion for calciphylaxis in patients with ESRD on chronic dialysis presenting with severely painful livedoid plaques or retiform purpura, particularly in fat-rich body sites.

• Biopsy often is nondiagnostic because of insufficient tissue sample size. Calcium stains will help highlight areas of vascular calcification, but “don’t assume just because the biopsy doesn’t show calcification that it is not calciphylaxis.” To improve diagnostic accuracy, biopsy specimens should be evaluated by experienced dermatopathologists who have seen calciphylaxis before.

• End-stage renal disease patients with calciphylaxis who are not currently on dialysis may benefit from starting it.

• Dermatologists should work in conjunction with nephrologists to optimize dialysis and other medications to treat underlying issues associated with calciphylaxis in the setting of ESRD.

• Data-driven diagnostic criteria and management guidelines for calciphylaxis are needed to improve patient care. The Society for Dermatology Hospitalists is working on pooling cases of calciphylaxis to generate a data-driven model of factors associated with the diagnosis.

Hosts: Elizabeth Mechcatie; Terry Rudd; Vincent A. DeLeo, MD (University of Southern California, Los Angeles). 

Guest: Robert G. Micheletti, MD (Departments of Dermatology and Medicine, University of Pennsylvania, Philadelphia).

Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie.

Contact us: [email protected]

Twitter: @MDedgeDerm

Rate us on iTunes!

To subscribe to this podcast and more, go to mdedge.com/podcasts.

In this episode, Dr. Vincent DeLeo talks to Dr. Shari Lipner about nail education gaps in the American Academy of Dermatology Basic Dermatology Curriculum. Although the curriculum is designed to introduce medical students to essential concepts in dermatology, nail-related topics such as diagnostic techniques, biopsy procedures, and skin cancers of the nail unit are inadequately covered. Dr. Lipner discusses strategies to close these gaps and improve nail education for medical students and dermatology residents. She also breaks down the mnemonic for identifying nail melanomas.

We also bring you the latest in dermatology news and research:

1. Gentamicin restores wound healing in hereditary epidermolysis bullosa.

2. Measles complications in the U.S. unchanged in posteradication era.

3. Dr. Adam Friedman outlines oral treatment options for hyperhidrosis.

Things you will learn in this episode: 

• A thorough full-body skin examination should include the skin, hair, and scalp, as well as the nails. Even while the patient is initially speaking, pay attention to the nails.
• Many dermatology residents and attendings are not familiar with the ABCDEF nail melanoma mnemonic, which is more complex than the mnemonic for cutaneous melanoma.
• There is a gap in educating dermatology residents on nail biopsies and surgical procedures.
• Nail education can be improved by encouraging medical students and residents to be aware of the nails, get comfortable with the nails, and incorporate nails into the didactics during medical school and training. More lectures at national and local conferences and hands-on learning also are helpful.
• “By understanding nails, both diagnosis and management, potentially we can improve patients' quality of life, and it can also be lifesaving in the case of malignancies.”

Hosts: Elizabeth Mechcatie; Terry Rudd; Vincent A. DeLeo, MD (Keck School of Medicine of University of Southern California, Los Angeles) 

Guest: Shari R. Lipner, MD, PhD (Weill Cornell Medicine, New York, New York) 

Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie.

Contact us: [email protected]

Twitter: @MDedgeDerm

Rate us on iTunes!

In this episode, Vincent DeLeo, MD, talks to Nanette B. Silverberg, MD, about the successful management of warts in the pediatric population. Warts are superficial viral infections of the skin that are extremely common in children and account for a large proportion of pediatric dermatology office visits. Although over-the-counter treatments for warts are widely available to patients, they are not universally effective. Dr. Silverberg outlines a detailed treatment paradigm for managing pediatric warts and reviews a variety of new and established treatment options in six therapeutic categories. She also reviews the latest human papillomavirus (HPV) vaccine recommendations for children.

We also bring you the latest in dermatology news and research:

1. Sunscreen ingredients found in bloodstream, but health impact unknown.

2. Females with acne stay on spironolactone longer than antibiotics in real-world usage study.

3. Employed physicians now outnumber independent doctors.

Things you will learn in this episode: 

• Warts are benign epidermal lesions caused by infection with HPV, which replicates in skin cells to induce a state of hyperkeratosis.
• There are more than 200 types of HPV, and warts have variable clinical and histologic features depending on type and location.
• The incidence of pediatric warts appears to peak in preadolescence.
• Children with atopic dermatitis may be at higher risk for developing warts and other extracutaneous infections. Warts in the setting of AD may indicate that a child is prone to other dermatologic or allergic conditions.
• Most warts in children are transmitted in close household, classroom, or sports settings. Evaluation for signs of sexual abuse always is warranted in children presenting with condyloma.
• Dermatologists should be aware of respiratory complications associated with HPV infection in children.
• The majority of warts likely will spontaneously resolve, but those that spread or do not resolve following observation or traditional therapies may require alternative treatment mechanisms.
• Treatment options for pediatric warts generally fall into six therapeutic categories: destructive, immune stimulating, immune modulating, irritant therapy, vascular destructive, and nitric oxide releasing.
• The therapeutic ladder for warts in children consists of seven rungs, beginning with diagnosis. If the clinical presentation is not clear, suspected warts should be biopsied prior to treatment to avoid unnecessary procedures or exacerbation of the condition. Avoid painful procedures in children.
• The most recent HPV vaccine offers broad protection and should be offered to both girls and boys before they become sexually active. The dosing schedule should be reviewed with the pediatrician.

Cohosts: Elizabeth Mechcatie; Terry Rudd; Vincent A. DeLeo, MD (Keck School of Medicine of University of Southern California, Los Angeles)

Guest: Nanette B. Silverberg, MD (Icahn School of Medicine at Mount Sinai, New York, New York)

Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie.

Contact us: [email protected]

Twitter: @MDedgeDerm

Rate us on iTunes!

In this episode, Dr. Vincent DeLeo discusses consumer misconceptions about parabens with Dr. Margo Reeder and Dr. Amber Atwater. Although consumers believe parabens are associated with health risks such as breast cancer and endocrine disruption, the data have not been conclusive regarding any harmful effects in humans. Dr. Reeder and Dr. Atwater explain the use of parabens as preservatives in cosmetic products, and they discuss the American Contact Dermatitis Society’s selection of parabens as the 2019 nonallergen of the year.

We also bring you the latest in dermatology news and research:

1. Surprise! Methotrexate proves effective in psoriatic arthritis.

2. Positive psoriatic arthritis screens occur often in psoriasis patients.

3. Tips for preventing complications in resurfacing skin of color.

Things you will learn in this episode: 

• Parabens are present in a number of cosmetic and household products and medications, but the maximum concentrations permitted generally are much lower than consumers may think.
• Consumers associate parabens with health risks such as breast cancer and endocrine disruption, but the actual data on estrogenic effects in humans are limited.
• Although parabens have been found in breast cancer tissue, findings have not been directly linked to use of topical axillary personal care products containing parabens, such as deodorants. Application of these products directly after shaving also has not been shown to increase breast cancer risk.
• Because of their low rate of associated allergic contact dermatitis, the American Contact Dermatitis Society named parabens the nonallergen of the year for 2019.
• Parabens are a safe choice for preservatives given their low allergenic potential.
• Dermatologists can ease patient concerns about parabens by explaining that a causative role in adverse health effects has not been proven.

Guests: Margo Reeder, MD (University of Wisconsin School of Medicine and Public Health, Madison); Amber Reck Atwater, MD (Duke University School of Medicine, Durham, N.C.) 

Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie.

Contact us: [email protected]

Twitter: @MDedgeDerm

Three dermatology residents -- Dr. Julie Croley, Dr. Elisabeth Tracey, and Dr. Daniel Mazori -- discuss their use of social media and its impact on patient care in this special resident takeover of the podcast. Beginning at 6:29, they talk about social media accounts they follow and medical influencers, as well as the use of social media as a marketing tool for practicing physicians. Social media also is a source of misinformation for patients, and they discuss how it can be used as an important tool to educate patients when advice comes from a validated source such as a health care professional. As a dermatologist, do you have a duty to take to social media to provide reputable health information?

We also bring you the latest in dermatology news and research:

1. First North American clinical guidelines for hidradenitis suppurativa released.

2. Dr. Jeniel Nett discusses the dangers of Candida auris.

Things you will learn in this episode:

• Possible social media accounts to follow for educational purposes, such as dermoscopy and lifestyle topics in medicine.
• Social media influencers in dermatology for cases, dermatopathology, and suture techniques.
• How to manage using social media for personal vs. professional purposes.
• Marketing and advertising on social media to optimize the reach of your dermatology practice.
• Ways in which patients are misinformed through social media, such as improper use of medications, and the need for patients to assess the source of the information they are reading online. Dr. Croley asks, “Do we, as dermatologists, have a duty to take to social media to provide reputable health information?”
• Movements such as #VerifyHealthcare help physicians to practice transparency and ensure integrity of information posted on social media.
• Patient education via social media to reinforce concepts discussed in the office for treatment compliance, such as patient handouts or videos with instructions on applying tretinoin properly, using wet wraps for atopic dermatitis or bleach baths for children, and applying topical steroids under occlusion.
• Campaigns such as #dontfryday for sun safety awareness, which can be used to encourage preventative care for patients. Support groups on social media also can be helpful for patients.
• The utility of hashtags on social media to filter out noise. Should certain medical hashtags be restricted to health care professionals who have been verified?

Guests: Julie Ann Amthor Croley, MD (the University of Texas Medical Branch at Galveston); Elisabeth Tracey, MD (Cleveland Clinic Foundation, Ohio); Daniel R. Mazori, MD (State University of New York Downstate Medical Center, Brooklyn).

Show notes by Melissa Sears, Alicia Sonners, and Elizabeth Mechcatie.

Contact us: [email protected]

Twitter: @MDedgeDerm

Today, Dr. Vincent DeLeo talks to Dr. Candrice Heath about managing postinflammatory hyperpigmentation (PIH) in children with skin of color. Many inflammatory conditions commonly seen in childhood and adolescence can result in pigmentary changes in darker-skinned individuals. Beginning at 5:05, Dr. Heath outlines various treatment plans for some of these conditions, such as atopic dermatitis, acne, and arthropod bites, and shares some early prevention strategies to limit the development of new and worsening PIH in pediatric skin of color patients.

Plus, Dr. A. Yasmine Kirkorian talks with Dr. Adam Friedman about some of the immunomodulators he turns to for treating inflammatory skin diseases. Their discussion begins at 22:09.

We also bring you the latest in dermatology news and research:

1. Low-dose isotretinoin plus pulsed dye laser found effective for papulopustular rosacea.

2. Cost gap widens between brand-name, generic drugs.

3. Busiest week yet brings 2019 measles total to 555 cases.

Contact us: [email protected]

Twitter: @MDedgeDerm

In this episode, Dr. A. Yasmine Kirkorian and Dr. Adam Friedman share their clinical pearls for using immunomodulators to treat pediatric skin diseases.

We also bring you the latest in dermatology news and research:

1. Survey finds high rate of complications from laser tattoo removal in non-clinic settings.

2. Survey finds psoriasis patients seek relief with alternative therapies.

Contact us: [email protected]

Twitter: @MDedgeDerm